COMMUNICATIONS TO THE EDITOR Clinical Case Reports Letters to the Editor will be and
as
published,
if suitable,
space permits. They should not exceed 1,000 words (double in length, and may be subject to editing or abridgment.
spaced)
Open Heart Surgery During
CASE REPORT
Pregnancy—Case Report
I.M. is a 32 year old woman who was admitted to Beilinson Hospital on Jan. 28th, 1974, because of’ severe pulmonary edema due to mitral restenosis in her 7th month of pregnancy. Three previous pregnancies terminated in spontaneous delivery of healthy babies and in a further one, therapeutic abortion was done because of’ heart failure. The patient suffered rheumatic fever at the age of 10 years. Following that, mitral stenosis was diagnosed and she became symptomatic and at the age of 14 she underwent closed mitral commissurotomy in another hospital. Her condition improved after the operation and she did well on limited activities. At the age of 21 she suffered another bout of rheumatic fever. During her 3rd pregnancy in 1968 she required digitalis and diuretics because of initial heart failure. At that time, mitral restenosis was first noted. Under close medical supervision this pregnancy ended by a spontaneous delivery of a normal baby. In 1970, a therapeutic abortion was performed in the third month of pregnancy. In 1973 she became again pregnant and this time she refused interruption. On January 28, 1974, she was admitted to the Intensive Care Unit of the Medical Department because of severe dyspnoea. On physical examination the patient was found to be in her seventh month of pregnancy. The blood pressure was 110/80, a pulse regular of 120/minute, and respiration 30 per minute. Slight rales were present over both lung bases. A grade 5/6 diastolic rumble was heard at the apex and a right ventricular heave was felt across the pericardium. The first heart sound was accentuated at the apex and the second sound was maximal in
J. SALOMON, M.D., R. YORTNER, M.D. MORRIS J. LEVY, M.D., F.I.C.A.
Brock1, Cooley and Chapman3, Logan and Turners and Mason were the first to report on surgical treatment of’ mitral stenosis during pregnancy. During the following years increasing number of patients who under-
commissurotomy during pregnancy reported utilising the closed method’°. Open heart surgery is at present more frequently utilized to help pregnant patients went were
in acute heart failure in which an immediate threat to the patient’s life is evident. The literature up to 1968 summerises about 30 cases of heart disease operated upon with the
open-heart technique during pregnancy. Most notable was the high fetal mortality (around 30%)&dquo;. Following operation, only 13 pregnant patients undergoing successful surgery involving cardiopulmonary bypass resulted in delivery of’ normal infants9. In 1969, Zitnik 12 reported another series of 21 cases treated during pregnancy by several surgeons who had all been in contact with the author. In his group one mother and seven children died (mortality rates of 5% and 33%, respec-
tively). An additional
case
of
a
7th month preg-
patient was operated upon urgently utilising the open-heart technique because of intractable pulmonary edema due to mitral restenosis, and this consists the basis for this nant
report. Thoracic-Cardiovascular Surgery Department, Beilinson Hospital. University of Tel-Aviv Medical School, Israel.
