- Email: [email protected]
Pregnancy following cardiac surgery
Pregnancy following cardiac surgery R I C H A R D L . B U R T, P H
•
D. , M. D .
ROBERT H. BOWDEN, JR., M.D. Winston-Salem, North Carolina
I T H A s long been recognized that the pregnant cardiac patient presents special problems in medical and obstetrical management. As emphasized by a number of authors, the cardinal prognostic problem when heart disease complicates pregnancy is assessment of the risk of congestive failure, the principal cause of death in these patients.4• 7 • 15 • 17 • 18 Various clinical indices, properly applied, are helpful in estimating the probability of a successful and productive outcome of pregnancy. These include the patient's functional classification, history of prior heart failure, age, presence or absence of cardiomegaly, and with particular reference to rheumatic heart disease, the place occupied by the patient in the natural history of the disease process. 4· 7 • 22 Despite capricious changes in cardiac status that may result from either normal or abnormal cardiovascular burdens coincidental to pregnancy, such criteria have provided a reasonable, if not precise, assessment of the patient's status and capability of success in the reproductive process. In the past, these prognostic guidelines have dictated not only the details of medical management but obstetrical treatment as well with particular reference to continuation of pregnancy, abortion, and sterilization.
Since the initial reports of Logan and Turner and of Brock in England3 ' 19 and of Cooley and Chapman in this country9 increasing interest has been fostered not only relative to the application of cardiac surgery during pregnancy, but to the changing perspectives concerning the feasibility of pregnancy under unfavorable conditions in cardiac patients to whom surgery has become available during the past decade. Although the indications for cardiac surgery in relation to pregnancy remain somewhat controversial, these new techniques have necessarily changed obstetrical concepts in many clinics concerning the place of abortion and/or sterilization in the management of the pregnant patient with heart disease. The cases summarized in Table I in no way resolve the debated points of management of the individual patient but indicate the potential benefits of surgery for selected patients in relation to reproduction. Comment
The cases presented are illustrative of our experience which is consistent with that of others in showing the possible benefits of cardiac surgery when applied to young women during the childbearing years. Our data are not so extensive as to permit generalizations or conclusions concerning still existent controversial issues, but in light of our experience and in consideration of the problems presented by the cardiac patient in pregnancy, a number of comments are permissible. Perhaps the widest application of cardiac surgery is that concerned with correction of valvular damage occasioned by rheumatic
From the Departments of Obstetrics and Gynecology, Bowman Gray School of Medicine, Wake Forest College, and the North Carolina Baptist Hospital. Presented by Invitation at the Twenty-sixth Annual Meeting of the South Atlantic Association of Obstetricians and Gynecologists, Bal Harbour, Florida, Jan. 26-29, 1964.
73
74
Burt and Bowden
\m.
Septt·mbc, l, J9b l J. Oh>t. & ( ;ynt·c.
Table I. Summary of clinical course of 11 cases ~~,-··-~~----------
I
I No. Patient I Dia({nosis
Age
O~era-1
Functional state I Before
tzon
Pregnancy
After
I oP.era- I oP.eraI
tzon
twn
Operative procedure
Operative result
Clinical coune
c. J.
Mitral stenosis
2.'i
26
II
I
Mitral valvotomy
Good
Pregnancy 1 year after surgery. Prenatal course, delivery and puerperium uneventful. Viable infant
2
H.P.
Mitral stenosis
28
28
IV
IV
Mitral valvotomy
Poor
First pregnancy with progressive pulmonary congestion since twelfth week. Conservative therapy in hospital at 22 weeks. Valvotomy at 23 weeks. Progressive deterioration and death 17 days postoperative
3
M.H. Mitral stenosis
32
34
III
I
Mitral valvotomy
Good
Pregnancy 2 years after surgery. Prenatal course normal until thirty-eighth week when complicated by severe pre-eclampsia. Blood pressure 160/100. Spontaneous labor in thirtyeighth week. Viable twins. Postpartum course morbid. Discharged well on twelfth postpartum day
4
A. P.
Mitral stenosis
27
29 32
III
I
Mitral valvotomy
Good
Normal pregnancy and delivery 2 years and 4 years after surgery. Viable infants. Five years after surgery deterioration to Class III
5
M.F. Mitral stenosis
33
34
III
II
Mitral valvot-
Fair
Uncomplicated pregnancy and delivery 1 year and 2 years after surgery. Viable infants. Maintenance of Class II functional class throughout
Mitral valvotomy
Good
Acute rheumatic carditis at age 24 and therapeutic abortion at 12 weeks. Valvotomy at age 25. Normal uncomplicated pregnancies at age 28 and 31
omy
I
6
N.S.
Mitral stenosis
25
28 31
III
7
M.B. Mitral stenosis
18
21
II
Mitral valvotamy
Good
Normal uncomplicated pregnancy and delivery of viable infant 3 years after mitral surgery
8
H. C.
Coarct ation of aorta
25
28
I
Repair of coarct ation
Good
Normal uncomplicated pregnancy at age 19 before surgery. Spontaneous abortion 2 years after operation. Normal pregnancy and delivery of viable infant at age 28, 3 years after surgery
Pregnancy following cardiac surgery
Volume 90 Number 1
75
Table 1-Cont'd
II
Ir,. ___Afeu___
II
No. Patient Diagnosis
I tion
VJn>U·
.a
lr;;~-
IFunction~ state I ~~~~:e I !!:~: VJ'Cilu.-
_,V}'C.IU ..
tion
I
l"h---•:...
\Jj'rJIU(If,(lc;
procedure
I
Of:~:a-
I
(lf,Vr;;
Clinical course
9
R. A.
Coarctation of aorta
20
20
10
C. B.
Tetralogy of Fallot
15
23
III
I
Pott's anas- Good Uncomplicated prenatal tomosis course 8 years after surgery. Premature labor at 36 weeks and neonatal death. Puerperium uncomplicated
11
S. F.
Pulmonary stenosis. Interventricular septal defect
19
23
II
I
Good Four years after surgery Resection patient was delivered at of pulmoterm after normal uncomnary plicated pregnancy. Viable stenosis. infant Repair of septal defect
I
I
Repair of coarctation
carditis. During pregnancy the incidence of heart disease is generally reported to be between 1.5 and 3.0 per centr, 24, 2s, 31, 32, 37 of which 80 to 90 per cent is rheumatic in etiology. 7 • 24 • 32 Of the rheumatic patients roughly three-quarters will have significant degrees of mitral stenosis 7 • 24 • 28 • 32 • 37 a lesion particularly amenable to surgical treatment, the results of which have been widely studied with reference to the outcome of pregnancy. 25 In this connection the successful outcome of pregnancy in 6 of the 7 cases we have reported are not unlike those of other authors. 1 15 ' 17 ' 18 ~ 24 ~ 38 Case ~~o. 3 is of particular interest in that the patient withstood severe pre-eclampsia, and puerperal morbidity but was delivered of viable twins. At no time did she exhibit signs or symptoms suggestive of pulmonary congestion or cardiac decompensation. The clinical behavior of patients with significant mitral stenosis during pregnancy is somewhat unpredictable because of the pathologic physiology developing in consequence of the lesion. The normal increase in cardiac output during pregnancy requires increased blood flow through the mitral !
