Response to Letter Regarding Article, “Management of Severe Mitral Stenosis During Pregnancy”
We appreciate the interest shown by Dr Harikrishnan and colleagues in our article.1 We agree with them that percutaneous balloon mitral valvuloplasty in pregnant women should be reserved for those patients in whom aggressive medical therapy fails and in patients for whom the benefits of intervention outweighs its risks. Certainly decreasing the heart rate is the main goal of medical therapy in patients with symptomatic mitral stenosis. Our patient was on very high dose of metoprolol (100 mg TID) and continued to be significantly symptomatic despite complete bed rest. In our experience, further addition of atrioventricular nodal blocking agents such as digoxin would not provide significant reduction in heart rate to provide adequate improvement in valve hemodynamics and symptoms.
We also agree with the importance of reduction in radiation exposure and fetal protection during the procedure. In our institution, it is routine practice to minimize fluoroscopy time, and to provide lead shielding to cover the lower abdominal segment, as well, which would not be readily visible on fluoroscopy images performed during balloon inflation. However we do routinely perform invasive hemodynamics during our valve procedures, because, in certain cases, important information can be obtained with no increase in fluoroscopy time.
With respect to anticoagulation in patients with rheumatic mitral stenosis, current American College of Chest Physicians guidelines2 recommend use of systemic anticoagulation if the left atrial diameter exceeds 55 mm, even if the patient is in sinus rhythm (albeit a grade 2C recommendation). Furthermore, American College of Chest Physicians guidelines for the antithrombotic therapy in pregnancy3 recommend the use of low-molecular-weight heparin over unfractionated heparin during pregnancy because of its improved safety profile. Needless to say, anticoagulation therapy during pregnancy needs to be individualized based on the overall risk/benefit assessment, patient preferences, and availability of resources, among other things.
Finally, by virtue of the fact that this article was published in the Images in Cardiovascular Medicine section of the Circulation, it is by no means meant to be comprehensive. Many areas in the care of patients with rheumatic heart disease were not covered. This case was presented to highlight some of the challenges in taking care of these patients during pregnancy.
Rebecca S. Norrad, MBBS, BSc (Hon)
Omid Salehian, MSc, MD, FRCPC, FACC, FAHA
Division of Cardiology
Department of Medicine
Hamilton, Ontario, Canada
- © 2012 American Heart Association, Inc.
- Norrad SN,
- Salehian O
- Whitlock RP,
- Sun JS,
- Fremes SE,
- Rubens FD,
- Teoh KH
- Bates SM,
- Greer IA,
- Middeldorp S,
- Veenstra DL,
- Prabulos AM,
- Vandvik PO