257
Downloaded from ves.sagepub.com at Purdue University on May 25, 2015
258 the second left intercostal space. An opening snap was heard as well i.e. all the clinical signs pointed to the diagnosis of severe mitral restenosis. Laboratory-studies: Hemoglobin 11.0 gm%, W.B.C. 8000, Urea 20 mgm%, Glucose 110 mgm%, blood electrolytes were within normal limits, prothrombin time was 90% of the normal, fibrinogen 390 mgm%, urine normal. E.C.G. showed sinus thythm, right axis deviation 60°, R.B.B.B., hypertrophy and strain on the right ventricle. Aggressive medical treatment including I.V. diuretics (up to 1.0 g of Lasix LV.) did not improve her condition. On the contrary she went soon into severe pulmonary edema which was refractory to medical treatment. At that point, after being 6 hours in pulmonary edema the patient was taken for emergency operation. The heart was exposed through a sternal
split thoracotomy. Cardiopulmonary bypass was
instituted and the left atrium
was ex-
if the &dquo;protective&dquo; influence of’ a decreased cardiac output that often is encountered in patients with mitral stenosis of any consequence is overruled by the general influence of pregnancy which tends to increase the cardiac output. Thus, the relative increase of cardiac output during pregnancy in mitral stenosis may be even larger than what is seen in the normal woman. This, in return may sometimes lead to a marked increase of pressures in the pulmonary circulation which in conjunction with the tendency to decreased pulmonary vascular resistance, increased basal heart rate, and dilutional anemia, markedly increases the risk of pulmonary edema in early pregnancy even with only moderate or mild stenosis. Such cases are mostly refractory to proper medical treatment and urgent surgical intervention to relieve the valvular obstruction may be inevitable. The common procedure has been mitral commissurotomy by the closed heart seems as
posed. The mitral valve orifice was found technique. Bader, Bader, Rose and Braunwald2 reseverely stenotic 8-10 mm in diameter and The leaflets were competent. moderately ported that the peripheral resistance is dethickened free of calcium deposit and with creased throughout pregnancy and reaches normal chordae. Both commissures were in- normal levels only at term, total oxygen cised widely allowing an orifice of about two consumption is progressively increased fingers. The valve remained competent. The throughout pregnancy and measures approxbypass time lasted 23 minutes during which imately 10 percent above normal at term and time a mean arterial pressure maintained at about 60 mmHg (average) and a mean systemic flow of 2800 cc/min. The patient’s postoperative course was uneventful. The pulmonary edema disappeared with the institution of the cardiac pulmonary bypass and did not return during the postoperative period. Two months later she delivered a normal female baby weighing 3Kg without any complications. Both mother and daughter at present, one year after operation, are well. DISCUSSION
Mitral stenosis is the commonest cause of heart failure in rheumatic heart disease during pregnancy. Patients with mitral stenosis who become pregnant, experience similar hemodynamic changes as normal women. It
the arteriovenous oxygen difference is decreased during the fourteenth to thirtieth weeks. The cardiac output is increased with peaks of 40 percent greater than normal during the twenty-fifth to twenty-seventh weeks of gestation, and then returns to normal at the thirty-sixth to fortieth weeks. Naturally pregnancy in patients with significant mitral stenosis adds further burden on an already overloaded circulatory system. All those hemodynamic changes in pregnancy lead to an increase load on the left atrium in mitral stenosis, explaining the high incidence of atrial arrhythmias, especially atrial fibrillation occurring during pregnancy. The sudden occurrence of’ atrial fibrillation may lead to marked increase in heart rate, decrease in ventricular diastolic filling time, sudden and marked increase in
Downloaded from ves.sagepub.com at Purdue University on May 25, 2015
259
pulmonary blood volume and pressure leading to a severe, life-threatening attack of pulmonary edema. Thus, elective surgery performed before pregnancy is to be prefered, even though surgery during pregnancy is quite feasible and may be life-saving. In a review of surgical treatment of rheumatic heart disease during pregnancy, Harken and Taylors in 1961 collected 394 cases.
The maternal
mortality
was
1.8%
(seven cases) and the fetal mortality 9% (35 cases). Ueland&dquo; four years later reported on an additional 120 pregnant women with a similar mortality (maternal 1.7%, fetal 7.5%). Only severely disabled patients in functional classes III and IV (NYHA) were subjected to closed commissurotomy. Ueland came to the conclusion that the overall results among patients treated surgically have been better than those treated medically, both for mother and child. He reported the maternal mortality in comparable medically treated series to be 4.2%-18.7% and a fetal mortality as high as 50% which he accounted in more recent material to be as a neglect on the part of the physician or patient as well. The low surgical mortality in these rather large series of patients are presumably attributable to two factors: 1) The young age of the patients, and 2) the presence of good myocardial function in a patient population that experiences clinical deterioration due to an abnormally high circulatory load. The favorable outcome of the pregnancy for both mother and child signifies clear-cut improvement in cardiac performance following sur-
gical
treatment.
