Cardiopulmonary Bypass During Pregnancy

Transcription

1 Cardiopulmonary Bypass During Pregnancy Anitha S. John, MD, PhD, Fionnuala Gurley, MD, Hartzell V. Schaff, MD, Carole A. Warnes, MD, Sabrina D. Phillips, MD, Katherine W. Arendt, MD, Martin D. Abel, MD, Carl H. Rose, MD, and Heidi M. Connolly, MD Division of Cardiology, Children s National Medical Center, George Washington University, Washington, DC; and Divisions of Cardiovascular Diseases, Cardiovascular Surgery, Cardiovascular Anesthesia, and Maternal-Fetal Medicine, Mayo Clinic, Rochester, Minnesota Background. Cardiac surgery during pregnancy carries significant maternal and fetal risk and is typically considered after failure of medical therapy. We sought to determine the maternal and neonatal outcomes of cardiopulmonary bypass during pregnancy. Methods. Twenty-one pregnant patients undergoing cardiothoracic surgery were identified from the Mayo Clinic surgical database (1976 to 2009). Maternal and neonatal outcomes were reviewed. Results. Operations included 8 aortic valve replacements, 6 mitral valve repair-replacements, 2 myxoma excisions, 1 patent foramen ovale closure, 1 myectomy, 2 aortic aneurysm repairs, and 1 prosthetic aortic valve thrombectomy. Median cardiopulmonary bypass time was 53 minutes (range 16 to 185). Twelve patients (57%) required emergent surgery with a median gestational age (GA) of 25 weeks (range 7 to 35.5). Seven patients underwent cesarean section immediately prior to sternotomy delivering viable infants (median GA 31 weeks). In the remaining patients, three additional preterm births occurred, all in operations performed at an early GA (13 to 15 weeks). Median follow-up was 16 months (range 3 to 305). All patients improved to New York Heart Association functional class I or II. One early maternal death occurred 2 days after emergent mechanical aortic valve thrombectomy and 3 late maternal deaths occurred 2, 10, and 19 years postoperatively. Three fetal deaths occurred in mothers with additional medical comorbidities. Conclusions. In the current era, cardiothoracic surgery can be performed with relative safety during pregnancy. Fetal complications (prematurity and death) are associated with urgent, high-risk surgery, maternal comorbidity, and early GA. Emergent surgery appears to confer a higher risk of maternal death. (Ann Thorac Surg 2011;91:1191 7) 2011 by The Society of Thoracic Surgeons Cardiac disease occurs in 2% to 4% of pregnancies, and if untreated accounts for up to 15% of maternal mortality in addition to conferring an increased risk of both preterm delivery and fetal mortality [1, 2]. Inthe Western world, congenital heart disease (CHD) accounts for an increasing proportion of cardiac disease encountered in pregnancy. Additionally, as CHD survival rates have improved, the number of women surviving to childbearing age with complex CHD has increased. It is estimated that CHD now comprises up to 50% of cardiac disease in pregnancy [1]. Rheumatic valvular heart disease is the cause of most acquired heart disease seen in pregnancy, with the mitral valve (MV) and aortic valve (AV) most commonly affected [3]. During a normal pregnancy, cardiovascular changes occur to maximize oxygen delivery to the fetus. Cardiac output increases up to 40% above baseline, with concurrent increases in both heart rate and plasma volume. As circulating blood volume increases, red cell mass increases correspondingly but at a lesser rate than the increase in plasma volume, producing a relative physiologic anemia. In addition, there is a drop in both systemic Accepted for publication Nov 15, Address correspondence to Dr Connolly, Division of Cardiology, Mayo Clinic, 200 First St SW, Rochester, MN 55905; connolly. heidi@mayo.edu. and pulmonary vascular resistances, reducing the blood pressure during the first half of pregnancy [3, 4]. Later in pregnancy, inferior vena cava compression can occur from the gravid uterus, decreasing venous return and eventually cardiac output [5]. While women with heart disease may be in a physiologically compensated state prior to pregnancy, the cardiovascular changes that occur during pregnancy can precipitate a decompensated state relatively unresponsive to medical therapy [3]. In fact, cardiac disease may initially present during a pregnancy. Cardiac surgery during pregnancy has been reported to carry significant maternal and fetal risk and is typically considered only after failure of medical therapy [6]. In this review, we present a summary of the Mayo Clinic experience with cardiopulmonary bypass in pregnancy and subsequent maternal and fetal outcomes. Material and Methods A total of 21 pregnant patients undergoing cardiothoracic surgery during the study interval (1976 to 2009) were identified from the Mayo Clinic surgical database. Medical and surgical records were reviewed for operative indications and the details regarding surgical repair. When available, maternal cardiovascular and functional status was determined before and after surgery with 2011 by The Society of Thoracic Surgeons /$36.00 Published by Elsevier Inc doi: /j.athoracsur

