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Ann Thorac Surg 2002;74:243-245
© 2002 The Society of Thoracic Surgeons

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Case report

Homograft aortic root replacement during pregnancy

^a Department of Surgery, Division of Cardiothoracic Surgery, Pennsylvania Hospital, Philadelphia, Pennsylvania, USA
^b Department of Medicine, Pennsylvania Hospital, Philadelphia, Pennsylvania, USA
^c Department of Anesthesiology, Pennsylvania Hospital, Philadelphia, Pennsylvania, USA
^d Department of Obstetrics and Gynecology, Pennsylvania Hospital, Philadelphia, Pennsylvania, USA
^e Division of Pediatric Cardiology, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA

Accepted for publication December 17, 2001.

* Address reprint requests to Dr Bridges, Division of Cardiothoracic Surgery, Pennsylvania Hospital, The Farm Journal Building, 230 W Washington Square, 3rd Floor, Philadelphia, PA 19106 USA
e-mail: cbridges{at}mail.med.upenn.edu

	Abstract

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Operative cardiac interventions have been performed on pregnant women with varying degrees of success since the late 1950s. Currently, reported maternal mortality for cardiac operations is similar to the mortality rate for nonpregnant female patients. However, fetal mortality remains high, at approximately 20%. Aortic root replacement with an aortic homograft in a 34-year-old pregnant woman with bacterial endocarditis at 18 weeks gestation is presented. Fetal echocardiography during and after bypass was employed.

	Introduction

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Valve replacement for the aortic valve during pregnancy presents unique challenges to the surgeon. The fetal mortality risk from cardiopulmonary bypass is significant. Fetal mortality and the risk of congenital malformations are highest when cardiac surgery is performed during the first two trimesters. Balancing the relative risks and benefits of surgical therapy to both patients requires complex decision making and informed maternal input. Valve selection and fetal management during operation both require careful consideration.

A 34-year-old female Vietnamese immigrant, gravida 4, para 2, at 18 weeks gestation, presented to Pennsylvania Hospital with complaints of recurrent fevers for 1 month associated with chills, myalgias, and shortness of breath. Ultrasound revealed the fetus was at 18 weeks gestation. The patient also described two brief episodes of right lower quadrant visual field defects that resolved spontaneously. On examination, her temperature was 101.2°F; she had a grade 3/6 decrescendo diastolic murmur at the right upper sternal border and a grade 2/6 systolic rumble at the apex without jugular venous distension or peripheral edema. Six out of six blood cultures were positive for -hemolytic Streptococcus. Therapy was initiated with intravenous ceftriaxone, 2 g every 24 hours. All subsequent blood cultures were negative. Transesophageal echocardiography revealed a 1.5-cm vegetation on the noncoronary cusp of the aortic valve with severe aortic insufficiency and normal left ventricular function. A purified protein derivative and a panorex image of her teeth were both negative. A magnetic resonance imaging scan of the head revealed a Chiari I malformation without evidence of embolic phenomena. Aortic valve replacement was recommended. The patient was counseled on the perioperative and postoperative risks to herself, her pregnancy, and the fetus. After careful consideration, she elected to maintain her pregnancy through the operation.

The patient was placed in a supine position, and the table was rotated to the left to minimize perturbation of placental blood flow by left uterine displacement. Anesthesia was induced and maintained with isoflurane, vecuronium, pancuronium, and fentanyl. Continuous intraoperative fetal echocardiography was performed. Before initiation of cardiopulmonary bypass (CPB), fetal heart motion was normal, with a heart rate of 140. The patient was started on CPB, and her temperature was allowed to lower gradually to 34°C. High-potassium blood cardioplegia was administered retrograde and directly through the coronary ostia. No change in fetal heart motion or heart rate was noted. Cardioplegia was maintained with intermittent doses (approximately 300 mL) of blood cardioplegia every 20 to 30 minutes during the aortic cross-clamp interval. Mean arterial pressure was maintained at 80 to 90 mm Hg during bypass. Blood flow ranged from 4.7 to 6.1 L/min. The aortic root was measured and successfully replaced with a 21-mm homograft. The fetal heart motions remained normal for the duration of CPB, and the fetal heart rate remained stable at 110 to 130 bpm until just before the patient was weaned from CPB. A fetal echocardiogram during CPB is shown in Figure 1.

