Percutaneous Balloon Mitral Valvotomy During Pregnancy
Rheumatic mitral valve stenosis continues to be the most frequently encountered clinically significant valvular abnormality in pregnant women. We retrospectively studied the fetal outcomes of patients with severe rheumatic Mitral Valve Stenosis (MS) admitted to hospital with heart failure and underwent Percutaneous Balloon Mitral Valvotomy (PBMV) during pregnancy. We identified all of the pregnant cases with rheumatic MS from February 1st 1994 till February 1st 2011 who underwent PBMV from medical records in the tertiary referral center of Madani Heart Hospital in Tabriz, Iran. Follow up was done by phone call and office visit. During this period 24 pregnant patients with mean ages of 29.45±5.05 (19-38) had undergone PBMV for severe MS. Fourteen patients could not be reached and were lost to follow-up. PBMV had been performed during second trimester of pregnancy in 20 cases (83.3%) and during third trimester in 4 patients (16.6%). The success rate of PBMV was 100%. Pulmonary artery pressure reduced from 58.88±21.97 to 38.50±8.87 (p<0.05), peak and mean transmitral valve gradient reduced 25.20±9.71 to 11.03±3.61 (p<0.0001), 14.18±7.60 to 5.00±1.39 (p = 0.004), respectively. We conducted follow up in 10 patients with good fetal outcome in all except in 2 infants who died during follow up with intractable heart failure. Twenty patients were in normal sinus rhythm at the time of procedure (83.3%) and 4 of them (16.7%) had arterial fibrillation. PBMV during pregnancy could be recommended as a relatively safe procedure for mother and fetus.
Received: November 02, 2012;
Accepted: February 13, 2013;
Published: March 16, 2013
Normal pregnancy is associated with 40-50% increase in cardiac output and decrease
in systemic vascular resistance (Goldust et al.,
2012; Norrad and Salehian, 2011). The increase in
blood volume and tachycardia during pregnancy, leads to pulmonary capillary
congestion. Thus heart failure and pulmonary edema can occur, especially in
peripartum period. (Bennis et al., 2007; Goldust
et al., 2013a). The hemodynamic changes of pregnancy leads to increase
in left atrial pressure and development or worsening of symptoms including dyspnea,
decrease exercise capacity, pulmonary edema and orthopnea and paroxysmal nocturnal
dyspnea (Lotti et al., 2013; Selamet
Tierney et al., 2007). Also with high left atrial pressure, risk
of atrial fibrillation increases. Mortality of pregnant women with minimal symptoms
is less than 1% with fetal or neonatal mortality rate of 12-13% (Goldust
et al., 2013b; Mangione et al., 2007)
Therefore, women with severe mitral stenosis or NYHA Class III or IV, should
be advised against pregnancy until corrective intervention are performed. During
pregnancy medical therapy is directed toward minimizing reduction of volume
over load with bed rest and diuretic therapy (Fawzy, 2007;
Goldust et al., 2013c). Optimal heart rate control
with beta blocker, calcium channel blockers, digoxin or DC shock is recommended
in atrial fibrillation rhythm. Balloon mitral valvuloplasty is preferred for
refractory symptoms despite optimal medical therapy and is a safe and effective
option (Sakal et al., 2006). However, using it,
during pregnancy remained limited. We evaluated the results of this technique
with maternal and fetal out come during 17 years in 24 pregnant women with rheumatic
MATERIALS AND METHODS
This was a retrospective analytics study. The authors analyzed the data from
24 pregnant women whom underwent percutaneous mitral balloon valvloplasty during
seventeen years in Tabriz Shahid Madani Hospital. This study was approved by
ethic committee of Tabriz University of Medical Sciences. Written consent was
obtained from all the patients. These patients have a history of previous rheumatic
mitral stenosis. Another inclusion criterion for these patients was complete
follow-up data from procedure to at least 17 years after diagnosis. We based
our review on medical records. Data collection during of follow-up; were age
and age of pregnancy during procedure, clinical outcomes, including hemodynamic
measurements, survival rates, complications, pulmonary artery pressure, arterial
fibrillation rhythm, peak and mean trans mitral valve gradient and also mitral
valve area. Long-term follow-up information was available in 10 of the total
patient population (41.7%). We reviewed all of the pregnant cases with rheumatic
MS since 1994 till 2011, who underwent PTMC during second trimester of pregnancy
because of pulmonary edema or intractable heart failure despite optimal medical
therapy, in tertiary referral center of Madani heart university hospital, in
Tabriz , Iran. Follow up was done by phone call and clinic visit. Data are expressed
as mean values±SD or proportions. A paired t test was used to investigate
the time-dependent variables and Student t test to compare 2 groups. A p-value
<0.05 was accepted as significant. SPSS 16 software (SPSS, Chicago, Illinois)
was used for statistical analysis.
