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Springhetti P, Abdoun K, Clavel MA. Sex Differences in Aortic Stenosis: From the Pathophysiology to the Intervention, Current Challenges, and Future Perspectives. J Clin Med 2024; 13:4237. [PMID: 39064275 PMCID: PMC11278486 DOI: 10.3390/jcm13144237] [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: 06/24/2024] [Revised: 07/16/2024] [Accepted: 07/17/2024] [Indexed: 07/28/2024] Open
Abstract
Calcific aortic stenosis (AS) is a major cause of morbidity and mortality in high-income countries. AS presents sex-specific features impacting pathophysiology, outcomes, and management strategies. In women, AS often manifests with a high valvular fibrotic burden, small valvular annuli, concentric left ventricular (LV) remodeling/hypertrophy, and, frequently, supernormal LV ejection fraction coupled with diastolic dysfunction. Paradoxical low-flow low-gradient AS epitomizes these traits, posing significant challenges post-aortic valve replacement due to limited positive remodeling and significant risk of patient-prosthesis mismatch. Conversely, men present more commonly with LV dilatation and dysfunction, indicating the phenotype of classical low-flow low-gradient AS, i.e., with decreased LV ejection fraction. However, these distinctions have not been fully incorporated into guidelines for AS management. The only treatment for AS is aortic valve replacement; women are frequently referred late, leading to increased heart damage caused by AS. Therefore, it is important to reassess surgical planning and timing to minimize irreversible cardiac damage in women. The integrity and the consideration of sex differences in the management of AS is critical. Further research, including sufficient representation of women, is needed to investigate these differences and to develop individualized, sex-specific management strategies.
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Affiliation(s)
- Paolo Springhetti
- Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Québec, QC G1V 4G5, Canada; (P.S.); (K.A.)
- Department of Medicine, Division of Cardiology, University of Verona, 37129 Verona, Italy
| | - Kathia Abdoun
- Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Québec, QC G1V 4G5, Canada; (P.S.); (K.A.)
| | - Marie-Annick Clavel
- Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Québec, QC G1V 4G5, Canada; (P.S.); (K.A.)
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2
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Youssef G, Mohamed TEH, Abdel Raouf MA, Fouad Tammam AS, Gabr AA. Early Versus Late Post Cesarean Section Warfarin Initiation and Increased Risk of Maternal Complications in Patients With Mechanical Heart Valves: A Randomized, Open-Label Pilot Study. Korean Circ J 2024; 54:54.e78. [PMID: 39175342 DOI: 10.4070/kcj.2024.0002] [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: 01/01/2024] [Revised: 05/23/2024] [Accepted: 06/11/2024] [Indexed: 08/24/2024] Open
Abstract
BACKGROUND AND OBJECTIVES The timing of the reinstitution of warfarin after cesarean section (CS) delivery was not adequately addressed in the literature. This study aims to evaluate the risks of early versus late initiation of warfarin post-CS in patients with mechanical heart valves. METHODS This randomized, open-label cohort study included 114 pregnant women with mechanical heart valves planned to be delivered by CS at or after 28 weeks of gestation. Patients were randomly divided into two groups: Day-2-group, where warfarin was started on day 2, and Day-5-group, where warfarin was started on day 5 after CS. Maternal postoperative bleeding complications, mechanical valve thrombosis, need for blood transfusion or reoperation, and maternal mortality were identified. RESULTS Ten women (8.8%) had 11 bleeding complications, of whom 2 patients (20%) had intraperitoneal hemorrhage (none in Day-2-group and 2 in Day-5-group), 3 patients (30%) had subcutaneous hematoma (none in Day-2-group and 3 in Day-5-group), and 6 patients (60%) had sub-rectus hematoma (3 in Day-2-group and 3 in Day-5-group). No mechanical valve thrombosis, other thromboembolic events, or in-hospital maternal mortality were reported. CONCLUSION Despite the small number of events, the bleeding risk was lower in the group with early post-CS warfarin introduction than in the group with late warfarin introduction in patients with prosthetic heart valves. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT04855110.
