Cardiovascular disease (CVD) complications affect up to 4% of all pregnancies, with approximately one-quarter of cases attributable to valvular heart disease.1,2 Overall, risk management guidelines emphasize the potential complications associated with stenotic valvular lesions. Regurgitant lesions, however, have been considered relatively benign during pregnancy.3

Study findings published in August 2021 in the American Journal of Cardiology suggested that regurgitant valves confer a higher risk for obstetrical complications than previously believed.3 Using medical records from the 2016 to 2018 National Inpatient Sample, researchers at the Johns Hopkins University in Baltimore, Maryland, compared adverse obstetric and cardiovascular events at delivery in women with various stenotic and regurgitant valvular diseases.

They identified valvular disease in 20,349 women among more than 11.2 million of those who had deliveries. According to the results, women with vs without valvular disease had greater adjusted odds ratios (aOR) for preeclampsia and/or eclampsia (aOR, 1.9; 95% CI, 1.8-2.2) and intrapartum/postpartum hemorrhage (aOR, 1.4; 95% CI, 1.2-1.6; all P <.001).


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Underlying cardiovascular comorbidities were also more common among women with valvular disease compared with those without, including hypertension (5.1% vs 0.25%, respectively) and pulmonary hypertension (7.0% vs <0.1%, respectively).

Additionally, women with valvular disease showed greater odds for all types of cardiovascular complications, including peripartum cardiomyopathy (aOR, 65; 95% CI, 53-78), pulmonary edema (aOR, 17; 95% CI, 13-22), acute ischemic heart disease (aOR, 19; 95% CI, 12-30), and arrhythmias (aOR, 22; 95% CI, 19-27 [all P <.001]).

“These complications are associated with all stenotic and regurgitant lesions and for both right and left-sided valves,” the authors of the study noted.3 These results highlight the need for increased vigilance in the risk stratification and management of pregnant women with any type of valvular disease.3

For further insights regarding these findings and their clinical implications, we interviewed lead study author Dr Anum Minhas, chief cardiology fellow at the Johns Hopkins School of Medicine, and Dr Jason Vaught, assistant professor of gynecology and obstetrics and director of labor and delivery at Johns Hopkins.

What are the potential reasons for the underrecognition of regurgitant heart valve disease risks in pregnancy?

Dr Minhas: During pregnancy, women can have lower blood pressure and lower systemic vascular resistance. It has long been thought by experts that this should reduce regurgitation for leaky heart valves. However, whether this actually occurs, and whether women with regurgitant heart valve disease do well with no issues in pregnancy, has not been well-studied in a large population of women.

It is important to remember that there are many cardiovascular changes that occur during pregnancy, some of which can potentially make regurgitation worse. Therefore, it is important to perform studies on a large scale to confirm or refute what we may expect to find.

Dr Vaught: Women with regurgitant lesions tend to do well in pregnancy, secondary to a lower afterload and higher cardiac output of pregnancy. Therefore, women tend to have fewer complaints or abnormal cardiovascular biomarkers with regurgitant lesions until they are severe. Although regurgitant lesions now tend to have favorable outcomes, large datasets in US populations are needed to really clarify and solidify plans of care.

Dr Minhas, you noted in a press release,4 –  “Unfortunately, so much of women’s health practices has been dominated by individual experiences and experts saying they believe something to be true rather than based on evidence.” Could you elaborate on this statement further? 

Dr Minhas: As physicians, we individually strive to provide the best clinical care for our patients. As researchers, we aim to determine what that may look like for large numbers of patients. Often in medicine, in the absence of large studies, we use our clinical judgment and past experiences to help with the management of our patients. However, if possible, we should always aim to produce large-scale studies to explore scientific questions before we arrive at conclusions, as sometimes what we expect to find may be different than the reality. 

What do your findings add to our understanding of regurgitant heart valve disease in pregnancy, and how can they guide treatment approaches in the future?

