Pregnancy & Heart Valve Disease: 15+ Important Facts
Written By: Adam Pick, Patient Advocate & Author
Medical Experts: Dr. Joanna Chikwe, MD, Chair of Cardiac Surgery, and Rose Tompkins, MD, Associate Director of the Congenital Heart Program at Cedars-Sinai Medical Center
Published: June 9, 2021
Patients with mild, moderate and severe heart valve disease are often confused about the realities of getting and/or staying pregnant.
To address the common misconceptions and learn the important facts about valvular disorders and giving birth, we interviewed Dr. Joanna Chikwe, the Chair of Cardiac Surgery, and Dr. Rose Tompkins, the Associate Director of the Adult Congenital Heart Program, at Cedars-Sinai Medical Center in Los Angeles, California. Here are the highlights of this special interview:
Key Learnings from Dr. Chikwe and Dr. Tompkins
Dr. Chikwe and Dr. Tompkins shared many important insights in this video. Here are key learnings for patients and their partners to consider:
- Pregnancy is often considered “Nature’s Stress Test”. The reason is that cardiac output will increase 100% during a pregnancy to keep the mother healthy and provide the nutrients required for fetus development. That said, it is critically important that a mother is and remains healthy before and during a pregnancy.
- For patients with heart valve disease… The use of Preconception Counseling with a cardiologist can help a family plan and manage all facets of a pregnancy. The goal of an effective Preconception Counseling program is to “optimize” the pregnancy relative to a heart valve disorder and provide multiple, monitoring benchmarks to guide a safe and healthy pregnancy.
- The potential impact of heart valve disease on a pregnancy varies from the perspectives of a heart surgeon and a cardiologist. For Dr. Chikwe, a heart surgeon, one of her concerns is specific to the utility of appropriate heart valve replacement devices. For example, Dr. Chikwe’s research suggests that female patients who receive a mechanical valve replacement are more likely to lose their child during pregnancy compared to women who had (i) a heart valve repair or (ii) a tissue valve replacement. For Dr. Tompkins, her concerns are managing and optimizing the pregnancy to avoid any miscarriages or interventions for the patient and/or the child during pregnancy.
- Pregnant mothers with heart valve disease need to be carefully monitored throughout the pregnancy. There are risks for mothers with heart valve disease including, but not limited to, heart failure, diuresis, going on bed rest, pre-mature delivery and abnormal heart rhythms (e.g atrial fibrillation).
- The Cedars-Sinai Medical Center has many success stories delivering healthy children by parents diagnosed with heart valve disorders including aortic stenosis and mitral regurgitation. To support patients who want to get pregnant, Cedars-Sinai has committed extensive resources and hired world-renowned experts to research heart valve disease, pregnancy and women’s health. Newly launched initiatives at Cedars-Sinai include the Barbara Streisand Women’s Heart Center and the Guerin Family Congenital Heart Program.
- A key misconception for female patients with heart valve disease is that they cannot get pregnant. For this reason, patients are often surprised to learn they are indeed pregnant. For that reason, Dr. Tompkins recommends contraception to patients who are not attempting to get pregnant.
- For heart valve patients who want to get pregnant at some point in their lives, Dr. Chikwe’s best piece of advice is to get a heart valve repair if possible. There are several reasons for this: patients will keep their own tissue, less risk of infection, reduced risk of stroke, the natural architecture of the patient’s valve is retained, longer durability, and freedom from re-operation.
Thanks Dr. Chikwe, Dr. Tompkins & Cedars-Sinai!
Many thanks to Dr. Chikwe and Dr. Tompkins for taking the time to share these important insights from their clinical experiences and research specific to heart valve disease and pregnancy. An additional thanks goes to Cedars-Sinai for making this topic such an important part of their cardiac care offerings for patients.
- See Dr. Chikwe’s Interactive Surgeon Profile
- Visit Dr. Tompkins Profile at Cedars-Sinai Website
- Explore the Cedars-Sinai Heart Valve Microsite
Keep on tickin!
P.S. For the hearing impaired members of our community, I have provided a written transcript of this video below.
Adam: Hi, everybody. It’s Adam with heartvalvesurgery.com. This is a very important doctor question and answer session all about pregnancy and heart valve disease. I’m thrilled to be joined by two leading physicians from Cedars-Sinai Medical Center in Los Angeles, California. They are Dr. Joanna Chikwe, who’s the founding chair of cardiac surgery, and Dr. Rose Tompkins, who’s the associate director of the adult congenital heart program. Dr. Chikwe and Dr. Tompkins, we’ve got a lot of important information to get to today. Let’s start with one of the patient questions which is how important is cardiac function during pregnancy.
Dr. Chikwe: That’s a great question. We call pregnancy nature’s stress test. That’s because your heart has to work twice as hard during pregnancy to do the job for both the mother and the child. It is really, really important to get yourself as healthy as possible, particularly if you’ve got valve disease, if you’re thinking of getting pregnant.