2 1192 JOHN ET AL Ann Thorac Surg PREGNANCY AND CARDIAC SURGERY 2011;91: Abbreviations and Acronyms AV aortic valve CHD congenital heart disease CPB cardiopulmonary bypass CS cesarean section EGA estimated gestational age MV mitral valve NYHA New York Heart Association SGA small for gestational age TAA thoracic aortic aneurysm echocardiography and clinical reports. Additional data were collected from Mayo Clinic visits immediately prior to surgery and from the most recent visit. Records were reviewed for neonatal outcome and complications. Patients were contacted by phone or mail for further details regarding their obstetrical history, fetal outcomes, and current state of health. Informed consent was obtained for those patients providing follow-up data. Abstracted variables included cardiac diagnosis and prior operations, maternal obstetrical history and pregnancy course, cardiovascular status prior to and after surgery, surgical details, and fetal outcome. The protocol was approved by the Mayo Clinic Institutional Review Board. Data were expressed as median (range) for continuous variables and as frequencies for nominal or ordinal values. Patients undergoing delivery by cesarean section (CS) at the time of cardiac surgery were included in the cohort. Operations not performed with cardiopulmonary bypass (CPB) were excluded from this series. Emergent surgery was defined by hemodynamic instability needing inotropic support or intubation; patients required hospitalization and immediate surgery. Urgent surgery was defined by symptoms of heart failure and (or) severe symptomatic valve stenosis not responsive to medical therapy; patients required hospitalization and underwent surgery within one week of presentation. Results Patient Demographics and Preoperative Data Details regarding each case, organized by fetal outcome, are summarized in Table 1. Median maternal age was 28 years (range 20 to 40 years). Median gestational age (GA) was 25 weeks (range 7 to 35.5). The etiology of maternal cardiac disease is summarized in Table 2. Congenital heart disease accounted for 48% of maternal cardiac disease, including 7 patients with bicuspid or unicuspid AV. Seven patients had previous cardiac surgery, and two of these patients had two prior operations. Previous procedures included tetralogy of Fallot repair, partial atrioventricular canal repair, coarctation repair, MV cleft repair, MV replacement, and two patients had AV replacement. The patients with two prior operations included a tetralogy of Fallot repair with subsequent AV replacement and tricuspid valve annuloplasty and the second patient had repair of aortic coarctation with subsequent AV replacement. Surgical and CPB Information Operations performed are summarized in Table 1. The median CPB time was 53 minutes (range 16 to 185), median cross-clamp time 35 minutes (range 9 to 128), median flow rate 2.55 L min 1 m 2 (range 2.2 to 2.7), and median perfusate temperature 37 C (range 20 to 37). Twelve patients (57%) required urgent or emergent surgery with seven undergoing CS immediately prior to sternotomy delivering viable infants (median GA 31 weeks) in all cases. Urgent or emergent procedures included two for ruptured thoracic aortic aneurysm, four for MV or AV prosthesis obstruction, five for severe AV stenosis, and one for severe MV stenosis. During the study period, normothermic, nonpulsatile CPB was performed using a flow rate of greater than 2.4 L min 1 m 2 while maintaining mean arterial pressure greater than 70 mm Hg. If the mean arterial pressure was lower than 70 mm Hg, the initial management was to increase pump flow; vasoconstrictors (phenylephrine or vasopressin) were used sparingly. Prior to initiating CPB, each patient received an initial dose of heparin (3 mg/kg) with a target activated clotting time of 550 seconds, and an additional dose of heparin (0.3 to 0.6 mg/kg) was administered to the patient if the activated clotting time was less than 550 seconds. The initial CPB prime was Plasma-Lyte solution (0.8 to 