aortic stenosis pregnancy

8/18/2019 Aortic Stenosis Pregnancy

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Aortic Stenosis in Pregnancy Aortic Stenosis in Pregnancy

Brendan Astley MDBrendan Astley MD

&& Norman Bolden MDNorman Bolden MD

Nov 2006


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18 year old G1P0 Spanis18 year old G1P0 Spanis

spea!ing "emalespea!ing "emale

PM#$ %#eart condition since age 12 'no "(rterPM#$ %#eart condition since age 12 'no "(rter

"ollo)$(p*"ollo)$(p*

S+B and ,P at rest and e-ertion )orse over lastS+B and ,P at rest and e-ertion )orse over last

t)o yearst)o years

PS#$ nonePS#$ none

Medications$ PN.Medications$ PN.

Allergies$ N/DA Allergies$ N/DA#$ (n!no)n#$ (n!no)n

S#$ no toacco 3t+# or dr(g (seS#$ no toacco 3t+# or dr(g (se


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Pysical 3-amPysical 3-am

.itals BP 104562 # 7 temp 96:6 18.itals BP 104562 # 7 temp 96:6 18

sat 100;sat 100;

#eigt 4 ?.5.? systolic m(rm(r@ cresendo$decresendom(rm(r )it no diastolic component eard est at m(rm(r )it no diastolic component eard est at (pper sternal order radiation to carotids ilaterally no(pper sternal order radiation to carotids ilaterally no.D no 9.D no 9rdrd or 4or 4tt eart so(ndeart so(nd

Air)ay> nml Mal ? Air)ay> nml Mal ?

(ngs> ,CA Bil: no )5r5r (ngs> ,CA Bil: no )5r5r Ad> NC gravid (ter(s so"t Ad> NC gravid (ter(s so"t

3-t> no edema good p(lses distally3-t> no edema good p(lses distally


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as B positiveas B positive

BNP E:EBNP E:E

=B, 8:71 #g 12:E #ct=B, 8:71 #g 12:E #ct

96:8 Plts 2E696:8 Plts 2E6Na 196 / 9: ,l 108Na 196 / 9: ,l 108

,+,+22 21 BFN E ,r 0:E21 BFN E ,r 0:E

Gl( 71Gl( 71

,a 8:E,a 8:ECS# 0: P N #?.CS# 0: P N #?.

. imm(ne ? G,5. imm(ne ? G,5

clam ep B all negativeclam ep B all negative

Plan Admit to antepart(mPlan Admit to antepart(m(nit 'social admission* to(nit 'social admission* to"acilitate cons(ltations y"acilitate cons(ltations yMaternal5etal MedicineMaternal5etal Medicine

,ardiology N?,F and,ardiology N?,F and Anestesiology: Anestesiology:


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,ardiology,ardiology

M(rm(r appreciated and eco per"ormed onM(rm(r appreciated and eco per"ormed on51E so)ing AS H:6cm51E so)ing AS H:6cm22 proale ic(spid proale ic(spidvalve and 3 6E;:valve and 3 6E;:

Pt "ollo)ed "or cange in symptoms@:Pt "ollo)ed "or cange in symptoms@:Mid +ct: at ao(t 9E )!s: Gestation seMid +ct: at ao(t 9E )!s: Gestation secomplains o" increased ,P and S+B especiallycomplains o" increased ,P and S+B especially)it e-ertion (t also at rest:)it e-ertion (t also at rest:

:1;$1:4; pregnancies )it clinically signi"icant:1;$1:4; pregnancies )it clinically signi"icantcardiac prolemscardiac prolems

Mortality "rom tese :E;$2:7;Mortality "rom tese :E;$2:7;


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,ardio cont


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3-pected 3/G canges )it AS3-pected 3/G canges )it AS

Left ventricular hypertrophy (LVH)Left ventricular hypertrophy (LVH)

There are many different criteria for LVH.There are many different criteria for LVH.

