Successful Management of an Emergent Cesarean Delivery in a Patient with History of Ross Procedure: A Case Report
Severe aortic valvular disease can be treated with valve replacement using an autologous pulmonary valve, also known as the Ross procedure. In young females who wish to bear children in the future, the Ross procedure may be a preferable option over mechanical or bioprosthetic valve replacement, as it offers long-term durability without the need for life-long anticoagulation. However, it is not without complications.
Here in, we present the successful perioperative anesthesia management of a patient with history of Ross procedure and mitral valve bioprosthesis, with subsequent development of severe aortic insufficiency and moderate mitral stenosis, who delivered a preterm infant via emergent Cesarean section. This case highlights the value of early identification of high-risk parturients, the benefit of early referral to anesthesia preoperative evaluation to establish an anesthetic plan, and the multidisciplinary involvement in the perioperative period.
Advances in medical and surgical treatments of congenital heart disease in conjunction with improvement in fertility interventions have led to an increase in the proportion of women with congenital cardiac disease and/or acquired heart disease that have the potential of becoming pregnant. Although pregnancy in women with prosthetic heart valves continues to show increased risk of adverse outcomes as compared to the general population, rates of maternal mortality and pregnancy loss have declined over the last two decades.
Common treatment options for severe aortic valvular disease include mechanical and bioprosthetic (heterograft, homograft and autograft) valve replacement, both providing advantages and limitations for young females who desire pregnancy in the future. Mechanical heart valves offer long-term durability and superior hemodynamic profile; however they are prothrombotic requiring life-long anticoagulation with potential increase risk to mom and foetus.
Bioprosthetic heart valves, on the other hand, do not require anticoagulation, but are less durable and frequently require reoperation. The Ross procedure, first described in 1967, involves the replacement of the aortic valve with an autologous pulmonary valve and an allograft in the pulmonary position. This procedure obviates the need for anticoagulation, and may potentially have longer durability than aortic bioprosthetic valves.
For these reasons, the Ross procedure is the preferred aortic valve replacement strategy for younger women who desire pregnancy in the future. Here we describe a case of a patient with history of Ross procedure and mitral valve replacement, with subsequent development of aortic insufficiency and mitral stenosis, who successfully delivered a preterm infant via emergent cesarean section, with a specific focus on the peri-operative anesthesia planning and management.
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