1.5 L; Baxter Healthcare Corp, Irvine, CA); however, when the anticipated hematocrit on CPB was below 24% (hemoglobin 8 g/dl), red blood cells were added to the prime. Heparin (10,000 units) was also added to the CPB prime. Current practice includes using smaller circuitry to minimize prime volume as well as the use of retrograde arterial or venous autologous priming. Over the 30 years, a variety of CPB pumps and oxygenators were used including, most recently, the Sorin S5 pump (Sorin Group USA, Arvada, CO) and the Terumo-Capiox membrane oxygenator (Terumo, Ann Arbor, MI). Maternal Obstetric History and Clinical Outcomes Maternal obstetric history and outcomes are reviewed in Table 3. Approximately half (52%) of the women had a history of prior successful pregnancies while 38% had a past history of miscarriage. Prior to surgery, 62% of women were NYHA (New York Heart Association) class III or IV with improvement to NYHA class I in 90% of women after repair (Table 4). Median length of hospitalization was eight days (5 to 17 days), and median time to follow-up was 16 months (range 3 to 305). There was one early maternal death two days after emergent mechanical AV thrombectomy (1985); a viable infant was delivered by CS prior to cardiac surgery. There were three late maternal deaths (Table 1). One case occurred two years after AV replacement due to endocarditis. The second case occurred ten years postoperatively due to congestive heart failure in a patient with MV stenosis and impaired cardiac function. The last case occurred from thrombosis of a prosthetic MV nineteen years postoperatively. Long-

3 Table 1. Summary of Cardiopulmonary Bypass Cases Performed in Pregnant Patients at Mayo Clinic Case Age (Years) Gestation (Weeks) Diagnosis Indications for Operation Surgical Procedure CPB Time (Minutes) Lowest Temperature Delivery Mode EGA (Weeks) a Outcome 1 b Severe AS, BAV Symptomatic severe AS Aortic valve replacement Unknown Unknown Unknown HOCM, SAM Symptomatic severe Septal myectomy SVD 38 Term, normal baby LVOTO PFO CVA, embolic event PFO closure SVD 40 Term, normal baby Severe AS, BAV Severe Symptomatic AS Aortic valve replacement CS 38 Term, normal baby Severe MS Symptomatic severe MS Mitral valve repair SVD 40 Term, normal baby 6 c Severe MS Cardiac failure Mitral valve replacement SVD 40 Term, normal baby Left atrial myxoma Mitral valve obstruction Myxoma excision SVD 40 Term, normal baby Severe MR, MVP Symptomatic severe MR Mitral valve repair Induced VD 39 Term, normal baby 9 c Severe MR, cleft mitral valve Symptomatic severe MR Mitral valve repair CS 36 Premature delivery, IUGR Left atrial myxoma Palpitations Myxoma excision SVD 33 Premature delivery 11 b Prosthetic AV Symptomatic severe AS Aortic valve replacement CS 27.5 Premature delivery obstruction 12 b 32 7 TAAA Ruptured aneurysm Graft repair 340 d 37 Spontaneous 7 Premature delivery abortion 13 b Severe AS, BAV, 2 Symptomatic severe AS Aortic valve replacement Dilation and 15 Premature delivery vessel CAD CABG Evacuation 14 b Severe MS Cardiac failure Mitral valve replacement SVD 26 Premature delivery 15 b Severe AS, calcific Symptomatic severe AS Aortic valve replacement CS e 27 Premature delivery 16 b Mechanical mitral valve Cardiac failure Mitral valve replacement CS e 35.5 Premature delivery thrombosis 17 b,c Severe AS, BAV Symptomatic severe AS Aortic valve replacement CS e 31 Premature delivery 18 b Severe AS, Cardiac failure Aortic valve replacement CS e 30 Premature delivery unicommissural 19 b Severe prosthetic AS, Symptomatic severe AS Aortic valve replacement CS e 31 Premature delivery repaired TOF 20 b,f Mechanical aortic valve Cardiac failure Aortic valve thrombectomy CS e 35 Premature delivery thrombosis 21 b Transverse aortic arch aneurysm Ruptured aneurysm Extraanatomic bypass graft CS e 33 Premature delivery a Gestational age at delivery. b Emergent or urgent surgery. c Late maternal death. d Partial bypass with surgical duration of 340 minutes. e Infants delivered by cesarean section immediately prior to maternal cardiac surgery. f Early maternal death. AS aortic stenosis; AV aortic valve; BAV Bicuspid aortic valve; CABG coronary artery bypass grafting; CAD coronary artery disease; CPB cardiopulmonary bypass; CS cesarean section; CVA cerebrovascular accident; EGA estimated gestational age; HOCM hypertrophic obstructive cardiomyopathy; IUGR intrauterine growth retardation; LVOTO left ventricular outflow tract obstruction; MR mitral regurgitation; MS mitral stenosis; MVP mitral valve prolapse; PFO patent foramen ovale; SAM systolic anterior motion of mitral valve; SVD spontaneous vaginal delivery; TAAA thoracoabdominal aortic aneurysm; TOF tetralogy of Fallot; VD vaginal delivery. Ann Thorac Surg JOHN ET AL 2011;91: PREGNANCY AND CARDIAC SURGERY 1193

