Pregnancy complicated by valvular heart disease: an update

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.

Do Maternal Heart Diseases Affect Fetal Cardiac Functions?

OBJECTIVES

To investigate whether fetal cardiac function is affected by underlying heart disease in pregnant women.

METHODS

A total of 100 pregnant women who were ≥34 gestational weeks were included in the study, 40 in the maternal heart disease (MHD) group diagnosed with heart disease and 60 in the control group. All cardiac diseases in pregnant women were diagnosed preconceptionally and categorized according to the New York Heart Association (NYHA) classification system. Fetal cardiac functions of study groups were evaluated by M-mode, color tissue Doppler imaging (c-TDI), and pulsed wave Doppler.

RESULTS

Tricuspid annular plane systolic excursion and myocardial performance index (MPI) values were significantly higher and isovolumetric relaxation time was prolonged in the MHD group. The MPI value was found higher in MHD group with NYHA Class II compared to those with NYHA Class I. No significant change in any of the fetal tricuspid annular peak velocity values measured by c-TDI in the MHD group. There were no differences in fetal cardiac functions and perinatal outcomes between pregnant women with acquired and congenital heart diseases. Patients in NYHA Class II had lower birth weight, 1st and 5th minute APGAR scores, and higher neonatal intensive care unit admission rates.

CONCLUSIONS

Underlying heart diseases in pregnant women can cause alterations in the systolic and diastolic function of the fetal heart. High fetal MPI values detected in cardiac patients may indicate that cardiac pathologies during pregnancy affect fetal cardiac globular myocardial function. Cardiac pathologies that progress with restricted physical activity may cause changes in fetal cardiac function and may be associated with adverse perinatal outcomes.

Peripartum Pharmacotherapy: A Pharmacist's Guide

Complications throughout the peripartum period may be caused by preexisting conditions or pregnancy-induced conditions and may alter pharmacotherapy management. Pharmacotherapy management during late pregnancy and delivery requires careful consideration due to changing hormones, hemodynamic status, and pharmacokinetics, and concerns for potential maternal and/or fetal morbidity. Increased maternal and fetal monitoring are often required and may lead to therapy changes. Pharmacists, as key members of the interprofessional team, can contribute essential perspective to the management of postpartum pharmacotherapy through assessment and recommendation of appropriate and judicious use of medications.

Neuraxial Anesthesia in Patients With Aortic Stenosis: A Systematic Review

Neuraxial anesthesia (NA) has been contraindicated in patients with aortic stenosis (AS) due to concerns of sympathetic blockade and hemodynamic instability. These considerations are based on precautionary expert recommendations, supported by expected physiologic effects, but in the absence of any published scientific evidence. In light of the increasing elderly population and the prevalence of AS, this systematic review compiles available literature on NA in patients with AS to address the understanding of the anesthetic practice and safety in this population. Using a systematic approach, PubMed, Embase, and Web of Science were searched for studies of patients with AS who exclusively received NA. Primary outcomes included intraoperative and postoperative complications. Of 1,433 citations, 61 met full-text inclusion criteria, including 3,228 patients undergoing noncardiac (n = 3,146, 97.5%), obstetric (n = 69, 2.1%), and cardiac (n = 13, 0.4%) procedures. Significant data heterogeneity (local anesthetic dosing, intraoperative interventions, and measured outcomes) prevented formal metanalysis, but descriptive data are presented. Spinal block (n = 2,856, 88.5%) and epidural anesthesia (n = 397, 12.3%) were administered most frequently. Hypotension requiring vasopressors was the most common intraoperative complication-noncardiac (n = 16, 9.9%), obstetric (n = 6, 13.0%), and cardiac (n = 1, 7.7%)-with resolution in all patients and no reported intraoperative cardiovascular collapse or mortality. The relative risk of different AS severities remains unclear, and optimal medication dosing remains elusive. The authors' data suggested that NA may not be contraindicated in carefully selected patients with AS. The authors' results should inform the design of future prospective studies comparing NA and general anesthesia in patients with AS.

Transcatheter heart valve interventions for patients with rheumatic heart disease

Rheumatic heart disease [RHD] is the most prevalent cause of valvular heart disease in the world, outstripping degenerative aortic stenosis numbers fourfold. Despite this, global resources are firmly aimed at improving the management of degenerative disease. Reasons remain complex and include lack of resources, expertise, and overall access to valve interventions in developing nations, where RHD is most prevalent. Is it time to consider less invasive alternatives to conventional valve surgery? Several anatomical and pathological differences exist between degenerative and rheumatic valves, including percutaneous valve landing zones. These are poorly documented and may require dedicated solutions when considering percutaneous intervention. Percutaneous balloon mitral valvuloplasty (PBMV) is the treatment of choice for severe mitral stenosis (MS) but is reserved for patients with suitable valve anatomy without significant mitral regurgitation (MR), the commonest lesion in RHD. Valvuloplasty also rarely offers a durable solution for patients with rheumatic aortic stenosis (AS) or aortic regurgitation (AR). MR and AR pose unique challenges to successful transcatheter valve implantation as landing zone calcification, so central in docking transcatheter aortic valves in degenerative AS, is often lacking. Surgery in young RHD patients requires mechanical prostheses for durability but morbidity and mortality from both thrombotic complications and bleeding on Warfarin remains excessively high. Also, redo surgery rates are high for progression of aortic valve disease in patients with prior mitral valve replacement (MVR). Transcatheter treatments may offer a solution to anticoagulation problems and address reoperation in patients with prior MVR or failing ventricles, but would have to be tailored to the rheumatic environment. The high prevalence of MR and AR, lack of calcification and other unique anatomical challenges remain. Improvements in tissue durability, the development of novel synthetic valve leaflet materials, dedicated delivery systems and docking stations or anchoring systems to securely land the transcatheter devices, would all require attention. We review the epidemiology of RHD and discuss anatomical differences between rheumatic valves and other pathologies with a view to transcatheter solutions. The shortcomings of current RHD management, including current transcatheter treatments, will be discussed and finally we look at future developments in the field.

