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Rhemtula HA, Schapkaitz E, Jacobson B, Chauke L. Anticoagulant therapy in pregnant women with mechanical and bioprosthetic heart valves. Int J Gynaecol Obstet 2024. [PMID: 39340465 DOI: 10.1002/ijgo.15935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2024] [Revised: 09/06/2024] [Accepted: 09/16/2024] [Indexed: 09/30/2024]
Abstract
OBJECTIVE The aim of the present study was to review maternal and fetal outcomes in pregnant women with prosthetic heart valves. METHODS A retrospective record review of pregnant women with prosthetic heart valves on anticoagulation was performed at the Specialist Cardiac Antenatal Clinic, Johannesburg South Africa from 2015 to 2023. RESULTS Fifty pregnancies with mechanical heart valves and three with tissue valves, on anticoagulation for comorbid atrial fibrillation were identified. The majority were of African ethnicity at a mean age of 33 ± 6 years. Anti-Xa adjusted enoxaparin was commenced at 10.5 ± 5.6 weeks' gestation until delivery in 48 (90.6%) pregnancies and warfarin was continued in five (9.4%) pregnancies. The live birth rates on enoxaparin and warfarin were 56.3% (95% confidence interval [CI]: 42.3-69.3) and 20.0% (95% CI: 2.0-64.0), respectively. There were 12 (22.6%) miscarriages at a mean of 11.3 ± 3.7 weeks' gestation, four (7.5%) intrauterine fetal deaths on warfarin and two (3.8%) warfarin embryopathy/fetopathy. The rates of antepartum/secondary postpartum bleeding and primary postpartum bleeding were 29.4% (95% CI: 18.6-43.1) and 5.9% (95% CI: 1.4-16.9), respectively. Maternal complications included anemia (n = 11, 20.8%), arrhythmia (n = 2, 3.8%), heart failure (n = 2, 3.8%) and paravalvular leak (n = 2, 3.8%). There was one (1.9%) mitral valve thrombosis and one (1.9%) stuck valve in pregnancies who defaulted warfarin prior to pregnancy. There were no maternal deaths. CONCLUSION Multidisciplinary management of pregnant women with prosthetic heart valves with anti-Xa adjusted low molecular weight heparin throughout pregnancy represents an effective anticoagulation option for low-middle-income countries.
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Affiliation(s)
- Haroun A Rhemtula
- Department of Obstetrics, Faculty of Health Sciences, University of Witwatersrand Medical School, Johannesburg, South Africa
| | - Elise Schapkaitz
- Department of Molecular Medicine and Hematology, Faculty of Health Sciences, University of Witwatersrand Medical School, Johannesburg, South Africa
| | - Barry Jacobson
- Department of Molecular Medicine and Hematology, Faculty of Health Sciences, University of Witwatersrand Medical School, Johannesburg, South Africa
| | - Lawrence Chauke
- Department of Obstetrics, Faculty of Health Sciences, University of Witwatersrand Medical School, Johannesburg, South Africa
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Campello E, Bucciarelli P, Catalani F, Erba N, Squizzato A, Poli D. Anticoagulant Therapy in Pregnant Women with Mechanical Heart Valves: Italian Federation of Centers for Diagnosis and Surveillance of the Antithrombotic Therapies (FCSA) Position Paper. Thromb Haemost 2024; 124:695-708. [PMID: 38744424 PMCID: PMC11259494 DOI: 10.1055/a-2325-5658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Accepted: 02/18/2024] [Indexed: 05/16/2024]
Abstract
The management of anticoagulant therapy in pregnant women with mechanical heart valves (MHVs) is difficult and often challenging even for clinicians experienced in the field. These pregnancies, indeed, are burdened with higher rates of complications for both the mother and the fetus, compared to those in women without MHVs. The maternal need for an optimal anticoagulation as provided by vitamin K antagonists is counterbalanced by their teratogen effect on the embryo and fetus. On the other hand, several concerns have been raised about the efficacy of heparins in pregnant women with MHVs, considering the high risk of thrombotic complications in these patients. Therefore, numerous clinical issues about the management of pregnant women with MHVs remain unanswered, such as the selection of the best anticoagulant agent, the optimal anticoagulation levels to be achieved and maintained, and the evaluation of long-term effects for both the mother and the fetus. Based on a comprehensive review of the current literature, the Italian Federation of the Centers for the Diagnosis and the Surveillance of the Antithrombotic Therapies (FCSA) proposes experience-based suggestions and expert opinions. Particularly, this consensus document aims at providing practical guidance for clinicians dealing with pregnant women with MHVs, to optimize maternal and fetal outcomes while guaranteeing adequate anticoagulation. Finally, FCSA highlights the need for the creation of multidisciplinary teams experienced in the management of pregnant women with MHVs during pregnancy, delivery, and postpartum, in order to better deal with such complex clinical issues and provide a comprehensive counseling to these patients.
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Affiliation(s)
- Elena Campello
- Department of Medicine, General Medicine and Thrombotic and Hemorrhagic Unit, University of Padova, Padova, Italy
| | - Paolo Bucciarelli
- Fondazione IRCCS Ca' Granda – Ospedale Maggiore Policlinico, A. Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy
| | - Filippo Catalani
- Department of Medicine, General Medicine and Thrombotic and Hemorrhagic Unit, University of Padova, Padova, Italy
| | | | - Alessandro Squizzato
- Research Center on Thromboembolic Disorders and Antithrombotic Therapies, ASST Lariana, University of Insubria, Como, Italy
| | - Daniela Poli
- Thrombosis Center, “Careggi” Hospital, Florence, Italy
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3
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Lee YS, Kim JS. Enoxaparin as an Anticoagulant in a Multipara with a Mechanical Mitral Valve: A Case Report. J Chest Surg 2023; 56:452-455. [PMID: 37518948 PMCID: PMC10625958 DOI: 10.5090/jcs.23.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 05/07/2023] [Accepted: 06/08/2023] [Indexed: 08/01/2023] Open
Abstract
Patients who have undergone mechanical valve replacement require anticoagulation therapy with warfarin to prevent thromboembolism. However, administering warfarin to pregnant patients increases their risk of warfarin embryopathy or central nervous system disorders. Consequently, safer alternatives, such as heparin or low-molecular-weight heparin injection, are substituted for warfarin. However, limited research has been conducted on this subject, with no large-scale studies and particularly few investigations involving multiparous patients. A patient who had previously undergone mechanical mitral valve replacement for atrial septal defect and mitral stenosis received anticoagulant therapy with enoxaparin during 2 pregnancies. Upon confirmation of pregnancy, warfarin was replaced with subcutaneously injected enoxaparin with a dosage of 1 mg/kg at 12-hour intervals. The enoxaparin dosage was controlled using an anti-factor Xa assay, with a target range of 0.3-0.7 IU/mL. Intravenous heparin injections were administered starting 3 days prior to the expected delivery date and were continued until delivery, after which warfarin was resumed. No complications were observed during the deliveries.
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Affiliation(s)
- Yo Seb Lee
- Department of Thoracic and Cardiovascular Surgery, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, Korea
| | - Jun Seok Kim
- Department of Thoracic and Cardiovascular Surgery, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, Korea
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4
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Lester W, Walker N, Bhatia K, Ciantar E, Banerjee A, Trinder J, Anderson J, Hodson K, Swan L, Bradbury C, Webster J, Tower C. British Society for Haematology guideline for anticoagulant management of pregnant individuals with mechanical heart valves. Br J Haematol 2023. [PMID: 37487690 DOI: 10.1111/bjh.18781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2023]
Affiliation(s)
- Will Lester
- Centre for Clinical Haematology, University Hospitals Birmingham NHS Foundation Trust Birmingham UK
| | - Niki Walker
- Department of Cardiology Golden Jubilee National Hospital West of Scotland Regional Heart and Lung Centre Clydebank UK
| | - Kailash Bhatia
- Department of Anaesthetics Manchester University NHS Foundation Trust Manchester UK
| | - Etienne Ciantar
- Department of Obstetrics & Gynaecology Leeds Teaching Hospitals NHS Trust Leeds UK
| | - Anita Banerjee
- Guy's and Saint Thomas' NHS Foundation Trust, Women's Services London UK
| | - Joanna Trinder
- Department of Obstetrics University Hospitals Bristol NHS Foundation Trust Bristol UK
| | | | - Kenneth Hodson
- Department of Maternity Newcastle Upon Tyne Hospitals NHS Foundation Trust Newcastle Upon Tyne UK
| | - Lorna Swan
- Department of Cardiology Golden Jubilee National Hospital West of Scotland Regional Heart and Lung Centre Clydebank UK
| | - Charlotte Bradbury
- Cellular and Molecular Medicine, University of Bristol Bristol UK
- Bristol Haematology and Oncology Centre Bristol UK
| | - Juliette Webster
- Department of Maternity Birmingham Women's and Children's NHS Foundation Trust Birmingham UK
| | - Clare Tower
- Department of Obstetric and Maternal and Fetal Medicine Manchester University NHS Foundation Trust Manchester UK
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5
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Jakobsen C, Larsen JB, Fuglsang J, Hvas AM. Mechanical Heart Valves, Pregnancy, and Bleeding: A Systematic Review and Meta-Analysis. Semin Thromb Hemost 2022. [PMID: 36174605 DOI: 10.1055/s-0042-1756707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
Anticoagulant therapy is essential in pregnant women with mechanical heart valves to prevent valve thrombosis. The risk of bleeding complications in these patients has not gained much attention. This systematic review and meta-analysis investigate the prevalence of bleeding peri-partum and post-partum in women with mechanical heart valves and also investigate whether bleeding risk differed across anticoagulant regimens or according to delivery mode. The present study was conducted according to The Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) statement. Studies reporting bleeding prevalence in pregnant women with mechanical heart valves receiving anticoagulant therapy were identified through PubMed and Embase on December 08, 2021. Data on bleeding complications, delivery mode, and anticoagulation therapy were extracted. A total of 37 studies were included, reporting 423 bleeding complications in 2,508 pregnancies. A meta-analysis calculated a pooled prevalence of 0.13 (95% confidence interval [CI]: 0.09-0.18) bleeding episodes per pregnancy across anticoagulant regimens. The combination of unfractionated heparin (UFH) and vitamin K antagonist (VKA) and single VKA therapy showed the lowest risk of bleeding (8 and 12%). Unexpectedly, the highest risk of bleeding was found in women receiving a combination of low-molecular-weight-heparin (LMWH) and VKA (33%) or mono-therapy with LMWH (22%). However, this could be dose related. No difference in bleeding was found between caesarean section versus vaginal delivery (p = 0.08). In conclusion, bleeding episodes are common during pregnancy in women with mechanical heart valves receiving anticoagulant therapy. A combination of UFH and VKA or VKA monotherapy showed the lowest risk of bleeding.