Sokolow + LyonSokolow + Lyon (Am Heart J, 1949;37:161(Am Heart J, 1949;37:161 > S V1+ R V5 or V6 > 35 S V1+ R V5 or V6 > 35

!ornell criteria!ornell criteria (!irc"#ation, 19$7;3: %6%&7'(!irc"#ation, 19$7;3: %6%&7'

> SV3 + R avl > "# in enSV3 + R avl > "# in en > SV3 + R avl > "$ in woenSV3 + R avl > "$ in woen

%rain&ha criteria%rain&ha criteria (!irc"#ation,199; $1:$1%&$'(!irc"#ation,199; $1:$1%&$' > R avl > 11' R V6 > "5R avl > 11' R V6 > "5 > S V13 > "5 ' S V1 or V" +S V13 > "5 ' S V1 or V" + > R V5 or V6 > 35 ' R * + S *** > "5 R V5 or V6 > 35 ' R * + S *** > "5

Rohilt + ,te,Rohilt + ,te, (Am Heart J, 19$6:7%:7%'&%$(Am Heart J, 19$6:7%:7%'&%$ > -oint ,core ,y,te-oint ,core ,y,te

Left atrial a.norality (/ilatation or hypertrophy)Left atrial a.norality (/ilatation or hypertrophy)

0 ,hape/ - wave in lea/ **0 ,hape/ - wave in lea/ **

proinent terinal ne&ative coponent to - wave in lea/ V1proinent terinal ne&ative coponent to - wave in lea/ V1


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K S(ggestions "or Anestetic PlanK S(ggestions "or Anestetic Plan

Anestesia "or .aginal Delivery Anestesia "or .aginal Delivery

Monitors "or .aginal deliveryMonitors "or .aginal delivery

Anestesia "or ,5S Anestesia "or ,5S

Monitors "or ,5S:Monitors "or ,5S:

Maternal$etal Medicine ,ardiology N?,F andMaternal$etal Medicine ,ardiology N?,F and

Anestesia develop )or!ing plan: Anestesia develop )or!ing plan:LLL?" possile avoid ,5S: ?" vaginal deliveryLLL?" possile avoid ,5S: ?" vaginal deliverym(st avoid valsalva:m(st avoid valsalva:


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Ne(roa-ial anestesia@Ne(roa-ial anestesia@

> ,ontin(o(s Spinal,ontin(o(s Spinal

Single sot spinal not reasonale "or prolonged laor Single sot spinal not reasonale "or prolonged laor

eliale loc!eliale loc!?ntratecal narcotics avoid te sympatectic loc! )it?ntratecal narcotics avoid te sympatectic loc! )it

ens(ing ypotensionens(ing ypotension

?ntratecal narcotics not e""ective "or second stage o" laor:?ntratecal narcotics not e""ective "or second stage o" laor:

Small doses o" intratecal As added to narcotics improveSmall doses o" intratecal As added to narcotics improve

analgesia )ile limiting emodynamic conseI(ences:analgesia )ile limiting emodynamic conseI(ences:,ance "or spinal eadace,ance "or spinal eadace


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Ne(roa-ial anestesia@Ne(roa-ial anestesia@

> 3pid(ral3pid(ral

Pros@titratale to prod(ce minimal emodynamicPros@titratale to prod(ce minimal emodynamic

canges adeI(ate anestesia possile "or vaginalcanges adeI(ate anestesia possile "or vaginalor ,$section i" per"ormed properly no spinalor ,$section i" per"ormed properly no spinal

eadaceseadaces

,ons@iger "ail(re rate compared )it spinal,ons@iger "ail(re rate compared )it spinal


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?. Narcotic analgesia 'P,A*?. Narcotic analgesia 'P,A* > Pros@)o(ld o""er patient some analgesiaPros@)o(ld o""er patient some analgesia

'most still report 8$10510 pain despite'most still report 8$10510 pain despiteentanyl P,A*entanyl P,A*

> ,ons@ espiratory Depression 'moter and,ons@ espiratory Depression 'moter and"et(s* Sedation 'moter and "et(s* N5."et(s* Sedation 'moter and "et(s* N5.decreased eat to eat variaility on "etaldecreased eat to eat variaility on "etaleart rate tracing:eart rate tracing:

