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Aortic Stenosis in Pregnancy. Brendan Astley MD & Norman Bolden MD. Nov 2006. PMH- “Heart condition” since age 12 (no further follow-up) SOB and CP at rest and exertion worse over last two years PSH- none Medications- PNV Allergies- NKDA FH- unknown SH- no tobacco, EtOH or drug use.

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aortic stenosis in pregnancy

Aortic Stenosis in Pregnancy

Brendan Astley MD

&

Norman Bolden MD

Nov 2006

18 year old g1p0 spanish speaking female
PMH- “Heart condition” since age 12 (no further follow-up)

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

PSH- none

Medications- PNV

Allergies- NKDA

FH- unknown

SH- no tobacco, EtOH or drug use

18 year old G1P0 Spanish speaking female
physical exam
Physical Exam
  • Vitals BP 104/62 HR 79 temp 36.6 RR 18

sat 100%

  • Height 4’10” Weight 99lbs. now 119lbs.
  • Heart– IV/VI systolic murmur… cresendo-decresendo murmur with no diastolic component, heard best at R upper sternal border, radiation to carotids bilaterally, no JVD, no 3rd or 4th heart sound
  • Airway– nml, Mal I
  • Lungs– CTA Bil., no w/r/r
  • Abd– NT gravid uterus, soft
  • Ext– no edema good pulses distally
slide4
Labs: B positive

BNP 5.5

WBC 8.71, Hg 12.5, Hct 36.8, Plts 256

Na 136, K 3.9, Cl 108, CO2 21, BUN 5, Cr 0.5, Glu 71

Ca 8.5

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

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

cardiology
Cardiology
  • Murmur appreciated and echo performed: on 9/15 showing AS <.6cm2, probable bicuspid valve and EF 65%.
  • Pt followed for change in symptoms….
  • Mid Oct. at about 35 wks. Gestation she complains of increased CP and SOB especially with exertion but also at rest.
  • .1%-1.4% pregnancies with clinically significant cardiac problems
  • Mortality from these .5%-2.7%
cardio cont d
Cardio cont’d
  • Echo shows peak gradient of 62mmHg and .58cm2 orifice by the continuity equation.
  • Velocity waveform is asymmetric which usually equates with less than severe stenosis.
  • CXR- WNL, no cardiopulmonary disease
    • CXR abnormalities may include enlarged aorta, cardiomyopathy and possibly pulm. edema
expected ekg changes with as
Expected EKG changes with AS

Left ventricular hypertrophy (LVH)

