p.69 抽出テキスト
Before recommending pregnancy, the following conditions need to be corrected: • MS with MVA <1.5 cm2, even when asymptomatic.971 • Severe AS with symptoms, or abnormal exercise test, or LV systolic dysfunction.972 • Heritable aortic disorders and high risk of aortic dissection: prophylactic aortic repair is recommended prior to pregnancy in women with Marfan syndrome and an aortic diameter of >45 mm, and may be considered in women with an aortic diameter between 40 and 45 mm when risk factors for dissection exist.973 Aneurysmal dilation in women with BAV should be corrected when the aortic diameter is ≥50 mm.974 Close follow-up in dedicated units and beta-blocker therapy during pregnancy and post-partum are recommended unless contraindicated, although strong evidence is only available for Marfan syndrome. Valvular regurgitant lesions are generally well tolerated during pregnancy. Prophylactic intervention is therefore not recommended in the absence of class I or IIa indications. The first therapeutic option for MS in a woman considering pregnancy should be PMC. When implantation of a prosthetic valve is necessary, BHVs are recommended, although early SVD remains a serious concern.975 Mechanical heart valves must be avoided due to the high risk of maternal and foetal complications linked to the potential teratogenic effects of VKAs, as well as the increased risk of bleeding.976 The Ross procedure may be considered for the treatment of AV disease at centres with expertise. 16.2 Management during pregnancy 16.2.1. Patients with native valve disease Pregnancy can worsen the clinical course of left-sided stenotic valvular lesions because increased cardiac output causes an increment of transvalvular gradient of ∼50%, mainly between the first and second trimesters. Regurgitant lesions are less likely to cause complications, except in high-risk cases (LV systolic dysfunction, PH, and cardiac events before pregnancy).977 Mild MS is generally well tolerated.978 Heart failure occurs in one-third of pregnant women with an MVA of <1.5 cm2 and in one-half of those with an MVA of <1.0 cm2, most often during the second trimester.971 Percutaneous mitral commissurotomy should be considered if symptoms or SPAP of >50 mmHg persist despite optimal medical therapy (diuretics and beta-1-selective beta-blockers), preferably after the 20th week of pregnancy. Regarding AS, pregnancy is generally well tolerated if prior exercise tolerance was normal, even in severe AS, while HF has been reported to occur in up to 25% of symptomatic patients.972 In symptomatic patients despite medical therapy (i.e. diuretics), TAVI seems to be the preferred option in very selected patients, although evidence is lacking. Percutaneous balloon valvuloplasty may be an alternative option. Procedures should be performed in an experienced valve centre.972,979,980 Surgery under cardiopulmonary bypass is associated with a high rate of foetal loss and should be restricted to conditions that threaten the mother’s life if transcatheter intervention is not possible or has failed. Vaginal delivery is the first choice for the majority of patients. Caesarean section is preferred if there is an obstetric indication, and in the case of severe MS or AS, ascending aortic diameter of >45 mm, severe PH, or if delivery starts while the patient is being treated with OAC. 16.2.2 Patients with prosthetic valves Pregnant patients with MHVs should be followed in a centre with corresponding expertise. In a cohort of 212 women with MHVs, valve thrombosis occurred in 10 (4.7%) pregnancies and haemorrhagic events occurred in 49 (23.1%).976 Therapeutic OAC during pregnancy is essential to avoid thrombosis. The higher efficacy of VKAs compared with LMWH to prevent thrombosis must be balanced against increased foetal risks.981 In patients requiring ≤5 mg/day of warfarin, OAC with warfarin throughout pregnancy, changing to UFH before delivery, is advocated, in order to reduce the risk of thrombosis. In patients requiring higher doses, switching to dose-adjusted LMWH at least twice per day with strict anti-Xa monitoring during the first trimester is recommended to avoid the teratogenic effect of VKAs (for corresponding flowcharts see the 2025 ESC Guidelines for the management of cardiovascular diseases during pregnancy968). Lifetime management of women with a BHV considering pregnancy is central and transcatheter valve-in-valve implantation may be considered as a bridge to MHV implantation.982 17 Sex-specific considerations in patients with valvular heart disease Although men and women are equally likely to experience VHD, sexspecific prevalence exists according to valve type and disease pathophysiology.644,648,983 Women more frequently suffer from MV disease such as prolapse, RHD or TR, while men more often present with AS or AR, especially associated with BAV.984 Men also suffer from endocarditis of any valve more frequently.985 Female sex is associated with higher mortality in the presence of various VHDs,986 including early post-treatment,987 and is included as a risk factor in surgical risk prediction tools such as the STS and EuroSCORE calculators. However, risk scores are often derived from populations including a majority of men.988 In addition, risk prediction scores are susceptible to referral bias that results in a wellestablished higher risk of undertreatment or delayed treatment of VHD in women.983,984,986 17.1 Aortic valve disease Female patients with severe AS present more often with shortness of breath, whereas males more frequently have angina, presumably due to the higher incidence of CAD.989 The pathophysiology of AS seems to differ according to sex, with women having less calcium and more fibrosis.990 Concentric ventricular hypertrophy and remodelling are also more frequently observed in women than in men, resulting in higher LVEF but smaller LV cavity and stroke volume.991 Consequently, paradoxical low-flow, low-gradient constellations are frequent and may both contribute to the underdiagnosis of severe AS in women and delay an intervention.992 The use of sex-specific thresholds to define flow limitation (<40 mL/m2 for men and <32 mL/m2 for women) has therefore been suggested,292 and the use of CCT to quantify the calcium score should be performed in women with discordant echocardiographic parameters.777 Women are less likely to be referred to a cardiologist and undergo investigations. Surgical aortic valve replacement is performed less frequently in women, especially if echocardiographic parameters are discordant.993 In patients presenting with severe ESC Guidelines 4703 Downloaded from academic.oup.com/eurheartj/article/46/44/4635/8234488 by guest on 07 October 2026