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Patel PA, Fernando RJ, MacKay EJ, Yoon J, Gutsche JT, Patel S, Shah R, Dashiell J, Weiss SJ, Goeddel L, Evans AS, Feinman JW, Augoustides JG. Acute Type A Aortic Dissection in Pregnancy-Diagnostic and Therapeutic Challenges in a Multidisciplinary Setting. J Cardiothorac Vasc Anesth 2018. [PMID: 29519602 DOI: 10.1053/j.jvca.2018.01.035] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- Prakash A Patel
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Rohesh J Fernando
- Cardiothoracic Section, Department of Anesthesiology, Wake Forest School of Medicine, Wake Forest University, Winston-Salem, NC
| | - Emily J MacKay
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Jeongae Yoon
- Cardiothoracic Anesthesiology, Department of Anesthesiology, Lewis School of Medicine, Temple University, Philadelphia, PA
| | - Jacob T Gutsche
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Saumil Patel
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Ronak Shah
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Jillian Dashiell
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Stuart J Weiss
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Lee Goeddel
- Divisions of Cardiac Anesthesia and Adult Critical Care, Department of Anesthesiology and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD
| | - Adam S Evans
- Department of Anesthesiology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Jared W Feinman
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - John G Augoustides
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.
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Goland S, Elkayam U. Pregnancy and Marfan syndrome. Ann Cardiothorac Surg 2017; 6:642-653. [PMID: 29270376 PMCID: PMC5721114 DOI: 10.21037/acs.2017.10.07] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Accepted: 10/16/2017] [Indexed: 01/15/2023]
Abstract
Pregnancy in women with Marfan syndrome (MFS) presents challenges to the clinician and the patient due to the increased incidence of maternal complications and involvement of the fetus, and deserves special consideration. The leading cause of morbidity and mortality in MFS is aortic dissection. This article presents an extensive review of available clinical information and provides recommendations for the management of patients with MFS during pregnancy.
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Affiliation(s)
- Sorel Goland
- Heart Institute, Kaplan Medical Center, Rehovot, affiliated to Hebrew University, Jerusalem, Israel
| | - Uri Elkayam
- Department of Medicine, Division of Cardiovascular Disease, and Department of Obstetrics and Gynaecology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
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Successful foetal delivery and emergency redo mitral valve replacement for acute prosthetic valve thrombosis in a 29-week pregnant woman. Hellenic J Cardiol 2017; 59:64-65. [PMID: 28888952 DOI: 10.1016/j.hjc.2017.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2017] [Revised: 08/19/2017] [Accepted: 08/24/2017] [Indexed: 11/23/2022] Open
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Taenaka H, Ootaki C, Matsuda C, Fujino Y. Successful pulmonary embolectomy for massive pulmonary embolism during pregnancy: a case report. JA Clin Rep 2017; 3:44. [PMID: 29457088 PMCID: PMC5804640 DOI: 10.1186/s40981-017-0116-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Accepted: 08/22/2017] [Indexed: 11/29/2022] Open
Abstract
Background Pulmonary embolism (PE) resulting from venous thromboembolism is a leading cause of maternal mortality in pregnancy. In patients with massive PE and hemodynamic instability, the treatment options often considered are thrombolytics, inferior vena caval filters, or embolectomy. We report here the case of a patient with massive PE at 28 weeks’ gestation, who underwent emergency pulmonary embolectomy via cardiopulmonary bypass. Case presentation A 35-year old primigravida with a history of massive PE at 25 weeks of gestation was referred to our hospital at 28 weeks of gestation, following treatment failure after insertion of an inferior vena cava filter and heparin administration. Emergency thrombectomy was performed, and intracardiac echography was used for intraoperative fetal heart rate monitoring. However, the patient developed hemodynamic collapse following anesthesia induction; hence, emergency cardiopulmonary bypass (CPB) was performed via median sternotomy. Thrombectomy and tricuspid valve plication were performed under cardiac arrest. After confirming postoperative hemostasis, heparin administration was resumed. At 40 weeks of gestation, labor was induced under epidural analgesia. Both mother and child were discharged with no complications. Conclusion In conclusion, intracardiac echography is useful for fetal heart rate monitoring during emergency cardiac surgery in pregnancy. Careful CPB management is important to maintain uteroplacental blood flow. Although there is no consensus on the delivery methods in such cases, epidural analgesia during labor was useful in reducing cardiac load and wound traction.
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Affiliation(s)
- Hiroki Taenaka
- Department of Anesthesiology and Intensive Care, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 5650871 Japan
| | - Chiyo Ootaki
- Department of Anesthesiology and Intensive Care, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 5650871 Japan
| | - Chie Matsuda
- Department of Anesthesiology and Intensive Care, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 5650871 Japan
| | - Yuji Fujino
- Department of Anesthesiology and Intensive Care, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 5650871 Japan
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Abstract
PURPOSE OF REVIEW The number of pregnancies complicated by valvular heart disease is increasing. This review describes the hemodynamic effects of clinically important valvular abnormalities during pregnancy and reviews current guideline-driven management strategies. RECENT FINDINGS Valvular heart disease in women of childbearing age is most commonly caused by congenital abnormalities and rheumatic heart disease. Regurgitant lesions are well tolerated, while stenotic lesions are associated with a higher risk of pregnancy-related complications. Management of symptomatic disease during pregnancy is primarily medical, with percutaneous interventions considered for refractory symptoms. Most guidelines addressing the management of valvular heart disease during pregnancy are based on case reports and observational studies. Additional investigation is required to further advance the care of this growing patient population.
