The impact of birth on left ventricle (LV) function and over the evolution of a congenital valvular heart disease incidentally discovered during the 12th week of pregnancy

Case presentation: We report the case of a 27-year-old woman with no cardiovascular risk factors presenting with acute heart failure symptoms. She was admitted in the Intensive Care Unit of our Cardiology Department for orthopnea and major legs swelling progressively aggravated in the last 3 weeks before addmission. Her medical history revealed: caesarean delivery 5 weeks earlier (at 37 week pregnancy), bicuspid aortic valve (BAV) with moderate stenosis and minimal regurgitation incidentally discovered with the occasion of a cardiac examination during pregnancy (aortic valvular mean gradient=35 mmHg, LVEF=60% at that time). She was monitored until birth with no significant changes of the aortic valvular dissease or LV function and she was counseled regarding the interruption of pregnancy in order to corect the AVD. Clinical exami-nation: severe dyspnea at rest, orthopnea, pulmonary, SaO2 75%, systemic congestion, BP=90/60 mmHg, 122 bpm, ejection aortic murmur, pallor. Laboratory tests: elevated NTproBNP level, moderate anemia, hepatic cytolysis. ECG:SR, no change of repolarization. Tran-sthoracic echocardiography: LV hypertrophy, severe global systolic LV dysfunction, LV apical trombosis, bicuspid aortic valve with severe stenosis, mild regurgitation. Transesophageal echocardiography: bicuspid aortic valve, commissures at 12 and 6 o’clock, raphe at 3 o’clock, severe aortic stenosis, two hyperecogenic structures in LA and LV apex. Positive diagnosis: acute congestive heart failure with LV severe dysfunction, BAV with low-flow low-gradient stenosis and minimal regurgitation. Differential diagnosis: peripartum cardiomyopathy, myocarditis, infective endocarditis and pulmonary thromboembolism (PE). Thoracic CT scan with intravenous contrast excluded PE, negative blood cultures, negative viral screening, negative culture from the postoperative wound, cardiac MRI excluded myocarditis, confirmed LV severe dysfunction (LVEF 15%), tetracameral heart dilatation and the presence of 2 thrombus (in LA and LV). Peripartum cardiomyopathy, with late postpartum onset left under discussion. The patient received conventional treatment for acute heart failure her evolution was favorable. Echocardiographic after 6 months: LVEF 40%.
Particularity of the case: BAV with moderate stenosis and minimal regurgitation, asymptomatic for 27 years, incidentally diagnosed with the occasion of cardiac examination during pregnancy of a patient that developed cardiomyopathy with severe LV dysfunction 2 weeks after child birth.
Conclusions: 1. Counseling of a nulliparous pregnant woman without other cardiovascular risk factors who was incidentally diagnosed with moderate congenital aortic valvular disease during pregnancy regarding the maintaining or not of the pregnancy before the correction of valvular disease. 2. Counseling the same patient for future pregnancies in relation to the risk of recurrence of cardiomyopathy.

ISSN – online: 2734 – 6382
ISSN-L 1220-658X
ISSN – print: 1220-658X
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CODE: 379
CME Credits: 10 (Romanian College of Physicians)