Native Valve Stenosis in Pregnancy

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Dima Nimri, M.D. [2]

Valvular Heart Disease in Pregnancy Microchapters
Cardiac disease in pregnancy
2014 AHA/ACC guideline for the management of patients with valvular heart disease
Native Valve Stenosis in Pregnancy
Native Valve Regurgitation in Pregnancy
Prosthetic Valves in Pregnancy

Native Valve Stenosis in Pregnancy

Recommendations

Class I

"1. All patients with suspected valve stenosis should undergo a clinical evaluation and TTE before pregnancy.(Level of Evidence: C)"

"2. All patients with severe valve stenosis (stages C and D) should undergo prepregnancy counseling by a cardiologist with expertise in managing patients with VHD during pregnancy.(Level of Evidence: C)"

"3. All patients referred for a valve operation before pregnancy should receive prepregnancy counseling by a cardiologist with expertise in managing patients with VHD during pregnancy about the risks and benefits of all options for operative interventions, including mechanical prosthesis, bioprosthesis, and valve repair.(Level of Evidence: C)"

"4. Pregnant patients with severe valve stenosis (stages C and D) should be monitored in a tertiary care center with a dedicated Heart Valve Team of cardiologists, surgeons, anesthesiologists, and obstetricians with expertise in the management of high-risk cardiac patients during pregnancy.(Level of Evidence: C)"

Diagnosis and Follow-up

Class IIa

"1. Exercise testing is reasonable in asymptomatic patients with severe AS (aortic velocity ‡4.0 m per second or mean pressure gradient ‡40 mm Hg, stage C) before pregnancy. (Level of Evidence: C)"

Medical Therapy

Class I

"1. Anticoagulation should be given to pregnant patients with MS and AF unless contraindicated.(Level of Evidence: C)"

Class IIa

"1. Use of beta blockers as required for rate control is reasonable for pregnant patients with MS in the absence of contraindica-tion if tolerated. (Level of Evidence: C)"

Class IIb

"1. Use of diuretics may be reasonable for pregnant patients with MS and HF symptoms (stage D). (Level of Evidence: C)"

Class III (Harm)

"1. ACE inhibitors and ARBs should not be given to pregnant patients with valve stenosis (Level of Evidence: B)"

Intervention

Class I

"1. Valve intervention is recommended before pregnancy for symptomatic patients with severe AS (aortic velocity ≥4.0 m per second or mean pressure gradient ≥40 mm Hg, stage D). (Level of Evidence: C)"

"2. Valve intervention is recommended before pregnancy for symptomatic patients with severe MS (mitral valve area ≤1.5 cm2, stage D)(Level of Evidence: C)"

"3. Percutaneous mitral balloon commissurotomy is recommended before pregnancy for asymptomatic patients with severe MS (mitral valve area ≤1.5 cm2, stage C) who have valve morphology favorable for percutaneous mitral balloon commissurotomy.(Level of Evidence: C)"

Class IIa

"1. Valve intervention is reasonable before pregnancy for asymp- tomatic patients with severe AS (aortic velocity ≥ 4.0 m per second or mean pressure gradient ≥ 40 mm Hg, stage C). (Level of Evidence: C)"

"2. Percutaneous mitral balloon commissurotomy is reasonable for pregnant patients with severe MS (mitral valve area ≤1.5 cm2, stage D) with valve morphology favorable for percutaneous mitral balloon commissurotomy who remain symptomatic with NYHA class III to IV HF symptoms despite medical therapy (Level of Evidence: B)"

"3. Valve intervention is reasonable for pregnant patients with severe MS (mitral valve area ≤1.5 cm2, stage D) and valve morphology not favorable for percutaneous mitral balloon commissurotomy only if there are refractory NYHA class IV HF symptoms. (Level of Evidence: C)"

"4. Valve intervention is reasonable for pregnant patients with se- vere AS (mean pressure gradient ≥40 mm Hg, stage D) only if there is hemodynamic deterioration or NYHA class III to IV HF symptoms (Level of Evidence: B)"

Class III (Harm)

"1. Valve operation should not be performed in pregnant patients with valve stenosis in the absence of severe HF symptoms. (Level of Evidence: C)"