The first open-heart surgical procedure was reported by Leysel, who corrected a congenital aortic stenosis during the 12th week of’ pregnancy. The by-pass lasted 20 minutes and the child exhibited multiple congenital defects when born at term. Since then the reported cases accumulated to over 50. Even though it is possible to
perform open-heart surgery during pregacceptable mortality for the mother, most surgeons prefer to do it as an elective procedure at a time when the patient
nancy with
is not pregnant. In most of the cases reported in the past, surgery was done early in pregnancy before the 12th week. Some authors like Condarsson and Werkol are in the opinion that the use of open-heart surgery in those greatly incapacitated women is a good alternative to therapeutic abortion, because even though the fetal mortality was rather high, only one child in their series was born
with congenital defects. On the other hand it is well known that internal organs in the fetus are formed by the eighth week of pregnancy and changes after this are the result of growth and development and so it may be wise to avoid surgery during this early developmental period if pregnancy is known to exist. It should be also stressed that an adequate perfusion with oxygenator and short perfusion times are mandatory to keep the placental perfusion optimal if the operation is performed in advanced pregnancy. SUMMARY
A case of 32-old woman in her 7th month of pregnancy presented with intractable pulmonary edema due to mitral restenosis is reported. Open-heart mitral commissurotomy was done as an emergency procedure. She continued pregnancy to term after the operation and delivered a healthy female
baby. The literature related to &dquo;the closed&dquo; and heart surgery during pregnancy has been reviewed. MORRIS J. LEVY, M.D., F.I.C.A. Beilinson Hospital Petah Tiqva, Israel
&dquo;open&dquo;
REFERENCES 1. Brock R. C.: 2.
Valvulotomy in pregnancy. Proc. Roy. Soc. Med. 45: 538, 1952 Bader R. A., Bader M. E., Rose D. J., and Braunwald D.: Hemodynamics at rest and during exercise in normal pregnancy as studied by cardiac catheterization. J. Clin. Invest. 34: 1524, 1955.
3.
Cooley D. A., Chapman D. W.: Mitral commissurotomy during pregnancy. J.A.M.A.
150: 1113, 1952. 4. Conradsson T. B., Werkö L.: Managemant of heart disease in pregnancy. Progress in Cardiovascular Diseases 16: 407, 1974
Downloaded from ves.sagepub.com at Purdue University on May 25, 2015
260 5. Harken D. E., Taylor W. J.: Cardiac surgery during pregnancy. Clin. Obstet. Gynecol. 4:
697, 1961 6. 7.
Logan A., Turner R. W. D.: Mitral valvulotomy in pregnancy, Lancet 1: 1286, 1952 Leyse R., Ofstun M., Dillard D. H. et al: Congenital aorticstenosis in pregnancy, corrected by extracorporeal circulation.
J.A.M.A. 176: 1009, 1961 8. Mason J. : In discussion of Stabler F. E., Szekely P. J. Obstet. Gynaecol, Brit. Emp., 59: 569, 1952.
9. Meffert W. G., Stansel H. C. Jr.: Open heart surgery during pregnancy. Am. J. Obstet. Gynecol. 102: 1116, 1968. 10. Neri A., Gans B., Salomon J.: Mitral commissurotomy in pregnancy J. Israel Med. Assoc. 70: 310, 1966 11. Ueland K.: Cardiac surgery and pregnancy. Am. J. Obstet. Gvnecol. 92: 148, 1965 12. Zitnik R. S., Brandenburg R. O., Sheldon et al: Pregnancy and open-heart surgery. Circulation 39 (Suppl. 1): 257, 1969.
