Physiologic multivalvular regurgitation during pregnancy: a longitudinal Doppler echocardiographic study

Campos, Orlando; Andrade, José L.; Bocanegra, José; Ambrose, John A.; Carvalho, Antônio Carlos; Harada, Kyoko; Martinez, Eulógio E.

doi:10.1016/0167-5273(93)90010-e

Cited by 107 publications

(34 citation statements)

References 19 publications

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“…These results stand in contrast with the clinical observation that about three times more women experience right-side regurgitation than left-side regurgitation (9). Returning to the full ANOVA results, we can isolate some intriguing, valve-specific remodeling effects associated with pregnancy.…”

Section: Discussioncontrasting

confidence: 54%

“…Indeed, valvular regurgitation is predominantly right-sided in pregnant women. Whereas 95% of pregnant women experience regurgitation on their right-side (low pressure) pulmonary and tricuspid valves, only 27% experience regurgitant flow on the mitral and none in the aortic valve (9). One explanation for this pattern is that only the left-sided valve leaflets remodel more during pregnancy and thus can better maintain coaptation.…”

mentioning

confidence: 95%

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Pregnancy-induced remodeling of heart valves

Pierlot

Moeller

Lee

et al. 2015

American Journal of Physiology-Heart and Circulatory Physiology

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Recent studies have demonstrated remodeling of aortic and mitral valves leaflets under the volume loading and cardiac expansion of pregnancy. Those valves' leaflets enlarge with altered collagen fiber architecture, content, and cross-linking and biphasic changes (decreases, then increases) in extensibility during gestation. This study extends our analyses to right-sided valves, with additional compositional measurements for all valves. Valve leaflets were harvested from nonpregnant heifers and pregnant cows. Leaflet structure was characterized by leaflet dimensions, and ECM composition was determined using standard biochemical assays. Histological studies assessed changes in cellular and ECM components. Leaflet mechanical properties were assessed using equibiaxial mechanical testing. Collagen thermal stability and cross-linking were assessed using denaturation and hydrothermal isometric tension tests. Pulmonary and tricuspid leaflet areas increased during pregnancy by 35 and 55%, respectively. Leaflet thickness increased by 20% only in the pulmonary valve and largely in the fibrosa (30% thickening). Collagen crimp length was reduced in both the tricuspid (61%) and pulmonary (42%) valves, with loss of crimped area in the pulmonary valve. Thermomechanics showed decreased collagen thermal stability with surprisingly maintained cross-link maturity. The pulmonary leaflet exhibited the biphasic change in extensibility seen in left side valves, whereas the tricuspid leaflet mechanics remained largely unchanged throughout pregnancy. The tricuspid valve exhibits a remodeling response during pregnancy that is significantly diminished from the other three valves. All valves of the heart remodel in pregnancy in a manner distinct from cardiac pathology, with much similarity valve to valve, but with interesting valve-specific responses in the aortic and tricuspid valves. HEART VALVES ARE COMPLEX and dynamic biological structures. They play important roles toward efficient cardiac pumping, ensuring unidirectional blood flow while opening and closing 3 billion times in a lifetime. The extent and the mechanisms via which the valves may adapt to changing loading conditions in either physiology or pathology remain unclear. Many investigations of valve adaptation have focused on physiological development (8,20,(51)(52)(53) or pathological conditions such as left ventricular (LV) dysfunction (10), mitral valve regurgitation (58), myxomatous degeneration (19), or heart failure (17). Recent studies from our laboratory, however, have demonstrated the capacity of maternal heart valve leaflets to remodel under the altered hemodynamics of pregnancy, a nonpathological condition (38,39,60). Pregnancy is accompanied by an increase in blood volume and cardiac output of ϳ50%, as the maternal circulation accommodates the developing fetoplacental unit. This volume overload produces cardiac enlargement (21, 45, 60) with expansion of valve orifices (areas increasing from 12-53% in humans; see Refs. 9 and 43). These changes in geometry then elevate...

