Asian Cardiovasc Thorac Ann 2004;12:233-235
© 2004 Asia Publishing EXchange Ltd
Transventricular Mitral Commissurotomy in Critical Mitral Stenosis during Pregnancy
Kasturi SVK Subbarao, MCh,
Muthuraman Nachiappan, MCh,
Antao P Irineu, DNB
Department of Cardiothoracic Surgery, Jawaharlal Institute of Post Graduate Medical Education and Research, Pondicherry, India
For reprint information contact: Kasturi SVK Subbarao, MCh Tel: 91 413 227 2210 Fax: 91 413 227 2067 Email: subbarao_ksvk{at}rediffmail.com Department of Cardiothoracic Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry 605006, India
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ABSTRACT
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The management of a pregnant patient with mitral stenosis is a subject of debate with regards to the optimal type of treatment and the time of intervention. We performed trans-ventricular mitral commissurotomy (TVMC) either as an isolated procedure in the second trimester, or in combination with Cesarian section at term. We retrospectively analyzed our experience with TVMC during pregnancy and formulated a protocol for its management. Between January 1987 and April 2002, fifty one patients underwent TVMC for critical mitral stenosis during pregnancy. In 38 patients, elective TVMC was performed during the second trimester, while in 12, it was performed as an initial procedure along with Cesarian section at term. One patient had an emergency TVMC in the second trimester when she presented with intractable acute pulmonary edema. There were no maternal mortalities. Three patients who developed post-operative mitral regurgitation were managed conservatively. Another two patients who developed cerebral embolism with hemiplegia recovered completely without any neurological deficit. There was only one fetal death in a patient where TVMC was performed as an emergency procedure for acute pulmonary edema. We conclude that TVMC in pregnancy is a safe, cost effective alternative in critical mitral stenosis complicating pregnancy.
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INTRODUCTION
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Rheumatic heart disease, while on the decline in developed countries, continues to be a major health problem in the developing world.1 It is not uncommon for patients with mitral stenosis during pregnancy presenting for the first time with complications. These include acute pulmonary edema, thrombo-embolism, and congestive cardiac failure and puts the lives of both mother and fetus at risk. There are conflicting reports about the optimal management of these patients either by percutaneous interventional techniques or by open or closed cardiac surgical procedures.2,3,4 Economic concern in developing countries is also a factor in determining the most cost-effective and safe protocol for the management of these patients.
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PATIENTS AND METHODS
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Over a 15-year period between January 1987 to April 2002, fifty-one patients presenting with mitral stenosis in pregnancy underwent trans-ventricular mitral commissurotomy (TVMC). Thirty-one patients were in the third decade of life with a mean age of 25 years; 18 were in the age group of 31 to 40 years and the remaining two were more than 40 years of age (Table 1
). With regards to their parity, 5 were primigravida while the majority of 46 were multigravidas with two pregnancies in 42, three pregnancies in 3 and four pregnancies in one.
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Table 1. Clinical Profile of Pregnant Women with Mitral Stenosis Undergoing Transventricular Mitral Commissurotomy
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At presentation, 38 were in New York Heart Association (NYHA) class III, 9 in class II and 4 in class IV. Atrial fibrillation was present in 24 (47%) patients, congestive cardiac failure in 8 (15.6%) patients, and acute pulmonary edema in 1 (1.9%) patient (Table 2). While 38 patients underwent an elective TVMC in the second trimester, 12 underwent TVMC as the initial component of a combined procedure with Cesarian section at term. One patient presenting with acute pulmonary edema in the second trimester underwent an emergency TVMC (Table 3).
All the patients were initially evaluated by thorough clinical examination, electrocardiogram (ECG) and echocardiography. Chest-X-Ray was not taken for fear of radiation exposure to the fetus. All the patients had critical mitral stenosis with a valve orifice less than 0.75 cm2. Leaflets were pliable with no calcification or regurgitation. Trans-thoracic echocardiography (TEE) did not reveal the presence of thrombus. However TEE was not performed in the early part of our study. In patients with atrial fibrillation, 5000 IU heparin was injected subcutaneously, twice daily, preoperatively, for two weeks. This was the practice for all other elective TVMCs for mitral stenosis with atrial fibrillation but without left atrial thrombus. These patients were not recommended for open mitral commissurotomy for obvious reasons. Whenever there is an acute mitral regurgitation with severe hemodynamic deterioration following TVMC, we have replaced those valves with gratifying results. However, it was not required in this subset of patients.
TVMC was indicated in patients presenting with acute pulmonary edema on an emergency basis. Thrombo-embolic phenomena, congestive cardiac failure, critical stenosis and NYHA class III or IV were considered elective indications for TVMC during the second trimester of pregnancy after optimizing them by appropriate drug therapy.
