VALVULAR
HEART DISEASE
Effectiveness of Percutaneous Balloon Mitral Valvotomy During Pregnancy Cesar A. Esteves, MD, Auristela I. 0. Ramos, MD, Sergio L. N. Braga, MD, J. Kevin Harrison, MD, and J. Eduardo M. R. Sousa, MD
During pregnancy, medically refractory congestive heart failure due to mitral stenosis continues to present a clinical challenge and optimal management remains controversial. Thirteen women underwent balloon mitral valvotomy for control of functional class Ill or IV congestive heart failure due to mitral stenosis during pregnancy. The mean gestational age at the time of valvotomy was 25 f 6 weeks. Percutaneous balloon mitral valvotomy was performed successfully in all patients. No maternal or fetal mortality occurred. The mean mitral valve area assessed by Doppler echocardiography increased from 0.9 f 0.3 cm* before to 2.1 f 0.3 cm* after valvotomy. The mean mitral valve gradient decreased from 20 f 7 to 4 f 2 mm Hg. This was associated with a decrease in the pulmonary artery systolic pressure from 62 f 24 to 32 f 14 mm Hg. Currently, 12 of the 13 patients have delivered at an average gestational age of 38 f 0.5 weeks. Symptoms of congestive heart failure improved in all women and all were in New York Heart Association functional class I at the time of delivery. One patient is still pregnant and symptom free. Ekven singlet pregnancies resulted in the birth of full-term, healthy infants (mean birth weight 3.2 kg). The woman carrying a twin pregnancy improved from New York Heart Association class IV to class I after balloon mitral valvotomy but delivered prematurely at 32 weeks. The premature twin infants weighed 1.0 and 1.5 kg and died from respiratory failure at 46 hours. Percutaneous balloon mitral valvotomy can be performed safely during pregnancy and is effective in relieving symptoms of severe congestive heart failure. Balloon mitral valvotomy offers an effective alternative for the pregnant patient with severe mitral stenosis when congestive heart failure is not controlled by conventional From the Division of Valvular Heart Disease and Hemodynamic Laboratory, Dante Pazzanese Institute of Cardiology, Sao Paula, Brazil, and the Department of Medicine, Division of Cardiology, Duke University Medical Center, Durham, North Carolina. Address for reprints: Cesar A. Esteves, MD, Instituto Dante Pazzanese de Cardiologia, P.O. Box 215, Sao Paula, 04012 Brazil. 930
THE AMERICAN
JOURNAL
OF CARDIOLOGY
VOLUME
68
medical treatment. The risk to the fetus appears lower than previous reports of surgical commissurotomy performed during pregnancy. (AmJCardid 1991;6&930-934)
heumatic mitral valve stenosis is the most common form of organic heart disease encountered during pregnancy, and continues to cause maternal and fetal mortality. 1,2The optimal management of women with medically refractory congestive heart failure due to mitral stenosis remains controversial.3 Surgical treatment has been required when medical treatment fails to control symptoms of congestive heart failure in pregnant women with severe mitral stenosis. Closed or open surgical commissurotomy, however, carries a significant risk of fetal death.4-11 Balloon mitral valvotomy has been shown to result in excellent immediate hemodynamic improvement in selected patients with mitral stenosis.12-l4 Case reports suggest that percutaneous balloon mitral valvotomy may offer effective treatment for severe mitral stenosis during pregnancy, with less risk of fetal death than surgical commissurotomy. ls,16 However, the data on balloon mitral valvotomy performed during pregnancy are limited.” The purpose of this study was to prospectively examine the hemodynamic results and clinical outcome of pregnant women undergoing percutaneous balloon mitral valvotomy for treatment of New York Heart Association class III or IV congestive heart failure secondary to severe mitral stenosis.
