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Challenges of the Transcatheter Approach to Mitral Valve Replacement in Women Contemplating Pregnancy

2020; Lippincott Williams & Wilkins; Volume: 13; Issue: 12 Linguagem: Inglês

10.1161/circinterventions.120.010227

1941-7632

Carole A. Warnes, Nadia R. Sutton,

Cardiac Structural Anomalies and Repair

HomeCirculation: Cardiovascular InterventionsVol. 13, No. 12Challenges of the Transcatheter Approach to Mitral Valve Replacement in Women Contemplating Pregnancy Free AccessEditorialPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyRedditDiggEmail Jump toFree AccessEditorialPDF/EPUBChallenges of the Transcatheter Approach to Mitral Valve Replacement in Women Contemplating Pregnancy Carole A. Warnes, MD Nadia R. SuttonMD, MPH Carole A. WarnesCarole A. Warnes Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN (C.A.W.). , Nadia R. SuttonNadia R. Sutton Correspondence to: Nadia R. Sutton, MD, MPH, Michigan Medicine, Frankel Cardiovascular Center CVC 2A192A/SPC 5869, 1500 E Medical Center Dr, Ann Arbor, MI 48109. Email E-mail Address: [email protected] https://orcid.org/0000-0002-0968-3085 Department of Internal Medicine, Division of Cardiovascular Medicine, Michigan Medicine, Ann Arbor (N.R.S.). Originally published2 Dec 2020https://doi.org/10.1161/CIRCINTERVENTIONS.120.010227Circulation: Cardiovascular Interventions. 2020;13:e010227This article is a commentary on the followingBalloon Versus Self-Expandable Valve for the Treatment of Bicuspid Aortic Valve StenosisSee Article by Fuchs et alYoung women with mitral valve disease face a dilemma when selecting a mitral prosthesis, and there is no perfect solution. In general, tissue prostheses are preferable in women who plan to become pregnant but degenerate more quickly in young patients necessitating a repeat intervention.1 Some may experience structural valve deterioration even before their first pregnancy, and at the time of a second operation, a mechanical valve is frequently advised.2 If they have babies before structural valve deterioration and die at reoperation, they leave children without a biological mother. The necessary anticoagulation that accompanies a mechanical valve poses significant maternal and fetal risks during the markedly prothrombotic state of pregnancy.3 Whichever anticoagulant strategy is selected, risks include maternal hemorrhage, valve thrombosis, miscarriage, and fetal demise.3 Registries report that women with mechanical heart valves have only a 58% chance of having an uncomplicated pregnancy with a live birth.3,4In the current issue of the journal, Fuchs et al5 report on a series of 12 women with degenerated mitral valve prostheses who underwent a transcatheter mitral valve replacement (TMVR) with either a valve-in-valve (ViV; 7 patients) or a valve-in-ring (ViR) procedure (5 patients) with the aim of facilitating a subsequent successful pregnancy, without the need for anticoagulation. Patients were deemed high risk with modest pulmonary hypertension and severe right ventricular dysfunction in 4.Although the absolute number of patients in the series was small, this represents the largest series to date of women undergoing TMVR with an expressed desire for subsequent pregnancy. Because large TMVR registries do not collect information on subsequent pregnancies and their outcomes, this study is the only available data on this population of patients.Although this series included women undergoing both ViV and ViR procedures, these are procedures with features that differ (eg, position of valve relative to the annuloplasty ring) that could impact thrombotic risk and the need for a second valve at the time of the procedure or subsequent surgery. Similar to prior reports, procedural success was better in women who had a ViV versus those who underwent ViR.6 The anticoagulation/antiplatelet strategy utilized was 3 months of warfarin plus aspirin, followed by aspirin alone. No deaths or strokes occurred within the first 30 days. One symptomatic valve thrombosis occurred in the ViR