Bioprosthetic aortic valve replacement is a reasonable option for women requiring treatment for aortic valve disease who may be contemplating future pregnancy, analysis of data from the SWEDEHEART registry looking at the long-term pregnancy and cardiovascular outcomes associated with surgical aortic valve replacement (SAVR), has shown.
Ruixin Lu (Karolinska Institutet, Stockholm, Sweden) and colleagues report their analysis of outcomes of aortic valve replacement (AVR) in women of reproductive age in a paper published in the Journal of the American College of Cardiology (JACC), including data from women aged 18 to 40 years who underwent surgery in Sweden between 1997 and 2024.
“Current American and European guidelines recommend bioprostheses over mechanical prostheses in young women contemplating pregnancy,” the authors write, acknowledging that long-term cardiovascular outcomes in this population are not well characterised, as previous studies have been limited by short follow-up, lack of distinction between valve positions, and a primary focus on obstetric rather than cardiovascular outcomes.
The analysis includes a total of 251 women, 93 (37%) who received a bioprosthetic valve and 158 (63%) who received a mechanical valve. Mean age at surgery was 29 years in the bioprosthesis group and 33 years in the mechanical group.
Lu and colleagues report that the 15-year cumulative incidence of delivery was 54% among women with bioprostheses with 47 (50.5%) of women in the bioprosthesis group having had at least one delivery, compared with 15 (9.5%) in the mechanical group.
Women with bioprostheses who delivered were younger, had higher income, and had lower body mass index than those who did not. A total of 22 (24%) women in the bioprosthesis group had more than one delivery.
The 15-year cumulative incidence of spontaneous abortion was 12.6% in the bioprosthesis group and 3.4% in the mechanical valve group, they note. The authors interpret the higher spontaneous abortion rate in the bioprosthesis group as reflecting a greater number of intended pregnancies.
Elsewhere, the study authors detail that the 15-year cumulative incidence of aortic valve reintervention was 46.5% in the bioprosthesis group and 6.9% in the mechanical group. Overall, 40 (43%) of patients with bioprostheses underwent reintervention; of these, 27 (67.5%) received a mechanical AVR and 5 (12.5%) underwent transcatheter aortic valve implantation (TAVI).
Fifteen-year cumulative incidence of all-cause mortality was 5.6% in the bioprosthesis group and 12.7% in the mechanical group.
“In clinical practice, bioprosthetic valves are often recommended for young women desiring pregnancy, and conception is generally advised soon after surgery, before the risk of structural valve deterioration increases,” Lu et al note, adding that women with mechanical valves face specific challenges surrounding conception and pregnancy.
The study has some limitations, the study team notes, including the unavailability of data on anticoagulation management, international normalised ratio values, foetal outcomes, pregnancy intention, and echocardiographic follow-up, but is strengthened by the high quality and completeness of Swedish national health registries, they write.
“Women of childbearing age undergoing bioprosthetic aortic valve replacement had favourable delivery outcomes despite high reintervention rates,” they conclude, adding that these data may help inform shared decision making in this patient population.