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Affiliation(s)
- Carina Jakobsen
- Thrombosis and Hemostasis Research Unit, Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus C, Denmark
| | - Julie Brogaard Larsen
- Thrombosis and Hemostasis Research Unit, Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus C, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus C, Denmark
| | - Jens Fuglsang
- Department of Clinical Medicine, Aarhus University, Aarhus C, Denmark.,Department of Obstetrics and Gynecology, Aarhus University Hospital, Aarhus C, Denmark
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Bouhout I, Kalfa D, Shah A, Goldstone AB, Harrington J, Bacha E. Surgical Management of Complex Aortic Valve Disease in Young Adults: Repair, Replacement, and Future Alternatives. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2022; 25:28-37. [PMID: 35835514 DOI: 10.1053/j.pcsu.2022.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 03/17/2022] [Accepted: 04/29/2022] [Indexed: 11/11/2022]
Abstract
The ideal aortic valve substitute in young adults remains unknown. Prosthetic valves are associated with a suboptimal survival and carry a significant risk of valve-related complications in young patients, mainly reinterventions with tissue valves and, thromboembolic events and major bleeding with mechanical prostheses. The Ross procedure is the only substitute that restores a survival curve similar to that of a matched general population, and permits a normal life without functional limitations. Though the risk of reintervention is the Achilles' heel of this procedure, it is very low in patients with aortic stenosis and can be mitigated in patients with aortic regurgitation by tailored surgical techniques. Finally, the Ozaki procedure and the transcatheter aortic valve implantation are seen by many as future alternatives but lack evidence and long-term follow-up in this specific patient population.
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Affiliation(s)
- Ismail Bouhout
- Division of Cardiothoracic and Vascular Surgery, Department of Surgery, Columbia University, New York, New York
| | - David Kalfa
- Division of Cardiothoracic and Vascular Surgery, Department of Surgery, Columbia University, New York, New York
| | - Amee Shah
- Division of Pediatric Cardiology, Department of Pediatrics, Columbia University, New York, New York
| | - Andrew B Goldstone
- Division of Cardiothoracic and Vascular Surgery, Department of Surgery, Columbia University, New York, New York
| | - Jamie Harrington
- Division of Pediatric Cardiology, Department of Pediatrics, Columbia University, New York, New York
| | - Emile Bacha
- Division of Cardiothoracic and Vascular Surgery, Department of Surgery, Columbia University, New York, New York.
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Voortman M, Roos JW, Slomp J, van Dijk AP, Bouma BJ, Sieswerda GT, Kiès P, MsC AB, Waskowsky WM, von Birgelen C, Wagenaar LJ. Strategies for low-molecular-weight heparin management in pregnant women with mechanical prosthetic heart valves: A nationwide survey of Dutch practice. INTERNATIONAL JOURNAL OF CARDIOLOGY CONGENITAL HEART DISEASE 2022. [DOI: 10.1016/j.ijcchd.2022.100373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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8
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Kietaibl S, Ferrandis R, Godier A, Llau J, Lobo C, Macfarlane AJ, Schlimp CJ, Vandermeulen E, Volk T, von Heymann C, Wolmarans M, Afshari A. Regional anaesthesia in patients on antithrombotic drugs: Joint ESAIC/ESRA guidelines. Eur J Anaesthesiol 2022; 39:100-132. [PMID: 34980845 DOI: 10.1097/eja.0000000000001600] [Citation(s) in RCA: 84] [Impact Index Per Article: 42.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Bleeding is a potential complication after neuraxial and peripheral nerve blocks. The risk is increased in patients on antiplatelet and anticoagulant drugs. This joint guideline from the European Society of Anaesthesiology and Intensive Care and the European Society of Regional Anaesthesia aims to provide an evidence-based set of recommendations and suggestions on how to reduce the risk of antithrombotic drug-induced haematoma formation related to the practice of regional anaesthesia and analgesia. DESIGN A systematic literature search was performed, examining seven drug comparators and 10 types of clinical intervention with the outcome being peripheral and neuraxial haematoma. Grading of Recommendations, Assessment, Development and Evaluation (GRADE) was used for assessing the methodological quality of the included studies and for formulating recommendations. A Delphi process was used to prepare a clinical practice guideline. RESULTS Clinical studies were limited in number and quality and the certainty of evidence was assessed to be GRADE C throughout. Forty clinical practice statements were formulated. Using the Delphi-process, strong consensus (>90% agreement) was achieved in 57.5% of recommendations and consensus (75 to 90% agreement) in 42.5%. DISCUSSION Specific time intervals should be observed concerning the adminstration of antithrombotic drugs both prior to, and after, neuraxial procedures or those peripheral nerve blocks with higher bleeding risk (deep, noncompressible). These time intervals vary according to the type and dose of anticoagulant drugs, renal function and whether a traumatic puncture has occured. Drug measurements may be used to guide certain time intervals, whilst specific reversal for vitamin K antagonists and dabigatran may also influence these. Ultrasound guidance, drug combinations and bleeding risk scores do not modify the time intervals. In peripheral nerve blocks with low bleeding risk (superficial, compressible), these time intervals do not apply. CONCLUSION In patients taking antiplatelet or anticoagulant medications, practitioners must consider the bleeding risk both before and after nerve blockade and during insertion or removal of a catheter. Healthcare teams managing such patients must be aware of the risk and be competent in detecting and managing any possible haematomas.
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Affiliation(s)
- Sibylle Kietaibl
- From the Department of Anaesthesia and Intensive Care, Evangelical Hospital Vienna and Sigmund Freud Private University, Vienna, Austria (SK), Department of Anaesthesiology and Critical Care, Hospital Universitari i Politècnic La Fe, Valencia, Spain (RF), Department of Anaesthesiology and Critical Care, European Georges Pompidou Hospital, Assistance Publique-Hôpitaux de Paris (AG), INSERM UMRS-1140 Paris University, Paris, France (AG), Department of Anaesthesiology and Critical Care, Doctor Peset University Hospital (JL), Department of Surgery, Valencia University, Valencia, Spain (JL), Serviço de Anestesiologia Hospital das Forças Armadas, Pólo Porto, Porto, Portugal (CL), Department of Anaesthesia Pain Medicine and Critical Care, Glasgow Royal Infirmary, University of Glasgow, Glasgow, UK (AM), Department of Anaesthesia and Intensive Care Medicine, AUVA Trauma Centre Linz, Linz (CJS); Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, AUVA Trauma Research Centre, Vienna, Austria (CJS), Department of Anaesthesia, University Hospitals Leuven. Catholic University of Leuven, Leuven, Belgium (EV), Department of Anaesthesiology, Intensive Care and Pain Therapy, Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg/Saar (TV), Department of Anaesthesia, Intensive Care Medicine, Emergency Medicine and Pain Therapy, Vivantes Klinikum im Friedrichshain, Berlin, Germany (CVH), Department of Anaesthesia, Norfolk and Norwich University Hospital NHS Trust, Norwich, Norfolk, UK (MW), and Department of Pediatric and Obstetric Anesthesia, Juliane Marie Center, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark (AA)
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[Aortic and valvular heart diseases, cardiomyopathies and heart failure in pregnancy : Risk assessment and management]. Herz 2021; 46:385-396. [PMID: 34259894 DOI: 10.1007/s00059-021-05049-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/25/2021] [Indexed: 11/26/2022]
Abstract
Women with known cardiovascular diseases (CVD) and a desire to have children should receive a timely comprehensive counselling before becoming pregnant. This is critical as the foundation for an informed decision-making process of the mother and her family. Furthermore, a detailed interdisciplinary management plan should be developed and discussed with the patient. The modified World Health Organization (mWHO) classification should be applied for maternal cardiovascular risk stratification. Although the prevalence of aortic pathologies is infrequent, they are often life-threatening conditions. Following the recent advances in terms of surgical management and anticoagulation, the adequate management of valvular heart disease is particularly challenging. Cardiomyopathies during pregnancy are associated with high maternal mortality and severe cardiovascular complications, such as progressive heart failure and thromboembolic events; however, novel treatment options have recently become available.
