From the Guidelines
Mitral regurgitation during pregnancy should be managed with a focus on symptom control and preventing complications, with surgical intervention reserved for refractory heart failure despite maximal medical therapy, as recommended by the 2014 AHA/ACC guideline 1. The management of mitral regurgitation in pregnancy involves a multidisciplinary approach, including cardiologists, obstetricians, and anesthesiologists.
Key Considerations
- Patients with severe valve regurgitation should undergo prepregnancy counseling by a cardiologist with expertise in managing patients with valvular heart disease during pregnancy 1.
- Pregnant patients with severe regurgitation should be monitored in a tertiary care center with a dedicated Heart Valve Team 1.
- Valve operation during pregnancy is high risk for both the mother and the fetus, and should be reserved for patients with refractory NYHA class IV HF symptoms (stage D) 1.
Medical Management
- Medications may include diuretics like furosemide (20-40mg daily) for fluid retention, beta-blockers such as metoprolol (25-100mg twice daily) to reduce heart rate and improve ventricular filling, and digoxin (0.125-0.25mg daily) for rate control in atrial fibrillation.
- Anticoagulation with low molecular weight heparin is necessary if atrial fibrillation develops.
Surgical Intervention
- Surgical intervention during pregnancy is reserved only for refractory heart failure despite maximal medical therapy, with valve repair preferred over replacement when possible 1.
- The timing of delivery should be determined by an interdisciplinary team, with vaginal delivery preferred for most women with appropriate pain management to minimize hemodynamic stress.
Monitoring and Delivery
- Close monitoring during labor with arterial line placement and careful fluid management is essential.
- The physiologic changes of pregnancy, including increased blood volume and cardiac output, can worsen regurgitation by increasing left ventricular volume load, making careful management crucial throughout pregnancy and the postpartum period. According to the 2014 AHA/ACC guideline, all patients with suspected valve regurgitation should undergo a clinical evaluation and TTE before pregnancy 1. Additionally, valve operation for pregnant patients with severe valve regurgitation is reasonable only if there are refractory NYHA class IV HF symptoms (stage D) 1. The management of mitral regurgitation during pregnancy requires careful consideration of the risks and benefits of different treatment options, and should be individualized based on the patient's specific condition and needs.
From the Research
Management of Mitral Regurgitation in Pregnancy
Mitral regurgitation is generally well-tolerated in pregnancy due to the decrease in vascular resistance that offsets the increase in volume 2. However, patients with left ventricular dysfunction, moderate pulmonary hypertension, or NYHA functional class III-IV are at increased risk for heart failure and arrhythmias 2.
Risk Factors for Adverse Cardiac Events
Adverse cardiac events, including heart failure, sustained arrhythmias, cardiac arrest, or death, occur in approximately 13% of pregnancies in women with moderate or severe regurgitant valve lesions 3. The risk is higher in women with multivalve disease, mitral regurgitation, or tricuspid regurgitation 3. Left ventricular systolic dysfunction, pulmonary hypertension, and cardiac events before pregnancy are important determinants of adverse cardiac events during pregnancy 3.
Treatment and Management
- Medical therapy, such as beta-1 antagonists and cautious diuresis, can be used to treat symptoms 2.
- Patients with heart failure unresponsive to treatment may undergo percutaneous balloon mitral valvuloplasty 2.
- Vaginal delivery is preferred, and caesarean section is reserved for obstetric indications 2.
- Invasive hemodynamic monitoring may be necessary for labor and delivery in high-risk patients 2.
- A multidisciplinary team, including cardiologists, cardiothoracic surgeons, and obstetricians, is essential for managing mitral regurgitation in pregnancy 4.