Certain women with bioprosthetic heart valves were more likely to have devices deteriorate by the time they got pregnant, opening the door to increased risk of maternal and fetal events, a retrospective study found.
At the first antenatal visit, structural valve dysfunction (SVD) of a bioprosthetic valve was already present in 27% of 125 pregnancies at two specialist centers in Canada. In turn, maternal cardiac events were more frequent in women with SVD compared with those with normally functioning bioprosthetic valves (26% vs 8%, P=0.005), reported Barbara Wichert-Schmitt, MD, of Kepler University Hospital Linz in Austria, and colleagues.
Regarding valve position, device dysfunction was disproportionately more common in pregnant women with left-sided versus right-sided bioprosthetic valves (44% vs 21%, P=0.009), they stated in the Journal of the American College of Cardiology.
Over 6-month follow-up postpartum, cardiac events were also associated with left-sided SVD but not right-sided SVD, and fetal events reached an especially high 60% in women with left-sided bioprosthetic valves with SVD, the authors reported.
“This is the first study to focus on SVD in young women with BPVs [bioprosthetic heart valves] and its impact on pregnancy outcomes,” Wichert-Schmitt’s group wrote.
“The high rates of SVD in this population of young women with BPVs highlight the need for ongoing close surveillance in such women. Furthermore, for women with SVD considering pregnancy, preconception counseling is important so that they understand the risks of pregnancy and can make informed pregnancy decisions,” they urged.
They identified left-sided aortic and/or mitral SVD, maternal age >35, and a composite variable of “high-risk” features as independent predictors of maternal cardiac events (defined as cardiac death or arrest, sustained arrhythmia, heart failure, thromboembolism, and stroke).
The good news was the finding that of the 20 pregnancies in women with the Ross operation, only one had dysfunction of the pulmonary autograft in the aortic position 18 years after surgery, suggesting that this may be a good valve choice for some women at expert centers, according to Wichert-Schmitt and colleagues.
These data are informative for women and clinicians, helping them choose a prosthetic valve and manage pregnancy, commented Deirdre Mattina, MD, Cleveland Clinic Beachwood Family Health and Surgery Center, and colleagues.
“Ultimately, multidisciplinary management through cardio-obstetric clinics or tertiary referral centers with experience in high-risk pregnancies should be considered for patients with left-sided BPV SVD,” Mattina’s group wrote in an accompanying editorial.
“Admittedly, we have no current data to show that pregnancy outcomes are improved by management through cardio-obstetric clinics,” the group said. “However, preconception counseling, access to timely prenatal care, and fourth trimester (postpartum) care have been recognized as critical components of pregnancy outcomes, and these resources may not be readily available or feasible for general community cardiologists.”
The present analysis included 101 women with 125 pregnancies who had received bioprosthetic valves prior to pregnancy and were enrolled prospectively into the CARPREG study.
Participants received obstetrical and cardiac care at two large tertiary care hospitals in Toronto and Vancouver in 1994-2019 and were followed until 6 months postpartum. Women with miscarriages at less than 20 weeks’ gestation or termination of pregnancy were excluded.
Study participants averaged age 31 and were pregnant a mean 6 years after valve implantation. Nine in 10 had a congenital heart disease (over half of them complex congenital heart disease such as Tetralogy of Fallot), and the remainder had rheumatic heart disease.
Pregnancies were in people with a right-sided bioprosthetic valve in 73% of cases, and a left-sided one in 27%. Wichert-Schmitt’s group cautioned that there were few women with tricuspid bioprosthetic valves in the study, however, leaving mostly people with pulmonary valves representing the cohort with right-sided devices.
The retrospective study also had a relatively high percentage of SVD in women left-sided bioprosthetic valves, which may not be generalizable to non-specialist centers.
“It is unclear whether the presence or absence of aspirin therapy contributed to underlying left-sided SVD at baseline, but there was no difference in aspirin use among those patients with or without cardiac events and fetal events in the study period. Notably, there were no fetal intracerebral hemorrhage events in any pregnancy in the cohort,” Mattina and colleagues noted.
They advocated for more data in racially diverse populations and information on percutaneous treatment during pregnancy and medical management of SVD beyond 6 months postpartum.
The study was supported by a grant from the Allan E. Tiffin Trust.
Wichert-Schmitt and co-authors disclosed no relationships with industry.
Mattina disclosed a relationship with Zoll Medical.