Aortic Stenosis in PregnancyAortic Stenosis in Pregnancy

Brendan Astley MD Brendan Astley MD

&&

Norman Bolden MDNorman Bolden MD

Nov 2006

18 year old G1P0 Spanish 18 year old G1P0 Spanish speaking femalespeaking female

PMH- “Heart condition” since age 12 (no further PMH- “Heart condition” since age 12 (no further follow-up)follow-up)

SOB and CP at rest and exertion worse over last SOB and CP at rest and exertion worse over last two yearstwo years

PSH- nonePSH- none

Medications- PNVMedications- PNV

Allergies- NKDAAllergies- NKDA

FH- unknownFH- unknown

SH- no tobacco, EtOH or drug useSH- no tobacco, EtOH or drug use

Physical ExamPhysical Exam

Vitals BP 104/62 HR 79 temp 36.6 RR 18 Vitals BP 104/62 HR 79 temp 36.6 RR 18 sat 100%sat 100%

Height 4’10” Weight 99lbs. now 119lbs. Height 4’10” Weight 99lbs. now 119lbs. Heart– IV/VI systolic murmur… cresendo-decresendo Heart– IV/VI systolic murmur… cresendo-decresendo murmur with no diastolic component, heard best at R murmur with no diastolic component, heard best at R upper sternal border, radiation to carotids bilaterally, no upper sternal border, radiation to carotids bilaterally, no JVD, no 3JVD, no 3rdrd or 4 or 4thth heart sound heart soundAirway– nml, Mal IAirway– nml, Mal ILungs– CTA Bil., no w/r/rLungs– CTA Bil., no w/r/rAbd– NT gravid uterus, softAbd– NT gravid uterus, softExt– no edema good pulses distallyExt– no edema good pulses distally

Labs: B positiveLabs: B positive

BNP 5.5BNP 5.5

WBC 8.71, Hg 12.5, Hct WBC 8.71, Hg 12.5, Hct 36.8, Plts 25636.8, Plts 256

Na 136, K 3.9, Cl 108, Na 136, K 3.9, Cl 108, COCO2 2 21, BUN 5, Cr 0.5, 21, BUN 5, Cr 0.5,

Glu 71Glu 71

Ca 8.5Ca 8.5

TSH 0.9, RPR, NR, HIV, TSH 0.9, RPR, NR, HIV, VZ immune, RI, GC/ VZ immune, RI, GC/ chlam, hep B all negativechlam, hep B all negative

Plan: Admit to Plan: Admit to antepartum unit (social antepartum unit (social admission) to facilitate admission) to facilitate consultations by consultations by Maternal/Fetal Medicine, Maternal/Fetal Medicine, Cardiology, NICU and Cardiology, NICU and Anesthesiology. Anesthesiology.

CardiologyCardiology

Murmur appreciated and echo performed: on Murmur appreciated and echo performed: on 9/15 showing AS <.6cm9/15 showing AS <.6cm22, probable bicuspid , probable bicuspid valve and EF 65%.valve and EF 65%.Pt followed for change in symptoms….Pt followed for change in symptoms….Mid Oct. at about 35 wks. Gestation she Mid Oct. at about 35 wks. Gestation she complains of increased CP and SOB especially complains of increased CP and SOB especially with exertion but also at rest. with exertion but also at rest. .1%-1.4% pregnancies with clinically significant .1%-1.4% pregnancies with clinically significant cardiac problemscardiac problemsMortality from these .5%-2.7%Mortality from these .5%-2.7%

Cardio cont’dCardio cont’d

Echo shows peak gradient of 62mmHg Echo shows peak gradient of 62mmHg and .58cmand .58cm2 2 orifice by the continuity orifice by the continuity equation.equation.Velocity waveform is asymmetric which Velocity waveform is asymmetric which usually equates with less than severe usually equates with less than severe stenosis.stenosis.CXR- WNL, no cardiopulmonary diseaseCXR- WNL, no cardiopulmonary disease– CXR abnormalities may include enlarged CXR abnormalities may include enlarged

aorta, cardiomyopathy and possibly pulm. aorta, cardiomyopathy and possibly pulm. edemaedema