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Affiliation(s)
- Ghada Youssef
- Department of Cardiovascular Medicine, Faculty of Medicine, Cairo University, Cairo, Egypt.
| | | | - Maged Ahmed Abdel Raouf
- Department of Obstetrics and Gynecology, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Amr Samir Fouad Tammam
- Department of Obstetrics and Gynecology, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Amir Araby Gabr
- Department of Obstetrics and Gynecology, Faculty of Medicine, Cairo University, Cairo, Egypt
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3
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Fass L, Sibbald C, Bailey E, Zhang W, Lucey M. Severe Elevated Bile Acids in Early Pregnancy. ACG Case Rep J 2024; 11:e01317. [PMID: 38560018 PMCID: PMC10977523 DOI: 10.14309/crj.0000000000001317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Accepted: 02/26/2024] [Indexed: 04/04/2024] Open
Abstract
Intrahepatic cholestasis of pregnancy (ICP) typically presents in the second half of pregnancy. Severe ICP is associated with increased risk of stillbirth. Little is known regarding elevated bile acids in the first trimester. We present a case of severely elevated bile acids in the first trimester, resistant to conservative management, in a patient with pre-existing cholestatic liver disease and aortic valve disease requiring anticoagulation. Therapeutic plasma exchange was used. In those with pre-existing cholestatic disease, early bile acid elevation is likely distinct from ICP, and conservative strategies may not be useful. In addition, therapeutic enoxaparin appears safe in therapeutic plasma exchange.
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Affiliation(s)
- Lucas Fass
- Department of Internal Medicine, University of Wisconsin Hospital and Clinics, Madison, WI
| | - Carrie Sibbald
- Department of Obstetrics and Gynecology, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Erin Bailey
- Department of Obstetrics and Gynecology, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Wei Zhang
- Department of Molecular and Laboratory Pathology, University of Kansas Medical Center, Kansas City, KS
| | - Michael Lucey
- Department of Gastroenterology and Hepatology, University of Wisconsin School of Medicine and Public Health, Madison, WI
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4
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Wander G, van der Zande JA, Patel RR, Johnson MR, Roos-Hesselink J. Pregnancy in women with congenital heart disease: a focus on management and preventing the risk of complications. Expert Rev Cardiovasc Ther 2023; 21:587-599. [PMID: 37470417 DOI: 10.1080/14779072.2023.2237886] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 07/14/2023] [Indexed: 07/21/2023]
Abstract
INTRODUCTION Congenital heart disease (CHD) is the most common cardiac disorder in pregnancy in the western world (around 80%). Due to improvements in surgical interventions more women with CHD are surviving to adulthood and choosing to become pregnant. AREAS COVERED Preconception counseling, antenatal management of CHDs and strategies to prevent maternal and fetal complications.Preconception counseling should start early, before the transition to adult care and be offered to both men and women. It should include the choice of contraception, lifestyle modifications, pre-pregnancy optimization of cardiac state, the chance of the child inheriting a similar cardiac lesion, the risks to the mother, and long-term prognosis. Pregnancy induces marked physiological changes in the cardiovascular system that may precipitate cardiac complications. Risk stratification is based on the underlying cardiac disease and data from studies including CARPREG, ZAHARA, and ROPAC. EXPERT OPINION Women with left to right shunts, regurgitant lesions, and most corrected CHDs are at lower risk and can be managed in secondary care. Complex CHD, including systemic right ventricle need expert counseling in a tertiary center. Those with severe stenotic lesions, pulmonary artery hypertension, and Eisenmenger's syndrome should avoid pregnancy, be given effective contraception and managed in a tertiary center if pregnancy does happen.
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Affiliation(s)
- Gurleen Wander
- Imperial College London, Chelsea and Westminster Hospital, London, UK
| | - Johanna A van der Zande
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Roshni R Patel
- Imperial College London, Chelsea and Westminster Hospital, London, UK
| | - Mark R Johnson
- Imperial College London, Chelsea and Westminster Hospital, London, UK
| | - Jolien Roos-Hesselink
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
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5
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Pavord S, Orchard L. Clear and present danger: Mechanical heart valves in pregnancy. Br J Haematol 2023. [PMID: 37140533 DOI: 10.1111/bjh.18820] [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: 04/04/2023] [Accepted: 04/09/2023] [Indexed: 05/05/2023]
Abstract
Specialists in Obstetric Haematology continue to be challenged by pregnant women with mechanical heart valves, who are at high risk of death or severe morbidity. Effective anticoagulation to reduce valve thrombosis inevitably increases risk of obstetric haemorrhage and fetal loss or harm, and difficult decisions need to be made. Lester and mulitdisciplinary colleagues on behalf of the British Society for Haematology review available evidence and provide comprehensive recommendations to guide management in this difficult area. Commentary on: Lester et al. British Society for Haematology guideline for anticoagulant management of pregnant individuals with mechanical heart valves. Br J Haematol 2023 (Online ahead of print). doi: https://doi.org/10.1111/bjh.18781.
