really interesting case that I think perhaps we'll come to back at the end with the panel discussion. So we'll go ahead and move on to our next speaker. Dr. Sintek can go ahead and bring up the slides. Dr. Mark Sintek is currently an assistant professor of interventional cardiology at Washington University in St. Louis. He performs procedures at Barnes-Jewish Hospital and has clinics at Heart Care Institute at Barnes-Jewish West County and Washington University in St. Louis South County Valve Center. Thank you Dr. Sintek. Thank you for the invitation tonight and it's a pleasure to be here. I would be remiss if I didn't thank the head of our cardio obstetrics program Kate Lindley for getting me involved with Dr. Park and all you guys. I always joke that maybe I should send her a fruit basket or maybe she should send me a fruit basket. I'm not really sure how that should work. But it's my pleasure to be here and talk about valvular heart disease and in particular, these are my disclosures, but in particular over the next maybe 12 to 15 minutes look a little bit at the epidemiology of valvular heart disease. I think that's pretty important especially when we're talking about its influence on pregnancy and outcomes and then really focus on two valves aortic stenosis and mitral stenosis. These are the most common sort of things I think that we will see and obviously with only a couple minutes we don't have time to talk about everything. But hopefully this will be informative. I have a couple of cases put in here too because you know if you're anything like me I really enjoy looking at cases and I learned a lot from that too. So hopefully between the cases and a couple of slides this will be a good 10 minutes. So this came from a recent review in Nature looking at sort of the global incidence of valvular heart disease and how it's changing over the course of time. Its focus was really on transcatheter aortic valve replacement but it did have some nice pearls for I think our discussion today. And you can see that you know in general we talk about calcific aortic valve disease. It's a disease of the elderly and the aged population and we know that from our TAVR experience. I draw your attention to degenerative mitral valve disease which is also as people age getting more but it vastly outstrips the the amount of aortic valve disease. But importantly if you look at rheumatic heart disease it has a preponderance for younger patients. And in this map on the right hand side you can see that the incidence of rheumatic heart disease tends to be in countries of lower socioeconomic status. And indeed when you look at pregnancy and valvular heart disease we see a lot of rheumatic heart disease and outcomes are are somewhat poor in these countries. Like for example in Brazil rheumatic mitral stenosis is associated with a pretty high incidence of maternal fetal mortality in that country still to this day. So when we talk about you know pregnancy related valve disease a lot of the focus ends up being on rheumatic heart disease and for good reason because that's pretty common. We don't see that as much in the United States although you know I think we've all seen patients that have immigrated from different countries and different backgrounds and we still do have rheumatic heart disease in this country although it's just not as widely prevalent as in other places. So I want to start with this case when I talk about aortic valve disease so that way if you get bored of hearing me talk you can think about what you might do with this lady. She's 30 years old. She had prior bicuspid aortic valve disease and had a 21 millimeter magna valve placed about five years prior to her presentation. She'd done really well and had one child before that and part of the reason why she selected the bioprosthetic valve was that she wanted to continue to have kiddos and didn't want to have to worry about the issue of coumadin in her pregnancy. So when she started her mean gradient actually wasn't too terrible and they put her on a treadmill walked her she did relatively well. It wasn't an exactly normal valve function but it wasn't you know it wasn't anything you'd worry about and then unfortunately over the course of her pregnancy her valve started to degrade quite a bit and when I got involved her peak gradient was 125 with a mean gradient of 84 and that was in the sort of third trimester of her pregnancy. She was largely asymptomatic did have some lower extremity swelling had some elevated blood pressures but this mean gradient of 84 got people's attention as I suspect it would for most people. So we're going to come back to this but I guess just be thinking about maybe what you would do for this lady what you'd recommend for her and her management particularly with regards to her delivery pregnancy and stuff like that. So a common theme I think amongst all of these different valve disorders and probably any disorder we're talking about women who are pregnant is sort of evaluating the risk. You know just because something's abnormal doesn't mean we always need to react to it and I think that that's a hard thing to learn but I learned it particularly in this patient population that it's really important to understand the risk in these patients. So really what we care about is high-risk patients and those are patients with obviously severe valve disease or severe AS, evidence of heart failure, syncope or angina. Those are the classic symptoms of AS but really I highlight LV dysfunction and I think that's where we really get some of our attention