Expected EKG changes with ASExpected EKG changes with ASLeft ventricular hypertrophy (LVH)Left ventricular hypertrophy (LVH)

There are many different criteria for LVH.There are many different criteria for LVH.Sokolow + Lyon Sokolow + Lyon (Am Heart J, 1949;37:161)(Am Heart J, 1949;37:161) – S V1+ R V5 or V6 > 35 mm S V1+ R V5 or V6 > 35 mm

Cornell criteria Cornell criteria (Circulation, 1987;3: 565-72)(Circulation, 1987;3: 565-72) – SV3 + R avl > 28 mm in men SV3 + R avl > 28 mm in men – SV3 + R avl > 20 mm in women SV3 + R avl > 20 mm in women

Framingham criteria Framingham criteria (Circulation,1990; 81:815-820)(Circulation,1990; 81:815-820) – R avl > 11mm, R V4-6 > 25mm R avl > 11mm, R V4-6 > 25mm – S V1-3 > 25 mm, S V1 or V2 + S V1-3 > 25 mm, S V1 or V2 + – R V5 or V6 > 35 mm, R I + S III > 25 mm R V5 or V6 > 35 mm, R I + S III > 25 mm

Romhilt + Estes Romhilt + Estes (Am Heart J, 1986:75:752-58)(Am Heart J, 1986:75:752-58) – Point score system Point score system

Left atrial abnormality (dilatation or hypertrophy)Left atrial abnormality (dilatation or hypertrophy)M shaped P wave in lead II M shaped P wave in lead II prominent terminal negative component to P wave in lead V1prominent terminal negative component to P wave in lead V1

? Suggestions for Anesthetic Plan? Suggestions for Anesthetic Plan

Anesthesia for Vaginal DeliveryAnesthesia for Vaginal Delivery Monitors for Vaginal deliveryMonitors for Vaginal delivery Anesthesia for C/SAnesthesia for C/S Monitors for C/S.Monitors for C/S.Maternal-Fetal Medicine, Cardiology , NICU, and Maternal-Fetal Medicine, Cardiology , NICU, and Anesthesia develop working plan.Anesthesia develop working plan.***If possible, avoid C/S. If vaginal delivery, ***If possible, avoid C/S. If vaginal delivery, must avoid valsalva.must avoid valsalva.

Anesthesia for Vaginal DeliveryAnesthesia for Vaginal Delivery

Neuroaxial anesthesia…Neuroaxial anesthesia…– Continuous SpinalContinuous Spinal

Single shot spinal not reasonable for prolonged laborSingle shot spinal not reasonable for prolonged labor

Reliable blockReliable block

Intrathecal narcotics avoid the sympathectic block with Intrathecal narcotics avoid the sympathectic block with ensuing hypotension ensuing hypotension

Intrathecal narcotics not effective for second stage of labor.Intrathecal narcotics not effective for second stage of labor.

Small doses of intrathecal LAs added to narcotics improve Small doses of intrathecal LAs added to narcotics improve analgesia while limiting hemodynamic consequences.analgesia while limiting hemodynamic consequences.

Chance for spinal headacheChance for spinal headache

Anesthesia for Vaginal DeliveryAnesthesia for Vaginal Delivery

Neuroaxial anesthesia…Neuroaxial anesthesia…– EpiduralEpidural

Pros…titratable to produce minimal hemodynamic Pros…titratable to produce minimal hemodynamic changes, adequate anesthesia possible for vaginal changes, adequate anesthesia possible for vaginal or C-section, if performed properly no spinal or C-section, if performed properly no spinal headachesheadaches

Cons…higher failure rate compared with spinalCons…higher failure rate compared with spinal

Anesthesia for Vaginal DeliveryAnesthesia for Vaginal DeliveryIV Narcotic analgesia (PCA)IV Narcotic analgesia (PCA)– Pros…would offer patient some analgesia Pros…would offer patient some analgesia

(most still report 8-10/10 pain despite (most still report 8-10/10 pain despite Fentanyl PCA)Fentanyl PCA)

– Cons… Respiratory Depression (mother and Cons… Respiratory Depression (mother and fetus), Sedation (mother and fetus), N/V, fetus), Sedation (mother and fetus), N/V, decreased beat to beat variability on fetal decreased beat to beat variability on fetal heart rate tracing.heart rate tracing.