Mode of delivery among women with maternal cardiac disease

OBJECTIVE

To determine if maternal cardiac disease affects delivery mode and to investigate maternal morbidity.

STUDY DESIGN

Retrospective cohort study performed using electronic medical record data. Primary outcome was mode of delivery; secondary outcomes included indication for cesarean delivery, and rates of severe maternal morbidity.

RESULTS

Among 14,160 deliveries meeting inclusion criteria, 218 (1.5%) had maternal cardiac disease. Cesarean delivery was more common in women with maternal cardiac disease (adjusted odds ratio 1.63 [95% confidence interval 1.18-2.25]). Patients delivered by cesarean delivery in the setting of maternal cardiac disease had significantly higher rates of severe maternal morbidity, with a 24.38-fold higher adjusted odds of severe maternal morbidity (95% confidence interval: 10.56-54.3).

CONCLUSION

While maternal cardiac disease was associated with increased risk of cesarean delivery, most were for obstetric indications. Additionally, cesarean delivery in the setting of maternal cardiac disease is associated with high rates of severe maternal morbidity.

Cesarean section of a patient with combined severe mitral and aortic stenosis: a case report

Cardiovascular diseases during pregnancy are rare but account for complications that pose risks to the mother as well as the child. In patients with fixed cardiac output due to stenotic valvular lesion(s), the physiological changes during pregnancy carry high risk of morbidity and mortality.

Case Presentation

Our patient was diagnosed with severe mitral and aortic stenosis at her first antenatal visit at 24 weeks of gestation. She was also diagnosed with intrauterine growth restriction and was therefore planned to be operated on at a gestational age of 34 weeks. After careful selection of monitoring and anesthetic regime, the patient was managed without any intraoperative or postoperative complications.

Clinical Discussion

This case reports how the anesthetists, obstetricians, and cardiac surgeons devised a well-designed plan to operate on a patient with a relatively rare disease manifestation. Our patient had coexisting severe stenotic lesions of both mitral and aortic valves and posed a clinical dilemma regarding the choice of anesthesia and perioperative management. Regardless of the anesthetic technique, goals for a patient with the combined valvular disease include maintenance of adequate preload, systemic vascular resistance, cardiac contractility, sinus rhythm and avoidance of tachycardia, bradycardia, aortocaval compression, and anesthetic or surgery-induced hemodynamic changes.

Conclusion

The course of management would give clinicians an idea of how to manage a patient with combined stenotic valvular lesions for cesarean section, ensuring a smooth course and a safe postoperative period.

Noonan syndrome and pregnancy outcomes

BACKGROUND

Noonan syndrome is a genetic disorder with high prevalence of congenital heart defects, such as pulmonary stenosis, atrial septal defect and hypertrophic cardiomyopathy. Scarce data exists regarding the safety of pregnancy in patients with Noonan syndrome, particularly in the context of maternal cardiac disease.

STUDY DESIGN

We performed a retrospective chart review of patients at Yale-New Haven Hospital from 2012 to 2020 with diagnoses of Noonan syndrome and pregnancy. We analysed medical records for pregnancy details and cardiac health, including echocardiograms to quantify maternal cardiac dysfunction through measurements of pulmonary valve peak gradient, structural heart defects and interventricular septal thickness.

RESULTS

We identified five women with Noonan syndrome (10 pregnancies). Three of five patients had pulmonary valve stenosis at the time of pregnancy, two of which had undergone cardiac procedures. 50% of pregnancies (5/10) resulted in pre-term birth. 80% (8/10) of all deliveries were converted to caesarean section after a trial of labour. One pregnancy resulted in intra-uterine fetal demise while nine pregnancies resulted in the birth of a living infant. 60% (6/10) of livebirths required care in the neonatal intensive care unit. One infant passed away at 5 weeks of age.

CONCLUSIONS

The majority of mothers had pre-existing, though mild, heart disease. We found high rates of prematurity, conversion to caesarean section, and elevated level of care. No maternal complications resulted in long-term morbidity. Our study suggests that women with Noonan syndrome and low-risk cardiac lesions can become pregnant and deliver a healthy infant with counselling and risk evaluation.

Preconception consultation using treadmill exercise stress echocardiography for pregnant women with the left-sided heart valve stenosis: A preliminary report

OBJECTIVE

Pregnancy can increase gradients across the heart valves and consequently deteriorates maternal and fetoneonatal conditions. Hence, pregnancy during heart valve diseases can be challenging and we need to risk stratify patients before conception. We tried to assess the role of preconception consultation using treadmill stress echocardiography (TSE) testing for identifying pregnancy outcomes in women with mitral valve stenosis (MS) or aortic valve stenosis (AS).

METHODS

Pregnant patients with a diagnosis of MS or AS were evaluated from January 2015 to December 2018. First group included patients undergoing the TSE testing and they were permitted to get pregnant if they met pre-defined criteria. Second group comprised women who did not undergo TSE testing. Maternal and fetoneonatal outcomes were also recorded.

