Validation of Risk Stratification for Valvular Heart Disease in Pregnancy

Quick Takes

  • Both DEVI and CARPREG-II risk prediction models are useful in pregnant patients with valvular heart disease.
  • The DEVI score may better identify risk of adverse cardiac outcomes among pregnant patients with valvular heart disease.

Study Questions:

Among pregnant women with valvular heart disease, what is the accuracy of the DEVI and CARPREG-II risk stratification tools?


A cohort of pregnant patients with valvular heart disease admitted to a tertiary care center in India was developed (2019–2022). Risk was calculated using the DEVI and CARPREG-II models. Performance was assessed with discrimination and calibration. Decision curve analysis was used to assess clinical utility.


Of 577 pregnancies with maternal valvular heart disease, 95% were related to rheumatic heart disease, and 48% had mitral regurgitation. Adverse cardiac events occurred in 12%. For DEVI, the area under the receiver-operating characteristic curve (AUC) was 0.884 (95% confidence interval [CI], 0.844-0.923). For CARPREG-II, the AUC was 0.808 (95% CI, 0.753-0.863). The DEVI score overestimated risk at higher probabilities and CARPREG-II overestimated risk at both extremes and underestimated risk at middle probabilities. Both models were useful across predicted probability thresholds between 10% and 50%.


Both the DEVI and CARPREG-II scores showed good discriminative ability and clinical utility in pregnant patients with valvular heart disease. The DEVI score appeared superior in this cohort.


Risk stratification is an essential component of managing patients with cardiac disease during pregnancy. Unfortunately, few tools have been developed and validated. The CARPREG-II model was developed in Canada, a high-income country, in a cohort with a high percentage of patients with congenital heart disease. In contrast, the DEVI score was developed from a similar population to the one assessed in this study (i.e., maternal valvular heart disease in middle-income settings). While the DEVI score predicts in-hospital complications, CARPREG-II includes complications within 6 months of delivery. Overall, both models performed relatively well. Among patients with valvular heart disease, the DEVI score may be superior; however, this score still needs to be externally validated in other countries and diverse settings. Improving accurate risk stratification is an important step towards improving our care of high-risk pregnant patients globally.

Clinical Topics: Valvular Heart Disease

Keywords: Heart Valve Diseases, Pregnancy, Rheumatic Heart Disease, Risk Assessment

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