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Juno and James Evans hold 3-month-old son Jaxson. Juno was pregnant when she learned that she needed surgery to fix a congenital heart defect.

Juno Evans poses for a portrait below a piece of art of the heartbeat of her 3-month old baby, Jaxon, Tuesday, April 19, 2022 in Katy. Juno Evans was pregnant when she learned that she needed open heart surgery. Open heart surgery would have been too risky and could have caused her to lose her baby. Instead a temporary balloon valvuloplasty (a balloon inserted through a catheter, then inflated in her aorta) was performed. Both mother and baby have been discharged from the hospital and are at home.

Juno Evans was winded, just walking from one room in the house to another. Even when making the bed, she had to stop halfway to catch her breath.

She thought it might be related to her pregnancy.

“I just ignored it,” the Katy resident said.

Evans didn’t realize it was a cry for help — from her struggling heart.

Evans was born with a bicuspid aortic valve. Instead of having the usual three flaps of tissue, or cusps, in the aortic valve, she was part of the 1 percent of the population with only two. She was diagnosed with these congenital defects before her earliest memories. She has only vague recollections of doctors’ appointments.

The aortic valve leaflets open and close to ensure blood flows in the right direction. The aorta is the main artery in the body — and the valve separates it from the left ventricle of the heart.

Because of the bicuspid aortic valve, Evans also had aortic stenosis, or narrowing of the valve that results in reduced blood flow from the heart to the body. In addition, there was constricting of the aorta called coarctation.

Evans was diagnosed with these congenital defects before her earliest memories.

Juno Evans holds her 3-month old baby, Jaxon, Tuesday, April 19, 2022 in Katy. Evans was pregnant when she learned that she needed open heart surgery. Open heart surgery would have been too risky and could have caused her to lose her baby. Instead a temporary balloon valvuloplasty (a balloon inserted through a catheter, then inflated in her aorta) was performed. Both mother and baby have been discharged from the hospital and are at home.

“When I was about 2 months old, my mom was giving me a bath, and I turned blue in the tub,” she said. “They rushed me to the hospital.”

As an infant, Evans had a procedure called a balloon aortic valvuloplasty, which widens the valve by inflating a balloon.

She underwent the same operation at age 5. “And that was my last surgery as a child,” Evans said.

Her annual checkups continued until age 18, when she was given a clean bill of health. “I took that as I don’t have to go anymore,” she said.

And Evans did not think of it again until she was 27 and in the early weeks of her pregnancy.

She began to wonder if her heart was healthy enough to support her growing baby. “It was on the back of my mind.”

An appointment with a cardiologist in Katy confirmed her worst fears. “I was scared,” she said. “The only thought in my mind was I don’t want to lose my baby.”

Evans’ cardiologist recommended Dr. Abhijeet Dhoble, director of Structural Heart Interventions at UTHealth’s McGovern Medical School.

From viewing her previous echocardiogram, Dhoble knew that her aortic stenosis was at a critical stage.

There are times, he said, when a balloon valvuloplasty can be performed and eliminate the need for future procedures. This was not one of those cases.

“Juno was told that her problems were cured, and she did not know that she would have any other issues,” he said. “But every patient is different. She was obviously not cured.”

The normal aortic valve area in an adult is usually greater than 2.5 square centimeters. Evans’ was less than 0.5 square centimeters, Dhoble said.

She faced a risk of death — and the fetus did too, he said.

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He called in a team of UTHealth and Memorial Hermann specialists, including cardiothoracic and vascular surgeon Dr. Anthony Estrera, vascular surgeon Dr. Rana Afifi and Dr. Poyee Tung, an adult congenital cardiovascular physician and cardiologist. Also part of the team were Dr. Baha Sibai and Dr. Michal Bartal, both maternal-fetal medicine physicians.

“This was not a one-man show,” Estrera said. “It was a huge effort by a lot of folks.”

Juno Evans poses for a portrait below a piece of art of the heartbeat of her 3-month old baby, Jaxon, Tuesday, April 19, 2022 in Katy. Juno Evans was pregnant when she learned that she needed open heart surgery. Open heart surgery would have been too risky and could have caused her to lose her baby. Instead a temporary balloon valvuloplasty (a balloon inserted through a catheter, then inflated in her aorta) was performed. Both mother and baby have been discharged from the hospital and are at home.

Their collaboration was necessary because of the difficulty of the case.

Evans had a mild leak, in addition to stenosis across her aortic valve, Estrera said.

“She was starting to have worsening symptoms,” he said. “And the blood that should be flowing in one direction, from her heart to the rest of her body, was coming back.”

Evans was basically in heart failure. She was only 17 weeks pregnant at the time.

Open-heart surgery during pregnancy was deemed too risky, but it was also too soon for an emergency C-section, Estrera explained.

“We started asking, ‘How do we buy time?’” he said.

Juno Evans poses for a portrait holding her 3-month old baby, Jaxon, below a piece of art of the baby’s heartbeat Tuesday, April 19, 2022 in Katy. Juno Evans was pregnant when she learned that she needed open heart surgery. Open heart surgery would have been too risky and could have caused her to lose her baby. Instead a temporary balloon valvuloplasty (a balloon inserted through a catheter, then inflated in her aorta) was performed. Both mother and baby have been discharged from the hospital and are at home.

