Valvular Heart Disease and Pregnancy

Cardiac physiology and pathophysiology in pregnancy

Cardiovascular disease is the leading indirect cause of maternal morbidity and mortality, accounting for nearly one third of maternal deaths during pregnancy. The burden of cardiovascular disease in pregnancy is increasing, as are the incidence of maternal morbidity and mortality. Normal physiologic adaptations to pregnancy, including increased cardiac output and plasma volume, may unmask cardiac conditions, exacerbate previously existing conditions, or create de novo complications. It is important for care providers to understand the normal physiologic changes of pregnancy and how they may impact the care of patients with cardiovascular disease. This review outlines the physiologic adaptions during pregnancy and their pathologic implications for some of the more common cardiovascular conditions in pregnancy.

Cardiovascular complications during pregnancy: Advancing cardio-obstetrics

As the incidence of cardiovascular diseases (CVDs) continues to rise among women of childbearing age, the pregnant population with pre-existing heart conditions presents a complex and heterogeneous profile. These women face varying degrees of risk concerning maternal cardiovascular, obstetric, and fetal complications. Effectively managing adverse cardiovascular events during pregnancy presents substantial clinical challenges. The uncertainties surrounding diagnostic and therapeutic approaches create a dynamic landscape with potential implications for maternal and fetal health. Cardio-obstetrics has become increasingly recognized as a vital multidisciplinary field necessitating a collaborative approach to managing cardiovascular conditions during pregnancy. In this review, we aim to provide a thorough and up-to-date examination of the existing evidence, offering a comprehensive overview of strategies and considerations in the management of cardiovascular complications during pregnancy. Special emphasis is placed on the safety assessment of diagnostic procedures and the exploration of treatment options designed to prioritize the well-being of the mother and fetus. We also explore the significance of a multidisciplinary cardio-obstetrics team in providing comprehensive care for women of childbearing age with or at risk for CVD.

Assessing the Role of Echocardiography in Pregnancy in First Nations Australian Women: Is it an Underutilised Resource?

BACKGROUND

Rheumatic heart disease (RHD) remains prevalent within First Nations Australian communities. RHD is more common in females and peak prevalence corresponds with childbearing age. Significant valvular disease can complicate pregnancy. Current practice in Northern Australia is to refer pregnant women for echocardiography if there are signs or symptoms of possible cardiac pathology or a history of acute rheumatic fever (ARF) or RHD. It is not currently routine practice to offer echocardiographic screening for all pregnant women at high risk of RHD.

AIM

This study aimed to assess the current referral practices for echocardiography and disease patterns in pregnant women in the Northern Territory, Australia-a region with a known high prevalence of RHD in the First Nations population.

METHOD

A retrospective analysis of all echocardiography referrals of pregnant women over a 4-year period was performed. Data included indication for echocardiography, clinical history, echocardiographic findings, and location of delivery. Comparisons were made using Fisher's exact and Mann-Whitney U tests.

RESULTS

A total of 322 women underwent echocardiography during pregnancy: 195 First Nations and 127 non-Indigenous women (median age, 25 vs 30 years, respectively; p<0.01). Indications for echocardiography differed by ethnicity, with history of ARF or RHD being the most common indication in First Nations women, and incidental murmur the most common in non-Indigenous women. First Nations women were more likely to have abnormal echocardiograms (35.9% vs 11.0% in non-Indigenous women; p<0.01) or a history of ARF or RHD (39.5% vs 0.8%; p<0.01), but less likely to have documented cardiac symptoms as an indication for echocardiography (8.2% vs 20.5%; p<0.01). New cardiac diagnoses were made during pregnancy in 11 (5.6%) First Nations and two (1.6%) non-Indigenous women (p=0.02). Moderate or severe valve lesions were detected in 26 (13.3%) First Nations women (all previously diagnosed), and 11 (5.6%) had previous cardiac surgery. No severe valve lesions were identified in the non-Indigenous group. Interstate transfer to a tertiary centre with valve intervention services was required during pregnancy or the puerperium for 12 (6.2%) First Nations women and no non-Indigenous women.

CONCLUSIONS

Amongst pregnant women in the Northern Territory who had an indication for echocardiography, First Nations women were more likely to have abnormal echocardiograms. This was mainly due to valvular disease secondary to RHD. Cardiac symptoms were infrequently recorded as an indication for echocardiography in First Nations women, suggesting possible underappreciation of symptoms. Having a low threshold for echocardiographic investigation, including consideration of universal screening during pregnancy, is important in a high RHD-burden setting such as ours. A better understanding of the true prevalence and spectrum of disease severity in this population would enable health services to invest in appropriate resources.

Routine Antenatal Echocardiography in High-Prevalence Areas of Rheumatic Heart Disease: A WHO-Guideline Systematic Review

Background

Rheumatic Heart Disease (RHD) is the most common cause of valvular heart disease worldwide. Undiagnosed or untreated RHD can complicate pregnancy and lead to poor maternal and fetal outcomes and is a significant factor in non-obstetric morbidity. Echocardiography has an emerging role in screening for RHD. We aimed to critically analyse the evidence on the use of echocardiography for screening pregnant women for RHD in high-prevalence areas.

Methods

We searched MEDLINE and Embase to identify the relevant reports. Two independent reviewers assessed the reports against the eligibility criteria in a double-blind process.

Results

The searches (date: 4 April 2023) identified 432 records for screening. Ten non-controlled observational studies were identified, five using portable or handheld echocardiography, comprising data from 23,166 women. Prevalence of RHD varied across the studies, ranging from 0.4 to 6.6% (I2, heterogeneity >90%). Other cardiac abnormalities (e.g., congenital heart disease and left ventricular systolic dysfunction) were also detected <1% to 2% of cases. Certainty of evidence was very low.

Conclusion

Echocardiography as part of antenatal care in high-prevalence areas may detect RHD or other cardiac abnormalities in asymptomatic pregnant women, potentially reducing the rates of disease progression and adverse labor-associated outcomes. However, this evidence is affected by the low certainty of evidence, and lack of studies comparing echocardiography versus standard antenatal care.

Prospective Registration

PROSPERO 2022 July 4; CRD42022344081 Available from: https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=344081.

Research question

'In areas with a high prevalence of rheumatic heart disease, should handheld echocardiography be added to routine antenatal care?'

Valvular Heart Disease in Pregnancy

Valvular heart disease is a common cause of peripartum cardiovascular morbidity and mortality. The hemodynamic changes of pregnancy and their impact on preexisting valvular lesions are described in this paper. Tools for calculation of maternal and fetal risk during pregnancy are also discussed. The pathophysiology and management of valvular lesions, both obstructive and regurgitant, are then described, followed by discussion of mechanical and bioprosthetic valve complications during pregnancy.