Dr. Tompkins: I would say that a preconception counseling with a cardiologist really is a priority. If you have valvular heart disease and you’re thinking is pregnancy in my future or you’re just curious about family planning opportunities, highly encourage you to seek out your cardiologist for that very dedicated specific counseling and really one that has a focus not only in valvular heart disease but comfortability in pregnancy as well so that you’re really hearing all the options and making sure you’re optimized as best as possible before proceeding with that nature stress test, as Dr. Chikwe mentioned.
Adam: For someone who’s never heard of preconception counseling, can you share with our community what that is?
Dr. Tompkins: Absolutely, that’s a great question. I think that the way I would phrase it is that you’re having a one-on-one meeting with the cardiologist specifically to talk about what your risk with pregnancy would entail. Before you go and embark on the fun part of conceiving, so to speak, really having that opportunity to understand what is involved, if you were to go through that pregnancy, what would that journey look like, what would be the monitoring that a cardiologist would want to do, understanding if you would need to be followed by a maternal fetal medicine doctor, which is a high-risk OB physician through your pregnancy. All of this just really helps with planning and I highly encourage bringing your partner along as well so that they can ask questions and feel fully informed because it really is a family decision at that point in time.
Adam: Thanks so much for that very helpful explanation, Dr. Tompkins. One of the big questions that came in was how does valve disease impact the development of a child during pregnancy?
Dr. Chikwe: I would say that Rose and I have a very different perspective on this. As a surgeon, I tend to see patients with much worse valve disease and much more serious problems and they may have actually had valve surgery and often valve replacements. Research that my team did show that, for example, in the worst-case scenarios, the type of valve replacement is a really important factor in your chances of having a safe and healthy pregnancy. With women that have had mechanical valve replacements, much, much more likely to lose their pregnancy than women that have had valve repairs or biological valve replacements. I’m curious to see what your experience has been, Rose.
Dr. Tompkins: Yeah, so Dr. Chikwe, couldn’t agree more. I think that the mechanical valves have been shown by far on many models for our pregnant patients to lead to worse outcomes. Particularly, as you mentioned, miscarriages can be at the top of that list or preterm delivery, small for gestational age. There are things that would need to be monitored very closely, both for the mom and then maternal fetal medicine OB for the baby’s health as well. In general, if the valve disease is optimized and if the patient has a bioprosthetic valve if they’ve already had to undergo valve replacement, in general, we think that those risks to the fetus are a little less in that the miscarriage rate is lower and we are able to often bring those patients to term.
Adam: A follow-up and very important question is all about mom. Are there any unique concerns for moms with valve disease during pregnancy?
Dr. Chikwe: For moms that have got valve disease that hasn’t been operated on, we always worry about the disease progressing and we’re desperately trying to plan ahead of time. Is it something that needs a surgical fix before the pregnancy? Can it wait until after the pregnancy? Because the last thing we want to do is cardiac surgery during pregnancy and that really underlines the importance of this preconception counseling. For moms that have valve replacements, again, it makes a huge difference to them during pregnancy and the risk of bleeding is obviously much, much higher with a mechanical valve. Generally, I think it’s just absolutely key to be with a really experienced team.
Dr. Tompkins: Most importantly, moms with valvular heart disease, some of the risk that they can encounter with pregnancy are heart failure. What that means is that the heart function is having difficulty keeping up with the stress test of pregnancy, so to speak. As Dr. Chikwe mentioned in the beginning, the cardiac output really has to rise to the challenge and will increase by upwards of 50% from preconception or pre-pregnancy levels. If the valve is not functioning well, it makes the pump less efficient and so you may not need that challenge. Moms may need to get admitted, have issues with needing diuresis, like getting Lasix, which is a diuretic through the IV, bed rest, being monitored, perhaps an earlier delivery depending on how bad their symptoms are, or worst-case scenario, a valve intervention during pregnancy, which we really want to avoid at all costs. The other thing that sometimes can pop up is abnormal heart rhythms or arrythmia with pregnancy. Valvular heart disease can make a mom more prone to experiencing that and oftentimes can be managed medically, worst-case scenario, with a cardio aversion or things like that, but again, these are the risks that we would like to discuss with patients ahead of time and things that we would monitor for with pregnancy.
Adam: Thanks for sharing a lot of those concerns that parents should be looking out for during a pregnancy. Maybe we could shift gears and talk about the miracle of birth. Dr. Tompkins, I know you’re just coming from a long lecture. Can you share some of the incredible outcomes that you and your team there at Cedars are having for parents with valve disease that are giving birth?