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10
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Kjaergaard AB, Fuglsang J, Hvas AM. Anti-Xa Monitoring of Low-Molecular-Weight Heparin during Pregnancy: A Systematic Review. Semin Thromb Hemost 2021; 47:824-842. [PMID: 34130342 DOI: 10.1055/s-0041-1726374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Low-molecular-weight heparin (LMWH) is commonly used for preventing or treating venous thromboembolic disease (VTE) during pregnancy. The physiological changes in maternal metabolism have led to discussions on optimal LMWH dosing strategy and possible need for monitoring. The aim of this systematic review is to summarize and discuss whether LMWH dose adjustment according to anti-Xa provides superior effectiveness and safety compared with weight adjusted or fixed dosed LMWH in pregnant women. A systematic literature search was performed in PubMed, Embase, and Scopus on September 26, 2020. The study is reported according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Effectiveness was defined as episodes of thrombosis and safety as bleeding episodes. In total, 33 studies were included: 4 randomized controlled studies and 29 cohort studies. Prophylactic dosing strategies employing weight dosed, fixed dosed, or anti-Xa adjusted LMWH dosing performed equal in effectiveness and safety. In pregnant women with VTE or high thromboembolic risk, therapeutic weight-adjusted LMWH and weight plus anti-Xa-adjusted LMWH provided equal results in terms of effectiveness and safety. Pregnant women with mechanical heart valves (MHVs) received therapeutic anti-Xa-adjusted LMWH with four out of seven studies presenting mean peak anti-Xa within target ranges. Still, pregnant women with MHV experienced both thrombosis and bleeding with anti-Xa in target. Based on the results of this systematic review, current evidence does not support the need for anti-Xa monitoring when using LMWH as thromboprophylaxis or treatment during pregnancy. Nonetheless, the need for anti-Xa monitoring in pregnant women with MHV may need further scrutiny.
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Affiliation(s)
| | - Jens Fuglsang
- Department of Obstetrics and Gynecology, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Anne-Mette Hvas
- Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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2020 ACC/AHA guideline for the management of patients with valvular heart disease: A report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Thorac Cardiovasc Surg 2021; 162:e183-e353. [PMID: 33972115 DOI: 10.1016/j.jtcvs.2021.04.002] [Citation(s) in RCA: 90] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F, Jneid H, Krieger EV, Mack M, McLeod C, O'Gara PT, Rigolin VH, Sundt TM, Thompson A, Toly C. 2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2021; 143:e72-e227. [PMID: 33332150 DOI: 10.1161/cir.0000000000000923] [Citation(s) in RCA: 568] [Impact Index Per Article: 189.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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13
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Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F, Jneid H, Krieger EV, Mack M, McLeod C, O'Gara PT, Rigolin VH, Sundt TM, Thompson A, Toly C. 2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2021; 143:e35-e71. [PMID: 33332149 DOI: 10.1161/cir.0000000000000932] [Citation(s) in RCA: 353] [Impact Index Per Article: 117.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
AIM This executive summary of the valvular heart disease guideline provides recommendations for clinicians to diagnose and manage valvular heart disease as well as supporting documentation to encourage their use. METHODS A comprehensive literature search was conducted from January 1, 2010, to March 1, 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, Cochrane, Agency for Healthcare Research and Quality Reports, and other selected database relevant to this guideline. Structure: Many recommendations from the earlier valvular heart disease guidelines have been updated with new evidence and provides newer options for diagnosis and treatment of valvular heart disease. This summary includes only the recommendations from the full guideline which focus on diagnostic work-up, the timing and choice of surgical and catheter interventions, and recommendations for medical therapy. The reader is referred to the full guideline for graphical flow charts, text, and tables with additional details about the rationale for and implementation of each recommendation, and the evidence tables detailing the data considered in developing these guidelines.
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Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F, Jneid H, Krieger EV, Mack M, McLeod C, O'Gara PT, Rigolin VH, Sundt TM, Thompson A, Toly C. 2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2021; 77:e25-e197. [PMID: 33342586 DOI: 10.1016/j.jacc.2020.11.018] [Citation(s) in RCA: 846] [Impact Index Per Article: 282.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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15
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Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F, Jneid H, Krieger EV, Mack M, McLeod C, O’Gara PT, Rigolin VH, Sundt TM, Thompson A, Toly C. 2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary. J Am Coll Cardiol 2021; 77:450-500. [DOI: 10.1016/j.jacc.2020.11.035] [Citation(s) in RCA: 272] [Impact Index Per Article: 90.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Nakanishi A, Kamiya CA, Shionoiri T, Iwanaga N, Sasaki H, Matsuda H, Yoshimatsu J. Clinical management of coagulation status and placenta previa in a pregnant woman with Marfan's syndrome after mitral and aortic mechanical heart valve replacement. Gen Thorac Cardiovasc Surg 2020; 69:550-554. [PMID: 32980987 DOI: 10.1007/s11748-020-01494-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 09/15/2020] [Indexed: 10/23/2022]
Abstract
Pregnancy with a mechanical heart valve (MHV) is high risk for valve thrombosis because pregnancy is a hyper-coagulation state. In addition, warfarin use during pregnancy is restricted due to its fetotoxicity, and postpartum bleeding may be increased with anticoagulation. In particular, placenta previa under anticoagulation may cause massive postpartum bleeding. The optimal anticoagulation for a pregnant woman with mitral and aortic double MHVs is not known. In addition, suitable techniques for control of bleeding in a case of placenta previa under anticoagulation are not known. Thus, a case of a pregnant woman with mitral and aortic double MHVs and placenta previa is presented. The case was managed without valve thrombosis through precise unfractionated heparin dose adjustment and frequent activated partial thromboplastin time monitoring, along with maintenance of antithrombin levels. Compression sutures were found to be effective for controlling bleeding from the attachment site of placenta previa even under anticoagulation.
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Affiliation(s)
- Atsushi Nakanishi
- Department of Obstetrics and Gynecology, National Cerebral and Cardiovascular Center, 6-1, Kishibeshinmachi, Suita City, Osaka Prefecture, Japan.