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Affiliation(s)
- Sarah A Goldstein
- Duke University Medical Center, 2301 Erwin Rd, Box 2819, Durham, NC, 27710, USA.
| | - Cary C Ward
- Duke University Medical Center, 2301 Erwin Rd, Box 2819, Durham, NC, 27710, USA
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Spontaneous Coronary Artery Dissection in Pregnancy: What Every Obstetrician Should Know. Obstet Gynecol 2017; 128:731-738. [PMID: 27607875 DOI: 10.1097/aog.0000000000001630] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Spontaneous coronary artery dissection is a major cause of myocardial infarction in pregnancy and the postpartum period. It occurs predominantly in young women with few or no conventional risk factors for atherosclerosis and has been clinically underrecognized. Treatment differs from that of myocardial infarction as a result of atherosclerosis and the diagnosis should be considered in all parturient and postpartum patients with acute coronary syndrome. Complications of spontaneous coronary artery dissection include recurrence, congestive heart failure, and death. Thus, specialist obstetrician-gynecologists and maternal-fetal medicine specialists need to gain knowledge of spontaneous coronary artery dissection to improve outcomes.
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Canobbio MM, Warnes CA, Aboulhosn J, Connolly HM, Khanna A, Koos BJ, Mital S, Rose C, Silversides C, Stout K. Management of Pregnancy in Patients With Complex Congenital Heart Disease: A Scientific Statement for Healthcare Professionals From the American Heart Association. Circulation 2017; 135:e50-e87. [PMID: 28082385 DOI: 10.1161/cir.0000000000000458] [Citation(s) in RCA: 232] [Impact Index Per Article: 33.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Today, most female children born with congenital heart disease will reach childbearing age. For many women with complex congenital heart disease, carrying a pregnancy carries a moderate to high risk for both the mother and her fetus. Many such women, however, do not have access to adult congenital heart disease tertiary centers with experienced reproductive programs. Therefore, it is important that all practitioners who will be managing these women have current information not only on preconception counseling and diagnostic evaluation to determine maternal and fetal risk but also on how to manage them once they are pregnant and when to refer them to a regional center with expertise in pregnancy management.
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De Backer J, Muiño-Mosquera L, Demulier L. Aortopathy. PREGNANCY AND CONGENITAL HEART DISEASE 2017. [DOI: 10.1007/978-3-319-38913-4_12] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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Davis E, Gorog DA, Rihal C, Prasad A, Srinivasan M. "Mind the gap" acute coronary syndrome in women: A contemporary review of current clinical evidence. Int J Cardiol 2016; 227:840-849. [PMID: 27829528 DOI: 10.1016/j.ijcard.2016.10.020] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2016] [Revised: 10/05/2016] [Accepted: 10/07/2016] [Indexed: 01/22/2023]
Abstract
The incidence and prevalence of coronary artery disease in women has exceeded that in men over the past four decades, and although a significant decline in mortality has occurred in the past two decades, there is a growing body of evidence suggesting that there are gender differences between the clinical manifestations and course of coronary artery disease, as well as differences in treatment and treatment response. This review article considers the current literature regarding the gender-specific manifestation of acute coronary syndromes. Through the review of basic science articles, subsets of trial data, and meta-analyses, the gender-specific differences in within acute coronary syndromes are considered in terms of diagnostic dilemmas, pathophysiology, and treatment options (including pharmacological, percutaneous and surgical methods). Finally, acute coronary syndromes and their management in the special circumstance of pregnancy are also reviewed.
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Affiliation(s)
- Elizabeth Davis
- Department of Cardiology, Papworth Hospital, Papworth Everard, UK.
| | - Diana A Gorog
- Hertfordshire Cardiology Centre, Lister Hospital, Stevenage, UK; Imperial College, London, UK; University of Hertfordshire, Herts, UK
| | - Charanjit Rihal
- The Division of Cardiovascular Diseases and Department of Internal Medicine, Mayo Clinic and Mayo Foundation, Rochester, MN, United States
| | - Abhiram Prasad
- The Division of Cardiovascular Diseases and Department of Internal Medicine, Mayo Clinic and Mayo Foundation, Rochester, MN, United States
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A Historic Case of Cardiac Surgery in Pregnancy. Case Rep Obstet Gynecol 2016; 2016:7518697. [PMID: 27803828 PMCID: PMC5075601 DOI: 10.1155/2016/7518697] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Accepted: 09/20/2016] [Indexed: 11/17/2022] Open
Abstract
Background. Heart disease is the leading cause of nonobstetric mortality in pregnant women. Because of high risk, medical management represents the first line of treatment. However, when medical treatment fails, cardiac surgery becomes necessary. Case Presentation. A 27-year-old female who underwent successfully cardiac surgery three times within 3 years. At the first time, she had an aortic valve replacement at 25 weeks of gestation after an infectious endocarditis complicated with an ischemic stroke. At 39 weeks of gestation, she had delivered, vaginally, a healthy baby boy weighing 2800 g. In the second time, pregnant again at 30 weeks of gestation, she had a mitral valve replacement with an aortic prosthesis reinforcement after a paraprosthetic regurgitation and a mitral vegetation. A fetal death in utero had occurred; the extraction of the fetus by cesarean section with a tubal ligation was performed after stabilization of the mother. In the third time, she underwent successfully a mitral prosthesis replacement with Bentall's procedure after a mitral prosthesis disinsertion with an abscess of aortic annulus due to new episode of infectious endocarditis. Conclusion. Our patient has assembled almost all poor prognosis factors, which makes her a real historic case, probably never described in the literature.
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Lansman SL, Goldberg JB, Kai M, Tang GHL, Malekan R, Spielvogel D. Aortic surgery in pregnancy. J Thorac Cardiovasc Surg 2016; 153:S44-S48. [PMID: 27431443 DOI: 10.1016/j.jtcvs.2016.06.015] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2016] [Revised: 05/05/2016] [Accepted: 06/11/2016] [Indexed: 02/03/2023]
Abstract
Pregnancy engenders changes in hemodynamics and the aortic wall that make a woman more susceptible to aortic dilatation and dissection. This is particularly true of women with aortic dilatation and an aortopathy, including the inherited fibrillinopathies, bicuspid aortic valve, and Turner syndrome. Women in these risk groups may be served best by undergoing elective aortic surgery before becoming pregnant. However, some women present during pregnancy with significant aortic dilatation, rapid expansion, or aortic dissection, and strategies to deal with these situations, while optimizing maternal and fetal outcomes, change as gestation progresses. This review summarizes the approaches to the management of aortic diseases and the conduct of aortic surgery in pregnancy.