Good Abortion advised but refused at 12 weeks' gestation. Coarctation repaired at 14 weeks' gestation. Pregnancy, delivery and puerperium uncomplicated. Viable infant
valve that in turn results in increased atrial pressure and increased pulmonary capillary pressure. The physiological load of pregnancy on the cardiovascular system thus places the patient in closer proximity to pulmonary edema, a fact emphasized by a number of authorities. 6 • 10 • 23 • 33 • 3 4 , 3 5 Response to digitalization is generally unsatisfactory because of the nature of the lesion and the altered dynamics of the pulmonary circulation. Valvotomy, however, when successful, obviates the difficulties encountered by restricted flow and may markedly change the functional status and prognosis of the cardiac patient in subsequent pregnancy. The application of mitral valvotomy to patients during pregnancy remains controversial. Certain authors maintain that this procedure is rarely justified 5 , 6 • 28 but in the experience of many, pregnancy does not appear to increase the operative risk 10 ' 12 ~ 17 ~ 18 ~ 23 24 29 34 , • , and a more liberal attitude toward the indications for surgery is advocated. That the decision to advise operation is often difficult is well known. First, the cardiac patient is difficult to evaluate during pregnancy either by physical signs which
76
Burt and Bowden
may be intensified because of the normally altered vascular dynamics and second, the symptomatology of normal pregnancy may be mistaken for that of pulmonary congestion.14• 18 • 35 It is generally agreed, however, that careful evaluation and selection of patients for surgery is necessary as it is well established that the majority may be managed by conservative medical treat~ ment. 5 • 6 • 13 • 28 With these general considerations in mind the following choices of management are available: ( 1) therapeutic abortion, (2) institution of or intensification of medical treatment, and ( 3) mitral valvotomy. The application of these procedures has been critically reviewed by a number of authors. 5, 18, 24, 28, 34, 35, 38 Although moral considerations will continue to limit the use of abortion in many clinics, this procedure has assumed an ever decreasing role of importance in the management of the pregnant cardiac during the past decade. In terms of maternal and fetal survival, however, excellent results are reported when abortion is rarely or never employed. 10 • 13 • 28 36 • In addition, the availability of cardiac surgery in recent years has contributed not only to the changing concepts of the place of therapeutic abortion, but also to the decreasing use of sterilization in unfavorable cardiac patients desirous of bearing children. Although the complex problems associated with abortion and sterilization are not germane to the present discussion, from the collective experience of many clinics the following conclusions concerning the interrelations of medical, surgical, and obstetrical management of the rheumatic patient seem reasonable. Mitral valvotomy may be employed during pregnancy in the occasional patient when the diagnosis of mitral stenosis is established with certainty and when pulmonary congestion is significant and progressive v;ithout control by vigorous medical treatment. The procedure should preferably be carried out during the first trimester before the peak loading of the myocardium develops, and should be withheld until after delivery if the patient has reached the
.\m.
Seplt·ml>t•I 1. 19li4 J. Ohst. & (;ynec.
thirty-sixth week when the cardiovascular load is decreasing. 13 • 24 • 39 Very rarely with development of frank pulmonary congestion not responding to medical management valvotomy may be carried out as an emergency lifesaving measure. 1 • 17 • ~:l. 27 • so It was on this basis that our fatal case was subjected to surgery, but the unfortunate outcome was primarily related to operative failure, a satisfactory split not being obtained. Therapeutic abortion is not generally advocated, but may in the occasional high risk patient be indicated during the first trimester only as a preparative step toward definitive mitral surgery after the patient's condition has stabilized. Sterilization, however, should not be employed as a supplementary procedure to therapeutic abortion when the outlook for successful pregnancy is reasonably good after appropriate surgical treatment. 5, 6, 16, 24 Close medical supervision and treatment will permit successful continuation of pregnancy in the majority of rheumatic patients as indicated by a number of reports 2 • H, 28 but it should be emphasized that cardiac surgery is not a panacea for rheumatic heart disease when performed either before or during pregnancy. The rheumatic process is not cured by the surgical procedure although the consequences of valvular damage may be significantly attenuated when the operative result is satisfactory. Functional deterioration may still occur, however, and has been reported as high as 16 per cent for the first postoperative year1 and 10 per cent per year after 5 yearsY Restenosis of the mitral valve is an important cause of deterioration 20 • 21 particularly in patients who have had poor operative results. 1 Even though prognosis for successful pregnancy can be improved, strict medical supervision is still required because of the normal as well as unpredictable abnormal !cads that may be imposed on the myocardium. The general features of congenital heart disease complicating pregnancy have been reviewed by a number of authors. 7 • s, 11 • 25 • 34 From our limited experience it is impossible
Pregnancy following cardiac surgery
Volume 90 Number 1
to define principles of treatment or generalize on the place of surgery in the management of these patients. From the collective experience of other clinics, however, it would appear that congenital heart disease is a somewhat less complex problem as regards surgical treatment than is acquired heart trouble of rheumatic etiology. 7 • 25 • 34 We are in agreement with others, that surgery should be employed prior to pregnancy when possible7 • 8 although it has been amply demonstrated, as in rheumatic heart disease, that surgery may be employed during pregnancy if necessary8 • 11 • 26 with functional deterioration and when termination is hazardous and i..tupracticaL Extreme individualization of medical and surgical management is required because of the wide variety of lesions possible. The principal cause of death in these patients as in acquired heart disease, appears to be congestive heart failure consequent to
REFERENCES
L Baker, C., and Hancock, W. E.: Brit. Heart J. 22: 281, 1960. 2. Baker, C., Brock, R. C., Campbell, M., and Wood, P.: Brit. M. J. 1: 1043, 1952. 3. Brock, R. C.: Proc. Roy. Soc. Med. 45: 538, 1952. 4. Bunim, J. J., and Rubricus, J.: Am. Heart J. 35: 282, 1948. 5. Burwell, C. S., and Ramsey, L. H.: Tr. A. Am. Physiol. 66: 303, 1953. 6. Burwell, C. S.: Bull. Johns Hopkins Hosp. 95: 130, 1954. 7. Burwell, C. S., and Metcalfe, J.: Heart Disease and Pregnancy, Boston, 1958, Little, Brown & Company. 8. Cannell, D. E., and Vernon, C. P.: AM. J. 0BST. & GYNEC. 85: 744, 1963. 9. Cooley, D. A., and Chapman, D. W.: J. A. M. A. 150: 1113, 1952. 10. Dogliotti, A. M., Dellepione, G., Dato, A. A., Gentilli, R., and Siliquine, P. N.: J. Thoracic & Cardiovasc. Surg. 39: 663, 1960. 11. Espino-Vela, J., and Castro-Abru, D.: Am. Heart J. 51: 542, 1956. 12. Glover, R. P., McDowell, D. E., O'Neill, T. J., and Janton, 0. H.: J. A. M. A. 158: !la~
VV.J'
a~~ 1 .J..oJ.J.Jo
13. Goodwin, J. F., Hunter, J. D., Cleland, W. P., Davies, L. G., and Steiner, R. E.: Brit. M. J. 2: 573, 1955. 14. Gorenberg, H., and Chesley, L. C.: Obst. & Gynec. 1: 15, 1953.
