ABC | Volume 114, Nº5, May 2020

Statement Brazilian Cardiology Society Statement for Management of Pregnancy and Family Planning in Women with Heart Disease – 2020 Arq Bras Cardiol. 2020; 114(5):849-942 Table 18 – Risk classification for heart valve disease during pregnancy. High risk Intermediate risk Acceptable risk Severe mitral stenosis BPV with moderate dysfunction Mild heart valve disease Severe aortic stenosis Severe pulmonary stenosis BPV without dysfunction Stenotic/calcified BPV MPV with dysfunction Heart valve disease + significant PH (PAP ≥ 50 mmHg) MPV Heart valve disease + LVEF normal Mitral MPV > risk of aortic MPV Aortic insufficiency + aortic disease Aortic insufficiency + aortic disease Heart valve disease without unfavorable factors Marfan syndrome (AAD > 45 mm) Marfan syndrome (AAD between 40 and 45 mm) Bicuspid aortic valve (AAD > 50 mm) Bicuspid aortic valve (AAD 45 to 50 mm) Heart valve disease + LVEF < 35% Patient requires use of anticoagulants AAD: ascending aorta diameter; BPV: bioprosthetic valve; LVEF: left ventricular ejection fraction left ventricular ejection fraction; MPV: mechanical prosthetic valve; PAP: pulmonary artery pressure; PH: pulmonary hypertension. Severe mitral and aortic stenosis are considered mitral valve area ≤ 1.0 cm 2 and aortic valve area < 1.0 cm 2 , respectively. and controlling pulmonary congestion, always paying attention to perinatal side effects, such as hypoglycemia, hyperbilirubinemia, and polycythemia, which have not been verified in these recommended doses. Acute AF should be promptly reversed by electric cardioversion in women with mitral heart valve disease, given that this procedure is considered harmless to the fetus, and it has the advantage of avoiding use of drugs at levels that are, at times, toxic. Additionally, atrial or ventricular ectopic beats and asymptomatic atrial tachycardia do not require the use of antiarrhythmic drugs. In order to control heart rate in patients with permanent AF, beta-blockers, or non-dihydropyridine calcium channel blocker (CCB) should be considered, in addition to anticoagulation. The need for intervention in heart valve disease during gestation is due to cases that are refractory to clinical treatment. Percutaneous procedures should be preferable to cardiopulmonary bypass (CPB) surgery. In aortic stenosis, balloon catheter valvuloplasty (BCV) has been indicated for heart valve disease whose etiology is congenital or in attempts to save the mother’s life in extremely severe cases. In mitral stenosis, it requires the absence of thrombi in the left atrium, at most mild mitral insufficiency, and Wilkins echocardiographic score ≤ 8. 149 3.1.2. Key Points • Stenotic valve lesion leads to more complications than regurgitation; • NYHA FC I/II in stenotic lesions do not guarantee good maternal evolution; • Complicating factors significantly increase the risk of heart valve disease; • Percutaneous intervention should be considered before gestation in women with severe mitral and aortic stenosis, even in asymptomatic patients; • Pregnancy does not change the criteria for indicating BCV; • Pharmacological treatment of complications during gestation should be considered as the first therapeutic option; • Prophylaxis of rheumatic disease should be maintained throughout gestation; • Postpartum consultation, in addition to maternal clinical examination and evaluation of the baby’s health, includes medication adjustments, lactation stimulation, and contraceptive counseling. 3.1.3. Valve Prosthesis The prevalence of rheumatic disease in Brazil and the growing number of patients with congenital heart disease who require valve replacement have led to an increase in women with valve prostheses in childbearing age. One favorable factor, in this age range, is left ventricular performance, which is generally preserved. From the hemodynamic point of view, valve prostheses improve functional capacity and promote clinical evolution during pregnancy. Biological prostheses have attributes that are favorable to evolution of pregnancy, as they do not require anticoagulation, and they are consideredWHO-risk II. Nevertheless, they have limited durability, with the possibility of short-term reoperation, including during pregnancy. Bioprosthetic valve (BPV) dysfunction due to calcification has poor evolution, and it leads to pulmonary congestion and low cardiac output, both of which are refractory to clinical treatment, in addition to causing a high risk of sudden death (WHO-risk IV). The occurrence of BPV calcification during pregnancy makes surgical indication for valve replacement mandatory, regardless of gestational age. 152 In contrast, gestation in women with mechanical valve prostheses (MPV) is considered WHO risk III. The risk of thrombosis due to maternal hypercoagulability and difficulties with long-term anticoagulation are associated with a variable incidence of embolic accidents, spontaneous abortion, warfarin embryopathy, and maternal and neonatal hemorrhagic phenomena. 96 876