Double Valve Replacement in the Pregnant Patient: A Successful Case and Brief Literature Review

Cardiovascular disease is the leading cause of maternal mortality accounting for >25% of maternal deaths. The risk of cardiac surgery is very high with poor neonatal outcomes. The authors would like to report a patient who was a 19 year old lady with 27 weeks gestation who had severe mitral stenosis (mitral valve area-0.9cm2, pulmonary artery systolic pressure (PaSP-90mm Hg)), moderate mitral regurgitation, moderate aortic stenosis with severe aortic regurgitation, (modified world health organization class (m WHO) class IV) who successfully underwent double valve replacement under cardiopulmonary bypass (CPB) and went on to deliver a healthy but premature male baby. Cardiac surgery especially cardiopulmonary bypass is high risk procedure when needed to be performed must be done in second trimester of prgnancy. The authors have divided the discussion into 4 parts for ease of discussion i.e Anesthetic, surgical, intensivist and perfusion related considerations. Anesthetic considerations included maintaining uteroplacental perfusion, higher cardiac index other considerations of pregnancy including low systemic vascular resistance, difficult airway, lateral tilt. Surgical considerations include minimizing cross clamp and bypass time to avoid fetal complications. Post operatively intensivist considerations include hemodynamic monitoring with regular point of care ultrasound (POCUS) for fluid management. Vasopressor and fluid management in our case was tailored to the Flo Trac (cardiac output) monitoring system and POCUS assessments. The patient had a successful outcome however delivered a premature baby at 33 weeks gestation. The incidence of premature delivery is about 50% as per literature review. The literature around cardiac bypass in pregnancy is limited and we hope that our case adds to further research on this topic.