77
the increased demands on the heart during pregnancy. 25 Following surgical correction of the congenital defect, however, pregnancy may be quite uneventful as in the cases we have observed. Moreover, termination of pregnancy is uncommonly required and sterilization rarely indicated'• 8 because of the potential for upgrading functional classification by appropriate surgery. Summary
1. The course of pregnancy in 11 patients following cardiac surgery is reported. Seven were of rheumatic etiology and 4 congenitaL One death occurred in the rheumatic group. cerning the place of cardiac surgery during pregnancy are discussed. 3. The interrelationships of therapeutic abortion, sterilization, and cardiac surgery are discussed with reference to medical management.
15. Hoffman, G. L., and Jeffers, W. A.: Am. J. M. Sc. 204: 157, 1942. 16. lgna, E. J., Detrick, M. F., Lam, C. R., Keyes, J. W., and Hodgkinson, C. P.: AM. J. OssT. & GYNEC. 71: 1024, 1956. 17. Jones, M.: Proc. Roy. Soc. M. 52: 767, 1959. 18. Kaufman, J. M., and Ruble, P. E.: Ann. Int. Med. 48: 1157, 1958. 19. Logan, A., and Turner, R. W. D.: Lancet 1: 1286, 1952. 20. Logan, A., Lowther, C. P., and Turner, R. W. D.: Lancet 1: 443, 1962. 2i. Lowther, C. P., and Turner, R. W. D.: Brit. M. J. 1: 1027, 1962. 22. Mark, G. E.: M. Clin. North America 33: 1735, 1949. 23. Marshall, R. J., and Pantridge, J. F.: Brit. M. J. 1: 1097, 1957. 24. Mendelson, C. L.: AM. J. OssT. & GvNEC. 69: 1233, 1955. 25. Mendelson, C. L.: Cardiac Disease in Pregnancy, Philadelphia, 1960, F. A. Davis. 26. Miller, R. L., and Falor, W. H.: J. A. M. A. 149: 740, 1952. ........ ..t u .. ,.T ........ t... .... u . n .... ~ .. T 27 . f1'~""""'""'..,.11 ,.... £"1 J•, a..u.u M. J. 1: 1191, 1955. 28. O'Driscoll, M. K., Barry, A. P., and Drury, M. I.: Brit. M. ]. 2: 1090, 1957. 29. Reid, J. M., Berger, R. L., and Stevenson, J. G.: Brit. M. J. 2: 1197, 1960. 30. Soulie, P., Acar, J., Degeorges, M., and Barrillon, A.: Arch. des Malades du Coeur 54: 361, 1961. ......, "-''VJ.J.U.\...-.1..1.'
.A..
"-"•
.I..LUJ.J.oc;a..u.y,
..., .. ,
.LJJ.J.\..
78
Burt and Bowden
31. Stromme, W. B., and Kuder, K.: AM. ]. 0BST. & GYNEC. 52: 264, 1946. 32. Sutherland, A. M., and Bruce, D. F.: J. Obst. & Gynaec. Brit. Comm. 69: 99, 1962. 33. Szekely, P., and Snaith, L.: J. Obst. & Gynaec. Brit. Emp. 64: 840, 1957. 34. Szekely, P., and Snaith, L.: J. Obst. & Gynaec. Brit. Comm. 70: 69, 1963. 35. Taylor, W. J., Black, H., Thrower, W. B., and Harken, D. E.: J. A. M. A. 166: 1013, 1958.
!>eptemher 1, 196+ Am. J. Obst. & Cynec.
36. Ullery,
J. C.:
AM.
J. OnsT.
& Gvm:c. 67:
834, 1954.
J. B., and Kuo, P. T.: AM. ]. OnsT. & GYNEC. 39: 2. 1950. 38. Wade, G., Nicholson, W.' F., and Jones, A. A.: Lancet 1: 559, 1958. 39. Watt, G. L., Bigelow, W. G., and Greenwood, W. F.: AM. J. 0BsT. & GYNEc. 67: 37. Van der Veer,
275, 1954. 300 South Hawthorn Road Winston-Salem, North Carolina
Discussion DR. GoRDON W. DouGLAs, New York, New York. During the past 10 years the application of cardiac surgery to the problem of rheumatic heart disease in pregnant women has produced gratifying results, particularly in patients for whom any attempt at childbearing was an invitation to disaster. There remain many questions, concerning the selection of patients for operation, the value of cardiac surgery in relation to the problem of heart failure in pregnancy, the effect of pregnancy on the recently operated patient, and the permanence of results. Under ideal circumstances, one might wish that all women with rheumatic heart disease would have mitral valve surgery prior to pregnancy, so that the functional result would be known in advance, the dangers of childbearing estimated, and the effect of pregnancy determined. Most of Dr. Burt's rheumatic cardiac cases fall into this group, and, where an excellent functional resuit was obtained from surgery, these patients demonstrated an ability to carry the cardiovascular burden of pregnancy successfully. At Bellevue Hospital, our recent experience with patients who have had cardiac surgery previous to pregnancy is somewhat different in that it demonstrates the clinical course in a subsequent pregnancy in both good and bad results from valvotomy. Four patients, who had regurgitation as well as stenosis, derived no benefit from cardiac surgery, and 3 of the 4 developed congestive failure between the fifth and seventh month of pregnancy. Two of these patients have since had an excellent result from open heart surgery. Four patients had an excellent result from original valvotomy, and 3 have had uncomplicated pregnancies. In the fourth case congestive failure developed at 24 weeks, but this
pregnancy occurred 8 years after the cardiac operation, and some progression in heart disease might have been expected over this span of time. A somewhat more interesting and controversial group are the patients subjected to cardiac surgery during pregnancy, which is the category in which one death occurred in Dr. Burt's series. We have had 6 such cases in the last 4 years, and they represent a uniform clinical group. All had pure mitral stenosis, and entered the hospital in congestive failure early in the second trimester. After initial treatment and study, valvotomy was carried out at the sixteenth to eighteenth week. In every instance the pregnancy carried to term, and was normally delivered. However, 2 of these patients have gone into failure in a subsequent pregnancy, and a third has shown signs of deteriorating function after 2 years. None of these cases had cardiac surgery as an emergency measure, though all were examples of congestive faiiure in pregnancy. This experience has raised the question in our minds of whether the rather poor subsequent function is related to the fact that cardiac surgery was done during pregnancy, and the recently operated valve exposed to the mounting cardiovascular strain of late gestation. Finally, there are the postpregnancy instances of cardiac surgery. In many respects this is the most interesting group of all, for it represents a decision to terminate pregnancy so that cardiac evaluation and surgery can be carried out under more favorable circumstances, or alternatively, a decision to carry pregnancy to term without cardiac operation, with expectation of postpartum surgery. We have 7 examples in the Bellevue series, of which 6 represented terminations, and one a conservatively managed patient in congestive failure at the t\vcntieth "Yveek,
Volume 90 Number l