group in a patient on a vitamin K antagonist in the setting of uncertain compliance with oral anticoagulation. Subclinical leaflet thrombosis occurred in 3 women during the follow-up period (median, 43 months). Three women had surgical rereplacement with a biological prosthesis between 6 months and 4 years post-intervention. Four women had 6 subsequent pregnancies, 1 complicated by valve thrombosis, 1 by peripartum hemorrhage, and all delivered prematurely.TMVR is emerging as a possible alternative to surgery in high-risk patients with degenerated mitral prostheses, and early outcomes are encouraging, although there are little data beyond 1 year.7 Results are less favorable with failed annuloplasty rings.6 Remaining concerns include increased gradients at 30 days versus early postprocedure and the development of valve thrombosis.8 Studies recommend 3 to 6 months of warfarin with consideration of long-term anticoagulation after discussion of risks and benefits.8 Given the high incidence of subsequent surgical valve replacement and 4 valve thromboses in follow-up, women treated with this strategy require close surveillance, particularly after a ViR procedure. Indeed, they may be more prone to requiring a near-term reoperation as a result of the original small ring or valve size, though may still elect for TMVR if there is the potential to complete a pregnancy without requiring anticoagulation.Mitral stenosis is usually well tolerated in pregnancy as long as patients are appropriately selected and managed carefully. Intervention is seldom required with β-blockers being the mainstay of therapy to slow the heart rate and prolong diastolic filling time. Intervention is recommended before pregnancy with native valve stenosis and valve area <1 cm2 and considered if valve area is 50 mm Hg despite medical therapy. For stenotic mitral tissue prostheses, experience suggests the same approaches apply.In this series, however, patients were more complex, and while 7 of 12 had dominant mitral stenosis with a mean gradient of 12 mm Hg, 4 had combined stenosis and regurgitation, 8 of 12 were in New York Heart Association III/IV, 7 had prior tricuspid valve surgery, and important pulmonary hypertension predominated with 4 having severe right ventricular dysfunction.5 Effective orifice area preprocedure is not reported, which is a limitation of the study. At last follow-up, 4 patients had mean gradients ≥10 mm Hg, and the rate of surgical mitral valve replacement was high, 16.7% at 3 years.It is notable that this study included patients treated with Sapien (Edwards Lifesciences) valves, originally designed for the aortic valve. It is unknown whether outcomes would be different for ViV and ViR interventions using valves specifically designed for TMVR.Thus, while this percutaneous approach may facilitate a successful pregnancy in some cases, important caveats must be considered, and questions remain. The mean patient age was 30±6 years, so fertility might be already diminishing. Only one-third of the women completed pregnancies, the reasons for which require further study. The higher number of ViR patients requiring a subsequent surgery within 5 years is an important caveat when considering TMVR. Whether the pulmonary hypertension improved to a significant degree following the procedure is unknown and this, coupled with severe right ventricular dysfunction and tricuspid regurgitation, which might not be expected to improve, raises concerns as to the wisdom of having a pregnancy in this context, with the 50% volume increase that pregnancy imposes.The most important imperative is the health of the prospective mother. Faced with a patient whose mitral prosthesis has undergone structural valve deterioration with pure mitral stenosis, most can be managed medically. For those with pure regurgitation or mixed lesions who are New York Heart Association II or worse, redo valve replacement is a consideration. TMVR may be considered with caution, but important concerns include valve thrombosis, possible stroke, and a high incidence of