Another balloon valvuloplasty — the same procedure performed during Evans’ childhood — seemed to be the only way forward.

“It’s not a permanent fix — but it would buy us time,” Estrera said.

The procedure also came with its own challenges.

“If it didn’t work, or caused excessive tearing of the leaflets causing a severe leak, I would have to operate on her, which would put the baby at significant risk of not surviving,” Estrera said.

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The day of the procedure, he was on standby — with an operating room reserved just in case.

Evans was admitted for the surgery on Oct. 4, the day of her husband James’ birthday.

She tried to be upbeat. As she was wheeled in for the operation, she prayed.

And Evans said she spoke to her baby, “We’re OK. We’ve got this. We’re strong.”

The cardiologists were meticulous — and the pressure was high.

The procedure involved placing a catheter through a small incision in her groin, Dhoble said.

The size of the balloon is based on CT and echocardiogram images of the patient’s heart. During the procedure, ultrasound imaging and fluoroscopy X-rays were used for guidance.

Pregnant patients are rare under the circumstance, so a lead shield was placed on Evans’ abdomen to protect the baby from excessive radiation.

Next, Dhoble stopped Evans’ heart for about 15 seconds — using a temporary pacemaker to create a rapid heart pace.

Jaxon Evans, Juno and James Evansí 3-month old baby, lies in his crib Tuesday, April 19, 2022 in Katy. Juno Evans was pregnant when she learned that she needed open heart surgery. Open heart surgery would have been too risky and could have caused her to lose her baby. Instead a temporary balloon valvuloplasty (a balloon inserted through a catheter, then inflated in her aorta) was performed. Both mother and baby have been discharged from the hospital and are at home.

“In that time, we inflated the balloon,” he said. And it worked.

Still, Evans had a momentary scare when she awoke. It took a while for the nurse to find her baby’s heartbeat.

Then, the familiar drumbeat became audible.

The team met to discuss the next step — and to determine the best timing. Waiting as long as possible for the C-section would be key to protecting the baby.

At the same time, open-heart surgery was inevitable.

“Open-heart surgery wasn’t a maybe,” Evans said. “It was absolute.”

The question remained — how long could she wait to mend her failing heart?

The debate finally settled. The C-section would be scheduled at 32 weeks.

“The cardiologists explained that it was getting worse,” Evans said.

She had to be admitted the day scheduled to be the baby shower. After celebrating with her friends and family for an hour, she and James drove to the hospital.

Evans gave birth to her son Jaxson on Jan. 11. He was taken to the neonatal intensive care unit, and she waited for about six days in the hospital for her operation.

“I spent every minute I could at NICU,” Evans said.

Estrera said that a period of recovery was necessary, allowing the patient to heal so the blood thinners required for heart surgery did not negatively affect her.

The night before surgery, Evans went to the NICU to see Jaxson.

Juno Evans puts her 3-month old baby, Jaxon, down for a nap Tuesday, April 19, 2022 in Katy. Juno Evans was pregnant when she learned that she needed open heart surgery. Open heart surgery would have been too risky and could have caused her to lose her baby. Instead a temporary balloon valvuloplasty (a balloon inserted through a catheter, then inflated in her aorta) was performed. Both mother and baby have been discharged from the hospital and are at home.

“I held onto my baby; I told him I love him,” she said.

She was afraid that something would go wrong during the operation.

“I told him goodbye, just in case,” she said. “It was the hardest thing I’ve ever done.”

The next morning, she was on the way to the operating room.

“It’s a fairly standard procedure,” Estrera said of replacing her aortic valve.

The technique used is a cardiopulmonary bypass, which involves a machine assuming the role of the heart and lungs during surgery.

“It allows me to operate on the heart and the aortic valve,” Estrera said.

He was able to enlarge her aortic valve with a larger mechanical replacement.

Juno Evans poses for a portrait with her 3-month old baby, Jaxon, and husband, James, Tuesday, April 19, 2022 in Katy. Juno Evans was pregnant when she learned that she needed open heart surgery. Open heart surgery would have been too risky and could have caused her to lose her baby. Instead a temporary balloon valvuloplasty (a balloon inserted through a catheter, then inflated in her aorta) was performed. Both mother and baby have been discharged from the hospital and are at home.

“If it’s too small, it does affect you long term,” Estrera said. “It’s like breathing through a straw. It would be so much harder. That’s the same concept.”

He explained that after the valve replacement, patients can reverse the damage done to their heart — and it can return to normal with time.

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Evans awoke immediately after the surgery and was discharged from the hospital Jan. 24.

Jaxson was able to go home from NICU on Feb. 1.

“He’s my little miracle,” Evans, now 28, said. She credits her son with saving her. If she hadn’t been pregnant with Jaxson, she may have continued to ignore her symptoms.

“It’s not what I expected for my pregnancy. It’s not how I pictured it at all. But I’m grateful where we all ended up.”

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Peyton is a Houston-based freelance writer.

Lindsay Peyton is ReNew Houston's Transformation columnist.

By Robert Downen and John Tedesco