RESULTS

A total of 29 and 18 patients with MS and AS, respectively, were recruited. Among MS patients, individuals without TSE had more functional deterioration (11.1% vs. 35%) and more fetoneonatal events (FNE) (22.2% vs. 55%) compared with those undergoing TSE. The rates of maternal events and mitral valvuloplasty during pregnancy were significantly higher in patients without TSE compared with those undergoing TSE (p=0.015 and p=0.042, respectively). Among AS patients, maternal and FNE were higher in patients without TSE compared with those undergoing TSE, but those were comparable.

CONCLUSION

Pregnant patients with the left-sided valvular stenosis who received preconception TSE testing had better outcomes compared with those who did not undergo preconception consultation. This underscores the utility of stress echocardiography in the risk stratification of pregnancies.

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.

Cardiovascular Imaging in Pregnancy: Valvulopathy, Hypertrophic Cardiomyopathy, and Aortopathy

Pregnancy is associated with profound hemodynamic changes that are particularly impactful in patients with underlying cardiovascular disease. Management of pregnant women with cardiovascular disease requires careful evaluation that considers the well-being of both the woman and the developing fetus. Clinical assessment begins before pregnancy and continues throughout gestation into the post-partum period and is supplemented by cardiac imaging. This review discusses the role of imaging, specifically echocardiography, cardiac MRI, and cardiac CT, in pregnant women with valvular diseases, hypertrophic cardiomyopathy, and aortic pathology.

Maternal and neonatal outcomes among pregnant women with cardiovascular disease in the Philippines: a retrospective cross-sectional study from 2015-2019

PURPOSE

Several studies link maternal cardiovascular disease (CVD) to maternal and fetal morbidity and mortality. This study describes the profile of maternal, obstetric, and neonatal outcomes among pregnant women with CVD in a tertiary hospital in the Philippines. It identifies the clinical and sociodemographic variables associated with these outcomes.

MATERIALS AND METHODS

A single-center, retrospective analysis of pregnant women admitted for delivery at the Philippine General Hospital from 2015 to 2019 was performed. Of these patients, pregnant women with CVD were identified as the cohort for this study. Data on clinical and sociodemographic factors, maternal major adverse cardiovascular events, neonatal adverse clinical events, and obstetric complications were collected. Logistic regression analysis was performed to determine the odds ratio for the risk factors for small-for-gestational-age (SGA) babies and preterm birth.

RESULTS

Among 30,053 delivery admissions in the Philippine General Hospital from 2015 to 2019, 293 (0.98%) pregnant women had CVD. Of the CVDs present in this cohort, congenital heart diseases (n = 119, 40.6%) were the most common, followed by rheumatic heart disease (n = 109, 37.2%). Maternal adverse events were rarely observed. Four women experienced symptomatic arrhythmias, two presented with worsening heart failure, three experienced thromboembolic events, and one had cerebrovascular infarction. There was no reported maternal death, cardiac arrest, shock, or acute renal failure. The majority (69.3%) of the women included in the study were delivered by spontaneous vaginal delivery and assisted vaginal delivery by vacuum or forceps; however, a significant portion of these women had undergone cesarean section. Almost all the study cohort delivered live births, with most neonates being delivered at 37-38 weeks gestational age (83.6%) and only 16.0% born preterm. However, a significant portion, a third of the neonates, were classified as having low birth weight. Around 17.4% of neonates born from gravidocardiac mothers were admitted neonatal intensive care unit. Conditions associated with preterm birth were low educational attainment, previous history of early neonatal death, maternal low ejection fraction, and abnormal maternal left ventricular geometry. The conditions associated with SGA babies were high gravidity and parity, a history of abortion/stillbirth, a history of previous cesarean section delivery, low ejection fraction, a history of multiple gestations, and higher BMI.

CONCLUSION

In this cohort study, adverse maternal outcomes were rarely observed. CVD in pregnancy is associated with an increased risk of preterm birth and SGA babies. We identified certain maternal conditions and sociodemographic factors associated with these outcomes. Despite having CVD, our study cohort had no mortality from the pregnancy.

Alternatives to Low Molecular Weight Heparin for Anticoagulation in Pregnant Women with Mechanical Heart Valves in Middle-Income Countries: A Cohort Study

Objective

To compare cardiac complications and pregnancy outcomes in women with mechanical heart valves (MHVs) on two different anticoagulation regimens in a middle-income country.

Methods

We conducted a retrospective cohort study comparing outcomes in pregnant women with MHVs that received vitamin K antagonists (VKAs) throughout pregnancy versus sequential anticoagulation (heparins in the first trimester and peripartum period and VKAs for the remainder of pregnancy), at a tertiary centre in South India, from January 2011 to August 2020.

Results

We identified 138 pregnancies in 121 women, of whom 32 received VKAs while 106 were on sequential anticoagulation. There were no differences between groups with regard to maternal deaths [0 vs. 6 (5.7%), p = 0.34], thromboembolic events [2 (6.3%) vs. 15 (14.2%), p = 0.36], haemorrhagic complications [4 (12.5%) vs. 12 (11.3%), p = 0.85], cardiac events [1 (3.1% vs. 17 (16%), p = 0.07], spontaneous miscarriages [5 (15.6%) vs. 13 (12.3%), p = 0.62], stillbirths [0 vs. 5 (5.4%), p = 0.581] or neonatal deaths [2 (8.7%) vs. 1 (1.1%), p = 0.11]. Both cases of warfarin embryopathy received >5 mg warfarin in the first trimester. Thromboembolic events were associated with subtherapeutic doses of heparin in the first and third trimesters and the early postpartum period. Fetal growth restriction and preterm birth complicated 34 (29.3%) and 26 (22.4%) pregnancies respectively.