| | - Chizuko A Kamiya
- Department of Obstetrics and Gynecology, National Cerebral and Cardiovascular Center, 6-1, Kishibeshinmachi, Suita City, Osaka Prefecture, Japan
| | - Tadasu Shionoiri
- Department of Obstetrics and Gynecology, National Cerebral and Cardiovascular Center, 6-1, Kishibeshinmachi, Suita City, Osaka Prefecture, Japan
| | - Naoko Iwanaga
- Department of Obstetrics and Gynecology, National Cerebral and Cardiovascular Center, 6-1, Kishibeshinmachi, Suita City, Osaka Prefecture, Japan
| | - Hiroaki Sasaki
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, 6-1, Kishibeshinmachi, Suita City, Osaka Prefecture, Japan
| | - Hitoshi Matsuda
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, 6-1, Kishibeshinmachi, Suita City, Osaka Prefecture, Japan
| | - Jun Yoshimatsu
- Department of Obstetrics and Gynecology, National Cerebral and Cardiovascular Center, 6-1, Kishibeshinmachi, Suita City, Osaka Prefecture, Japan
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Avila WS, Alexandre ERG, Castro MLD, Lucena AJGD, Marques-Santos C, Freire CMV, Rossi EG, Campanharo FF, Rivera IR, Costa MENC, Rivera MAM, Carvalho RCMD, Abzaid A, Moron AF, Ramos AIDO, Albuquerque CJDM, Feio CMA, Born D, Silva FBD, Nani FS, Tarasoutchi F, Costa Junior JDR, Melo Filho JXD, Katz L, Almeida MCC, Grinberg M, Amorim MMRD, Melo NRD, Medeiros OOD, Pomerantzeff PMA, Braga SLN, Cristino SC, Martinez TLDR, Leal TDCAT. Brazilian Cardiology Society Statement for Management of Pregnancy and Family Planning in Women with Heart Disease - 2020. Arq Bras Cardiol 2020; 114:849-942. [PMID: 32491078 PMCID: PMC8386991 DOI: 10.36660/abc.20200406] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Affiliation(s)
- Walkiria Samuel Avila
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HC-FMUSP),São Paulo, SP - Brasil
| | | | - Marildes Luiza de Castro
- Hospital das Clínicas da Faculdade de Medicina da Universidade Federal de Minas gerais (UFMG),Belo Horizonte, MG - Brasil
| | | | - Celi Marques-Santos
- Universidade Tiradentes,Aracaju, SE - Brasil
- Hospital São Lucas, Rede D'Or Aracaju,Aracaju, SE - Brasil
| | | | - Eduardo Giusti Rossi
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HC-FMUSP),São Paulo, SP - Brasil
| | - Felipe Favorette Campanharo
- Universidade Federal de São Paulo (UNIFESP), Escola Paulista de Medicina (EPM),São Paulo, SP - Brasil
- Hospital Israelita Albert Einstein,São Paulo, SP - Brasil
| | | | - Maria Elizabeth Navegantes Caetano Costa
- Cardio Diagnóstico,Belém, PA - Brasil
- Centro Universitário Metropolitano da Amazônia (UNIFAMAZ),Belém, PA - Brasil
- Centro Universitário do Estado Pará (CESUPA),Belém, PA - Brasil
| | | | | | - Alexandre Abzaid
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HC-FMUSP),São Paulo, SP - Brasil
| | - Antonio Fernandes Moron
- Universidade Federal de São Paulo (UNIFESP), Escola Paulista de Medicina (EPM),São Paulo, SP - Brasil
| | | | - Carlos Japhet da Mata Albuquerque
- Instituto de Medicina Integral Professor Fernando Figueira (IMIP), Recife, PE – Brazil
- Hospital Barão de Lucena, Recife, PE – Brazil
- Hospital EMCOR, Recife, PE – Brazil
- Diagnósticos do Coração LTDA, Recife, PE – Brazil
| | | | - Daniel Born
- Universidade Federal de São Paulo (UNIFESP), Escola Paulista de Medicina (EPM),São Paulo, SP - Brasil
| | | | - Fernando Souza Nani
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HC-FMUSP),São Paulo, SP - Brasil
| | - Flavio Tarasoutchi
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HC-FMUSP),São Paulo, SP - Brasil
| | - José de Ribamar Costa Junior
- Hospital do Coração (HCor),São Paulo, SP - Brasil
- Instituto Dante Pazzanese de Cardiologia,São Paulo, SP - Brasil
| | | | - Leila Katz
- Instituto de Medicina Integral Professor Fernando Figueira (IMIP), Recife, PE – Brazil
| | | | - Max Grinberg
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HC-FMUSP),São Paulo, SP - Brasil
| | | | - Nilson Roberto de Melo
- Departamento de Obstetrícia e Ginecologia da Faculdade de Medicina da Universidade de São Paulo (USP), São Paulo, SP – Brazil
| | | | - Pablo Maria Alberto Pomerantzeff
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HC-FMUSP),São Paulo, SP - Brasil
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Meng ML, Landau R, Haythe J, Takayama H, Spellman J. Mechanical Aortic Valve Thrombus in Pregnancy: A Case Report. A A Pract 2019; 13:44-47. [PMID: 30807301 DOI: 10.1213/xaa.0000000000000984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Cardiac disease is one of the leading causes of maternal mortality in developed countries. The presence of a mechanical valve is a predictor of cardiac complications in obstetric patients, likely due to the challenges associated with pregnancy hypercoagulability and the imperative of meticulous management of anticoagulation throughout pregnancy, delivery, and the postpartum and to prevent the devastating event of a mechanical valve thrombosis. We report on the management of a pregnant woman with a mechanical aortic valve found to have a thrombus at 37 weeks gestation. It was decided to perform cesarean delivery to allow for a reoperative mechanical aortic valve replacement 24 hours thereafter.
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Affiliation(s)
| | | | | | - Hiroo Takayama
- Surgery, Columbia University Medical Center, New York, New York
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19
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Sathananthan G, Johal N, Grewal J. A case report: mechanical tricuspid valve thrombosis necessitating cardiac surgery during pregnancy. EUROPEAN HEART JOURNAL-CASE REPORTS 2019; 3:5509972. [PMID: 31449635 PMCID: PMC6601239 DOI: 10.1093/ehjcr/ytz080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Revised: 12/12/2018] [Accepted: 05/16/2019] [Indexed: 11/16/2022]
Abstract
Background Pregnant women with mechanical valves are considered a high-risk pregnancy. They carry an increased risk of both maternal and foetal complications. This includes maternal valve thrombosis, foetal embryopathy, and haemorrhage. Cardiac surgery is generally avoided during pregnancy, and is used when there are no other alternative options. Cardiopulmonary bypass (CPB) during pregnancy is associated with high foetal mortality. Maternal mortality in the setting of CPB however, is not dissimilar to a non-pregnant woman. Case summary We present the case of a 29-year-old woman with Ebstein’s anomaly who developed thrombosis of her mechanical tricuspid valve at 4 weeks’ gestation. This was suspected to be likely due to sub-therapeutic anticoagulation at the time of presentation. She underwent a tricuspid valve replacement during the first trimester of pregnancy after failing medical therapy, with overall favourable maternal and foetal outcomes. Discussion Valve thrombosis during pregnancy is a devastating complication. There is limited data surrounding the best management strategy of valve thrombosis in pregnancy. Cardiac surgery with CPB is reserved for cases refractory to appropriate medical therapy. Though maternal mortality is largely unaffected, foetal mortality with CPB remains high. The management of pregnant women undergoing CPB is unique and extremely challenging. It requires a meticulous, multidisciplinary approach to improve overall outcomes.
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Affiliation(s)
- Gnalini Sathananthan
- Department of Cardiology, St. Paul's Hospital, 1081 Burrard St., Vancouver, British Columbia, Canada
| | - Niall Johal
- Department of Cardiology, St. Paul's Hospital, 1081 Burrard St., Vancouver, British Columbia, Canada
| | - Jasmine Grewal
- Department of Cardiology, St. Paul's Hospital, 1081 Burrard St., Vancouver, British Columbia, Canada
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20
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Obstetric anesthesia management of the patient with cardiac disease. Int J Obstet Anesth 2019; 37:73-85. [DOI: 10.1016/j.ijoa.2018.09.011] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Revised: 09/09/2018] [Accepted: 09/19/2018] [Indexed: 02/06/2023]
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21
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Adam K. Pregnancy in Women with Cardiovascular Diseases. Methodist Debakey Cardiovasc J 2018; 13:209-215. [PMID: 29744013 DOI: 10.14797/mdcj-13-4-209] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Patients with cardiovascular disease represent a significant cohort at risk for complications during pregnancy. The normal physiologic changes of pregnancy could further compromise the hemodynamics of various cardiovascular conditions, resulting in clinical deterioration and even death. The fetus of a gravida with cardiovascular disease also has an increased risk of morbidity, including an increased risk of inherited cardiac genetic disorders, fetal growth restriction, and premature delivery. These complications also increase the risk for antenatal and perinatal mortality. Ideally, the management of a patient with cardiac disease who is considering pregnancy should start with pre-conception counseling that outlines the maternal and fetal complications associated with her particular cardiac disorder. The pregnancy is best managed by a dedicated team of specialists in maternal-fetal medicine, cardiology, cardiovascular surgery, anesthesiology, and neonatology, preferably in a tertiary care center.
