On-pump Cardiac Surgery During Pregnancy
Sergii Siromakha1, Vitalii Kravchenko1, Vasyl Lazoryshynets1, Yulia Davydova2, Artem Ogorodnik2, Iryna Osadovska1, Iryna Zinovchyk1.
1Amosov National Institute of cardio-vascular surgery, Kyiv, Ukraine, 2Institute of Pediatrics, Obstetrics and Gynecology of NAMS of Ukraine, Kyiv, Ukraine.
Cardiac surgery in pregnancy, especially intervention with CPB, is always a difficult challenge for a woman and fetus as well as for a pregnancy heart team. The guidelines of ESC recommend to perform cesarean section before a surgery, but it also depends on the statistics for outcomes of deep-preterm newborns. Methods. This paper presents the experience of minimally invasive cardiac surgery in pregnant women with “fetus in utero” by specialists of a national multidisciplinary team. Based on the significant experience in different types of cardiac interventions in Amosov National Institute of cardiovascular surgery, achievements of National Pregnancy Heart Team, high morbidity and probability of disabilities in preterm infants born at 25-28 gestational weeks, the following strategy for pregnant of high cardiovascular risk cohort was determined: (1) observation and conservative therapy (if necessary) in the first trimester - (2) elective cardiac surgery at 18-21 gestational weeks - (3) prolongation of pregnancy up to 36-38 gestational weeks with further delivery under permanent care by a multidisciplinary team. In the cases of acute heart pathology pregnant women underwent cardiac surgery regardless the term of gestation. We performed 72 cardiac interventions in 70 pregnant and parturient women during the years 2013-2019. There were 58 cases with fetus in utero, 17 of these were on-pump surgeries. Urgent surgeries with fetus in utero (n-5) were performed for pulmonary embolism, thrombosis of valve prosthesis, critical aortic and subaortic stenosis. The elective cardiac surgery (n-12) was performed for critical aortic stenosis, infective endocarditis, aortic aneurysm. Special parameters for CPB and fetal monitoring were applied. In last group of pregnant women, we performed 7 aortic valve replacement from partial J-sternotomy. Results. There were no cases of maternal mortality in the group of pregnant women who underwent open-heart cardiac surgery during pregnancy. There were two cases of antenatal fetal death (11,7%) from mothers who underwent urgent heart surgery. In all other cases, the immediate maternal and perinatal results were good. Follow-up for 12 cases we could observed (6 to 59 months after surgery) testified about good long term outcomes for mothers and children. Conclusions. The vision of pregnancy heart team is an effective strategy of highly specialized care for pregnant with critical pathology of heart and great vessels. The greatest achievement is a possibility to perform elective and urgent cardiosurgery in all terms of pregnancy with moderate risk for mother and fetus. Urgent and emergency on-pump surgery increases risk for fetus and newborn. Primary and secondary prevention of major heart events in pregnant women are powerful tools to reduce maternal, perinatal mortality and disability. Minimally invasive cardiac surgery with CPB for the pregnant in high-experienced centers with the pregnancy heart team care is a good option for shortening operative trauma, blood loss and rehabilitation period for these women.
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