The impact of pulmonary valve replacement on pregnancy outcomes in women with tetralogy of Fallot

https://doi.org/10.1016/j.ijcard.2021.02.006Get rights and content

Highlights

  • Clinical outcomes of pregnancy were not impacted by pulmonary valve replacement.

  • Right ventricular volumes were stable in mothers with pulmonary valve replacement.

  • Right ventricular size enlarged post pregnancy without pulmonary valve replacement.

Abstract

Background

Pregnant women with repaired tetralogy of Fallot (rTOF) are at increased risk of adverse outcomes. Although pre-pregnancy pulmonary valve replacement (PVR) may be considered in some women to attenuate risk, published data to support this practice are lacking. Our objective was to explore the impact of pre-pregnancy PVR on pregnancy outcomes in rTOF.

Methods

Women with rTOF and cardiovascular magnetic resonance imaging (CMR) before and after pregnancy were included if CMR studies were completed within 3 years of pregnancy. Subjects were compared according to presence (+) or absence (−) of PVR at pre-pregnancy CMR. Pregnancy outcomes (cardiovascular, obstetric, and fetal/neonatal) were documented.

Results

Of the 29 study women identified, 7 were PVR+ and 22 were PVR-. Post-pregnancy, the PVR- group demonstrated interval increase in indexed right ventricular end-diastolic volumes (RVEDVi) (157 ± 28 versus 166 ± 33 ml/m2, p = 0.003) and end-systolic volumes (RVESVi) (82 ± 17 versus 89 ± 20 ml/m2, p = 0.003) as compared with pre-pregnancy, but no significant change in RV ejection fraction, RV mass, or left ventricular measurements. In the PVR+ group, there were no interval changes in RV measurements pre-versus post pregnancy. Interval rate of change in RVESVi of PVR- exceeded PVR+ women (+3.7 ± 5.0 versus −2.2 ± 5.0 ml/m2/year, p = 0.03). Pregnancy outcomes did not differ in PVR+ versus PVR- women.

Conclusions

Pregnancy outcomes did not differ according to PVR status in our cohort. While RV volumes remained unchanged in PVR+ women, interval RV dilation was observed in PVR- women. Additional study of a larger population with longer follow-up may further inform clinical practice regarding pre-pregnancy PVR.

Introduction

Tetralogy of Fallot (TOF) is the most common form of cyanotic congenital heart disease [1]. Notwithstanding successful repair in childhood, important residual hemodynamic sequelae, including pulmonary valve regurgitation (PR), are prevalent and have been associated with late morbidity and increased mortality [2]. Pulmonary valve replacement (PVR) is often performed to restore valve function, to facilitate RV reverse remodeling, and to mitigate risk of adverse outcomes, although published data to support the latter are relatively scarce [3,4]. Survival after primary repair of TOF (rTOF) has improved considerably over recent decades and, as a result, increasing numbers of women are reaching childbearing age. Even in the absence of cardiac disease, anticipated hemodynamic changes in the context of pregnancy are substantial. These include elevation in heart rate and augmentation of stroke volume, in order to achieve an increase in cardiac output of up to 50%, which typically peaks in the third trimester. Less is known about precise physiologic adaptations to pregnancy in women with rTOF.

While it is recognized that pregnancy is generally uncomplicated in the majority of women with rTOF, these women remain at increased risk of adverse pregnancy outcomes as compared with the general population [[5], [6], [7]], with the highest risk observed in those with RV dysfunction and/or severe PR [[8], [9], [10]]. Studies focused on imaging have demonstrated unfavorable RV remodeling as a result of pregnancy in select mothers with rTOF, particularly when the RV is known to be substantially dilated preconceptually [[11], [12], [13], [14]]. Although some advocate for proactive preconceptual PVR in women with significant PR and concomitant RV dilation in order to attenuate risk of poor pregnancy outcomes, data to support this practice are lacking. Therefore, the objective of this study was to explore the impact of pre-pregnancy PVR on clinical outcomes of pregnancy and on serial CMR measurements. We hypothesized that mothers with pre-pregnancy PVR would have superior maternal/fetal outcomes and better preservation of ventricular dimensions following pregnancy as compared with mothers without PVR.

Section snippets

Study population

Women with rTOF receiving clinical care during pregnancy in Boston (Boston Children's Hospital and Brigham and Women's Hospital: Standardized Outcomes in Cardiovascular Care [STORCC] Initiative) or in Toronto (University Health Network and Mount Sinai Hospital) with sequential pre-pregnancy (baseline) and post-pregnancy (follow-up) CMR examinations between 2001 and 2018 were retrospectively identified. Candidates were included if a baseline and a follow-up CMR study were available for analysis

Baseline demographics

Of the 29 women who met inclusion criteria, 7 underwent PVR before pregnancy (PVR+) and 22 did not (PVR-). Among the 7 women in the PVR+ group, 5 women had surgical PVR and 2 had percutaneous pulmonary valve implantation. The majority of women had an underlying diagnosis of TOF with pulmonary stenosis (n = 24) and a smaller number had more complex anatomy consisting of pulmonary atresia (n = 4) or absent pulmonary valve (n = 1). The baseline characteristics of the PVR+ and the PVR- groups are

Discussion

To our knowledge, this is the first study to explore the association between PVR status and pregnancy outcomes in women with rTOF. In keeping with previous studies, cardiovascular, obstetric, and fetal/neonatal outcomes in this cohort of mothers with rTOF were relatively favorable as compared with other forms of moderately complex congenital heart disease [19]. Furthermore, adverse events did not differ according to the presence or absence of pre-pregnancy PVR. A notable observation in this

Conclusions

Clinical outcomes in rTOF mothers and their offspring did not differ according to PVR status. In women without PVR, significant enlargement in RV size was observed following pregnancy, whereas women with pre-pregnancy PVR had no appreciable change in CMR parameters after pregnancy. Future study of a larger population with a longer follow-up may further inform clinical practice regarding indications for pre-pregnancy PVR.

Grant support

Canadian Institutes of Health Research Operating Grant (MOP 119353) to RW. VD is supported in part by a grant through the Adult Congenital Heart Association. The STORCC initiative is funded by the Brigham and Women's Watkins Discovery Award and the Barton Weinberg Family Fund to AMV.

Author statement

Each author listed on the manuscript takes responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation.

Declaration of competing interest

None.

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