Dr Minhas: We find that regurgitant heart valve lesions may not be benign during pregnancy and that women who have these lesions may be at elevated risk for cardiovascular complications during pregnancy. We hope that these findings will help increase clinician and patient awareness of the potential complications that may occur with regurgitant valve lesions, so that women presenting with these complications will receive the appropriate medical or surgical therapy.

How can obstetricians and cardiologists collaborate to optimally provide care for patients with valvular heart disease?

Dr Minhas: Patients with any form of heart disease, including valvular heart disease, can be challenging to manage during pregnancy due to the multiple cardiovascular changes occurring during this period. Additionally, during pregnancy we are caring for both the mom and the baby. Cardiologists and obstetricians are both superbly trained in their respective areas, and during pregnancy for women with heart disease, we should combine our expertise to provide the best collaborative care for mothers and babies. This should involve managing patients together as part of a Pregnancy Heart Team.1

Dr Vaught: Valvular disease in pregnancy is increasing in the US population. This is likely secondary to the survival of women with repaired congenital heart disease and women with previous histories of endocarditis secondary to polysubstance abuse.5,6 Both groups have a higher tendency to have valvular disease and to have had valvular surgery. The strong collaboration between obstetrics and cardiology is essential for positive outcomes in this special patient population. 

Collaboration of the Pregnancy Heart Team should be tripartite: patient care, education, and research. Patient care is always the priority, and this collaborative effort allows for the consolidation and centralization of resources to streamline care. Education of faculty and trainees is also a common practice. Further, teams should form registries and biobanks at their institutions to collaborate and share data with others in an effort to produce nonbiased, contemporaneous research.  

What are the next steps needed to improve understanding and treatment in this area?

Dr Minhas: Our study3 used national data from delivery admissions to assess for complications among women with valvular heart disease. Future studies should aim to follow large numbers of women with valvular heart disease through their entire pregnancy and the initial postpartum timeframe. We should also enhance efforts to increase awareness among providers, patients, and our medical trainees about CVD during pregnancy, so that we, as a medical community, can improve maternal outcomes.

Dr Vaught: I agree with Dr Minhas. I also think biobanking specimens — maternal serum/plasma, placenta, and umbilical cord blood — in both normal pregnancies and in women with CVD is also necessary to better understand the patient population. Further, translational research that examines the relationship of pregnancy, biomarkers, and cardiovascular imaging is essential.

References

  1. Lewey J, Andrade L, Levine LD. Valvular heart disease in pregnancy. Cardiol Clin. 2021;39(1):151-161. doi:10.1016/j.ccl.2020.09.010
  2. Anthony J, Osman A, Sani MU. Valvular heart disease in pregnancy. Cardiovasc J Afr. 2016;27(2):111-118. doi:10.5830/CVJA-2016-052
  3. Minhas AS, Rahman F, Gavin N, et al. Cardiovascular and obstetric delivery complications in pregnant women with valvular heart disease. Am J Cardiol. 2021;158:90-97. doi:10.1016/j.amjcard.2021.07.038
  4. Johns Hopkins Newsroom. ‘Leaky’ heart valves in pregnant women need more attention than once thought, study suggests. Published online September 2, 2021. Accessed October 20, 2021. https://www.hopkinsmedicine.org/news/newsroom/news-releases/leaky-heart-valves-in-pregnant-women-need-more-attention-than-once-thought-study-suggests
  5. Lindley K, Williams D. Valvular heart disease in pregnancy. J Am Coll Cardiol. Published online February 12, 2018. Accessed October 21, 2021. https://www.acc.org/latest-in-cardiology/articles/2018/02/12/07/29/valvular-heart-disease-in-pregnancy
  6. Kebed KY, Bishu K, Al Adham RI, et al. Pregnancy and postpartum infective endocarditis: a systematic review. Mayo Clin Proc. 2014;89(8):1143-1152. doi:10.1016/j.mayocp.2014.04.024