Doctors at Hamilton Health Sciences have performed what is believed to be the world's first minimally invasive replacement of an aortic valve on a pregnant woman.

The 45-minute procedure, called transcatheter aortic valve implantation or TAVI, was carried out April 9 when the 29-year-old Cambridge mom was 16 weeks pregnant and in danger of dying because the valve was not opening properly, making it hard for the heart to pump blood through the body.

Sarah Sayle went home days after the successful valve replacement and on Sept. 22 had a healthy baby boy, named Peter Bell, who weighed seven pounds and 12 ounces.

"It's a game changer," said Dr. Eric Horlick, cardiologist at Toronto's Peter Munk Cardiac Centre, of the of pioneering procedure. "It has a lot of significance."

Until now, pregnant women needing aortic valve replacement had to decide between three difficult options.

They could have an abortion. Or, doctors could try opening the valve, but the minimally invasive procedure had limited success and sometimes didn't last. Or they could have open heart surgery, following which roughly one-third of mothers lose their baby. The babies who lived were still at risk from the difficult drug regimen the mom would be required to take following surgery.

Waiting for the baby to be born wasn't a possibility.

"She would not have survived," said Dr. Richard Whitlock, the cardiac surgeon who did the procedure. "Her valve was so tight, it was without doubt."

The stay-at-home mom with two toddlers "definitely wanted to continue with this pregnancy," said Whitlock. "Our main goal was to save Sarah's life."

Whitlock, along with a team of specialists, turned to a procedure used in Canada for the last decade to treat patients too frail or sick to undergo open heart surgery.

TAVI has been suggested in medical literature as a possibility for pregnant women but the Hamilton surgeons could find no evidence of anyone actually doing it. They consulted colleagues across Canada before deciding to be the first.

"The doctors were very confident," Sayle said. "I was nervous but I felt good about it . I'm grateful I was able to be the first in a long line of hopefully many other women who will now be able to get this procedure."

While her engineer husband sat in the hospital waiting room working to distract himself, doctors made a small incision in Sayle's groin and snaked a long narrow tube called a catheter through a large blood vessel. They expanded a balloon at the end of the catheter that pushed the dysfunctional valve out and implanted a new one made out of animal tissue.

"It was perfect," Whitlock said. "It was a textbook case. Everything went smooth."

The doctors, who have performed more than 250 TAVI procedures in other circumstances, had to make only minor adjustments to their usual routine to account for Sayle's pregnancy, such as covering the uterine area when using the X-ray machines that guide the surgery. In addition, Sayle had a tougher recovery without pain killers.

The groundbreaking case will now be written up for a medical journal to show it's a safe and valuable approach.

"It's exciting to see how a group of physicians came together as a team to provide this care," said Whitlock. "We got Sarah through this. It's fantastic."

It is not expected the procedure will be used often, as usually heart problems should are treated before a woman becomes pregnant.

"It's not something you ever plan because of the risk to the mother and baby," said Horlick, the Toronto cardiologist. "It's a very unusual situation."

But sometimes valve replacement is not possible beforehand because of unexpected pregnancies or the problem emerges in an immigrant or refugee who did not have access to good health care before coming to Canada.

In Sayle's case, the valve didn't need replacing until after she became pregnant.

"It was a surprise," she said. "As soon as I got pregnant, I got really tired. I got dizzy spells with not much exertion and I was sweating. When I started getting heart palpitations, I was sure there was a problem."

Sayle was born with a congenital heart defect but didn't know until she was 25 years old and engaged to be married.

"It was scary," she said. "I wanted a family and I was worried this would stop it."

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She had open-heart surgery to replace the valve before having children. The valve, which was made out of animal tissue, was supposed to last 10 to 15 years. She was expected to have a second open-heart surgery to replace it with a longer-lasting mechanical valve once she had decided not to have any more children. That type of valve requires blood thinners, which are risky during pregnancy, so it is usually implanted only after the child-bearing years.

Sayle had her two daughters without any complications, but the valve gave out during her third pregnancy only four years after it was implanted.

"It was terrifying - scarier than the first time because we have two daughters at home," said Sayle.

She was taken right from the ultrasound of her heart and admitted to Hamilton General Hospital where she remained until she had the surgery weeks later.

"I didn't know what was going to happen," said her husband. "She went for a doctor's appointment in the morning and was supposed to be back by noon and instead was admitted to hospital."

It was a true emergency, explained her obstetrician, Dr. Michelle Morais.

"This is something that needs urgent attention," she said. "This is something that needs to get fixed."

It was the first time Morais had ever encountered a case like this.

"It's something you read about in a textbook," she said. "You maybe see it once or twice in a career."

After having the valve replaced, Sayle was able to carry her baby to term. She was induced at 38 weeks and had a normal delivery at McMaster University Medical Centre.

The baby spent his first days in the neonatal intensive care unit at McMaster Children's Hospital to make sure his heart was strong.

"There doesn't seem to be any effect from the surgery," Morais said.

Sayle and baby Peter were expected to go home Friday.

"He likes to cuddle," said the proud mom, who is thankful for the first-ever procedure that saved them both. "He's a sweet baby."

How you can help

Hamilton Health Sciences is fundraising for a hybrid operating suite for minimally invasive surgeries like TAVI.

Donate at hamiltonhealth.ca

There is a wine-tasting fundraiser Oct. 30 from 6 p.m. to 9:30 p.m. at Mercedes-Benz Burlington, 441 North Service Rd. Wines are from Halpern Enterprises. Tickets are $150 per person and space is limited.

For tickets, go to Hamiltonhealth.ca/PremierCru or email mcintyremi@hhsc.ca or call 905-521-2100 ext. 76787.