– Cons….Would not effectively control the pain Cons….Would not effectively control the pain from second stage of labor and therefore from second stage of labor and therefore would not attenuate the increase in HR would not attenuate the increase in HR associated with delivery.associated with delivery.

Stages of LaborStages of Labor

11stst stage – 2 phases: stage – 2 phases: – latent phase encompasses the onset of pain latent phase encompasses the onset of pain

to the first noticed change in cervical dilationto the first noticed change in cervical dilation– Maximal dilation phase…begins around 3 cm Maximal dilation phase…begins around 3 cm

22ndnd stage – Maximal cervical dilation 10cm stage – Maximal cervical dilation 10cm until delivery of fetusuntil delivery of fetus

33rdrd stage – After delivery of fetus until stage – After delivery of fetus until delivery of placentadelivery of placenta

Board Questions??Board Questions??

During the first stage of labor, the pain of During the first stage of labor, the pain of uterine contractions is transmitted via uterine contractions is transmitted via spinal cord segments..spinal cord segments..– A…T6 to L1A…T6 to L1– B…T6 to L5B…T6 to L5– C…T10 to L1C…T10 to L1– D…T10 to S1D…T10 to S1– E…T10 to S5E…T10 to S5

Answer is….CAnswer is….C

Anesthesia for C-sectionAnesthesia for C-section

General anesthesia…General anesthesia…– Pros…good airway control, minimal hemodynamic Pros…good airway control, minimal hemodynamic

changes compared to epidural/spinal boluses to start changes compared to epidural/spinal boluses to start case, can treat hemodynamic changes rapidly with case, can treat hemodynamic changes rapidly with close monitoringclose monitoring

– Cons…possible difficult airway, aspiration risks, Cons…possible difficult airway, aspiration risks, tachycardia and/or hypertension on induction or tachycardia and/or hypertension on induction or emergence, caution with volatile agents and emergence, caution with volatile agents and hypotension or myocardial depressionhypotension or myocardial depression

Hospital CourseHospital Course

Induced to L & D at 35 weeks.Induced to L & D at 35 weeks.

Arterial line placedArterial line placed

Swan-Ganz catheter placedSwan-Ganz catheter placed

Early epidural also placed by anesthesiaEarly epidural also placed by anesthesia

Continuous Telemetry monitoringContinuous Telemetry monitoring

Pitocin was started on the night of 11/7 Pitocin was started on the night of 11/7 and by morning she was well dilated and and by morning she was well dilated and contracting regularlycontracting regularly

PCWP/CVP readingsPCWP/CVP readings

11/711/71950hrs: PCWP 10-11, CVP 5-7, good UOP1950hrs: PCWP 10-11, CVP 5-7, good UOP2330hr: PCWP 10-132330hr: PCWP 10-13

11/8 11/8 0100: PCWP 7-9…complains of CP0100: PCWP 7-9…complains of CP0300:CVP 15-16, trop .15 0300:CVP 15-16, trop .15 0500: PCWP 11-15, CO 5L/min0500: PCWP 11-15, CO 5L/min0800: trop <.1 (nml)0800: trop <.1 (nml)Wedge maintained in above normal range Wedge maintained in above normal range Delivery at 1130am Delivery at 1130am

Hospital Course cont’dHospital Course cont’d

No symptoms of AS during induction No symptoms of AS during induction course.course.

Ready for delivery in AM with forcepsReady for delivery in AM with forceps

No valsalva by mother and epidural No valsalva by mother and epidural working well with slow dosing.working well with slow dosing.

PCWP and urine output maintained PCWP and urine output maintained throughout delivery with fluids and gentle throughout delivery with fluids and gentle epidural dosing.epidural dosing.

Hospital Course cont’dHospital Course cont’d

After forceps delivery pt transferred to Step-After forceps delivery pt transferred to Step-Down on esmolol drip due tachycardia.Down on esmolol drip due tachycardia.