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Affiliation(s)
- Steven L Lansman
- Westchester Medical Center, Valhalla, NY; Department of Surgery, Section of Cardiothoracic Surgery, New York Medical College, Valhalla, NY.
| | - Joshua B Goldberg
- Westchester Medical Center, Valhalla, NY; Department of Surgery, Section of Cardiothoracic Surgery, New York Medical College, Valhalla, NY
| | - Masashi Kai
- Westchester Medical Center, Valhalla, NY; Department of Surgery, Section of Cardiothoracic Surgery, New York Medical College, Valhalla, NY
| | - Gilbert H L Tang
- Westchester Medical Center, Valhalla, NY; Department of Surgery, Section of Cardiothoracic Surgery, New York Medical College, Valhalla, NY
| | - Ramin Malekan
- Westchester Medical Center, Valhalla, NY; Department of Surgery, Section of Cardiothoracic Surgery, New York Medical College, Valhalla, NY
| | - David Spielvogel
- Westchester Medical Center, Valhalla, NY; Department of Surgery, Section of Cardiothoracic Surgery, New York Medical College, Valhalla, NY
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Dong X, Lu J, Cheng W, Wang C. An atypical presentation of chronic Stanford type A aortic dissection during pregnancy. J Clin Anesth 2016; 33:337-40. [PMID: 27555189 DOI: 10.1016/j.jclinane.2016.04.039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2015] [Revised: 03/19/2016] [Accepted: 04/24/2016] [Indexed: 02/03/2023]
Abstract
Aortic dissection is a rare but devastating disease during pregnancy, usually presenting with sharp pains on the chest or back. We report a pregnant woman suffering from chronic Stanford type A aortic dissection presented with atypical symptoms without pain in the third trimester with markedly dilated aortic root and congestive heart failure, who received concomitant cesarean delivery and aortic repair with good maternal and fetal outcomes. Multidisciplinary approach and tight hemodynamic control are very important. More attention should be paid to those atypical symptoms so as to early identify this scarce but disastrous disease during pregnancy.
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Affiliation(s)
- Xiuhua Dong
- Department of Anesthesiology, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing, China
| | - Jiakai Lu
- Department of Anesthesiology, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing, China.
| | - Weiping Cheng
- Department of Anesthesiology, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing, China
| | - Chengbin Wang
- Department of Anesthesiology, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing, China
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Yuan SM. Cardiac myxoma in pregnancy: a comprehensive review. Braz J Cardiovasc Surg 2016; 30:386-94. [PMID: 26313731 PMCID: PMC4541787 DOI: 10.5935/1678-9741.20150012] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2014] [Accepted: 02/16/2015] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVE Cardiac myxoma in pregnancy is rare and the clinical characteristics of this entity have been insufficiently elucidated. This article aims to describe the treatment options and the risk factors responsible for the maternal and feto-neonatal prognoses. METHODS A comprehensive search of the literature of cardiac myxoma in pregnancy was conducted and 44 articles with 51 patients were included in the present review. RESULTS Transthoracic echocardiography was the most common diagnostic tool for the diagnosis of cardiac myxoma during pregnancy. Cardiac myxoma resection was performed in 95.9% (47/49); while no surgical resection was performed in 4.1% (2/49) patients (P=0.000). More patients had an isolated cardiac myxoma resection in comparison to those with a concurrent or staged additional cardiac operation [87.2% (41/47) vs. 12.8% (6/47), P=0.000]. A voluntary termination of the pregnancy was done in 7 (13.7%) cases. In the remaining 31 (60.8%) pregnant patients, cesarean section was the most common delivery mode representing 61.3% and vaginal delivery was more common accounting for 19.4%. Cardiac surgery was performed in the first, second and third trimester in 5 (13.9%), 14 (38.9%) and 17 (47.2%) patients, respectively. No patients died. In the delivery group, 20 (76.9%) neonates were event-free survivals, 4 (15.4%) were complicated and 2 (7.7%) died. Neonatal prognoses did not differ between the delivery modes, treatment options, timing of cardiac surgery and sequence of cardiac myxoma resection in relation to delivery. CONCLUSION The diagnosis of cardiac myxoma in pregnancy is important. Surgical treatment of cardiac myxoma in the pregnant patients has brought about favorable maternal and feto-neonatal outcomes in the delivery group, which might be attributable to the shorter operation duration and non-emergency nature of the surgical intervention. Proper timing of cardiac surgery and improved cardiopulmonary bypass conditions may result in even better maternal and feto-neonatal survivals.
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Affiliation(s)
- Shi-Min Yuan
- The First Hospital of Putian, Teaching Hospital, Fujian Medical University, Putian, Fujian Province, CN
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69
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Khafaga M, Kresoja KP, Urlesberger B, Knez I, Klaritsch P, Lumenta DB, Krause R, von Lewinski D. Staphylococcus lugdunensis Endocarditis in a 35-Year-Old Woman in Her 24th Week of Pregnancy. Case Rep Obstet Gynecol 2016; 2016:7030382. [PMID: 27051543 PMCID: PMC4804077 DOI: 10.1155/2016/7030382] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2015] [Revised: 02/03/2016] [Accepted: 02/11/2016] [Indexed: 11/30/2022] Open
Abstract
Background. Infective endocarditis is associated with considerable morbidity and mortality. Guidelines addressing prophylaxis and management of infective endocarditis do not extensively deal with concomitant pregnancy, and case reports on infective endocarditis are scarce. This is the first published report of infective endocarditis by Staphylococcus lugdunensis in a pregnant woman. Case Presentation. We report a single case of a 35-year-old woman in her 24th week of pregnancy who was admitted to our intensive care unit with fever and suspected infectious endocarditis. Blood culture detected Staphylococcus lugdunensis. A vegetation and severe mitral regurgitation due to complete destruction of the valve confirmed the diagnosis. An interdisciplinary panel of cardiologists, maternal-fetal medicine specialists, cardiac and plastic surgeons, infectiologists, anesthesiologists, and neonatologists was formed to determine the best therapeutic strategy. Conclusions. Timing and indications for surgical intervention to prevent embolic complications in infective endocarditis remain controversial. This original case report illustrates how managing infective endocarditis by Staphylococcus lugdunensis particularly in the 24th week of pregnancy can represent a therapeutic challenge to a broad section of specialties across medicine. Critical cases like this require a thorough weighing of risks and benefits followed by swift action to protect the mother and her unborn child.