  • There are many different criteria for LVH.
  • Sokolow + Lyon (Am Heart J, 1949;37:161)
    • S V1+ R V5 or V6 > 35 mm
  • Cornell criteria (Circulation, 1987;3: 565-72)
    • SV3 + R avl > 28 mm in men
    • SV3 + R avl > 20 mm in women
  • Framingham criteria (Circulation,1990; 81:815-820)
    • R avl > 11mm, R V4-6 > 25mm
    • S V1-3 > 25 mm, S V1 or V2 +
    • R V5 or V6 > 35 mm, R I + S III > 25 mm
  • Romhilt + Estes (Am Heart J, 1986:75:752-58)
    • Point score system
  • Left atrial abnormality (dilatation or hypertrophy)
  • M shaped P wave in lead II
  • prominent terminal negative component to P wave in lead V1
suggestions for anesthetic plan
? Suggestions for Anesthetic Plan
  • Anesthesia for Vaginal Delivery
  • Monitors for Vaginal delivery
  • Anesthesia for C/S
  • Monitors for C/S.
  • Maternal-Fetal Medicine, Cardiology , NICU, and Anesthesia develop working plan.
  • ***If possible, avoid C/S. If vaginal delivery, must avoid valsalva.
anesthesia for vaginal delivery
Anesthesia for Vaginal Delivery
  • Neuroaxial anesthesia…
    • Continuous Spinal
      • Single shot spinal not reasonable for prolonged labor
      • Reliable block
      • Intrathecal narcotics avoid the sympathectic block with ensuing hypotension
      • Intrathecal narcotics not effective for second stage of labor.
      • Small doses of intrathecal LAs added to narcotics improve analgesia while limiting hemodynamic consequences.
      • Chance for spinal headache
anesthesia for vaginal delivery14
Anesthesia for Vaginal Delivery
  • Neuroaxial anesthesia…
    • Epidural
      • Pros…titratable to produce minimal hemodynamic changes, adequate anesthesia possible for vaginal or C-section, if performed properly no spinal headaches
      • Cons…higher failure rate compared with spinal
anesthesia for vaginal delivery15
Anesthesia for Vaginal Delivery
  • IV Narcotic analgesia (PCA)
    • Pros…would offer patient some analgesia (most still report 8-10/10 pain despite Fentanyl PCA)
    • Cons… Respiratory Depression (mother and fetus), Sedation (mother and fetus), N/V, decreased beat to beat variability on fetal heart rate tracing.
    • Cons….Would not effectively control the pain from second stage of labor and therefore would not attenuate the increase in HR associated with delivery.
stages of labor
Stages of Labor
  • 1st stage – 2 phases:
    • latent phase encompasses the onset of pain to the first noticed change in cervical dilation
    • Maximal dilation phase…begins around 3 cm
  • 2nd stage – Maximal cervical dilation 10cm until delivery of fetus
  • 3rd stage – After delivery of fetus until delivery of placenta
board questions
Board Questions??
  • During the first stage of labor, the pain of uterine contractions is transmitted via spinal cord segments..
    • A…T6 to L1
    • B…T6 to L5
    • C…T10 to L1
    • D…T10 to S1
    • E…T10 to S5
  • Answer is….C
anesthesia for c section
Anesthesia for C-section
  • General anesthesia…
    • Pros…good airway control, minimal hemodynamic changes compared to epidural/spinal boluses to start case, can treat hemodynamic changes rapidly with close monitoring
    • Cons…possible difficult airway, aspiration risks, tachycardia and/or hypertension on induction or emergence, caution with volatile agents and hypotension or myocardial depression
hospital course
Hospital Course
  • Induced to L & D at 35 weeks.
  • Arterial line placed
  • Swan-Ganz catheter placed
  • Early epidural also placed by anesthesia
  • Continuous Telemetry monitoring
  • Pitocin was started on the night of 11/7 and by morning she was well dilated and contracting regularly
pcwp cvp readings
11/7

1950hrs: PCWP 10-11, CVP 5-7, good UOP

2330hr: PCWP 10-13

11/8

0100: PCWP 7-9…complains of CP

0300:CVP 15-16, trop .15

0500: PCWP 11-15, CO 5L/min

0800: trop <.1 (nml)

Wedge maintained in above normal range

Delivery at 1130am

PCWP/CVP readings
hospital course cont d
Hospital Course cont’d
  • No symptoms of AS during induction course.
  • Ready for delivery in AM with forceps
  • No valsalva by mother and epidural working well with slow dosing.
  • PCWP and urine output maintained throughout delivery with fluids and gentle epidural dosing.
hospital course cont d25
Hospital Course cont’d
  • After forceps delivery pt transferred to Step-Down on esmolol drip due tachycardia.
  • Drip stopped in CCU 11/8 and gentle diuresis started with Lasix.
  • Stable vital signs throughout hospital stay.
  • Day #3 post-forceps delivery patient transferred home with 6 week follow-up with cardiology for possible valve replacement.
physiologic changes during pregnancy
Physiologic Changes during pregnancy
  • Beginning to change at 5 weeks…10 fold increase in uterine blood flow at term
  • Cardiovascular : Blood volume 35%, CO

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

  • Cardiovascular : SVR 15%, sys and diastolic BP 10mmHg
  • Pulmonary Changes: O2 consumption 20%, RR 15%, MV 50%, TV 40%, alv vent. 70%

