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CardioNerds (Amit Goyal and Daniel Ambinder), Cardio-OB series co-chair and University of Texas Southwestern Cardiology Fellow, Dr. Sonia Shah, and episode FIT lead and UT Southwestern Cardiology Fellow Dr. Laurie Femnou discuss valvular heart disease in pregnancy with cardio-obstetrics expert Dr. Uri Elkayam, Professor of Medicine and OB Gyn at the University of Southern California.
In this pearl-packed episode, we discuss the diagnosis, acute management, and long-term considerations of valvular heart disease in pregnancy. Through a series of cases, we review the physiologic changes in pregnancy that make certain valvular lesions well-tolerated, while others are associated with a much higher risk of peripartum complications. We also discuss which patients to consider referring for valvular intervention, the ideal timing, and which valvular interventions are safest in the peripartum period. We promise, you won’t want to miss this clinically high-yield episode with Dr. Elkayam, the father of cardio-obstetrics and an absolute legend in the field!
Audio editing by CardioNerds Academy Intern, Adriana Mares.
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- Most women with severe valvular heart disease can be managed medically throughout pregnancy.
- Right sided valvular lesions are generally better tolerated than left-sides lesions, and regurgitant lesions are generally better tolerated than stenotic lesions. However, the context and etiology of the valve dysfunction must be taken into consideration. Severe tricuspid valve regurgitation, for example, can be associated with a failing right ventricle and undiagnosed pulmonary hypertension.
- Changes in BNP, severity of symptoms, and right ventricular systolic pressure (RVSP) assessed by echocardiography can be helpful in differentiating normal pregnancy-related symptoms from symptoms due to hemodynamically significant valvular lesions.
- Valvular interventions during pregnancy are safe when well-planned and performed by experienced operators, and they can significantly improve morbidity and mortality in women who remain symptomatic despite medical management.
- A multidisciplinary team-based approach is important when managing patients with valvular heart disease during pregnancy.
- “We do not need to perform prophylactic valvular intervention in women prior to pregnancy if they do not meet criteria for intervention otherwise. A patient with regurgitant lesion will tolerate pregnancy well, provided that they are not candidates for surgery already.”
- “Valvuloplasty during pregnancy is a great and effective procedure, but restenosis occurs. For women who desire future pregnancies, preconception evaluation is important to determine if valve intervention is indicated prior to conceiving.”
- What is the epidemiology of valvular heart disease in pregnancy?
- Cardiovascular conditions affect up to 4% of pregnancies, with valvular heart disease being the most common cardiac pathology encountered during pregnancy worldwide.
- In the developing world, rheumatic valve disease is still the most common etiology, with mitral valve most commonly affected, followed by the aortic valve.
- In the developed world, congenital aortic valve pathology is most common.
- What are the hemodynamic effects of stenotic vs. regurgitant lesions during pregnancy?
- In normal pregnancy, there is a significant drop in systemic vascular resistance as early as 5 weeks gestational age. This drop leads to a transient decrease in perfusion to the kidneys, causing an increase in fluid retention and expansion of plasma volume. At the same time, there is an increase in heart rate which becomes more pronounced later in the second trimester.
- These changes ultimately lead to an increase in cardiac output. Patients with stenotic lesions have a fixed obstruction, and therefore can have a difficult time adjusting to these physiologic changes of pregnancy. In mitral stenosis for example, the increase in heart rate leads to less atrial emptying time in diastole, which leads to an underfilled left ventricle and increase in left atrial preload.
- In contrast, regurgitation lesions are often better tolerated than stenotic lesions during pregnancy because of the ability of the cardiac chambers to dilate and accommodate the increase in plasma volume.
- These rules are generally true, provided that the ventricular systolic function is preserved. A patient with functional mitral regurgitation secondary to a failing left ventricle may not tolerate the hemodynamic changes of pregnancy well.
- What is involved with preconception evaluation and valvular heart disease?
- Preconception evaluation and counseling is recommended for all women with a history of heart disease to assess risk and modify them if indicated. If already pregnant, a complete risk assessment should be performed as soon as possible by the cardio-obstetrics team.
- Women with a known or suspected valvular lesion should have a complete echocardiogram performed as part of their assessment. It is important to also assess functional status, as poor baseline functional status is associated with worse outcome during pregnancy. For women with severe valvular lesions and no symptoms at baseline, stress testing can be helpful in assessing functional capacity.
- Modified WHO, CARPREG and ZAHARA are risk assessment tools that can be used during pregnancy to counsel patients. (See below)
- Preconception evaluation is a good opportunity to review medications and stop potential teratogenic medications depending on the risks and benefits.
- What are the guidelines for the management of valve disease during pregnancy: medical vs invasive management?