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22
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Regitz-Zagrosek V, Roos-Hesselink JW, Bauersachs J, Blomström-Lundqvist C, Cífková R, De Bonis M, Iung B, Johnson MR, Kintscher U, Kranke P, Lang IM, Morais J, Pieper PG, Presbitero P, Price S, Rosano GMC, Seeland U, Simoncini T, Swan L, Warnes CA. 2018 ESC Guidelines for the management of cardiovascular diseases during pregnancy. Eur Heart J 2018; 39:3165-3241. [PMID: 30165544 DOI: 10.1093/eurheartj/ehy340] [Citation(s) in RCA: 1165] [Impact Index Per Article: 194.2] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
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23
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Viaris de Lesegno B, Nelson-Piercy C. Advances in the management of cardiovascular disease during pregnancy. Future Cardiol 2018; 14:269-272. [PMID: 29932743 DOI: 10.2217/fca-2018-0033] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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24
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Biological versus mechanical heart valve prosthesis during pregnancy in women with congenital heart disease. Int J Cardiol 2018; 268:106-112. [PMID: 29848449 DOI: 10.1016/j.ijcard.2018.05.038] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2018] [Revised: 04/01/2018] [Accepted: 05/14/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND We evaluate pregnancy outcome and anticoagulation regimes in women with mechanical and biological prosthetic heart valves (PHV) for congenital heart disease. METHODS Retrospective multicenter cohort studying pregnancy outcomes in an existing cohort of patients with PHV. RESULTS 52 women had 102 pregnancies of which 78 pregnancies (46 women) ≥20 weeks duration (59 biological, 19 mechanical PHV). Miscarriages (n = 19, ≤20 weeks) occurred more frequently in women using anticoagulation (P < .05). During 42% of pregnancies of women with mechanical PHV a combined low molecular weight heparin (LMWH) vitamin-K-antagonist anticoagulation regime was used (n = 8). Overall, cardiovascular, obstetric and fetal/neonatal complications occurred in 17% (n = 13), 68% (n = 42) and 42% (n = 27) of the pregnancies. Women with mechanical PHV had significantly higher cardiovascular (12% vs 32%, P < .05), obstetric (59% vs 85%, P = .02) and fetal/neonatal (34% vs 61%, P < .05) complication rates than women with biological PHV. This was related to PHV thrombosis (n = 3, P < .02), post-partum hemorrhage (P < .02), cesarean section (P < .02), low birth weight and small for gestational age (both P < .05). PHV thrombosis occurred in 3 pregnancies, including 2/5 pregnancies with pulmonary mechanical PHV. PHV thrombosis was related to necessary cessation of anticoagulation therapy or insufficient monitoring of LMWH. Other cardiovascular complications occurred equally frequent in both groups. CONCLUSION Complications occur more often in pregnancies of women with a mechanical PHV than in women with a biological PHV, mainly caused by PHV thrombosis and bleeding complications. Meticulous monitoring of anticoagulation in pregnant women is necessary. Women with a pulmonary mechanical PHV are at high risk of complications.
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25
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D'Souza R, Ostro J, Shah PS, Silversides CK, Malinowski A, Murphy KE, Sermer M, Shehata N. Anticoagulation for pregnant women with mechanical heart valves: a systematic review and meta-analysis. Eur Heart J 2018; 38:1509-1516. [PMID: 28329059 PMCID: PMC5429939 DOI: 10.1093/eurheartj/ehx032] [Citation(s) in RCA: 111] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2016] [Accepted: 02/13/2017] [Indexed: 12/21/2022] Open
Abstract
Aims To review maternal and foetal outcomes in women with mechanical heart valves (MHVs) treated with vitamin-K antagonists (VKAs), first-trimester heparin followed by VKAs (sequential treatment), low molecular weight heparin (LMWH) and unfractionated heparin (UFH) during pregnancy, in order to inform practice. Methods and results Medline, Embase and Central were searched from inception until February 2016. Two reviewers independently screened 1786 titles, reviewed 110 full-texts and extracted data and assessed risk-of-bias from 46 articles. Pooled incidence (95% confidence intervals) was calculated for maternal and foetal outcomes. Included studies had a moderate or high risk-of-bias. With VKAs, sequential treatment and LMWH, maternal mortality occurred in 0.9% (0.4–1.4), 2.0% (0.8–3.1) and 2.9% (0.2–5.7), thromboembolic complications in 2.7% (1.4–4.0), 5.8% (3.8–7.7) and 8.7% (3.9–13.4), livebirths in 64.5% (48.8–80.2), 79.9% (74.3–85.6) and 92.0% (86.1–98.0) and anticoagulant-related foetal/neonatal adverse events (embryopathy or foetopathy) in 2.0% (0.3–3.7), 1.4% (0.3–2.5) and 0%, respectively. When UFH is used throughout pregnancy, 11.2% (2.8–19.6) suffered thromboembolic complications. Foetal loss and adverse events occurred with first-trimester warfarin doses ≤ 5 mg/day, although there were more livebirths [83.6% (75.8–91.4) vs. 43.9% (32.8–55.0)] and fewer foetal anomalies [2.3% (0.7–4.0) vs. 12.4% (3.3–21.6)] with lower doses than with warfarin > 5 mg/day. Conclusions VKAs are associated with fewest maternal complications but also with fewest livebirths. Sequential treatment does not eliminate anticoagulant-related foetal/neonatal adverse events. LMWH is associated with the highest number of livebirths. The safety of UFH throughout pregnancy and first-trimester warfarin ≤ 5 mg/day remains unconfirmed.
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Affiliation(s)
- Rohan D'Souza
- Department of Obstetrics and Gynaecology, Division of Maternal and Fetal Medicine, Mount Sinai Hospital, University of Toronto, 700 University Avenue, Toronto ON M5G 1Z5, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, 155 College Street, Toronto ON M5T 3M6, Canada
| | - Jackie Ostro
- Department of Medicine, Division of Hematology, University of Toronto, Toronto, Canada
| | - Prakesh S Shah
- Institute of Health Policy, Management and Evaluation, University of Toronto, 155 College Street, Toronto ON M5T 3M6, Canada.,Department of Paediatrics, Division of Neonatology, Mount Sinai Hospital, University of Toronto, 700 University Avenue, Toronto ON M5G 1Z5, Canada
| | - Candice K Silversides
- Department of Medicine, Division of Cardiology, Obstetric Medicine Program, Mount Sinai Hospital, University of Toronto, 700 University Avenue, Toronto ON M5G 1Z5, Canada
| | - Ann Malinowski
- Department of Obstetrics and Gynaecology, Division of Maternal and Fetal Medicine, Mount Sinai Hospital, University of Toronto, 700 University Avenue, Toronto ON M5G 1Z5, Canada
| | - Kellie E Murphy
- Department of Obstetrics and Gynaecology, Division of Maternal and Fetal Medicine, Mount Sinai Hospital, University of Toronto, 700 University Avenue, Toronto ON M5G 1Z5, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, 155 College Street, Toronto ON M5T 3M6, Canada
| | - Mathew Sermer
- Department of Obstetrics and Gynaecology, Division of Maternal and Fetal Medicine, Mount Sinai Hospital, University of Toronto, 700 University Avenue, Toronto ON M5G 1Z5, Canada
| | - Nadine Shehata
- Institute of Health Policy, Management and Evaluation, University of Toronto, 155 College Street, Toronto ON M5T 3M6, Canada.,Departments of Medicine and Laboratory Medicine and Pathobiology, Mount Sinai Hospital, Division of Hematology, Mount Sinai Hospital, University of Toronto, 700 University Avenue, Toronto ON M5G 1Z5, Canada
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26
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Snape E, Thachil J, Clarke B, Vause S. Anti-Xa based dose changes during low molecular weight heparin anticoagulation for mechanical prosthetic heart valves during pregnancy. J OBSTET GYNAECOL 2018; 38:721-722. [PMID: 29436886 DOI: 10.1080/01443615.2017.1387521] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Eleanor Snape
- a Obstetrics Department , St. Mary's Hospital , Manchester , UK
| | - Jecko Thachil
- b Haematology Department , Manchester Royal Infirmary , Manchester , UK
| | - Bernard Clarke
- c Cardiology Department , Manchester Royal Infirmary , Manchester , UK
| | - Sarah Vause
- a Obstetrics Department , St. Mary's Hospital , Manchester , UK
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27
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Galrinho A. Comment on ‘‘Maternal and fetal outcomes of anticoagulation in pregnant women with mechanical heart valves’’. REVISTA PORTUGUESA DE CARDIOLOGIA (ENGLISH EDITION) 2017. [DOI: 10.1016/j.repce.2017.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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28
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Galrinho A. Comentário a «Prognóstico materno e fetal em grávidas anticoaguladas e portadores de próteses valvulares mecânicas». Rev Port Cardiol 2017. [DOI: 10.1016/j.repc.2017.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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29
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Steinberg ZL, Dominguez-Islas CP, Otto CM, Stout KK, Krieger EV. Maternal and Fetal Outcomes of Anticoagulation in Pregnant Women With Mechanical Heart Valves. J Am Coll Cardiol 2017; 69:2681-2691. [PMID: 28571631 PMCID: PMC5457289 DOI: 10.1016/j.jacc.2017.03.605] [Citation(s) in RCA: 92] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2016] [Revised: 03/26/2017] [Accepted: 03/28/2017] [Indexed: 01/18/2023]
Abstract
Background Anticoagulation for mechanical heart valves during pregnancy is essential to prevent thromboembolic events. Each regimen has drawbacks with regard to maternal or fetal risk. Objectives This meta-analysis sought to estimate and compare the risk of adverse maternal and fetal outcomes in pregnant women with mechanical heart valves who received different methods of anticoagulation. Methods Studies were identified using a Medline search including all publications up to June 5, 2016. Study inclusion required reporting of maternal death, thromboembolism, and valve failure, and/or fetal spontaneous abortion, death, and congenital defects in pregnant women treated with any of the following: 1) a vitamin K antagonist (VKA) throughout pregnancy; 2) low-molecular-weight heparin (LMWH) throughout pregnancy; 3) LMWH for the first trimester, followed by a VKA (LMWH and VKA); or 4) unfractionated heparin for the first trimester, followed by a VKA (UFH and VKA). Results A total of 800 pregnancies from 18 publications were included. Composite maternal risk was lowest with VKA (5%), compared with LMWH (16%; ratio of averaged risk [RAR]: 3.2; 95% confidence interval [CI]: 1.5 to 7.5), LMWH and VKA (16%; RAR: 3.1; 95% CI: 1.2 to 7.5), or UFH and VKA (16%; RAR: 3.1; 95% CI: 1.5 to 7.1). Composite fetal risk was lowest with LMWH (13%; RAR: 0.3; 95% CI: 0.1 to 0.8), compared with VKA (39%), LMWH and VKA (23%), or UFH and VKA (34%). No significant difference in fetal risk was observed between women taking ≤5 mg daily warfarin and those with an LMWH regimen (RAR: 0.9; 95% CI: 0.3 to 2.4). Conclusions VKA treatment was associated with the lowest risk of adverse maternal outcomes, whereas the use of LMWH throughout pregnancy was associated with the lowest risk of adverse fetal outcomes. Fetal risk was similar between women taking ≤5 mg warfarin daily and women treated with LMWH.