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Affiliation(s)
- Mounir Khafaga
- Department of Cardiology, Medical University of Graz, 8036 Graz, Austria
| | | | - Berndt Urlesberger
- Division of Neonatology, Department of Paediatrics, Medical University of Graz, 8036 Graz, Austria
| | - Igor Knez
- Division of Cardiac Surgery, Department of Surgery, Medical University of Graz, 8036 Graz, Austria
| | - Philipp Klaritsch
- Department of Obstetrics and Gynecology, Medical University of Graz, 8036 Graz, Austria
| | - David Benjamin Lumenta
- Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, 8036 Graz, Austria
| | - Robert Krause
- Section of Infectious Diseases and Tropical Medicine, Department of Internal Medicine, Medical University of Graz, 8036 Graz, Austria
| | - Dirk von Lewinski
- Department of Cardiology, Medical University of Graz, 8036 Graz, Austria
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Saito A. Editorial: Pregnant patients and open-heart surgery - Decision-making for appropriate timing and surgical strategy. J Cardiol Cases 2016; 13:70-71. [PMID: 30546608 PMCID: PMC6280683 DOI: 10.1016/j.jccase.2015.12.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2015] [Indexed: 10/22/2022] Open
Affiliation(s)
- Aya Saito
- Division of Cardiovascular Surgery, Toho University Sakura Medical Center, Sakura, Chiba, Japan
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71
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Coulon C. Thoracic aortic aneurysms and pregnancy. Presse Med 2015; 44:1126-35. [DOI: 10.1016/j.lpm.2015.02.024] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2014] [Accepted: 02/10/2015] [Indexed: 12/12/2022] Open
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Botta L, Merati R, Vignati G, Orcese CA, De Chiara B, Cannata A, Bruschi G, Fratto P. Mitral valve endocarditis due to Abiotrophia defectiva in a 14th week pregnant woman. Interact Cardiovasc Thorac Surg 2015; 22:112-4. [PMID: 26487436 DOI: 10.1093/icvts/ivv289] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2015] [Accepted: 09/03/2015] [Indexed: 11/13/2022] Open
Abstract
Infective endocarditis during pregnancy carries a high mortality risk, both for the mother and for the foetus and requires a multidisciplinary team in the management of complicated cases. We report our experience with a 39-year old patient, affected by an acute active mitral endocarditis due to Abiotrophia defectiva at the 14th gestational week, strongly motivated to continue the pregnancy. Our patient successfully underwent mitral valve replacement with a normothermic high-flow cardiopulmonary bypass under continuous intraoperative foetal monitoring. Caesarean section occurred at the 38th gestational week. The delivery was uneventful and both the mother and child are doing well at the 16-month follow-up.
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Affiliation(s)
- Luca Botta
- Department of Cardiac Surgery, Niguarda Hospital, Milan, Italy
| | - Roberto Merati
- Department of Gynecology, Niguarda Hospital, Milan, Italy
| | - Gabriele Vignati
- Department of Paediatric Cardiology, Niguarda Hospital, Milan, Italy
| | | | | | - Aldo Cannata
- Department of Cardiac Surgery, Niguarda Hospital, Milan, Italy
| | | | - Pasquale Fratto
- Department of Cardiac Surgery, Niguarda Hospital, Milan, Italy
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Abstract
Management of peripartum heart disease in the intensive care unit requires optimization of maternal hemodynamics and maintenance of fetal perfusion. This requires fetal monitoring and should address the parturient's oxygen saturation, hemoglobin, and cardiac output as it relates to uterine blood flow. Pharmacologic strategies have limited evidence pertaining to hemodynamic stabilization and fetal perfusion. There is some evidence that surgical management of critical mitral stenosis should be percutaneous when possible because cardiac bypass is associated with increased fetal mortality. Fetal monitoring strategies should address central organ perfusion because peripheral scalp pH has not been associated with improved fetal outcomes.
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Affiliation(s)
- Huayong Hu
- Department of Anesthesiology, Yale New Haven Hospital, New Haven, CT, USA.
| | - Ioana Pasca
- Department of Anesthesiology, Loma Linda University Medical Center, Loma Linda, CA, USA
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74
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Pregnancy and Thoracic Aortic Disease: Managing the Risks. Can J Cardiol 2015; 32:78-85. [PMID: 26604124 DOI: 10.1016/j.cjca.2015.09.003] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Revised: 09/11/2015] [Accepted: 09/11/2015] [Indexed: 12/24/2022] Open
Abstract
The most common aortopathies in women of childbearing age are bicuspid aortic valve, coarctation of the aorta, Marfan syndrome, Ehlers-Danlos syndrome, Loeys-Dietz syndrome, SMAD3 aortopathy, Turner syndrome, and familial thoracic aneurysm and dissection. The hemodynamic and hormonal changes of pregnancy increase the risk of progressive dilatation or dissection of the aorta in these women. The presence of hypertension increases the risk further. Therefore, appropriate preconception counselling is advised. For women who become pregnant, serial follow-up by a specialized multidisciplinary team throughout pregnancy and postpartum period is required. In this review we discuss risk assessment and management strategies for women with aortopathies.