During this period 24 pregnant women who were symptomatic despite optimal medical
therapy with mean age of 29.45±5.05 (19-38), underwent PBMV in our center.
PBMV were done in 14 cases (83.3%) during second and 4 patients (16.6%) in third
trimester. The success rate of PBMV was 100% and pulmonary artery systolic pressure
reduced from 58.88±21.97 to 38.5±8.8 (p<0.05), peak and mean
transmitral valve gradient (TMVG) dropped from 25.20±9. 7 to 11.03±3.61
(p<0.0001) and 14.18±7.6 to 5.00±1.39 (p = 0.004), respectively.
Fourteen patients were lost to follow up but in 10 patients fetal outcome was
good. There were only 2 infant deaths (1.4%), because of intractable heart failure.
Also Mitral Valve Aread (MVA) increased from 0.92±0.15 (1.1, 0.6) to
1.57±0.16 (1.2, 1.8) cm2 (p<0.05). Complete data are shown
in Table 1. Mean long-term follow-up were 1 to 204 mouths.
|| Hemodynamic results before and immediately after PTMC
All children in this followed up period had uneventful development for their
respective ages and also didn't show any clinical abnormalities. Amount of Contrast
using was registered in 10 cases with mean of 59.00±20.24 cc (MAX: 100,
Mitral stenosis is a very common valvular disease in developing countries.
It is also a common valvular heart disease in pregnant women (Sivadasanpillai
et al., 2005). Physiologic increment of cardiac output during pregnancy,
especially in the middle of second trimester, with the increasing of heart rate,
leads to development or worsening of symptoms during pregnancy without intervention,
maternal mortality even for patients with NYHA functional class I and II and
in severe MS is 0-4% and significantly increases to 6-8% in those with NYHA
functional class of III and IV (Aggarwal et al.,
2005; Horstkotte et al., 2005; Weiss,
2005). The perinatal mortality is between 15-20%. All of our patients in
this study were in functional class IV despite full medical treatment so intervention
in form of PBMV or mitral valve replacement was needed. Surgery during pregnancy
carries high risk of fetal death due to hypothermia induced uterine contractions
and reduction of placental flow (Stiefelhagen, 2004).
Decrement of systolic PAP immediately after PBMV and also increment of MVA let
pregnant women carry out pregnancy without major complications for both mother
and fetus (Iung et al., 1994) on 100 pregnant
patients with severe mitral stenosis, found that PBMV is safe for mother and
fetus (Iung et al., 1994). In this study, also
hemodynamic parameters of mothers immediately improved in patients with acceptable
echocardiographic score after PBMV. However, PBMV is recommended for patients
with suitable anatomy, it is now the accepted procedure during pregnancy depending
on precise assessment of commissure morphology and clinical status of patients
(Iung et al., 1994; Subbarao
et al., 2004). The risk of fetal radiation may be minimized by shielding
of mothers abdomen and pelvis. With these precautions PBMV can be safely
performed. Shirodaria et al. (2004) reported
optimal long term results in pregnant patients who underwent PBMV during the
second trimester of pregnancy. Congenital heart disease occurs in 0.8% of newborn
infants around the world. It is responsible for many neonatal death of newborns
from mothers suffering from any type of cardiac disease with poor functional
class and left heart obstruction to flow (which restricts cardiac output and
thus flow to the placenta) and is amplified by any other obstetric risk factors.
Radiation and low cardiac output of mothers maybe the underlying causes of heart
failure in some newborns (Routray et al., 2004).
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