Conclusion

Pregnancy complications associated with MHVs in middle-income countries may be reduced by multidisciplinary surveillance, avoiding first-trimester warfarin if daily doses >5 mg and ensuring therapeutic levels of heparin during bridging in the first and third trimesters and peripartum period. Administration of low-dose aspirin should be considered as this may prevent placentally-mediated complications of pregnancy.

Highlights

Pregnancy complications associated with MHVs in LMICs may be reduced by multidisciplinary surveillance, avoiding first-trimester warfarin if the daily dose is >5 mg, ensuring therapeutic levels of heparin in the first trimester and peripartum period.Placentally-mediated complications of pregnancy can be prevented by administering low-dose aspirin.Vitamin K antagonists or sequential regimen can be used as suitable alternatives to LMWH for anticoagulation in pregnant women with MHVs.

Mitral Regurgitation in Patients Undergoing Noncardiac Surgery

Mitral regurgitation (MR) is one of the most frequently encountered types of valvular heart disease in the United States. Patients with significant MR (moderate-to-severe or severe) undergoing noncardiac surgery have an increased risk of perioperative cardiovascular complications. MR can arise from a diverse array of causes that fall into 2 broad categories: primary (diseases intrinsic to the valvular apparatus) and secondary (diseases that disrupt normal valve function via effects on the left ventricle or mitral annulus). This article highlights key guideline updates from the American College of Cardiologists (ACC) and the American Heart Association (AHA) that inform decision-making for the anesthesiologist caring for a patient with MR undergoing noncardiac surgery. The pathophysiology and natural history of acute and chronic MR, staging of chronic primary and secondary MR, and considerations for timing of valvular corrective surgery are reviewed. These topics are then applied to a discussion of anesthetic management, including preoperative risk evaluation, anesthetic selection, hemodynamic goals, and intraoperative monitoring of the noncardiac surgical patient with MR.

Thrombosis of mechanical mitral valve prosthesis during pregnancy: An ongoing "saga" in need of comprehensive solutions

Emergency treatment for thrombosed mechanical valve prothesis during pregnancy is not uncommon in low- and middle-income countries. The presence of a mechanical valve continues to be an important cause of maternal morbidity and mortality. There is a pressing need for increasing awareness and feasible solutions for this huge problem. We here describe four patients who needed emergency treatment for thrombosis of mechanical valve prothesis during pregnancy and review the evolving comprehensive strategies for dealing with this issue.

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.

Percutaneous balloon mitral valvotomy during pregnancy: A systematic review and meta-analysis

INTRODUCTION

The objective of this study was to systematically review the maternal and fetal outcomes in pregnant women who underwent percutaneous balloon mitral valvuloplasty (PBMV) during pregnancy.

MATERIAL AND METHODS

A search was conducted on MEDLINE and Embase databases to identify studies published between 2000 and 2018 that reported on maternal and fetal outcomes following PBMV performed in pregnancy. Randomized controlled trials, cohort studies, case-control studies, cross-sectional studies and case series with four or more pregnancies in which PBMV was performed during pregnancy were included. Reference lists from relevant articles were also hand-searched for relevant citations. A successful procedure was defined as one where there was a reported improvement in the valve area or reduction in the mitral valve gradient. A random effects model was used to derive pooled estimates of various outcomes and the final estimates were reported as percentages with a 95% confidence interval (95% CI).

RESULTS

Twenty-one observational studies reporting 745 pregnancies were included in the review, all of them having reported outcomes without a comparison group. Most of the studies fell into the low-risk category as determined using the Joanna Briggs Institute (JBI) critical appraisal checklist for case series. Most of the studies (86%) were reported from low- to middle-income countries and PBMV was mostly performed during the second trimester of pregnancy. Forty-three procedures (5.7%) were unsuccessful, nearly half (n = 19) of them reported among women with the severe subvalve disease (Wilkins subvalve score 3 or more). There were 11 maternal deaths among those with suboptimal valve anatomy (severe subvalve disease or Wilkin score >8). Mitral regurgitation was the most common cardiac complication (12.7%; 95% CI 7.3%-19.1%), followed by restenosis (2.4%; 95% CI 0.02%-7.2%). Pooled incidence of cesarean section was 12.1% (95% CI 3.6%-23.8%), preterm delivery 3.9% (95% CI 0.6%-9.0%), stillbirth 0.9% (95%CI 0.2%-2.2%) and low birthweight 5.4% (95% CI 0.2%-14.7%).

CONCLUSIONS

PBMV may be an effective and safe procedure for optimizing outcomes in pregnant women with mitral stenosis in the absence of severe subvalve disease.

Interventional Cardiology and Catheter-Based Interventions in Pregnancy

Cardiovascular disease is the leading cause of maternal mortality worldwide and has been increasing in prevalence over the last several decades. Pregnancy is associated with significant hemodynamic changes that can overwhelm the maternal cardiovascular reserve, and may exacerbate previously asymptomatic cardiovascular disease. Complications associated with these may cause substantial harm to both the mother and the fetus, and the management of these conditions is often challenging. Numerous novel treatments and interventions have demonstrated the safety and efficacy of managing these conditions outside of pregnancy. However, there are little data regarding their use in the pregnant population. In this review, we describe the common cardiovascular diseases encountered during pregnancy and discuss their management strategies, with a particular focus on the role of percutaneous, catheter-based therapeutic interventions.