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Varnier NA, Pettit F, Rees D, Thou S, Brown M, Henry A. Coronary artery disease secondary to familial hypercholesterolaemia: An infrequent cause of increasingly common pregnancy co-morbidity. Obstet Med 2015; 8:152-4. [DOI: 10.1177/1753495x15593451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background Cardiovascular disease affects 0.2–4% of pregnancies. Coupled with the physiological stress of pregnancy, cardiovascular disease may present significant management challenges including appropriate risk:benefit analysis of medical and surgical management options. Case A 33-year-old gravida 4 para 1 miscarriage 2 presented at 18 weeks’ gestation to the high-risk pregnancy service with a history of coronary artery disease and homozygous familial hypercholesterolaemia. Pre-pregnancy echocardiogram showed probable aortic xanthoma and preserved cardiac function. Prior to planned interventional cardiology assessment for her coronary artery disease she became pregnant, taking aspirin and multivitamins only. She had exertional angina responsive to metoprolol, agreed to recommencing statin therapy when serum cholesterol worsened, but declined angiography during pregnancy. At 36 weeks’ gestation, she had further angina symptoms but no acute coronary syndrome. Induction in the High Dependency Unit with elective assisted vaginal delivery of a healthy female infant (birthweight 2460 g) occurred at 37 weeks. She underwent triple-vessel coronary artery bypass postpartum, recovering well. Conclusion Whilst this specific condition is rare, the increase in cardiovascular disease and cardiovascular risks in the obstetric population emphasises the need for clear, multidisciplinary management from the outset of pregnancy for these women.
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Affiliation(s)
- Nicla A Varnier
- Department of Women’s and Children’s Health, St George Hospital, Kogarah, NSW, Australia
| | - Franzisca Pettit
- Department of Renal Medicine, St George Hospital, Kogarah, NSW, Australia
- School of Medicine, University of New South Wales, Sydney, Australia
| | - David Rees
- Department of Cardiology, St George Hospital, Kogarah, NSW, Australia
| | - Steven Thou
- Department of Women’s and Children’s Health, St George Hospital, Kogarah, NSW, Australia
| | - Mark Brown
- Department of Renal Medicine, St George Hospital, Kogarah, NSW, Australia
- School of Medicine, University of New South Wales, Sydney, Australia
| | - Amanda Henry
- Department of Women’s and Children’s Health, St George Hospital, Kogarah, NSW, Australia
- School of Medicine, University of New South Wales, Sydney, Australia
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Abstract
Because of the growing population of patients with congenital heart disease (CHD), most maternal cardiac disease is now congenital in origin. For women with complex CHD, pregnancy poses an increased risk for both the mother, with complications of arrhythmias and heart failure being the most common, and the baby, with a higher chance of miscarriage, intrauterine growth retardation, and the need for early delivery. Pre-pregnancy counseling must be performed by cardiologists who have expertise in both CHD and pregnancy, with a detailed clinical assessment of the patient and the current hemodynamic situation, including echocardiography and an exercise test. In each case the approach must be individualized with consideration of the risks in each case. In some cases, such as Eisenmenger syndrome, pregnancy is contraindicated. Optimum outcomes in these complex patients are achieved when a multidisciplinary approach is used, involving maternal-fetal medicine specialists, cardiologists with expertise in CHD and obstetric anesthesia.
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77
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Sliwa K, Johnson MR, Zilla P, Roos-Hesselink JW. Management of valvular disease in pregnancy: a global perspective. Eur Heart J 2015; 36:1078-89. [DOI: 10.1093/eurheartj/ehv050] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2014] [Accepted: 02/09/2015] [Indexed: 11/14/2022] Open
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78
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Abstract
Due to advances in paediatric congenital heart surgery, there are a growing number of women with congenital heart disease (CHD) reaching childbearing age. Pregnancy, however, is associated with haemodynamic stresses which can result in cardiac decompensation in women with CHD. Many women with CHD are aware of their cardiac condition prior to pregnancy, and preconception counselling is an important aspect of their care. Preconception counselling allows women to make informed pregnancy decisions, provides an opportunity for modifications of teratogenic medications and, when necessary, repair of cardiac lesions prior to pregnancy. Less commonly, the haemodynamic changes of pregnancy unmask a previously unrecognised heart lesion. In general, pregnancy outcomes are favourable for women with CHD, but there are some cardiac lesions that carry high risk for both the mother and the baby, and this group of women require care by an experienced multidisciplinary team. This review discusses preconception counselling including contraception, an approach to risk stratification and management recommendations in women with some common CHDs.