Downloaded from ves.sagepub.com at Purdue University on May 25, 2015
as
published,
if suitable,
space permits. They should not exceed 1,000 words (double in length, and may be subject to editing or abridgment.
spaced)
Open Heart Surgery During
CASE REPORT
Pregnancy—Case Report
I.M. is a 32 year old woman who was admitted to Beilinson Hospital on Jan. 28th, 1974, because of’ severe pulmonary edema due to mitral restenosis in her 7th month of pregnancy. Three previous pregnancies terminated in spontaneous delivery of healthy babies and in a further one, therapeutic abortion was done because of’ heart failure. The patient suffered rheumatic fever at the age of 10 years. Following that, mitral stenosis was diagnosed and she became symptomatic and at the age of 14 she underwent closed mitral commissurotomy in another hospital. Her condition improved after the operation and she did well on limited activities. At the age of 21 she suffered another bout of rheumatic fever. During her 3rd pregnancy in 1968 she required digitalis and diuretics because of initial heart failure. At that time, mitral restenosis was first noted. Under close medical supervision this pregnancy ended by a spontaneous delivery of a normal baby. In 1970, a therapeutic abortion was performed in the third month of pregnancy. In 1973 she became again pregnant and this time she refused interruption. On January 28, 1974, she was admitted to the Intensive Care Unit of the Medical Department because of severe dyspnoea. On physical examination the patient was found to be in her seventh month of pregnancy. The blood pressure was 110/80, a pulse regular of 120/minute, and respiration 30 per minute. Slight rales were present over both lung bases. A grade 5/6 diastolic rumble was heard at the apex and a right ventricular heave was felt across the pericardium. The first heart sound was accentuated at the apex and the second sound was maximal in
J. SALOMON, M.D., R. YORTNER, M.D. MORRIS J. LEVY, M.D., F.I.C.A.
Brock1, Cooley and Chapman3, Logan and Turners and Mason were the first to report on surgical treatment of’ mitral stenosis during pregnancy. During the following years increasing number of patients who under-
commissurotomy during pregnancy reported utilising the closed method’°. Open heart surgery is at present more frequently utilized to help pregnant patients went were
in acute heart failure in which an immediate threat to the patient’s life is evident. The literature up to 1968 summerises about 30 cases of heart disease operated upon with the
open-heart technique during pregnancy. Most notable was the high fetal mortality (around 30%)&dquo;. Following operation, only 13 pregnant patients undergoing successful surgery involving cardiopulmonary bypass resulted in delivery of’ normal infants9. In 1969, Zitnik 12 reported another series of 21 cases treated during pregnancy by several surgeons who had all been in contact with the author. In his group one mother and seven children died (mortality rates of 5% and 33%, respec-
tively). An additional
case
of
a
7th month preg-
patient was operated upon urgently utilising the open-heart technique because of intractable pulmonary edema due to mitral restenosis, and this consists the basis for this nant
report. Thoracic-Cardiovascular Surgery Department, Beilinson Hospital. University of Tel-Aviv Medical School, Israel.