Case report of pregnancy complicated by severe pulmonary hypertension from mitral stenosis and placenta accreta spectrum disorder: management of two life-threatening conditions

Background

Antenatal cardiovascular disease is a major cause of maternal morbidity and mortality. Severe rheumatic mitral stenosis is especially poorly tolerated during pregnancy.

Case Summary

We present a young woman with severe pulmonary hypertension secondary to rheumatic mitral stenosis. She presented at 25 weeks 4 days gestation for evaluation of a pregnancy complicated by placenta accreta spectrum disorder. Invasive hemodynamic testing was carried out to delineate her hemodynamics, and a multidisciplinary cardio-obstetrics team collaborated closely with the patient and her partner to create a management plan. Ultimately, the patient was initiated on veno-arterial extracorporeal membrane oxygenation and underwent caesarean section delivery followed by hysterectomy and subsequent valve replacement surgery.

Discussion

This case describes the treatment options considered to balance the risk of decompensation in the setting of severe pulmonary hypertension with hemorrhage associated with placenta accreta spectrum disorder. It highlights the importance of a multidisciplinary, team-based approach to the management of high-risk cardiac conditions throughout pregnancy.

Pregnancy in women with congenital heart disease: a focus on management and preventing the risk of complications

INTRODUCTION

Congenital heart disease (CHD) is the most common cardiac disorder in pregnancy in the western world (around 80%). Due to improvements in surgical interventions more women with CHD are surviving to adulthood and choosing to become pregnant.

AREAS COVERED

Preconception counseling, antenatal management of CHDs and strategies to prevent maternal and fetal complications.Preconception counseling should start early, before the transition to adult care and be offered to both men and women. It should include the choice of contraception, lifestyle modifications, pre-pregnancy optimization of cardiac state, the chance of the child inheriting a similar cardiac lesion, the risks to the mother, and long-term prognosis. Pregnancy induces marked physiological changes in the cardiovascular system that may precipitate cardiac complications. Risk stratification is based on the underlying cardiac disease and data from studies including CARPREG, ZAHARA, and ROPAC.

EXPERT OPINION

Women with left to right shunts, regurgitant lesions, and most corrected CHDs are at lower risk and can be managed in secondary care. Complex CHD, including systemic right ventricle need expert counseling in a tertiary center. Those with severe stenotic lesions, pulmonary artery hypertension, and Eisenmenger's syndrome should avoid pregnancy, be given effective contraception and managed in a tertiary center if pregnancy does happen.

Aortic Stenosis Phenotypes and Precision Transcatheter Aortic Valve Implantation

Patients with a clinical indication for aortic valve replacement can either undergo surgical aortic valve replacement (SAVR) or Transcatheter Aortic Valve Implantation (TAVI). There are many different factors that go into determining which type of replacement to undergo, including age, life expectancy, comorbidities, frailty, and patient preference. While both options offer significant benefits to patients in terms of clinical outcomes and quality of life, there is growing interest in expanding the indications for TAVI due to its minimally invasive approach. However, it is worth noting that there are several discrepancies in TAVI outcomes in regards to various endpoints, including death, stroke, and major cardiovascular events. It is unclear why these discrepancies exist, but potential explanations include the diversity of etiologies for aortic stenosis, complex patient comorbidities, and ongoing advancements in both medical therapies and devices. Of these possibilities, we propose that phenotypic variation of aortic stenosis has the most significant impact on post-TAVI clinical outcomes. Such variability in phenotypes is often due to a complex interplay between underlying comorbidities and environmental and inherent patient risk factors. However, there is growing evidence to suggest that patient genetics may also play a role in aortic stenosis pathology. As such, we propose that the selection and management of TAVI patients should emphasize a precision medicine approach.

Immediate maternal and fetal outcome following percutaneous mitral valve balloon commissurotomy: a 6-year single-center experience from sub-Saharan Africa

BACKGROUND

Mitral stenosis is the most common valvular heart disease during pregnancy. When severe, it leads to significant maternal and fetal morbidity and mortality. Percutaneous mitral valve balloon commissurotomy can be performed during pregnancy, and the present study aimed to describe the immediate maternal and fetal outcomes after percutaneous mitral valve balloon commissurotomy was done in a cohort of 23 pregnant patients with severe mitral stenosis in Addis Ababa, Ethiopia.

METHODS

Included in the current study were all pregnant mothers who had severe rheumatic mitral valve stenosis and who underwent percutaneous mitral valve balloon commissurotomy at the Cardiac Center of Ethiopia over 6-year period. Data were collected through chart abstraction using a structured proforma and then analysed using STATA version 13.0.

RESULT

Median gestational age was 22 weeks and percutaneous mitral valve balloon commissurotomy was successful resulting in a significant increase in the mean mitral valve area of the group from 0.78 ± 0.20 cm² to 1.89 ± 0.31 cm² (p < 0.001). The mean mitral valve inflow gradient of the group was 23.95 ± 6.27 mmHg and 6.80 ± 2.44 mmHg, respectively, before and after the percutaneous mitral valve balloon commissurotomy procedure (p < 0.001). Post-procedure, there was no significant increment in mitral valve incompetence. The mean pulmonary artery pressure of the group decreased from 77.68 ± 23.19 mmHg to 42.31 ± 9.95 mmHg (p < 0.001). There was no fetal or maternal death following the procedure. Pregnancy ended at term gestation for 19/23 (82.6%) of the mothers and the mean birth weight of the neonates was 2800 g.

CONCLUSION

Percutaneous mitral valve balloon commissurotomy procedure can safely be done for severe symptomatic rheumatic mitral stenosis in pregnancy in our setting.

A “Grave” Case of Mitral Regurgitation

A 26-year-old woman presented at 26 weeks of pregnancy with severe mitral regurgitation (MR) and cardiogenic shock in the setting of profound hyperthyroidism. An intra-aortic balloon pump was placed, and surgical intervention was considered. However, with management of thyrotoxicosis and delivery, complete resolution of MR and cardiogenic shock was achieved. (Level of Difficulty: Intermediate.)

Catheter-Based Interventions for the Management of Valvular Heart Disease During Pregnancy

Pregnancy is associated with a significant increase in hemodynamic burden. These changes can lead to maternal morbidity and mortality as well as unfavorable fetal outcomes in patients with valvular heart disease and limited cardiac reserve. Mechanical interventions may be needed for the management of severe hemodynamic deterioration not responding to medical therapy. Catheter-based percutaneous interventions can provide an alternative therapy to surgery during pregnancy. The purpose of this article is to review indications, potential advantages, and limitations of catheter-based interventions for the management of women with valvular heart disease in pregnancy.

The Spectrum, Severity and Outcomes of Rheumatic Mitral Valve Disease in Pregnant Women in Australia and New Zealand

BACKGROUND

Rheumatic heart disease (RHD) poses significant perinatal risks. We aimed to describe the spectrum, severity and outcomes of rheumatic mitral valve disease in pregnancy in Australia and New Zealand.

