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 Prevention of premature labor with the use of natural progesterone suppositories (50 mg, every 12 hours during the intra- and postoperative) is preferable, given that indometacin may lead to closure of the arterial canal, especially after 26th week of gestation. 365 Cardiac surgery, even though it constitutes a high risk for pregnancy, should be indicated for clinical conditions without other therapeutic options for maternal survival. Surgical procedures in emergency situations are significantly correlated with maternal complications during the postoperative period; for this reason, the moment of surgical indication has direct implications on maternal-fetal results. 361,366 5.5.1. Key Points • Cardiac surgery during pregnancy should be indicated in clinical conditions without other therapeutic options for maternal survival; • Emergency surgery is significantly correlated with maternal complications during the postoperative period; • Cardiac surgery during pregnancy requires differentiated precautions and a hospital protocol. 5.6. Percutaneous Cardiac Intervention 5.6.1. General Principles The use of percutaneous interventions during gestation has gradually increased, driven by their greater availability and by the risks imposed during surgery with CPB. In general, these interventions are considered during gestation for severe symptomatic heart diseases whose treatment cannot be postponed because they pose risks to the mother’s life. 52 The goal of percutaneous intervention during gestation is to save the mother’s life and protect the fetus from the potential risks of radiation. Accordingly, proposing that intervention be performed at the beginning of the second trimester takes the following into consideration: (1) organogenesis is almost complete; (2) fetal thyroid function is not active; (3) uterine volume is moderately increased (greater distance between the fetus and the maternal thorax); 4) facility of using barrier devices for protection. 52 An alternative method to protect the fetus is by using echo (transthoracic, esophageal, or 3-dimensional) as a substitute to fluoroscopy. This makes it possible to place the catheters and to measure valve orifice diameters and aortic coronary outflow position; it also serves as a guide for balloon catheter valvuloplasty procedures and prosthetic valve insertion, including valve-in-valve procedures, and it assists coronary stent release. Fluoroscopy should follow the criteria that include; (1) low radiation doses, (2) abdominal shielding, (3) distancing direct radiation from the abdominal region. Procedure duration should be as short as possible, because the risk of radiation to the fetus must always be taken into consideration. Nevertheless, this concern should not impede the use of essential diagnostic procedures, making use of the best available method for the given clinical situation. 52 5.6.2. Percutaneous Valve Interventions 5.6.2.1. Balloon Catheter Valvuloplasty in Mitral Stenosis BCV in mitral stenosis should preferably be performed during the second trimester of gestation, and it should be indicated for women with significant mitral stenosis in NYHA FC III/IV, who do not respond satisfactorily to conventional clinical treatment. 52 The results of BCV, when its indications are followed, have been shown to be superior to those of conventional surgery, with lower mortality and better clinical condition in approximately 80% of cases. 367 The criteria for indicating mitral BCV include the following: • Absence of: (1) severe mitral regurgitation; (2) concomitant valve or coronary lesion requiring correction; (3) left atrial thrombus proven by transesophageal echo; • Compatible anatomical condition of the mitral valve, namely: (1) certain flexibility; (2) non-excessive calcification; (3) commissural fusion; (4) approachable subvalvular portion; • Wilkins echocardiographic score equal to or less than 8, allowing for better immediate and long-term result. 368 Expanding to include patients with Wilkins score up to 10 as a result of pregnancy is controversial, because the potential for complications such as acute mitral insufficiency can be fatal. In very special situations, mitral BCV with an index above 8 requires previous discussion with a heart team and availability of resources in the event that emergency surgery is necessary. 369 5.6.2.2. Aortic Stenosis Patients who present severe aortic stenosis withmanifestations of HF, limiting angina, and syncope during pregnancy are indicated for valve intervention, and balloon aortic valvuloplasty (BAV) may be performed by an experienced operator. 370 In adolescents, it has good immediate and long‑term results; in patients in higher age ranges, however, results are worse. BAVmay thus serve as a “bridge” 371 to temporary improvement in clinical condition, making it possible to reach gestational age for safe delivery in favorable hemodynamic conditions. It is worthwhile to remember that, when the procedure is performed, conventional rescue surgery should be available in the event of emergency. It is, furthermore, essential that, after gestation, these patients receive follow up with clinical examinations and periodic echo to determine the eventual need for definitive heart valve disease correction. 5.6.2.3. Congenital Pulmonary Valve Stenosis Severe, symptomatic pulmonary valve stenosis (PVS) with manifestations of HF, arrhythmias, or syncope is uncommon during pregnancy. In this situation, BCV has been indicated with immediate success. 372 5.6.2.4. Percutaneous Implantation of Prosthetic Valve In recent years, we have witnessed the development of transcatheter aortic valve implantation (TAVI). It has the great 916