257
Downloaded from ves.sagepub.com at Purdue University on May 25, 2015
258 the second left intercostal space. An opening snap was heard as well i.e. all the clinical signs pointed to the diagnosis of severe mitral restenosis. Laboratory-studies: Hemoglobin 11.0 gm%, W.B.C. 8000, Urea 20 mgm%, Glucose 110 mgm%, blood electrolytes were within normal limits, prothrombin time was 90% of the normal, fibrinogen 390 mgm%, urine normal. E.C.G. showed sinus thythm, right axis deviation 60°, R.B.B.B., hypertrophy and strain on the right ventricle. Aggressive medical treatment including I.V. diuretics (up to 1.0 g of Lasix LV.) did not improve her condition. On the contrary she went soon into severe pulmonary edema which was refractory to medical treatment. At that point, after being 6 hours in pulmonary edema the patient was taken for emergency operation. The heart was exposed through a sternal
split thoracotomy. Cardiopulmonary bypass was
instituted and the left atrium
was ex-
if the &dquo;protective&dquo; influence of’ a decreased cardiac output that often is encountered in patients with mitral stenosis of any consequence is overruled by the general influence of pregnancy which tends to increase the cardiac output. Thus, the relative increase of cardiac output during pregnancy in mitral stenosis may be even larger than what is seen in the normal woman. This, in return may sometimes lead to a marked increase of pressures in the pulmonary circulation which in conjunction with the tendency to decreased pulmonary vascular resistance, increased basal heart rate, and dilutional anemia, markedly increases the risk of pulmonary edema in early pregnancy even with only moderate or mild stenosis. Such cases are mostly refractory to proper medical treatment and urgent surgical intervention to relieve the valvular obstruction may be inevitable. The common procedure has been mitral commissurotomy by the closed heart seems as
posed. The mitral valve orifice was found technique. Bader, Bader, Rose and Braunwald2 reseverely stenotic 8-10 mm in diameter and The leaflets were competent. moderately ported that the peripheral resistance is dethickened free of calcium deposit and with creased throughout pregnancy and reaches normal chordae. Both commissures were in- normal levels only at term, total oxygen cised widely allowing an orifice of about two consumption is progressively increased fingers. The valve remained competent. The throughout pregnancy and measures approxbypass time lasted 23 minutes during which imately 10 percent above normal at term and time a mean arterial pressure maintained at about 60 mmHg (average) and a mean systemic flow of 2800 cc/min. The patient’s postoperative course was uneventful. The pulmonary edema disappeared with the institution of the cardiac pulmonary bypass and did not return during the postoperative period. Two months later she delivered a normal female baby weighing 3Kg without any complications. Both mother and daughter at present, one year after operation, are well. DISCUSSION
Mitral stenosis is the commonest cause of heart failure in rheumatic heart disease during pregnancy. Patients with mitral stenosis who become pregnant, experience similar hemodynamic changes as normal women. It
the arteriovenous oxygen difference is decreased during the fourteenth to thirtieth weeks. The cardiac output is increased with peaks of 40 percent greater than normal during the twenty-fifth to twenty-seventh weeks of gestation, and then returns to normal at the thirty-sixth to fortieth weeks. Naturally pregnancy in patients with significant mitral stenosis adds further burden on an already overloaded circulatory system. All those hemodynamic changes in pregnancy lead to an increase load on the left atrium in mitral stenosis, explaining the high incidence of atrial arrhythmias, especially atrial fibrillation occurring during pregnancy. The sudden occurrence of’ atrial fibrillation may lead to marked increase in heart rate, decrease in ventricular diastolic filling time, sudden and marked increase in
Downloaded from ves.sagepub.com at Purdue University on May 25, 2015
259
pulmonary blood volume and pressure leading to a severe, life-threatening attack of pulmonary edema. Thus, elective surgery performed before pregnancy is to be prefered, even though surgery during pregnancy is quite feasible and may be life-saving. In a review of surgical treatment of rheumatic heart disease during pregnancy, Harken and Taylors in 1961 collected 394 cases.
The maternal
mortality
was
1.8%
(seven cases) and the fetal mortality 9% (35 cases). Ueland&dquo; four years later reported on an additional 120 pregnant women with a similar mortality (maternal 1.7%, fetal 7.5%). Only severely disabled patients in functional classes III and IV (NYHA) were subjected to closed commissurotomy. Ueland came to the conclusion that the overall results among patients treated surgically have been better than those treated medically, both for mother and child. He reported the maternal mortality in comparable medically treated series to be 4.2%-18.7% and a fetal mortality as high as 50% which he accounted in more recent material to be as a neglect on the part of the physician or patient as well. The low surgical mortality in these rather large series of patients are presumably attributable to two factors: 1) The young age of the patients, and 2) the presence of good myocardial function in a patient population that experiences clinical deterioration due to an abnormally high circulatory load. The favorable outcome of the pregnancy for both mother and child signifies clear-cut improvement in cardiac performance following sur-
gical
treatment.