Valvular Heart Disease in Pregnancy

The number of reproductive age women with valvular heart disease is rising and accounts for one third of all heart disease among pregnant women. Severe, symptomatic left-sided cardiac lesions, particularly mitral and aortic stenosis, and mechanical heart valves, are associated with adverse maternal and fetal outcomes. Decreasing maternal and fetal risk requires shared decision-making among patients and the heart team, consisting of obstetricians, maternal-fetal medicine subspecialists, and cardiologists.

Risk of Mitral Valve Prolapse in Patients with Keratoconus in Taiwan: A Population-Based Cohort Study

This retrospective, nationwide, matched-cohort study included 4488 new-onset keratoconus (KCN) patients, ≥12 years old, recruited between 2004 and 2011 from the Taiwan National Health Insurance Research Database. The control group included 26,928 non-KCN patients selected from the Taiwan Longitudinal Health Insurance Database 2000. Information for each patient was collected and tracked from the index date until December 2013. The incidence rate of mitral valve prolapse (MVP) was 1.77 times (95% confidence interval (CI) = 1.09–2.88; p = 0.0206) higher in KCN patients ≥40 years old and 1.49 times (95% CI = 1.12–1.98; p = 0.0060) higher in female KCN patients than in controls. After using the Cox proportional hazard regression analysis to adjust for potential confounders, including hypertension, hyperlipidemia, and congestive heart failure, KCN maintained an independent risk factor, MVP being 1.77 times (adjusted hazard ratio (HR) = 1.77, 95% CI = 1.09–2.88) and 1.48 times (adjusted HR = 1.48, 95% CI = 1.11–1.97) more likely to develop in patients ≥40 years old and female patients in the study cohort, respectively. We found that KCN patients ≥40 years of age and female KCN patients have increased risks of MVP. Therefore, it is recommended that KCN patients should be alerted to MVP.

Valvular Heart Disease in Pregnancy: Anticoagulation and the Role of Percutaneous Treatment

Valvular heart disease is present in about 1% of pregnancies, and it poses a management challenge as both fetal and maternal lives are at risk of complications. Pregnancy is associated with significant hemodynamic changes, which can compromise the cardiac status in women with underlying valvular disorders. Management of valvular heart diseases has undergone considerable innovation and advancement with newer techniques, approaches and devices being employed. The decision regarding the management of anticoagulation, especially in patients with prosthetic valves, raises distinct questions and challenges. In this review, we describe the management of common valvular heart diseases encountered during pregnancy, role of percutaneous catheter based therapeutic interventions, the importance of a team-based approach, and the challenges given existing gaps in the literature.

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.

Doppler gradients, valve area and ventricular function in pregnant women with aortic or pulmonary valve disease: Left versus right

OBJECTIVE

Little is known about the course of echocardiographic parameters used for the evaluation of valvular heart disease (VHD) during pregnancy, hampering interpretation of possible changes (physiological vs. pathophysiological). Therefore we studied the course of these parameters and ventricular function in pregnant women with aortic and pulmonary VHD.

METHODS

The cohort comprised 66 pregnant women enrolled in the prospective ZAHARA studies or evaluated by an identical protocol who had pulmonary VHD or aortic VHD (stenosis/prosthetic valve). The control group comprised 46 healthy pregnant women. Echocardiography was performed preconception, during pregnancy and 1 year postpartum. Peak gradient, mean gradient, aortic valve area (AVA)/effective orifice area (EOA), left ventricular ejection fraction (LVEF) and right ventricular function (RVF; TAPSE) were assessed.

RESULTS

Peak and mean gradients increased during pregnancy compared to preconception in women with aortic VHD and controls (p < 0.0125), but not in women with pulmonary VHD. AVA/EOA remained unchanged. Preconception and postpartum gradients were comparable in all groups. Mean LVEF was normal in pregnant women with VHD and controls. Mean TAPSE was lower (p < 0.001) in women with pulmonary VHD compared to women with aortic VHD and controls (<20 mm vs. ≥23 mm; p < 0.001). In women with pulmonary VHD a decrease of TAPSE was observed during pregnancy (p = 0.005).

CONCLUSION

Physiological changes during pregnancy lead to increased Doppler gradients in women with aortic VHD. This increase was not found in women with pulmonary VHD, probably caused by impaired RVF. Therefore, evaluation of RVF during pregnancy might be important to prevent underestimation of the degree of stenosis.

Drugs in pregnancy: Pharmacologic and physiologic changes that affect clinical care

Pharmacologic interventions play a major role in obstetrical care throughout pregnancy, labor and delivery and the postpartum. Traditionally, obstetrical providers have utilized standard dosing regimens developed for non-obstetrical indications based on pharmacokinetic knowledge from studies in men or non-pregnant women. With the recognition of pregnancy as a special pharmacokinetic population in the late 1990s, investigators have begun to study drug disposition in this unique patient dyad. Many of the basic physiologic changes that occur during pregnancy have significant impact on drug absorption, distribution and clearance. Activity of Phase I and Phase II drug metabolizing enzymes are differentially altered by pregnancy, resulting in drug concentrations sufficiently different for some medications that efficacy or toxicity is affected. Placental transporters play a major dynamic role in determining fetal drug exposure. In the past two decades, we have begun to expand our understanding of obstetrical pharmacology; however, to truly optimize pharmacologic care of our pregnant patients and their developing fetus, additional research is critically needed.

