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3 . 2021

Replacement of the aortic valve and the ascending aorta in a patient at 27 weeks of gestation

Abstract

The article presents a clinical case of surgical correction of an ascending aortic aneurysm in combination with severe stenosis of the aortic valve in a 36-year-old pregnant woman at 27 weeks of gestation. Witt's procedure was performed (prosthetics of the aortic valve with a mechanical prosthesis and the ascending aorta with a dacron vascular prosthesis).

Cardiopulmonary bypass (CPB) was performed with normothermia, protection of the myocardium was carried out by warm blood cardioplegia selectively in the coronary arteries; CPB time was 70 min, aortic cross clamp period was 56 min, the total duration of the operation was 177 min. The length of stay in the intensive care unit was 2 days, in the hospital 15 days.

The postoperative period proceeded without complications; the woman was discharged from the hospital in a good condition. Pregnancy was saved, successfully prolonged and ended with a planned caesarean section (CS) at 38 weeks, the child (girl) was born healthy, weighing 3150 grams with an Apgar score of 8/8 points.

Keywords:cardiopulmonary bypass, pregnancy, bicuspid aortic valve

Funding. The study had no sponsor support.
Conflict of interest. The authors declare no conflict of interest.
For citation: Bazylev V.V., Evdokimov M.E., Voevodin A.B., Pantyuhina M.A., Berezina E.G. Replacement of the aortic valve and the ascending aorta in a patient at 27 weeks of gestation. Clinical and Experimental Surgery. Petrovsky Journal. 2021; 9 (3): 136-42. DOI: https://doi.org/10.33029/2308-1198-2021-9-3-136-142 (in Russian)

References

1.    Wanga S., Silversides C., Dore A., De Waard V., Mulder B. Pregnancy and thoracic aortic disease: managing the risks. Can J Cardiol. 2016; 32 (1): 78-85. DOI: https://doi.org/10.1016/j.cjca.2015.09.003

2.    Nishimura R., Otto C., Bonow R., Carabello B., Erwin J., Guyton R., et al.; American College of Cardiol-ogy/American Heart Association Task Force on Practice Guidelines. 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2014; 63 (22): 57-185. DOI: https://doi.org/10.1016/j.jacc.2014.02.536

3.    Meierhofer C., Schneider E., Lyko C., Hutter A., Martinoff S., Markl M., et al. Wall shear stress and flow patterns in the ascending aorta in patients with bicuspid aortic valves differ significantly from tricuspid aortic valves: a prospective study. Eur Heart J Cardiovasc Imaging. 2013; 14 (8): 797-804. DOI: https://doi.org/10.1093/ehjci/jes273

4.    Michelena H., Desjardins V., Avierinos J. Russo A., Nkomo V., Sundt T., et al. Natural history of asymptomatic patients with normally functioning or minimally dysfunctional bicuspid aortic valve in the community. Circulation 2008; 117: 2776-84. DOI: https://doi.org/10.1161/CIR-CULATIONAHA.107.740878

5.    Braverman A., Beardslee M., Otto C., Bonow R. The bicuspid aortic valve: pregnancy and the bicuspid aortic valve. In: Valvular Heart Disease: a Companion to Braunwald’s Heart Disease. 3rd ed. Philadelphia: Saun-ders/Elsevier, 2009: 169-86.

6.    Elkayam U., Goland S., Pieper P., Silversides C., et al. High-risk cardiac disease in pregnancy: part II. J Am Coll Cardiol. 2016; 68 (5): 502-16. DOI: https://doi.org/10.1016/j.jacc.2016.05.050

7.    Immer F., Bansi A., Mc Dougall J., Zehr K., Schaff H., Carrel T., et al. Aortic dissection in pregnancy: analysis of risk factors and outcome. Ann Thorac Surg. 2003; 76:    309-14. DOI: https://doi.org/10.1016/S0003-4975(03)00169-3

8.    Regitz-Zagrosek V., Roos-Hesselink J., Bauer-sachs J., Blomstrom-Lundqvist C., Cffkova R., De Bonis M., et al. 2018 ESC guidelines for the management of cardiovascular diseases during pregnancy. The Task Force for the Management of Cardiovascular Diseases during Pregnancy of the European Society of Cardiology (ESC). Eur Heart J. 2018; 39 (34) 3165-241. DOI: https://doi.org/10.1093/eurheartj/ehy340

9.    Pisano C., Maresi E., Balistreri C., Candore G., Merlo D., Fattouch K., et al. Histological and genetic studies in patients with bicuspid aortic valve and ascending aorta complications. Interact Cardiovasc Thorac Surg. 2012; 14 (3). DOI: https://doi.org10.1093/icvts/ivr114

10.    Pape L., Tsai T., Isselbacher E., Oh J., O’gara P., Evangelista A., et al.; International Registry of Acute Aortic Dissection (IRAD) Investigators. Aortic diameter > 5.5 cm is not a good predictor of type A aortic dissection: observations from the International Registry of Acute Aortic Dissection (IRAD). Circulation. 2007; 116: 1120-7. DOI: https://doi.org/10.1161/CIRCULA-TIONAHA.107.702720

11.    Braverman A., Mittauer E., Harris K., Evangelista A., Pyeritz R., Brinster D. Clinical features and outcomes of pregnancy-related acute aortic dissection. JAMA Cardiol. 2020; Oct 14; e204876. DOI: https://doi.org/10.1001/jamacardio.2020.4876