4 1194 JOHN ET AL Ann Thorac Surg PREGNANCY AND CARDIAC SURGERY 2011;91: Table 2. Etiology of Maternal Cardiac Disease Etiology of Maternal Cardiac Disease (n 21) term follow-up data were available in seven women: three women went on to have additional successful pregnancies. Fetal Outcome There were three fetal deaths related to cardiac surgery during pregnancy (see Table 1). A spontaneous abortion (GA 7 weeks) was associated with thoracic aortic aneurysm repair using partial bypass (surgery duration 340 minutes) in a patient who abused methamphetamine. The second occurred in a patient with poorly controlled type 1 diabetes mellitus undergoing aortic valve replacement and coronary artery bypass grafting (GA 15 weeks). The third fetal death (stillborn at 26 weeks) occurred after MV replacement (1986) using deep hypothermic circulatory arrest at 28 C (GA 26 weeks). Table 3. Summary of Maternal Obstetric Data and History Maternal Obstetric Data No. of Patients (% total) Congenital heart disease 10 (48%) Bicuspid AV 5 Bicuspid AV/aortic coarctation 1 Unicuspid AV 1 Tetralogy of Fallot 1 Cleft mitral valve/incomplete AV canal 1 Patent foramen ovale 1 Rheumatic heart disease (mitral stenosis) 3 (14%) Mitral valve prolapsed 2 (10%) Left atrial myxoma 2 (10%) Aortic aneurysm 2 (10%) Hypertrophic cardiomyopathy 1 (4%) Other valve disease 1 (4%) AV aortic valve. Value Age, years (median) 29 years (20 40) Length of hospital stay, days (median) 8 days (5 17) Number of women a with Prior pregnancies 14 (67%) Prior miscarriages 8 (38%) Prior successful pregnancies 11 (52%) Delivery by cesarean section a 10 (48%) Cesarean section (CS) performed prior 7 (33%) to cardiac surgery Obstetrical complications: a Pre-eclampsia 2 (10%) Perioperative preterm labor/contractions 3 (14%) b Preterm labor/contractions 6 (29%) c Preterm delivery (including CS prior to 11 (19%) surgery) a Number 21 women; data expressed as total number of women and percentage of total. Delivery data and obstetrical complications refer to pregnancies at the time of cardiopulmonary bypass. b All cases of fetal loss/stillbirth. c Includes cases of perioperative preterm labor. Table 4. Maternal New York Heart Association (NYHA) Functional Class Before and After Surgery Maternal NYHA Functional Class a Preoperative Postoperative I 4 (19%) 19 (90%) II 4 (19%) 1 (5%) III 7 (33%) 0 IV 6 (29%) 1 (5%) b a Number 21 women; data expressed as total number of women and percentage of total. b Case of early maternal mortality after aortic valve prosthesis thrombectomy. The modes of delivery are summarized in Table 1. Seven infants were delivered by CS immediately prior to maternal cardiac surgery (median GA 31 weeks) for a total of 11 preterm births (52%). Of the preterm births, six infants had extreme prematurity with an estimated GA of less than 33 weeks (see Table 5). Neonatal complications occurred only in those infants born preterm and included intrauterine growth restriction, respiratory distress syndrome, and prolonged hospital stay. Long-term data were available for seven infants. Three infants had developmental delay and all were born preterm (27 to 30 weeks estimated GA). Cesarean Section and CPB Seven patients had delivery by cesarean section immediately prior to cardiac surgery. Cesarean section was performed first under general anesthesia. After delivery, the uterine incision was closed, and the abdominal wound was packed. Median sternotomy was then performed and CPB was initiated. After completion of the cardiac procedure and chest closure, the abdominal wound was then inspected and closed after hemostasis was established. Patients did require additional blood products during surgery as median blood loss from the CS was 800 cc (range 500 cc to 1,000 cc). No patients had Table 5. Summary of Neonatal Outcomes Outcome Measure No. Patients (%) Full-term delivery (GA 36 weeks) 7 (33%) Vaginal delivery 6 (29%) Cesarean section 1 (5%) Premature delivery 11 (52%) Less than 33 weeks GA 6 (29%) 33 to 36 weeks GA 5 (24%) Vaginal delivery 2 (10%) Cesarean section 9 (43%) Stillborn (fetal demise) 1 (5%) Neonatal complications Intrauterine growth restriction 1 (5%) Respiratory distress syndrome 7 (33%) Hospital stay 7 days 8 (38%) Developmental delay a 3 (14%) a Long-term follow-up data were available in 7 patients only. GA estimated gestational age.

