Transcatheter Aortic Valve Implantation During Pregnancy
Presenter
Pavan Thaneeru, MBBS, Christchurch Hospital and Canterbury DHB, Dunedin, New Zealand
Pavan Thaneeru, MBBS1, David Smyth2, Philip Adamson2 and James Blake2, (1)Christchurch Hospital and Canterbury DHB, Dunedin, New Zealand, (2)Christchurch Hospital and Canterbury DHB, Christchurch, New Zealand
Title:
Transcatheter Aortic Valve Implantation During Pregnancy
Introduction:
Severe symptomatic aortic stenosis (AS) during pregnancy is a high-risk condition for both the mother and foetus. A 37-year-old secundigravida woman presented with symptomatic (NYHA class II) severe AS at 14 weeks of gestation. Echocardiography demonstrated normal left ventricular systolic function and a congenital bicuspid aortic valve with mean gradient of 64.5 mmHg and valve area of 0.55 cm2. The maximal diameter of the ascending aorta was 3.9 cm.
Clinical Case:
Following heart team evaluation, valve intervention was recommended. Surgical aortic valve replacement, balloon aortic valvuloplasty (BAV), and transcatheter aortic valve implantation (TAVI) were considered. Estimated risks of surgery included a 30% risk of foetal demise and 2.9% maternal mortality. The post-BAV outcome was considered unpredictable and risk of severe aortic regurgitation. In contrast, TAVI offered a high likelihood of success and low probability of short-term complications. To minimise ionising radiation exposure, pre-procedural planning was guided by contrast-enhanced computed tomography angiography that was limited to the aortic annulus. Ultrasound was used for transfemoral access, fluoroscope imaging was avoided below the diaphragm, and cineangiography was not used. Direct left ventricular pacing was used to minimise radiation exposure. A 23 mm Edwards Sapien 3 ultra-valve was successfully implanted under conscious sedation. The patient had radiation exposure of 10.5 mGy and 52 ml of contrast was used. Post-procedure, the patient felt better clinically. An echocardiogram showed acceptable prosthetic valve function without paravalvar regurgitation. Foetal monitoring did not reveal evidence of distress.
Discussion:
This case highlights the numbers of measures undertaken to minimise the radiation exposure in a pregnant patient. The case emphasis the importance of the heart team approach to manage a complex case.