Yousuf Muhammad Saad, Ali Misbah Qurban, Ahmed Syed Shabbir, Naqvi Hamid Iqil, Siddiqui Khalid, Samad Khalid
Department of Anaesthesiology, The Aga Khan University Hospital, P.O Box 3500, Stadium Road, Karachi 74800, Pakistan.
Department of Anaesthesiology, The Aga Khan University Hospital, P.O Box 3500, Stadium Road, Karachi 74800, Pakistan.
Int J Surg Case Rep. 2024 Sep;122:110176. doi: 10.1016/j.ijscr.2024.110176. Epub 2024 Aug 14.
Redo aortic valve replacement in twin pregnancy presents significant challenges because of the elevated risks for both maternal and fetal health. Mortality rates range from 12 % to 21 % in specialised centres, with previous cardiac surgeries further elevating the risk. Pregnancy complicates cardiac surgery, with fetal mortality rates as high as 16-33 %.
A 31-year-old woman, 15 weeks pregnant with twins and with a history of mechanical aortic valve replacement, presented with worsening breathlessness and grade III dyspnoea. Echocardiography revealed severe valve obstruction, necessitating redo-aortic valve replacement and posterior aortic root enlargement. Despite intraoperative challenges, including ventricular fibrillation and postoperative heart block, she underwent successful surgery and pacemaker implantation, with both mother and fetuses remaining stable.
Optimal timing of surgery is crucial, considering fetal developmental vulnerability in the first trimester and maternal cardiac workload in the third trimester. Second-trimester risks are comparable to non-pregnant patients. A limited understanding of fetal-placental perfusion during bypass necessitates cautious management strategies, with emerging techniques like pulsatile perfusion showing promise. Anaesthesia selection prioritises fetal safety while monitoring fetal distress during surgery remains challenging. To achieve successful outcomes for both mother and babies in a twin pregnancy undergoing a redo aortic valve replacement, careful timing, appropriate surgical techniques, and meticulous perioperative care are essential.
A multidisciplinary approach is crucial for managing twin pregnancy following redo aortic valve surgery. Careful planning, close monitoring, and specialised surgical and anaesthetic techniques are key to minimising risks to both mother and fetus.
双胎妊娠患者再次进行主动脉瓣置换术面临重大挑战，因为这对母体和胎儿健康都有较高风险。在专业中心，死亡率在12%至21%之间，既往心脏手术会进一步增加风险。妊娠会使心脏手术复杂化，胎儿死亡率高达16% - 33%。
一名31岁女性，怀有15周双胎，有机械主动脉瓣置换史，出现呼吸急促加重及Ⅲ级呼吸困难。超声心动图显示严重瓣膜梗阻，需要再次进行主动脉瓣置换及主动脉根部扩大术。尽管术中面临包括室颤和术后心脏传导阻滞等挑战，但她成功接受了手术并植入了起搏器，母婴均保持稳定。
考虑到孕早期胎儿发育的脆弱性以及孕晚期母体心脏负荷，手术的最佳时机至关重要。孕中期的风险与非孕患者相当。对体外循环期间胎儿 - 胎盘灌注的了解有限，需要谨慎的管理策略，像搏动灌注等新兴技术显示出前景。麻醉选择优先考虑胎儿安全，而在手术期间监测胎儿窘迫仍然具有挑战性。对于接受再次主动脉瓣置换术的双胎妊娠患者，要实现母婴均成功的结局，仔细的时机选择、合适的手术技术以及精心的围手术期护理至关重要。
多学科方法对于再次主动脉瓣置换术后双胎妊娠的管理至关重要。仔细规划、密切监测以及专业的手术和麻醉技术是将母婴风险降至最低的关键。