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Affiliation(s)
- Sue Pavord
- Department of Haematology, Oxford University Hospitals NHS FT, Oxford, UK
| | - Liz Orchard
- Department of Cardiology, Oxford University Hospitals NHS FT, Oxford, UK
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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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7
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León-García M, Humphries B, Maraboto A, Rabassa M, Boehmer KR, Perestelo-Perez L, Xie F, Pelayo I, Eckman M, Bates S, Selva A, Alonso-Coello P. Women's values and preferences on low-molecular-weight heparin and pregnancy: a mixed-methods systematic review. BMC Pregnancy Childbirth 2022; 22:747. [PMID: 36199014 PMCID: PMC9533610 DOI: 10.1186/s12884-022-05042-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 09/09/2022] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Venous thromboembolism (VTE) in pregnancy is an important cause of maternal morbidity and mortality. Low-molecular-weight heparin (LMWH) is the cornerstone of prophylaxis and treatment of thrombotic events during pregnancy. LMWH has fewer adverse effects than other anticoagulants, does not cross the placenta, and is safe for the fetus. However, the use of LMWH during pregnancy is sensitive to womens' underlying preferences. The objective of this review is to systematically assess women's values and preferences research evidence on this topic. METHODS We searched four electronic databases from inception to March 2022, and included studies examining values and preferences of using LMWH among pregnant women at risk of VTE. We followed a convergent integrated mixed-methods design to compare and contrast quantitative outcomes (utility and non-utility measures) and qualitative findings. We assessed the certainty of the values and preferences evidence with the GRADE approach for quantitative findings, and with GRADE-CERqual for qualitative evidence. Results were presented in a conjoint display. RESULTS We screened 3,393 references and identified seven eligible studies. The mixed methods analysis resulted in four themes. Datasets confirmed each other in that: 1) the majority of women consider that benefits of treatment outweigh the inconveniences of daily injections; and 2) main concerns around medication are safety and injections administration. Quantitative outcomes expanded on the qualitative findings in that: 3) participants who perceived a higher risk of VTE were more willing to take LMWH. Finally, we found a discrepancy between the datasets around: 4) the amount of information preferred to make the decision; however, qualitative data expanded to clarify that women prefer making informed decisions and receive support from their clinician in their decision-making process. CONCLUSIONS We are moderately confident that in the context of pregnancy, using LMWH is preferred by women given its net beneficial balance. Integrating data from different sources of evidence, and representing them in a jointly manner helps to identify patient's values and preferences. Our results may inform clinical practice guidelines and support shared decision-making process in the clinical encounter for the management of VTE in the context of pregnancy.
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Affiliation(s)
- Montserrat León-García
- Biomedical Research Institute Sant Pau (IIB Sant Pau), Barcelona, Spain.
- Department of Pediatrics, Obstetrics, Gynaecology and Preventive Medicine, Universidad Autónoma de Barcelona, Barcelona, Spain.
- Knowledge and Evaluation Research Unit, Department of Medicine, Mayo Clinic, Rochester, MN, USA.