carried to term, and was operated upon post partum. Here, I believe our interest lies less in the results of cardiac surgery, and more in the considerations leading to interruption of pregnancy. Is therapeutic abortion or termination ever indicated in patients with rheumatic heart disease? Dr. Burt's paper would indicate, and our experience certainly confirms, that there is no valid indication for this procedure to "protect" a good result of previous cardiac surgery. Such women tolerate the stresses of pregnancy remarkably well. Moreover, Dr. Burt has correctly summarized the views in the recent literature, which state that interruption is seidom if ever indicated. I believe this to be in error, and our experience would indicate several exceptions. Therapeutic abortion is the only recourse in the patient whose cardiac surgery has been unsuccessful, and in whom previous experience, and usually previous experience with a pregnancy, indicates that the cardiovascular burden of the present gestation will be disastrous. Therapeutic abortion is indicated in the patient with severe cardiac problems who goes into failure early in pregnancy, and who refuses, or cannot be properly evaluated and prepared for, cardiac surgery. Finally, there are rare situations in which interruption of pregnancy may be life-saving. In cases where congestive failure begins in the first trimester or early second trimester of pregnancy, and in whom response to conservative measures in medical management is poor, it is clear that either cardiac surgery or interruption is required if the patient is to survive. There is a dictum in obstetrics, faithfully repeated in every publication on the subject, that hysterotomy is more dangerous to the pregnant cardiac patient in failure than conservative management and delivery at term. We have found reason to question this. Several years ago a patient entered Bellevue Hospital at the twentyfourth week of pregnancy, in congestive heart failure due to mitral stenosis and some degree of insufficiency. Despite vigorous medical management, including phlebotomy, she continued to have episodes of hemoptysis and pulmonary edema. With the peak cardiac load ahead, it seemed clear that cardiac surgery or termination was required for survival. A cardiac operation under these circumstances could have been no more than an empiric procedure undertaken with high risk. Instead, the patient was lightly anesthetized with Fluothane, and given muscle
Pregnancy following cardiac surgery
79
relaxants. A rapid supracervical hysterectomy was done, and the patient was conscious within minutes of completion. Her clinical improvement within a few hours was striking, and cardiac surgery was carried out successfuliy during the same hospitalization. We have handled two other cases in similar fashion, and have been impressed with rapid clinical improvement in each instance. Studies of plasma volume in these patients have shown a substantial decrease, but it seems likely that much of the improvement is due to diminished anxiety, and decreased tachycardia. Then is no question that cardiac surgery in the your:g rheumatic cardiac patient provides the opportunity for safe childbearing, and the development of open heart procedures for the incompetent valve has extended this benefit to patients with mitral insufficiency as well as stenosis. When congestive failure occurs during pregnancy, one usually has a choice between conservative management and cardiac surgery, and here we have employed operation more frequently when congestive failure begins early. Under certain circumstances, interruption, even in the second trimester, is a valuable means of avoiding cardiac operation under hurried and dangerous circumstances. DR. THOMAS A. HARRis,* Atlanta, Georgia. Most of the experience with pregnancy and cardiac wrgery in Atlanta has been in patients with congenital heart disease. Ten cases of corrected congenital heart disease were found in the obstetrical records of Grady Memorial Hospital and Georgia Baptist HospitaL 1 nese patients have been followed through 16 subsequent pregnancies and deliveries without difficulty. In the last 5 years at Georgia Baptist Hospital we have had only 3 recorded cases of rheumatic heart disease with mitral commissurotomy prior to pregnancy and all 3 patients did well in the subsequent pregnancy. There have been 4 patients who have been subjected to therapeutic abortion, 2 patients having rheumatic heart disease with mitral stenosis, 1 with uncorrected coarctation of the aorta, and 1 with severe coronary artery disease. There have been no maternal deaths in the last ten years at Georgia Baptist Hospital attributable to heart disease. Our incidence of heart disease and pregnancy has been much less than the usual reported incidence, there being only 36 recorded cases *By invi1:ation.
80
Burt and Bowden
m 22,459 deliveries for the past 5 years, 1959 through 1963. This low figure probably indicates that the vast majority of the less serious cases of rheumatic heart disease in pregn:mcy arc overlooked and tolerate pregnancy and delivery extremely well. As has been shown by many authors including Dr. Burt's presentation, the management of pregnancy after successful cardiac surgery, is relatively uncomplicated. One must bear in mind, however, that the problem of so-called "natural course of rheumatic heart disease" is always present, and postoperative patients should continue to receive intensive medical management. The use of serial vital capacity determinations is a reliable prognostic aid, and a sudden decrease in vital capacity may represent one of the earliest signs of impending congestive heart failure. Also, restenosis of the mitral valve may take place at anytime postoperatively and patients must be followed as carefully through the second or third pregnancy after surgery as they were through the first. The principal controversy regarding pregnancy and cardiac surgery is whether or not such surgery should ever be done during the course of pregnancy. Many authorities feel that heart surgery should always be avoided during pregnancy except under the most unusual of circumstances and Dr. Burt's Case l'~o. 2 would seen1 to be of this sort. When cardiac surgery is carried out during pregnancy, it would seem desirable to always attempt to have the surgery completed as early in pregnancy as possible, preferably before the twentieth week. In the final analysis, it seems to me that cardiac surgery before and during pregnancy has proved to be of value largely in the patient severely affected who formerly would have undergone therapeutic abortion with tubal ligation.
Seplt·mhe• 1, Am. j. Ohst.
& (
196~
;ynt'C.
Such patients can now occasionally b,~ carried through one or two pregnancies after cardiac surgery. Due to the tendency of all patients with rheumatic heart disease to undergo progressive deterioration, however, it stili seems wise to ~terilize most such patients after one or two pregnancies. Other patients who have benefitted markedly from cardiac surgery have, of course, been those with congenital heart disease. Cardiac surgery is a field in which much progress is constantly being made, and complete valve replacement is now being done according to the Starr technique. Some patients have been reported that have had as many as three of their heart valves cor.npletely replaced, including the
mitral, tricuspid, and aortic valves. As has been mentioned, experience in our region has been rather limited. The vast majority of pregnant cardiac patients are managed by medical means alone. The aim of mitral valvotomy during pregnancy should be to reduce the maternal mortality rate in patients with congestive heart failure or in those who are showing other signs of progressive deterioration in their cardiac status. In most such paiicnts it would seem that the risk of cardiac surgery during pregnancy in an already seriously ill patient would be considerably greater than in those carried through pregnancy with medical rnanagen-.ent alone and surgery consideied later. In the occasional rheumatic heart patient with progressive congestive failure who has not responded to medical management or in patients with profuse hemoptysis, such surgery might be necessary during pregnancy. With more intensive medical management and earlier suspicion of cardiac disease by those of us who are responsible for these young women, such surgery during the course of pregnancy may become even more infrequent.