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Affiliation(s)
- Zachary L Steinberg
- Division of Cardiology, Department of Medicine, University of Washington School of Medicine, Seattle, Washington.
| | - Clara P Dominguez-Islas
- Medical Research Council Biostatistics Unit, School of Clinical Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Catherine M Otto
- Division of Cardiology, Department of Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Karen K Stout
- Division of Cardiology, Department of Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Eric V Krieger
- Division of Cardiology, Department of Medicine, University of Washington School of Medicine, Seattle, Washington
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30
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Anticoagulation Therapy for Pregnant Women With Mechanical Prosthetic Heart Valves. J Am Coll Cardiol 2017; 69:2692-2695. [DOI: 10.1016/j.jacc.2017.04.034] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2017] [Accepted: 04/24/2017] [Indexed: 11/19/2022]
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31
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The value and impact of anti-Xa activity monitoring for prophylactic dose adjustment of low-molecular-weight heparin during pregnancy. Blood Coagul Fibrinolysis 2017; 28:199-204. [DOI: 10.1097/mbc.0000000000000573] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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32
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Canobbio MM, Warnes CA, Aboulhosn J, Connolly HM, Khanna A, Koos BJ, Mital S, Rose C, Silversides C, Stout K. Management of Pregnancy in Patients With Complex Congenital Heart Disease: A Scientific Statement for Healthcare Professionals From the American Heart Association. Circulation 2017; 135:e50-e87. [PMID: 28082385 DOI: 10.1161/cir.0000000000000458] [Citation(s) in RCA: 233] [Impact Index Per Article: 33.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Today, most female children born with congenital heart disease will reach childbearing age. For many women with complex congenital heart disease, carrying a pregnancy carries a moderate to high risk for both the mother and her fetus. Many such women, however, do not have access to adult congenital heart disease tertiary centers with experienced reproductive programs. Therefore, it is important that all practitioners who will be managing these women have current information not only on preconception counseling and diagnostic evaluation to determine maternal and fetal risk but also on how to manage them once they are pregnant and when to refer them to a regional center with expertise in pregnancy management.
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Vause S, Clarke B, Tower CL, Hay CRM, Knight M. Pregnancy outcomes in women with mechanical prosthetic heart valves: a prospective descriptive population based study using the United Kingdom Obstetric Surveillance System (UKOSS) data collection system. BJOG 2016; 124:1411-1419. [DOI: 10.1111/1471-0528.14478] [Citation(s) in RCA: 66] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/09/2016] [Indexed: 11/28/2022]
Affiliation(s)
- S Vause
- Obstetric Directorate; St Mary's Hospital; Central Manchester University Hospitals NHS Foundation Trust; Manchester UK
- Institute of Human Development; Manchester Academic Health Science Centre; University of Manchester; Manchester UK
| | - B Clarke
- Manchester Heart Centre; Manchester Royal Infirmary; Central Manchester University Hospitals NHS Foundation Trust; Manchester UK
- Institute of Cardiovascular Sciences; Manchester Academic Health Science Centre; University of Manchester; Manchester UK
| | - CL Tower
- Obstetric Directorate; St Mary's Hospital; Central Manchester University Hospitals NHS Foundation Trust; Manchester UK
- Institute of Human Development; Manchester Academic Health Science Centre; University of Manchester; Manchester UK
| | - CRM Hay
- Department of Haematology; Manchester Royal Infirmary; Central Manchester University Hospitals NHS Foundation Trust; Manchester UK
- Institute of Cancer Sciences; Manchester Academic Health Science Centre; University of Manchester; Manchester UK
| | - M Knight
- National Perinatal Epidemiology Unit; University of Oxford; Oxford UK
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Anticoagulation Regimens During Pregnancy in Patients With Mechanical Heart Valves: A Systematic Review and Meta-analysis. Can J Cardiol 2016; 32:1248.e1-1248.e9. [DOI: 10.1016/j.cjca.2015.11.005] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Revised: 10/30/2015] [Accepted: 11/04/2015] [Indexed: 11/24/2022] Open
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35
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Bhagra CJ, D'Souza R, Silversides CK. Valvular heart disease and pregnancy part II: management of prosthetic valves. Heart 2016; 103:244-252. [PMID: 27670966 DOI: 10.1136/heartjnl-2015-308199] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Catriona J Bhagra
- Division of Cardiology, University of Toronto Pregnancy and Heart Disease Program, Mount Sinai Hospital and University Health Network, Toronto, Ontario, Canada
| | - Rohan D'Souza
- Department of Obstetrics and Gynaecology, Division of Maternal and Fetal Medicine, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Candice K Silversides
- Division of Cardiology, University of Toronto Pregnancy and Heart Disease Program, Mount Sinai Hospital and University Health Network, Toronto, Ontario, Canada
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36
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Rare case of a patient with recurrent thrombosis of a mechanical valve during pregnancy. COR ET VASA 2016. [DOI: 10.1016/j.crvasa.2015.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Petrie S, Barras M, Lust K, Fagermo N, Allen J, Martin JH. Evaluation of therapeutic enoxaparin in a pregnant population at a tertiary hospital. Intern Med J 2016; 46:826-33. [DOI: 10.1111/imj.13117] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2014] [Revised: 11/07/2015] [Accepted: 04/06/2016] [Indexed: 11/27/2022]
Affiliation(s)
- S. Petrie
- Department of Medicine; Royal Brisbane and Women's Hospital; Brisbane Queensland Australia
| | - M. Barras
- Department of Pharmacy; Royal Brisbane and Women's Hospital; Brisbane Queensland Australia
- University of Queensland; Brisbane Queensland Australia
| | - K. Lust
- Department of Medicine; Royal Brisbane and Women's Hospital; Brisbane Queensland Australia
| | - N. Fagermo
- Department of Medicine; Royal Brisbane and Women's Hospital; Brisbane Queensland Australia
| | - J. Allen
- Department of Medicine; Royal Brisbane and Women's Hospital; Brisbane Queensland Australia
| | - J. H. Martin
- University of Queensland; Brisbane Queensland Australia
- School of Medicine and Public Health; University of Newcastle; Newcastle New South Wales Australia
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Ayad SW, Hassanein MM, Mohamed EA, Gohar AM. Maternal and Fetal Outcomes in Pregnant Women with a Prosthetic Mechanical Heart Valve. CLINICAL MEDICINE INSIGHTS-CARDIOLOGY 2016; 10:11-7. [PMID: 26884686 PMCID: PMC4750893 DOI: 10.4137/cmc.s36740] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2015] [Revised: 12/28/2015] [Accepted: 01/02/2016] [Indexed: 12/01/2022]
Abstract
BACKGROUND Pregnancy is associated with several cardiocirculatory changes that can significantly impact underlying cardiac disease. These changes include an increase in cardiac output, sodium, and water retention leading to blood volume expansion, and reductions in systemic vascular resistance and systemic blood pressure. In addition, pregnancy results in a hypercoagulable state that increases the risk of thromboembolic complications. OBJECTIVES The aim of this study is to assess the maternal and fetal outcomes of pregnant women with mechanical prosthetic heart valves (PHVs). METHODS This is a prospective observational study that included 100 pregnant patients with cardiac mechanical valve prostheses on anticoagulant therapy. The main maternal outcomes included thromboembolic or hemorrhagic complications, prosthetic valve thrombosis, and acute decompensated heart failure. Fetal outcomes included miscarriage, fetal death, live birth, small-for-gestational age, and warfarin embryopathy. The relationship between the following were observed:
– Maternal and fetal complications and the site of the replaced valve (mitral, aortic, or double) – Maternal and fetal complications and warfarin dosage (≤5 mg, >5 mg) – Maternal and fetal complications and the type of anticoagulation administered during the first trimester
RESULTS This study included 60 patients (60%) with mitral valve replacement (MVR), 22 patients (22%) with aortic valve replacement (AVR), and 18 patients (18%) with double valve replacement (DVR). A total of 65 patients (65%) received >5 mg of oral anticoagulant (warfarin), 33 patients (33%) received ≤5 mg of warfarin, and 2 patients (2%) received low-molecular-weight heparin (LMWH; enoxaparin sodium) throughout the pregnancy. A total of 17 patients (17%) received oral anticoagulant (warfarin) during the first trimester: 9 patients received a daily warfarin dose of >5 mg while the remaining 8 patients received a daily dose of ≤5 mg. Twenty-eight patients (28%) received subcutaneous (SC) heparin calcium and 53 patients (53%) received SC LMWH (enoxaparin sodium). Prosthetic valve thrombosis occurred more frequently in patients with MVR (P = 0.008). Postpartum hemorrhage was more common in patients with aortic valve prostheses than in patients with mitral valve prostheses (P = 0.005). The incidence of perinatal death was higher in patients with AVR (P = 0.014). The incidence of live birth was higher in patients with DVR (P = 0.012). The incidence of postpartum hemorrhage was higher in patients who received a daily dose of >5 mg of warfarin than in patients who received ≤5 mg of warfarin (P = 0.05). The incidence of spontaneous abortion was also higher in patients receiving >5 mg of warfarin (P ≤ 0.001), while the incidence of live births was higher in patients receiving ≤5 mg of warfarin (P = 0.008). There was a statistically significant difference between the anticoagulant received during the first trimester and cardiac outcomes. Specifically, patients on heparin developed more heart failure (P = 0.008), arrhythmias (P = 0.008), and endocarditis (P = 0.016). There was a statistically significant relationship between heparin shifts during the first trimester and spontaneous abortion (P = 0.003). CONCLUSION Warfarin use during the first trimester is safer for the mother but is associated with more fetal loss, especially in doses that exceed 5 mg. The incidence of maternal complications is greater in women who receive LMWH or unfractionated heparin during the first trimester, especially prosthetic valve thrombosis, although the fetal outcome is better because heparin does not cross the placenta.
