Risk of Pregnancy in Aortic Stenosis

Study Questions:

What are maternal and fetal outcomes among patients with aortic stenosis (AS)?

Methods:

The Registry on Pregnancy and Cardiac Disease (ROPAC) is a global, prospective, observational registry of women with structural heart disease providing a uniquely large study population. Data on women with moderate (peak gradient 36-63 mm Hg) and severe (peak gradient ≥64 mm Hg) AS were analyzed.

Results:

Of 2,966 pregnancies in the ROPAC, 96 women with at least moderate AS were identified (34 with severe AS). Before pregnancy, 36 patients (38%) were symptomatic (32 [33%] class II, 4 [4%] class III). No deaths were observed during pregnancy and in the first week after delivery. However, 20.8% of women were hospitalized for cardiac reasons during pregnancy. This was significantly more common in patients with severe AS compared with moderate AS (35.3% vs. 12.9%, p = 0.02), and reached the highest rate (42.1%) in severe, symptomatic AS. Pregnancy was complicated by heart failure in 6.7% of asymptomatic and 26.3% of symptomatic patients, but could be managed medically in all but one patient who was symptomatic prior to pregnancy and underwent balloon valvotomy. Children of patients with severe AS had a significantly higher percentage of low birth weight compared to patients with moderate AS (35.0% vs. 6.0%, p = 0.006).

Conclusions:

In the current era, mortality in pregnant women with AS, including those with severe AS, appears to be close to zero. Symptomatic and severe AS does, however, carry a substantial risk of heart failure and is associated with high rates of hospitalization for cardiac reasons, although heart failure nearly always can be managed medically.

Perspective:

These data suggest that patients with moderate and probably severe AS can tolerate pregnancy with a relatively low risk of morbid and mortal events. That 38% of patients had symptomatic AS (and therefore an indication for aortic valve intervention) prior to pregnancy reinforces the importance of appropriate preconception patient evaluation and counseling.

Clinical Topics: Congenital Heart Disease and Pediatric Cardiology, Heart Failure and Cardiomyopathies, Valvular Heart Disease, Congenital Heart Disease, CHD & Pediatrics and Quality Improvement, Acute Heart Failure

Keywords: Aortic Valve Stenosis, Balloon Valvuloplasty, Counseling, Heart Defects, Congenital, Heart Failure, Heart Valve Diseases, Infant, Low Birth Weight, Mortality, Pregnancy, Risk


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