Thread by @dr_benoy_n_shah

**VALVE CASE OF THE WEEK**
@BrHeartValveSoc

32yr old lady with moderate mitral stenosis tells you in clinic she is planning on trying for a baby...is that ok? Denies any symptoms, feels well. Echo - mean MVG 6mmHg. RVSP ~ 20mmHg. What would you say / do / advise?

Parasternal X-plane...

Ap 4Ch zoom of MV

MV colour

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Ok, 398 votes, good effort! Exercise stress echo a clear winner in that poll.

So...

I'm not a "heart disease in pregnancy" specialist so was clearly going to refer her on, but felt I needed to give the ACHD guys more info than just a resting echo. We know pregnancy will...

...increase HR and significantly increase preload (circulating volume ++) so that will only worsen the gradient between LA and LV. Can right heart cope? So, I arranged an exercise SE.

I know I'll get beaten but we used a treadmill - for MS I feel it's fine! I prefer it actually

She managed 9mins Bruce protocol before asking to stop with SOB. No chest pain, no new AF. Immediate post-stress echo showed a clear increase in turbulence as expected with tachycardia and after exercise, with a peak mean MVG of...

26mmHg! As I recorded that and saw MV E Velocity of >3m/s, you know the RVSP must be high, so then I went TR hunting..!

RVSP >60mmHg

So, a 32yr old can only manage 9mins Bruce protocol which is definitely reduced and increases mitral gradient from 6-->26 and RVSP from ~20-->64mmHg.

Then I made the ACHD referral, thinking she'll need something doing before she gets pregnant

Our specialists saw her, went through all options and also advised against pregnancy without some treatment...so she had a date with the balloon in the cath lab...

Anyway, MS decreased but MR increased. Eventually, after further meetings with ACHD specialists, she decided against pregnancy (has children already) and wants mechanical MVR.

The comments have been very instructive, I agree little evidence for SE being used to influence outcome

in pregnancy setting, but for symptomatic patients with moderate MS at rest we do find SE useful. Different setting, I agree.

Anyway...new case next week!