Pregnancy in women with valvular heart disease: a call to action to reduce morbidity and mortality in both mother and child

Correspondence to Dr Vera H Rigolin, Medicine/Cardiology, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA; VRigolin@nm.org The scope of the problem Cardiovascular disease is the most common cause of pregnancy-related mortality in countries with medium or higher human development index (HDI).1 2 In parallel, medical advancements in the treatment of cardiovascular disease have allowed for more women with structural and congenital heart disease to survive and reach childbearing age, and the number of pregnancies in women with congenital and acquired valvular or ischaemic heart disease is increasing.1 Women with valvular heart disease (VHD) are important to identify as the haemodynamic burden of pregnancy may be particularly difficult for them to tolerate. Starting in the first trimester, as early as 6-week to 8-week gestation, the plasma volume increases (in part due to activation of the renin-angiotensin system) as does the cardiac output, peaking in the second trimester; heart rate continues to increase into the third trimester.3 These shifts lead to an increased risk of heart failure symptoms and arrhythmias in pregnant women with VHD. Secondary outcomes included maternal heart failure symptoms (New York Heart Association class III-IV), pulmonary oedema, arrhythmias or need for valvular intervention during pregnancy, and fetal outcomes including small for gestational age neonates (birth weight below the 10th percentile) and preterm birth (before 37 weeks of gestation). The situation is particularly challenging for women with severe VHD with no percutaneous treatment options, since the presence of prosthetic valves significantly increases maternal and fetal risk, especially if anticoagulation is required.6 The World Heart Organization classification, the Cardiac Disease in Pregnancy (CARPREG) and ZAHARA studies are the most commonly used risk stratification tools to quantify maternal risk with pregnancy.