12.    Neri E., Barabes L., Buklas D., Vricella L., Ben-venuti A., Tucci E., et al. Limited role of aortic size in the genesis of acute type A aortic dissection. Eur J Cardio-thorac Surg. 2005; 28 (6): 857-63. DOI: https://doi.org/10.1016/j.ejcts.2005.10.013

13.    Yuan S. Bicuspid aortic valve in pregnancy. Taiwan J Obstet Gynecol. 2014; 53 (4) 476-80.

14.    Aburawi E., O’Sullivan J. Relation of aortic root dilatation and age in Marfan’s syndrome. Eur Heart J. 2007; 28: 376-9. DOI: https://doi.org/10.1093/eur-heartj/ehl457

15.    Kim W., Kim D., Hong J. Acute aortic dissection in pregnancy with the Marfan syndrome. Korean J Thorac Cardiovasc Surg. 2014; 47 (3): 291-3. DOI: https://doi.org/10.5090/kjtcs.2014.47.3.291

16.    Kapoor M. Cardiopulmonary bypass in pregnancy. Ann Card Anaesth. 2014; 17: 33-9. DOI: https://doi.org/10.4103/0971-9784.124133

17.    Yates M., Soppa G., Smelt J., Fletcher N., Van Be-souw J., Thilaganathan B., et al. Perioperative management and outcomes of aortic surgery during pregnancy. J Thorac Cardiovasc Surg. 2015; 149: 607-10. DOI: https://doi.org/10.1016/jjtcvs.2014.10.038

18.    Guo С., Xu D., Wang C. Successful treatment for acute aortic dissection in pregnancy - Bentall procedure concomitant with cesarean section. J Cardiothorac Surg. 2011; 6: 139. DOI: https://doi.org/10.1186/1749-80906-139

19.    Ayad S., Hassanein M., Mohamed E., Gohar A. Maternal and fetal outcomes in pregnant women with a prosthetic mechanical heart valve. Clin Med Insights Cardiol. 2016; 10: 11-7. DOI: https://doi.org/10.4137/CMC.S36740

20.    Vause S., Clarke B., Tower C., Hay C., Knight M. Pregnancy outcomes in women with mechanical prosthetic heart valves: a prospective descriptive population-based study using the United Kingdom Obstetric Surveillance System (UKOSS) data collection system. BJOG. 2017; 124 (9): 1411-9. DOI: https://doi.org/10.1111/1471-0528.14478

21.    Yang P., Zhang J., Li Y., Wang H., Zheng J. Maternal and fetal outcomes with aortic dissection in pregnant patients with Marfan syndrome. Zhonghua Fu Chan Ke Za Zhi. 2015; 50 (5): 334-40.

22.    John A., Gurley F., Schaff H., Warnes C., Phillips S., Arendt K., et al. Cardiopulmonary bypass during pregnancy. Ann Thorac Surg. 2011; 91: 1191-6. DOI: https://doi.org/10.1016/j.athoracsur. 2010.11.037

23.    Yuan S. Indications for cardiopulmonary bypass during pregnancy and impact on fetal outcomes. Geburt-shilfe Frauenheilkd. 2014; 74 (1): 55 - 62. DOI: https://doi.org/10.1055/s-0033-1350997.

24.    Lin T., Chiu K., Shieh J., Chu S. Emergency redo mitral valve replacement in a pregnant woman at third trimester: case report and literature review. Circ J. 2008; 72: 1715-7. DOI: https://doi.org/10.1253/circj.cj-07-0775

25.    Pomini F., Mercogliano D., Cavalletti C., Caruso A., Pomini P. Cardiopulmonary bypass in pregnancy. Ann Thorac Surg. 1996; 61: 259-68.

26.    Champsaur G., Parisot P., Martinot S., Ninet J., Robin J., Ovize M., et al. Pulsatility improves hemodynamics during fetal bypass. Experimental comparative study of pulsatile versus steady flow. Circulation. 1994; 90: 47-50.

27.    Vedrinne C., Tronc F., Martinot S., Robin J., All-evard A., Vincent M., et al. Better preservation of endothelial function and decreased activation of the fetal renin-angiotensin pathway with the use of pulsatile flow during experimental fetal bypass. J Thorac Cardiovasc Surg. 2000; 120: 770-7. DOI: https://doi.org/10.1067/mtc.2000.108902

28.    Goland S., Elkayam U. Pregnancy and Marfan syndrome. Ann Cardiothorac Surg. 2017; 6(6): 642-653. https://dx.doi.org/10.21037/acs.2017.10.07.

29.    Levinson G., Shnider S., De Lorimier A., Stef-fenson J. Effects of maternal hyperventilation on uterine blood flow and fetal oxygenation and acid base status. Anesthesiology. 1974; 40(4): 340-347.

30.    Cauldwell M., Johnson M., Jahangiri M, Roos -Hesselink J. Cardiac interventions and cardiac surgery and pregnancy. Int J Cardiol. 2019; 276: 43-47. https://dx.doi.org/10.1016/j.ijcard.2018.09.100.

31.    Liu Y., Han F., Zhuang J., Liu X., Chen J., Huang H., et al. Cardiac operation under cardiopulmonary bypass during pregnancy. J Cardiothorac Surg. 2020; 15(1): 92.  https://dx.doi.org/10.1186/s13019-020-01136-9.

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CHIEF EDITOR
CHIEF EDITOR
Sergey L. Dzemeshkevich
MD, Professor (Moscow, Russia)

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