> ,ons@:=o(ld not e""ectively control te pain,ons@:=o(ld not e""ectively control te pain"rom second stage o" laor and tere"ore"rom second stage o" laor and tere"ore)o(ld not atten(ate te increase in #)o(ld not atten(ate te increase in #associated )it delivery:associated )it delivery:


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Stages o" aor Stages o" aor

11stst stage > 2 pasesstage > 2 pases

> latent pase encompasses te onset o" painlatent pase encompasses te onset o" pain

to te "irst noticed cange in cervical dilationto te "irst noticed cange in cervical dilation

> Ma-imal dilation pase@egins aro(nd 9 cmMa-imal dilation pase@egins aro(nd 9 cm

22ndnd stage > Ma-imal cervical dilation 10cmstage > Ma-imal cervical dilation 10cm

(ntil delivery o" "et(s(ntil delivery o" "et(s

99rdrd stage > A"ter delivery o" "et(s (ntilstage > A"ter delivery o" "et(s (ntil

delivery o" placentadelivery o" placenta


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Board (estionsKKBoard (estionsKK

D(ring te "irst stage o" laor te pain o"D(ring te "irst stage o" laor te pain o"(terine contractions is transmitted via(terine contractions is transmitted viaspinal cord segments::spinal cord segments::

> A@C6 to 1 A@C6 to 1 > B@C6 to EB@C6 to E

> ,@C10 to 1,@C10 to 1

> D@C10 to S1D@C10 to S1 > 3@C10 to SE3@C10 to SE

Ans)er is@:, Ans)er is@:,


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Anestesia "or ,$section Anestesia "or ,$section

General anestesia@General anestesia@

> Pros@good air)ay control minimal emodynamicPros@good air)ay control minimal emodynamic

canges compared to epid(ral5spinal ol(ses to startcanges compared to epid(ral5spinal ol(ses to start

case can treat emodynamic canges rapidly )itcase can treat emodynamic canges rapidly )itclose monitoringclose monitoring

> ,ons@possile di""ic(lt air)ay aspiration ris!s,ons@possile di""ic(lt air)ay aspiration ris!s

tacycardia and5or ypertension on ind(ction ortacycardia and5or ypertension on ind(ction or

emergence ca(tion )it volatile agents andemergence ca(tion )it volatile agents and

ypotension or myocardial depressionypotension or myocardial depression


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#ospital ,o(rse#ospital ,o(rse

?nd(ced to & D at 9E )ee!s:?nd(ced to & D at 9E )ee!s:

Arterial line placed Arterial line placed

S)an$Gan cateter placedS)an$Gan cateter placed3arly epid(ral also placed y anestesia3arly epid(ral also placed y anestesia

,ontin(o(s Celemetry monitoring,ontin(o(s Celemetry monitoring

Pitocin )as started on te nigt o" 1157Pitocin )as started on te nigt o" 1157and y morning se )as )ell dilated andand y morning se )as )ell dilated and

contracting reg(larlycontracting reg(larly


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P,=P5,.P readingsP,=P5,.P readings

11571157

1E0rs P,=P 10$11 ,.P E$7 good F+P1E0rs P,=P 10$11 ,.P E$7 good F+P

2990r P,=P 10$192990r P,=P 10$19

115811580100 P,=P 7$@complains o" ,P0100 P,=P 7$@complains o" ,P

0900,.P 1E$16 trop :1E0900,.P 1E$16 trop :1E

0E00 P,=P 11$1E ,+ E5min0E00 P,=P 11$1E ,+ E5min0800 trop H:1 'nml*0800 trop H:1 'nml*