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Affiliation(s)
- Rohan D'Souza
- Division of Maternal and Fetal Medicine, Department of Obstetrics & Gynaecology, University of Toronto, Mount Sinai Hospital, Toronto, Canada
| | - Mathew Sermer
- Division of Maternal and Fetal Medicine, Department of Obstetrics & Gynaecology, University of Toronto, Mount Sinai Hospital, Toronto, Canada
- Obstetric Medicine Program, Division of Cardiology, Department of Medicine, University of Toronto, Mount Sinai Hospital and University Health Network, Canada
| | - Candice K Silversides
- Division of Maternal and Fetal Medicine, Department of Obstetrics & Gynaecology, University of Toronto, Mount Sinai Hospital, Toronto, Canada
- Obstetric Medicine Program, Division of Cardiology, Department of Medicine, University of Toronto, Mount Sinai Hospital and University Health Network, Canada
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79
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Balsam LB, DeAnda A. Double the jeopardy: Balancing maternal and fetal risk during cardiac surgery. J Thorac Cardiovasc Surg 2015; 149:611-2. [DOI: 10.1016/j.jtcvs.2014.11.057] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2014] [Accepted: 11/19/2014] [Indexed: 02/01/2023]
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80
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Yates MT, Soppa G, Smelt J, Fletcher N, van Besouw JP, Thilaganathan B, Jahangiri M. Perioperative management and outcomes of aortic surgery during pregnancy. J Thorac Cardiovasc Surg 2015; 149:607-10. [DOI: 10.1016/j.jtcvs.2014.10.038] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2014] [Revised: 09/24/2014] [Accepted: 10/04/2014] [Indexed: 01/08/2023]
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81
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Rajagopalan S, Nwazota N, Chandrasekhar S. Outcomes in pregnant women with acute aortic dissections: a review of the literature from 2003 to 2013. Int J Obstet Anesth 2014; 23:348-56. [PMID: 25223644 DOI: 10.1016/j.ijoa.2014.05.001] [Citation(s) in RCA: 64] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2014] [Revised: 04/07/2014] [Accepted: 05/05/2014] [Indexed: 12/24/2022]
Abstract
BACKGROUND Acute aortic dissection in pregnant women is a rare but potentially life-threatening event. Our aim was to evaluate maternal and fetal outcomes of acute aortic dissection during pregnancy. METHODS We conducted a review of literature of the PubMed database to identify publications related to pregnant women with acute aortic dissections during the period 2003-2013: 59 articles were included in the study. RESULTS A total of 75 patients were included in the analyses. Stanford type A dissections were the most common form, accounting for 77% of all cases. The majority (78%) occurred in the third trimester and immediate postpartum period. Inherited connective tissue disorders were causative in 49% of patients. Maternal mortality was not statistical different between type A and type B dissections (21% vs. 23%), but fetal outcomes were worse in type B dissections (35% vs. 10.3%; P<0.05). Fetal mortality in type A dissections was dependent on the timing of aortic repair, with antepartum aortic repair associated with a higher mortality (36%). CONCLUSION Despite advances in diagnostic and surgical techniques, maternal and fetal mortalities in pregnant patients with aortic dissection remain high. Patients undergoing combined cesarean section with aortic repair had favorable fetal outcomes.
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Affiliation(s)
- S Rajagopalan
- Department of Anesthesiology, Baylor College of Medicine, Houston, TX, USA.
| | - N Nwazota
- Department of Anesthesiology, Baylor College of Medicine, Houston, TX, USA
| | - S Chandrasekhar
- Department of Anesthesiology, Baylor College of Medicine, Houston, TX, USA
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82
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van Hagen IM, Roos-Hesselink JW. Aorta pathology and pregnancy. Best Pract Res Clin Obstet Gynaecol 2014; 28:537-50. [DOI: 10.1016/j.bpobgyn.2014.03.007] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2013] [Revised: 03/07/2014] [Accepted: 03/18/2014] [Indexed: 01/15/2023]
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83
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Elassy SM, Elmidany AA, Elbawab HY. Urgent Cardiac Surgery During Pregnancy: A Continuous Challenge. Ann Thorac Surg 2014; 97:1624-9. [DOI: 10.1016/j.athoracsur.2013.10.067] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2013] [Revised: 10/10/2013] [Accepted: 10/15/2013] [Indexed: 11/25/2022]
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84
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Yuan SM. Indications for Cardiopulmonary Bypass During Pregnancy and Impact on Fetal Outcomes. Geburtshilfe Frauenheilkd 2014; 74:55-62. [PMID: 24741119 DOI: 10.1055/s-0033-1350997] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2013] [Revised: 09/29/2013] [Accepted: 10/01/2013] [Indexed: 01/03/2023] Open
Abstract
Background: Cardiac operations in pregnant patients are a challenge for physicians in multidisciplinary teams due to the complexity of the condition which affects both mother and baby. Management strategies vary on a case-by-case basis. Feto-neonatal and maternal outcomes after cardiopulmonary bypass (CPB) in pregnancy, especially long-term follow-up results, have not been sufficiently described. Methods: This review was based on a complete literature retrieval of articles published between 1991 and April 30, 2013. Results: Indications for CPB during pregnancy were cardiac surgery in 150 (96.8 %) patients, most of which consisted of valve replacements for mitral and/or aortic valve disorders, resuscitation due to amniotic fluid embolism, autotransfusion, and circulatory support during cesarean section to improve patient survival in 5 (3.2 %) patients. During CPB, fetuses showed either a brief heart rate drop with natural recovery after surgery or, in most cases, fetal heart rate remained normal throughout the whole course of CPB. Overall feto-neonatal mortality was 18.6 %. In comparison with pregnant patients whose baby survived, feto-neonatal death occurred after a significantly shorter gestational period at the time of onset of cardiac symptoms, cardiac surgery/resuscitation under CPB in the whole patient setting, or cardiac surgery/resuscitation with CPB prior to delivery. Conclusions: The most common surgical indications for CPB during pregnancy were cardiac surgery, followed by resuscitation for cardiopulmonary collapse. CPB was used most frequently in maternal cardiac surgery/resuscitation in the second trimester. Improved CPB conditions including high flow, high pressure and normothermia or mild hypothermia during pregnancy have benefited maternal and feto-neonatal outcomes. A shorter gestational period and the use of CPB during pregnancy were closely associated with feto-neonatal mortality. It is therefore important to attempt delivery ahead of surgery/CPB or to defer surgery till late pregnancy.