Management of Extracorporeal Membrane Oxygenation for Obstetric Patients: Concerns for Critical Care Nurses

Critical care nurses are faced with many challenges, and one that is particularly stressful is caring for obstetric patients. This care can become more complex when the obstetric patient requires extracorporeal membrane oxygenation. It is imperative that critical care nurses have knowledge about this unique population, the expected physical changes of pregnancy, and the management of extracorporeal membrane oxygenation. Obstetric patients present unique challenges, and care is focused on the woman and her family. The purpose of this paper is to provide information for critical care nurses regarding care of obstetric patients who receive extracorporeal membrane oxygenation.

Heart disease in pregnancy-clinical pattern and prevalence: initial data from the first cardio-maternal unit in Iraq

Objectives

The purpose of this study to determine the clinical pattern and prevalence of heart disease in pregnancy at the first established cardio-maternal unit in Iraq over the last 4 years; since January 2015 till May 2019. Data are presented as number and percentage.

Results

A total of 252 pregnant women presented to cardio-maternal unit included in this study. According to the collected data, among the main diagnosis of heart disease during pregnancy was valvular heart disease 34.1%, followed by congenital heart disease 30.5%, cardiomyopathy 29.8%, pulmonary hypertension 4%, and ischemic heart disease 1.6%. Among subtypes of the main heart diseases in pregnant women, the most clinical pattern was: the prosthetic heart valve (26.7%) in valvular heart disease, both atrial septal defect and ventricular septal defect (35%) in congenital heart disease, and peripartum cardiomyopathy (76%) among cardiomyopathies.

Peripartum cardiomyopathy

Peripartum cardiomyopathy (PPCM) is a rare and potentially life-threatening disease that occurs toward the end of pregnancy or in the months following delivery in previously heart-healthy women. The incidence varies widely depending on geographical region and ethnic background, with an estimated number of 1 in 1000–1500 pregnancies in Germany. The course of the disease ranges from mild forms with minor symptoms to severe forms with acute heart failure and cardiogenic shock. The understanding of the etiology of PPCM has evolved in recent years. An oxidative stress-mediated cleaved 16-kDa fragment of the nursing hormone prolactin is thought to damage endothelial cells and cardiomyocytes. Bromocriptine, a dopamine-receptor agonist, effectively blocks prolactin release from the pituitary gland. In addition to standard heart failure therapy, this disease-specific treatment reduces morbidity and mortality in PPCM patients. This review summarizes the current knowledge on PPCM and the disease-specific treatment options.

Validation of the Risk Score for Maternal Cardiac Complications in Women with Cardiac Disease in Pregnancy: A Retrospective Study

Aim of the Study

To validate the new cardiac risk scoring system, Sheela's Cardiac Disease in Pregnancy (SHE-CDIP), in predicting the cardiac complications in women with cardiac disease in pregnancy.

Materials and Methods

The study was conducted at a tertiary care hospital in South India, over a period of 5 years from January 2010 to January 2015. Pregnant women with heart disease included in this study were 102, and data was collected from medical records. Risk Score was calculated at booking according to both the new scoring system (SHE-CDIP) and the standard CARPREG scoring system. The validation was done by assessing the ability of the new scoring system to predict maternal cardiac complications by comparing with the CARPREG scoring system.

Statistical Methods

The validation of the SHE-CDIP score was done against CARPREG score using cross tabulation between current cardiac risk score with CARPREG score. McNemar square test was done to compare the proportion between two scoring methods. Agreement between CARPREG and SHE-CDIP risk score was analyzed using Kappa statistics, and accuracy was reported.

Results

Comparing the two risk scores using Kappa statistics, accuracy and good agreement were noted (kappa = 0.70). Sensitivity of 83%, specificity of 88%, positive predictive value of 86% and negative predictive value of 84% for the SHE-CDIP scoring system were noted.

Conclusion

The new risk score (SHE-CDIP) would be useful to stratify the risk in Indian cohort of women with cardiac disease in pregnancy as it is population specific.

Large Thrombus on a Prosthetic Mitral Valve During Early Pregnancy

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Incidence, outcomes and guideline compliance of out-of-hospital maternal cardiac arrest resuscitations: A population-based cohort study

BACKGROUND

Incidence and survival rates after cardiac arrest among pregnant women are reported for in-hospital cardiac arrests; the incidence and outcomes of maternal out-of-hospital cardiac arrest (OHCA) are unknown. Current cardiopulmonary resuscitation guidelines contain recommendations specific to this population; compliance with these has not been investigated.

OBJECTIVE

To report maternal OHCA incidence, outcomes, and compliance with recommended treatment guidelines.

METHODS

A population-based cohort study of consecutive maternal OHCAs from 2010 to 2014. Census data of all women of childbearing age provided the comparison. Resuscitation performance was measured against the 2010 American Heart Association (AHA) Guidelines.

RESULTS

Six maternal OHCAs were identified among 1085 OHCAs occurring in females of child bearing age (15-49) years; Incidence 1.71 per 100,000 pregnant women (95% CI 0.21 to 6.18) vs. 20.18 OHCAs per 100,000 females of child bearing age (95% CI, 18 to 22.62) p < 0.0001. Survival to hospital discharge was 16.7% (95% CI 3.0, 56.4%) after maternal OHCA vs. 6.8% (95% CI 5.4, 8.4) p < 0.0001 after OHCA in all females of childbearing age, and neonatal survival was 33.3% (95% CI 9.7, 70%). CPR quality metric compliance averaged 83% (range 75% to 100%); compliance with pregnancy-specific resuscitation guidelines ranged from 0% (uterine displacement) to 100% (intravenous line insertion above diaphragm and prehospital maternal team activation).

CONCLUSION

The incidence of maternal OHCA was 1.71:100,000. Survival was higher after maternal OHCA than after OHCA of non-pregnant females of childbearing age. Pregnancy-specific guideline compliance was low suggesting a need for training and better documentation to improve outcomes in these rare events.

