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 advantage of avoiding cardiac surgery with CPB, but it requires intensive use of ionizing radiation by means of aortic valve tomography for preliminary study of the structures involved (aortic ring, prosthesis diameter, coronary height, and the thoracic and peripheral arterial system), as well as radioscopy during the procedure, to assist in catheter placement and visualization of prosthesis expansion. Conventional TAVI is thus, not approved, during gestation, due to the high fetal radiation burden. This notwithstanding, arterial ultrasound for evaluation of the arterial system (iliac, aorta, and coronary height), in conjunction with 3-dimensional echo (evaluation of the valve ring) was successful in the first reported case of TAVI during gestation, 373 which used short periods of radioscopy to place the prosthesis. The fact that pregnant women are younger, with healthy arterial vascular beds, facilitates navigation with catheters; nevertheless, there should exist a degree of valve calcification to allow for prosthesis placement, and this is not always found in this group of patients. 5.6.2.5. Valve-in-Valve Procedure for Bioprosthetic Valve Dysfunction BPV dysfunction is very common in young women, and it sometimes requires valve replacement during gestation. In this scenario, valve-in-valve type procedures are promising in order to avoid surgery with CPB. Prostheses are introduced by means of catheters, using the following routes: femoral artery or other arterial accesses to the aorta, femoral vein followed by transseptal puncture and left atrial access, and left ventricular apical (transapical) incision. A case report 374 during pregnancy has described transapical implantation of 2 prostheses, mitral and aortic, with the aid of transesophageal echo and restricted use of fluoroscopy, which made it possible to reach vaginal delivery with positive maternal-fetal results. 5.6.2.6. Coronary Angioplasty Primary percutaneous coronary intervention is the treatment of choice for acute coronary syndrome during gestation, while thrombolysis is less utilized. Coronary angioplasty with conventional stents has been considered safe in cases of obstructive arterial disease due to atherosclerotic disease. While the safety of drug-eluting stents is still not known, the need for dual antiplatelet therapy for a prolonged period of time with this type of stent constitutes a serious restriction to their use during gestation, owing to the hemorrhagic risks. Furthermore, clopidogrel should be interrupted 7 days before delivery, which adds a risk of stent thrombosis. In spontaneous coronary dissection, the indication for angioplasty should consider the technical difficulties and the vascular fragility peculiar to this situation, which increases the risk of extension of coronary damage, in addition to the fact that its success is considered suboptimal. 375 For this reason, most cases of coronary dissection benefit from conservative treatment. 376,377 In situations where coronary angioplasty is indicated, the option to use the latest generation of drug‑eluting stents, which require dual antiplatelet therapy for a shorter time (3 months) may be a safer option. The dilemma of this decision is that obstetric risk (maternal hemorrhage) and cardiac risk (stent thrombosis) must be judged on a case-by-case basis by an interdisciplinary team, because, to date, there are no studies on these circumstances that support decision making. 5.6.3. Key Points • Percutaneous intervention during pregnancy should be indicated in cases of complications refractory to conventional clinical treatment or in conditions of imminent risk of maternal life; • Percutaneous intervention should always be performed after discussion with the Heart Team in Tertiary Cardiology Services. 5.7. Cardiovascular Emergencies 5.7.1. Acute Heart Failure Circulatory overload during the pregnancy and postpartum period in patients with structural heart disease, even if it is asymptomatic, may be responsible for acute heart failure (AHF), 378 treating it during gestation can lead to improvement of symptoms and prevention of maternal death. The orientation of attendance follows the recommendations for patients with HF in the emergency room 345 (Figure 12), but it is necessary to consider the risks of medication use regarding the mother, the fetus, labor, and lactation, as well as necessary adjustments according to gestational age. It is worth mentioning that in addition to the symptoms of CHF, the identification of systemic and/or pulmonary congestion and low output, supported by subsidiary exams, define the determining cause in most cases. 345,378,379 Laboratory examinations should be part of the investigation of AHF during pregnancy, and they include the following: electrolyte dosage, BNP, 348,380 renal function, markers of myocardial necrosis, thyroid profile, blood count, and other infectious parameters. Interaction with the obstetric team is mandatory to determine both gestational age and parameters of fetal vitality and viability. Eventual indication of therapeutic delivery and the route of delivery should be part of the algorithm for attending cases with AHF during pregnancy. Acute dyspnea during pregnancy should include the following differential diagnoses: AMI, pulmonary congestion in preexisting heart disease, PPCM, PTE, and myocarditis. 222 Orientation for differential diagnosis may be summarized by the following points: • AMI: dyspnea and angina pain; over 35 years of age; history of tobacco use and use of contraceptives with estrogen components; elevated serum troponin levels; echo with alterations in segmental motility. Definitive diagnosis is made by coronary cineangiography; • Preexisting heart disease: Dyspnea is more frequent during the second and third trimesters. Serum levels of BNP may be elevated, and echo shows structural cardiac injury. In Brazil, acute pulmonary edema is common as the first manifestation of mitral stenosis, from the second trimester of gestation on; 917