valvular heart disease in pregnancy€¦ · management of lec sided regurgitant lesions in...
TRANSCRIPT
KathrynJ.Lindley,MD,FACC
AssistantProfessorofMedicineAssistantProfessorofObstetricsandGynecology
WashingtonUniversityinSt.Louis
ValvularHeartDiseaseinPregnancy
NoFinancialDisclosures
ObjecHves
• DiscusscommonvalvularheartcondiHonsinwomenofchildbearingage
• IdenHfyhighriskvalvularheartcondiHonsduringpregnancy
• DiscussmanagementofcommonvalvularheartcondiHonsduringpregnancy
ValvesandPregnancy
• IngeneralLsidedhigherriskthanRsided
• Nomedicalcure– Cantemporarilymanage
• PerACC/AHAguidelines,endocardiHsprophylaxisislikelyunnecessary
RiskStraHficaHon
CARPREGII ZAHARA
WHOCLASSINohigherriskofmaternaldeaththangeneral
populaHon
WHOCLASSIISmallincreasedriskofmaternaldeath/
complicaHons
WHOCLASSII-III(MaybeclassifiedasclassIIorIIIdependingon
individual)
WHOCLASSIIISignificantriskofmaternaldeath/complicaHons.RequiresexpertCV
andOBcare
WHOCLASSIVPregnancycontraindicated;veryhighriskofmaternaldeathor
complicaHons
Uncomplicated,smallormildlesionsincludingpulmonarystenosis,VSD,
PDAandMVPwithnomorethantrivialMR
Un-operatedASD MildLVimpairment Mechanicalvalve PAHofanycause
SuccessfullyrepairedsimplelesionsincludingosHumsecundumASD,VSD,PDA,
TAPVD
RepairedTetralogyoffallot
HypertrophicCM SystemicRV(ieL-TGA,D-TGAs/pMustardorSenning)
SevereLVdysfuncHon(EF<30%orNYHA3-4)
IsolatedPVCsandPACs Mostarrhythmias Marfan’swithoutaorHcdilaHon
PostFontanoperaHon PreviousperipartumcardiomyopathywithanyresidualimpairmentofLVfuncHon
CoarctaHonoftheaortawithoutsignificantgradientoraneurysm
(repairedorunrepaired)
Hearttransplant CyanoHcheartdisease SeverelecheartobstrucHonAVA<1cm^2orpeakgradient>50mmHg
MVA<1.5cm^2LongQTsyndrome NaHveorHssuevalveheart
diseasenotconsideredWHOclass4
Othercomplexcongenitalheartrepair
MarfansyndromewithaorHcdilaHon>45mm
BicuspidaorHcvalvewithoutaorHcdilataHon
AorHcdilaHonwithnoknownfibrinogendisease
BicuspidAVwithaorHcdilaHon>50mm
CoarctaHonoftheaortawithresidualgradientoraneurysm(repairedorunrepaired)MarfanSyndromewithaorHcrootdilaHon<45mmors/paorHcreplacementBicuspidAVwithaorHcrootdilaHon45-50mm
StenoHcLesions
• Generallypoorlytolerated• IncreasedCOandHRwill
increasepressuregradient
• Pre-loaddependentlesions• **ValveareawillNOT
changeover9months…butpressuregradientWILL!**
RegurgitantLesions• Generallywell-tolerated
– Volumeoverloadinglesions
– Pregnancyisalreadyavolumeoverloadedstate– ReducedSVRofpregnancyreducesregurgitaHonduringpregnancy
• Acerload-responsivelesions• Highestrisk:WorseningregurgitaHon/reversibleheartfailurepost-partumorthirdtrimester
LecSidedObstrucHveLesions
ValvularAorHcStenosis
• BicuspidValve>>>RheumaHc
• Severe:– Peakgradient>64mmHg
• >50mmHgperriskstraHficaHontools
• ConsiderexercisetesHngintheasymptomaHcpaHent
BicuspidAV
• Mostcommoncongenitalheartdefect• IncreasedriskforcoarctaHonandaorHcaneurysms– MRAforallpaHents– Aortopathymorelikelytodictateseverityofrisk
• RiskforbothASandAI• Surprisinglylimiteddata…likelyindicateslowrisk
ManagementofASinPregnancy• LikelyComplicaHons:
– ReversibleCHF>Arrhythmia
• SymptomManagement– Beta-blockade(reduceflow)– DiureHcsasneeded– Balloonvalvuloplastyinselectcasesifnecessary
MedicaHonSafety• Beta-Blockers
– ExcepHon:AvoidATENOLOL
– Preferred:Propranolol,Metoprolol,Nadolol,Labetalol
• CalciumChannelBlockers– DilHazem,Nifedipine,Verapamil
• DiureHcs-Furosemide
• AnHarrhythmics– AvoidAMIODARONEifpossible
– Sotalol,Flecainide,Quinidine,Procainamide
• Digoxin• Adenosine• Plavix• Aspirin–81mg
MitralStenosis• EHology:
– CongenitalMS–ParachuteMV/ShoneComplex– RheumaHcHeartDisease
• SevereMSisveryhighrisklesion• “Severe”:
– MVA<1.5byriskstraHficaHontools
– Meangradient>10mmHg
• Flow-dependent:gradientsWILLincreasewithpregnancy
• ExercisetesHngcanbeuseful
ShoneComplex
• SerialLsidedobstrucHveLesions–atleast3– ParachuteMV
– Supravalvularmitralmembrane
– SubaorHcStenosis– BicuspidAV– CoarctaHon
RheumaHcHeartDisease
• Decreasinginincidence– Immigrants/Refugees
• CalcificaHonofmitralleafletHpsandchordae
• MitralstenosisandregurgitaHon
ComplicaHonsofMSinPregnancy