| | - Brittany Humphries
- Cytel Inc, Toronto, ON, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Andrea Maraboto
- Knowledge and Evaluation Research Unit, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | | | - Kasey R Boehmer
- Knowledge and Evaluation Research Unit, Department of Medicine, Mayo Clinic, Rochester, MN, USA
- Division of Health Care Delivery Research, Mayo Clinic, Rochester, MN, USA
| | - Lilisbeth Perestelo-Perez
- Evaluation Unit (SESCS), Canary Islands Health Service (SCS), Tenerife, Spain
- Research Network On Health Services in Chronic Diseases (REDISSEC), Tenerife, Spain
- Network for Research On Chronicity, Primary Care, and Health Promotion (RICAPPS), Tenerife, Spain
| | - Feng Xie
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
- Centre for Health Economics and Policy Analysis, McMaster University, Hamilton, ON, Canada
| | - Irene Pelayo
- Department of Obstetrics and Gynecology, Ramón y Cajal Hospital, Madrid, Spain
- Faculty of Medicine, Alcalá de Henares University, Madrid, Spain
| | - Mark Eckman
- Division of General Internal Medicine and Center for Clinical Effectiveness, University of Cincinnati School of Medicine, Cincinnati, OH, USA
| | - Shannon Bates
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Anna Selva
- Department of Pediatrics, Obstetrics, Gynaecology and Preventive Medicine, Universidad Autónoma de Barcelona, Barcelona, Spain
- Clinical Epidemiology and Cancer Screening, Corporació Sanitaria Parc Taulí, Sabadell, Barcelona, Spain
| | - Pablo Alonso-Coello
- Biomedical Research Institute Sant Pau (IIB Sant Pau), Barcelona, Spain
- CIBER of Epidemiology and Public Health, CIBERESP, Madrid, Spain
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8
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Kirkpatrick L, Waters J, O'Neal MA. Preventive Approaches in Women's Neurology: Prepartum, Pregnancy, and Postpartum. Semin Neurol 2022; 42:665-678. [PMID: 36216357 DOI: 10.1055/a-1958-0633] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Women's neurology is the subspecialty within neurology concerned with the distinct healthcare needs of women. In this article, we review current literature and expert management strategies regarding disease-specific neurologic concerns of women, with an emphasis on issues related to contraception, pregnancy, and lactation. Health conditions that we discuss in this article include epilepsy, headache, stroke, multiple sclerosis, and Chiari I malformation. Current findings on neurologic disease in women suggest that many women with neurologic disease can safely manage their disease during pregnancy and have healthy children, though pregnancy planning is important in many conditions to mitigate risks and effective contraceptive management is important when pregnancy prevention is desired.
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Affiliation(s)
- Laura Kirkpatrick
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Janet Waters
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Mary Angela O'Neal
- Department of Neurology, Brigham and Women's Hospital, Boston, Massachusetts
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9
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Bhatia K, Shehata N, D'Souza R. Anaesthetic considerations and anticoagulation in pregnant patients with mechanical heart valves. BJA Educ 2022; 22:273-281. [DOI: 10.1016/j.bjae.2022.01.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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10
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Hage A, Hage F, Valdis M, Guo L, Chu MWA. The Ross procedure is the optimal solution for young adults with unrepairable aortic valve disease. Ann Cardiothorac Surg 2021; 10:454-462. [PMID: 34422557 DOI: 10.21037/acs-2021-rp-26] [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: 01/30/2021] [Accepted: 05/05/2021] [Indexed: 11/06/2022]
Abstract
While aortic valve repair remains the ideal intervention to restore normal valvular function, the optimal aortic valve substitute for patients with a non-repairable aortic valve remains an ongoing subject for debate. In particular, younger patients with a non-repairable valve represent a unique challenge because of their active lifestyle and long life expectancy, which carries a higher cumulative risk of prosthesis-related complications. The Ross procedure, unlike prosthetic or homograft aortic valve replacement (AVR), provides an expected survival equivalent to that of the age and gender-matched general population. Contemporary data has shown that the Ross procedure can be performed safely in centers with expertise, and is associated with improved valvular durability, hemodynamics and quality of life.
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Affiliation(s)
- Ali Hage
- Division of Cardiac Surgery, Department of Surgery, Western University, London Health Sciences Centre, London, ON, Canada
| | - Fadi Hage
- Division of Cardiac Surgery, Department of Surgery, Western University, London Health Sciences Centre, London, ON, Canada
| | - Matthew Valdis
- Division of Cardiac Surgery, Department of Surgery, Western University, London Health Sciences Centre, London, ON, Canada
| | - Linrui Guo
- Division of Cardiac Surgery, Department of Surgery, Western University, London Health Sciences Centre, London, ON, Canada
| | - Michael W A Chu
- Division of Cardiac Surgery, Department of Surgery, Western University, London Health Sciences Centre, London, ON, Canada
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11
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Sceales P, Bampoe S. Managing anticoagulation in pregnancy for the anaesthetist on the labour ward. Br J Hosp Med (Lond) 2021; 82:1-7. [PMID: 33792389 DOI: 10.12968/hmed.2020.0589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Pregnancy is a hypercoaguable state. As part of the multidisciplinary team on labour ward, the anaesthetist plays a role particularly in advising the women and the obstetric team regarding the timing and even choice of regional analgesia given the potential risk of complications, as this may be affected by the anticoagulation treatment pregnant women may be on. It is important to understand the type of anticoagulation regimens parturients might be on and what sort of risk assessment they must undergo, as this has obstetric and anaesthetic implications. Although a rare presentation, management of women with mechanical prosthetic heart valves who are pregnant requires detailed and highly specialised care in tertiary care centres with a well-developed multidisciplinary team and pathway. Despite their rare presentation, it is important to understand the intricate and complex management that these women require as they have a high morbidity and mortality rate.