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Affiliation(s)
- S-M Yuan
- Department of Cardiothoracic Surgery, The First Hospital of Putian, Teaching Hospital, Fujian Medical University, Putian, Fujian Province, China
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85
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Lichtman AD, Kjaer K. Combined Cesarean Delivery and Repair of Acute Ascending and Aortic Arch Dissection at 32 Weeks of Pregnancy. J Cardiothorac Vasc Anesth 2013; 27:731-4. [DOI: 10.1053/j.jvca.2011.11.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2011] [Indexed: 11/11/2022]
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86
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Ngo Nonga B, Pasquet A, De Kherkove L, Glineur D, Debieve F, Hubinont C, El khoury G, Noirhomme P. Emergent cardiac surgery with cardiopulmonary bypass in early pregnancy: report of four cases. Res Cardiovasc Med 2013; 2:140-4. [PMID: 25478510 PMCID: PMC4253769 DOI: 10.5812/cardiovascmed.11281] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2013] [Revised: 04/28/2013] [Accepted: 05/01/2013] [Indexed: 11/16/2022] Open
Abstract
Background: Due to current medical improvements, more women with cardiac disease are being operated during pregnancy. Fetal loss has been found to be significant between 9-30% of them and the surgery is supposed to be done maximal in the first trimester. Objectives: The aim of this study was to report our experience with urgent cardiopulmonary bypass carried out in early pregnancy and to analyze factors that may influence fetal and maternal morbidity and mortality after surgery. Materials and Methods: We have retrospectively reviewed the case notes of the patients who underwent cardiac surgery during early pregnancy in our institution from January 1997 to October 2011. Results: During that period cardiac surgery was done in 305 patients in childbearing age (between 15-50 years) from which 4 were pregnant and in the first half of their pregnancy. All of them had previous surgery due to rhumatismal heart disease .The surgery was emergent in 3 cases and urgent in 1 case. They were operated under normothermic conditions, high flow and hemodynamic stability throughout the procedure. There was no fetal loss but one patient sustained a cardiac arrest secondary to asthma complicated by post-anoxic brain injury. Conclusions: Normothermia and hemodynamic stability are the most important factors which help to reduce fetal loss during open heart surgery in pregnancy. The fetus has an auto-regulation which comes into play when the mother is experiencing shock.
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Affiliation(s)
- Bernadette Ngo Nonga
- Service of Thoracic and Cardiovascular Surgery, Department of Cardiovascular Diseases, Brussels’s St Luc University Hospital Center, Brussels, Belgium
- Corresponding author: Bernadette Ngo Nonga, Department of Cardiovascular Diseases, Brussels’s St Luc University Hospital Center. Brussels, Belgium. Tel/Fax: +23-733779597, E-mail:
| | - Agnès Pasquet
- Service of Cardiology, Department of Cardiovascular Diseases, Brussels’s St Luc University Hospital Center, Brussels, Belgium
| | - Laurent De Kherkove
- Service of Thoracic and Cardiovascular Surgery, Department of Cardiovascular Diseases, Brussels’s St Luc University Hospital Center, Brussels, Belgium
| | - David Glineur
- Service of Thoracic and Cardiovascular Surgery, Department of Cardiovascular Diseases, Brussels’s St Luc University Hospital Center, Brussels, Belgium
| | - Frederic Debieve
- Department of Obstetrics and Gynecology, Brussels’s St Luc University Hospital Center, Brussels, Belgium
| | - Corinne Hubinont
- Department of Obstetrics and Gynecology, Brussels’s St Luc University Hospital Center, Brussels, Belgium
| | - Gebrine El khoury
- Service of Thoracic and Cardiovascular Surgery, Department of Cardiovascular Diseases, Brussels’s St Luc University Hospital Center, Brussels, Belgium
| | - Philippe Noirhomme
- Service of Thoracic and Cardiovascular Surgery, Department of Cardiovascular Diseases, Brussels’s St Luc University Hospital Center, Brussels, Belgium
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87
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Echeverría LE, Figueredo A, Gómez JC, Salazar LA, Rodriguez JA, Pizarro CE, Riaño CE, Perroni A, Cuadros AL, Villamizar MC, Suárez EU. [High risk infective endocarditis embolism during pregnancy: Medical or surgical management?]. ARCHIVOS DE CARDIOLOGIA DE MEXICO 2013; 83:209-13. [PMID: 23896064 DOI: 10.1016/j.acmx.2013.04.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2012] [Revised: 04/04/2013] [Accepted: 04/04/2013] [Indexed: 10/26/2022] Open
Abstract
A 22-year-old pregnant woman was seen at 14 weeks of pregnancy for infective endocarditis with a vegetation of 15 mm and wide mobility, which affected the native mitral valve accompanied by severe valvular insufficiency. Antibiotic treatment was given for 4 weeks despite the embolism risk. Due to persistence of vegetation size and after considering the fetal and maternal risk, the surgical procedure was favored. We decided to perform valvuloplasty and removal of lesion at 18 weeks of pregnancy. Fetal protection techniques were used and a bioprosthesis was placed before attempting a repair. The postoperative follow-up was satisfactory, achieving a successful birth by cesarean section at 30 weeks.
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Affiliation(s)
- Luis Eduardo Echeverría
- Clínica de Falla Cardíaca, Fundación Cardiovascular de Colombia, Floridablanca, Santander, Colombia; Departamento de Ecocardiografía, Fundación Cardiovascular de Colombia, Floridablanca, Santander, Colombia.
