A ‘do-or-die’ path to motherhood
Houston doctor’s cutting-edge treatments help heart patients’ risky pregnancies
Cecilia Figueroa started feeling sick about the ninth week of her pregnancy, so short of breath from walking just a few steps that she felt like she was about to pass out.
Port Arthur doctors confirmed what Figueroa already suspected: The problem was a heart valve transplanted a few years earlier because congenital kidney problems had caused so much damage to the original. Now, despite her doctor’s prepregnancy assurances to the contrary, the transplant was failing, too.
Her doctor’s new advice: consider terminating the pregnancy, then have open-heart surgery to replace the transplanted valve.
The advice didn’t go over well with Figueroa, a 31-year-old stay-at-home mom who had been waiting for years to have a second child.
“I don’t know that I’m not going to die on the operating table if I go to surgery,” said Figueroa. “Only God knows that — if I’m going to die, I’m going to die trying to save my baby.”
Figueroa sought second opinions from doctor after doctor, but none offered any real hope until she found her way to a Texas Medical Center cardiologist daring enough to propose a cutting-edge, minimally invasive procedure not exactly envisioned for expectant young mothers.
The procedure involves threading a slender tube, a catheter, from a blood vessel in the groin to the heart. There, the doctor inflates a balloon at the catheter’s end that inflates a folded-up valve, which clamps at the site, induces tissue to form, grows into the heart and takes over the regulation of blood flow. Patients, awake throughout the procedure, barely feel a thing.
The procedure was developed for and tested on the frail and elderly, but Memorial Hermann Hospital’s Dr. Richard Smalling saw no reason it shouldn’t work in Figueroa.
Without any other options, Figueroa jumped at the suggestion.
The procedure, known as a transcatheter aortic valve replacement, or TAVR, was approved for the elderly and those at high risk of complications in cardiovascular surgery in 2011, after years of testing in the sickest of patients. In 2017, Memorial Hermann performed 524, more than any hospital in the country.
None previously involved a pregnant patient.
That’s no wonder, and not just because Figueroa’s condition is rare in pregnant women. Doctors generally don’t relish the idea of trying novel heart procedures on two patients at once, putting both in greater peril because of the increased risk of complications.
‘God, you take this’
But Smalling had reason to be optimistic: He’d recently performed a minimally invasive heart procedure in another pregnant patient — Nora Rangel, a Pearland woman born with a small hole between the top two chambers of the heart. The hole, which can allow blood clots to reach the brain, caused a stroke in 2015, when she was 26, though doctors weren’t able to diagnose it at the time.
They told Rangel to go off birth control, which increases the risk of strokes. Her husband had a vasectomy, but she became pregnant anyway. Doctors said the tubes reconnected, a one-in-thousand occurrence.
Six months into the pregnancy, Rangel suffered a mini-stroke. Doctors finally diagnosed the hole, known as a patent foramen ovale, or PFO, a leading cause of otherwise inexplicable strokes in people under 55.
Rangel was told the pregnancy was too risky to continue. She didn’t believe in abortion, but an obstetrician-gynecologist’s counsel that it wouldn’t be fair to her three children if she died delivering the fourth resonated enough that she checked it out, only to be told that her condition made it too risky to terminate the pregnancy.
“I cried that day,” said Rangel. “I felt that if God gave me this baby, I’ve got to have it. But I didn’t know what to do. Finally, I just said ‘God, you take this.’”
Rangel’s ob-gyn put her in touch with Smalling, a leading proponent of a new approach to treat PFOs that uses a tiny metal device to plug the hole after it’s passed through — what else? — a catheter inserted into a leg vein and threaded to the heart.
A do-or-die situation
Figueroa thought she had the flu — fever, aches, coughing, vomiting — before she learned her kidneys, small at birth, had begun failing at the age of 23. She spent that birthday in the hospital, immediately put on dialysis.
She remained on dialysis for six years, during which time calcium deposits formed on her aortic valve, a common consequence. Such deposits narrow the valve’s opening and reduce blood flow.
Still, Figueroa didn’t begin experiencing heart symptoms until 2014, when she got dizzy easily and began passing out. Doctors initially told her it was an anxiety attack but ultimately spotted the damage to the valve.
She left the hospital in tears, convinced she was going to die, before returning a week later for openheart surgery to implant a biologic valve. It was the most painful surgery she’d ever had, she said, but she slowly felt her heart function get better.
Eight months later, Figueroa got a kidney transplant. She said she felt considerably better after awakening from the surgery.
In early 2017, Figueroa sought doctors’ approval to have another child, no minor undertaking given her medical history. Her cardiologist gave her the thumbs up following an echocardiogram done to determine if the new valve could tolerate a pregnancy. Within a month she was pregnant.
