Case Presentation
A 32-year-old woman with a known history of dilated cardiomyopathy and moderate secondary mitral regurgitation (MR) presented at 6 weeks’ gestation. She was asymptomatic while on bisoprolol (10 mg) and furosemide (80 mg), with other heart failure medications discontinued due to pregnancy.
Past Medical History
One year earlier, the patient had been hospitalized for heart failure at 22 weeks of her first pregnancy. She had no prior medical history before this event. Transthoracic echocardiography (TTE) revealed moderate left ventricular (LV) dysfunction with an ejection fraction (LVEF) of 40% and severe secondary MR. Despite diuretic therapy, she remained symptomatic and underwent an emergency cesarean delivery at 27 weeks. Unfortunately, the neonate did not survive due to complications from enterocolitis. Extensive investigations, including genetic evaluation, failed to identify an underlying cause for her cardiomyopathy. She was initiated on guideline-directed medical therapy, including ramipril, bisoprolol, eplerenone, and a sodium-glucose co-transporter-2 inhibitor. Over six months postpartum, her condition improved, with LVEF increasing to 50% and MR reducing from severe to mild.
Differential Diagnosis
The primary differential diagnosis considered was peripartum cardiomyopathy. However, her initial heart failure symptoms occurred early in pregnancy rather than postpartum, which is atypical for peripartum cardiomyopathy. Despite extensive investigations, including genetic testing, no clear cause for her cardiomyopathy was identified.
Investigations
Six weeks into her second pregnancy, laboratory tests showed normal liver and kidney function, and N-terminal pro–B-type natriuretic peptide levels were within normal limits (78 ng/L). TTE showed mild LV dysfunction (LVEF 45-50%) with dilation and mild-to-moderate secondary MR caused by restricted posterior leaflet closure. Systolic pulmonary artery pressure was measured at 37 mm Hg.
Management
Given the patient’s history and the expected hemodynamic burden of pregnancy, a team of obstetricians, cardiologists, and anesthesiologists assessed her case. Due to the high risk of heart failure worsening with pregnancy progression, an early mitral transcatheter edge-to-edge repair (TEER) was planned.
At 8 weeks’ gestation, the patient underwent TEER under general anesthesia with minimal fluoroscopic exposure (35 seconds, 13 cGy∙cm²). A transcatheter mitral valve repair device was placed centrally at the A2-P2 segments, reducing MR to mild with a mean transmitral gradient of 4 mm Hg. The procedure was uneventful, and she was discharged on bisoprolol (10 mg) and furosemide (20 mg).
Outcome and Follow-Up
The patient was followed with monthly clinical assessments and TTE. At 22 weeks’ gestation, she was hospitalized for threatened preterm labor. During her stay, she developed worsening heart failure symptoms, including orthopnea and pulmonary congestion. TTE showed severe MR recurrence despite the transcatheter mitral valve repair device. Her medical therapy was intensified with increased diuretics and beta-blockers, which stabilized her condition without requiring oxygen support.
At 29 weeks, she underwent cesarean delivery due to obstetric indications unrelated to her cardiomyopathy. The infant, born preterm, required neonatal intensive care but survived. Postpartum, the patient resumed optimal guideline-directed therapy, and at 6 months, she remained asymptomatic with an LVEF of 50% and mild-to-moderate MR.
This case highlights the challenges of managing heart failure during pregnancy and highlights the role of TEER in mitigating cardiac complications while balancing fetal outcomes.