particularly you know our last presenter talked about shock and decompensation and the LV dysfunction is what really ends up getting people into trouble particularly after they deliver. And so that's what we're looking for when we decide what we're going to do for these patients. We really are talking about bicuspid valve disease. It's the most common cause of aortic valve disease in younger patients and the issue is it can be associated with pretty significant aortic insufficiency which plays into this idea of what are we going to do for therapy. I kind of highlight this and this is a I want to take away message for I think both valve lesions today is whenever I see these patients I always think about can I do a valvuloplasty or do we need to do a valvuloplasty procedure as a bridge through pregnancy and although valvuloplasty is not a great therapy for aortic valve disease in the in the long term it actually works pretty well in the short term and it works pretty darn well actually in younger patients. Our congenital heart disease folks know this quite well and it's really a different animal you know when we advise people who are older and we do a BAV we say maybe you got a couple of months that it'll last but in younger patients they can have years with the result of after their valvuloplasty. So it's something to really think about when we're talking about these patients. It has been shown to be safe like anything in this population there's not large series of patients to draw from but plenty of small series that have shown excellent results. I would really avoid thinking about this if there was severe aortic insufficiency at baseline. A theme of what was said on the last one that this is really kind of a team sport and I agree with that we really need the full support of maternal fetal medicine and anesthesia and you really have to come up with a plan as to what you're going to do with these patients if something goes wrong and I think that is another key takeaway message that if something goes wrong here it's going to go wrong quickly and you needed a very concrete plan as ECMO, SAVR, TAVR, C-section all of those things need to be in place if you're going to do this procedure for these patients. I want to highlight another kind of novel tool that some of you may have used for other instances and I think is a perfect application for this. This is the TruFlow balloon for aortic valvuloplasty. What it is is it's actually a valvuloplasty balloon that has a bunch of little what are balloons around the side and what this allows for is you can do a valvuloplasty and here on the bottom video you can see there's flow through the valve the whole time so you don't have this idea of rapid ventricular pacing a drop in blood pressure and then inflating the balloon. We use this a lot for patients with LV dysfunction when we don't want to do that rapid pacing run and I think in this population with someone who's who's pregnant that might be a nice use of this balloon. You can see on the left hand side this is a still frame of it and this was the hemos when I was doing it. You can see that you do get obviously a low diastolic blood pressure at a big swing but you maintain the blood pressure and pulse facility throughout the whole thing. So this is a great little tool to have in the toolbox and I think would be incredibly useful for these patients when you're doing a valvuloplasty to minimize hemodynamic consequences. It doesn't work quite as well as some of the other valvuloplasty balloons but it still will work well enough to kind of get you by I think in a gym. So what about TAVR? This is obviously near and dear to my heart. I do a lot of TAVR. Can we do it in these patients? Certainly we can. There's some case reports of doing this. Remember our standard protocol is a contrasted CT scan which I think you definitely can do. You know if that's what you think is most important I would definitely do that but we have been able to do it with 3D TE sizing. You know intravascular ultrasound of the legs and non-contrasted CTs and you could piece it together pretty well for that. I think really what I would consider TAVR is in patients who really can't have a valvuloplasty because this is a little bit more complicated of a procedure and has a higher chance of bad outcomes that could be potentially catastrophic for the mom or baby. And so you know really in patients that are valve and valve bioprosthetic valve dysfunction it does not lend itself to valvuloplasty. It has a very high incidence of tearing the valve and so it's not something that we can really use very easily in those patients. And then of course if you have severe inconsistency and you do a valvuloplasty that could make things worse. You know I think when you're thinking about doing these things what you want to ask yourself is what something terrible I can do and how often is that going to happen because it may be worse to do a valvuloplasty and create severe acute AI for this patient than it would be to just leave them alone with severe AS. So I'd be very mindful of that whenever you're thinking about what to do. So what about our patients? You can see this is one of my favorite cases. We did get a TAVR protocol CT on her. Realized that the radiation exposure is quite small particularly in the third trimester. And when we're talking about planning a valve and valve transcatheter valve replacement it's very important to understand the coronary distance as I've shown here from the valve prosthesis. Because when we put a valve inside there we're going to