Severe High-Gradient Aortic Stenosis in Pregnancy Due to a Bicuspid Aortic Valve

Severe High-Gradient Aortic Stenosis in Pregnancy Due to a Bicuspid Aortic ValveAlthough severe aortic stenosis (AS) is encountered infrequently during pregnancy, it can be life-threatening, and in women of childbearing age the dominant underlying cause is a bicuspid aortic valve.When the left ventricle must eject against a fixed outflow obstruction, the additional hemodynamic load of pregnancy can tip a previously stable patient into decompensation.We describe a 40-year-old woman, 23 weeks pregnant following in vitro fertilization, who carried a known bicuspid valve and a previously diagnosed cardiomyopathy for which she had fallen out of follow-up.Despite being free of symptoms, she was found on echocardiography to have severe high-gradient AS together with a preserved ejection fraction and concentric hypertrophy.The very high gradient and velocity satisfied intervention thresholds in the absence of symptoms.After review by a multidisciplinary Pregnancy Heart Team and a period of serial echocardiographic monitoring, she underwent cesarean delivery at 34 weeks, immediately followed in the same sitting by mechanical aortic valve replacement.Both procedures were uncomplicated for mother and neonate.For appropriately selected women, scheduling a preterm cesarean delivery and combining it with valve replacement in a single operation can deliver good results for both mother and child while sparing the fetus any exposure to cardiopulmonary bypass.