ERV 20%, FRC 20%

aortic stenosis
Aortic Stenosis
  • In the past Rheumatic Valvular degeneration was the primary cause
  • Congenitally bicuspid valves become calcified and cause stenosis most commonly now…(1-2% of population)
  • Senile degeneration can also occur
  • 30% of patients older than 85 have significant changes
  • Risk for sudden death with AS increases when grad. >50mmHg and orifice less than .8cm2
as 2d echo
AS 2D echo
  • Two-dimensional echocardiogram from a patient with aortic stenosis due to a bicuspid aortic valve (congenital). a. Parasternal long-axis view shows systolic doming (bowing) of the anterior and posterior cusps of the aortic valve (arrowheads). b. Parasternal short-axis view at the level of the aorta shows only two cusps (arrowheads). Ao, aorta; LVOT, left ventricular outflow tract; RVOT, right ventricular outflow tract; RA, right atrium; LA, left atrium; RV, right ventricle.
  • J.M. Felner M.D., R.P. Martin M.D., The Echocardiogram, The Hurst's The Heart, 8th ed., p 406. (modified)
symptoms
Symptoms
  • Rheumatic AS patients may remain asymptomatic for 40 years
  • Bicuspid valve patients will develop symptoms between 15-65 years of age
  • Calcifications of the valve usually occur after age 30
  • THE TRIAD….
the triad
The triad…
  • Any one of these symptoms being present is ominous and the patient’s life expectancy is less than 5 years…
  • ANGINA
  • SYNCOPE
  • CHF
angina
Angina
  • This is the initial symptom in 50-70% of patients. Most commonly occurring with exertion
  • May be present without CAD b/c of…
    • Increased myocardial O2 consumption, with increased myocardial thickness and increased afterload
    • Also increased LVEDP impairing flow to subendocardial layers
syncope
Syncope
  • First symptom in 15-30% of patients
  • Once this occurs the average life expectancy is 3-4 years
  • Origin of syncope is controversial, however it may be related to uncompensated decrease in SVR with exercise
slide37
CHF
  • Due to diastolic dysfunction (increased LV thickness) or systolic dysfunction (increased afterload or decreased myocardial contractility)
  • Once LV failure occurs the average life expectancy is 1-2 years
  • All AS patients are at increased risk of sudden death, as previously stated and….
  • Only 18% of patients are alive 5 years after the peak systolic gradient is >50mmHg or the orifice <0.7cm2
pathophysiology
Pathophysiology
  • Stage 1: asymptomatic—mild stenosis
    • Normal stroke volume maintained as gradient between LV and aorta increases
    • Higher gradient results in concentric LV hypertrophy
pathophysiology39
Pathophysiology
  • Stage 2: moderate stenosis—symptomatic
    • Dilation as well as hypertrophy occur in this stage
    • Decreased EF may be noted (due to decreased contractility)
    • Increased LVEDP and LVEDV leads to increased myocardial work and O2 consumption….at risk myocardium
pathophysiology40
Pathophysiology
  • Stage 3: critical AS
    • Valve area is less than .5cm2/m2 and EF decreases further with further increases in LVEDP
    • Pulmonary edema when LA >25-30 mmHg
    • RV failure will develop if sudden death does not occur first
calculation of stenosis
Calculation of Stenosis
  • Gorlin equation: AV area (cm2)=

