Transcatheter or Surgical Aortic Valve Replacement in Pregnant Women? A Comprehensive Review of the Current Literature: An Interview With Aparna Kuchibhatla
Aparna Kuchibhatla shares background and insights on her article, "Transcatheter or Surgical Aortic Valve Replacement in Pregnant Women? A Comprehensive Review of the Current Literature".
Transcript:
Aparna Kuchibhatla: Hi! My name is Aparna Kuchibhatla, and I'm a third-year medical student at Queen's University, in Kingston, Ontario, Canada, and I'm really excited to be talking a little bit about our paper, titled Transcatheter or Surgical Aortic Valve Replacement in Pregnant Woman? A Comprehensive Review of the Current Literature.
00:28: Could you please tell us about what inspired your group to conduct this study.
Aparna Kuchibhatla: Our research team was really inspired to conduct this study mainly because there's always room to expand on research surrounding women's cardiovascular health. Aortic stenosis is a very well-documented condition, but our team quickly realized that there is still a lot to learn in terms of the management and treatment of the condition during pregnancy. Pregnancy itself is a stage of significant hemodynamic changes, and that often poses a lot of unique maternal and fetal challenges, and that's really what piqued our team's interest to research more on this topic. The overall goal of this paper was really to explore the benefits, limitations, and the clinical outcomes of not only TAVR, but also surgical aortic valve replacement (SAVR) as well as percutaneous balloon aortic valvuloplasty. Our goal with this paper was not only to contribute to the growing literature that already exists on valvular heart disease, but also hopefully spark further investigation into the management of cardiovascular conditions in women, particularly during very important stages of their life, such as pregnancy.
1:55: Can you summarize the risk and benefits associated with TAVR for pregnant patients?
Aparna Kuchibhatla: When we consider the benefits of TAVR, it's important to note that the current data regarding the survival rates and outcomes of TAVR arise from the general population with no reciprocated results in pregnant patients. Some of these benefits include quicker mobilization, earlier recovery times, as well as improved quality of life measures; when applied in the context of pregnancy, it might be beneficial for patients. Now, some of the limitations of the procedure mainly pertain to the risk of fetal irradiation. These can pose complications such as intellectual disability, growth restriction, and pregnancy loss, mainly associated with radiation dosages greater than 100 milligray. So, in the first trimester it's recommended to keep radiation dosages less than 50 milligray, and then, in the second and third trimester, up to 500 milligray of radiation is considered safe. So, for this reason it's really important that the interventional cardiology team as well as the medical physics team have in-depth discussions to determine the safe radiation dose, while also keeping it as minimal as possible. Some of the other risks of the procedure surround long-term concerns of prosthetic valve degeneration mainly in implantation of TAVR in previous SAVR procedures, as well as repeat pregnancies. The TAVR-and-SAVR and TAVR-in-SAVR procedures also increase the risk of valve migration, embolization, paravalvular leak, and patient prosthesis mismatch. There also remains a general uncertainty on the tolerability of future pregnancies in patients who have undergone TAVR procedures in the past. And then, just overall pregnancy itself poses further challenges in relation to the hormone-mediated changes on the aortic wall itself, so this might increase the risk of dissection of the ascending and descending thoracic aorta, and there might also be increased dependency on permanent pacemaking, especially with the self-expanding valves, or in patients that have pre-existing electric conduction abnormalities, which overall increases the risk of long-term complications.
4:42: What are the key considerations for ensuring the safety of both the mother and the fetus during TAVR?
Aparna Kuchibhatla: So, through this study we were able to determine several pre-intra and post-procedural recommendations to ensure both maternal and fetal safety during the TAVR procedure. So, when considering pre-procedural recommendations, it's recommended that the TAVR procedure is performed during the second trimester of pregnancy. This is to reduce the likelihood of spontaneous abortions, spontaneous labor, and teratogenesis, which can all occur during various stages of pregnancy.
For intra-procedural recommendations, it's recommended that conscious sedation is preferred over general anesthesia, and this is to avoid the risk of hypoxia as well as regurgitation and aspiration that can occur during the induction and emergence phases of general anesthesia. For imaging, transesophageal echocardiogram and intravascular ultrasound are recommended for evaluation because of the lower risk of fetal irradiation, compared to the standard CT angiography. It's also important to ensure that minimal fetal and maternal radiation are used, as previously mentioned. This can be achieved through a variety of different strategies, such as using an ideal table length, shortening the frame rate, and just overall reducing unnecessary radiation investigations. To prevent maternal supine hypotension syndrome, as well as aortocaval compression, a 15-degree left uterine displacement is also recommended.
When we think about the post-procedural recommendations, low molecular weight heparin is preferred over unfractionated heparin, mainly due to its superior safety profile, and this is used for short-term anticoagulation. Now, if the patient has significant renal impairment, that's when we would consider using unfractionated heparin. A low dose of aspirin is also recommended for post-procedural antiplatelet therapy. Finally, the American College of Cardiology and Heart Association recommend a multidisciplinary team approach consisting of cardiologists, cardiac surgeons, obstetricians, neonatologists, and anesthesiologists to really provide patient-tailored care to ensure the best possible clinical outcome.
7:35: What advice would you give to pregnant women who are diagnosed with aortic valve issues and are considering their treatment options?
Aparna Kuchibhatla: A key recommendation that we have highlighted throughout our study is the importance of seeking multidisciplinary team discussions, and a multidisciplinary team approach where a range of specialties are really collaborating together. We want to encourage patients to be a part of these conversations and really learn about all the various treatment options that are available to them to reduce both maternal and fetal risks as much as possible. For example, percutaneous balloon aortic valvuloplasty might be a considered treatment option for patients that have a favorable valvular anatomy. Although currently there aren't any large series of studies on this procedure—that might limit the use of the treatment—however, there have been several case reports that have demonstrated favorable results in this population. The other recommendation for patients is to understand the severity of their aortic stenosis through these conversations with their team to determine is it mild, moderate, or severe? As well as discussing the severity of their symptoms, because this will really guide the course of the treatment that they receive.
9:02: Have there been any updates in this space since the completion of the study? And is your team currently engaged in any upcoming research?
Aparna Kuchibhatla: As previously mentioned, there's always opportunity for more research in women's cardiovascular health. Our team is currently working towards publishing a review paper looking into valvular heart disease in women, and we're looking forward to having that out soon.
9:27: Is there anything else you'd like to share with our audience?
Aparna Kuchibhatla: I'd just like to extend a thank you to the Journal of Invasive Cardiology for this opportunity. I speak on behalf of all of my co-authors that we feel very honored and excited to be sharing this work. This review study is really a first looking into TAVR, SAVR, as well as percutaneous balloon aortic valvuloplasty in pregnant patients. We'd like to recommend not only interventional cardiologists and cardiac surgeons to read this paper, but also obstetricians and anesthesiologists, as it really looks into the benefits, limitations, and outcomes of each procedure in pregnancy. Thank you so much.
The transcripts have been edited for clarity and length.