=edge maintained in aove normal range=edge maintained in aove normal range

Delivery at 1190amDelivery at 1190am


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#ospital ,o(rse cont


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#ospital ,o(rse cont


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Pysiologic ,anges d(ringPysiologic ,anges d(ring

pregnancypregnancy

Beginning to cange at E )ee!s@10 "oldBeginning to cange at E )ee!s@10 "old

increase in (terine lood "lo) at termincrease in (terine lood "lo) at term

,ardiovasc(lar Blood vol(me 9E; ,+,ardiovasc(lar Blood vol(me 9E; ,+

40$E0; S. 90; # 1E$20;40$E0; S. 90; # 1E$20;

,ardiovasc(lar S. 1E; sys and diastolic,ardiovasc(lar S. 1E; sys and diastolic

BP 10mm#gBP 10mm#g

P(lmonary ,anges +2 cons(mption 20;P(lmonary ,anges +2 cons(mption 20; 1E; M. E0; C. 40; alv vent: 70; 1E; M. E0; C. 40; alv vent: 70;

3. 20; , 20;3. 20; , 20;


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Aortic Stenosis Aortic Stenosis

?n te past e(matic .alv(lar degeneration?n te past e(matic .alv(lar degeneration)as te primary ca(se)as te primary ca(se

,ongenitally ic(spid valves ecome calci"ied,ongenitally ic(spid valves ecome calci"ied

and ca(se stenosis most commonly no)@'1$2;and ca(se stenosis most commonly no)@'1$2;o" pop(lation*o" pop(lation*

Senile degeneration can also occ(r Senile degeneration can also occ(r

90; o" patients older tan 8E ave signi"icant90; o" patients older tan 8E ave signi"icant

cangescangesis! "or s(dden deat )it AS increases )enis! "or s(dden deat )it AS increases )engrad: E0mm#g and ori"ice less tan :8cmgrad: E0mm#g and ori"ice less tan :8cm22


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Normal AnatomyNormal Anatomy


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Aortic stenosis Anatomy Aortic stenosis Anatomy


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AS 2D eco AS 2D eco


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SymptomsSymptoms

e(matic AS patients may remaine(matic AS patients may remain

asymptomatic "or 40 yearsasymptomatic "or 40 years

Bic(spid valve patients )ill developBic(spid valve patients )ill develop

symptoms et)een 1E$6E years o" agesymptoms et)een 1E$6E years o" age

,alci"ications o" te valve (s(ally occ(r,alci"ications o" te valve (s(ally occ(r

a"ter age 90a"ter age 90

C#3 C?AD@:C#3 C?AD@:


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Ce triad@Ce triad@

Any one o" tese symptoms eing present Any one o" tese symptoms eing present

is omino(s and te patient


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Angina Angina

Cis is te initial symptom in E0$70; o"Cis is te initial symptom in E0$70; o"

patients: Most commonly occ(rring )itpatients: Most commonly occ(rring )it

e-ertione-ertion

May e present )ito(t ,AD 5c o"@May e present )ito(t ,AD 5c o"@

> ?ncreased myocardial +?ncreased myocardial +22 cons(mption )itcons(mption )it

increased myocardial tic!ness and increasedincreased myocardial tic!ness and increased

a"terloada"terload > Also increased .3DP impairing "lo) to Also increased .3DP impairing "lo) to

s(endocardial layerss(endocardial layers


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SyncopeSyncope

irst symptom in 1E$90; o" patientsirst symptom in 1E$90; o" patients

+nce tis occ(rs te average li"e+nce tis occ(rs te average li"e

e-pectancy is 9$4 yearse-pectancy is 9$4 years

+rigin o" syncope is controversial+rigin o" syncope is controversial

o)ever it may e related too)ever it may e related to

(ncompensated decrease in S. )it(ncompensated decrease in S. )it

e-ercisee-ercise


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,#,#

D(e to diastolic dys"(nction 'increased .D(e to diastolic dys"(nction 'increased .tic!ness* or systolic dys"(nction 'increasedtic!ness* or systolic dys"(nction 'increaseda"terload or decreased myocardial contractility*a"terload or decreased myocardial contractility*

+nce . "ail(re occ(rs te average li"e+nce . "ail(re occ(rs te average li"ee-pectancy is 1$2 yearse-pectancy is 1$2 years