CO (L/min)/

Mean pressure gradient1/2

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

continuity equations
Continuity equations
  • AV area=LVOT velocity/AV velocity x LVOT area ---LVOT calculation can have errors because it’s an area squared.
  • AV area= CO/(HR x systolic ejection period x 44.3 x gradient in mmHG1/2) ---Gorlin equation weak under low CO states
  • Hakki equation—based on the fact that HR x sys ejection period x 44.3= 1000; therefore AV Area= CO/ sq root of gradient (mmHg)
pa cath
PA Cath
  • Because of increased LVEDP stretching the mitral annulus a prominent v wave can be observed with disease progression. LA hypertrophy develops and the A wave becomes prominent
  • Example to follow on next slide…
arterial line
Arterial line
  • Pulsus parvus (narrow pulse pressure)
  • Pulsus tardus (delayed upstroke)
  • These features make the wave appear overdampened
hemodynamic profile
Hemodynamic profile
  • AS– increase LV preload and SVR
    • Decrease HR
    • Keep contractile force and PVR constant
  • Preload – because of Decreased LV compliance as well as Increased LVEDP preload augmentation is needed
    • (caution with nitro)
hemodynamics continued
Hemodynamics continued
  • Heart rate– no extremes of HR
    • Increase HR = decreased coronary perfusion
    • Sinus rhythm important for added EF
  • Contractility
    • avoid B-blockers they can increase LVEDP and decrease CO
hemodynamics continued47
Hemodynamics continued
  • SVR– most of afterload is due to stenotic lesion, therefore it’s fixed.
    • If SBP is decreased the patient can develop subendocardial ischemia
    • Early alpha-adrengic agonists needed as treatment
  • PVR– this stays normal until very late in the disease process
toronto study
Toronto study
  • 1986-2000 of 49 pregnancies in women with AS
    • Mild AS (>1.5cm2 or grad<36mmHg)
    • Mod AS (1.0-1.5cm2 or grad 36-63mmHg)
    • Severe AS (<1.0cm2 or grad >63mmHg)
  • All women had functional NYHA class I or II disease when enrolled
  • 59% of patients, 29/49 had severe AS
  • 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;91:11
nyha functional classification
NYHA functional classification
  • Class I – Asymptomatic
  • Class II – Symptoms with greater than normal activity
  • Class III – Symptoms with normal activity
  • Class IV – Symptoms at rest
toronto study continued
Toronto study continued
  • 10% of severe AS patients (3/29) had early cardiac complications (pulmonary edema or atrial arrhythmias)…no complications in mild/mod groups
  • One pt. had AVA .5cm2, peak gradient 112mmHg, she developed pulmonary edema at 12 weeks had emergent aortic valvuloplasty then had a Ross procedure 4 years after delivery
  • The second pt. had gradient of 104mmHg; she had postpartum hemorrhage, hypotension and subsequent pulmonary edema. Resection of her subaortic membrane was performed 17 months after delivery.
  • The third pt had a bicuspid valve AVA .7cm2, gradient of 64mmHg, she had atrial arrhythmias during antepartum period. She underwent a Ross procedure 18 months postpartum.
toronto study continued51
Toronto Study continued
  • 8% mild/mod AS had cardiac surgery in follow-up and 41% of severe AS group had post-partum cardiac surgery…10% with severe AS had cardiac complications during pregnancy
  • 12 pregnancies complicated by preterm birth, resp. distress syndrome, IUGR
    • Rate is similar general population
  • No fetal or neonatal deaths
  • 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
brazilian study
Brazilian study
  • Study of 1000 women with heart disease followed between 1989-1999
  • HD-- Rheumatic HD 55.7%, Congenital HD 19.1%, Chagas disease 8.5%, arrhythmias 5.1% and cardiomyopathies 4.3%
  • A subset of patients who had moderate to severe AS experienced 68.5% maternal morbidity…i.e. CHF & angina
  • 2 needed Aortic valve replacement
  • 1 sudden death
  • 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 2003;26(3):135-42
anesthetic management goals
Anesthetic management goals
  • Maintain Normal Sinus Rhythm: up to 20% of CO is provided by atrial kick in a normal patient and possibly up to 40% in AS pts.
  • Maintain HR 70-90: Bradycardia decreases CO in pt with fixed stenotic lesion and tachycardia does not allow for diastolic filling of ventricles.
  • Generous preload: maintain at normal to high range.
anes management goals cont d
Anes. Management goals cont’d
  • Close hemodynamic monitoring: Arterial line and with moderate to severe stenosis- PA cath/TEE to help delineate hypovolemia from CHF. Be prepared for cardioversion urgently
    • Lidco may be useful
  • No Valsalva and minimize pain. These could affect preload and sympathetic response (HR, BP) and worsen her condition acutely.
  • Narcotic based anesthetic preferred in unstable or severe AS patients (50-100mcg/kg IV)
after hospital stay
After Hospital stay
  • Pt seen by cardiology follow up post-op and Cardiothoracic surgery…
  • She was recommended for valve surgery
  • Cardiology has sent her letters warning of sudden death as this patient has no longer been coming to her appointments and is currently lost to follow up…with no valve replacement