Poor Outcome of Surgical Management of Acute Malfunctioning Mechanical Mitral Valve During Pregnancy. Should Centers with Limited Resources Find Different Options?

Abstract

Background: Rheumatic heart disease (RHD) is the most common cardiac disease in pregnancy in developing countries with the mitral valve being the most affected. In this study, the results of surgical intervention in pregnant women presented with acute malfunctioning mechanical mitral valve were discussed.

Methods: All patients underwent emergency redo mitral valve replacement due to acute malfunctioning mechanical mitral valve during pregnancy in a single center between January 2005 and December 2017. These patients were retrospectively analyzed. Additionally, anticoagulation strategy before the event and outcomes for the mother and the fetus were outlined.

Results: Between 2005 and 2017, 16 pregnant women arrived in a single tertiary center with acute malfunctioning mechanical mitral valves. The mean gestational age at the time of presentation was 13.19 ± 2.6 weeks. Fifteen out of the 16 patients changed their anticoagulation regimen either with or without medical advice. After replacing the valve, cardiopulmonary bypass successfully was weaned in 12 patients, who were transferred to the ICU sedated and ventilated with variable doses of chemical Inotropes. The remaining 4 patients died on the table after failure of weaning from bypass. In one case, the patient developed immediate postoperative stroke with the Glasgow Coma Scale (GCS) of 7, CT brain revealed massive infarction, her fetus was not viable, she remained sedated and ventilated, and she passed away on post-operative Day 12, due to pneumonia and sepsis. Another patient, with a viable fetus, passed away on post-operative Day 1, due to low cardiac output.

Conclusion: Acute malfunctioning MHV during pregnancy represents a real dilemma to patients and caregivers. It carries high fetal and maternal morbidity and mortality, especially in centers with limited resources. We believe that an alternative plane must be formulated for such patients to avoid devastating complications, including maternal and fetal deaths.