METHODS

A prospective, population-based cohort study of pregnant women with RHD recruited 2013-14 through the hospital-based Australasian Maternity Outcomes Surveillance System. Outcome measures included maternal and perinatal morbidity and mortality. Univariable and multivariable logistic regression analyses were undertaken to test for predictors of adverse maternal and perinatal outcomes.

RESULTS

Of 274 pregnant women identified with RHD, 124 (45.3%) had mitral stenosis (MS) and 150 (54.7%) had isolated mitral regurgitation (MR). One woman with mild MS/moderate MR died. There were six (2.2%) stillbirths and two (0.7%) neonatal deaths. Babies born to women with MS were twice as likely to be small-for-gestational-age (22.7% vs 11.4%, p=0.013). In women with MS, use of cardiac medication (AOR 7.42) and having severe stenosis (AOR 16.35) were independently associated with adverse cardiac outcomes, while NYHA class >1 (AOR 3.94) was an independent predictor of adverse perinatal events. In women with isolated MR, use of cardiac medications (AOR 7.03) and use of anticoagulants (AOR 6.05) were independently associated with adverse cardiac outcomes.

CONCLUSIONS

Careful monitoring and specialist care for women with RHD in pregnancy is required, particularly for women with severe MS, those on cardiac medication, and those on anticoagulation, as these are associated with increased risk of adverse maternal cardiac outcomes. In the context of pregnancy, contraception and preconception planning are important for young women diagnosed with RHD.

Cardiovascular and Obstetric Delivery Complications in Pregnant Women With Valvular Heart Disease

Women with valvular heart disease may be more likely to have adverse obstetric and cardiovascular complications during pregnancy. Most current recommendations focus on stenotic lesions with less guidance regarding regurgitant lesions. We aimed to compare adverse events at delivery for women with various stenotic and regurgitant valvular diseases. We used the 2016 to 2018 National Inpatient Sample data to compare demographics, comorbidities, and obstetric and cardiovascular complications during delivery hospitalizations. After adjusting for clinical and socioeconomic factors, logistic regression was performed to investigate associations between valvular disease and outcomes. Among >11.2 million deliveries, 20,349 were in women with valvular disease. Women with valvular disease were older, had longer length of stays, and higher costs associated with delivery. They had higher prevalence of underlying cardiovascular comorbidities compared with women without valvular disease (hypertension: 5.1 vs 0.25%; pulmonary hypertension: 7.0 vs <0.1%). At delivery, they had higher adjusted odds of obstetric events including preeclampsia and/or eclampsia (aOR 1.9 [1.8 to 2.2]) and intrapartum/postpartum hemorrhage (aOR 1.4 [1.2 to 1.6]), and cardiovascular events including peripartum cardiomyopathy (aOR 65 [53 to 78]), pulmonary edema (aOR 17 [13 to 22]), acute ischemic heart disease (aOR 19 [12 to 30]) and arrhythmias (aOR 22 [19 to 27]). There were valve lesion-specific differences in the magnitude of risk but both stenotic and regurgitant lesions were associated with elevated risk of cardiovascular complications. In conclusion, pregnant women with stenotic and regurgitant valvular disease have a greater burden of cardiovascular comorbidities and increased odds of obstetric and cardiovascular events at delivery. These women may benefit from specialized care from a Cardio-Obstetrics team.

Cardiac Complications in Pregnant Women With Isolated Mitral Stenosis and Their Association With Echocardiographic Changes During Pregnancy

In women with mitral stenosis (MS), mitral valve gradients and right ventricular systolic pressure (RVSP) can increase in response to the physiologic stress of pregnancy. The prognostic significance of these echocardiographic changes has not been well studied. Pregnancy outcomes and serial echocardiograms were collected in women with MS prospectively recruited as part of a larger study on pregnancy outcomes. Third trimester echocardiograms were compared with baseline echocardiograms. Changes in mitral valve area (MVA), transmitral mean gradient (MG), and RVSP during pregnancy and their relationship to adverse cardiac events (CE) were examined. Fifty-six pregnancies in 47 women with MS were included. The MVA did not change during pregnancy (1.6 ± 0.6 cm² at baseline vs 1.7 ± 0.6 cm² in the third trimester, p = 0.46). There was an increase in the MG (8 ± 3 vs 11 ± 6 mm Hg, p <0.001) and the RVSP (39 ± 14 vs 47 ± 20 mm Hg, p <0.001) during the third trimester. Adverse CE occurred in 45% (25/56) of pregnancies. CE were associated with baseline MG>10 mm Hg, baseline RVSP >40 mm Hg, third-trimester MG>10 mm Hg, and RVSP >40 mm Hg. Women with mitral valve MG ≤10 mm Hg who had a normal RVSP at baseline and in the third trimester were at lowest risk for CE (11%) with a negative predictive value of 89%. In conclusion, baseline echocardiographic assessment of MS severity as well as changing echocardiographic parameters during pregnancy can help identify women at risk for cardiac complications during pregnancy.

Pregnancy related changes in Doppler gradients and left ventricular mechanics in women with sub-valvular or valvular aortic stenosis

BACKGROUND

The aim of our study was to characterize echocardiographic changes during pregnancy in women with known LVOT obstruction or AS compared to the healthy pregnancy controls, and to assess the relationship with pregnancy outcomes.

METHODS

We retrospectively studied 34 pregnant patients with congenital LVOT obstruction or AS with healthy age-matched pregnant controls. Patients with other significant valvular lesions, structural heart disease (LVEF < 40%), or prior valve surgery were excluded. All LVOTO/AS patients underwent a minimum of two consecutive echocardiograms between 1 year pre-conception and 1 year postpartum, with at least two studies during the pregnancy. Comprehensive echocardiographic evaluation was performed including speckle-tracking LV global longitudinal strain.

RESULTS

A total of 83 echocardiograms from the study group and 34 echocardiograms from the control group were evaluated. Over the range of LVOTO/AS, a significantly greater increase in the AV gradients and LV and LA volumes were observed as compared with the controls. In the sub-group of LVOTO/AS pregnant women with ≥ moderate (n = 8) versus < moderate LVOTO/AS (n = 26), averaged 2^nd /3^rd trimester LVEF was lower (51 ± 12)% versus (58 ± 4)%, (p = 0.02) and GLS was lower (-19.5 ± 2.8) versus (21.2 ± 2.4), (p = 0.06). Pregnancy was well tolerated despite these changes.

CONCLUSION

Among pregnant women with even milder forms of LVOTO/AS, increases in cardiac volumes and AV gradients can be expected over the course of pregnancy. Significant decreases in LV function and mechanics were only observed in women with moderate or greater LVOTO/AS, although still remained in normal range.

