Management of anesthesia for open heart surgery during pregnancy
F. George Estafanous, M.D.
Department of Cardiothoracic Anesthesia
S. Buckley, M.D.
Department of General Anesthesia
Rheumatic heart disease, particularly mitral stenosis, is the principal type of heart disease during pregnancy,1,2 and the leading, indirect cause of maternal mortality in the United States.3
During pregnancy blood volume and cardiac output are increased 30% to 50% and oxygen consumption is increased 20%. These changes make patients with mitral stenosis more vulnerable to acute heart failure and emergency heart surgery is often indicated.
Mitral commissurotomy was first performed on the pregnant patient in 1952,1 and in 1958 Leyse et al4 reported the first use of cardiopulmonary bypass during pregnancy. In 1967, Hart horne et al3 reported the first insertion of a Starr-Edwards prosthesis during pregnancy. They reviewed a series of 394 patients who had heart surgery during pregnancy; maternal mortality was 1.8% and fetal mortality was 9%. The maternal mortality of pregnant patients from the same age group who were managed medically during their pregnancies was 4.2% to 18.7% and fetal mortality as high as 50%.3 Currently, it is believed that surgical mortality and morbidity following open mitral commissurotomy are not increased during pregnancy.5 Surgical experience in heart surgery during pregnancy was frequently reviewed; however, the anesthesia literature lacked such information.
A 31-year-old white woman in the 22nd week of gestation was admitted to the Cleveland Clinic for acute hemoptysis. She had had a heart murmur since age 3 and in the past 3 years dyspnea on mild exertion and occasional tachycardia developed. She denied having any ankle edema or paroxysmal nocturnal dyspnea. The night prior. . .