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Affiliation(s)
- Penny Sceales
- Department of Anaesthesia, Queen Charlotte's and Chelsea Hospital, London, UK
| | - Sohail Bampoe
- Department of Anaesthesia and Perioperative Medicine, University College Hospital NHS Foundation Trust, London, UK
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12
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Mahgoub A, Kotit S, Bakry K, Magdy A, Hosny H, Yacoub M. Thrombosis of mechanical mitral valve prosthesis during pregnancy: An ongoing "saga" in need of comprehensive solutions. Glob Cardiol Sci Pract 2020; 2020:e202032. [PMID: 33598492 PMCID: PMC7868097 DOI: 10.21542/gcsp.2020.32] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2020] [Accepted: 12/20/2020] [Indexed: 11/08/2022] Open
Abstract
Emergency treatment for thrombosed mechanical valve prothesis during pregnancy is not uncommon in low- and middle-income countries. The presence of a mechanical valve continues to be an important cause of maternal morbidity and mortality. There is a pressing need for increasing awareness and feasible solutions for this huge problem. We here describe four patients who needed emergency treatment for thrombosis of mechanical valve prothesis during pregnancy and review the evolving comprehensive strategies for dealing with this issue.
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13
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Gupta R, Malik AH, Ranchal P, Aronow WS, Vyas AV, Rajeswaran Y, Quinones J, Ahnert AM. Valvular Heart Disease in Pregnancy: Anticoagulation and the Role of Percutaneous Treatment. Curr Probl Cardiol 2020; 46:100679. [PMID: 32868039 DOI: 10.1016/j.cpcardiol.2020.100679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 07/26/2020] [Indexed: 10/23/2022]
Abstract
Valvular heart disease is present in about 1% of pregnancies, and it poses a management challenge as both fetal and maternal lives are at risk of complications. Pregnancy is associated with significant hemodynamic changes, which can compromise the cardiac status in women with underlying valvular disorders. Management of valvular heart diseases has undergone considerable innovation and advancement with newer techniques, approaches and devices being employed. The decision regarding the management of anticoagulation, especially in patients with prosthetic valves, raises distinct questions and challenges. In this review, we describe the management of common valvular heart diseases encountered during pregnancy, role of percutaneous catheter based therapeutic interventions, the importance of a team-based approach, and the challenges given existing gaps in the literature.
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Affiliation(s)
- Rahul Gupta
- Lehigh Valley Heart Institute, Lehigh Valley Health Network, Allentown, PA.
| | - Aaqib H Malik
- Department of Cardiology, Westchester Medical Center and New York Medical College, Valhalla, NY
| | - Purva Ranchal
- Department of Internal Medicine, Boston University, MA
| | - Wilbert S Aronow
- Department of Cardiology, Westchester Medical Center and New York Medical College, Valhalla, NY
| | - Apurva V Vyas
- Lehigh Valley Heart Institute, Lehigh Valley Health Network, Allentown, PA.
| | - Yasotha Rajeswaran
- Lehigh Valley Heart Institute, Lehigh Valley Health Network, Allentown, PA.
| | - Joanne Quinones
- Lehigh Valley Heart Institute, Lehigh Valley Health Network, Allentown, PA.
| | - Amy M Ahnert
- Lehigh Valley Heart Institute, Lehigh Valley Health Network, Allentown, PA.