Cardiogenic Shock after Nifedipine Administration in a Pregnant Patient: A Case Report and Review of the Literature

We present a case of a 21-year-old Caucasian woman at 27 weeks of pregnancy who was admitted to the obstetric department for pre-term labor. She received 10 mg of nifedipine 4 times in 1 h, according to the internal protocol. Shortly after, she brutally deteriorated with pulmonary edema and hypoxemia requiring transfer to the intensive care unit (ICU) for mechanical ventilation. She finally improved and was successfully extubated after undergoing a percutaneous valvuloplasty of the mitral valve. This case illustrates a severe cardiogenic shock after administration of nifedipine for premature labor in a context of unknown rheumatic mitral stenosis. Nifedipine induces a reflex tachycardia that reduces the diastolic period and thereby precipitates pulmonary edema in case of mitral stenosis. This case emphasizes the fact that this drug may be severely harmful and should never be used before a careful physical examination and echocardiography if valvular heart disease is suspected.

Anesthetic Treatment of Cardiac Disease During Pregnancy

PURPOSE OF REVIEW

This review summarizes the pathophysiology, peripartum treatment, and anesthetic management of parturients with cardiac disease. Valvular disease, coronary disease, and cardiomyopathy are specifically addressed in the context of the normal physiologic changes of pregnancy. We offer recommendations for anesthetic approaches, hemodynamic goals with an emphasis on interdisciplinary planning between anesthesiologists, cardiologists, cardiothoracic surgeons, obstetricians, maternal fetal medicine specialists, and neonatologists.

RECENT FINDINGS

Vaginal delivery with neuraxial analgesia can be well tolerated by many pregnant patients with cardiac disease when coordinated by an interdisciplinary team of experts. Cardiac disease in pregnancy can present a significant challenge for the interdisciplinary care team. A detailed understanding of each patient's cardiac pathology and the physiologic changes of pregnancy are critical to ensure a safe and successful labor and delivery. Optimized medical therapy in the peripartum period and neuraxial anesthesia with the judicious use of vasoactive agents can be of great benefit for these parturients. As is generally the case, cesarean delivery should be primarily reserved for obstetric indications and maternal wellbeing, with careful consideration of the fetus to guide best practices.

Rheumatic heart disease in pregnancy: a report of 2 cases

Pregnant women with severe mitral stenosis tend to experience clinical decompensation with approximately 50% mortality and they may experience adverse effects of the medication they are taking, notably congenital malformations from warfarin exposure. Corrective heart surgery may increase the risk of pregnancy loss. We present 2 cases of RHD in pregnancy. The first case was a 27-year-old patient in her first pregnancy with severe mitral stenosis. Caesarean section was done for foetal distress and she delivered a small for gestational age baby. She was closely monitored postpartum and was stable on discharge. She presented with supraventricular tachycardia and died in the coronary care unit 4 weeks postpartum. The second case was a 28-year-old who was on warfarin for a mechanical mitral valve. A foetal anomaly scan done at 20 weeks showed severe congenital malformations which were not compatible with extra-uterine life. The pregnancy was terminated and she recovered well. The first case illustrates the significant mortality risk with uncorrected severe rheumatic heart disease. The second case highlights the risks of warfarin on the foetus and the need to avoid mechanical heart valves if possible in young women. RHD patients require preconception counselling so they can make informed reproductive choices.

Valvular Heart Disease and Pregnancy

With improving reproductive assistive technologies, advancing maternal age, and improved survival of patients with congenital heart disease, valvular heart disease has become an important cause of morbidity and mortality in pregnant women. In general, stenotic lesions, even those in the moderate range, are poorly tolerated in the face of hemodynamic changes of pregnancy. Regurgitant lesions, however, fare better due to the physiologic afterload reduction that occurs. Intervention on regurgitant valve preconception follows the same principles as a non-pregnant population. Prosthetic valves in pregnancy are increasingly commonplace, presenting new management challenges including valve deterioration and valve thrombosis. In particular, anticoagulation during pregnancy is challenging. Pregnancy is a hypercoagulable state and the risks of maternal bleeding and fetal anticoagulant risks need to be balanced. Maternal mortality and complications are lowest with warfarin use throughout pregnancy; however, fetal outcomes are best with low molecular weight heparin use. ACC/AHA guidelines recommend warfarin use, even in the first trimester, if doses are less than 5 mg/day; however, adverse fetal events are not zero at this dose. In addition, it is unclear if better monitoring of low molecular weight heparin with peak and trough anti-Xa levels would lower maternal risks as this has been inconsistently monitored in reported studies. Fortunately, with the emergence of newer data, our understanding of anticoagulant strategies in pregnancy is improving over time which should translate to better pregnancy outcomes in this higher risk population.

The Role of Cardiac Biomarkers in Pregnancy

OPINION STATEMENT

Cardiovascular disease (CVD) is the leading cause of pregnancy-associated mortality, with an increasingly complex pregnant population. While our understanding of CVD in pregnancy continues to evolve, there remains a need to develop widely accessible tools to follow pregnant women both with and without preexisting disease with respect to cardiovascular risk, particularly for those presenting with symptoms suggestive of cardiovascular pathology. Thus, research is emerging with respect to the potential role of novel and established cardiac biomarkers in diagnosing and following CVD in pregnancy. Here, we review the normal hemodynamics of pregnancy and the behavior of various biomarkers in both normal and complicated pregnancies.