5 Ann Thorac Surg JOHN ET AL 2011;91: PREGNANCY AND CARDIAC SURGERY 1195 excessive bleeding necessitating prolonged packing of the abdominal wound or hysterectomy. Comment Cardiac disease in pregnancy accounts for 10% to 15% of maternal mortality. As the life expectancy of the CHD population continues to improve the number of women of childbearing age with complex cardiac disease will increase, as will the need for surgical treatment options. Our study sought to review the maternal and fetal outcomes of cardiopulmonary bypass performed in pregnancy. Maternal Outcomes and Risks Previous reports suggested that the maternal mortality associated with CPB during pregnancy occurred at a rate of 3% to 15% [7]. In the current era, however, the maternal mortality rate is reported to be similar to that of CPB in nonpregnant women, unless the surgery is performed on an emergent basis [8]. Our data further support this finding. In our series, one early maternal death occurred in a patient with AV prosthesis thrombosis and severe left ventricular dysfunction requiring emergent surgery (performed in 1985). She had a prolonged bypass time and left ventricular assist device placement, but ultimately died within two days of presentation. No early deaths occurred in patients with procedures performed after This patient had been lost to cardiac follow-up prior to presentation and likely had not maintained adequate anticoagulation during pregnancy. This case stresses the importance of not only regular cardiac follow-up with adequate prenatal counseling, but also the need for multidisciplinary management of these patients. Additional maternal risks are related to maternal CHD and are discussed separately. Fetal Outcomes and Risks Cardiopulmonary bypass during pregnancy has been associated with a fetal mortality rate of 16% to 33% [7]. During CPB, a decrease in maternal mean arterial blood pressure occurs as well as reduction in pulsatile flow, which is thought to result in uteroplacental hypoperfusion. This can precipitate uterine contractions. Importantly, these contractions can also occur after CPB and surgery. In our cohort, two women had early contractions after CPB that were treated successfully with intravenous magnesium tocolysis; in one additional patient, a stillbirth occurred shortly after surgery. Of the 14 patients who had delivery after surgery (excluding those patients with cesarean section immediately prior to delivery), there were three fetal losses, three preterm deliveries, seven term infants, and one patient lost to follow-up. Of the three fetal losses, two of the mothers had additional comorbidities. All three cases of fetal losses occurred 1 to 3 days after CPB and all occurred in cases of urgent surgery performed at early GA. These data support that of Weiss and colleagues [9] who found that fetal mortality declined as cardiac surgery was delayed and the fetus was allowed to mature. Fetal losses appeared to be associated with urgent, high-risk cardiac surgery, maternal comorbidities, and operations performed at an early GA. Two patients had prior documented cardiac disease but had not maintained follow-up with cardiology. This again stresses the importance of prenatal counseling and multidisciplinary management. As our case series spans over 30 years the era of surgery also impacted on neonatal outcomes. Two cases of preterm delivery (one resulting in stillbirth) occurred in patients when hypothermia was used during CPB. These operations were performed in 1985 and 1986, respectively. Currently, operations performed at our center avoid hypothermia and, therefore, reduces the risk of prematurity [6, 10]. Additional strategies that we currently use to minimize fetal risks include minimizing intraoperative blood loss, maintaining uterine displacement to avoid aortocaval compression, using normothermic CPB, minimizing CPB times, maintaining a high flow rate ( 2.4 L/min/m 2 ), and mean arterial pressures greater than 70 to 75 mm Hg [5]. Uterine displacement can be maintained by placing the patient in the left lateral recumbent position during CPB. This should be done for any parturient greater than GA of 20 weeks to avoid impairment of uteroplacental blood flow. Serum potassium concentration (goal 5 mmol/l) also is closely monitored as cardioplegia may increase serum potassium levels in cases with prolonged periods of cardioplegic arrest. In addition, optimizing maternal oxygen saturation and avoiding maternal hypoglycemia are important for preventing fetal bradycardia [11, 12]. With a GA greater than 24 weeks, many experts recommend monitoring the fetal heart rate during CPB in order to adjust the flow rate, the mean arterial pressure, and the maternal temperature to maintain fetal heart rates between 110 and 160 beats per minute. If possible, attempting to delay surgery until an advanced GA would also minimize the risks associated