Aortic valve repair and arch replacement during pregnancy: a case report

A 25-year-old with a history of childhood rheumatic fever and resultant mild aortic insufficiency presented for routine prenatal care during her sixth pregnancy. At 14 weeks' gestation; a significant diastolic murmur was identified. Further evaluation revealed a massively dilated, aneurysmal aortic root, moderate to severe aortic insufficiency, and mild left ventricular hypertrophy. Because of the risk of sudden aneurysm rupture and the high mortality associated with this lesion, the patient was advised to undergo therapeutic abortion and aortic valve replacement with arch repair. The patient refused abortion but desired repair during pregnancy in spite of the increased fetal risk. At 17 weeks' gestation, aortic valve replacement and ascending aortic aneurysm excision were performed under pulsatile cardiopulmonary bypass and mild hypothermia. The patient's postoperative course and pregnancy proceeded uneventfully except for one episode of postpericardiotomy syndrome. A healthy, full-term male infant was delivered by spontaneous vaginal delivery. The carefully coordinated combination of obstetric and cardiovascular anesthesia contributed to this successful outcome for mother and child. The principles for fetal preservation and anesthetic considerations for pregnant women undergoing open heart surgery are reviewed.