Delivering Coordinated Cardio-Obstetric Care from Preconception through Postpartum

Coordinated preconception through postpartum cardio-obstetrics care is necessary to optimize both maternal and fetal health. Maternal mortality in the United States is increasing, largely driven by increasing cardiovascular (CV) disease burden during pregnancy and needs to be addressed emergently. Both for women with congenital and acquired heart disease, CV complications during pregnancy are associated with increased future risk of CV disease. Comprehensive cardio-obstetrics care is a powerful way of ensuring that women's CV risks before and during pregnancy are appropriately identified and treated and that they remain engaged in CV care long term to prevent future CV complications.

Rheumatic heart disease in pregnancy and neonatal outcomes: A systematic review and meta-analysis

Purpose

Associations between rheumatic heart disease (RHD) in pregnancy and fetal outcomes are relatively unknown. This study aimed to review rates and predictors of major adverse fetal outcomes of RHD in pregnancy.

Methods

Medline (Ovid), Pubmed, EMcare, Scopus, CINAHL, Informit, and WHOICTRP databases were searched for studies that reported rates of adverse perinatal events in women with RHD during pregnancy. Outcomes included preterm birth, intra-uterine growth restriction (IUGR), low-birth weight (LBW), perinatal death and percutaneous balloon mitral valvuloplasty intervention. Meta-analysis of fetal events by the New-York Heart Association (NYHA) heart failure classification, and the Mitral-valve Area (MVA) severity score was performed with unadjusted random effects models and heterogeneity of risk ratios (RR) was assessed with the I² statistic. Quality of evidence was evaluated using the GRADE approach. The study was registered in PROSPERO (CRD42020161529).

Findings

The search identified 5949 non-duplicate records of which 136 full-text articles were assessed for eligibility and 22 studies included, 11 studies were eligible for meta-analyses. In 3928 pregnancies, high rates of preterm birth (9.35%-42.97%), LBW (12.98%-39.70%), IUGR (6.76%-22.40%) and perinatal death (0.00%-9.41%) were reported. NYHA III/IV pre-pregnancy was associated with higher rates of preterm birth (5 studies, RR 2.86, 95%CI 1.54–5.33), and perinatal death (6 studies, RR 3.23, 1.92–5.44). Moderate /severe mitral stenosis (MS) was associated with higher rates of preterm birth (3 studies, RR 2.05, 95%CI 1.02–4.11) and IUGR (3 studies, RR 2.46, 95%CI 1.02–5.95).

Interpretation

RHD during pregnancy is associated with adverse fetal outcomes. Maternal NYHA III/IV and moderate/severe MS in particular may predict poor prognosis.

Risk Associated With Valvular Regurgitation During Pregnancy

BACKGROUND

Pregnancies in women with regurgitant valve lesions are generally considered low risk, but this has not been well studied.

OBJECTIVES

This study determined the frequency of adverse cardiac events (CEs) in pregnant women with moderate or severe regurgitant valve lesions.

METHODS

Maternal and fetal outcomes in women with moderate or severe chronic valve regurgitation enrolled in a prospective multicenter study on pregnancy outcomes were examined. Adverse CEs included heart failure, sustained arrhythmias, cardiac arrest, or death. A multivariate logistic regression model was used to identify determinants of CEs in women at the highest risk.

RESULTS

Outcomes of 430 pregnancies in women with moderate or severe regurgitant lesions were examined: 145 with mitral regurgitation (MR), 101 with pulmonary regurgitation (PR), 71 with multivalve disease, 73 with tricuspid regurgitation (TR), and 40 with aortic regurgitation (AR). Most women had associated congenital or acquired heart disease. Adverse CEs occurred in 13% of pregnancies: 27% of pregnancies with multivalve disease; 15% with MR; 15% with TR; 5% with AR; and 3% with PR. Maternal mortality was rare. In women with MR, TR, or multivalve disease (n = 289), left ventricular systolic dysfunction (p = 0.001), pulmonary hypertension (p = 0.005), and cardiac events before pregnancy (p < 0.001) were important determinants of CEs during pregnancy.

CONCLUSIONS

Women with AR and PR are at low risk for cardiac complications during pregnancy. While many women with MR, TR, and multivalve regurgitation do well during pregnancy, additional clinical variables help stratify those at highest risk. This new information will enhance the quality and precision of preconception counseling and pregnancy planning.

Echocardiography for the Pregnant Heart

Purpose of review

Pregnancy is associated with significant hemodynamic changes, making it a potentially high-risk period for women with underlying cardiovascular disease. Echocardiography remains the preferred modality for diagnosis and monitoring of pregnant women with cardiovascular disease as it is widely available and does not require radiation. This paper reviews the role of echocardiography along the continuum of pregnancy in at-risk patients, with a focus on key cardiac disease states in pregnancy.

Recent findings

In the preconception stage, risk stratification scores such as CARPREG II, ZAHARA and the modified WHO remain central to counseling and planning. As such, echocardiography serves an important role in assessing the severity of pre-existing structural disease. Among women with pre-existing cardiovascular disease who become pregnant-as well as those who develop cardiovascular symptoms during pregnancy-echocardiography is a key imaging tool for assessment of hemodynamic and structural changes and is recommended as the first-line imaging modality when appropriate by both the American College of Obstetricians and Gynecologists (ACOG) and the Food and Drug Administration (FDA). However, routine screening intervals during pregnancy for various cardiac lesions are not well defined, resulting in clinical heterogeneity in care.

Summary

Echocardiography is the imaging modality of choice for defining, risk stratifying, and monitoring cardiovascular changes throughout pregnancy. Once identified, at-risk patients should receive careful individual counseling and follow-up with a multidisciplinary team. Echocardiography serves as a widely available tool for serial monitoring of pregnant women with cardiovascular disease throughout pregnancy and the postpartum period.

Managing asymptomatic severe rheumatic mitral stenosis in pregnancy: a case report

Background

Rheumatic heart disease (RHD) is a disease of disparity most prevalent in developing countries and among immigrant populations. Mitral stenosis (MS) is a common sequalae of RHD and affects females disproportionately more than males. Rheumatic MS remains a significant management challenge as severe MS is usually poorly tolerated in pregnancy due to haemodynamic changes and increased cardiovascular demands of progressing pregnancy. Pregnancy remains contraindicated in current management guidelines based on expert consensus, due to a paucity of evidence-based literature.

Case summary

A 28-year-old aboriginal woman with known severe MS was found to be pregnant during routine health review, despite contraceptive efforts. Echocardiography demonstrated mean mitral valve (MV) gradient 14 mmHg; stress echocardiography demonstrated increased MV gradient 28–32 mmHg at peak exercise and post-exercise pulmonary artery pressure 56 + 3 mmHg with marked dynamic D-shaped septal flattening. Left ventricular systolic function remained preserved. She remained remarkably asymptomatic and underwent successful elective induction of labour at 34 weeks. Postpartum, she remained euvolaemic despite worsening MV gradients and new atrial fibrillation (AF). She subsequently underwent balloon mitral valvuloplasty with good result.

