February 19, 2018
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Mitral stenosis elevates risk for HF during pregnancy

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Women with symptomatic moderate or severe rheumatic mitral stenosis before pregnancy had an increased risk for complications during pregnancy, including HF, according to a study published in the Go Red for Women’s Issue of Circulation.

Iris M. van Hagen, MD, PhD, cardiology resident at Erasmus Medical Center in Rotterdam, the Netherlands, and colleagues analyzed data from 390 women (mean age, 29 years; 75.4% from emerging countries) from the ROPAC registry with rheumatic mitral valve disease. Those with a bioprosthetic or mechanical valve were excluded.

Prepregnancy, postpartum data

Women had a term date up to October 2013, and follow-up was conducted until April 2014. Data including prepregnancy patient characteristics, outcomes, maternal cardiac events and fetal adverse outcomes were reviewed less than a week after delivery and at 6 months. Six-month data were available for 53% of women.

Mitral valve stenosis severity was defined as mild (valve area > 1.5 cm2 or mean gradient < 6 mm Hg), moderate (valve area between 1 cm2 and 1.5 cm2 or mean gradient between 6 mm Hg to 12 mm Hg) or severe (valve area < 1 cm2 or mean gradient > 12 mm Hg). Quantitative measurements and visual inspection were used to determine mitral valve regurgitation quantification.

And about one-quarter of women were pregnant for the first time (26.4%).

Mitral stenosis with or without mitral regurgitation was seen in 273 women, and 117 women only had mitral regurgitation. Most women had moderate mitral stenosis (39.2%), followed by mild (20.9%) and severe (19.8%). Severity was unknown in 20.1% of women.

One woman with severe mitral stenosis died during pregnancy. Hospital admission was required in 23.1% of women with mitral stenosis during pregnancy, mainly due to HF. Regardless of mitral regurgitation status, HF was diagnosed in 15.8% of women with mild mitral stenosis, 31.8% with moderate stenosis and 48.1% with severe stenosis (P = .001). HF was also seen in 23.1% of women with moderate or severe mitral regurgitation.

Interventions were performed in 5.9% of women with mitral stenosis, including surgical valve replacement (n = 2) and percutaneous balloon mitral commissurotomy (n = 14).

Independent predictors

NYHA class II or greater in women with mitral stenosis before pregnancy was an independent predictor of maternal cardiac events. Severe mitral stenosis was linked to adverse fetal outcomes.

In women with 6-month postpartum data, three women died, including one with moderate mitral stenosis, one with severe mitral stenosis and one with moderate to severe mitral regurgitation.

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Athena Poppas

“Mortality and cardiac deterioration in this cohort could have been reduced by appropriate prepregnancy assessment and intervention, as suggested by the guidelines,” van Hagen and colleagues wrote. “A delay in patients seeking help is often the main contributing factor to maternal cardiovascular death in emerging countries, which may contribute to the previously described high maternal and fetal mortality in sub-Saharan countries. Hence, adequate counseling of adolescents and young women with rheumatic heart disease about the risks of pregnancy is of utmost importance to convince them to see a cardiologist before getting pregnant. There seems to be a real task here, and this societal issue might be political support.”

“Rheumatic fever and RHD thrive in squalid conditions and in regions with poor public health systems,” Katherine A. French, MD, cardiologist and director of the Women’s Cardiac Center at Lifespan Cardiovascular Institute in East Providence, Rhode Island, and Athena Poppas, MD, FACC, FASE, director of the Lifespan Cardiovascular Institute, wrote in a related editorial. “Prevention is cheap, readily available and cost-effective. Accurate and contemporary data emerging from large registries such as the ROPAC registry are imperative for securing political and financial commitment at the global and local levels with the goal of eradicating RHD.” – by Darlene Dobkowski

Disclosures: The EURObservational Research Programme has been supported by Abbott Vascular International, The Alliance Daiichi Sankyo Europe GmbH and Eli Lilly and Company, Amgen Cardiovascular, AstraZeneca, Bayer, Boehringer Ingelheim, Boston Scientific, The Bristol-Myers Squibb and Pfizer Alliance, Edwards, Gedeon Richter, Menarini International, Merck Sharp and Dohme-Merck and Company, Novartis Pharma AG, ResMed, Sanofi and Servier. Van Hagen, French and Poppas report no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.