•
D. , M. D .
ROBERT H. BOWDEN, JR., M.D. Winston-Salem, North Carolina
I T H A s long been recognized that the pregnant cardiac patient presents special problems in medical and obstetrical management. As emphasized by a number of authors, the cardinal prognostic problem when heart disease complicates pregnancy is assessment of the risk of congestive failure, the principal cause of death in these patients.4• 7 • 15 • 17 • 18 Various clinical indices, properly applied, are helpful in estimating the probability of a successful and productive outcome of pregnancy. These include the patient's functional classification, history of prior heart failure, age, presence or absence of cardiomegaly, and with particular reference to rheumatic heart disease, the place occupied by the patient in the natural history of the disease process. 4· 7 • 22 Despite capricious changes in cardiac status that may result from either normal or abnormal cardiovascular burdens coincidental to pregnancy, such criteria have provided a reasonable, if not precise, assessment of the patient's status and capability of success in the reproductive process. In the past, these prognostic guidelines have dictated not only the details of medical management but obstetrical treatment as well with particular reference to continuation of pregnancy, abortion, and sterilization.
Since the initial reports of Logan and Turner and of Brock in England3 ' 19 and of Cooley and Chapman in this country9 increasing interest has been fostered not only relative to the application of cardiac surgery during pregnancy, but to the changing perspectives concerning the feasibility of pregnancy under unfavorable conditions in cardiac patients to whom surgery has become available during the past decade. Although the indications for cardiac surgery in relation to pregnancy remain somewhat controversial, these new techniques have necessarily changed obstetrical concepts in many clinics concerning the place of abortion and/or sterilization in the management of the pregnant patient with heart disease. The cases summarized in Table I in no way resolve the debated points of management of the individual patient but indicate the potential benefits of surgery for selected patients in relation to reproduction. Comment
The cases presented are illustrative of our experience which is consistent with that of others in showing the possible benefits of cardiac surgery when applied to young women during the childbearing years. Our data are not so extensive as to permit generalizations or conclusions concerning still existent controversial issues, but in light of our experience and in consideration of the problems presented by the cardiac patient in pregnancy, a number of comments are permissible. Perhaps the widest application of cardiac surgery is that concerned with correction of valvular damage occasioned by rheumatic
From the Departments of Obstetrics and Gynecology, Bowman Gray School of Medicine, Wake Forest College, and the North Carolina Baptist Hospital. Presented by Invitation at the Twenty-sixth Annual Meeting of the South Atlantic Association of Obstetricians and Gynecologists, Bal Harbour, Florida, Jan. 26-29, 1964.
73
74
Burt and Bowden
\m.
Septt·mbc, l, J9b l J. Oh>t. & ( ;ynt·c.
Table I. Summary of clinical course of 11 cases ~~,-··-~~----------
I
I No. Patient I Dia({nosis
Age
O~era-1
Functional state I Before
tzon
Pregnancy
After
I oP.era- I oP.eraI
tzon
twn
Operative procedure
Operative result
Clinical coune
c. J.
Mitral stenosis
2.'i
26
II
I
Mitral valvotomy
Good
Pregnancy 1 year after surgery. Prenatal course, delivery and puerperium uneventful. Viable infant
2
H.P.
Mitral stenosis
28
28
IV
IV
Mitral valvotomy
Poor
First pregnancy with progressive pulmonary congestion since twelfth week. Conservative therapy in hospital at 22 weeks. Valvotomy at 23 weeks. Progressive deterioration and death 17 days postoperative
3
M.H. Mitral stenosis
32
34
III
I
Mitral valvotomy
Good
Pregnancy 2 years after surgery. Prenatal course normal until thirty-eighth week when complicated by severe pre-eclampsia. Blood pressure 160/100. Spontaneous labor in thirtyeighth week. Viable twins. Postpartum course morbid. Discharged well on twelfth postpartum day
4
A. P.
Mitral stenosis
27
29 32
III
I
Mitral valvotomy
Good
Normal pregnancy and delivery 2 years and 4 years after surgery. Viable infants. Five years after surgery deterioration to Class III
5
M.F. Mitral stenosis
33
34
III
II
Mitral valvot-
Fair
Uncomplicated pregnancy and delivery 1 year and 2 years after surgery. Viable infants. Maintenance of Class II functional class throughout
Mitral valvotomy
Good
Acute rheumatic carditis at age 24 and therapeutic abortion at 12 weeks. Valvotomy at age 25. Normal uncomplicated pregnancies at age 28 and 31
omy
I
6
N.S.
Mitral stenosis
25
28 31
III
7
M.B. Mitral stenosis
18
21
II
Mitral valvotamy
Good
Normal uncomplicated pregnancy and delivery of viable infant 3 years after mitral surgery
8
H. C.
Coarct ation of aorta
25
28
I
Repair of coarct ation
Good
Normal uncomplicated pregnancy at age 19 before surgery. Spontaneous abortion 2 years after operation. Normal pregnancy and delivery of viable infant at age 28, 3 years after surgery
Pregnancy following cardiac surgery
Volume 90 Number 1
75
Table 1-Cont'd
II
Ir,. ___Afeu___
II
No. Patient Diagnosis
I tion
VJn>U·
.a
lr;;~-
IFunction~ state I ~~~~:e I !!:~: VJ'Cilu.-
_,V}'C.IU ..
tion
I
l"h---•:...
\Jj'rJIU(If,(lc;
procedure
I
Of:~:a-
I
(lf,Vr;;
Clinical course
9
R. A.
Coarctation of aorta
20
20
10
C. B.
Tetralogy of Fallot
15
23
III
I
Pott's anas- Good Uncomplicated prenatal tomosis course 8 years after surgery. Premature labor at 36 weeks and neonatal death. Puerperium uncomplicated
11
S. F.
Pulmonary stenosis. Interventricular septal defect
19
23
II
I
Good Four years after surgery Resection patient was delivered at of pulmoterm after normal uncomnary plicated pregnancy. Viable stenosis. infant Repair of septal defect
I
I
Repair of coarctation
carditis. During pregnancy the incidence of heart disease is generally reported to be between 1.5 and 3.0 per centr, 24, 2s, 31, 32, 37 of which 80 to 90 per cent is rheumatic in etiology. 7 • 24 • 32 Of the rheumatic patients roughly three-quarters will have significant degrees of mitral stenosis 7 • 24 • 28 • 32 • 37 a lesion particularly amenable to surgical treatment, the results of which have been widely studied with reference to the outcome of pregnancy. 25 In this connection the successful outcome of pregnancy in 6 of the 7 cases we have reported are not unlike those of other authors. 1 15 ' 17 ' 18 ~ 24 ~ 38 Case ~~o. 3 is of particular interest in that the patient withstood severe pre-eclampsia, and puerperal morbidity but was delivered of viable twins. At no time did she exhibit signs or symptoms suggestive of pulmonary congestion or cardiac decompensation. The clinical behavior of patients with significant mitral stenosis during pregnancy is somewhat unpredictable because of the pathologic physiology developing in consequence of the lesion. The normal increase in cardiac output during pregnancy requires increased blood flow through the mitral !