create a tube graft and that tube graft can include the coronaries and that would be catastrophic in the study. So I felt pretty strongly that we needed this information and you know the risk to the baby is quite minimal and if we have a plan then to do TAVR we have to have all the information that we need. You can see here she had adequate femoral size to get up and I show this because you can see here is the fetus that's in the pelvis. I always at one point in the year I have our structural files look through some of these TAVR cases and I show this one and I just wait to see if they pick up on it because it's pretty abnormal to see a baby when you're looking at femorals for a TAVR CT. So we got together as a heart team and we all looked over this and said you know yes we can definitely do TAVR in this patient. We can definitely get a good result if we need to do that. But you know that the point is we didn't necessarily have to do that. They watched her very closely. They made appropriate plans in the operating room. Had ECMO on standby. Had us on standby. Delivered a healthy baby via c-section. She had no problems with that and then later that admission they actually did a SAVR with a mechanical valve and she's doing quite well now post that procedure. So you know we didn't end up doing TAVR but we were all ready to do TAVR. We made the appropriate plans and worked together as a group and I think it's just a nice example of we could have easily done it it's just she didn't need it so we didn't end up doing it. So let's change gears a little bit to rheumatic mitral stenosis. So this is a 38 year old female. A nice lady from the Philippines that had immigrated over to the United States a couple years prior. Had no rheumatic heart disease when she first got here but it was more moderate mitral stenosis and unfortunately was lost to follow-up and didn't see a cardiologist and definitely wasn't a part of our cardio obstetrics program. So she showed up for her c-section in the breech position to maternal-fetal medicine and they ended up saying well you have moderate mitral stenosis we should probably get an echo. Got an echo and it showed normal LV function but moderate RV dysfunction with pretty severe pulmonary hypertension and pretty bad mitral stenosis with a mean gradient of 15 and a valve rate of 1.1 on that particular echo. Realized that you know when we talk about mitral stenosis a valve rate less than 1.5 is something that we get our attention. So I'm sure people in the audience and people on the panel have had this happen where a person shows up kind of at the end of their pregnancy with severe cardiovascular disease and you say well what are you supposed to do with this. So I guess keep this in mind when we talk about mitral valve disease and again we're talking about high risk versus low risk and you know of all the valvular heart disease lesions you're going to see in women that are pregnant this is going to be the most common. This comes from a European registry of valvular heart disease in pregnancy. It's a global registry and you can see if you you know take mitral regurgitation stenosis and mixed valve disease together that accounts for almost you know 75 percent of the cases of valvular heart disease in this registry. So this is probably what you're going to see more than anything with with these patient populations. You know low risk I think would be a mitral valve area of greater than 1.5. Now remember and I'm sure this has been covered in multiple different ways but as the cardiac output increases during pregnancy you know the gradients can go up quite a bit. So you have to be mindful of the idea of it's not just about the gradients it's also about kind of the valve area and what they start with at baseline. High risk is symptoms of heart failure obviously a mitral valve area less than 1.5. A mean gradient that's elevated like I kind of put a question mark about that usually we say greater than 10 should get your attention but a lot of these patients have gradients of 15, 20, 25 that that would definitely get my attention. Severe pulmonary hypertension with a mean gradient greater than 50 that's a big one right. The one the the women that do very poorly with delivery in our experience have been the ones with pulmonary hypertension and right heart failure. These are the ones that really crash after they deliver and that can be from underlying pulmonary arterial hypertension or underlying mitral valve disease and those ones really should get our attention as to what to do. So what about mitral valvuloplasty in these particular patients? This is a great therapy this is a great therapy for rheumatic mitral stenosis just period in general and this has been done a lot throughout the world and has very durable results. We want to avoid this in unfavorable anatomy so this would be a Wilkins score greater than equal to eight. I know this is a small series that this was done and this is you know somewhat questionable in some respects but personally I don't think we should really be taking big risks with this patient population so I'd be very hesitant to do a mitral valvuloplasty on a woman who's pregnant with a high Wilkins score. I think that could lead to some definite trouble. Again same thing as aortic stenosis if you're going to do a procedure like this on a woman who's pregnant you want to have the full set of complement of tools and activities and support from your group. This table is looking at actually the very first reported series of valvuloplasty in five women who are pregnant. You