All AS patients are at increased ris! o" s(dden All AS patients are at increased ris! o" s(ddendeat as previo(sly stated and@:deat as previo(sly stated and@:

+nly 18; o" patients are alive E years a"ter te+nly 18; o" patients are alive E years a"ter tepea! systolic gradient is E0mm#g or te ori"icepea! systolic gradient is E0mm#g or te ori"iceH0:7cmH0:7cm22


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PatopysiologyPatopysiology

Stage 1 asymptomaticRmild stenosisStage 1 asymptomaticRmild stenosis

> Normal stro!e vol(me maintained as gradientNormal stro!e vol(me maintained as gradient

et)een . and aorta increaseset)een . and aorta increases

> #iger gradient res(lts in concentric .#iger gradient res(lts in concentric .

ypertropyypertropy


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Stage 2 moderate stenosisRsymptomaticStage 2 moderate stenosisRsymptomatic

> Dilation as )ell as ypertropy occ(r in tisDilation as )ell as ypertropy occ(r in tis

stagestage

> Decreased 3 may e noted 'd(e toDecreased 3 may e noted 'd(e to

decreased contractility*decreased contractility*

> ?ncreased .3DP and .3D. leads to?ncreased .3DP and .3D. leads to

increased myocardial )or! and +2increased myocardial )or! and +2cons(mption@:at ris! myocardi(mcons(mption@:at ris! myocardi(m


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Stage 9 critical ASStage 9 critical AS

> .alve area is less tan :Ecm.alve area is less tan :Ecm225m5m22 and 3and 3

decreases "(rter )it "(rter increases indecreases "(rter )it "(rter increases in

.3DP.3DP > P(lmonary edema )en A 2E$90 mm#gP(lmonary edema )en A 2E$90 mm#g

> . "ail(re )ill develop i" s(dden deat does. "ail(re )ill develop i" s(dden deat does

not occ(r "irstnot occ(r "irst


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,alc(lation o" Stenosis,alc(lation o" Stenosis

Gorlin eI(ation A. area 'cmGorlin eI(ation A. area 'cm22**

,+ '5min*5,+ '5min*5

Mean press(re gradientMean press(re gradient152152

Cis is te simpli"ied version o" te GorlinCis is te simpli"ied version o" te Gorlin

eI(ation '#a!!i eI(ation*eI(ation '#a!!i eI(ation*


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,ontin(ity eI(ations,ontin(ity eI(ations

A. area.+C velocity5A. velocity - .+C area A. area.+C velocity5A. velocity - .+C area

$$$.+C calc(lation can ave errors eca(se it


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PA ,atPA ,at

Beca(se o" increased .3DP stretcingBeca(se o" increased .3DP stretcing

te mitral ann(l(s a prominent v )ave cante mitral ann(l(s a prominent v )ave can

e oserved )it disease progression: Ae oserved )it disease progression: A

ypertropy develops and te A )aveypertropy develops and te A )aveecomes prominentecomes prominent

3-ample to "ollo) on ne-t slide@3-ample to "ollo) on ne-t slide@


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Arterial line Arterial line

P(ls(s parv(s 'narro) p(lse press(re*P(ls(s parv(s 'narro) p(lse press(re*

P(ls(s tard(s 'delayed (pstro!e*P(ls(s tard(s 'delayed (pstro!e*

Cese "eat(res ma!e te )ave appearCese "eat(res ma!e te )ave appear

overdampenedoverdampened


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#emodynamic pro"ile#emodynamic pro"ile

AS> increase . preload and S. AS> increase . preload and S.

