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 19 – Recommendations for clinical practice in acquired and congenital native valve disease. 149,150 Heart valve disease Preconception counseling Gestation Maternal risk Fetal risk Intervention Severe rheumatic mitral stenosis FC ≥ II or asymptomatic + PH > 50 mmHg or AF recent onset consider BCV or CPB Increased risk if • HF • AF Death < 3% Prematurity 20% to 30% IUGR 5% to 20% Stillbirth Increases with maternal FC III/IV Beta-blocker diuretic Anticoagulation if AF if Refractory FC III/IV consider BCV or CPB Severe rheumatic aortic stenosis congenital (bicuspid) degenerative Symptomatic or asymptomatic + altered ET or EF < 50% or AVA < 0.7 cm 2 average gradient > 60 mmHg or Bicuspid valve + AAD > 45 mm consider VCP or CPB Increased risk HF - 10% Arrhythmia 3% to 25% Syncope Sudden death Complications - 25% Prematurity IUGR Low birth weight Stillbirth Rest diuretics with criterion If AF beta-blocker or CCB Anticoagulation Severe HF or syncope consider BCV or CPB Mitral insufficiency Significant rheumatic degenerative valve prolapse FC ≥ II or Complicated asymptomatic + EF ≤ 60% + SPAP ≥ 50 mmHg + LVSD ≥ 40 mm consider CPB (plasty or prosthesis) HF AF Risk increases with EF < 35% Low risk Diuretic hydralazine digoxin If refractory HF consider CPB or “mitraclip” Significant rheumatic aortic insufficiency congenital (bicuspid) degenerative Symptomatic FC ≥ II or Unfavorable factors EF < 50% LVDD > 70 mm (75 if rheumatic) LVSD > 50 mm (55 if rheumatic) consider CPB If Bicuspid valve isolated AAD > 45 mm consider Proximal aortic intervention Low risk Asymptomatic normal EF FC > II or EF < 35% HF and/or AF Low risk Diuretic hydralazine digoxin If refractory HF consider If Bicuspid valve AAD > 45 mm consider Proximal aortic intervention AAD: aorta diameter; AF: atrial fibrillation; AoS: aortic stenosis; AVA: aortic valve area; AVM: mitral valve area; BCV: balloon catheter valvuloplasty; CCB: calcium channel blocker; CPB: cardiac surgery with cardiopulmonary bypass; echo: echocardiography; EF: echocardiographic ejection fraction; ET: ergometric test; FC: functional class; HF: heart failure; IUGR: intrauterine growth restriction; LVDD: left ventricular diastolic diameter; LVSD: left ventricular systolic diameter; ME: mitral stenosis; NYHA: New York Heart Association; PH: pulmonary hypertension; SPAP: systolic pulmonary artery pressure. Severe mitral and aortic stenosis are considered MVA ≤ 1.0 cm 2 and AVA < 1.0 cm 2 , respectively. It is estimated that the probability of pregnancy to be maternal-fetal free of events is 58.3% for BPV and 46.9% for MPV 96,153 and no differences in mortality rates for both prosthesis types, were observed . Although it is controversial, BPV may be considered the more adequate form of replacement for women of fertile age, except in adolescent patients, where premature calcification of BPV would favor the choice of MPV. The following factors are related to prognosis of pregnancy: • Prosthesis functional status; • Cardiac rhythm (AF); • Ventricular dysfunction; • NYHA FC; • Prior incidence of IE, HF, or thromboembolism. 3.1.4. Maternal Risk Women with MPV present an estimated risk of 5% for valve thrombosis during gestation; maternal mortality varies between 9% and 20% associated with thromboembolic complications. 96 This incidence of thrombosis in MPV varies according to the anticoagulation regime, but it is signicantly higher during heparin use 154-157 The incidence of thromboembolism with 877