Discussion

Severe rheumatic MS in pregnancy carries significant morbidity and mortality, due to an already fragile predisposition towards heart failure development compounded by altered haemodynamics. Pregnancy avoidance and valvular intervention prior to conception or in the second trimester remain the mainstay of MS management; however, we present an encouraging case of successful near-term pregnancy with minimal complications in a medically managed asymptomatic patient with critical MS, who subsequently underwent valvular intervention post-partum.

2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

This executive summary of the valvular heart disease guideline provides recommendations for clinicians to diagnose and manage valvular heart disease as well as supporting documentation to encourage their use.

METHODS

A comprehensive literature search was conducted from January 1, 2010, to March 1, 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, Cochrane, Agency for Healthcare Research and Quality Reports, and other selected database relevant to this guideline. Structure: Many recommendations from the earlier valvular heart disease guidelines have been updated with new evidence and provides newer options for diagnosis and treatment of valvular heart disease. This summary includes only the recommendations from the full guideline which focus on diagnostic work-up, the timing and choice of surgical and catheter interventions, and recommendations for medical therapy. The reader is referred to the full guideline for graphical flow charts, text, and tables with additional details about the rationale for and implementation of each recommendation, and the evidence tables detailing the data considered in developing these guidelines.

Management of Anticoagulation in Pregnant Women With Mechanical Heart Valves

Importance

Mechanical heart valves (MHVs) pose significant thrombogenic risks to pregnant women and their fetuses, yet the choice of anticoagulation in this clinical setting remains unclear. Various therapeutic strategies carry distinct risk profiles that must be considered when making the decision about optimal anticoagulation.

Objective

We sought to review existing data and offer recommendations for the anticoagulation of pregnant women with MHVs, as well as management of anticoagulation in the peripartum period.

Evidence Acquisition

We performed a literature review of studies examining outcomes in pregnant women receiving systemic anticoagulation for mechanical valves, and also reviewed data on the safety profiles of various anticoagulant strategies in the setting of pregnancy.

Results

Warfarin has been shown to increase rates of embryopathy and fetal demise, although it has traditionally been the favored anticoagulant in this setting. Low-molecular-weight heparin, when dosed appropriately with close therapeutic monitoring, has been shown to be safe for both mother and fetus.

Conclusions

We favor the use of low-molecular-weight heparin with appropriate dosing and monitoring for the anticoagulation of pregnant women with MHVs. Data suggest that this approach minimizes the thrombotic risk associated with the valve while also providing safe and effective anticoagulation that can be easily managed in the peripartum period.

Valvular Heart Disease in Pregnancy

Valvular heart disease (VHD) is generally well tolerated during pregnancy; however, the dramatic changes in hemodynamics that occur during pregnancy can lead to clinical decompensation in high-risk women. Women with VHD considering pregnancy should undergo preconception counseling with a high-risk obstetrician and cardiologist to review the maternal, fetal, and obstetric risks of pregnancy and delivery. Vaginal delivery is recommended for most women with VHD. Given the complexity of managing VHD during pregnancy, women should be managed by a multidisciplinary Pregnancy Heart Team during pregnancy, consisting of a high-risk obstetrician, cardiologist, and cardiac anesthesiologist.

Pregnancy and Congenital Heart Disease: A Brief Review of Risk Assessment and Management

Cardiac disease is a leading cause of morbidity and mortality in pregnant women. An increased prevalence of the cardiovascular disease has been found in women of childbearing age, in which the responsibility of the treating physician extends to the mother and to the unborn fetus. As a result, care of these high-risk pregnant women with cardiovascular disease including those with congenital heart disease (CHD) require a team approach including specialists in maternal-fetal medicine, adult congenital cardiology, and obstetrical anesthesia. The human body undergoes significant amounts of physiological changes during this period of time and the underlying cardiac disease can affect both the mother and the fetus. Today, most female children born with CHD will reach childbearing age. For many women with complex CHD, carrying a pregnancy has a moderate to high risk for both the mother and her fetus. This chapter will review the epidemiology, risk factors, clinical presentation including common signs and symptoms, physiological changes in pregnancy, and the medical approach including cardiac medications, percutaneous interventions, and surgical procedures for pregnant women with CHD.

Management of valvular heart disease in the pregnant patient

INTRODUCTION

Among cardiovascular disease in pregnancy, valvular heart disease remains a prevalent cause of maternal and fetal morbidity. The physiological changes of pregnancy can lead to decompensation of known or silent valvular heart disease. This poses a challenge to both physicians and patients in determining the best timing and management of valvular disease in the pre and post conception settings. This condition requires specific care to minimize both maternal and fetal morbidity and mortality.

AREAS COVERED

In this article, we review the recommended management of valvular heart disease in pregnancy, which include stenotic lesions, regurgitant lesions and prosthetic valves.

EXPERT OPINION

Overall, left sided stenotic lesions are poorly tolerated and require intervention prior to pregnancy in cases of severe or symptomatic stenosis. Regurgitant lesions, isolated right sided lesions and bioprosthetic valves are better tolerated. Mechanical valves pose a challenging scenario given the high risk for valve thrombosis which must be balanced with the risk of bleeding and fetal embryopathy. Shared decision making is primordial in choosing the anticoagulant strategy during pregnancy in patients with mechanical valves.

Prediction of adverse cardiac events in pregnant women with valvular rheumatic heart disease

OBJECTIVE

To assess the incidence of adverse cardiac events in pregnant women with rheumatic valvular heart disease (RHD) and to derive a clinical risk scoring for predicting it.

METHODS

This is an observational study involving pregnant women with RHD, attending a tertiary centre in south India. Data regarding obstetric history, medical history, maternal complications and perinatal outcome till discharge were collected. Eight-hundred and twenty pregnancies among 681 women were included in the analysis. Primary outcome was composite adverse cardiac event defined as occurrence of one or more of complications such as death, cardiac arrest, heart failure, cerebrovascular accident from thromboembolism and new-onset arrhythmias.

RESULTS

Of the 681 women with RHD, 180 (26.3%) were diagnosed during pregnancy. Composite adverse cardiac outcome during pregnancy/post partum occurred in 122 (14.9%) pregnancies, with 12 of them succumbed to the disease. In multivariate analysis, prior adverse cardiac events (OR=8.35, 95% CI 3.54 to 19.71), cardiac medications at booking (OR=0.53, 95% CI 0.32 to 0.86), mitral stenosis (mild OR=2.48, 95% CI 1.08 to 5.69; moderate OR=2.23, 95% CI 1.19 to 4.18; severe OR=7.72,95% 4.05 to 12.89), valve replacement (OR=2.53, 95% CI 1.28 to 5.02) and pulmonary hypertension (OR=6.90, 3.81 to 12.46) were predictive of composite adverse cardiac events with a good discrimination (area under the curve=0.803) and acceptable calibration. A predictive score combining these factors is proposed for clinical utility.

