p.27 抽出テキスト

............................................................................................................................................................................. exercise tolerance, BP response, and arrhythmias, and exercise echocardiography may provide additional information. In women with bicuspid aortic valve, aortic diameters should be assessed before and during pregnancy.

Medical therapy. Medical treatment and restricted activities are indicated if HF occurs during pregnancy. Diuretics can be administered for congestive symptoms.

Interventions. All symptomatic patients with severe AS or asymptomatic patients with impaired LV function or a pathological exercise test should be counselled against pregnancy, and surgery should be performed prepregnancy.10,204 Pregnancy should not be discouraged in asymptomatic patients, even with severe AS, when LV size and function and the exercise test are normal (see table ‘General Recommendations’). There should also be no recent progression of AS. During pregnancy in patients who are severely symptomatic despite medical therapy, percutaneous valvuloplasty can be undertaken by an experienced operator.207 If this is not possible and patients have life-threatening symptoms, valve replacement should be considered after early delivery by caesarean section if this is an option (see table ‘General Recommendations’). Given the foetal risk of surgery, transcatheter aortic valve implantation is a promising alternative, but experience during pregnancy is very limited.

Follow-up during pregnancy. Regular follow-up is required by an experienced team. In severe AS, monthly or bimonthly cardiac evaluations including echocardiography are advised.

Labour and delivery. In severe symptomatic AS, caesarean delivery should be preferred. An individual approach is recommended for asymptomatic severe AS. In non-severe AS, vaginal delivery is favoured.

Follow-up and prognosis after delivery. Disease progression is frequent after delivery and requires close follow-up.204,208,210

6.2 Regurgitant lesions

6.2.1 Mitral and aortic regurgitation Mitral and aortic regurgitation can be of rheumatic, congenital, or degenerative origin.92,199

6.2.1.1 Maternal risk Women with severe regurgitation and symptoms or compromised LV function are at high-risk of HF.194,199 HF occurs in 20–25% of women with moderate or severe rheumatic MR.199 Acute severe regurgitation is poorly tolerated. In women with congenital heart disease, significant left AV valve regurgitation is associated with cardiac complications during pregnancy. A persistent worsening of regurgitation may occur.42

6.2.1.2 Obstetric and offspring risk No increased risk of obstetric complications has been reported. Intrauterine growth retardation occurs in 5–10%, and other offspring complications in <5%, of women with moderate or severe MR.199 6.2.1.3 Management

Diagnosis. Evaluation, preferably pre-conception, should include the assessment of symptoms and comprehensive echocardiographic evaluation of regurgitation severity, LV dimensions, and function.204 Ascending aortic diameters should be measured in women with aortic regurgitation, especially in those with bicuspid valves.

Medical therapy. Symptoms of fluid overload can usually be managed medically.

Interventions. Pre-pregnancy surgery favouring valve repair should be performed according to guidelines.204 In acute severe regurgitation with therapy-refractory HF, surgery is sometimes unavoidable during pregnancy. If the foetus is sufficiently mature, delivery should be undertaken prior to cardiac surgery (see table ‘General Recommendations’).

Follow-up during pregnancy. Follow-up is required every trimester in mild/moderate regurgitation, and more often in severe regurgitation.

Labour and delivery. Vaginal delivery with epidural anaesthesia and shortened second stage is advisable.

Follow-up and prognosis after delivery. The prognosis depends on the regurgitation severity and its consequences on symptoms, LV size, and function.

6.2.2 Tricuspid regurgitation Secondary TR is more frequent than primary TR, which may be due to endocarditis or Ebstein’s anomaly. Maternal risk is usually determined by left-sided valve disease or PH. However, maternal risk can be increased in severe symptomatic TR or in women with RV dysfunction.50 In women with congenital heart disease, moderate/severe AV valve regurgitation may be associated with maternal cardiac complications, which are mainly arrhythmias.42 Even severe TR with HF can usually be managed conservatively during pregnancy (see table ‘General Recommendations’). When surgery is necessary for left-sided valve lesions, additional tricuspid repair is indicated in severe TR and should be considered in moderate TR with annular dilatation (>_ 40 mm).204 In severe symptomatic TR, repair should be considered pre-pregnancy.

6.3 Atrial fibrillation in native heart valve

disease A high thrombo-embolic risk is associated with AF, particularly in clinically significant MS. Immediate anticoagulation is required, using LMWH at therapeutic doses in the first and last trimesters, and VKAs with the usual target INRs or LMWH for the second trimester. Non- VKA OACs are contraindicated throughout pregnancy. The choice between cardioversion and rate control using digoxin or betablockers depends on the severity of the underlying valve disease and the tolerance (see section 12).

6.4 Prosthetic valves

6.4.1 Choice of valve prosthesis When implantation of a prosthetic valve is unavoidable in a woman who wants to become pregnant in the future, valve selection is Downloaded from academic.oup.com/eurheartj/article/39/34/3165/5078465 by guest on 07 October 2026