Abstract Body (Do not enter title and authors here): Introduction
Valvular heart disease affects approximately 1% of pregnant women, with left-sided obstructive lesions such as severe symptomatic aortic stenosis (AS) carrying the highest risk. In AS patients of childbearing age, 95% have bicuspid aortic valve (BAV). For preconception intervention, percutaneous balloon aortic valvuloplasty (PBAV) is often favored over surgical valve replacement. This decision becomes more nuanced when a symptomatic patient is pregnant, as we need to weigh the benefits of relieving obstruction with the risks of fetal radiation exposure.
Description of Case
32 year old female with BAV presented pregnant at 10 weeks gestation with new symptomatic severe AS, mean gradient 49 mmHg, aortic valve area (AVA) 0.72 cm2. She reported dyspnea with minimal exertion and an episode of presyncope. After multidisciplinary meeting between congenital cardiology, obstetrics and cardiac anesthesia, decision was made to pursue PBAV. At 17 weeks gestation, she was placed under general anesthesia, after which a TEE was performed for aortic annulus sizing. A 10 Fr x 80 cm sheath was placed in the left femoral artery for catheter and wire exchange without need for fluoroscopy. Under TEE guidance, we crossed the stenotic valve via retrograde approach. Based on measured annulus size, we advanced a 20 mm VIDA balloon across the aortic valve and inflated the balloon to nominal volume with simultaneous rapid pacing. There was mild-moderate AS with moderate aortic regurgitation after PBAV, AVA 1.27 cm2. Total radiation exposure was 5 mGy with maximum collimation, low fluoroscopy frame rates and use of "fluoro-store". Patient tolerated procedure well without complications and was seen in follow up visit with significantly improved exercise capacity.
Discussion
Studies have shown that interventions should be avoided during the first trimester of pregnancy when there is highest risk of fetal radiosensitivity, and to limit radiation exposure dose to less than 50 mGy. Our case demonstrates that transcatheter interventions can be safely performed during early second trimester of pregnancy with minimal radiation exposure and optimal results, with the use of multimodality imaging guidance and good radiation safety habits. It should be noted that any intervention can still pose a non-negligible risk to mother and fetus and should only be performed in symptomatic patients refractory to medical therapy, with consensus by a multidisciplinary cardio-obstetrics team.