CONCLUSION

Heart failure remains the most common adverse cardiac event during pregnancy or puerperium. Combining the lesion-specific characteristics and clinical information into a predictive score, which is simple and effective, could be used in routine clinical practice.

Pregnancy and cardiac interventions: What are the optimal management options?

Cardiac disease is the leading cause of maternal mortality in the United Kingdom. Major causes of cardiac death in pregnant women include cardiomyopathies, myocardial infarction, ischemic heart disease, and aortic dissection. Uncorrected congenital heart disease and women who have had corrective or palliative surgery may have complicated pregnancies as well. Some women with significant cardiac disease are unable to meet the increased physiological demands of pregnancy. Of these, those who do not respond to medical treatment may require surgical correction such as coronary artery bypass grafting. The risk of cardiac operations for pregnant women is similar to that for nonpregnant women but the fetal mortality rate remains high. Contributing factors to high fetal mortality rates include timing, urgency of operation, and the fetal/fetoplacental response to cardiopulmonary bypass. The aim of this review is to summarize current evidence in utilizing the different management approaches of cardiac issues during pregnancy.

Immediate and long-term outcomes of balloon mitral valvotomy in pregnancy

Objectives

To study the immediate maternal and fetal outcomes and long term maternal outcomes in pregnant women undergoing balloon mitral valvotomy.

Methods

We retrospectively analyzed balloon mitral valvotomy during pregnancy performed between January 2008 and July 2018.

Results

BMV was carried out in 97 pregnant women with mean age of 26.1 ± 4.5 years, at mean gestational age of 23.1 ± 4.6 weeks. The procedure was successful in 95 patients (97.9%). There was one maternal death post procedure due to intra-uterine death and disseminated intravascular coagulation. Adverse immediate fetal outcome was seen in 2 cases with one intra-uterine fetal demise and one preterm labour. Mitral valve area increased from mean of 0.82 ± 0.12 cm to 1.66 ± 0.14 cm (p < 0.001). Mean trans-mitral diastolic gradient decreased from 19.7 ± 5.6 mm Hg to 7.5 ± 2 mm Hg. Right ventricular systolic pressure decreased significantly from mean of 56.7 ± 16.2 mm Hg to mean of 35.6 ± 11 mm Hg. Survival analysis showed cumulative event free survival of 89% at 5 years and 65% at 10 years, considering a composite endpoint of clinical restenosis, repeat BMV or MVR or cardiovascular death.

Conclusions

Balloon mitral valvotomy is a safe and effective treatment for severe mitral stenosis during pregnancy. Long term maternal outcomes after BMV done during pregnancy are good and comparable to that of BMV done in non-pregnant patients.

The Use of Echocardiography and Advanced Cardiac Ultrasonography During Pregnancy

PURPOSE OF REVIEW

Pregnancy is a time of significant cardiovascular change. Echocardiography is the primary imaging modality used to assess cardiovascular anatomy and physiology during pregnancy. Both two-dimensional (2D) echocardiography and advanced cardiac ultrasound modalities play pivotal roles in identifying and monitoring these changes, especially in women with preexisting or new cardiac disease. This paper reviews the role of echocardiography and advanced cardiac ultrasound during normal pregnancy and pregnancy complicated by hypertensive disorders, valvular disorders, and cardiomyopathy. It also examines the role of echocardiography in guiding decisions about delivery.

RECENT FINDINGS

The data establishing normal echo parameters during pregnancy are inconsistent. In addition, there is limited research exploring the role of advanced cardiac ultrasound modalities, such as tissue Doppler imaging or speckle tracking echocardiography, in assessing cardiac function during pregnancy. What data there are suggest that these advanced modalities can be used to identify subclinical changes before traditional echocardiography can, and thus have clear utility in identifying early abnormal cardiac responses to pregnancy. Echocardiography is the modality of choice for imaging the heart in pregnant women. Advanced ultrasound modalities increasingly play a role in identifying abnormal adaptations to pregnancy and detecting subclinical changes. This, in turn, can help promote a healthy pregnancy for both mother and fetus.

Mechanical Valve Thrombosis in a Pregnant Patient: A Case of Therapeutic Failure

Mechanical valve thrombosis is life-threatening complication especially in pregnant patients. The optimal anticoagulation regimen is still not certain as there are different fetal and maternal risks associated with anticoagulation. A 37-year-old woman with a history of rheumatic heart disease with a mechanical mitral valve replacement 13 years prior presented to the hospital with dyspnea on mild exertion associated with orthopnea for three days. She was nine weeks pregnant, she had been on warfarin prior to pregnancy, and was switched to low molecular weight heparin (LMWH) in her 6th week of pregnancy. Fluoroscopy showed that one leaflet of the mitral valve was nearly fixed, while the other leaflet had restricted motion at maximal opening. Transesophageal echocardiogram (TEE) showed a very large thrombus approximately 3-4 cm2 encompassing the entire mechanical valve with one immobile leaflet and limited mobility in other leaflet. In view of her clinical status (dyspnea with NYHA Class IV symptoms), the patient underwent uncomplicated bioprosthetic mitral valve replacement. However, the fetus did not survive. Mechanical heart valve (MHV) thrombosis is life-threatening complication in pregnancy. The optimal anticoagulation therapy in pregnancy is unclear. This case report brings into light that in spite of adequate anticoagulation, pregnant patients with mechanical heart valves are still at a high risk of developing valve thrombosis. It highlights the use of transthoracic and transesophageal echocardiogram along with fluoroscopy in diagnosing this and discusses the therapeutic options for this unique condition.

Evaluation and Management of Maternal Congenital Heart Disease: A Review

Objective

Congenital heart defects represent the most common major congenital anomalies. The objective of this review was to define the most common forms of congenital heart disease (CHD) in pregnancy, outline preconception counseling, discuss the associated morbidity and mortality of each lesion, and review current recommendations for management of CHD in pregnancy.

Evidence Acquisition

A MEDLINE search of "congenital heart disease in pregnancy" and specific conditions in pregnancy including "ventricular septal defect," "atrial septal defect," "left outflow obstruction," "right outflow obstruction," "tetralogy of Fallot," and "transposition of the great vessels" was performed.

Results

The evidence included in the review contains 18 retrospective studies, 8 meta-analyses or systematic reviews or expert opinions, 5 case reports including surgical case reports, 2 prospective studies, and 2 clinical texts.

Conclusions

Given advances in surgical and medical management, women with a history of congenital cardiac defects are more frequently reaching childbearing age and requiring obstetric care. Many women with CHD can have successful pregnancies, although there are a few conditions that confer significant maternal risk, and pregnancy may even be contraindicated. Appropriate care for women with CHD requires a knowledge of cardiac physiology in pregnancy, the common lesions of CHD, and coordinated care from cardiology and maternal-fetal medicine specialists.