subsequent surgical re-intervention in a relatively short time frame (with attendant potential for morbidity and mortality). Such decisions are challenging and complex both for providers and patients, and all need to make informed decisions with advice from multidisciplinary teams who are experienced not only in interventions but also in the management of patients with heart disease and pregnancy.DisclosuresNone.FootnotesThe opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.For Disclosures, see page 396.Correspondence to: Nadia R. Sutton, MD, MPH, Michigan Medicine, Frankel Cardiovascular Center CVC 2A192A/SPC 5869, 1500 E Medical Center Dr, Ann Arbor, MI 48109. Email [email protected]umich.eduReferences1. Dvir D, Bourguignon T, Otto CM, Hahn RT, Rosenhek R, Webb JG, Treede H, Sarano ME, Feldman T, Wijeysundera HC, et al.; VIVID (Valve in Valve International Data) Investigators. Standardized definition of structural valve degeneration for surgical and transcatheter bioprosthetic aortic valves.Circulation. 2018; 137:388–399. doi: 10.1161/CIRCULATIONAHA.117.030729LinkGoogle Scholar2. Pibarot P, Dumesnil JG. Prosthetic heart valves: selection of the optimal prosthesis and long-term management.Circulation. 2009; 119:1034–1048. doi: 10.1161/CIRCULATIONAHA.108.778886LinkGoogle Scholar3. van Hagen IM, Roos-Hesselink JW, Ruys TP, Merz WM, Goland S, Gabriel H, Lelonek M, Trojnarska O, Al Mahmeed WA, Balint HO, et al.; ROPAC Investigators and the EURObservational Research Programme (EORP) Team*. Pregnancy in women with a mechanical heart valve: data of the European society of cardiology registry of pregnancy and cardiac disease (ROPAC).Circulation. 2015; 132:132–142. doi: 10.1161/CIRCULATIONAHA.115.015242LinkGoogle Scholar4. Steinberg ZL, Dominguez-Islas CP, Otto CM, Stout KK, Krieger EV. Maternal and fetal outcomes of anticoagulation in pregnant women with mechanical heart valves.J Am Coll Cardiol. 2017; 69:2681–2691. doi: 10.1016/j.jacc.2017.03.605CrossrefMedlineGoogle Scholar5. Fuchs A, Urena M, Chong-Nguyen C, Kikoïne J, Brochet E, Abtan J, Fischer Q, Ducrocq G, Vahanian A, Iung B, et al.. Valve-in-valve and valve-in-ring transcatheter mitral valve implantation in young women contemplating pregnancy.Circ Cardiovasc Interv. 2020; 13:e009579. doi: 10.1161/CIRCINTERVENTIONS.120.009579LinkGoogle Scholar6. Guerrero M, Vemulapalli S, Xiang Q, Wang DD, Eleid M, Cabalka AK, Sandhu G, Salinger M, Russell H, Greenbaum A, et al.. Thirty-day outcomes of transcatheter mitral valve replacement for degenerated mitral bioprostheses (valve-in-valve), failed surgical rings (valve-in-ring), and native valve with severe mitral annular calcification (valve-in-mitral annular calcification) in the United States: data from the society of thoracic surgeons/American College of cardiology/transcatheter valve therapy registry.Circ Cardiovasc Interv. 2020; 13:e008425. doi: 10.1161/CIRCINTERVENTIONS.119.008425LinkGoogle Scholar7. Whisenant B, Kapadia SR, Eleid MF, Kodali SK, McCabe JM, Krishnaswamy A, Morse M, Smalling RW, Reisman M, Mack M, et al.. One-year outcomes of mitral valve-in-valve using the SAPIEN 3 transcatheter heart valve.JAMA Cardiol. 2020:e202974. doi: 10.1001/jamacardio.2020.2974Google Scholar8. Pagnesi M, Moroni F, Beneduce A, Giannini F, Colombo A, Weisz G, Latib A. Thrombotic risk and antithrombotic strategies after transcatheter mitral valve replacement.JACC Cardiovasc Interv. 2019; 12:2388–2401. doi: 10.1016/j.jcin.2019.07.055CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsRelated articlesBalloon Versus Self-Expandable Valve for the Treatment of Bicuspid Aortic Valve StenosisAntonio Mangieri, et al. Circulation: Cardiovascular Interventions. 2020;13 December 2020Vol 13, Issue 12Article InformationMetrics Download: 44 © 2020 American Heart Association, Inc.https://doi.org/10.1161/CIRCINTERVENTIONS.120.010227PMID: 33320711 Originally publishedDecember 2, 2020 Keywordspregnancymitral valve stenosisEditorialsmitral valve insufficiencylive birthPDF download SubjectsCatheter-Based Coronary and Valvular Interventions