can see their various gestational ages their mean gradients varied quite a bit between the LA and LV. Some of these I don't quite understand like this one that was you know 14 or so you can see the bottom one is sort of before and after. So a nice reduction in valvuloplasty in the gradients and a nice increase in the valve area after they do the valvuloplasty. All these survived all the babies survived in this initial series. They looked at this this is probably the largest series. It's from 1984 onwards at a single center so you know that that's not a lot of patients if they only have 45. But they compared mitral commiserotomy which is you know surgical in nature versus a mitral valvuloplasty. And we can see is on the left hand side you know valvuloplasty gets an excellent result with a drop in gradient a drop in LA pressures which is what we really care about right is a drop in LA pressures because that's what is going to cause symptoms pulmonary edema will cause problems. And then you can see here neonatal and fetal mortality was almost non-existent in the mitral valvuloplasty group and none of the moms passed away. 95% success rate of valvuloplasty and so this is suggestive of it being a much more favorable approach than surgical commiserotomy. And I think that's probably true for you know mitral rheumatic mitral stenosis in general. We don't do a lot of commiserotomy anymore. We do more just valvuloplasty and if that doesn't work go to surgery. So here's our lady. We did a mitral valvuloplasty. You can see we're using intracardiac echo which I think is a nice use in these patients. This is the transeptal needle that gets across and you can see us doing a little injection. We use the Bayless radiofrequency ablation needle. This was actually the valvuloplasty procedure. So this is the Inouye balloon. This has been around for a long time. It hasn't changed much. It's a volume-based device so when you're watching this balloon inflation you'll see there's a waste in the particular balloon right there and then if you watch it'll release right there and that's the popping of the mitral valve. So whenever you see that you know you've done a good job. It's a little bit of a no crap moment sometimes too. This is a very uncontrolled situation so anybody who's done a lot of mitral valvuloplasty knows it can be fun but as soon as you tear one of these things it's not fun at all and there's really no control over it. You just inflate the balloon and hope for the best. We always do an LV gram afterwards and you can see here hardly any mitral regurgitation in this lady after we did the LV gram. Now truth be told on this particular lady she actually delivered her baby first with the support of echo and things like that. She was largely asymptomatic and they felt they could do the c-section pretty quickly and she'd tolerate that and so we did this valvuloplasty actually about a day or two after she delivered but we got a great result. We increased her valvular from 0.7 to 1.5. Early pressure dropped from 40 down to 14 and she continues to do well after this procedure. We would probably if she hadn't just delivered been a little bit more aggressive and tried to get it a little bit better than 1.5 but since I had a two-fold increase in her valvular and stuff and I didn't want to harm her after she had just delivered a little baby I decided to kind of punt in with this but she's you know it's been a couple of years and she's done just fine with it hasn't had anything done with her valve since and has been feeling well. So kind of conclusions I you know I think to emphasize never make decisions alone particularly with these patients. This is a team sport if there ever was one because this is requires immense amount of planning and work together and to be truthful I still I'm learning every day when we have these patients I don't understand all the details that our maternal fetal medicine colleagues do or even you know our cardio obstetric colleagues do so I think it's important to work together. I learned this from from Dr. Lindley a long time ago and I think most people would agree with this you know we always want to think about saving the mom first you know obviously it would be devastating to lose a neonate and things like that but the truth of the matter is if mom doesn't make it probably the kid's not going to make it either and so a lot of times we have to ignore the fact that people are pregnant when we decide these things and when we make these recommendations and I learned that from her a long time ago and it's really gone a long way to helping kind of do the right thing for these patients. So now I would emphasize when you're thinking about doing procedures on these folks it's always good to get all the information you can sometimes it's better just to pretend like they're not pregnant when you're ordering CT scans and stuff like that. Always look for a way to do a valvuloplasty. I think that that's probably the simplest most straightforward way to help bridge these patients through this if you need to and then always have a backup plan always always have a backup plan and usually it's ECMO or some other surgical support. I would never do these procedures without maternal fetal medicine on standby for a c-section ECMO support all those things just to be on the safe side. That's all I got I think we're gonna take questions at the end so but thank you for your attention. I appreciate it.

valvular heart disease

pregnancy outcomes

aortic stenosis

mitral stenosis

rheumatic heart disease

management options