A Pregnant Woman With Severe Symptomatic Aortic Stenosis -How Should We Treat? (JACC Case Reports February 2024)-Article: A Pregnant Woman With Severe Symptomatic Aortic Stenosis -How Should We Treat?

Article: A Pregnant Woman With Severe Symptomatic Aortic Stenosis -How Should We Treat?

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A 31-year-old pregnant woman with end-stage kidney disease and severe aortic stenosis (AS) presented with heart failure in the second trimester. Despite being informed of the risks, she chose to continue the pregnancy. After consultation with a multidisciplinary team, urgent transcatheter aortic valve replacement (TAVR) was performed. The patient had regular dialysis and clinic visits throughout the pregnancy, with echocardiography showing the worsening of AS. Initially, balloon aortic valvuloplasty (BAV) was attempted but was unsuccessful, resulting in moderate aortic regurgitation. TAVR was then performed successfully, and the patient recovered well. She delivered a healthy baby via vacuum delivery at 35 weeks. Post-delivery, echocardiogram showed improved gradients, and a computed tomography scan confirmed proper valve positioning. The patient and baby are currently doing well.<br /><br />Severe AS in pregnancy carries risks of heart failure, arrhythmias, and preterm birth. Repairing severe stenosis before pregnancy is recommended. BAV is the initial treatment for symptomatic severe AS. TAVR and surgical aortic valve replacement (SAVR) are also options, but SAVR carries a high risk to the fetus. The presence of end-stage kidney disease complicates pregnancy and worsens the prognosis of AS. Arteriovenous fistula can mask AS symptoms and complicate AS assessment. Intervention during the second and third trimesters poses the highest risk to the mother and fetus. Performing a cesarean delivery before cardiac surgery reduces fetal mortality.<br /><br />This case highlights the importance of a multidisciplinary team in managing complex clinical cases, particularly when there is an ethical consideration to respect the patient's autonomy. The team made decisions based on individualized assessment and the patient's preferences. Overall, this case demonstrates the successful management of a pregnant woman with severe AS and end-stage kidney disease.

Keywords

pregnant woman

end-stage kidney disease

severe aortic stenosis

heart failure

second trimester

transcatheter aortic valve replacement

TAVR

balloon aortic valvuloplasty

aortic regurgitation

vacuum delivery