> Decrease #Decrease #

> /eep contractile "orce and P. constant/eep contractile "orce and P. constant

Preload > eca(se o" Decreased .Preload > eca(se o" Decreased .

compliance as )ell as ?ncreased .3DPcompliance as )ell as ?ncreased .3DP

preload a(gmentation is neededpreload a(gmentation is needed

> 'ca(tion )it nitro*'ca(tion )it nitro*


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#emodynamics contin(ed#emodynamics contin(ed

#eart rate> no e-tremes o" ##eart rate> no e-tremes o" #

> ?ncrease # decreased coronary per"(sion?ncrease # decreased coronary per"(sion

> Sin(s rytm important "or added 3Sin(s rytm important "or added 3

,ontractility,ontractility

> avoid B$loc!ers tey can increase .3DPavoid B$loc!ers tey can increase .3DP

and decrease ,+and decrease ,+


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#emodynamics contin(ed#emodynamics contin(ed

S.> most o" a"terload is d(e to stenoticS.> most o" a"terload is d(e to stenotic

lesion tere"ore it


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Coronto st(dyCoronto st(dy

186$2000 o" 4 pregnancies in )omen186$2000 o" 4 pregnancies in )omen)it AS)it AS > Mild AS '1:EcmMild AS '1:Ecm22 or gradH96mm#g*or gradH96mm#g*

> Mod AS '1:0$1:EcmMod AS '1:0$1:Ecm22 or grad 96$69mm#g*or grad 96$69mm#g* > Severe AS 'H1:0cmSevere AS 'H1:0cm22 or grad 69mm#g*or grad 69mm#g*

All )omen ad "(nctional NQ#A class ? or All )omen ad "(nctional NQ#A class ? or

?? disease )en enrolled?? disease )en enrolledE; o" patients 254 ad severe ASE; o" patients 254 ad severe ASSilversides ,:/: ,olman :M: Sermer M: arine D: S(i S: ,: 3arly and intermediate$term o(tcomes o" pregnancy )it congential aorticSilversides ,:/: ,olman :M: Sermer M: arine D: S(i S: ,: 3arly and intermediate$term o(tcomes o" pregnancy )it congential aorticstenosis: American o(rnal o" ,ardiology 2009U111stenosis: American o(rnal o" ,ardiology 2009U111


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NQ#A "(nctional classi"icationNQ#A "(nctional classi"ication

,lass ? > Asymptomatic,lass ? > Asymptomatic

,lass ?? > Symptoms )it greater tan,lass ?? > Symptoms )it greater tan

normal activitynormal activity

,lass ??? > Symptoms )it normal activity,lass ??? > Symptoms )it normal activity

,lass ?. > Symptoms at rest,lass ?. > Symptoms at rest


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Coronto st(dy contin(edCoronto st(dy contin(ed

10; o" severe AS patients '952* ad early cardiac10; o" severe AS patients '952* ad early cardiaccomplications 'p(lmonary edema or atrial arrytmias*@complications 'p(lmonary edema or atrial arrytmias*@no complications in mild5mod gro(psno complications in mild5mod gro(ps

+ne pt: ad A.A :Ecm+ne pt: ad A.A :Ecm22 pea! gradient 112mm#g sepea! gradient 112mm#g sedeveloped p(lmonary edema at 12 )ee!s ad emergentdeveloped p(lmonary edema at 12 )ee!s ad emergent

aortic valv(loplasty ten ad a oss proced(re 4 yearsaortic valv(loplasty ten ad a oss proced(re 4 yearsa"ter deliverya"ter delivery

Ce second pt: ad gradient o" 104mm#gU se adCe second pt: ad gradient o" 104mm#gU se adpostpart(m emorrage ypotension and s(seI(entpostpart(m emorrage ypotension and s(seI(entp(lmonary edema: esection o" er s(aortic memranep(lmonary edema: esection o" er s(aortic memrane

)as per"ormed 17 monts a"ter delivery:)as per"ormed 17 monts a"ter delivery:

Ce tird pt ad a ic(spid valve A.A :7cmCe tird pt ad a ic(spid valve A.A :7cm22 gradient o" gradient o"64mm#g se ad atrial arrytmias d(ring antepart(m64mm#g se ad atrial arrytmias d(ring antepart(mperiod: Se (nder)ent a oss proced(re 18 montsperiod: Se (nder)ent a oss proced(re 18 monts

postpart(m:postpart(m:


