From the Guidelines
The best recommendation for this patient is percutaneous balloon mitral valvuloplasty before attempting pregnancy. This 31-year-old woman has mitral stenosis, likely rheumatic in origin given her emigration from Brazil where rheumatic heart disease is more prevalent. Her echocardiogram shows a significantly reduced mitral valve area of 1.2 cm2 (normal is 4-6 cm2) with minimal leaflet thickening and calcification, making her an ideal candidate for balloon valvuloplasty. Pregnancy creates a significant hemodynamic burden with increased blood volume and cardiac output, which would worsen her already symptomatic mitral stenosis (evidenced by her shortness of breath on moderate exertion).
Key Considerations
- Balloon valvuloplasty is preferred over medical management because it can substantially improve valve function before pregnancy, reducing maternal and fetal risks.
- The procedure involves inserting a balloon catheter across the stenotic mitral valve and inflating it to separate the fused commissures, thereby increasing the valve area.
- This intervention is particularly appropriate given her favorable valve morphology with minimal thickening and calcification.
- Addressing her mitral stenosis before conception is crucial as the hemodynamic changes of pregnancy could lead to heart failure, pulmonary edema, arrhythmias, and poor fetal outcomes if left untreated, as supported by the guidelines from the American College of Cardiology/American Heart Association task force on practice guidelines 1.
Recommendations
- Percutaneous balloon mitral valvuloplasty is the recommended intervention before pregnancy for patients with severe mitral stenosis (mitral valve area ≤1.5 cm2) and favorable valve morphology, as stated in the guidelines 1.
- The patient should be counseled by a cardiologist with expertise in managing patients with valvular heart disease during pregnancy, as recommended by the guidelines 1.
- The patient should be monitored in a tertiary care center with a dedicated Heart Valve Team of cardiologists, surgeons, anesthesiologists, and obstetricians who have expertise in managing high-risk cardiac patients, as recommended by the guidelines 1.
From the Research
Patient Assessment
- The patient is a 31-year-old nulligravida woman with a sedentary lifestyle, experiencing shortness of breath on moderate exertion.
- She has a murmur and her transthoracic echocardiogram reveals mitral leaflet restriction with an estimated mitral valve area of 1.2 cm2.
- The patient's mitral leaflets and subvalvular apparatus are not significantly thickened, and there is minimal calcification with minimal mitral regurgitation.
Treatment Options
- Percutaneous balloon mitral commissurotomy (PMC) is a recommended treatment for patients with severe mitral stenosis, especially those with favorable valve anatomy 2, 3, 4, 5, 6.
- The patient's valve anatomy, with minimal thickening and calcification, makes her a suitable candidate for PMC.
- PMC has been shown to improve hemodynamics and symptoms in patients with severe mitral stenosis, including those who are pregnant 2.
Considerations for Pregnancy
- The patient is planning to become pregnant soon, and PMC can be performed safely during pregnancy 2.
- The procedure can improve symptoms and hemodynamics, reducing the risk of complications during pregnancy.
- The patient's current symptoms and valve anatomy suggest that PMC may be necessary to improve her condition before becoming pregnant.
Recommendations
- Based on the patient's symptoms, valve anatomy, and plans for pregnancy, PMC is a recommended treatment option.
- The procedure should be performed by an experienced operator, and the patient should be closely monitored for any complications.
- The patient's condition and symptoms should be reassessed after the procedure to determine the best course of action for her pregnancy 3, 4, 5, 6.