A pregnant women with valvular heart disease

A pregnant women with

valvular heart disease

Bernard Iung, MDBichat Hospital, Paris, France

Case History

• 28 year-old woman originating from Northern Africa

• Known but non investigated valvular heart disease

• Uneventful pregnancy 7 years ago

• NYHA class II dyspnea without medical therapy

• Consultation at 8th week of her second pregnancy in

2008

• Stable NYHA class II dyspnea

• Holosystolic murmur 3/6 at the apex

• No signs of congestive heart failure

• Blood pressure 104/60 mmHg

ECG

Echocardiography: apical 4-chamber view

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Echocardiography: colour Doppler

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Echocardiography: Summary

• Mitral valve area 2.2 cm², mean gradient 7 mmHg

• Mitral regurgitation

− Vena contracta 7 mm

− Effective regurgitant orifice area 0.41 cm²

− Regurgitant volume 65 ml

• Mild aortic regurgitation

• Systolic pulmonary artery pressure 34 mmHg

• Left ventricle 47 / 29 mm, ejection fraction 69%

• Left atrium 68 ml

What is your conclusion?

1. Pure severe organic mitral regurgitation

2. Mixed mitral valve disease with predominant regurgitation

3. Mixed mitral valve disease with predominant stenosis

4. Functional mitral regurgitation

What is your conclusion?

1. Pure severe organic mitral regurgitation

2. Mixed mitral valve disease with predominant regurgitation

3. Mixed mitral valve disease with predominant stenosis

4. Functional mitral regurgitation

Analysis of valvular disease

• Mitral valve disease is of rheumatic origin:− restrictive motion of posterior leaflet, but thickened valve and

normal LV rule out functional MR− valve anatomy and patient origin are consistent with

rheumatic mitral valve disease

• Mitral regurgitation is severe

• Mitral stenosis is mild

• There are no consequences on left ventricle and pulmonary artery pressures

Analysis of valvular disease

• Mitral regurgitation is severe, as attested by the concordance between different criteria− Vena contracta > 7 mm− ERO ≥ 0.40 cm², regurgitant volume ≥ 60 ml− Extension of regurgitant jet in left atrium is not reliable

• Mitral stenosis is mild (valve area > 2 cm²)− Increased gradient is due to increased transmitral flow

(regurgitation + pregnancy)− Planimetry is the reference method for assessing MS severity

Echocardiographic assessment of valve stenosis: EAE/ASE recommendations for clinical practice. Eur J Echocardiogr 2009;10:1-25

EAE recommendations for the assessment of valvular regurgitation. Part 2: mitral and tricuspid regurgitation (native valve disease). Eur J Echocardiogr 2010;11:307-32.

Guidelines on the management of valvular heart disease (version 2012).Eur Heart J 2012;33:2451-496.

What do you advise?

1. Consider termination of pregnancy

2. Start medical therapy

3. Indication of mitral valve repair

4. Indication of mitral valve replacement

5. No treatment and close follow-up

What do you advise?

1. Consider termination of pregnancy

2. Start medical therapy

3. Indication of mitral valve repair

4. Indication of mitral valve replacement

5. No treatment and close follow-up

Tolerance of haemodynamic changes during pregnancy

• The 30-50% increase in cardiac output during pregnancy may decompensate valvular disease

• Regurgitations are well tolerated due to tachycardia and decreased systemic vascular resistance

• The risk of decompensation is higher for severe stenosis

ESC Guidelines on the management of cardiovascular diseasesduring pregnancy. Eur Heart J 2011;32:3147-97.

(Thorne Heart 2004;90:450-6)

Rationale for follow-up without specific treatment

• Pregnancy is well tolerated in women with regurgitant valvular disease, even if severe, when LV function is preserved

• Cardiac surgery carries a high fetal risk when performed during pregnancy

• Medical therapy is not required due to the good tolerance and potential harm of drug therapy

– Diuretics impair uteroplacental perfusion– ACE inhibitors are contraindicated throughout

pregnancy

Follow-up during pregnancy

• Stable NYHA class II without medical therapy

• No change in clinical examination

• Echocardiographic follow-up:

Term (weeks) 8 18 32 36

NYHA class II II II II

Mean gradient (mmHg) 7 10 10 9

LV (mm) 47/29 52/30 53/31 52/30

Systolic PAP (mmHg) 34 40 45 40

How to plan delivery?

1. Vaginal delivery after inducement of labour at 37-38 weeks

2. Caesarean section at 37-38 weeks

3. Vaginal delivery with close haemodynamic monitoring

4. Vaginal delivery at normal term

How to plan delivery?

1. Vaginal delivery after inducement of labour at 37-38 weeks

2. Caesarean section at 37-38 weeks

3. Vaginal delivery with close haemodynamic monitoring

4. Vaginal delivery at normal term

Delivery and heart diseases

• Labour and delivery represent an additional haemodynamic stress

• However, vaginal delivery is safe in most heart diseases provided their functional tolerance has been good during pregnancy (NYHA class I-II)

• Cesarean section avoids the stress caused by labour but is associated with other complications (thromboembolism, bleeding, anaesthesia…)

Delivery and heart diseases

• Cesarean section is recommended for:– Pre-term labour on oral anticoagulants– Marfan and other aortic aneurysms – Aortic dissection– Severe aortic stenosis

• Induction of labour requires favourable local conditions and is not indicated here

Favour spontaneous onset of labour and vaginal delivery in most cases of stable heart disease

ESC Guidelines on the management of cardiovascular diseasesduring pregnancy. Eur Heart J 2011;32:3147-97.

Pregnancy outcome

• Multidisciplinary decision of vaginal delivery

• Spontaneous labour

• Vaginal delivery at 40 weeks + 2 days under epidural

analgesia

• Good haemodynamic tolerance

• Healthy newborn− 3300 g

− 51 cm

− Apgar 10/10

Take-Home messages

• Comprehensive evaluation of valvular disease is required in young women contemplating pregnancy

• Regurgitant valve disease, even severe, is well tolerated during pregnancy, provided left ventricular function is preserved

• Cardiac surgery should be avoided during pregnancy because of its fetal risk

• Multidisciplinary management is needed during pregnancy, in particular for planning delivery

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