• ReversibleCHF– IncreasedMVgradients!Pulmonaryedema
• Atrialarrhythmias– LAenlargement!atrialfibrillaHon,SVT
• Thromboembolism– LAenlargement/afib!CVA
ManagementofMSinPregnancy• Frequentclinicalandechofollowup• ExerciserestricHonifsymptomaHc• Beta-blockade(reduceflow)!reducegradients
• DiureHcsasneeded• TherapeuHcAnHcoagulaHon
– IfAF,LAthrombus,priorCVA,spontaneousechocontrastinLA,orLAVI>40ml/m2
• Balloonvalvuloplastyinselectcasesifnecessary– NYHAIII-IVpaHentswithfavorableanatomy
– Secondtrimester
Delivery:HemodynamicsandPosiHoning
• CardiacOutputIncreases– 30%duringfirststage– Upto80%immediatelypost-partum
• 300-500cc“autotransfusion”witheachcontracHon
• BloodpressureincreaseswitheachcontracHon
• Post-partumincreaseinpre-loadduetoreliefofIVCobstrucHon
DeliverywithLecSidedObstrucHveLesions
• Pre-loadDependent– *ALSOriskforpulmonaryedema
• Maintaineuvolemia• Earlyepidural
– SlowHtraHon,nobolus– Avoidspinalanesthesia
• LaborinleclateraldecubitusposiHon• Assistedsecondstagevs.cesareandelivery
Post-Partum=THEWEEDS!
PostpartumManagement• Gradualreturntobaselinehemodynamics
– 6monthsforcompletenormalizaHon– Mostchangesinfirst2weeks
• ReducedmyocardialcontracHlity• SignificantmobilizaHonoffluid24-72hoursacerdelivery– POST-PARTUMISMOSTCOMMONTIMEFORCARDIACCOMPLICATIONS
– SickestpaHentsshouldbemonitoredinICU48-72hours
• RuleofThumb–Neverletaparturientleavethehospitalunlessshecanlieflat
LecSidedRegurgitantLesions
AorHcRegurgitaHon
• EHology:– BicuspidAV– AorHcrootdilataHon
• Marfan,Loeys-Dietz,Ehler’sDanlos
– PriorendocardiHs• LVVolumeOverloadand
DilaHon
• Generallywell-tolerated
MitralRegurgitaHon
• EHology:– MitralValveProlapse
– Ischemic
– FuncHonal– ClecMitralValve
– PriorendocardiHs• Generallywell-tolerated• FourchamberdilataHonof
pregnancymaytransientlyworsenMR
ManagementofLecSidedRegurgitantLesionsinPregnancy
• LikelyComplicaHons:– ReversibleCHF>>Arrhythmia
• SymptomManagement– AcerloadReducHon(hydralazine,nitrates)– DiureHcsasneeded
DeliverywithLecSidedRegurgitantLesions
• Acerloadresponsive• Riskforpulmonaryedema
– Maintaineuvolemiatoslightlydry
– MaintainacerloadreducHon
• NocontraindicaHontovaginaldeliveryunlessacutedecompensatedCHF
• ANTICIPATEVOLUMEOVERLOAD24-48hourspostpartum
PulmonicValve
ManagementofPSinPregnancy
• Verywelltoleratedevenifsevere(peakgradient>60mmHg)– ParHcularlyifasymptomaHcandnormalRV
• ***Pulmonarystenosis≠PulmonaryHTN***• MostcommoncomplicaHons
– ReversibleRVfailure,arrhythmias
• SymptomManagement– PRNdiureHcs,beta-blockade
• Balloonvalvuloplastyunlikelytobeneeded
DeliveryinSeverePS
• Pre-loadDependent• MaintainadequatehydraHon• Earlyepidural• LaborinleclateraldecubitusposiHon• Assistedsecondstage• Mayneedgentlediuresis24-48hourspostpartum
PulmonicRegurgitaHon
• EHology:– TetralogyofFallot– TetralogyofFallot– TetralogyofFallot– PriorvalvotomyforPS
• RVVolumeOverloadandDilaHon
• Generallywell-tolerated–caneventuallyleadtoRVfailure
ManagementofPIinPregnancy
• LikelyComplicaHons:– Generallywell-tolerated– Pre-pregnancyNYHAandRVfuncHoncanhelpgaugerisk– ReversibleRightsidedCHF,Arrhythmia
• SymptomManagement– DiureHcsasneeded– Digoxin/inotropesifsevereRVdysfuncHon
DeliveryinSeverePI
• Epidural• NocontraindicaHontovaginaldeliveryunlessacutedecompensatedCHF
• Mayneedgentlediuresis24-48hourspostpartum
• IfsevereRVdysfuncHon,considertemporarydobutamineforRVsupport
ProstheHcValvesinPregnancy
• BioprostheHc• Mechanical• RossProcedure• ValvularRepairs• Priorvalvuloplasty/valvotomy
BioprostheHcValves
• Last10-20years– PaHentswilllikelyneedanothervalveintervenHoninlifeHme
– ?AcceleratedvalvedegeneraHonwithpregnancy– PronetostenosisandregurgitaHon
• ASAforthrombusprevenHon
• NoneedforIEprophylaxiswithdelivery• LowriskforcomplicaHonwithpregnancy/delivery
MechanicalValvesinPregnancy
MechanicalValvesinPregnancy
• WHOClassIII• HighriskofbleedingANDthrombosis
– Pregnancyandpost-partumareMARKEDLYhypercoagulableperiods
• TeratogenicriskofWarfarin
• ConcernsaboutinadequacyofLMWH
• Thrombosisrisk:TV>MV>PV>AV– IncreasedwithventriculardysfuncHon,afib
MechanicalValves
Steinberg ZL et al. JACC 2017;9(22):2681-91.
