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CONGESTIVE HEART FAILURE IN A PREGNANT WOMAN WITH TRANSPOSITION OF THE GREAT ARTERIES S/P ATRIAL SWITCH SURGERY

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PATIENT STORY 1

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A 29-year-old woman with complete transposition of the great arteries (TGA) repaired with a Mustard atrial switch surgery presented with heart failure symptoms 7 days postpartum. TGA is a form of cyanotic congenital heart disease (CHD) in which the aorta originates from the right ventricle (RV) pumping deoxygenated blood to the body and the pulmonary artery (PA) originates from the left ventricle (LV) pumping oxygenated blood to the lungs. This lesion is often incompatible with life and many adults currently living with TGA have undergone atrial switch surgeries as infants to direct deoxygenated blood to the LV to be pumped to the lungs and oxygenated blood to the RV to be pumped to the body (Figure 11-1A). The RV in patients who have undergone the atrial switch procedure is the systemic ventricle and becomes hypertrophied, dilated, and often dysfunctional.

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FIGURE 11-1

A. D-transposition Transposition of the great arteries with an atrial switch procedure. B. Postpartum echocardiogram in a woman with d-transposition of the great arteries and an atrial switch procedure demonstrating a dilated, hypertrophied systemic right ventricle who presented with heart failure in the postpartum period. Ao, aorta; LV, left ventricle; PA, pulmonary artery; RV, right ventricle. *Pulmonary vein entering the pulmonary venous atrium.

Graphic Jump Location
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This woman had an uncomplicated pregnancy and underwent a cesarean section for obstetrical reasons during which time she received several liters of intravenous fluids. On presentation, one week postpartum, she presented with dyspnea and edema. She underwent an echocardiogram that did not reveal any changes in systemic ventricular function and tricuspid valve regurgitation (Figure 11-1B). She was treated with intravenous furosemide and her symptoms dramatically improved. The increased volume load of pregnancy is not tolerated well in some women with CHD, particularly those with underlying ventricular dysfunction. Symptoms may be exacerbated in the postpartum period when afterload increases and dramatic changes in volume loading may occur.

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CASE EXPLANATION
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  • The presence of cardiovascular disease in pregnant women poses a difficult clinical scenario in which the responsibility of the treating physician extends not only to the mother but also to the unborn fetus.

  • Pregnancy has a profound effect on the circulatory system. Most of these hemodynamic changes start in the first trimester, peak during the second trimester, and plateau during the third trimester.

  • The delivery and immediate postpartum period is associated with further profound and rapid changes in the circulatory system. During delivery, cardiac output, heart rate, blood pressure, and systemic vascular resistance increase with each uterine contraction.1

  • Immediately postpartum, the delivery of the placenta increases afterload by removing the low-resistance circulation and increases the preload by returning placental blood to the maternal circulation. This increase ...

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