Infective Endocarditis Requiring Mitral Valve Replacement During Second Trimester of Pregnancy

Infective endocarditis requiring mitral valve replacement during pregnancy is a rare event. We present a case of infective endocarditis of the mitral valve during second trimester and report maternal and perinatal outcomes. Prompt identification and interdisciplinary treatment is crucial; maternal and fetal follow-up including serial fetal neurosonography is recommended.

tis (IE) of the mitral valve (MV) was referred to the intensive care unit of our institution at 17þ0 weeks of gestation (WoG).The patient had presented at a district hospital 5 days earlier with severe headache, difficulties moving around and finding words, as well as rapidly deteriorating general condition.
Informed consent was obtained from the patient.

PAST MEDICAL HISTORY
Her past medical history was non-contributory and no predisposing risk factors were present.

DIFFERENTIAL DIAGNOSIS
Differential diagnoses considered were atrial fibrillation with a consecutive cerebral embolic event, meningitis, and influenza.

INVESTIGATIONS
Mobile vegetations at the basal posterior MV leaflet (20 Â 13 mm) were observed on transesophageal

LEARNING OBJECTIVES
To recall that symptoms such as shortness of breath and fatigue are common during pregnancy and may be mistaken for trivial complaints.A thorough history-taking and detailed clinical examination is therefore crucial, and further investigations need to be performed without delay.To be aware that a multidisciplinary approach in pregnant patients with IE is essential.To recognize that CPB during pregnancy may affect fetal development.Close follow-up including neurosonography should therefore be considered.To increase the chance of fetal survival, CPB adjustments have been proposed.These include the choice of cannulation site avoiding retrograde aortic perfusion, eschewing hypothermia, avoiding hypotension, and maintaining potassium concentrations within normal range. 5During general anesthesia for open cardiac surgery on CPB, there is a risk for maternal hypoxia and hypotension, which is highest during transition from corporal to extracorporeal circulation. 4Little is known about the effect of these changes on the fetal cerebral perfusion and its sequelae.In term or near-term infants, there is evidence that acute perinatal hypoxia can cause fetal encephalopathy. 6In pre-term and pre-viable fetuses, our knowledge about mechanisms leading to brain injury is more limited.Fetal stroke can be caused by ischemic, thrombotic, or hemorrhagic injury.53127 Bonn, Germany.E-mail: philipp.kosian@ukbonn.de.

FIGURE 1 4 Mitral
FIGURE 1 Maternal Brain Magnetic Resonance Imaging

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A C C : C A S E R E P O R T S , V O L . 2 9 , 2 0 2 4 take corrective action.Because of limited data on fetal surveillance during open heart surgery on CPB and its benefits, especially before fetal viability, no standards or guidelines are currently in place.In our case, we decided against fetal monitoring during surgery because of the gestational age.

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Mechanisms thought to contribute to fetal brain injury include isolated hypoxia and hypoxia combined with hypercapnia (termed asphyxia).Depending on the severity and gestational age at onset of either one or both of those mechanisms, different patterns of brain injury (ventriculomegaly, periventricular leukomalacia, delay of maturation) might be detected later in the fetus.8,9In general, in a surviving fetus after an episode of severe maternal hypotension or prolonged hypoxia, brain injury can only be detected with a delay of several weeks.Avoiding maternal hypotension and hypercapnia might prevent fetal brain injury; however, serial ultrasound examinations of the fetal brain after surgery over a period of 6 to 8 weeks are recommended.In case of abnormal findings, detailed counseling of the parents is required.In Figure3A, normal neurosonographic findings of our case at 23þ0 WoG are shown 6 weeks after MV replacement.For comparison, Figure3Bshows fetal ventriculomegaly due to ischemia and hypotension in a patient on extracorporeal membrane oxygenation due to severe acute respiratory syndrome coronavirus 2 infection in 25þ5 WoG as an exemplary case.FOLLOW-UPAt the time of reporting, the newborn (6 months of age) and his mother are in good condition and were both discharged from the hospital.CONCLUSIONSMembers of the pregnancy heart team including obstetricians, maternal-fetal medicine specialists, cardiologists, cardiothoracic surgeons, infectious disease specialists, anesthesiologists, and neonatologists need to work together.Close maternal and fetal monitoring throughout the remaining pregnancy is essential.FUNDING SUPPORT AND AUTHOR DISCLOSURESThis work was supported by the Open Access Publication Fund of the University of Bonn.The authors have reported that they have no relationships relevant to the contents of this paper to disclose.ADDRESS FOR CORRESPONDENCE: Dr Philipp Kosian, Department of Obstetrics and Prenatal Medicine, University Hospital Bonn, Venusberg Campus 1,