A 27 year old woman who is 26 weeks pregnant is admitted to the ICU with pulmonary edema. She is intubated, paralyzed and treated with broad spectrum antibiotics. TTE shows rheumatic mitral stenosis with mean gradient of 16 mm Hg at HR 115 BPM (sinus tachycardia). Her BP is 105/76. No murmur is audible. Fetal heart sounds are normal and the maternal fetal medicine group is following.

Select the best initial management strategy:

  1. Terminate Pregnancy
  2. Intravenous beta-blocker
  3. Intravenous unfractionated heparin
  4. Consult cardiac surgery

Correct Answer: B

Rationale:

This patient has mitral stenosis with a high mean diastolic gradient at a fast heart rate. Tachycardia exacerbates the underlying pathophysiology of mitral stenosis due to the associated reduction in the LV diastolic filling period. Achievement of longer filling times at slower heart rates, as could be achieved by use of a beta-blocker, is the first therapeutic target in this case. It is too premature to terminate the pregnancy, there is no indication for heparin anticoagulation in the absence of atrial fibrillation, and the performance of cardiac surgery is not necessary at this stage. In addition, percutaneous balloon mitral commissurotomy is the preferred intervention for anatomically appropriate candidates.

References:

2014 AHA/ACC Valve Guidelines.

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