1. A pregnant women with
valvular heart disease
Bernard Iung, MD
Bichat Hospital, Paris, France

2. Case History
• 28 year-old woman originating from Northern Africa
• Known but non investigated valvular heart disease
• Uneventful pregnancy 7 years ago
• NYHA class II dyspnea without medical therapy
• Consultation at 8th week of her second pregnancy in
2008
• Stable NYHA class II dyspnea
• Holosystolic murmur 3/6 at the apex
• No signs of congestive heart failure
• Blood pressure 104/60 mmHg

3. ECG

4. Echocardiography: apical 4-chamber view
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5. Echocardiography: colour Doppler
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6. Echocardiography: Summary
• Mitral valve area 2.2 cm², mean gradient 7 mmHg
• Mitral regurgitation
− Vena contracta 7 mm
− Effective regurgitant orifice area 0.41 cm²
− Regurgitant volume 65 ml
• Mild aortic regurgitation
• Systolic pulmonary artery pressure 34 mmHg
• Left ventricle 47 / 29 mm, ejection fraction 69%
• Left atrium 68 ml

7. What is your conclusion?
1. Pure severe organic mitral regurgitation
2. Mixed mitral valve disease with
predominant regurgitation
3. Mixed mitral valve disease with
predominant stenosis
4. Functional mitral regurgitation

8. What is your conclusion?
1. Pure severe organic mitral regurgitation
2. Mixed mitral valve disease with
predominant regurgitation
3. Mixed mitral valve disease with
predominant stenosis
4. Functional mitral regurgitation

9. Analysis of valvular disease
• Mitral valve disease is of rheumatic origin:
− restrictive motion of posterior leaflet, but thickened valve and
normal LV rule out functional MR
− valve anatomy and patient origin are consistent with
rheumatic mitral valve disease
• Mitral regurgitation is severe
• Mitral stenosis is mild
• There are no consequences on left ventricle
and pulmonary artery pressures

10. Analysis of valvular disease
• Mitral regurgitation is severe, as attested by the
concordance between different criteria
− Vena contracta > 7 mm
− ERO ≥ 0.40 cm², regurgitant volume ≥ 60 ml
− Extension of regurgitant jet in left atrium is not reliable
• Mitral stenosis is mild (valve area > 2 cm²)
− Increased gradient is due to increased transmitral flow
(regurgitation + pregnancy)
− Planimetry is the reference method for assessing MS severity
Echocardiographic assessment of valve stenosis: EAE/ASE recommendations for clinical
practice. Eur J Echocardiogr 2009;10:1-25
EAE recommendations for the assessment of valvular regurgitation. Part 2: mitral and
tricuspid regurgitation (native valve disease). Eur J Echocardiogr 2010;11:307-32.
Guidelines on the management of valvular heart disease (version 2012).
Eur Heart J 2012;33:2451-496.

11. What do you advise?
1. Consider termination of pregnancy
2. Start medical therapy
3. Indication of mitral valve repair
4. Indication of mitral valve replacement
5. No treatment and close follow-up

12. What do you advise?
1. Consider termination of pregnancy
2. Start medical therapy
3. Indication of mitral valve repair
4. Indication of mitral valve replacement
5. No treatment and close follow-up

13. Tolerance of haemodynamic changes during
pregnancy
• The 30-50% increase in cardiac
output during pregnancy may
decompensate valvular disease
• Regurgitations are well tolerated
due to tachycardia and decreased
systemic vascular resistance
(Thorne Heart 2004;90:450-6)
• The risk of decompensation is higher for severe
stenosis
ESC Guidelines on the management of cardiovascular diseases
during pregnancy. Eur Heart J 2011;32:3147-97.

14. Rationale for follow-up without specific
treatment
• Pregnancy is well tolerated in women with
regurgitant valvular disease, even if severe,
when LV function is preserved
• Cardiac surgery carries a high fetal risk
when performed during pregnancy
• Medical therapy is not required due to the
good tolerance and potential harm of drug
therapy
– Diuretics impair uteroplacental perfusion
– ACE inhibitors are contraindicated throughout pregnancy

16. Follow-up during pregnancy
• Stable NYHA class II without medical therapy
• No change in clinical examination
• Echocardiographic follow-up:
Term (weeks)
8
NYHA class
II
Mean gradient (mmHg)
LV (mm)
Systolic PAP (mmHg)
18
32
36
II
II
II
7
10
10
9
47/29
52/30
53/31
52/30
34
40
45
40

17. How to plan delivery?
1. Vaginal delivery after inducement of labour
at 37-38 weeks
2. Caesarean section at 37-38 weeks
3. Vaginal delivery with close haemodynamic
monitoring
4. Vaginal delivery at normal term

18. How to plan delivery?
1. Vaginal delivery after inducement of labour
at 37-38 weeks
2. Caesarean section at 37-38 weeks
3. Vaginal delivery with close haemodynamic
monitoring
4. Vaginal delivery at normal term

19. Delivery and heart diseases
• Labour and delivery represent an additional
haemodynamic stress
• However, vaginal delivery is safe in most heart
diseases provided their functional tolerance has
been good during pregnancy (NYHA class I-II)
• Cesarean section avoids the stress caused by labour
but is associated with other complications
(thromboembolism, bleeding, anaesthesia…)

20. Delivery and heart diseases
• Cesarean section is recommended for:
–
–
–
–
Pre-term labour on oral anticoagulants
Marfan and other aortic aneurysms
Aortic dissection
Severe aortic stenosis
• Induction of labour requires favourable local
conditions and is not indicated here
Favour spontaneous onset of labour and
vaginal delivery in most cases of stable heart
disease
ESC Guidelines on the management of cardiovascular diseases
during pregnancy. Eur Heart J 2011;32:3147-97.

21. Pregnancy outcome
• Multidisciplinary decision of vaginal delivery
• Spontaneous labour
• Vaginal delivery at 40 weeks + 2 days under epidural
analgesia
• Good haemodynamic tolerance
• Healthy newborn
− 3300 g
− 51 cm
− Apgar 10/10

22. Take-Home messages
• Comprehensive evaluation of valvular disease is
required in young women contemplating pregnancy
• Regurgitant valve disease, even severe, is well
tolerated during pregnancy, provided left
ventricular function is preserved
• Cardiac surgery should be avoided during
pregnancy because of its fetal risk
• Multidisciplinary management is needed during
pregnancy, in particular for planning delivery

23. Join the ESC Working Group
on Valvular Heart Disease
and take part in its
activities !
Membership is FREE!