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Affiliation(s)
- Sherif W Ayad
- Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | | | | | - Ahmed M Gohar
- Faculty of Medicine, Alexandria University, Alexandria, Egypt
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Lawley CM, Lain SJ, Algert CS, Ford JB, Figtree GA, Roberts CL. Prosthetic heart valves in pregnancy, outcomes for women and their babies: a systematic review and meta-analysis. BJOG 2015; 122:1446-55. [PMID: 26119028 DOI: 10.1111/1471-0528.13491] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/17/2015] [Indexed: 11/27/2022]
Abstract
BACKGROUND Historically, pregnancies among women with prosthetic heart valves have been associated with an increased incidence of adverse outcomes. OBJECTIVES Systematic review to assess risk of adverse pregnancy outcomes among women with a prosthetic heart valve(s) over the last 20 years. SEARCH STRATEGY Electronic literature search of Medline, The Cochrane Library, Cumulative Index to Nursing and Allied Health Literature and Embase to find recent studies. SELECTION CRITERIA Studies of pregnant women with heart valve prostheses including trials, cohort studies and unselected case series. DATA COLLECTION AND ANALYSIS Primary analysis calculated absolute risks and 95% confidence intervals (CI) for pregnancy outcomes using a random effects model. The Freeman-Tukey transformation was utilised in secondary analysis due to the large number of individual study outcomes with zero events. MAIN RESULTS Eleven studies capturing 499 pregnancies among women with heart valve prostheses, including 256 mechanical and 59 bioprosthetic, were eligible for inclusion. Pooled estimate of maternal mortality was 1.2/100 pregnancies (95% CI 0.5-2.2), for mechanical valves subgroup 1.8/100 (95% CI 0.5-3.7) and bioprosthetic subgroup 0.7/100 (95% CI 0.1-4.5), overall pregnancy loss 20.8/100 pregnancies (95% CI 9.5-35.1), perinatal mortality 5.0/100 births (95%CI 1.8-9.8) and thromboembolism 9.3/100 pregnancies (95% CI 4.0-16.5). CONCLUSIONS Women with heart valve prostheses experienced higher rates of adverse outcomes than expected in a general obstetric population; however, lower than previously reported. Women with bioprostheses had significantly fewer thromboembolic events compared to women with mechanical valves. Women should be counselled pre-pregnancy about risk of maternal death and pregnancy loss. Vigilant surveillance by a multidisciplinary team throughout the perinatal period remains warranted for these women and their infants. TWEETABLE ABSTRACT Metaanalysis suggests improvement in #pregnancy outcomes among women with #heartvalveprostheses.
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Affiliation(s)
- C M Lawley
- Clinical Population Perinatal Health Research, Kolling Institute, University of Sydney, Sydney, NSW, Australia.,Department of Cardiology, Royal North Shore Hospital, St Leonards, NSW, Australia
| | - S J Lain
- Clinical Population Perinatal Health Research, Kolling Institute, University of Sydney, Sydney, NSW, Australia
| | - C S Algert
- Clinical Population Perinatal Health Research, Kolling Institute, University of Sydney, Sydney, NSW, Australia
| | - J B Ford
- Clinical Population Perinatal Health Research, Kolling Institute, University of Sydney, Sydney, NSW, Australia
| | - G A Figtree
- Department of Cardiology, Royal North Shore Hospital, St Leonards, NSW, Australia
| | - C L Roberts
- Clinical Population Perinatal Health Research, Kolling Institute, University of Sydney, Sydney, NSW, Australia
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Abstract
Because of the growing population of patients with congenital heart disease (CHD), most maternal cardiac disease is now congenital in origin. For women with complex CHD, pregnancy poses an increased risk for both the mother, with complications of arrhythmias and heart failure being the most common, and the baby, with a higher chance of miscarriage, intrauterine growth retardation, and the need for early delivery. Pre-pregnancy counseling must be performed by cardiologists who have expertise in both CHD and pregnancy, with a detailed clinical assessment of the patient and the current hemodynamic situation, including echocardiography and an exercise test. In each case the approach must be individualized with consideration of the risks in each case. In some cases, such as Eisenmenger syndrome, pregnancy is contraindicated. Optimum outcomes in these complex patients are achieved when a multidisciplinary approach is used, involving maternal-fetal medicine specialists, cardiologists with expertise in CHD and obstetric anesthesia.
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Berresheim M, Wilkie J, Nerenberg KA, Ibrahim Q, Bungard TJ. A case series of LMWH use in pregnancy: Should trough anti-Xa levels guide dosing? Thromb Res 2014; 134:1234-40. [DOI: 10.1016/j.thromres.2014.09.033] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2014] [Revised: 09/11/2014] [Accepted: 09/23/2014] [Indexed: 11/25/2022]
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Taghadosi M, Memarian R, Ahmadi F. The experiences of "difficult life" in heart valve replaced patients. IRANIAN RED CRESCENT MEDICAL JOURNAL 2014; 16:e19147. [PMID: 25389487 PMCID: PMC4222013 DOI: 10.5812/ircmj.19147] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/27/2014] [Revised: 06/30/2014] [Accepted: 07/26/2014] [Indexed: 11/19/2022]
Abstract
Background: Several reports, however, not comprehensive, have been presented about the experiences of patients with replaced heart-valve. Objectives: This study explores the experiences of the patients with heart valve replacement. Patients and Methods: A qualitative research with a content analysis approach was carried out on the patients with cardiac valve replacement during the year 2012 and 2013. A purposeful sampling using a semi-structured interview and open-ended questions (with the main question of "What problems did you have after the valve replacement?" followed by the exploratory questions) were performed until the data saturation. All interviews were recorded, then transcribed and typed. The data analysis was done according to Grancheim and Lundmen content analysis using the MAXQDA software. Results: Of 22 interviews taken from 13 participants, 430 codes were taken. Out of them, after deleting the similar items, 162 initial, 18 subcategory, and 5 subsidiary themes (problematic exposure with valve replacement, continuity of some difficulties, aggravation of life problems, insufficient support, and following a perceived care) were extracted. Based on the abstract and deep perception of the categories, the main theme of "difficult life" was explored. Conclusions: Aggravation and the continuity of some physical problems, and insufficient support after the valve replacement make the life difficult for the patients. Identification of these problems is necessary for planning and improvement of the patients' care, life quality, and survival through consultations, rehabilitation and education.
