Cardiology and Cardiac Surgery collaboration leads to life-saving treatment after childbirth
Tatyana Ferreira knows she is lucky to be alive. Suffering from an undetected weakened aorta she developed while pregnant with her daughter last year, it progressed into an aortic dissection while giving birth. The condition should have killed her, said Cape Cod Hospital/Brigham and Women’s Cardiac Surgeon Anastasios Konstantakos, MD, FACS. Instead, she went nearly half a year after her baby was born before the trouble was diagnosed and treated.
“She was basically a time bomb for six months,” he said.
But, thanks to an almost perfect synchronicity of care between Dr. Konstantakos and cardiac surgery teams at Cape Cod Hospital and, later, Brigham and Women’s Hospital, the 36-year-old woman is home with her husband and two children today, doing well and able to tell the tale.
“I believe it’s a miracle,” Ferreira said recently.
“It was a rare case, a rare presentation, and the coordination of care between the Cape (Cape Cod Hospital) and Boston (Brigham and Women’s Hospital) was perfect,” said Dr. Konstantakos.
Cardiac surgeons may go their whole career without even seeing one case of an aortic dissection during pregnancy, but Ferreira’s case was the second that Dr. Konstantakos had encountered. Fifteen years ago, while practicing at a hospital in Montana, he had helped save the life of a woman in her 30s who was eight months pregnant when she collapsed in her bedroom. Her husband called 911 and at the hospital, Dr. Konstantakos then worked simultaneously with an obstetrics team to replace her aorta and deliver her baby via c-section. Both mom and baby survived and did well; he ran into them while shopping at a local Walmart several weeks later, he said.
But, Ferreira’s case was even more amazing because she had survived going about her life for so long before the aortic dissection was discovered, he said.
“The first (case) was once in a lifetime. This one was even more rare,” he said.
Ferreira’s experience was distinguished also by the fact that her case was the first time in the region that a cardiac surgery team had replaced an aorta and aortic valve together with a brand new device known as biological valved-conduit (Konect Resilia Graft ®, Edwards Lifesciences Corporation). The new device, which came on the market just recently, differs from the one the Montana woman received (which was a mechanical valve pre-sewn to a Dacron polyester tube) because it is made of cow heart membrane restructured into a human-shaped valve.
Traditionally, patients with a mechanical valve need to be on blood thinners for the rest of their lives to keep the valve functioning and to prevent clots from forming. However, for women of child-bearing age, being on blood thinners such as warfarin can predispose them to birth defects and possibly stillbirths. With the new graft, blood thinners such as warfarin are not required, potentially allowing women of child-bearing age to conceive.
Fatigue After Delivery
Ferreira’s story began in mid-2020 when she delivered a healthy baby boy at Cape Cod Hospital. For the next two weeks, she complained of back pain and fatigue. Her family doctor, meeting with her virtually due to the pandemic, monitored the situation.
Six months later, Ferreira, who works as a housekeeper in a senior living facility, was still bothered by fatigue and pain. Her doctor picked up a heart murmur and sent her to a cardiologist for an echocardiogram. She had to wait two more weeks for the exam due to an exposure to COVID-19. By that time, it was late January 2021.
When she finally had the test, the cardiologist saw the dissection and Ferreira was rushed to the hospital for emergency open heart surgery.
“They called me in and, not only had her aorta dissected all the way from her aortic valve through the arch of the aorta, and - this is even more rare - the ascending aorta had become aneurysmal,” said Dr. Konstantakos.
In rare cases, aortic dissections can happen to pregnant women because during pregnancy the elasticity of the tissues can change, he explained.
“The uterus, the aorta, and various tissues can get softer because Mother Nature wants the mom to be able to adapt and deliver a baby,” he said. “But in some people, whether it’s genetics, high blood pressure or whatever reason – nobody really can predict – that’s the time when a tear in the aorta can happen. In this scenario, as the mom is delivering the child, a sudden aortic tear can start and progress to a complete rupture.
Without emergency surgery, a ruptured aortic dissection is almost always deadly for both mom and the baby, he said.
“The aorta peels apart like a banana, but in this case the peel of the aorta was strong enough until it ballooned out to an aneurysm. It’s like a water balloon ready to explode,” he said. “When that happens, the person dies within seconds, so that’s what makes Tatyana’s case so remarkable.”
