Successful Valve-in-Valve TAVI in Pregnancy for Severe Degenerative Bioprosthetic Aortic Valve Stenosis

Author: Sumeet Gandhi, Javier Ganame, Richard Whitlock, Madhu Natarajan, James Velianou, McMaster University, Hamilton, Canada

Background: Patients with prosthetic valves are at high risk for complications in pregnancy.

Case: 29-year-old female at 12 weeks gestation presented with dyspnea and exertional chest pain. Her medical history included congenital bicuspid aortic valve stenosis, at the age of 24 she underwent aortic valve replacement with a #23 Carpentier-Edwards Magna Ease porcine bioprosthesis. She then underwent two uncomplicated pregnancies, her last echocardiogram one year prior showed appropriate gradients with normal systolic function. Current echocardiogram showed severe prosthetic valve stenosis with peak/mean gradient of 149mmHg/98mmHg, DVI 0.28, AVA 0.8cm2, no regurgitation, with hyperdynamic left ventricular systolic function. Transesophageal echocardiogram did not reveal evidence of thrombus, pannus, or vegetation.

Decision-making: Consensus discussion with regional experts deemed that her current cardiovascular status would further deteriorate without intervention; the patient was not keen for termination of the pregnancy. Both surgical AVR and TAVI were considered; it was felt surgery would carry a 30% risk of fetal demise and at least a 2-3% risk of maternal mortality. TAVI would provide superior hemodynamic stability, avoid placental hypoperfusion with cardiopulmonary bypass, with a strategy to avoid fetal and maternal radiation. At 13 weeks gestation, she underwent successful valve-in-valve TAVI with a #23 Edwards Sapien XT valve. Post-procedure echocardiogram showed normal functioning bioprosthesis and hyperdynamic systolic function. Fetal monitoring post-operatively did not reveal any evidence of distress. She was discharged postoperative day 5 without any complications. She progressed well throughout the remainder of pregnancy, without significant increase in gradients across her prosthetic valve. At 39 weeks, she underwent planned induction with epidural anesthesia without complications.

Conclusion: This case highlights degeneration of bioprosthetic aortic valve in pregnancy, importance of the heart team for clinical decision making with consideration of maternal and fetal risk, and successful valve-in-valve TAVI.

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