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14
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Dos Santos F, Baris L, Varley A, Cornette J, Allam J, Steer P, Swan L, Gatzoulis M, Roos-Hesselink J, Johnson MR. Mechanical heart valves and pregnancy: Issues surrounding anticoagulation. Experience from two obstetric cardiac centres. Obstet Med 2020; 14:95-101. [PMID: 34394718 DOI: 10.1177/1753495x20924937] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Accepted: 04/05/2020] [Indexed: 11/17/2022] Open
Abstract
Background Pregnant women with mechanical heart valves are at significant risk of obstetric/cardiac complications. This study compares the anticoagulation management in two obstetric cardiac centres. Methods Retrospective case-note review from Chelsea and Westminster/Royal Brompton Hospitals (CR) and Erasmus Medical Centre (EMC). Main outcome measure was mechanical heart valve thrombosis. Results Nineteen pregnancies from CR and 25 pregnancies from EMC were included. Most women were on low-molecular-weight heparin (LMWH) throughout pregnancy at CR, whereas at EMC most had LMWH in the first trimester and vitamin K antagonists in subsequent trimesters. Peak anti-factor Xa were performed monthly at CR, levels 0.39-1.51 IU/mL (mean 0.82 IU/mL). Anticoagulation management peri-partum was inconsistent. Delivery was mainly by caesarean section at CR (74%) and vaginal delivery at EMC (64%). No maternal deaths and only one mechanical heart valve thrombosis at CR. Two mechanical heart valve thromboses and one maternal death at EMC. Conclusion Peri-partum anticoagulation strategies, anticoagulation monitoring and mode of delivery inconsistencies reported.
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Affiliation(s)
- Francois Dos Santos
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
| | - Lucia Baris
- Department of Cardiology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Alice Varley
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
| | - Jerome Cornette
- Department of Obstetric Medicine, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Joanna Allam
- Department of Anaesthesia, Chelsea and Westminster Hospital, London, UK
| | - Philip Steer
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
| | - Lorna Swan
- Department of Cardiology, Toronto General Hospital, Toronto, Canada
| | | | | | - Mark R Johnson
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
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15
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North AM, Barrett HL, Lust KM, Whitfield KM. Therapeutic anticoagulation during the postnatal peripartum period: a survey of clinical practice. JOURNAL OF PHARMACY PRACTICE AND RESEARCH 2020. [DOI: 10.1002/jppr.1617] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Affiliation(s)
| | - Helen L. Barrett
- Department of Endocrinology and Diabetes Mater Misericordiae Brisbane Australia
- Mater Research Institute The University of Queensland Brisbane Australia
| | - Karin M. Lust
- Royal Brisbane and Women's Hospital Brisbane Australia
- The University of Queensland Brisbane Australia
| | - Karen M. Whitfield
- Royal Brisbane and Women's Hospital Brisbane Australia
- The University of Queensland Brisbane Australia
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16
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Tse E, Khurana R, Clarke G, Sia W. Using anti-Xa level for adjusting intravenous unfractionated heparin infusion in peripartum thromboembolic disease. Obstet Med 2019; 12:146-150. [PMID: 31523272 DOI: 10.1177/1753495x18772993] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Accepted: 03/01/2018] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Intravenous unfractionated heparin infusion is often used to minimize the duration of time without anticoagulation around delivery in pregnant patients with high thrombotic risk. Activated partial thromboplastin time is commonly used to monitor and adjust heparin dose. However, using activated partial thromboplastin time is problematic in pregnancy because activated partial thromboplastin time response to unfractionated heparin is attenuated due to elevated Factor VIII levels and may lead to incorrect dosing. CASE We report a case of deep venous thrombosis occurring in a term pregnancy managed by intravenous unfractionated heparin adjusted using anti-Xa level around the time of delivery. We modified the intravenous unfractionated heparin nomogram by using anti-Xa levels instead of activated partial thromboplastin time and observed lower dosing of unfractionated heparin than otherwise required to achieve and maintain target levels. CONCLUSION This report demonstrates the feasibility and effectiveness of using anti-Xa level to monitor and adjust intravenous unfractionated heparin infusion in pregnancy.
