2024 FSA Podium and Poster Abstracts

P030: MULTIDISCIPLINARY MANAGEMENT OF PATENT DUCTUS ARTERIOSUS IN A HIGH-RISK PREGNANCY
Miguel Escanelle, MD; Alexander Hall, MBBS; Harrish Ram, MD; Selina Patel, MBBS; University of Miami

Introduction: Heart disease remains the principal cause of maternal mortality during pregnancy, with congenital heart defects posing a significant and potentially lethal threat if undetected in expectant mothers. Among these, intracardiac shunts like the Patent Ductus Arteriosus (PDA) are particularly perilous to overlook. Unrepaired, PDAs may progress to Eisenmenger syndrome, associated with a 50%-65% mortality rate in pregnant women. The physiological adaptations during pregnancy, such as reduced systemic vascular resistance, exacerbate the risks for those with congenital heart disease by increasing right-to-left shunting. This shift can diminish pulmonary blood flow, leading to hypoxemia and, consequently, further clinical deterioration, heightening maternal and fetal morbidity and mortality rates.

Case Presentation: A 19-year-old Guatemalan woman at 38.5 weeks gestation presented with labor concerns and high blood pressure, leading to her referral to a hospital. An echocardiogram revealed a large Patent Ductus Arteriosus (PDA) and severe pulmonary hypertension, prompting her transfer to JMH for specialized care, where she was diagnosed with severe preeclampsia. The pre-delivery TTE showed normal heart structure but significant PDA with left-to-right shunting and a peak gradient of 73 mmHg, suggesting an estimated systolic pulmonary artery pressure of 109 mmHg. Additionally, severe left ventricular dilation and flat septal curvature indicated right ventricular pressure surpassing half the systemic pressure. After a multidisciplinary consultation involving Maternal Fetal Medicine, Cardiology, and Anesthesiology, an elective cesarean section was scheduled with the ECMO team on standby. In the OR, a right radial arterial line, epidural anesthesia, and a right internal jugular central line were established. Monitoring with a Swan-Ganz catheter showed systolic arterial pressures between 110-120 mmHg and systemic pressures of 150-170 mmHg. The team managed systemic pressures to avoid right-to-left shunts, considering the patient's significant heart dilation. Blood pressure was maintained with milrinone and vasopressin, ensuring stable hemodynamics. Post-surgery, the patient was monitored in the CVICU. The PDA was successfully closed using a 16 mm Amplatzer device in the cath lab, halving RV pressures. The patient was discharged three days later for outpatient care.

Discussion: The patient had a large PDA and a low-normal LVEF, accompanied by severely dilated LA and LV, placing her at high risk for peripartum decompensation. Ideally, the PDA would have been closed before attempting pregnancy. However, upon presenting at 38 weeks' gestation, she was at maximal volume expansion, making the risks of PDA closure outweigh the benefits. This management decision necessitated a thoughtful discussion with a multidisciplinary team. This case highlights the critical role of collaboration among maternal-fetal medicine, cardiology, and anesthesiology to achieve favorable outcomes for both mother and child, emphasizing the importance of tailored care strategies for pregnant patients with congenital heart disease.