Feasibility and effectiveness of percutaneous balloon mitral valvuloplasty under echocardiographic guidance only

OBJECTIVE

Percutaneous balloon mitral valvuloplasty (PBMV) is the treatment of choice in patients with isolated mitral stenosis. This study aimed to assess the feasibility of PBMV under echocardiography guidance only of isolated mitral stenosis (MS).

METHODS

From October 2016 to Dec 2017, 20 consecutive patients with severe MS underwent PBMV with echocardiography as the only imaging modality at a single center. Outpatient follow-up including chest radiography, electrocardiography, and transthoracic echocardiography was conducted at 1, 3,6, and 12 months after the procedure.

RESULTS

All 20 patients successfully underwent PBMV under echocardiography guidance without radiation and contrast agent. Among them, 2 patients were pregnant, 5 had chronic renal failure, and 1 had history of allergy to contrast. Mitral transvalvular pressure gradient measured at catheterization dropped from 13.35 ± 2.85 mm Hg to 5.10 ± 1.17 mm Hg (P < .01). Mitral valve area increased from 0.82 ± 0.10 cm² pre-PBMV to 1.88 ± 0.24 cm² post-PBMV (P < .01). Mean balloon diameter was 26.63 ± 0.93 mm. Mild mitral regurgitation developed in 6 patients. Mean follow-up duration was 6.27 ± 3.12 months. At last follow-up, mitral valve area remained high (1.71 ± 0.14 cm² ) and mean transmitral pressure gradient low (6.07 ± 1.03 mm Hg). No pericardial effusion or peripheral vascular complications occurred.

CONCLUSION

In this small experience, PBMV could be successfully performed under only echocardiography guidance and appeared safe and effective while avoiding radiation and contrast agent use.

[Management of mitral valve stenosis during pregnancy at the Oran university hospital center: About 83 cases]

INTRODUCTION

The management of pregnancy in patients with mitral valve stenosis disease continues to pose a challenge to the clinician.

OBJECTIVE

The aim of study was to evaluate the association between mitral valve stenosis and maternal and fetal out come.

MATERIEL AND METHOD

Eighty-three pregnant women with mitral valve disease, followed-up from 2009 to 2012, were prospectively evaluated medical history, NYHA class assessment, ECG and echocardiography were performed during pregnancy and after delivery.

RESULTS

Women with mitral stenosis had significantly clinical higher incidence of complications deterioration of clinical status was observed (44.57%, P=0.0001) congestive heart failure had observed (27.71%, P=0.0001), hospitalization (33.73%, P=0.0001), need of cardiac medications (53.75%, P=0.009), arrhythmias (16%, P<0.05), New born outcome, mitral stenosis had an effect on fetal outcome. We had increasing preterm, delivery (17.50%, P=0.018), hypotrophy (20.48%, P=0.001), intra-uterine growth retardation (12.04%, P=0.011) new born hospitalizations (13.25%, P=0.03) Increased maternal morbidity and unfavorable fetal outcome was seen mostly in patients with moderate and severe mitral stenosis.

CONCLUSION

Pregnant with critical mitral stenosis form a high-risk groups of life-threatening complications. There is need for close maternal follow-up and fetal surveillance and repair of mitral stenosis should be performed before pregnancy.

Evaluation and Management of Right-Sided Heart Failure: A Scientific Statement From the American Heart Association

Background and Purpose:

The diverse causes of right-sided heart failure (RHF) include, among others, primary cardiomyopathies with right ventricular (RV) involvement, RV ischemia and infarction, volume loading caused by cardiac lesions associated with congenital heart disease and valvular pathologies, and pressure loading resulting from pulmonic stenosis or pulmonary hypertension from a variety of causes, including left-sided heart disease. Progressive RV dysfunction in these disease states is associated with increased morbidity and mortality. The purpose of this scientific statement is to provide guidance on the assessment and management of RHF.

Methods:

The writing group used systematic literature reviews, published translational and clinical studies, clinical practice guidelines, and expert opinion/statements to summarize existing evidence and to identify areas of inadequacy requiring future research. The panel reviewed the most relevant adult medical literature excluding routine laboratory tests using MEDLINE, EMBASE, and Web of Science through September 2017. The document is organized and classified according to the American Heart Association to provide specific suggestions, considerations, or reference to contemporary clinical practice recommendations.

Results:

Chronic RHF is associated with decreased exercise tolerance, poor functional capacity, decreased cardiac output and progressive end-organ damage (caused by a combination of end-organ venous congestion and underperfusion), and cachexia resulting from poor absorption of nutrients, as well as a systemic proinflammatory state. It is the principal cause of death in patients with pulmonary arterial hypertension. Similarly, acute RHF is associated with hemodynamic instability and is the primary cause of death in patients presenting with massive pulmonary embolism, RV myocardial infarction, and postcardiotomy shock associated with cardiac surgery. Functional assessment of the right side of the heart can be hindered by its complex geometry. Multiple hemodynamic and biochemical markers are associated with worsening RHF and can serve to guide clinical assessment and therapeutic decision making. Pharmacological and mechanical interventions targeting isolated acute and chronic RHF have not been well investigated. Specific therapies promoting stabilization and recovery of RV function are lacking.

Conclusions:

RHF is a complex syndrome including diverse causes, pathways, and pathological processes. In this scientific statement, we review the causes and epidemiology of RV dysfunction and the pathophysiology of acute and chronic RHF and provide guidance for the management of the associated conditions leading to and caused by RHF.

Maternal and Fetal Outcome After Cardiac Operations During Pregnancy: A Meta-Analysis

BACKGROUND

In the past, cardiac surgical procedures during pregnancy have been associated with a high risk of adverse maternal and fetal outcomes. Therefore, this meta-analysis of more recent studies was done to assess the fetomaternal risk after cardiac operations during pregnancy using cardiopulmonary bypass.

METHODS

The MEDLINE, Embase, and Cochrane library were searched to find studies from January 1, 1990, to July 31, 2016, without language restriction. We selected studies that included at least 4 women to report fetomaternal outcomes after a cardiac operation using cardiopulmonary bypass during pregnancy. Two authors independently extracted data from the selected studies. The studies were assessed for methodological qualities using the Newcastle-Ottawa Scale. The primary outcomes included maternal death and any pregnancy loss. The secondary outcomes were maternal complications and neonatal complications. Primary analysis calculated absolute risks and 95% confidence intervals (CIs) for pregnancy outcomes using the DerSimonian-Laird random effects model. Heterogeneity was assessed by I² statistic and visual plot.

RESULTS

Ten studies, including 154 women, were eligible for inclusion in this study. The patients underwent cardiac operations during pregnancy involving cardiopulmonary bypass. As calculated per 100 pregnancies, the pooled unadjusted estimate of maternal mortality was 11.2 (95% CI, 6.8 to 17.8), pregnancy loss was 33.1 (95% CI, 25.1 to 41.2), maternal complications were 8.8 (95% CI, 2.8 to 24.2), and neonatal complications were 10.8 (95% CI, 4.2 to 25.2). The risks of preterm labor and cesarean delivery were 28 per 100 pregnancies (95% CI, 15.6 to 45) and 33.8 per 100 pregnancies (95% CI, 19.1 to 52.4), respectively.

