Valve-in-Valve and Valve-in-Ring Transcatheter Mitral Valve Implantation in Women Contemplating Pregnancy
abstract
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Access this abstract nowBackground
Transcatheter mitral valve implantation (TMVI) is emerging as an alternative to surgical mitral valve replacement in selected high-risk patients. Delaying definitive mechanical mitral valve replacement and the constraints of anticoagulation thanks to TMVI may be an attractive option in young women contemplating pregnancy and suffering from failure of mitral bioprosthesis or annuloplasty. The aim of the study was to evaluate the possibility, safety, and outcomes of pregnancy after TMVI in this population.Methods
From 2013 to 2019, 12 young women contemplating pregnancy underwent transseptal valve-in-valve or valve-in-ring TMVI using the Edwards SAPIEN XT/3 valves and were prospectively followed up at 1 month, 6 months, 1 year, and yearly thereafter.
Results
Mean age of the patients was 30±6 years. Bioprosthesis degeneration was observed in 7 cases and annuloplasty failure in 5. Three valve-in-ring patients required the implantation of a second valve, which led to an overall procedural success rate of 75%. One delayed left ventricular outflow tract obstruction required elective surgical mitral valve replacement. At 6 months/1 year, 83% of the patients were in New York Heart Association classes I/II. Mitral regurgitation was ≤2+ in all the cases and mean gradient was 7±2 mm Hg. Four patients could complete 6 full-term pregnancies. One symptomatic thrombosis occurred and resolved under aspirin and anticoagulation therapy. All others pregnancies were uneventful. Predelivery mean gradient was 11 mm Hg, and systolic pulmonary artery pressure was 32 mm Hg. There were 4 vaginal deliveries and 2 cesarians. Newborns were alive and healthy. At last follow-up, there was no death, and 3 patients required elective surgical mitral valve replacement at 6- to 54-month follow-up.
Conclusions
Our study suggests that, in young women, transseptal TMVI to treat failing bioprostheses may result in good short-term outcomes that allow uneventful pregnancies. The results are less favorable in women with failed annuloplasty rings.
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Additional Info
Disclosure statements are available on the authors' profiles:
For women who have undergone prior mitral valve surgery with progressive valvar dysfunction, the choice of subsequent interventions is often influenced by the desire for future pregnancy. Women with mechanical mitral valves require meticulous monitoring of anticoagulation during pregnancy, and, despite that, have a high incidence of bleeding and thrombotic complications. Therefore, development of safe alternative valvular interventions aimed at delaying mechanical valve placement in women of childbearing age is needed. Fuchs et al report the short-term outcomes of 12 women with prior mitral valve surgery who underwent a transcatheter mitral valve implantation (TMVI) with Sapien (Edwards Lifesciences) valves. The etiology of the mitral valve disease was rheumatic in 75% and endocarditis in the remaining 25%. In this study, 7 women had undergone prior surgical bioprosthetic valve placement and 5 had annuloplasty rings. Procedural success was 100% in the valve-in-valve group, and only 40% in the valve-in-ring group, consistent with prior reports. Importantly, at 5 years, the rate of surgical valve replacement was 47.9%.
A total of 4 women in this cohort subsequently completed 6 pregnancies following TMVI; 3 women did well clinically and were managed with aspirin alone throughout pregnancy; 1 woman did experience early recurrence of valve thrombosis in the setting of uncertain compliance with a vitamin K antagonist and was switched to low-molecular weight heparin and aspirin with a decline in the mean transmitral gradient. She underwent a successful vaginal delivery and did experience a postpartum hemorrhage without hemodynamic instability. Of note, although 6 successful pregnancies were reported, the fetal age at delivery ranged from preterm to at best early-term deliveries (33–37 weeks’ gestation), raising concern for increased rates of preterm birth in this series.
This report suggests that TMVI is reasonable to consider as an alternative to surgical mitral valve replacement in women contemplating pregnancy. However, the rate of surgical valve replacement in the ensuing 5 years was close to 50%, and it should be emphasized that subsequent valve surgery will most likely be required in the future, particularly for those with valve-in-ring prostheses.