Emergent balloon mitral valvotomy in pregnant women presenting with refractory pulmonary edema

Abstract

Background: Mitral stenosis is the most common valvular heart lesion found in pregnancy. When severe, it leads to significant risk of mortality for both mother and fetus, since the hemodynamic adaptations to pregnancy are badly tolerated. Many pregnant women with mitral stenosis present in a critically ill condition. The role of Balloon Mitral Valvotomy (BMV) in such patients is ill-defined. Purpose: We sought to evaluate the feasibility, efficacy and safety of emergent BMV in pregnant patients with refractory pulmonary edema and to determine maternal and fetal outcome. Methods: Of 88 patients undergoing BMV during pregnancy from January 1990 to December 2011 in Cardiology A Department of Monastir Hospital, 28 women were in New York Heart Association functional class IV and underwent emergent BMV. During the procedure, radiation exposure was minimized by means of total abdominal and pelvic shielding. Results: The mothers's mean age at the time of BMV was 28.86±5.7 (range 19–43) years, and the gestation period was 30±5.1 (range 20 –39) weeks. Ten patients were primiparas. Mitral valve (MV) was assessed using the Wilkins score which averaged 7.4±1.8 (range 4 to 14). Fluoroscopy time was 7.8±1.9 minutes. The BMV procedure was successful in 25 (89.3%) patients with a dramatic improvement in patient symptoms. The mitral valve area increased from 0.8±0.2 cm2 to 2.2±0.42 cm2 (p < 0.0001). The mitral valve pressure gradient decreased from 22.2±9.3 to 5.7±4 mm Hg (p < 0.0001). The left atrial pressure decreased from 29.4±9.3 to 15.4±7.3 mm Hg (p < 0.0001). The pulmonary artery pressure decreased from 58.8±21.1 to 37.2±14.3 mm Hg (p < 0.0001). One patient developed severe mitral regurgitation and required urgent mitral valve replacement. There was no maternal mortality or significant foetal morbidity. Pregnancy was uneventful in all patients, all babies were born at full term by spontaneous vaginal delivery in 24 cases (85.7%) and by cesarian section for obstetrical reasons in 4 (14.3%), with no obvious malformations (4 of them were twin babies). None of the babies needed intensive care monitoring. The average Apgar scores at 1 min were 8.6±1. The mean birth weight was 3.1 Kilograms ranged from 1.9 to 3.8 kg. Conclusion: During pregnancy, emergent BMV is safe and feasible in patients with symptomatic mitral stenosis and severe pulmonary edema. There is marked symptomatic relief, along with excellent maternal and fetal outcomes.