Drip stopped in CCU 11/8 and gentle diuresis Drip stopped in CCU 11/8 and gentle diuresis started with Lasix.started with Lasix.

Stable vital signs throughout hospital stay.Stable vital signs throughout hospital stay.

Day #3 post-forceps delivery patient transferred Day #3 post-forceps delivery patient transferred home with 6 week follow-up with cardiology for home with 6 week follow-up with cardiology for possible valve replacement.possible valve replacement.

Physiologic Changes during Physiologic Changes during pregnancypregnancy

Beginning to change at 5 weeks…10 fold Beginning to change at 5 weeks…10 fold increase in uterine blood flow at termincrease in uterine blood flow at term

Cardiovascular : Blood volume 35%, CO Cardiovascular : Blood volume 35%, CO

40-50%, SV 30%, HR 15-20%40-50%, SV 30%, HR 15-20%

Cardiovascular : SVR 15%, sys and diastolic Cardiovascular : SVR 15%, sys and diastolic BP 10mmHgBP 10mmHg

Pulmonary Changes: O2 consumption 20%, Pulmonary Changes: O2 consumption 20%, RR 15%, MV 50%, TV 40%, alv vent. 70%RR 15%, MV 50%, TV 40%, alv vent. 70%

ERV 20%, FRC 20% ERV 20%, FRC 20%

Aortic StenosisAortic Stenosis

In the past Rheumatic Valvular degeneration In the past Rheumatic Valvular degeneration was the primary causewas the primary causeCongenitally bicuspid valves become calcified Congenitally bicuspid valves become calcified and cause stenosis most commonly now…(1-2% and cause stenosis most commonly now…(1-2% of population)of population)Senile degeneration can also occurSenile degeneration can also occur30% of patients older than 85 have significant 30% of patients older than 85 have significant changeschangesRisk for sudden death with AS increases when Risk for sudden death with AS increases when grad. >50mmHg and orifice less than .8cmgrad. >50mmHg and orifice less than .8cm22

Normal AnatomyNormal Anatomy

Aortic stenosis AnatomyAortic stenosis Anatomy

AS 2D echoAS 2D echo

SymptomsSymptoms

Rheumatic AS patients may remain Rheumatic AS patients may remain asymptomatic for 40 yearsasymptomatic for 40 years

Bicuspid valve patients will develop Bicuspid valve patients will develop symptoms between 15-65 years of agesymptoms between 15-65 years of age

Calcifications of the valve usually occur Calcifications of the valve usually occur after age 30after age 30

THE TRIAD….THE TRIAD….

The triad…The triad…

Any one of these symptoms being present Any one of these symptoms being present is ominous and the patient’s life is ominous and the patient’s life expectancy is less than 5 years…expectancy is less than 5 years…

ANGINAANGINA

SYNCOPESYNCOPE

CHFCHF

AnginaAngina

This is the initial symptom in 50-70% of This is the initial symptom in 50-70% of patients. Most commonly occurring with patients. Most commonly occurring with exertionexertion

May be present without CAD b/c of…May be present without CAD b/c of…– Increased myocardial OIncreased myocardial O22 consumption, with consumption, with

increased myocardial thickness and increased increased myocardial thickness and increased afterloadafterload

– Also increased LVEDP impairing flow to Also increased LVEDP impairing flow to subendocardial layerssubendocardial layers

SyncopeSyncope

First symptom in 15-30% of patientsFirst symptom in 15-30% of patients

Once this occurs the average life Once this occurs the average life expectancy is 3-4 yearsexpectancy is 3-4 years

Origin of syncope is controversial, Origin of syncope is controversial, however it may be related to however it may be related to uncompensated decrease in SVR with uncompensated decrease in SVR with exerciseexercise