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88
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Hajj-Chahine J, Tomasi J, Houmaida H, Corbi P. eComment. Cardiopulmonary bypass and pregnancy. Interact Cardiovasc Thorac Surg 2013; 15:1070-1. [PMID: 23166221 DOI: 10.1093/icvts/ivs425] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Jamil Hajj-Chahine
- Department of Cardio-Thoracic surgery, University Hospital of Poitiers, Poitiers, France
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89
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Chauhan A, Musunuru H, Donnino M, McCurdy MT, Chauhan V, Walsh M. The Use of Therapeutic Hypothermia After Cardiac Arrest in a Pregnant Patient. Ann Emerg Med 2012; 60:786-9. [DOI: 10.1016/j.annemergmed.2012.06.004] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2012] [Revised: 05/25/2012] [Accepted: 06/04/2012] [Indexed: 11/16/2022]
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90
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Hajj-Chahine J, Jayle C, Tomasi J, Corbi P. eComment. Left tilt position for cardiopulmonary bypass in parturient patients. Interact Cardiovasc Thorac Surg 2012; 15:287. [PMID: 22802512 DOI: 10.1093/icvts/ivs222] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Jamil Hajj-Chahine
- Department of Cardio-Thoracic Surgery, University Hospital of Poitiers, Poitiers, France
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91
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Pieper PG, Hoendermis ES, Drijver YN. Cardiac surgery and percutaneous intervention in pregnant women with heart disease. Neth Heart J 2012; 20:125-8. [PMID: 22351585 PMCID: PMC3286507 DOI: 10.1007/s12471-012-0244-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
In pregnant women with heart disease, complications can arise due to the haemodynamic burden of pregnancy and to hypercoagulation. Most problems can be managed medically, but sometimes cardiac surgery or percutaneous intervention is unavoidable. Cardiac surgery has similar maternal mortality to that outside pregnancy, but foetal mortality and morbidity are considerable. Measures to reduce the risk by adaptation of the management of cardiopulmonary bypass are described. When gestational age is > 28 weeks, pre-surgery delivery of the foetus should be considered. Percutaneous intervention exposes the foetus to radiation. The radiation dose for common cardiac procedures, however, does not result in detectable harmful foetal effects.
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Affiliation(s)
- P G Pieper
- Department of Cardiology, University Medical Centre Groningen, University of Groningen, PO Box 30.001, 9700, RB, Groningen, the Netherlands,
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92
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Sepehripour AH, Lo TT, Shipolini AR, McCormack DJ. Can pregnant women be safely placed on cardiopulmonary bypass? Interact Cardiovasc Thorac Surg 2012; 15:1063-70. [PMID: 22945848 DOI: 10.1093/icvts/ivs318] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
A best evidence topic was written according to a structured protocol. The question addressed was whether cardiopulmonary bypass can be used safely with satisfactory maternal and foetal outcomes in pregnant patients undergoing cardiac surgery. A total of 679 papers were found using the reported searches of which 14 represented the best evidence to answer the clinical question. The authors, date, journal, study type, population, main outcome measures and results are tabulated. Reported measures were maternal and foetal mortality and complications, mode of delivery, cardiopulmonary bypass and aortic cross-clamp times, perfusate flow rate and temperature and maternal NYHA functional class. The most recent of the best evidence studies, a retrospective observational study of 21 pregnant patients reported early and late maternal mortalities of 4.8 and 14.3%, respectively, and a foetal mortality of 14.3%. Median cardiopulmonary bypass and aortic cross-clamp times were 53 and 35 min, respectively, and the median bypass temperature was 37°C. Three larger retrospective reviews of the literature reported maternal mortality rates of 2.9-5.1% and foetal mortality rates of 19-29%. Mean cardiopulmonary bypass times ranged from 50.5 to 77.8 min. Another retrospective observational study reported maternal mortality of 13.3% and foetal mortality of 38.5%. Mean cardiopulmonary bypass and aortic cross-clamp times were 89.1 and 62.8 min, respectively, with a mean bypass temperature of 31.8°C. A retrospective case series reported no maternal mortality and one case of foetal mortality. Median cardiopulmonary bypass and aortic cross-clamp times were 101 and 88 min, respectively. Eight case reports described 10 patients undergoing cardiopulmonary bypass. There were no reports of maternal mortality and one report of foetal mortality. Mean cardiopulmonary bypass and aortic cross-clamp times were 105 and 50 min, respectively. We conclude that while the use of cardiopulmonary bypass during pregnancy poses a high risk for both the mother and the foetus, the use of high-flow, high-pressure, pulsatile, normothermic bypass and continuous foetal and uterine monitoring can allow cardiac surgery with the use of cardiopulmonary bypass to be performed with the greatest control of risk in the pregnant patient.
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Affiliation(s)
- Amir H Sepehripour
- Department of Cardiothoracic Surgery, Wythenshawe Hospital, Manchester, UK
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93
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Reitman E, Flood P. Anaesthetic considerations for non-obstetric surgery during pregnancy. Br J Anaesth 2012; 107 Suppl 1:i72-8. [PMID: 22156272 DOI: 10.1093/bja/aer343] [Citation(s) in RCA: 146] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Surgery during pregnancy is complicated by the need to balance the requirements of two patients. Under usual circumstances, surgery is only conducted during pregnancy when it is absolutely necessary for the wellbeing of the mother, fetus, or both. Even so, the outcome is generally favourable for both the mother and the fetus. All general anaesthetic drugs cross the placenta and there is no optimal general anaesthetic technique. Neither is there convincing evidence that any particular anaesthetic drug is toxic in humans. There is weak evidence that nitrous oxide should be avoided in early pregnancy due to a potential association with pregnancy loss with high exposure. There is evidence in animal models that many general anaesthetic techniques cause inappropriate neuronal apoptosis and behavioural deficits in later life. It is not known whether these considerations affect the human fetus but studies are underway. Given the general considerations of avoiding fetal exposure to unnecessary medication and potential protection of the maternal airway, regional anaesthesia is usually preferred in pregnancy when it is practical for the medical and surgical condition. When surgery is indicated during pregnancy maintenance of maternal oxygenation, perfusion and homeostasis with the least extensive anaesthetic that is practical will assure the best outcome for the fetus.
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Affiliation(s)
- E Reitman
- Department of Anesthesiology, Columbia University, New York, NY 10032, USA
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95
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96
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Jahangiri M, van Besouw JP. Pulsatile perfusion during pregnancy. Ann Thorac Surg 2011; 93:356; author reply 356-7. [PMID: 22186471 DOI: 10.1016/j.athoracsur.2011.06.059] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2011] [Revised: 05/19/2011] [Accepted: 06/14/2011] [Indexed: 11/15/2022]
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97
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Affiliation(s)
- Andrea J Carpenter
- Division of Thoracic Surgery, University of Texas Health Science Center, San Antonio, 7703 Floyd Curl Dr, MC 7841, San Antonio, TX 78229, USA.
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