Anesthetic Management of a Pregnant Patient With Mixed Aortic Valve Disease Undergoing Cesarean Section

Aortic stenosis is a condition with multiple etiologies that can remain clinically silent for years. The enhanced cardiovascular demands of pregnancy can unmask a previously undetected disease or worsen existing symptoms. Managing anesthesia in pregnant patients with cardiac valvular disease is a complex task that requires a coordinated, multidisciplinary approach. This case report presents a 28-year-old pregnant Hispanic patient with known severe aortic stenosis who was admitted to our hospital at 30 weeks of gestation for multidisciplinary management and delivery planning. Her only symptom was dyspnea, classified as NYHA class II. Upon admission, a transesophageal echocardiogram (TEE) revealed severe subvalvular aortic stenosis caused by a membrane and moderate aortic valve regurgitation with a preserved left ventricular ejection fraction.  Initially, a cesarean section was planned due to breech presentation. The procedure was scheduled for 34 weeks but postponed to 36 weeks of gestational age due to the patient's stable hemodynamic status. The anesthetic approach was a combined spinal-epidural technique that provided better hemodynamic stability and effective pain control and minimized the risk of broncho-aspiration and the maternal-fetal transfer of obstetric drugs associated with general anesthesia. Careful patient selection and continuous hemodynamic monitoring were essential to avoid complications and guarantee a successful outcome. This approach proved to be safe and effective for our patient. This case highlights the importance of a multidisciplinary team approach in managing pregnant patients with cardiac disease. It also demonstrated that combined spinal-epidural anesthesia is a safe and viable option for anesthesiologists caring for these patients.