CHFCHF

Due to diastolic dysfunction (increased LV Due to diastolic dysfunction (increased LV thickness) or systolic dysfunction (increased thickness) or systolic dysfunction (increased afterload or decreased myocardial contractility)afterload or decreased myocardial contractility)Once LV failure occurs the average life Once LV failure occurs the average life expectancy is 1-2 yearsexpectancy is 1-2 yearsAll AS patients are at increased risk of sudden All AS patients are at increased risk of sudden death, as previously stated and….death, as previously stated and….Only 18% of patients are alive 5 years after the Only 18% of patients are alive 5 years after the peak systolic gradient is >50mmHg or the orifice peak systolic gradient is >50mmHg or the orifice <0.7cm<0.7cm22

PathophysiologyPathophysiology

Stage 1: asymptomatic—mild stenosisStage 1: asymptomatic—mild stenosis– Normal stroke volume maintained as gradient Normal stroke volume maintained as gradient

between LV and aorta increasesbetween LV and aorta increases– Higher gradient results in concentric LV Higher gradient results in concentric LV

hypertrophyhypertrophy

PathophysiologyPathophysiology

Stage 2: moderate stenosis—symptomaticStage 2: moderate stenosis—symptomatic– Dilation as well as hypertrophy occur in this Dilation as well as hypertrophy occur in this

stagestage– Decreased EF may be noted (due to Decreased EF may be noted (due to

decreased contractility)decreased contractility)– Increased LVEDP and LVEDV leads to Increased LVEDP and LVEDV leads to

increased myocardial work and O2 increased myocardial work and O2 consumption….at risk myocardiumconsumption….at risk myocardium

PathophysiologyPathophysiology

Stage 3: critical AS Stage 3: critical AS – Valve area is less than .5cmValve area is less than .5cm22/m/m22 and EF and EF

decreases further with further increases in decreases further with further increases in LVEDPLVEDP

– Pulmonary edema when LA >25-30 mmHgPulmonary edema when LA >25-30 mmHg– RV failure will develop if sudden death does RV failure will develop if sudden death does

not occur firstnot occur first

Calculation of StenosisCalculation of Stenosis

Gorlin equation: AV area (cmGorlin equation: AV area (cm22)= )=

CO (L/min)/CO (L/min)/

Mean pressure gradientMean pressure gradient1/21/2

This is the simplified version of the Gorlin This is the simplified version of the Gorlin equation (Hakki equation)equation (Hakki equation)

Continuity equationsContinuity equations

AV area=LVOT velocity/AV velocity x LVOT area AV area=LVOT velocity/AV velocity x LVOT area ---LVOT calculation can have errors because it’s ---LVOT calculation can have errors because it’s an area squared.an area squared.

AV area= CO/(HR x systolic ejection period x AV area= CO/(HR x systolic ejection period x 44.3 x gradient in mmHG44.3 x gradient in mmHG1/21/2) ---Gorlin equation ) ---Gorlin equation weak under low CO statesweak under low CO states

Hakki equation—based on the fact that HR x sys Hakki equation—based on the fact that HR x sys ejection period x 44.3= 1000; therefore AV ejection period x 44.3= 1000; therefore AV Area= CO/ sq root of gradient (mmHg)Area= CO/ sq root of gradient (mmHg)

PA CathPA Cath

Because of increased LVEDP stretching Because of increased LVEDP stretching the mitral annulus a prominent v wave can the mitral annulus a prominent v wave can be observed with disease progression. LA be observed with disease progression. LA hypertrophy develops and the A wave hypertrophy develops and the A wave becomes prominentbecomes prominent

Example to follow on next slide…Example to follow on next slide…

Arterial lineArterial line

Pulsus parvus (narrow pulse pressure)Pulsus parvus (narrow pulse pressure)

Pulsus tardus (delayed upstroke)Pulsus tardus (delayed upstroke)

These features make the wave appear These features make the wave appear overdampenedoverdampened

Hemodynamic profileHemodynamic profile

AS– increase LV preload and SVRAS– increase LV preload and SVR– Decrease HRDecrease HR– Keep contractile force and PVR constantKeep contractile force and PVR constant

Preload – because of Decreased LV Preload – because of Decreased LV compliance as well as Increased LVEDP compliance as well as Increased LVEDP preload augmentation is needed preload augmentation is needed – (caution with nitro)(caution with nitro)