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Affiliation(s)
- Mohsen Taghadosi
- Department of Nursing, Faculty of Medical Sciences, Tarbiat Modares University, Tehran, IR Iran
| | - Robabeh Memarian
- Department of Nursing, Faculty of Medical Sciences, Tarbiat Modares University, Tehran, IR Iran
- Corresponding Author: Robabeh Memarian, Department of Nursing, Faculty of Medical Sciences, Tarbiat Modares University, Tehran, IR Iran. Tel: +98-9133634439, E-mail: .
| | - Fazlollah Ahmadi
- Department of Nursing, Faculty of Medical Sciences, Tarbiat Modares University, Tehran, IR Iran
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Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA, O’Gara PT, Ruiz CE, Skubas NJ, Sorajja P, Sundt TM, Thomas JD, Anderson JL, Halperin JL, Albert NM, Bozkurt B, Brindis RG, Creager MA, Curtis LH, DeMets D, Guyton RA, Hochman JS, Kovacs RJ, Ohman EM, Pressler SJ, Sellke FW, Shen WK, Stevenson WG, Yancy CW. 2014 AHA/ACC guideline for the management of patients with valvular heart disease. J Thorac Cardiovasc Surg 2014; 148:e1-e132. [DOI: 10.1016/j.jtcvs.2014.05.014] [Citation(s) in RCA: 631] [Impact Index Per Article: 63.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Lawley CM, Algert CS, Ford JB, Nippita TA, Figtree GA, Roberts CL. Heart valve prostheses in pregnancy: outcomes for women and their infants. J Am Heart Assoc 2014; 3:e000953. [PMID: 24970269 PMCID: PMC4309100 DOI: 10.1161/jaha.114.000953] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND As the prognosis of women with prosthetic heart valves improves, an increasing number are contemplating and undertaking pregnancy. Accurate knowledge of perinatal outcomes is essential, assisting counseling and guiding care. The aims of this study were to assess outcomes in a contemporary population of women with heart valve prostheses undertaking pregnancy and to compare outcomes for women with mechanical and bioprosthetic prostheses. METHODS AND RESULTS Longitudinally linked population health data sets containing birth and hospital admissions data were obtained for all women giving birth in New South Wales, Australia, 2000-2011. This included information identifying presence of maternal prosthetic heart valve. Cardiovascular and birth outcomes were evaluated. Among 1 144 156 pregnancies, 136 involved women with a heart valve prosthesis (1 per 10 000). No maternal mortality was seen among these women, although the relative risk for an adverse event was higher than the general population, including severe maternal morbidity (139 versus 14 per 1000 births, rate ratio [RR]=9.96, 95% CI 6.32 to 15.7), major maternal cardiovascular event (44 versus 1 per 1000, RR 34.6, 95% CI 14.6 to 81.6), preterm birth (183 versus 66 per 1000, RR=2.77, 95% CI 1.88 to 4.07), and small-for-gestational-age infants (193 versus 95 per 1000, RR=2.03, 95% CI 1.40 to 2.96). There was a trend toward increased maternal and perinatal morbidity in women with a mechanical valve compared with those with a bioprosthetic valve. CONCLUSIONS Pregnancies in women with a prosthetic heart valve demonstrate an increased risk of an adverse outcome, for both mothers and infants, compared with pregnancies in the absence of heart valve prostheses. In this contemporary population, the risk was lower than previously reported.
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Affiliation(s)
- Claire M Lawley
- Clinical Population Perinatal Health Research, Kolling Institute, University of Sydney, Sydney, Australia (C.M.L., C.S.A., J.B.F., C.L.R.) Department of Cardiology, Royal North Shore Hospital, St Leonards, Australia (C.M.L., G.A.F.)
| | - Charles S Algert
- Clinical Population Perinatal Health Research, Kolling Institute, University of Sydney, Sydney, Australia (C.M.L., C.S.A., J.B.F., C.L.R.)
| | - Jane B Ford
- Clinical Population Perinatal Health Research, Kolling Institute, University of Sydney, Sydney, Australia (C.M.L., C.S.A., J.B.F., C.L.R.)
| | - Tanya A Nippita
- Department of Obstetrics and Gynaecology, Royal North Shore Hospital, St Leonards, Australia (T.A.N.)
| | - Gemma A Figtree
- Department of Cardiology, Royal North Shore Hospital, St Leonards, Australia (C.M.L., G.A.F.)
| | - Christine L Roberts
- Clinical Population Perinatal Health Research, Kolling Institute, University of Sydney, Sydney, Australia (C.M.L., C.S.A., J.B.F., C.L.R.)
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Affiliation(s)
- Michael Nanna
- Yale University School of Medicine and Yale New Haven Hospital, Department of Medicine, New Haven, CT (M.N.)
| | - Kathleen Stergiopoulos
- Division of Cardiovascular Disease, Department of Medicine, Stony Brook University Medical Center, Stony Brook, NY (K.S.)
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Roche-Kelly E, Nelson-Piercy C. Managing cardiovascular disease during pregnancy: best practice to optimize outcomes. Future Cardiol 2014; 10:421-33. [DOI: 10.2217/fca.14.21] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
ABSTRACT: Cardiac disease is the most common cause of death in pregnancy in the UK. Optimal management requires an understanding of the physiological changes of the cardiovascular system during pregnancy, and their impact on existing or developing heart disease. Pregnancy itself is associated with the onset of cardiomyopathy, and a potential risk factor for ischemic heart disease and aortic dissection. Women with valvular disease and aortopathy require regular follow-up in specialized centers, and those requiring long-term anticoagulation face difficult challenges to balance maternal and fetal risks. In the UK, the Confidential Enquiries into maternal deaths and the UK Obstetric Surveillance system are examples of existing systems for identifying clinical risks and provide examples of potential improvements in care.
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Affiliation(s)
- Emma Roche-Kelly
- King’s College Hospital NHS Foundation Trust, King’s College Hospital, London, SE5 9RS, UK
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Windram JD, Colman JM, Wald RM, Udell JA, Siu SC, Silversides CK. Valvular heart disease in pregnancy. Best Pract Res Clin Obstet Gynaecol 2014; 28:507-18. [DOI: 10.1016/j.bpobgyn.2014.03.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2014] [Revised: 03/13/2014] [Accepted: 03/26/2014] [Indexed: 10/25/2022]
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Bouhout I, Poirier N, Mazine A, Dore A, Mercier LA, Leduc L, El-Hamamsy I. Cardiac, obstetric, and fetal outcomes during pregnancy after biological or mechanical aortic valve replacement. Can J Cardiol 2014; 30:801-7. [PMID: 24970791 DOI: 10.1016/j.cjca.2014.03.036] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2014] [Revised: 03/27/2014] [Accepted: 03/28/2014] [Indexed: 10/25/2022] Open
Abstract
BACKGROUND The aim of this study was to assess pregnancy-related cardiac, maternal, and fetal outcomes in women who underwent aortic valve replacement (AVR). METHODS From 1978-2011, 67 women < 40 years of age underwent 74 isolated AVRs (52 mechanical prostheses and 22 bioprostheses). All patients were prospectively followed at our dedicated valve clinic. Patients with Turner syndrome, previous hysterectomy, or tubal ligation were excluded. Cardiovascular, obstetric, and fetal outcomes were gathered from medical records and telephone interviews. RESULTS A total of 27 pregnancies were reported in 14 patients (bioprosthetic AVR, n = 20; mechanical AVR, n = 7). In the bioprosthetic AVR group, the following adverse events occurred: hospitalizations for syncope (n = 2), prosthetic valve deterioration after pregnancy necessitating reintervention 6 months postpartum (n = 1), miscarriages (n = 9), and preterm birth (n = 1). In the mechanical AVR group, the following adverse events occurred: embolic myocardial infarctions with a decrease in systolic function (n = 2; 1 pregnancy was terminated and 1 was completed), miscarriage (n = 1), postpartum bleeding (n = 1), urgent cesarean section for placental abruption (n = 1), and preterm birth (n = 1). CONCLUSIONS Findings from this study suggest that pregnancies in women with mechanical AVRs are associated with a higher risk of cardiac and obstetric adverse events. Thus, from this limited cohort, it appears that pregnancies in women with bioprostheses are safer than those in patients with mechanical AVRs.
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Affiliation(s)
- Ismail Bouhout
- Department of Cardiac Surgery, Montreal Heart Institute, Université de Montréal, Montreal, Québec, Canada
| | - Nancy Poirier
- Department of Cardiac Surgery, Montreal Heart Institute, Université de Montréal, Montreal, Québec, Canada
| | - Amine Mazine
- Department of Cardiac Surgery, Montreal Heart Institute, Université de Montréal, Montreal, Québec, Canada
| | - Annie Dore
- Department of Medicine, Montreal Heart Institute, Université de Montréal, Montreal, Québec, Canada
| | - Lise-Andrée Mercier
- Department of Medicine, Montreal Heart Institute, Université de Montréal, Montreal, Québec, Canada
| | - Line Leduc
- Department of Obstetrics and Gynaecology, CHU Ste-Justine, Université de Montréal, Montreal, Québec, Canada
| | - Ismail El-Hamamsy
- Department of Cardiac Surgery, Montreal Heart Institute, Université de Montréal, Montreal, Québec, Canada.
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