MEDizzy - A 22-year-old woman presents with a heart murmur in the 12th

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Valvular Heart Disease

A 22-year-old woman presents with a heart murmur in the 12th wk of pregnancy. She never had any prior history of heart disease and is an active person, walking 1–2 miles per day without any limitations. This is her first pregnancy, and there has been no problem with the pregnancy. Her obstetrician noted a heart murmur and has sent her to you for further evaluation. She has no other medical problems.Her BP is 110/70 mmHg and pulse is 70 bpm and regular. The JVP and carotid upstroke are normal. The lungs are clear. The LV impulse is tapping. The first heart sound is loud. The second heart sound is split with inspiration with a normal pulmonic component intensity. There is a crisp opening snap approximately 80 msec from the second heart sound and a 2/6 diastolic rumble is present with a presystolic accentuation. A TTE is performed. This shows normal LV size and function with an EF of 60%. The LA is moderately enlarged. There is evidence of MS with diastolic doming of the mitral valve leaflets but they are pliable and noncalcified. The mean gradient across the mitral valve is 8 mmHg and the MVA calculated by diastolic half-time is 1.2 cm2. There was no MR. PA systolic pressure is calculated to be 40 mmHg. In this woman who is 12 wks pregnant, what would you do at this point in time?

ExplanationThis woman has moderately severe MS. However, she is completely asymptomatic and does not have significant elevation of her PA pressure. The majority of patients with asymptomatic or minimally symptomatic MS can have an uncomplicated pregnancy with careful monitoring. Pregnant patients with heart disease should have frequent rest periods during the day, consisting of 20 to 30 mins in the left lateral decubitus position (to avoid the compression of the interior vena cava by the fetus). Patients should be watched closely for the onset of AF and cardioversion should be performed with fetal monitoring should this occur. If the patient were symptomatic before pregnancy, intervention with PMBV would have been appropriate. If she does develop significant symptoms unresponsive to beta blockade, then PMBV could be performed during pregnancy (preferably after 20 wks) with appropriate shielding of the fetus.