CONCLUSIONS

The fetomaternal mortality and morbidity after a cardiac operation during pregnancy are higher than that reported in the earlier literature (PROSPERO No. CRD42016047093).

Mechanical Mitral Valve Replacement during the 2nd Trimester of Pregnancy

We report the case of a 44-year-old pregnant woman who was diagnosed with symptomatic severe mitral stenosis that did not respond to optimal medical therapy and balloon valvuloplasty. After a multidisciplinary team discussion on the timing and risks of interventions and postoperative optimization of peripartum anticoagulation, the patient underwent mechanical mitral valve replacement during the 2nd trimester of pregnancy. The outcome was excellent for the mother and the infant. This case emphasizes the importance of a multidisciplinary approach in managing unusual cases.

Clinical 'Pearls' of maternal critical care: part I

PURPOSE OF REVIEW

This review outlines the challenges in looking after pregnant women with thromboembolism and sepsis who either become or are at risk of becoming critically ill during pregnancy.

RECENT FINDINGS

The Pregnancy Mortality Surveillance systems in both the USA and UK record the most common causes of maternal death as thromboembolism and sepsis. Both of these conditions have improved outcomes with timely maternal critical care provided by a multidisciplinary team.

SUMMARY

In this review, we discuss the pathophysiology, diagnosis, and management of thromboembolism and sepsis, two very important conditions with high mortality requiring admission to intensive care.

Cardiovascular Emergencies in Pregnancy

Heart disease in pregnancy may manifest as acute coronary syndromes, decompensated valvular disease, and acute heart failure. These disease processes may represent progression of preexisting disease versus newly developed disease resulting from the physiologic changes of pregnancy. Early recognition of clinical presentations, judicious use of diagnostic studies, and multidisciplinary management of patient and fetal considerations can lead to optimal outcomes in this unique patient subset.

Congenital and Acquired Valvular Heart Disease in Pregnancy

PURPOSE OF REVIEW

The number of pregnancies complicated by valvular heart disease is increasing. This review describes the hemodynamic effects of clinically important valvular abnormalities during pregnancy and reviews current guideline-driven management strategies.

RECENT FINDINGS

Valvular heart disease in women of childbearing age is most commonly caused by congenital abnormalities and rheumatic heart disease. Regurgitant lesions are well tolerated, while stenotic lesions are associated with a higher risk of pregnancy-related complications. Management of symptomatic disease during pregnancy is primarily medical, with percutaneous interventions considered for refractory symptoms. Most guidelines addressing the management of valvular heart disease during pregnancy are based on case reports and observational studies. Additional investigation is required to further advance the care of this growing patient population.

Consensus Document of the Italian Association of Hospital Cardiologists (ANMCO), Italian Society of Pediatric Cardiology (SICP), and Italian Society of Gynaecologists and Obstetrics (SIGO): pregnancy and congenital heart diseases

The success of cardiac surgery over the past 50 years has increased numbers and median age of survivors with congenital heart disease (CHD). Adults now represent two-thirds of patients with CHD; in the USA alone the number is estimated to exceed 1 million. In this population, many affected women reach reproductive age and wish to have children. While in many CHD patients pregnancy can be accomplished successfully, some special situations with complex anatomy, iatrogenic or residual pathology are associated with an increased risk of severe maternal and fetal complications. Pre-conception counselling allows women to come to truly informed choices. Risk stratification tools can also help high-risk women to eventually renounce to pregnancy and to adopt safe contraception options. Once pregnant, women identified as intermediate or high risk should receive multidisciplinary care involving a cardiologist, an obstetrician and an anesthesiologist with specific expertise in managing this peculiar medical challenge. This document is intended to provide cardiologists working in hospitals where an Obstetrics and Gynecology Department is available with a streamlined and practical tool, useful for them to select the best management strategies to deal with a woman affected by CHD who desires to plan pregnancy or is already pregnant.

Immediate Outcome of Balloon Mitral Valvuloplasty with JOMIVA Balloon during Pregnancy

INTRODUCTION

Rheumatic mitral stenosis is the most common Valvular Heart Disease encountered during pregnancy. Balloon Mitral Valvuloplasty (BMV) is one of the treatment option available if the symptoms are refractory to the medical management and the valve anatomy is suitable for balloon dilatation. BMV with Inoue balloon is the most common technique being followed worldwide. Over the wire BMV is a modified technique using Joseph Mitral Valvuloplasty (JOMIVA) balloon catheter which is being followed in certain centres.

AIM

To assess the immediate post procedure outcome of over the wire BMV with JOMIVA balloon.

MATERIALS AND METHODS

Clinical and echocardiographic parameters of pregnant women with significant mitral stenosis who underwent elective BMV with JOMIVA balloon in our institute from 2005 to 2015 were analysed retrospectively. Severity of breathlessness (New York Heart Association Functional Class), and duration of pregnancy was included in the analysis. Pre procedural echocardiographic parameters which included severity of mitral stenosis and Wilkin's scoring were analysed. Clinical, haemodynamic and echocardiographic outcomes immediately after the procedure were analysed.

RESULTS

Among the patients who underwent BMV in our Institute 38 were pregnant women. Twenty four patients (63%) were in New York Heart Association (NYHA) Class III. All of them were in sinus rhythm except two (5%) who had atrial fibrillation. Thirty four patients (89.5%) were in second trimester of pregnancy at the time of presentation and four (10.5%) were in third trimester. Echocardiographic analysis of the mitral valve showed that the mean Wilkin's score was 7.3. Mean mitral valve area pre procedure was 0.8 cm². Mean gradient across the valve was 18 mmHg. Ten patients (26.5%) had mild mitral regurgitation and none had more than mild mitral regurgitation. Thirty six patients had pulmonary hypertension as assessed by tricuspid regurgitation jet velocity. All of them underwent BMV with JOMIVA balloon. Post procedure mean mitral valve area was 1.7 cm² as assessed by echocardiography. Post procedure mean gradient across the mitral valve as assessed by echocardiography was 5 mmHg. Two patients had moderate to severe mitral regurgitation after the procedure and the rest had either no mitral regurgitation or mild mitral regurgitation after the procedure. None of the patients warranted mitral valve replacement after BMV. No patients had any manifestations of systemic embolism like cerebrovascular accident or limb ischemia after the procedure. None of the patients had preterm delivery or adverse fetal outcome during index hospitalisation.

CONCLUSION

Over the wire BMV is safe and effective method during pregnancy. The results are comparable to that of Inoue technique. BMV offers a good symptomatic improvement in pregnant women presenting with symptoms of pulmonary congestion because of Rheumatic mitral stenosis.