Nearly two decades ago, when he was training to become a cardiac surgeon at Brigham and Women’s Hospital, it was rare to see patients who were pregnant who suffered a ruptured dissection and lived, Dr. Konstantakos said. “It was more common than not that the mom and the baby did not survive. That’s what made the first case so rare and this case even rarer because the mom essentially survived the rupture after her pregnancy.”
Ferreira’s experience was even more incredible because she was able to continue to live and function for so long after the dissection, he said.
Rushed to Surgery
Rushed into surgery at Cape Cod Hospital, Ferreira’s surgical team, dressed in full COVID-19 protective equipment, worked to save her life. During surgery, patients are placed on a heart-lung machine, which allows the surgical team to stop their heart and continue to provide blood to their heart, lungs, brain and the rest of their body throughout the operation. The temperature of the circulating blood is cooled almost to freezing and the patient is then warmed up. The cooling and warming prevents the blood cells from clotting as they normally would, causing massive bleeding and swelling inside the chest cavity.
“You have to understand that this was rare for her to survive from pregnancy until her operation, but getting through the operation was also a huge physiological stress for her,” Dr. Konstantakos said. “There’s so many things that could have gone wrong. She could have had a stroke, she could be on permanent dialysis, she could be paralyzed, she could have had a heart attack or sepsis.”
After her aortic tear was repaired Ferreira was still not out of the woods. To take care of the large amount of internal swelling in her chest cavity from the procedure, Ferreira needed another procedure known as a “washout” the following day at Cape Cod Hospital. In addition, due to the overall stress on the body from the operation, internal organs such as the kidneys can shut down, and the patient must be on a special type of dialysis, for which a transfer to Brigham and Women’s Hospital was necessary. Ferreira was then flown by medical helicopter from Cape Cod Hospital – still unconscious with her chest open – to the Boston medical center.
“Because of the complexity of the operation and recovery, she had to remain paralyzed, on the breathing tube,” Dr. Konstantakos said.
It was Ferreira’s husband, Admilson, who put his faith in Dr. Konstantakos to travel to Boston with his wife and complete the operation. The surgeon, who has been a member of the Cape Cod Hospital staff for just over one year, at first had thought he would hand the second part of the procedure over to the cardiac surgical team at Brigham and Women’s. But Admilson’s request convinced him to go. Cape Cod Hospital and Brigham and Women’s Hospital have a partnership for their cardiac surgery program whereby Dr. Konstantakos and other CCH cardiac surgeons are on staff at both hospitals.
When Ferreira awoke from the operation she was disoriented, asking why she was there and when she could go home. A Brazilian citizen who has lived on Cape Cod for nearly three years, Portuguese is her first language, which made the communication difficult. Due to COVID, an in-person interpreter was not possible, so she had to use an electronic interpreter to talk with doctors and nurses.
“COVID was a big deal because you couldn’t have asked for worse timing for all of this,” Dr. Konstantakos said. “The logistics were quite challenging.”
The pandemic also prevented Admilson from visiting his wife, but he and other family members stayed in touch with her constantly via Facetime. Ferreira remained at Brigham and Women’s for about two and a half weeks before finally going home to her family.
With the assistance of Cape Cod Hospital medical interpreter Catarina Hegner, Ferreira said her ordeal “was unreal; out of this world.” While in a coma following the surgery, she said she felt as if she was awake and could hear certain things being said and happening around her.
“After four days, I started waking up but I couldn’t remember much,” she said. “Around five to seven days, I realized what had happened.”
Ferreira has recovered remarkably well, according to Dr. Konstantakos, who last saw her in April. She was off dialysis within a month of surgery and now only needs to take a baby aspirin each day. She sees her cardiologist every two months.
Thanks to the new aortic device, she and Admilson can consider having more children, but Ferreira admitted “I’m a little afraid right now.”
Down the road, she will likely need to have the valve portion of the device replaced, due to natural deterioration. Hopefully, that will can be done with a minimally invasive procedure known as the transcatheter aortic valve replacement.
For now, Ferreira is enjoying her new lease on life and has high praise for those who cared for her during her surgery, especially Dr. Konstantakos.
“I’m very, very grateful for what he did. He brought me back to life and I am very grateful.”