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Affiliation(s)
- Enrica Tse
- Department of Obstetrics and Gynecology, University of Alberta, Edmonton, Alberta, Canada
| | - Rshmi Khurana
- Departments of Medicine and Obstetrics and Gynecology, University of Alberta, Edmonton, Alberta, Canada
| | - Gwen Clarke
- Canadian Blood Services, Edmonton, Alberta, Canada
| | - Winnie Sia
- Departments of Medicine and Obstetrics and Gynecology, University of Alberta, Edmonton, Alberta, Canada
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Gupta R, Ranchal P, Harburger J. Mechanical Valve Thrombosis in a Pregnant Patient: A Case of Therapeutic Failure. Cureus 2019; 11:e5615. [PMID: 31720131 PMCID: PMC6822999 DOI: 10.7759/cureus.5615] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Accepted: 09/10/2019] [Indexed: 11/05/2022] Open
Abstract
Mechanical valve thrombosis is life-threatening complication especially in pregnant patients. The optimal anticoagulation regimen is still not certain as there are different fetal and maternal risks associated with anticoagulation. A 37-year-old woman with a history of rheumatic heart disease with a mechanical mitral valve replacement 13 years prior presented to the hospital with dyspnea on mild exertion associated with orthopnea for three days. She was nine weeks pregnant, she had been on warfarin prior to pregnancy, and was switched to low molecular weight heparin (LMWH) in her 6th week of pregnancy. Fluoroscopy showed that one leaflet of the mitral valve was nearly fixed, while the other leaflet had restricted motion at maximal opening. Transesophageal echocardiogram (TEE) showed a very large thrombus approximately 3-4 cm2 encompassing the entire mechanical valve with one immobile leaflet and limited mobility in other leaflet. In view of her clinical status (dyspnea with NYHA Class IV symptoms), the patient underwent uncomplicated bioprosthetic mitral valve replacement. However, the fetus did not survive. Mechanical heart valve (MHV) thrombosis is life-threatening complication in pregnancy. The optimal anticoagulation therapy in pregnancy is unclear. This case report brings into light that in spite of adequate anticoagulation, pregnant patients with mechanical heart valves are still at a high risk of developing valve thrombosis. It highlights the use of transthoracic and transesophageal echocardiogram along with fluoroscopy in diagnosing this and discusses the therapeutic options for this unique condition.
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Affiliation(s)
- Rahul Gupta
- Internal Medicine, Westchester Medical Center, Valhalla, USA
| | - Purva Ranchal
- Internal Medicine, Westchester Medical Center, Valhalla, USA
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Bernard C, Pekny C, Omukagah CO, Bernard CO, Manji I, Pastakia SD, Christoffersen-Deb A. Integration of contraceptive services into anticoagulation management services improves access to long-acting reversible contraception. Contraception 2018; 98:486-491. [PMID: 30076833 PMCID: PMC6941485 DOI: 10.1016/j.contraception.2018.07.139] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Revised: 07/22/2018] [Accepted: 07/29/2018] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Integration of services is a promising way to improve access to contraception in sub-Saharan Africa, but few studies have evaluated this strategy to increase access to contraception among women requiring anticoagulation. Our objective was to evaluate a model of care integrating contraceptive counseling and provision within an anticoagulation management clinic in Eldoret, Kenya, to determine the impact on long-acting reversible contraception (LARC) use. STUDY DESIGN We performed a prospective observational study of reproductive-age women referred for integrated services from the anticoagulation management clinic at Moi Teaching and Referral Hospital from March 2015 to March 2016. All participants received disease-specific contraceptive counseling and provision, free reversible methods (excluding hormonal intrauterine devices [IUDs]) and follow-up care. We compared LARC use 3 months postintervention to preintervention using the proportions test. Logistic regression analysis was used to determine factors related to use of contraceptive implants and copper IUDs. RESULTS Of 190 participants, 171 (90%) completed 3-month follow-up. There was a significant increase in contraceptive implant use from 10% to 19%, p=.02, and injectable contraceptive use from 14% to 24%, p=.013. There was a concomitant decrease in the use of no method/abstinence from 57% to 39% (33% decrease, p<.001). Younger age, having at least one child and discussing family planning with a partner were predictive of LARC use. CONCLUSION Integrating contraceptive services into an anticoagulation management clinic increases the use of highly effective contraception for women with cardiovascular disease. Implementation of similar models of care should be evaluated within other sites for chronic disease management. IMPLICATIONS A model of care integrating contraceptive counseling and provision into anticoagulation management services is an effective strategy to improve LARC and overall highly effective contraceptive use among women with cardiovascular disease requiring anticoagulation. This model of care may be utilized to prevent maternal morbidity and mortality among this high-risk population.
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Affiliation(s)
- Caitlin Bernard
- AMPATH/Indiana University, P.O. Box 4606, Eldoret, Kenya, 30100.
| | - Chelsea Pekny
- AMPATH/Purdue University, P.O. Box 4606, Eldoret, Kenya, 30100.
| | | | | | - Imran Manji
- AMPATH/Moi Teaching & Referral Hospital, P.O. Box 4606, Eldoret, