Valvular Heart Disease in Pregnancy€¦ · Management of Lec Sided Regurgitant Lesions in...
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Kathryn J. Lindley, MD, FACC Assistant Professor of Medicine Assistant Professor of Obstetrics and Gynecology Washington University in St. Louis Valvular Heart Disease in Pregnancy
Transcript of Valvular Heart Disease in Pregnancy€¦ · Management of Lec Sided Regurgitant Lesions in...
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!!