Good Abortion advised but refused at 12 weeks' gestation. Coarctation repaired at 14 weeks' gestation. Pregnancy, delivery and puerperium uncomplicated. Viable infant
valve that in turn results in increased atrial pressure and increased pulmonary capillary pressure. The physiological load of pregnancy on the cardiovascular system thus places the patient in closer proximity to pulmonary edema, a fact emphasized by a number of authorities. 6 • 10 • 23 • 33 • 3 4 , 3 5 Response to digitalization is generally unsatisfactory because of the nature of the lesion and the altered dynamics of the pulmonary circulation. Valvotomy, however, when successful, obviates the difficulties encountered by restricted flow and may markedly change the functional status and prognosis of the cardiac patient in subsequent pregnancy. The application of mitral valvotomy to patients during pregnancy remains controversial. Certain authors maintain that this procedure is rarely justified 5 , 6 • 28 but in the experience of many, pregnancy does not appear to increase the operative risk 10 ' 12 ~ 17 ~ 18 ~ 23 24 29 34 , • , and a more liberal attitude toward the indications for surgery is advocated. That the decision to advise operation is often difficult is well known. First, the cardiac patient is difficult to evaluate during pregnancy either by physical signs which
76
Burt and Bowden
may be intensified because of the normally altered vascular dynamics and second, the symptomatology of normal pregnancy may be mistaken for that of pulmonary congestion.14• 18 • 35 It is generally agreed, however, that careful evaluation and selection of patients for surgery is necessary as it is well established that the majority may be managed by conservative medical treat~ ment. 5 • 6 • 13 • 28 With these general considerations in mind the following choices of management are available: ( 1) therapeutic abortion, (2) institution of or intensification of medical treatment, and ( 3) mitral valvotomy. The application of these procedures has been critically reviewed by a number of authors. 5, 18, 24, 28, 34, 35, 38 Although moral considerations will continue to limit the use of abortion in many clinics, this procedure has assumed an ever decreasing role of importance in the management of the pregnant cardiac during the past decade. In terms of maternal and fetal survival, however, excellent results are reported when abortion is rarely or never employed. 10 • 13 • 28 36 • In addition, the availability of cardiac surgery in recent years has contributed not only to the changing concepts of the place of therapeutic abortion, but also to the decreasing use of sterilization in unfavorable cardiac patients desirous of bearing children. Although the complex problems associated with abortion and sterilization are not germane to the present discussion, from the collective experience of many clinics the following conclusions concerning the interrelations of medical, surgical, and obstetrical management of the rheumatic patient seem reasonable. Mitral valvotomy may be employed during pregnancy in the occasional patient when the diagnosis of mitral stenosis is established with certainty and when pulmonary congestion is significant and progressive v;ithout control by vigorous medical treatment. The procedure should preferably be carried out during the first trimester before the peak loading of the myocardium develops, and should be withheld until after delivery if the patient has reached the
.\m.
Seplt·ml>t•I 1. 19li4 J. Ohst. & (;ynec.
thirty-sixth week when the cardiovascular load is decreasing. 13 • 24 • 39 Very rarely with development of frank pulmonary congestion not responding to medical management valvotomy may be carried out as an emergency lifesaving measure. 1 • 17 • ~:l. 27 • so It was on this basis that our fatal case was subjected to surgery, but the unfortunate outcome was primarily related to operative failure, a satisfactory split not being obtained. Therapeutic abortion is not generally advocated, but may in the occasional high risk patient be indicated during the first trimester only as a preparative step toward definitive mitral surgery after the patient's condition has stabilized. Sterilization, however, should not be employed as a supplementary procedure to therapeutic abortion when the outlook for successful pregnancy is reasonably good after appropriate surgical treatment. 5, 6, 16, 24 Close medical supervision and treatment will permit successful continuation of pregnancy in the majority of rheumatic patients as indicated by a number of reports 2 • H, 28 but it should be emphasized that cardiac surgery is not a panacea for rheumatic heart disease when performed either before or during pregnancy. The rheumatic process is not cured by the surgical procedure although the consequences of valvular damage may be significantly attenuated when the operative result is satisfactory. Functional deterioration may still occur, however, and has been reported as high as 16 per cent for the first postoperative year1 and 10 per cent per year after 5 yearsY Restenosis of the mitral valve is an important cause of deterioration 20 • 21 particularly in patients who have had poor operative results. 1 Even though prognosis for successful pregnancy can be improved, strict medical supervision is still required because of the normal as well as unpredictable abnormal !cads that may be imposed on the myocardium. The general features of congenital heart disease complicating pregnancy have been reviewed by a number of authors. 7 • s, 11 • 25 • 34 From our limited experience it is impossible
Pregnancy following cardiac surgery
Volume 90 Number 1
to define principles of treatment or generalize on the place of surgery in the management of these patients. From the collective experience of other clinics, however, it would appear that congenital heart disease is a somewhat less complex problem as regards surgical treatment than is acquired heart trouble of rheumatic etiology. 7 • 25 • 34 We are in agreement with others, that surgery should be employed prior to pregnancy when possible7 • 8 although it has been amply demonstrated, as in rheumatic heart disease, that surgery may be employed during pregnancy if necessary8 • 11 • 26 with functional deterioration and when termination is hazardous and i..tupracticaL Extreme individualization of medical and surgical management is required because of the wide variety of lesions possible. The principal cause of death in these patients as in acquired heart disease, appears to be congestive heart failure consequent to
REFERENCES
L Baker, C., and Hancock, W. E.: Brit. Heart J. 22: 281, 1960. 2. Baker, C., Brock, R. C., Campbell, M., and Wood, P.: Brit. M. J. 1: 1043, 1952. 3. Brock, R. C.: Proc. Roy. Soc. Med. 45: 538, 1952. 4. Bunim, J. J., and Rubricus, J.: Am. Heart J. 35: 282, 1948. 5. Burwell, C. S., and Ramsey, L. H.: Tr. A. Am. Physiol. 66: 303, 1953. 6. Burwell, C. S.: Bull. Johns Hopkins Hosp. 95: 130, 1954. 7. Burwell, C. S., and Metcalfe, J.: Heart Disease and Pregnancy, Boston, 1958, Little, Brown & Company. 8. Cannell, D. E., and Vernon, C. P.: AM. J. 0BST. & GYNEC. 85: 744, 1963. 9. Cooley, D. A., and Chapman, D. W.: J. A. M. A. 150: 1113, 1952. 10. Dogliotti, A. M., Dellepione, G., Dato, A. A., Gentilli, R., and Siliquine, P. N.: J. Thoracic & Cardiovasc. Surg. 39: 663, 1960. 11. Espino-Vela, J., and Castro-Abru, D.: Am. Heart J. 51: 542, 1956. 12. Glover, R. P., McDowell, D. E., O'Neill, T. J., and Janton, 0. H.: J. A. M. A. 158: !la~
VV.J'
a~~ 1 .J..oJ.J.Jo
13. Goodwin, J. F., Hunter, J. D., Cleland, W. P., Davies, L. G., and Steiner, R. E.: Brit. M. J. 2: 573, 1955. 14. Gorenberg, H., and Chesley, L. C.: Obst. & Gynec. 1: 15, 1953.
