p.48 抽出テキスト

......................................................................... management before and during pregnancy should be taken after multidisciplinary discussion in the pregnancy Heart Team involving cardiologists, cardiac surgeons, obstetricians, neonatologists, and anaesthesiologists.

13.1 Management before pregnancy

Valve disease should be evaluated before pregnancy and treated if necessary.554,555 Pregnancy should be discouraged, and intervention should be recommended before pregnancy in the following cases: • Patients with mitral stenosis and a valve area <1.5 cm2 (especially if <1.0 cm2).554,556 • All symptomatic patients with severe AS or asymptomatic patients with impaired LV function (LVEF <50%) or an abnormal exercise test should be counselled against pregnancy, and surgery should be performed pre-pregnancy.554,557 • Women with Marfan syndrome and an aortic diameter >45 mm should be strongly discouraged from becoming pregnant without prior aortic repair because of the high risk of aortic dissection. Although an aortic diameter <40 mm is rarely associated with aortic dissection, a completely safe diameter does not exist. With an aortic diameter between 40 and 45 mm, previous aortic growth and family history are important for advising pregnancy with or without aortic repair.558 Although the actual risk of dissection is not well documented in the setting of bicuspid valves, counselling against pregnancy is recommended in the setting of aortic diameters >50 mm (>27 mm2 BSA).559 Finally, an aortic diameter >25 mm/m2 BSA in Turner syndrome and all patients with vascular Ehlers-Danlos syndrome are also contraindications for pregnancy.

In women considering pregnancy and requiring heart valve replacement, it is recommended to choose the prosthesis in consultation with a pregnancy Heart Team.554,560 Pregnancy in women with a mechanical valve, especially in the mitral position, is associated with a high risk of maternal and foetal complications,554,561 which should be carefully discussed with the patient and family.

13.2 Management during pregnancy

13.2.1 Patients with native valve disease Moderate or severe mitral stenosis with a valve area <1.5 cm2 in pregnant women is usually poorly tolerated. PMC should be considered in severely symptomatic patients [New York Heart Association (NYHA) class IIIIV] and/or those with SPAP >50 mmHg despite optimal therapy. PMC should preferably be performed after the 20th week of pregnancy in experienced centres.554

Urgent or elective NCS

Management of non-cardiac surgery (NCS) in patients with severe aortic stenosis

Patient risk for AV procedure (TAVI/SAVR)

Risk of NCS

Heart Team decision:

SAVR or TAVI NCS under strict

monitoring NCS Consider BAV before NCS if doable, or NCS under strict monitoring

HIGH LOW

Risk of NCS Symptoms

HIGH Y

HIGH LOW-MODERATE

ELECTIVE URGENT

N

Figure 11 Management of non-cardiac surgery (NCS) in patients with severe aortic stenosis. AV= aortic valve; BAV = balloon aortic valvuloplasty; NCS= non cardiac surgery; SAVR= surgical aortic valve replacement; TAVI = transcatheter aortic valve implantation. Downloaded from academic.oup.com/eurheartj/article/43/7/561/6358470 by guest on 07 October 2026