158. Cardio-Obstetrics: Pregnancy and Valvular Heart Disease with Dr. Uri Elkayam

CardioNerds (Amit Goyal and Daniel Ambinder), Cardio-OB series co-chair and University of Texas Southwestern Cardiology Fellow, Dr. Sonia Shah, and episode FIT lead and UT Southwestern Cardiology Fellow Dr. Laurie Femnou discuss valvular heart disease in pregnancy with cardio-obstetrics expert Dr. Uri Elkayam, Professor of Medicine and OB Gyn at the University of Southern California.

In this pearl-packed episode, we discuss the diagnosis, acute management, and long-term considerations of valvular heart disease in pregnancy. Through a series of cases, we review the physiologic changes in pregnancy that make certain valvular lesions well-tolerated, while others are associated with a much higher risk of peripartum complications. We also discuss which patients to consider referring for valvular intervention, the ideal timing, and which valvular interventions are safest in the peripartum period. We promise, you won’t want to miss this clinically high-yield episode with Dr. Elkayam, the father of cardio-obstetrics and an absolute legend in the field!

Audio editing by CardioNerds Academy Intern, Adriana Mares.

Pearls • Notes • References • Guest Profiles • Production Team

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Pearls

Most women with severe valvular heart disease can be managed medically throughout pregnancy.Right sided valvular lesions are generally better tolerated than left-sides lesions, and regurgitant lesions are generally better tolerated than stenotic lesions. However, the context and etiology of the valve dysfunction must be taken into consideration. Severe tricuspid valve regurgitation, for example, can be associated with a failing right ventricle and undiagnosed pulmonary hypertension. Changes in BNP, severity of symptoms, and right ventricular systolic pressure (RVSP) assessed by echocardiography can be helpful in differentiating normal pregnancy-related symptoms from symptoms due to hemodynamically significant valvular lesions.Valvular interventions during pregnancy are safe when well-planned and performed by experienced operators, and they can significantly improve morbidity and mortality in women who remain symptomatic despite medical management.A multidisciplinary team-based approach is important when managing patients with valvular heart disease during pregnancy.

Quatables

“We do not need to perform prophylactic valvular intervention in women prior to pregnancy if they do not meet criteria for intervention otherwise. A patient with regurgitant lesion will tolerate pregnancy well, provided that they are not                candidates for surgery already.”

“Valvuloplasty during pregnancy is a great and effective procedure, but restenosis occurs. For women who desire future pregnancies, preconception evaluation is important to determine if valve intervention is indicated prior to conceiving.”

Show notes

What is the epidemiology of valvular heart disease in pregnancy?Cardiovascular conditions affect up to 4% of pregnancies, with valvular heart disease being the most common cardiac pathology encountered during pregnancy worldwide.In the developing world, rheumatic valve disease is still the most common etiology, with mitral valve most commonly affected, followed by the aortic valve.In the developed world, congenital aortic valve pathology is most common.

What are the hemodynamic effects of stenotic vs. regurgitant lesions during pregnancy?In normal pregnancy, there is a significant drop in systemic vascular resistance as early as 5 weeks gestational age. This drop leads to a transient decrease in perfusion to the kidneys, causing an increase in fluid retention and expansion of plasma volume. At the same time, there is an increase in heart rate which becomes more pronounced la...