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Coronto St(dy contin(edCoronto St(dy contin(ed

8; mild5mod AS ad cardiac s(rgery in "ollo)$8; mild5mod AS ad cardiac s(rgery in "ollo)$

(p and 41; o" severe AS gro(p ad post$(p and 41; o" severe AS gro(p ad post$

part(m cardiac s(rgery@10; )it severe ASpart(m cardiac s(rgery@10; )it severe AS

ad cardiac complications d(ring pregnancyad cardiac complications d(ring pregnancy12 pregnancies complicated y preterm irt12 pregnancies complicated y preterm irt

resp: distress syndrome ?FGresp: distress syndrome ?FG

> ate is similar general pop(lationate is similar general pop(lation

No "etal or neonatal deatsNo "etal or neonatal deatsSilversides ,/ ,olman M Sermer M arine D Si( S,: 3arly and intermediate$term o(tcomesSilversides ,/ ,olman M Sermer M arine D Si( S,: 3arly and intermediate$term o(tcomes

o" pregnancy )it congenital aortic stenosis: Am ,ardiol 2009U1'11*1986$o" pregnancy )it congenital aortic stenosis: Am ,ardiol 2009U1'11*1986$


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Brailian st(dyBrailian st(dy

St(dy o" 1000 )omen )it eart diseaseSt(dy o" 1000 )omen )it eart disease"ollo)ed et)een 18$1"ollo)ed et)een 18$1

#D$$ e(matic #D EE:7; ,ongenital #D#D$$ e(matic #D EE:7; ,ongenital #D1:1; ,agas disease 8:E; arrytmias1:1; ,agas disease 8:E; arrytmias

E:1; and cardiomyopaties 4:9;E:1; and cardiomyopaties 4:9; A s(set o" patients )o ad moderate to A s(set o" patients )o ad moderate tosevere AS e-perienced 68:E; maternalsevere AS e-perienced 68:E; maternalmoridity@i:e: ,# & anginamoridity@i:e: ,# & angina

2 needed Aortic valve replacement2 needed Aortic valve replacement1 s(dden deat1 s(dden deat

Avila =S ossi 3G amires A Grinerg M Bortolotto M (gai M et al: Avila =S ossi 3G amires A Grinerg M Bortolotto M (gai M et al:Pregnancy in patients )it eart diseasee-perience )it 1000 cases: ,lin ,ardiolPregnancy in patients )it eart diseasee-perience )it 1000 cases: ,lin ,ardiol2009U26'9*19E$422009U26'9*19E$42


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Anestetic management goals Anestetic management goals

Maintain Normal Sin(s ytm (p to 20;Maintain Normal Sin(s ytm (p to 20;o" ,+ is provided y atrial !ic! in a normalo" ,+ is provided y atrial !ic! in a normalpatient and possily (p to 40; in AS pts:patient and possily (p to 40; in AS pts:

Maintain # 70$0 BradycardiaMaintain # 70$0 Bradycardiadecreases ,+ in pt )it "i-ed stenoticdecreases ,+ in pt )it "i-ed stenoticlesion and tacycardia does not allo) "orlesion and tacycardia does not allo) "ordiastolic "illing o" ventricles:diastolic "illing o" ventricles:

Genero(s preload maintain at normal toGenero(s preload maintain at normal toig range:ig range:


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Anes: Management goals cont


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A"ter #ospital stay A"ter #ospital stay

Pt seen y cardiology "ollo) (p post$opPt seen y cardiology "ollo) (p post$op

and ,ardiotoracic s(rgery@and ,ardiotoracic s(rgery@

Se )as recommended "or valve s(rgerySe )as recommended "or valve s(rgery

,ardiology as sent er letters )arning o",ardiology as sent er letters )arning o"

s(dden deat as tis patient as no longers(dden deat as tis patient as no longer

een coming to er appointments and iseen coming to er appointments and is

c(rrently lost to "ollo) (p@)it no valvec(rrently lost to "ollo) (p@)it no valve

replacementreplacement


58/58

aortic stenosis pregnancy

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