The first open-heart surgical procedure was reported by Leysel, who corrected a congenital aortic stenosis during the 12th week of’ pregnancy. The by-pass lasted 20 minutes and the child exhibited multiple congenital defects when born at term. Since then the reported cases accumulated to over 50. Even though it is possible to
perform open-heart surgery during pregacceptable mortality for the mother, most surgeons prefer to do it as an elective procedure at a time when the patient
nancy with
is not pregnant. In most of the cases reported in the past, surgery was done early in pregnancy before the 12th week. Some authors like Condarsson and Werkol are in the opinion that the use of open-heart surgery in those greatly incapacitated women is a good alternative to therapeutic abortion, because even though the fetal mortality was rather high, only one child in their series was born
with congenital defects. On the other hand it is well known that internal organs in the fetus are formed by the eighth week of pregnancy and changes after this are the result of growth and development and so it may be wise to avoid surgery during this early developmental period if pregnancy is known to exist. It should be also stressed that an adequate perfusion with oxygenator and short perfusion times are mandatory to keep the placental perfusion optimal if the operation is performed in advanced pregnancy. SUMMARY
A case of 32-old woman in her 7th month of pregnancy presented with intractable pulmonary edema due to mitral restenosis is reported. Open-heart mitral commissurotomy was done as an emergency procedure. She continued pregnancy to term after the operation and delivered a healthy female
baby. The literature related to &dquo;the closed&dquo; and heart surgery during pregnancy has been reviewed. MORRIS J. LEVY, M.D., F.I.C.A. Beilinson Hospital Petah Tiqva, Israel
&dquo;open&dquo;
REFERENCES 1. Brock R. C.: 2.
Valvulotomy in pregnancy. Proc. Roy. Soc. Med. 45: 538, 1952 Bader R. A., Bader M. E., Rose D. J., and Braunwald D.: Hemodynamics at rest and during exercise in normal pregnancy as studied by cardiac catheterization. J. Clin. Invest. 34: 1524, 1955.
3.
Cooley D. A., Chapman D. W.: Mitral commissurotomy during pregnancy. J.A.M.A.
150: 1113, 1952. 4. Conradsson T. B., Werkö L.: Managemant of heart disease in pregnancy. Progress in Cardiovascular Diseases 16: 407, 1974
Downloaded from ves.sagepub.com at Purdue University on May 25, 2015
260 5. Harken D. E., Taylor W. J.: Cardiac surgery during pregnancy. Clin. Obstet. Gynecol. 4:
697, 1961 6. 7.
Logan A., Turner R. W. D.: Mitral valvulotomy in pregnancy, Lancet 1: 1286, 1952 Leyse R., Ofstun M., Dillard D. H. et al: Congenital aorticstenosis in pregnancy, corrected by extracorporeal circulation.
J.A.M.A. 176: 1009, 1961 8. Mason J. : In discussion of Stabler F. E., Szekely P. J. Obstet. Gynaecol, Brit. Emp., 59: 569, 1952.
9. Meffert W. G., Stansel H. C. Jr.: Open heart surgery during pregnancy. Am. J. Obstet. Gynecol. 102: 1116, 1968. 10. Neri A., Gans B., Salomon J.: Mitral commissurotomy in pregnancy J. Israel Med. Assoc. 70: 310, 1966 11. Ueland K.: Cardiac surgery and pregnancy. Am. J. Obstet. Gvnecol. 92: 148, 1965 12. Zitnik R. S., Brandenburg R. O., Sheldon et al: Pregnancy and open-heart surgery. Circulation 39 (Suppl. 1): 257, 1969.
Downloaded from ves.sagepub.com at Purdue University on May 25, 2015