Maternal hemodynamic changes and predictors of poor obstetric outcome in women with rheumatic heart disease: a five-year observational study

OBJECTIVE

To assess prospectively the maternal cardiovascular hemodynamic changes and obstetric outcome in women with rheumatic heart disease (RHD) and to detect predictors of poor outcome.

METHODS

This prospective observational study included 204 pregnant patients with RHD who were divided into two groups; successful pregnancy group with living fetus (n = 126) and poor obstetric outcome group with fetal or neonatal loss (n = 78). Hemodynamic changes, maternal and fetal outcome were assessed and recorded.

RESULTS

There was a highly significant difference between the two groups regarding disease criteria with more women suffering from stenotic lesions (mitral and aortic), pulmonary hypertension, previous heart failure, receiving cardiac medications and higher NYHA class (III and IV) in the poor obstetric outcome group (p < .001). These patients were more prone to maternal and fetal morbidity. Maternal age above 28 years, body mass index higher than 28, mean pulmonary artery pressure higher than 50 mmHg, NYHA class III-IV and development of heart failure or cyanosis are predictors of poor outcome (p < .001).

CONCLUSIONS

Increased maternal age and body mass index together with NYHA class III-IV, significant pulmonary hypertension, reduced ejection fraction and development of heart failure during pregnancy are strong predictors of poor maternal and fetal outcome.

Group A Streptococcus, Acute Rheumatic Fever and Rheumatic Heart Disease: Epidemiology and Clinical Considerations

OPINION STATEMENT

Early recognition of group A streptococcal pharyngitis and appropriate management with benzathine penicillin using local clinical prediction rules together with validated rapi-strep testing when available should be incorporated in primary health care. A directed approach to the differential diagnosis of acute rheumatic fever now includes the concept of low-risk versus medium-to-high risk populations. Initiation of secondary prophylaxis and the establishment of early medium to long-term care plans is a key aspect of the management of ARF. It is a requirement to identify high-risk individuals with RHD such as those with heart failure, pregnant women, and those with severe disease and multiple valve involvement. As penicillin is the mainstay of primary and secondary prevention, further research into penicillin supply chains, alternate preparations and modes of delivery is required.

Echocardiographic Evaluation of Hemodynamic Changes in Left-Sided Heart Valves in Pregnant Women With Valvular Heart Disease

Physiologic changes during pregnancy can deteriorate or improve patients' hemodynamic status in the setting of valvular heart disease. There are sparse data regarding the effect of pregnancy on valve hemodynamics in normal pregnant women with known valvular heart disease. In a prospective study from July 2014 to January 2016, a total of 52 normal pregnant women who had mitral stenosis, aortic stenosis, or a history of mitral valve or aortic valve replacements were assessed. All patients underwent echocardiographic examinations and hemodynamic parameters were measured for both the mitral valve and aortic valve at first, second, and third trimesters. The parameters included mean gradient, peak gradient, mean gradient/heart rate, peak gradient/heart rate, pressure halftime, dimensionless velocity index, and valve area. Although most hemodynamic parameters (i.e., mean gradient, peak gradient, mean gradient/heart rate, and peak gradient/heart rate) increased approximately 50% from first to second trimester and first to third trimester (p <0.05) but those remained stable at third compared with second trimester (p >0.05). The ratio of changes between trimesters for valve area and dimensionless velocity index were comparable. No clinical decompensations were observed except for 3 and 7 cases of deterioration to functional class II at second and third trimesters, respectively. In conclusion, during a full-term and uncomplicated pregnancy, mitral and aortic valve gradients increase without significant changes in valve area that are more marked between the second and first trimester than between the third and second trimester.

Postpartum hemorrhage in the setting of a mechanical heart valve

Background:

Therapeutic anticoagulation is required for all patients with prosthetic mitral valves. Anticoagulation with warfarin is recommended; however, warfarin is teratogenic in early pregnancy and therefore alternate anticoagulation regimens are suggested for pregnant patients.

Case:

A 28-year-old gravida 2, para 1 woman at 36 weeks’ gestation with a prosthetic mitral valve and a history of a corrected anomalous origin of the left coronary artery arising from the left pulmonary artery presented in labor. She underwent a spontaneous vaginal delivery complicated by a postpartum hemorrhage necessitating a hysterectomy.

Conclusion:

Management of mechanical valves in pregnancy is controversial. The provider must weigh the risks of life threatening valve thrombosis and malfunction against the risk of significant hemorrhage. This case report reviews peripartum anticoagulation protocols and management of massive hemorrhage in patients with prosthetic mechanical valves.

Mitral Valve Prolapse in Pregnancy

Mitral valve prolapse is a benign condition. Mitral regurgitation is only complicated in patients with severe mitral valve prolapse. Women with mitral valve prolapse in the absence of other cardiovascular disorders tolerate pregnancy well and do not develop remarkable cardiac complications. Nevertheless, serious complications of mitral valve prolapse, including arrhythmia, infective endocarditis and cerebral ischemic events, can be present in pregnancy. Debates remain with regard to the use of prophylactic antibiotics and β-blockers in the pregnant women with mitral valve prolapse. The prognosis of the pregnant patients might be closely related to the pathological and (or) functional changes of the mitral valve. Non-myxomatous mitral valve prolapse poses no or little obstetric risks in terms of pregnancy, labor and neonatal complications; whereas myxomatous mitral valve prolapse is a major etiology of valvular heart disease in women of childbearing age. In the pregnant patients with mitral valve prolapse progressing into major complications, surgical interventions are considered. Medicinal treatment of such patients with β-blockers should be a concern for the fetal safety.