with prematurity and fetal demise. Timing of Delivery in Relation to CPB In seven cases, cardiopulmonary bypass was performed after elective preterm delivery by CS (see Table 1). In two of these cases (GA 27 weeks and GA 30 weeks) there was evidence of fetal distress, prompting early delivery. In the remaining five cases it was felt that the fetus was mature enough to survive preterm delivery, and the maternal surgery was complicated enough to warrant this strategy. In addition, five of these seven cases involved mechanical prosthetic valve placement, and the issue of anticoagulation during pregnancy and delivery added an additional factor toward the decision of delivery prior to cardiac surgery. Determining the optimal timing of cardiac surgical intervention is one of the most challenging and critical clinical decisions in the care of the pregnant patient with cardiac disease and needs to be made on a case by case basis. Early intervention will decrease maternal risk but may result in fetal demise. Alternatively, delaying cardiac surgery until after delivery may result in maternal death. If the fetus is of advanced enough gestational age and the planned mater-

6 1196 JOHN ET AL Ann Thorac Surg PREGNANCY AND CARDIAC SURGERY 2011;91: nal surgery is anticipated to be complicated, prolonged in length, or anticoagulation will be needed, delivery prior to CPB should be considered. Congenital Heart Disease and Pregnancy Congenital heart disease comprises an increasing percentage of cardiac disease seen in pregnancy [13]. In our cohort, 48% of patients had CHD, with bicuspid AV being the largest subset (Table 2). Adult CHD patients present special challenges as many patients have had surgical repairs in the past. In our series, all patients with one or more prior operations had CHD. In addition, eight out of the 12 cases requiring emergent or urgent operations were patients with CHD, as was the early maternal death (Table 1). Consequently, the patients with CHD also had a higher rate of preterm deliveries. Neonatal complications such as prematurity are seen in up to 20% of offspring of mothers with cardiac disease [14]. Therefore, this population represents a high-risk group at baseline, now with the additive risks of CPB. Of the 11 cases of preterm delivery, nine were born to mothers with a history of CHD. In addition, five of the seven women with prior operations delivered preterm infants and all of these cases had underlying CHD. In fact, mothers with CHD have a fourfold increase in fetal mortality rate and a higher rate of preterm deliveries (16% vs 12%) compared with the general population [15]. Anesthesia Considerations Most adverse maternal and fetal outcomes from cardiac surgery during pregnancy are a result of CPB and the underlying cardiac status of the mother, not the anesthetic agent used. Reported risks from anesthetic agents come largely from animal studies although a few human studies do exist [16]. Sympathomimetic agents such as ephedrine and phenylephrine can be used to maintain perfusion pressure, although increasing CPB flow rates are preferable and will also result in increasing placental perfusion. Antifibrinolytic agents such as tranexamic acid are generally not recommended as pregnancy is an intrinsically hypercoagulable state. Use should be confined to those patients with bleeding concerns [16]. Study Limitations This is a retrospective review of cases performed at a single referral center over an extended time interval. Because the cases are collected from a single institution with expertise in cardiac surgery, the data may not be applicable to all centers. Operations were performed by ten different surgeons and managed by different multidisciplinary specialists so outcomes are not dependent on a single operator expertise. As our center is a tertiary referral site, long-term clinical follow-up was not available for many. In addition, referrals to a tertiary center are often the sickest patients at the greatest risk of complications. Conclusions Cardiac surgery during pregnancy should still be reserved for use only after medical therapy has failed; however in the current era, CPB during pregnancy can be performed with relative safety when performed at tertiary centers with expertise. Patients with CHD more frequently required emergent-urgent surgery and had higher rates of preterm deliveries as compared with the mothers with other cardiac disease. Fetal losses occurred in cases of urgent, high-risk surgery performed at an early GA in mothers with additional comorbidities. Maintaining normothermic, high flow CPB and avoiding surgery at an early GA, if possible, should be attempted to minimize fetal complications. Elective delivery prior to cardiac surgery should be considered in cases where the fetus is of adequate GA and the CPB is anticipated to be prolonged. 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