A Pregnant Woman With Severe Symptomatic Aortic Stenosis

A 31-year-old woman with end-stage kidney disease and with a bicuspid aortic valve presented with acute heart failure in the second trimester of pregnancy. The patient received a diagnosis of severe aortic stenosis and chose to continue the pregnancy against medical advice. Following a multidisciplinary team consultation, she underwent urgent transcatheter aortic valve replacement.

pregnancy, she was informed about the potential life-threatening risks associated with this pregnancy but made the decision to continue the pregnancy.At the 15th week of gestation, she underwent an indicated cerclage procedure using regional anesthesia, and it was uneventful.At the 22nd week of gestation, she presented with increased dyspnea on exertion and orthopnea while undergoing hemodialysis.On admission, her hemodynamic status was stable, and the physical examination revealed prominent jugular venous distention, a 3/6 systolic ejection murmur, clear lung sounds, a gravid abdomen, and no peripheral edema.She was admitted to the cardiac intensive care unit for further investigation.

PAST MEDICAL HISTORY
The patient has ESKD secondary to nephronophthisis, an autosomal recessive inherited disease.She has been treated with hemodialysis through arteriovenous

LEARNING OBJECTIVES
To understand the management challenges and treatment options for a pregnant patient with severe AS and end-stage kidney failure who is undergoing hemodialysis.To recognize the importance of multidisciplinary collaboration in decision making in complex clinical cases, particularly when there is an ethical consideration to respect the patient's autonomy, which may contradict the recommended medical practice.Yagel et al Severe AS in Pregnancy There was no evidence of fetal distress after the procedure, and findings on targeted ultrasound of the fetal brain were normal.The patient was discharged  4B).Currently, 9 months later, the patient and the baby are doing well.

QUESTION 1: WHAT ARE THE POTENTIAL RISKS OF CONTINUING WITH THE PREGNANCY IN A PATIENT WITH SEVERE AORTIC STENOSIS?
Severe AS in pregnancy is associated with an increased risk of heart failure, cardiac arrhythmias, and rarely death, and it is recommended that severe stenosis be repaired before contemplating pregnancy.
If the patient is asymptomatic before pregnancy, AS can be tolerated well during pregnancy.Given the absence of large, randomized studies on severe AS during pregnancy, the treatment approach is primarily guided by expert opinion.BAV is considered the preferred initial treatment for symptomatic severe AS. 1 BAV has demonstrated a lower complication rate compared with TAVR. 3 The European Heart Society guidelines for managing Yagel et al Severe AS in Pregnancy cardiovascular diseases during pregnancy acknowledge TAVR as a promising treatment option, but its application is still constrained by limited experience and data availability. 4SAVR performed during pregnancy carries an increased, yet manageable, risk for the mother (3%-7%).However, it poses a significantly high risk to the fetus.The estimated risk of fetal loss during SAVR is approximately 20%.The highest risk of hemodynamic compromise and heart failure occurs during the second and third trimesters, during labor and delivery, and in the 24 to 72 hours following delivery, times coinciding with the peak of cardiac output. 10Fetal mortality following maternal cardiac surgery is notably high, particularly during the first and second trimesters.Performing a cesarean delivery before cardiac surgery, particularly in the third trimester, is an independent factor associated with reduced fetal mortality in cases where cardiac surgery is required.

FUNDING SUPPORT AND AUTHOR DISCLOSURES
The authors have reported that they have no relationships relevant to the contents of this paper to disclose.

FIGURE 1
FIGURE 1 Echocardiogram: Continuous-Wave Doppler Imaging of the Aortic Valve 2 0 2 4 : 1 0 2 2 0 5 continued during resuscitation, with patient stabilization after the valve was fully deployed.An Evolut Pro 23 valve (Medtronic) was implanted successfully without significant perivalvular leak (Figures 3A and 3B), resulting in a peak-to-peak gradient of 35 mm Hg (Figure 2C).Subsequently, a balloon post-dilatation was performed using a 20-mm balloon (VACS III, OSYPKA), thus reducing the peak-to-peak gradient to 20 mm Hg.The patient underwent successful extubation and was admitted back to the intensive cardiac care unit.The day after TAVR, an echocardiogram was performed, which showed peak and mean gradients of 53 mm Hg and 34 mm Hg, respectively (Figure 1B).

FIGURE 2
FIGURE 2 Peak-to-Peak Gradients

FIGURE 3
FIGURE 3 Transesophageal Echocardiogram of the Aortic Valve