Dr. Tompkins: Absolutely, and I think that while we’re trying to paint a very realistic picture in being aware of all of the potential risks, it’s really important to highly that despite all of this, we can actually take a lot of patients very successfully through pregnancy where moms and babies both do quite well. I actually can prevent many patients from hopefully seeing Dr. Chikwe. That’s not the best time to meet Dr. Chikwe. From our perspective, really having that chance to optimize you before a pregnancy, meeting the team that’s really dedicated to your success and monitoring you. We can really mitigate many of these risks and really have a beautiful and wonderful experience on the other side. Actually, that’s one of my joys of this job, actually, is really seeing these young families come together. It’s always so happy to meet the new family member.
Adam: It is wonderful to hear about those special moments that you’re having with your patients there at Cedars. Another question that came in is are there any misconceptions about heart valve disease and pregnancy?
Dr. Tompkins: Oftentimes, many of our patients, when they come especially from pediatric care, are told I cannot get pregnant or do not get pregnant, and they misinterpret that as perhaps they are biologically incapable of getting pregnant. I find that that’s a common misconception and so they’re often not using contraception. In fact, many patients are perfectly capable of getting pregnant and being really clear that should not get pregnant is very different than cannot. Contraception also really has to be part of those conversations with these patients as well as we really believe that planned pregnancy is the best pregnancy.
Adam: Dr. Tompkins, I loved hearing about that misconception. I want to turn it over to Dr. Chikwe. Dr. Chikwe, how about you? Are there any misconceptions with your patients about pregnancy?
Dr. Chikwe: I’d say the largest misconception is also a misconception that we have to deal with any young patient with valve disease that needs it corrected. That’s the misconception that valve replacements, particularly a mechanical valve replacement, is a solution for life. It can be but it’s not the best solution for life for many, many patients. The best solution is a valve repair, particularly if you’ve got mitral valve disease or tricuspid valve disease and a leaking aortic valve. It really ensures if you’re a woman of child bearing age that your pregnancy is most likely to be safe, both for you and for your child.
Adam: Really important point, Dr. Chikwe. I imagine the patients out there are wondering why would a valve repair be potentially safer and give me more likelihood of having a child compared to a valve replacement?
Dr. Chikwe: That’s a really great question. I would say there are three reasons why a successful valve repair is always going to be better than a valve replacement. The first reason is it’s an immediate reason, you’re keeping your own natural tissue that’s much less likely to get blood clots that can cause strokes or infected. It’s the best thing for you, much, much better than a valve replacement. The second reason is that a valve repair keeps the natural architecture of your heart so not only your valve but your whole heart still works better. It’ll last you longer. The third reason why a valve repair is better is that it lasts longer. You’re much less likely to need repeat surgery in the future if you have a successful valve repair than if you have a valve replacement.
Adam: Dr. Chikwe and Dr. Tompkins, I’ve got to ask you, what is your number one piece of advice for a patient with heart valve disease who is considering getting pregnant?
Dr. Chikwe: I think our number one piece of advice, and it’s the thing that we wish every woman knew, is just the importance of finding an expert team. Each mother is so different and we’ve just scratched the surface today. What you want is a team that can manage any aspect of heart disease, any aspect of a pregnancy, however high risk. It’s a place like Cedars where we have the Barbara Streisand Women’s Heart Disease Center and the Guerin Congenital Heart Program. That just gives us a wonderful range of experts that are able to manage even the most high-risk and complex pregnancy safely.
Adam: Dr. Chikwe, Dr. Tompkins, I can’t tell you how thankful I am to hear about the resources and the research that’s being done there at Cedars. Being specialists in this field, I’m curious to know, is there anything else that you and your team and working on to help patients with valve disease during pregnancy?
Dr. Tompkins: Yes, thank you for the opportunity to mention we’re really excited about a registry that’s coming. It’s the HOPE registry. It stands for heart outcomes and pregnancy expectations. It’s one of the first registry of its kind in the United States that’s going to be following women with all types of cardiac disease, including valvular heart disease, and what happens with pregnancy so that we can better optimize outcomes. We’ve never had a registry like this in the United States. It’s going to be multi-institutional, a lot of different places, including Cedars participating. I have to say it’s been spearheaded out of the Saint Luke’s Medical Center in Kansas City, Missouri. We’re very thankful for this opportunity and we’re really looking forward to joining this in the near future.
Adam: Dr. Chikwe and Dr. Tompkins, I can’t thank you enough for taking time away from your very busy practices there at Cedars and educating our community about heart valve disease and pregnancy. Thanks as always from our community for being such a great supporter of patients with heart valve disease. Thank you so much.
Dr. Chikwe: Thank you, Adam. It’s always a pleasure.
Dr. Tompkins: Really appreciate the opportunity. This was wonderful. Thank you.
Adam: All right, Dr. Chikwe, Dr. Tompkins, bye.
Dr. Chikwe: Bye.
Dr. Tompkins: Bye.