77
the increased demands on the heart during pregnancy. 25 Following surgical correction of the congenital defect, however, pregnancy may be quite uneventful as in the cases we have observed. Moreover, termination of pregnancy is uncommonly required and sterilization rarely indicated'• 8 because of the potential for upgrading functional classification by appropriate surgery. Summary
1. The course of pregnancy in 11 patients following cardiac surgery is reported. Seven were of rheumatic etiology and 4 congenitaL One death occurred in the rheumatic group. cerning the place of cardiac surgery during pregnancy are discussed. 3. The interrelationships of therapeutic abortion, sterilization, and cardiac surgery are discussed with reference to medical management.
15. Hoffman, G. L., and Jeffers, W. A.: Am. J. M. Sc. 204: 157, 1942. 16. lgna, E. J., Detrick, M. F., Lam, C. R., Keyes, J. W., and Hodgkinson, C. P.: AM. J. OssT. & GYNEC. 71: 1024, 1956. 17. Jones, M.: Proc. Roy. Soc. M. 52: 767, 1959. 18. Kaufman, J. M., and Ruble, P. E.: Ann. Int. Med. 48: 1157, 1958. 19. Logan, A., and Turner, R. W. D.: Lancet 1: 1286, 1952. 20. Logan, A., Lowther, C. P., and Turner, R. W. D.: Lancet 1: 443, 1962. 2i. Lowther, C. P., and Turner, R. W. D.: Brit. M. J. 1: 1027, 1962. 22. Mark, G. E.: M. Clin. North America 33: 1735, 1949. 23. Marshall, R. J., and Pantridge, J. F.: Brit. M. J. 1: 1097, 1957. 24. Mendelson, C. L.: AM. J. OssT. & GvNEC. 69: 1233, 1955. 25. Mendelson, C. L.: Cardiac Disease in Pregnancy, Philadelphia, 1960, F. A. Davis. 26. Miller, R. L., and Falor, W. H.: J. A. M. A. 149: 740, 1952. ........ ..t u .. ,.T ........ t... .... u . n .... ~ .. T 27 . f1'~""""'""'..,.11 ,.... £"1 J•, a..u.u M. J. 1: 1191, 1955. 28. O'Driscoll, M. K., Barry, A. P., and Drury, M. I.: Brit. M. ]. 2: 1090, 1957. 29. Reid, J. M., Berger, R. L., and Stevenson, J. G.: Brit. M. J. 2: 1197, 1960. 30. Soulie, P., Acar, J., Degeorges, M., and Barrillon, A.: Arch. des Malades du Coeur 54: 361, 1961. ......, "-''VJ.J.U.\...-.1..1.'
.A..
"-"•
.I..LUJ.J.oc;a..u.y,
..., .. ,
.LJJ.J.\..
78
Burt and Bowden
31. Stromme, W. B., and Kuder, K.: AM. ]. 0BST. & GYNEC. 52: 264, 1946. 32. Sutherland, A. M., and Bruce, D. F.: J. Obst. & Gynaec. Brit. Comm. 69: 99, 1962. 33. Szekely, P., and Snaith, L.: J. Obst. & Gynaec. Brit. Emp. 64: 840, 1957. 34. Szekely, P., and Snaith, L.: J. Obst. & Gynaec. Brit. Comm. 70: 69, 1963. 35. Taylor, W. J., Black, H., Thrower, W. B., and Harken, D. E.: J. A. M. A. 166: 1013, 1958.
!>eptemher 1, 196+ Am. J. Obst. & Cynec.
36. Ullery,
J. C.:
AM.
J. OnsT.
& Gvm:c. 67:
834, 1954.
J. B., and Kuo, P. T.: AM. ]. OnsT. & GYNEC. 39: 2. 1950. 38. Wade, G., Nicholson, W.' F., and Jones, A. A.: Lancet 1: 559, 1958. 39. Watt, G. L., Bigelow, W. G., and Greenwood, W. F.: AM. J. 0BsT. & GYNEc. 67: 37. Van der Veer,
275, 1954. 300 South Hawthorn Road Winston-Salem, North Carolina
Discussion DR. GoRDON W. DouGLAs, New York, New York. During the past 10 years the application of cardiac surgery to the problem of rheumatic heart disease in pregnant women has produced gratifying results, particularly in patients for whom any attempt at childbearing was an invitation to disaster. There remain many questions, concerning the selection of patients for operation, the value of cardiac surgery in relation to the problem of heart failure in pregnancy, the effect of pregnancy on the recently operated patient, and the permanence of results. Under ideal circumstances, one might wish that all women with rheumatic heart disease would have mitral valve surgery prior to pregnancy, so that the functional result would be known in advance, the dangers of childbearing estimated, and the effect of pregnancy determined. Most of Dr. Burt's rheumatic cardiac cases fall into this group, and, where an excellent functional resuit was obtained from surgery, these patients demonstrated an ability to carry the cardiovascular burden of pregnancy successfully. At Bellevue Hospital, our recent experience with patients who have had cardiac surgery previous to pregnancy is somewhat different in that it demonstrates the clinical course in a subsequent pregnancy in both good and bad results from valvotomy. Four patients, who had regurgitation as well as stenosis, derived no benefit from cardiac surgery, and 3 of the 4 developed congestive failure between the fifth and seventh month of pregnancy. Two of these patients have since had an excellent result from open heart surgery. Four patients had an excellent result from original valvotomy, and 3 have had uncomplicated pregnancies. In the fourth case congestive failure developed at 24 weeks, but this
pregnancy occurred 8 years after the cardiac operation, and some progression in heart disease might have been expected over this span of time. A somewhat more interesting and controversial group are the patients subjected to cardiac surgery during pregnancy, which is the category in which one death occurred in Dr. Burt's series. We have had 6 such cases in the last 4 years, and they represent a uniform clinical group. All had pure mitral stenosis, and entered the hospital in congestive failure early in the second trimester. After initial treatment and study, valvotomy was carried out at the sixteenth to eighteenth week. In every instance the pregnancy carried to term, and was normally delivered. However, 2 of these patients have gone into failure in a subsequent pregnancy, and a third has shown signs of deteriorating function after 2 years. None of these cases had cardiac surgery as an emergency measure, though all were examples of congestive faiiure in pregnancy. This experience has raised the question in our minds of whether the rather poor subsequent function is related to the fact that cardiac surgery was done during pregnancy, and the recently operated valve exposed to the mounting cardiovascular strain of late gestation. Finally, there are the postpregnancy instances of cardiac surgery. In many respects this is the most interesting group of all, for it represents a decision to terminate pregnancy so that cardiac evaluation and surgery can be carried out under more favorable circumstances, or alternatively, a decision to carry pregnancy to term without cardiac operation, with expectation of postpartum surgery. We have 7 examples in the Bellevue series, of which 6 represented terminations, and one a conservatively managed patient in congestive failure at the t\vcntieth "Yveek,
Volume 90 Number l