View larger version (164K): [in this window] [in a new window]   Fig 1. Fetal echocardiogram, four-chamber view, demonstrating normal offset of the fetal atrioventricular valves and visible moderator band (MB) within the body of the right ventricular (RV) cavity. The left ventricle (LV), right atrium (RA), and left atrium (LA) are shown as well.

	Comment

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We have not seen any other cases reported of homograft aortic root replacement during pregnancy or of the use of fetal echocardiography during CPB. In a recent review of 69 cases of CPB during pregnancy, maternal and fetal mortality were 2.9% and 20.2%, respectively. The last 40 of these 69 cases had a reported maternal mortality of 0% and a fetal mortality of 12.5% [1]. Thus, the overall risk of CPB has recently shifted mostly to the fetus. Despite the limited experimental data regarding the effect of CPB on uterine/placental blood flow and its effect on the fetus, it has been postulated that pulsatile, high-flow, high-pressure, normothermic bypass poses the least risk to the fetus [2–4]. Clinical data suggest that the increased uterine contractions coupled with the relative hypotension experienced during CPB result in decreased perfusion to the fetus, with subsequent fetal bradycardia. Fetal bradycardia has been shown to resolve in response to increasing maternal blood flow [1, 3]. The use of dopamine and -adrenergic agents does not appear to have negative effects on fetal outcome [1].

Parry and Westaby [3] recommend waiting until the 28th week of gestation to perform cardiac surgery if possible, because cesarean section can be performed before surgery and there is increased likelihood of fetal survival in the event of postoperative spontaneous abortion. Our patient required an aortic valve replacement at 18 weeks gestation because of severe aortic insufficiency complicated by two episodes of presumed embolic phenomena manifested as transient visual field defects.

Pregnancy has not been shown to increase the rate of valve loss with the use of mechanical or bioprosthetic valves or homografts [5]. However, it has been shown that young women with cardiac valve replacements have a greater 10-year survival with the use of homografts (96%) as compared with mechanical (70%) or bioprosthetic (84%) valves [5]. The risk of valve loss at 10 years with the use of bioprosthetic valves (82%) was significantly higher than with the use of mechanical valves (29%) or homografts (28%) [5]. Thromboembolic complications affected 45% of the patients with mechanical valves, compared with only 13% of the patients with bioprosthetic valves. Thus the risk/benefit analysis in our patient favored the use of an aortic homograft.

In conclusion, there is no standard protocol for the use of CPB in cardiac surgery during pregnancy. A careful review of the literature allowed us to devise a plan for homograft aortic root replacement with the use of high-pressure, high-flow, and normothermic bypass with a favorable maternal and fetal outcome. We found fetal echocardiography to be a convenient and reliable means of monitoring fetal homeostasis during bypass.

	References

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1. Pomini F., Mercogliano D., Cavalletti C., Caruso A., Pomini P. Cardiopulmonary bypass in pregnancy. Ann Thorac Surg 1996;61:259-268.[Abstract/Free Full Text]
2. Mahli A., Izdes S., Coskun D. Cardiac operations during pregnancy: review of factors influencing fetal outcome. Ann Thorac Surg 2000;69:1622-1626.[Abstract/Free Full Text]
3. Parry A.J., Westaby S. Cardiopulmonary bypass during pregnancy. Ann Thorac Surg 1996;61:1865-1869.[Abstract/Free Full Text]
4. Westaby S., Parry A.J., Forfar J.C. Reoperation for prosthetic valve endocarditis in the third trimester of pregnancy. Ann Thorac Surg 1992;53:263-265.[Abstract/Free Full Text]
5. North R.A., Sadler L., Stewart A.W., McCowan L.M.E., Kerr A.R., White H.D. Long-term survival and valve-related complications in young women with cardiac valve replacements. Circulation 1999;99:2669-2676.[Abstract/Free Full Text]

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Joseph E. Bavaria Charles R. Bridges Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Gopal, K. Articles by Bridges, C. R. Search for Related Content PubMed PubMed Citation Articles by Gopal, K. Articles by Bridges, C. R. Related Collections Valve disease