Management of valvular heart disease in the pregnant patient

ABSTRACT

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.

KEYWORDS:

• Pregnancy
• valvular disease
• anticoagulation
• physiological changes
• preconception
• maternal risk

Article highlights

• Physiological changes of pregnancy can lead to decompensation of known or silent valvular heart disease.

• Valvular heart disease and specifically left-sided valvular disease pose the highest preconception risk.

• Preconception risk stratification should be assessed in women of childbearing age using the modified WHO classification.

• Severe symptomatic mitral and aortic stenosis are contraindications to pregnancy and should be repaired prior to pregnancy.

• Postconception management of severe symptomatic mitral and aortic stenosis is challenging and should be managed medically or with salvage balloon valvuloplasty/valve repair in refractory cases.

• Regurgitation lesions are better tolerated during pregnancy and only require intervention in the presence of symptoms AND left ventricular dysfunction.

• Mechanical and bioprosthetic valves are well tolerated during pregnancy in the absence of lesions. Mechanical valves are more durable than bioprosthetic valves but are associated with higher risk of valve thrombosis and bleeding.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose. 

Additional information

Funding

This paper was not funded.