carried to term, and was operated upon post partum. Here, I believe our interest lies less in the results of cardiac surgery, and more in the considerations leading to interruption of pregnancy. Is therapeutic abortion or termination ever indicated in patients with rheumatic heart disease? Dr. Burt's paper would indicate, and our experience certainly confirms, that there is no valid indication for this procedure to "protect" a good result of previous cardiac surgery. Such women tolerate the stresses of pregnancy remarkably well. Moreover, Dr. Burt has correctly summarized the views in the recent literature, which state that interruption is seidom if ever indicated. I believe this to be in error, and our experience would indicate several exceptions. Therapeutic abortion is the only recourse in the patient whose cardiac surgery has been unsuccessful, and in whom previous experience, and usually previous experience with a pregnancy, indicates that the cardiovascular burden of the present gestation will be disastrous. Therapeutic abortion is indicated in the patient with severe cardiac problems who goes into failure early in pregnancy, and who refuses, or cannot be properly evaluated and prepared for, cardiac surgery. Finally, there are rare situations in which interruption of pregnancy may be life-saving. In cases where congestive failure begins in the first trimester or early second trimester of pregnancy, and in whom response to conservative measures in medical management is poor, it is clear that either cardiac surgery or interruption is required if the patient is to survive. There is a dictum in obstetrics, faithfully repeated in every publication on the subject, that hysterotomy is more dangerous to the pregnant cardiac patient in failure than conservative management and delivery at term. We have found reason to question this. Several years ago a patient entered Bellevue Hospital at the twentyfourth week of pregnancy, in congestive heart failure due to mitral stenosis and some degree of insufficiency. Despite vigorous medical management, including phlebotomy, she continued to have episodes of hemoptysis and pulmonary edema. With the peak cardiac load ahead, it seemed clear that cardiac surgery or termination was required for survival. A cardiac operation under these circumstances could have been no more than an empiric procedure undertaken with high risk. Instead, the patient was lightly anesthetized with Fluothane, and given muscle
Pregnancy following cardiac surgery
79
relaxants. A rapid supracervical hysterectomy was done, and the patient was conscious within minutes of completion. Her clinical improvement within a few hours was striking, and cardiac surgery was carried out successfuliy during the same hospitalization. We have handled two other cases in similar fashion, and have been impressed with rapid clinical improvement in each instance. Studies of plasma volume in these patients have shown a substantial decrease, but it seems likely that much of the improvement is due to diminished anxiety, and decreased tachycardia. Then is no question that cardiac surgery in the your:g rheumatic cardiac patient provides the opportunity for safe childbearing, and the development of open heart procedures for the incompetent valve has extended this benefit to patients with mitral insufficiency as well as stenosis. When congestive failure occurs during pregnancy, one usually has a choice between conservative management and cardiac surgery, and here we have employed operation more frequently when congestive failure begins early. Under certain circumstances, interruption, even in the second trimester, is a valuable means of avoiding cardiac operation under hurried and dangerous circumstances. DR. THOMAS A. HARRis,* Atlanta, Georgia. Most of the experience with pregnancy and cardiac wrgery in Atlanta has been in patients with congenital heart disease. Ten cases of corrected congenital heart disease were found in the obstetrical records of Grady Memorial Hospital and Georgia Baptist HospitaL 1 nese patients have been followed through 16 subsequent pregnancies and deliveries without difficulty. In the last 5 years at Georgia Baptist Hospital we have had only 3 recorded cases of rheumatic heart disease with mitral commissurotomy prior to pregnancy and all 3 patients did well in the subsequent pregnancy. There have been 4 patients who have been subjected to therapeutic abortion, 2 patients having rheumatic heart disease with mitral stenosis, 1 with uncorrected coarctation of the aorta, and 1 with severe coronary artery disease. There have been no maternal deaths in the last ten years at Georgia Baptist Hospital attributable to heart disease. Our incidence of heart disease and pregnancy has been much less than the usual reported incidence, there being only 36 recorded cases *By invi1:ation.
80
Burt and Bowden
m 22,459 deliveries for the past 5 years, 1959 through 1963. This low figure probably indicates that the vast majority of the less serious cases of rheumatic heart disease in pregn:mcy arc overlooked and tolerate pregnancy and delivery extremely well. As has been shown by many authors including Dr. Burt's presentation, the management of pregnancy after successful cardiac surgery, is relatively uncomplicated. One must bear in mind, however, that the problem of so-called "natural course of rheumatic heart disease" is always present, and postoperative patients should continue to receive intensive medical management. The use of serial vital capacity determinations is a reliable prognostic aid, and a sudden decrease in vital capacity may represent one of the earliest signs of impending congestive heart failure. Also, restenosis of the mitral valve may take place at anytime postoperatively and patients must be followed as carefully through the second or third pregnancy after surgery as they were through the first. The principal controversy regarding pregnancy and cardiac surgery is whether or not such surgery should ever be done during the course of pregnancy. Many authorities feel that heart surgery should always be avoided during pregnancy except under the most unusual of circumstances and Dr. Burt's Case l'~o. 2 would seen1 to be of this sort. When cardiac surgery is carried out during pregnancy, it would seem desirable to always attempt to have the surgery completed as early in pregnancy as possible, preferably before the twentieth week. In the final analysis, it seems to me that cardiac surgery before and during pregnancy has proved to be of value largely in the patient severely affected who formerly would have undergone therapeutic abortion with tubal ligation.
Seplt·mhe• 1, Am. j. Ohst.
& (
196~
;ynt'C.
Such patients can now occasionally b,~ carried through one or two pregnancies after cardiac surgery. Due to the tendency of all patients with rheumatic heart disease to undergo progressive deterioration, however, it stili seems wise to ~terilize most such patients after one or two pregnancies. Other patients who have benefitted markedly from cardiac surgery have, of course, been those with congenital heart disease. Cardiac surgery is a field in which much progress is constantly being made, and complete valve replacement is now being done according to the Starr technique. Some patients have been reported that have had as many as three of their heart valves cor.npletely replaced, including the
mitral, tricuspid, and aortic valves. As has been mentioned, experience in our region has been rather limited. The vast majority of pregnant cardiac patients are managed by medical means alone. The aim of mitral valvotomy during pregnancy should be to reduce the maternal mortality rate in patients with congestive heart failure or in those who are showing other signs of progressive deterioration in their cardiac status. In most such paiicnts it would seem that the risk of cardiac surgery during pregnancy in an already seriously ill patient would be considerably greater than in those carried through pregnancy with medical rnanagen-.ent alone and surgery consideied later. In the occasional rheumatic heart patient with progressive congestive failure who has not responded to medical management or in patients with profuse hemoptysis, such surgery might be necessary during pregnancy. With more intensive medical management and earlier suspicion of cardiac disease by those of us who are responsible for these young women, such surgery during the course of pregnancy may become even more infrequent.