R
METHODS Patient group (Table I): Between August 1989 and
July 1990, a consecutive series of 13 pregnant women (Mean age 26 f 7 years [range 16 to 4.51) underwent percutaneous balloon mitral valvotomy for treatment of rheumatic mitral stenosis at the Dante Pazzanese Institute of Cardiology. Six patients had class IV and 7 had New York Heart Association functional class III symptoms of congestive heart failure not controlled by bedrest, diuretics and p blockers. All were in sinus rhythm. Twelve patients had single pregnancies and 1 patient was carrying twins. During this time interval, no pregnant patients underwent mitral valve surgery. OCTOBER
1. 1991
TABLE
I Hemodynamic
and Doppler
Results of Balloon
MVA km*) Pt. No. 1 2 3 4 5 6 7 8 9 10 11 12
13 Mean f SD
Mitral
Valvotomy
MMVG (mm Hg)
PASP (mm Hg)
Before BMV
After BMV
Before BMV
After BMV
0.8 0.5 1.1 1.1 1.0 1.4 1.0 1.3 0.9 0.5 1.0 0.4 0.8
2.3 2.4 2.4 1.9 2.3 1.8 2.2 2.5 2.4 1.8 1.7 1.7 1.9
18 24 20 30 26 7 21 18 17 26 14 28 16
4 8 2 5 5 2 1 4 3 3 1 4 9
0.9 2 0.3 (p
HEART DISEASE
Effectiveness of Percutaneous Balloon Mitral Valvotomy During Pregnancy Cesar A. Esteves, MD, Auristela I. 0. Ramos, MD, Sergio L. N. Braga, MD, J. Kevin Harrison, MD, and J. Eduardo M. R. Sousa, MD
During pregnancy, medically refractory congestive heart failure due to mitral stenosis continues to present a clinical challenge and optimal management remains controversial. Thirteen women underwent balloon mitral valvotomy for control of functional class Ill or IV congestive heart failure due to mitral stenosis during pregnancy. The mean gestational age at the time of valvotomy was 25 f 6 weeks. Percutaneous balloon mitral valvotomy was performed successfully in all patients. No maternal or fetal mortality occurred. The mean mitral valve area assessed by Doppler echocardiography increased from 0.9 f 0.3 cm* before to 2.1 f 0.3 cm* after valvotomy. The mean mitral valve gradient decreased from 20 f 7 to 4 f 2 mm Hg. This was associated with a decrease in the pulmonary artery systolic pressure from 62 f 24 to 32 f 14 mm Hg. Currently, 12 of the 13 patients have delivered at an average gestational age of 38 f 0.5 weeks. Symptoms of congestive heart failure improved in all women and all were in New York Heart Association functional class I at the time of delivery. One patient is still pregnant and symptom free. Ekven singlet pregnancies resulted in the birth of full-term, healthy infants (mean birth weight 3.2 kg). The woman carrying a twin pregnancy improved from New York Heart Association class IV to class I after balloon mitral valvotomy but delivered prematurely at 32 weeks. The premature twin infants weighed 1.0 and 1.5 kg and died from respiratory failure at 46 hours. Percutaneous balloon mitral valvotomy can be performed safely during pregnancy and is effective in relieving symptoms of severe congestive heart failure. Balloon mitral valvotomy offers an effective alternative for the pregnant patient with severe mitral stenosis when congestive heart failure is not controlled by conventional From the Division of Valvular Heart Disease and Hemodynamic Laboratory, Dante Pazzanese Institute of Cardiology, Sao Paula, Brazil, and the Department of Medicine, Division of Cardiology, Duke University Medical Center, Durham, North Carolina. Address for reprints: Cesar A. Esteves, MD, Instituto Dante Pazzanese de Cardiologia, P.O. Box 215, Sao Paula, 04012 Brazil. 930
THE AMERICAN
JOURNAL
OF CARDIOLOGY
VOLUME
68
medical treatment. The risk to the fetus appears lower than previous reports of surgical commissurotomy performed during pregnancy. (AmJCardid 1991;6&930-934)
heumatic mitral valve stenosis is the most common form of organic heart disease encountered during pregnancy, and continues to cause maternal and fetal mortality. 1,2The optimal management of women with medically refractory congestive heart failure due to mitral stenosis remains controversial.3 Surgical treatment has been required when medical treatment fails to control symptoms of congestive heart failure in pregnant women with severe mitral stenosis. Closed or open surgical commissurotomy, however, carries a significant risk of fetal death.4-11 Balloon mitral valvotomy has been shown to result in excellent immediate hemodynamic improvement in selected patients with mitral stenosis.12-l4 Case reports suggest that percutaneous balloon mitral valvotomy may offer effective treatment for severe mitral stenosis during pregnancy, with less risk of fetal death than surgical commissurotomy. ls,16 However, the data on balloon mitral valvotomy performed during pregnancy are limited.” The purpose of this study was to prospectively examine the hemodynamic results and clinical outcome of pregnant women undergoing percutaneous balloon mitral valvotomy for treatment of New York Heart Association class III or IV congestive heart failure secondary to severe mitral stenosis.
R
METHODS Patient group (Table I): Between August 1989 and
July 1990, a consecutive series of 13 pregnant women (Mean age 26 f 7 years [range 16 to 4.51) underwent percutaneous balloon mitral valvotomy for treatment of rheumatic mitral stenosis at the Dante Pazzanese Institute of Cardiology. Six patients had class IV and 7 had New York Heart Association functional class III symptoms of congestive heart failure not controlled by bedrest, diuretics and p blockers. All were in sinus rhythm. Twelve patients had single pregnancies and 1 patient was carrying twins. During this time interval, no pregnant patients underwent mitral valve surgery. OCTOBER
1. 1991
TABLE
I Hemodynamic
and Doppler
Results of Balloon
MVA km*) Pt. No. 1 2 3 4 5 6 7 8 9 10 11 12
13 Mean f SD
Mitral
Valvotomy
MMVG (mm Hg)
PASP (mm Hg)
Before BMV
After BMV
Before BMV
After BMV
0.8 0.5 1.1 1.1 1.0 1.4 1.0 1.3 0.9 0.5 1.0 0.4 0.8
2.3 2.4 2.4 1.9 2.3 1.8 2.2 2.5 2.4 1.8 1.7 1.7 1.9
18 24 20 30 26 7 21 18 17 26 14 28 16
4 8 2 5 5 2 1 4 3 3 1 4 9
0.9 2 0.3 (p