Hemodynamics continuedHemodynamics continued

Heart rate– no extremes of HRHeart rate– no extremes of HR– Increase HR = decreased coronary perfusionIncrease HR = decreased coronary perfusion– Sinus rhythm important for added EFSinus rhythm important for added EF

ContractilityContractility– avoid B-blockers they can increase LVEDP avoid B-blockers they can increase LVEDP

and decrease COand decrease CO

Hemodynamics continuedHemodynamics continued

SVR– most of afterload is due to stenotic SVR– most of afterload is due to stenotic lesion, therefore it’s fixed.lesion, therefore it’s fixed.– If SBP is decreased the patient can develop If SBP is decreased the patient can develop

subendocardial ischemiasubendocardial ischemia– Early alpha-adrengic agonists needed as Early alpha-adrengic agonists needed as

treatmenttreatment

PVR– this stays normal until very late in PVR– this stays normal until very late in the disease processthe disease process

Toronto studyToronto study

1986-2000 of 49 pregnancies in women 1986-2000 of 49 pregnancies in women with ASwith AS– Mild AS (>1.5cmMild AS (>1.5cm22 or grad<36mmHg) or grad<36mmHg)– Mod AS (1.0-1.5cmMod AS (1.0-1.5cm22 or grad 36-63mmHg) or grad 36-63mmHg)– Severe AS (<1.0cmSevere AS (<1.0cm22 or grad >63mmHg) or grad >63mmHg)

All women had functional NYHA class I or All women had functional NYHA class I or II disease when enrolledII disease when enrolled59% of patients, 29/49 had severe AS59% of patients, 29/49 had severe ASSilversides C.K., Colman J.M., Sermer M., Farine D., Sui S. C., Early and intermediate-term outcomes of pregnancy with congential aortic Silversides C.K., Colman J.M., Sermer M., Farine D., Sui S. C., Early and intermediate-term outcomes of pregnancy with congential aortic stenosis. American Journal of Cardiology 2003;91:11stenosis. American Journal of Cardiology 2003;91:11

NYHA functional classificationNYHA functional classification

Class I – AsymptomaticClass I – Asymptomatic

Class II – Symptoms with greater than Class II – Symptoms with greater than normal activitynormal activity

Class III – Symptoms with normal activityClass III – Symptoms with normal activity

Class IV – Symptoms at restClass IV – Symptoms at rest

Toronto study continuedToronto study continued10% of severe AS patients (3/29) had early cardiac 10% of severe AS patients (3/29) had early cardiac complications (pulmonary edema or atrial arrhythmias)…complications (pulmonary edema or atrial arrhythmias)…no complications in mild/mod groupsno complications in mild/mod groupsOne pt. had AVA .5cmOne pt. had AVA .5cm2, 2, peak gradient 112mmHg, she peak gradient 112mmHg, she developed pulmonary edema at 12 weeks had emergent developed pulmonary edema at 12 weeks had emergent aortic valvuloplasty then had a Ross procedure 4 years aortic valvuloplasty then had a Ross procedure 4 years after deliveryafter deliveryThe second pt. had gradient of 104mmHg; she had The second pt. had gradient of 104mmHg; she had postpartum hemorrhage, hypotension and subsequent postpartum hemorrhage, hypotension and subsequent pulmonary edema. Resection of her subaortic membrane pulmonary edema. Resection of her subaortic membrane was performed 17 months after delivery.was performed 17 months after delivery.The third pt had a bicuspid valve AVA .7cmThe third pt had a bicuspid valve AVA .7cm22, gradient of , gradient of 64mmHg, she had atrial arrhythmias during antepartum 64mmHg, she had atrial arrhythmias during antepartum period. She underwent a Ross procedure 18 months period. She underwent a Ross procedure 18 months postpartum.postpartum.