- Women who otherwise qualify for valve repair or replacement should be strongly considered for valve intervention prior to pregnancy.
|Intervention before pregnancy in asymptomatic MS with VA <1.5 cm2||I|
|Aortic valve intervention in severe AS prior to pregnancy if asymptomatic||IIa|
|PMBC should be considered during pregnancy refractory symptoms despite medical management||IIa|
|BAV should be considered during pregnancy with severe symptoms despite medical management||IIa|
|Valve operation should not be performed during pregnancy in the absence of severe refractory HF||III|
Shared decision-making is important when it comes to evaluating therapeutic and interventional options for women who want to become pregnant with valve disease. Mechanical valve replacement, for example, is typically the most durable option for a young patient, but the need for systemic anticoagulation during pregnancy often makes it an unattractive option for some patients. Bioprosthetic valve is an alternative if trying to avoid systemic anticoagulation during pregnancy, with the understanding that patient will likely need reoperation in the future. For women with aortic valve dysfunction, a Ross procedure is another option. In this procedure, a patient’s own pulmonic valve is placed in the aortic position, and the pulmonic valve is replaced using a donor valve. The advantage of this is that no anticoagulation is necessary. It is a more complex surgery, but outcomes are good when performed by experienced operators. Balloon valvuloplasty can also be performed with good result, although restenosis can occur within months of initial procedure; women who undergo valvuloplasty should have repeat assessment immediately prior to conception to ensure that the valve is not re-stenosed.
For women who are already pregnant with persistent symptoms despite medical therapy, balloon valvuloplasty should be considered.
- How should be monitor women with valvular heart disease during pregnancy?
- The frequency of monitoring during pregnancy depends on the severity of disease and symptoms. Serial echocardiograms in the absence of symptoms are usually not required.
- Echocardiograms can be helpful in estimating pulmonary pressures and left atrial pressures. Gradients across the valves in stenotic lesions are expected to increase due to the increase flow and management should not be guided based on this alone.
- Obtaining cardiac biomarkers such as BNP early in pregnancy can help differentiate between normal symptoms of pregnancy versus hemodynamic compromise from valve disease.
- Right heart catheterization can be helpful in cases where the symptoms are discordant with the objective data (echo and BNP) especially when result can affect major decision like cesarian section versus vaginal delivery. However, this should be done in expert hands given the increased risk of vascular complications during pregnancy.
- What is the morbidity and mortality associated with severe left sided valvular obstruction during pregnancy?
- Women with severe left-sided valvular obstruction have the highest risk of morbidity and mortality during pregnancy. A recent meta-analysis of studies published between 1985 and 2019 of women treated in specialized centers in developed countries showed a mortality rate of 3% and 2% in severe mitral and aortic stenosis respectively. Heart failure was more common in mitral stenosis 37% as compared to 9% in AS. New or recurrent arrhythmia were reported in 16% of women with severe MS and 4% in women with severe AS.
- Fetal outcomes were similarly worse than in the general population.
- Women who remain symptomatic after initiation of adequate medical therapy should be considered for intervention, as they are in the highest risk group.
- Valvuloplasty, if valve anatomy allows, to relieve the obstruction is preferred over surgery given high risk of morbidity and fetal loss with cardiac surgery. There are multiple tools used in the cardiac catheterization laboratory to reduce the risk and radiation exposure both to the mother and fetus.
2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease (Journal of the American College of Cardiology). March 3, 2014
Hameed, Afshan B. MD; Mehra, Anilkumar MD; Rahimtoola, Shahbudin H. MB, FRCP The Role of Catheter Balloon Commissurotomy for Severe Mitral Stenosis in Pregnancy. Obstetrics & Gynecology. 2009 – Volume 114 – Issue 6 – p 1336-1340 doi: 10.1097/AOG.0b013e3181bea92d
Ducas RA, Javier DA, D’Souza R, Silversides CK, Tsang W. Pregnancy outcomes in women with significant valve disease: a systematic review and meta-analysis. Heart. 2020;106(7):512-519. doi:10.1136/heartjnl-2019-315859
Elkayam U, Goland S, Pieper PG, Silversides CK. High-Risk Cardiac Disease in Pregnancy: Part II. J Am Coll Cardiol. 2016;68(5):502-516. doi:10.1016/j.jacc.2016.05.050
Dr. Elkayam is an internationally known expert in heart failure and heart disease in pregnancy. Dr. Elkayam did his medical training in Austria and Israel before completing his cardiology fellowships at Albert Einstein College of Medicine and Cedars Sinai Medical Center. He is currently a dual professor of Medicine and OB Gyn at the University of Southern California, Former Chief of Cardiology at USC University Hospital, and Director of the USC Heart Failure Program. He has been involved in more than 100 self-initiated NIH and industry funded research projects, and has authored over 200 peer review articles and 80 book chapters.
Dr. Laurie Femnou Mbuntum is currently a general cardiology fellow at The University of Texas Southwestern. She completed her undergraduate degree at The University of Maryland Baltimore County. She then moved down South to complete residency at The University of Texas Southwestern where she stayed for cardiology fellowship where she is planning to stay for advanced training in interventional cardiology. She has a special interest in cardio obstetrics and figuring out ways to reduce cardiovascular maternal death. When not in the hospital, she loves spending time with her two boys and learning more about makeup artistry.