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Section: Discussioncontrasting

confidence: 54%

mentioning

confidence: 95%

Pregnancy-induced remodeling of heart valves

Pierlot

Moeller

Lee

et al. 2015

American Journal of Physiology-Heart and Circulatory Physiology

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“…Echocardiography is the noninvasive investigation of choice in pregnancy because it provides important cardiac structural and functional information and does not involve exposure to radiation (75,76). It should be arranged urgently in the setting of suspected HF in the pregnant patient.…”

Section: Evaluation Of Hf In Pregnancymentioning

confidence: 99%

The 2010 Canadian Cardiovascular Society guidelines for the diagnosis and management of heart failure update: Heart failure in ethnic minority populations, heart failure and pregnancy, disease management, and quality improvement/assurance programs

Howlett¹,

McKelvie²,

Costigan³

et al. 2010

Canadian Journal of Cardiology

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“…Aortic regurgitation is not seen in a normal pregnancy. 46 Echocardiography is the most common imaging technique used in pregnancy, but it has some limitations, including observer variability in interpretation and poor image quality in some women. Cardiovascular magnetic resonance use in pregnancy is safe for the mother and fetus 47 and assesses left ventricular volumes better.…”

Section: Transthoracic Echocardiography and Cardiovascular Magnetic Rmentioning

confidence: 99%

Cardiovascular Physiology of Pregnancy

2014

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1003P regnancy is a dynamic process associated with significant physiological changes in the cardiovascular system. These changes are mechanisms that the body has adapted to meet the increased metabolic demands of the mother and fetus and to ensure adequate uteroplacental circulation for fetal growth and development. Insufficient hemodynamic changes can result in maternal and fetal morbidity, as seen in preeclampsia and intrauterine growth retardation. In addition, maternal inability to adapt to these physiological changes can expose underlying, previously silent, cardiac pathology, which is why some call pregnancy nature's stress test. Indeed, cardiovascular disease in pregnancy is the leading cause of maternal mortality in North America. 1 We therefore review here the normal cardiovascular physiology of pregnancy to provide clinicians with a basis for understanding how the presence of cardiovascular disease may compromise the mother and fetus and how their decisions about medical care may need adjustment. Maternal Hemodynamic ChangesPregnancy is associated with vasodilation of the systemic vasculature and the maternal kidneys. The systemic vasodilation of pregnancy occurs as early as at 5 weeks and therefore precedes full placentation and the complete development of the uteroplacental circulation.2 In the first trimester, there is a substantial decrease in peripheral vascular resistance, which decreases to a nadir during the middle of the second trimester with a subsequent plateau or slight increase for the remainder of the pregnancy 3 ( Figure 1). The decrease is ≈35% to 40% of baseline. Systemic vascular resistance increases to near-prepregnancy levels postpartum, 4 and by 2 weeks after delivery, maternal hemodynamics have largely returned to nonpregnant levels.5 Increased vascular distensibility, or compliance, has been observed in normal human pregnancy starting in the first trimester.6 Systemic vascular resistance increases to nearprepregnancy levels postpartum. 4 Vasodilation of the kidneys results in a 50% increase in renal plasma flow and glomerular filtration rates by the end of the first trimester. This results in decreases in serum creatinine, urea, and uric acid values. Cardiac OutputCardiac output increases throughout pregnancy.8 Invasive measuring techniques are rarely used during pregnancy, so echocardiography is most commonly used to assess hemodynamics in pregnancy. Cardiac output measurements are usually made with the mother in the left lateral decubitus position to avoid positional variation. The sharpest rise in cardiac output occurs by the beginning of the first trimester, and there is a continued increase into the second trimester.9 After the second trimester, there is debate as to whether cardiac output increases, decreases, or plateaus. By 24 weeks, the increase in cardiac output can be up to 45% in a normal, singleton pregnancy. 10Echocardiography and cardiac magnetic resonance imaging estimates of cardiac output trend similarly in pregnancy. In a comparative study of 34 normal pregna...

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Physiologic multivalvular regurgitation during pregnancy: a longitudinal Doppler echocardiographic study

Cited by 107 publications

References 19 publications

Pregnancy-induced remodeling of heart valves

Pregnancy-induced remodeling of heart valves

The 2010 Canadian Cardiovascular Society guidelines for the diagnosis and management of heart failure update: Heart failure in ethnic minority populations, heart failure and pregnancy, disease management, and quality improvement/assurance programs

Cardiovascular Physiology of Pregnancy

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