In the current issue of Cardiovascular Innovations and Applications (Volume 2, Number 4, 2018, pp 439-446(8); DOI: https://doi.org/10.15212/CVIA.2017.0027, researchers Yee-Ping Sun and Patrick T. O'Gara, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA present a case study of management of rheumatic mitral regurgitation in a woman contemplating pregnancy.
Management of rheumatic mitral regurgitation in a woman contemplating pregnancy presents unique challenges for the clinician. When tasked with taking care of this type of patient, attention needs to be paid to the patient's functional status to determine if symptoms are present. In addition to this clinical assessment, transthoracic echocardiography is also critical. It provides insight into the etiology of the mitral regurgitation, assesses for the presence of concomitant mitral stenosis or other valvular abnormalities, characterizes the severity of mitral regurgitation through an integrative approach and identifies high risk findings including progressive left ventricular (LV) dilation and LV dysfunction.
Surgical intervention is recommended for symptomatic patients and in asymptomatic patients with evidence of progressive LV dilation and a LV ejection fraction of less than 60%. While the presence of pulmonary hypertension and atrial fibrillation have been shown to be risk factors in degenerative mitral regurgitation, the same has not been demonstrated in rheumatic mitral valve disease. While mitral regurgitation may be reasonably well tolerated during pregnancy, symptomatic patients are at higher risk for adverse maternal and fetal outcomes, and therefore, it is recommended that mitral valve surgery be performed prior to pregnancy.
Once the decision has been made to proceed to surgery, mitral repair, performed at a Heart Valve Center of Excellence is recommended if possible due to improved outcomes. Mitral valve repair is possible in >80% cases of rheumatic mitral regurgitation. If repair is not possible, replacement with either a bioprosthetic or mechanical valve are reasonable options. There are advantages and disadvantages to each approach and the choice of prosthesis should be a shared decision between the patient and her treatment team.