Based on experience gained over the last 15 years, we have devised the following protocol for management of patients with critical mitral stenosis in pregnancy with encouraging results.
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MANAGEMENT PROTOCOL
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Two options are recommended for the first trimester:
- Medical termination of pregnancy, if it is not a "precious baby"; and elective intervention of mitral stenosis and advising pregnancy later.
- Continuation of pregnancy under intensive medical therapy into the second trimester, with semi-emergency surgical intervention, if warranted.
In the second trimester, there are two therapeutic options:
- Continuation of pregnancy under intensive medical therapy or
- Elective TVMC under cover of progesterone (long-acting) in case cardiac decompensation is anticipated during the subsequent period of pregnancy.
In the third trimester, there are also two options:
- Allowing a normal delivery in a patient with no anticipated cardiac decompensation during labour with management of the mitral stenosis electively later or
- Elective combined TVMC and Cesarian section; TVMC being the first component of such a procedure, where hemodynamic burden of mitral stenosis is going to affect the fetus and mother.
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RESULTS
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There were no perioperative maternal mortalities (Table 4). There were 3 cases of mitral regurgitation, two requiring positive pressure ventilation but they were successfully managed conservatively. Two developed cerebral thrombo-embolism with hemiplegia. They improved on medical management and are doing well on follow-up with no residual neurological deficit. Two patients went into preterm labour; one was managed successfully with tocolytics and she delivered normally at term. The second patient presenting with acute pulmonary edema resulted in preterm labour in the second trimester and fetal loss. In all 51 patients, the valve could be opened fully, commissure to commissure, with an effective orifice of about 2.5 to 3.5 cm2. Forty-five of these patients remained symptom-free at the end of 10 to 15 years. The remaining 6 returned with restenosis and are awaiting further surgery.
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DISCUSSION
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Rheumatic heart disease remains a health problem in the developing world therefore, it is not uncommon to encounter a pregnant patient with rheumatic mitral stenosis for the first time during pregnancy.1 The management of a pregnant patient with mitral stenosis is a subject of debate with regards to the optimal type of intervention; percutaneous intervention, closed heart or open heart procedures, and, with regards to the timing of the intervention.2 Economic factors also play a role when deciding the management in cash-strapped public health care services in developing countries. It is estimated that percutaneous balloon valvuloplasty would cost about INR 75,000 (US$1,596) and open mitral valvotomy, INR 90,000 (US$1,915), whereas TVMC would cost only INR 20,000 (US$426).
While balloon mitral valvotomy is associated with relatively lower trauma compared to closed or open heart procedures, its routine use is restricted in the developing world by its limited availability and the cost. The relatively limited duration of freedom from symptoms due to early restenosis, coupled with the risk of radiation hazard restricts its use in the first trimester. The major advantage of balloon mitral valvuloplasty is that it can be performed under local analgesia. However, if the patient is in acute pulmonary edema requiring ventilator support, TVMC is a better option. There is always the possibility of an emergency surgical intervention in the event of failure of the interventional procedure.3,4
The open cardiac surgical procedures in the form of either an open mitral valvotomy or mitral valve replacement are associated with a higher incidence of maternal morbidity, mortality, as well as fetal loss. A maternal mortality of up to 2.9% and fetal loss as high as 35% have been reported. Pomini et al reported a fetal loss of 12.5% in a series of 40 patients undergoing an open-heart procedure although there was no maternal mortalities.5 In our study of 51 patients, there was only a single case of fetal loss (1.96%), but no maternal death. Additionally, open heart procedures are a limited option in an economically compromised population, while closed mitral valvotomy is a relatively safe and cost effective option.6 Careful selection of patients are necessary for this procedure. All of them were evaluated by echocardiography and only patients with pliable and uncalcified leaflets were selected. The presence of mild mitral regurgitation or aortic regurgitation is not a contraindication. The presence of a thrombus is an absolute contraindication. Presently, TEE is performed to exclude thrombus both in the left atrial body and the appendage. In the earlier part of our series, the TEE was not available and some of these patients probably had soft clots and developed post-operative embolism. Those who developed cerebral embolism were treated conservatively with anti-oedema measures and recovered completely. After TEE, none of the patients developed post-operative embolism.
Prevention is important. In the presence of mitral stenosis, females contemplating pregnancy should be counseled to have the mitral stenosis managed before pregnancy. Secondly, if critical mitral stenosis is detected in the first trimester, counsel for medical termination of pregnancy is advisable. Following delivery, an advice on permanent sterilization is important.
In conclusion, TVMC is a safe and cost-effective procedure for critical mitral stenosis complicating pregnancy particularly in the regions with an increased prevalence of rheumatic heart disease with complications.
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REFERENCES
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