Having a first baby is a life-changing event, one bundled with joy, sleep deprivation and strange new hardware from bouncers to bassinets. Katie Parton got all that plus a new aortic valve.
Katie, who lives in Cheyenne, Wyoming, was 24 when daughter Lily joined her and husband Chris in early 2016. The delivery went smoothly, but the new mom ended up back at Cheyenne Regional Medical Center a week later with pneumonia. Doctors checked her heart and found minor regurgitation – blood flowing the wrong way. Katie had never had heart problems and felt just fine. The medical team suggested she come back in six weeks for a second scan. That one showed the regurgitation had become severe. She still felt fine, but, as she put it, if she didn’t get the aortic valve replaced, she would “live a completely normal life for a while, then drop dead at 40.”
That’s not the sort of news a new mother – or anyone else – wants to hear.
Aortic-valve replacement is rare for patients as young as Katie. Add to that her status as a new mom still flush with maternal hormones, and the medical team in Wyoming recognized that she needed interdisciplinary, specialized care. They referred her to UCHealth University of Colorado Hospital at the Anschutz Medical Campus. Dr. Amber Khanna, associate director of the adult congenital heart disease program at the University of Colorado School of Medicine, took the lead.
Pregnancy does more to a woman’s body than bulge the belly. Hormones that persuade pelvic ligaments relax for childbirth have systemic effects that can stretch out the aorta and affect the aortic valve. There’s also more blood flow in general. Still, Khanna said, Katie’s case was unusual in how her pregnancy triggered a quick, serious valve degeneration.
Usually, the 10 to 20 pregnant patients the Adult Congenital Heart Disease Program works with at any given time have had heart problems before pregnancy, Khanna said. She and colleagues devised a care plan for Katie.
Option 2
To give Katie’s hormones time to settle back to normal, they would wait until baby Lily was three months old. They then would implant one of two types of aortic valves.
The first option would be a mechanical valve made of metal and plastic. These are robust – enough so that even a patient as young as Katie could expect it to last the rest of her life. But there are drawbacks with mechanical valves. Blood clots are likely enough to form on them that patients must stay on blood thinners, period.
The second option would be either a pig (porcine) valve or a valve constructed from cow (bovine) tissue. Neither attracts clots like the mechanical valves, so blood thinners aren’t required. But they only last 10 to 15 years, so Katie would eventually need a replacement.
Katie, Chris, and the medical team decided to go with a bovine valve. There was one big reason.
“We did bovine because we knew we wanted to have at least one more child,” Katie said.
In addition to a heightened general risk of bleeding, blood thinners such as warfarin cross into the fetal bloodstream, and warfarin taken during the first trimester is associated with birth defects. It also inhibits coagulation, which could affect the unborn child if there’s a brain or other bleed. Also, pregnant women and new mothers form blood clots easily, making dangerous clotting around the mechanical valve a real concern. That can not only lead to strokes, but also to the valve sticking open or closed, which can be fatal.
Surgery
CU School of Medicine cardiothoracic surgeon Dr. T. Brett Reece performed the open-heart surgery on April 5, 2016. While minimally invasive TAVR aortic valve replacement is making news these days – and is a mainstay procedure at UCHealth, where doctors have played key roles in clinical trials for years – TAVR was approved only for patients too sick to withstand traditional surgery. Reece did one adjustment, though: making use of the extra skin Lily’s gestation had availed around Katie’s belly, he was able to stretch and tape skin such that the resulting scar would be several inches lower and less obvious.
Recovery went without complication, though Katie wasn’t allowed to hold Lily without a spotter because, if Lily arched her back and eluded her grasp, motherly instincts might take over at the expense of sternum sutures. Echocardiograms showed the new aortic valve to be performing well. Before too long, Katie was working out six days a week and burning off pregnancy pounds. She made good use of MyHealthConnection, and Khanna eased the commute from Cheyenne by meeting her at UCHealth Maternal Care – Loveland, where Khanna sees patients once a month.
“Outreach is something the adult congenital heart disease team feels strongly about,” Khanna said. “Every time I drive up there, it saves eight or 10 people from driving down to Aurora. It’s a part of our clinical program that we really feel is important.”
No. 2?
During one of those visits with Khanna in 2017, Katie broached the topic of whether or not it would be safe to get pregnant again.
“She laughed and gave me all of her demands as far as what she wanted to do the next few months,” Katie recalled. “I said whoa, whoa, whoa – I’m not pregnant yet.”
Khanna was relieved, “Oh, good,” she said. “Many women come to me when they’re already pregnant, and I have to figure out how to make it safe.”
Katie’s approach was the right one, Khanna said.
“It’s far and away better to have the conversation before she’s pregnant, because often there are things we can do and medications we should change beforehand,” she explained.
Katie and Chris decided to wait another year, just to be safe. By autumn 2018, she was pregnant again. Khanna presented Katie’s case at a monthly meeting in which cardiologists and high-risk obstetricians from the Maternal Fetal Medicine Program discuss complex cases. Among other things, they decided that the gestating baby would get an echocardiogram heart scan, just in case she (and it will be a she, named Claire) inherited her mother’s abnormal heart valve. Dr. Terry Harper, who leads the CU School of Medicine’s Maternal Fetal Medicine Program, sees Katie at the Cheyenne Women’s Clinic, where the program has a satellite presence. Harper does a monthly ultrasound check of Claire’s growth to make sure Katie’s blood-pressure medicine, metoprolol, isn’t slowing baby’s growth.
Harper and Khanna “are watching over her together to ensure that her heart handles the increased blood volume of pregnancy, especially in the third trimester,” Harper said in an email.
No regrets
Katie is due in late June, and the plan is to have her deliver in Cheyenne. Khanna will do an ultrasound scan of the aortic valve again in the third trimester, and then again a few weeks after delivery. If things look good then, Katie’s next heart scan won’t happen until Claire is entering the “terrible twos.” Katie knows that, one day, the heart valve that made Claire possible will need replacing. Khanna said they will discuss if it should be a mechanical one next time, or if perhaps they should consider implanting another tissue valve using TAVR.
Katie knew this was the price she would pay for her second child, and has no regrets about it. She’s thankful for her care at UCHealth.
“They take on the risky pregnancies and the risky heart surgeries,” she said. “The fact that they were willing to work with me, that they listened to my life concerns, was huge. Because often doctors say, ‘You have one child. Let’s not worry about more children.’”