The echocardiogram actually did show damage, something the doctor admitted after she started experiencing symptoms.
Her husband thought they should sue, but Figueroa was more concerned about her health and the pregnancy. She resolved to keep the pregnancy going as long as possible to at least to save the baby. She had a difficult conversation with her then 12-year-old son about what she faced.
The night before the scheduled TAVR procedure, she said she was so nervous she didn’t sleep.
“Every surgery is a door-die thing,” she said.
“But this time it wasn’t just me. I had a baby inside me.”
Options for women
There are no shortage of reasons why open-heart surgery is considered prohibitive for a pregnant patient. Pregnancy carries an increased risk of clotting because of hormones; the amount of blood thinners necessary for such an invasive procedure is bad for the baby; there are dangerous risks of bleeding and drops in blood pressure.
Minimally invasive interventions don’t carry as much risk but they’re not free of them. So Smalling’s team employs “a few tricks” — they don’t turn on the X-ray machine around the uterus; they only briefly thin the blood, which minimizes the baby’s exposure; they take extra caution.
It helps that Smalling’s early academic back“The ground was as an engineer. He emphasizes the importance of devising a game plan, thinking three or four steps ahead — “What are we going to do if this or that happens?” — and having a good support staff ready. He jokes that he doesn’t think the maternal doctors had an emergency bassinet in the room, but says they were closely monitoring the baby throughout.
Smalling, 71, downplays any personal nervousness about performing the procedure, acknowledging a little but comparing his situation to a quarterback who’s thrown thousands of passes in a career facing an All-Pro cornerback. “You’re a little more careful, but you’ve been doing it long enough that you trust your instincts,” he said.
Rangel’s procedure, just 20 minutes long, went off without a hitch, the patient reporting feeling only a vibration in the heart, no pain. Smalling said the team “high-fived all around” at its conclusion. case really gave us more courage to do these minimally invasive heart procedures without exposing the baby to much risk,” said Smalling, an interventional cardiologist at Memorial Hermann’s Heart & Vascular Institute and the University of Texas Health Science Center at Houston. “Women need to know that. If a heart issue is discovered and you’re told nothing can be done, explore your options.”
Though Rangel and Figueroa suffered from rare conditions, the potential patient population is probably larger than people think. It’s unclear how many, but Dr. Baha Sibai, the ob-gyn who referred Rangel and Figueroa to Smalling, says he sees a few pregnant patients every week with cardiac issues, part of the nation’s growing problem of pregnancy-related deaths and disease.
Healthy babies
Figueroa’s case — transplanted kidney, transplanted and deteriorating heart valve, and a history of dialysis — certainly fit the pregnancy-related death and disease profile. But during the 1½-hour TAVR procedure, a more perilous task than the PFO, Smalling encountered no difficulties implanting the valve. When Figueroa awoke, able to breathe normally again, the first thing she noticed was the baby kicking — “his way of saying, I’m OK, you’re OK,” she told a nurse.
The pregnancy survived Hurricane Harvey, which briefly stranded Figueroa, her husband and son in her two-bedroom, second-story apartment of a building that took on first-floor flooding the first few days. Her parents and two brothers soon moved in for three cramped months because of the storm’s damage to their place.
But in November, Figueroa gave birth to a healthy 6-pound baby, Sebastian, their “miracle boy.” Figueroa describes him as either happy or grumpy — “there’s no in-between” — but says their shared survivor bond is unmistakable. To her husband’s frustration, she’s the only one he’ll let put him to sleep.
Earlier in 2017, Rangel gave birth to a healthy 6pound girl, Victoria, now 16 months old, who she describes as “clever, smart, amazing,” even though her first word was “Daddy.” “I carried you for nine months and you can’t say mommy?” Rangel teases her.
Rangel didn’t emerge from her health issues unscathed. Though sealing the hole in her heart should prevent future strokes, the original one left her with mild aphasia, characterized by an occasional difficulty finding the right words, as well as brain damage that can still cause seizures, including an episode two weeks before labor and another just a few weeks ago.
Unfazed, Rangel describes herself as “grateful just to be here” and “to be Victoria’s mom.”
Figueroa has one more pregnancy-related order of business: a July marriage in a church, a promise the couple made to God even though they’re already legally wed.
“When you’re in difficult circumstances, you make all kinds of promises to God,” said Figueroa. “They’re not always easy to live up to, but we’re trying to make good on them all.”
“I felt that if God gave me this baby, I’ve got to have it. But I didn’t know what to do. Finally, I just said ‘God, you take this.’ ” Nora Rangel, Pearland resident