• Information
  1. Low Maternal and Fetal Risk
  2. High Maternal and Fetal Risk
  3. High Maternal Risk
  4. High Neonatal Risk
  5. Evaluation

A. Low Maternal and Fetal Risk

1. Asymptomatic Aortic Stenosis
   1. Low mean outflow gradient (<50 mmHg)
   2. Normal left ventricular (LV) systolic function
2. Aortic Regurgitation
   1. New York Heart Association (NYHA) Class I or II
   2. Normal LV systolic function
3. Mitral Regurgitation
   1. NYHA Class I or II
   2. Normal LV systolic function
4. Mitral Valve Prolapse
   1. No mitral regurgitation (MR) OR
   2. Mild-to-moderate MR and normal LV systolic function
5. Mild to moderate Mitral Stenosis
   1. Mitral valve area >1.5cm2, gradient <5 mmHg
   2. Absence of severe pulmonary hypertension (P-HTN)
6. Mild to moderate pulmonary valve stenosis

B. High Maternal and Fetal Risk

1. Severe Aortic Stenosis - with or without symptoms
2. Aortic Regurgitation - NYHA Class III or IV
3. Mitral Stenosis - NYHA Class II, III, or IV
4. Mitral Regurgitation - NYHA Class III or IV
5. Valve Associated P-HTN
   1. Severe P-HTN with pulmonary pressures >75% of systolic pressures
   2. Associated with aortic or mitral valve disease (or both)
6. Valve Associated LV Systolic Dysfunction
   1. LV ejection fraction (EF) <40%
   2. Associated with aortic or mitral valve disease (or both)
7. Maternal Cyanosis
8. Any reduced functional status with NYHA Class III or IV

C. High Maternal Risk

1. Reduced LV systolic function: LV EF <40%
2. Previous congestive heart failure (CHF)
3. Previous stroke or transient ischemic attack

D. High Neonatal Risk

1. Maternal age <20 or >35 years with heart valve disease
2. Use of anticogaulant therapy throughout pregnancy
3. Smoking during pregnancy
4. Multiple gestations

E. Evaluation

1. Ideally, full cardiac evaluation should occur prior to conception
2. Echocardiography is the cornerstone of cardiac valve and function evaluation
   1. Pulmonary pressures
   2. Full valve function evaluation
3. Exercise testing - useful if functional capacity can be evaluated
4. Full physical and echocardiographic evaluation at least every trimester
5. Full evaluation whenever functional status changes
6. Specialists must be involved and can guide individualized therapy

References

1. Reimold SC and Rutherford JD. 2003. NEJM. 349(1):52