Percutaneous Valve Replacement Therapy Sometimes an Option During Pregnancy

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Most pregnant women with cardiac disease can be managed with close surveillance and medical therapy, but some inevitably need invasive or surgical therapy. Open cardiac surgery is inherently dangerous for the mother (mortality of 3%–11%) and especially for the fetus (mortality of 20%–30%).

In Clinical Obstetrics and Gynecology, Lydia L. Shook, MD, maternal-fetal medicine fellow, and William Barth, MD, vice chair for Obstetrics at Massachusetts General Hospital, update a 2009 paper by Dr. Barth that reviewed cardiac surgery in pregnant women. Like its predecessor, the new paper gives detail on risk stratification systems and surgical considerations for valvular heart disease, aortic dissection and aortic aneurysm, coronary artery disease and congenital heart disease.

A highlight of the revised review is the discussion of percutaneous valve replacement therapy in pregnancy.

Mitral Stenosis

The team's opinion is that surgical or percutaneous management of mitral stenosis is indicated during pregnancy in several circumstances:

• Prophylactically for women with a valve area <1.5 cm2 or New York Heart Association functional class of III or IV
• Therapeutically for women whose functional status has deteriorated despite optimal medical therapy
• Therapeutically for acute pulmonary edema or congestive heart failure not immediately responsive to medical therapy

Percutaneous balloon mitral valvuloplasty (PBMV) is now the treatment of choice when mitral valve repair is indicated during pregnancy. Closed mitral valvotomy is more invasive and has no proven advantage over PBMV. Although variably defined, success rates of PBMV are 95% to 97%. Immediate and durable long-term improvements have been reported in mean left atrial pressure, mean diastolic valve gradient and mean pulmonary capillary wedge pressure.

Complications of PBMV are rare but include atrial perforation, cardiac tamponade, arrhythmias, emboli, mitral regurgitation, hypotension and maternal death. Women with poor response to medical management who have heavily calcified, noncompliant valves may not be good candidates. Women who develop severe mitral regurgitation with ventricular dysfunction as a complication of PBMV may need open cardiac surgery during pregnancy.

Aortic Stenosis

Experience with balloon aortic valvuloplasty in pregnancy is limited, and the effects are not permanent. Even in nonpregnant patients, balloon aortic valvuloplasty is considered a bridge to valve replacement.

Pregnant patients in need of aortic valve repair should be considered for balloon aortic valvuloplasty as a temporizing measure until definitive surgery can be performed, or they should be delivered early by cesarean section if the risk of further maternal deterioration outweighs the risks of prematurity for the newborn.

Transcatheter aortic valve replacement (TAVR) is an approved procedure for patients with severe, symptomatic aortic stenosis who are considered high risk for open surgery and in whom balloon valvuloplasty is predicted to result in severe valvular incompetence. The use of TAVR in pregnancy is a promising alternative to surgery, but experience is quite limited.

Four recent case reports of TAVR in pregnancy describe the successful performance of the procedure and promising results for both native and bioprosthetic stenotic aortic valves. However, no data are available on long-term outcomes.

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Learn more about the Obstetrics Program at Mass General

Refer a patient to the Department of Obstetrics and Gynecology