MechanicalValves
Steinberg ZL et al. JACC 2017;9(22):2681-91.
AnH-XaMonitoring
• Typicallyfollowpeaklevelsonceweekly– IncreasedvolumeofdistribuHon
– Increasingweight– Increasedrenalclearance
• Lackofevidenceregarding:– Peakvstroughmonitoring
– IdealtherapeuHclevels– Idealmeasurementintervals
AnHcoagulaHonRecommendaHons
• ConHnuewarfarinthroughoutpregnancyifmaintenancedose≤5mg/day
• AlternaHvelysubsHtuteweightbasedlovenoxweeks6-12– WeeklypeakanH-Xalevelmonitoring
• Goal1.0-1.2– ?WeeklytroughanH-Xalevel>0.6
DeliverywithMechanicalValves• Planneddelivery• SwitchfromwarfarintoIVheparinorLMWHat36weeks
– UFH–aPTT>2xcontrol– AnH-Xalevel1.0-1.2
• SwitchfromLMWHtoUFH36hourspriortodelivery*– Holdheparin4hourspriortodelivery– Resume6-12hoursacerdelivery
– Resumewarfarineveningofdelivery
– Aspirinduringlabor/delivery
• Ifdeliveryoccurswhileonwarfarin!cesarean– Warfarincrossesplacenta!intracranialhemorrhage
ContracepHon
• WomenwithheartdiseaseshouldreceivecounselingoncontracepHon– PLANNINGpregnancyforlower-riskpaHents– PREVENTINGpregnancyforhighest-riskpaHents
• Manywomendonotrecalldiscussingwiththeircardiologist
• OthersrecallinaccurateinformaHon
Vigl, M., et al. (2010). "Contraception in women with congenital heart disease." Am J Cardiol 106(9): 1317-1321.
Kovacs, A. H., et al. (2008). "Pregnancy and contraception in congenital heart disease: what women are not told." J Am Coll Cardiol 52(7): 577-578.
ContracepHon
• Isitsafe?• Doesitwork?
SafetyConcerns
• Combinedhormonalmethods– Pill,patch,andring– Associatedwithincreasedriskofthromboembolism
– AbsoluteorrelaHvecontraindicaHoninsomecardiovascularcondiHons
Thorne, S., et al. (2006). "Risks of contraception and pregnancy in heart disease." Heart 92(10): 1520-1525.
WHOCOCRisk:ContraindicaHons• PHTNorFontanPalliaHon• AtrialFibrillaHon• MechanicalValves
• RtoLShunt• CoronaryorAorHcDiseases• PreviousThromboembolism
• LVDysfuncHon• Hypertension(relaHve)
Adapted from Thorne, S., et al. (2006). "Risks of contraception and pregnancy in heart disease." Heart 92(10): 1520-1525.
TiersofContracepHveEffecHveness
• I–FailureRate<1%– PermanentsterilizaHon– LongAcHngReversibleContracepHon(LARC)
• II–FailureRate6-12%– CombinedHormonalContracepHves– ProgesHnOnlyContracepHves
• III–FailureRate12-24%– Barriermethods– Withdrawal– FerHlityawarenessmethods
• None–85%pregnancyratewithin1year
LongAcHngReversibleContracepHon
• 3OpHons:– LevonorgestrelimpregnatedIUD
• Mirena,Skyla,Lile|a,Kyleena
– CopperIUD– Etonogestrelimpregnatedrod
• MoreeffecHvethantuballigaHon• Estrogen-free• Completelyreversible• FDAapprovedfor3to10years
RecommendaHons:ContracepHonforWomenwithHeartDisease
• MethodofcontracepHonassessedanddocumentedannually
• LongacHngreversiblecontracepHonshouldbepreferredmethodfor:– WHOClassIII-IV
– AllpaHentstakingpotenHallyteratogenicmedicaHons
ThankYou!!