Toronto Study continuedToronto Study continued

8% mild/mod AS had cardiac surgery in follow-8% mild/mod AS had cardiac surgery in follow-up and 41% of severe AS group had post-up and 41% of severe AS group had post-partum cardiac surgery…10% with severe AS partum cardiac surgery…10% with severe AS had cardiac complications during pregnancyhad cardiac complications during pregnancy

12 pregnancies complicated by preterm birth, 12 pregnancies complicated by preterm birth, resp. distress syndrome, IUGRresp. distress syndrome, IUGR– Rate is similar general populationRate is similar general population

No fetal or neonatal deathsNo fetal or neonatal deathsSilversides CK, Colman JM, Sermer M, Farine D, Siu SC. Early and intermediate-term outcomes Silversides CK, Colman JM, Sermer M, Farine D, Siu SC. Early and intermediate-term outcomes of pregnancy with congenital aortic stenosis. Am J Cardiol 2003;91(11):1386-9 of pregnancy with congenital aortic stenosis. Am J Cardiol 2003;91(11):1386-9

Brazilian studyBrazilian studyStudy of 1000 women with heart disease Study of 1000 women with heart disease followed between 1989-1999followed between 1989-1999HD-- Rheumatic HD 55.7%, Congenital HD-- Rheumatic HD 55.7%, Congenital HD 19.1%, Chagas disease 8.5%, HD 19.1%, Chagas disease 8.5%, arrhythmias 5.1% and cardiomyopathies arrhythmias 5.1% and cardiomyopathies 4.3%4.3%A subset of patients who had moderate to A subset of patients who had moderate to severe AS experienced 68.5% maternal severe AS experienced 68.5% maternal morbidity…i.e. CHF & angina morbidity…i.e. CHF & angina 2 needed Aortic valve replacement2 needed Aortic valve replacement1 sudden death1 sudden deathAvila WS, Rossi EG, Ramires JA, Grinberg M, Bortolotto MR, Zugaib M, et al. Avila WS, Rossi EG, Ramires JA, Grinberg M, Bortolotto MR, Zugaib M, et al. Pregnancy in patients with heart disease:experience with 1000 cases. Clin Cardiol Pregnancy in patients with heart disease:experience with 1000 cases. Clin Cardiol 2003;26(3):135-422003;26(3):135-42

Anesthetic management goalsAnesthetic management goals

Maintain Normal Sinus Rhythm: up to 20% Maintain Normal Sinus Rhythm: up to 20% of CO is provided by atrial kick in a normal of CO is provided by atrial kick in a normal patient and possibly up to 40% in AS pts.patient and possibly up to 40% in AS pts.Maintain HR 70-90: Bradycardia Maintain HR 70-90: Bradycardia decreases CO in pt with fixed stenotic decreases CO in pt with fixed stenotic lesion and tachycardia does not allow for lesion and tachycardia does not allow for diastolic filling of ventricles.diastolic filling of ventricles.Generous preload: maintain at normal to Generous preload: maintain at normal to high range. high range.

Anes. Management goals cont’dAnes. Management goals cont’d

Close hemodynamic monitoring: Arterial line and Close hemodynamic monitoring: Arterial line and with moderate to severe stenosis- PA cath/TEE with moderate to severe stenosis- PA cath/TEE to help delineate hypovolemia from CHF. Be to help delineate hypovolemia from CHF. Be prepared for cardioversion urgentlyprepared for cardioversion urgently– Lidco may be usefulLidco may be useful

No Valsalva and minimize pain. These could No Valsalva and minimize pain. These could affect preload and sympathetic response (HR, affect preload and sympathetic response (HR, BP) and worsen her condition acutely. BP) and worsen her condition acutely. Narcotic based anesthetic preferred in unstable Narcotic based anesthetic preferred in unstable or severe AS patients (50-100mcg/kg IV)or severe AS patients (50-100mcg/kg IV)

After Hospital stayAfter Hospital stay

Pt seen by cardiology follow up post-op Pt seen by cardiology follow up post-op and Cardiothoracic surgery…and Cardiothoracic surgery…

She was recommended for valve surgery She was recommended for valve surgery

Cardiology has sent her letters warning of Cardiology has sent her letters warning of sudden death as this patient has no longer sudden death as this patient has no longer been coming to her appointments and is been coming to her appointments and is currently lost to follow up…with no valve currently lost to follow up…with no valve replacementreplacement