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A Pregnant Woman With Shortness of Breath

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

A 40-year-old woman presented with a history of mitral valve (MV) endocarditis leading to MV repair (without annuloplasty) 15 years ago. Four years ago while pregnant, she had recurrent endocarditis complicated by severe symptomatic mitral regurgitation, but she was successfully brought to term and had a cesarean delivery. Post partum, her symptoms resolved, but she had persistent marked mitral regurgitation related to a severely deformed posterior leaflet. She wished to have another child, and after extensive counseling she elected to undergo a complex redo MV repair (annuloplasty) 2 years ago. She developed perioperative atrial fibrillation but declined anticoagulation and has not had further arrhythmias. Serial transthoracic echocardiograms have demonstrated normal biventricular function and pulmonary pressures. Her postoperative MV gradient was 10 mm Hg (heart rate, 90 beats per minute [bpm]) and has been stably elevated since surgery.

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Severe mitral stenosis (MS) after complex MV repair worsened by hemodynamic changes of pregnancy

C. Trial medical management with metoprolol and enoxaparin

Severe MS in pregnancy is associated with increased risk of maternal heart failure, maternal arrhythmia, and preterm birth.1 Additionally, pulmonary arterial hypertension in pregnancy is associated with 15% to 50% maternal mortality.2 These lesions are classified by the American Heart Association as World Health Organization pregnancy risk category IV (high risk of maternal morbidity and mortality).3 Patients with severe MS who are contemplating pregnancy should be extensively counseled on these risks and offered transcatheter or surgical management prior to conception when possible; individuals who are already pregnant should additionally be counseled about all reproductive choice options, including termination.

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Article Information

Corresponding Author: Sarah Chuzi, MD, Division of Cardiology, Northwestern University Feinberg School of Medicine, 676 N St Clair St, Ste 600, Chicago, IL 60611 (sarah-chuzi@northwestern.edu).

Published Online: November 11, 2020. doi:10.1001/jamacardio.2020.5587

Conflict of Interest Disclosures: None reported.

Additional Contributions: We thank the patient for granting permission to publish this information. We also thank the patient’s cardiologists, Robert Bonow, MD (Northwestern Memorial Hospital), and Marla Mendelson, MD (Northwestern Memorial Hospital), and her obstetrician, Patricia Garcia, MD (Northwestern Memorial Hospital), for their excellent, thoughtful care of this patient. Drs Bonow, Mendelson, and Garcia did not receive additional compensation.

References
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2.
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3.
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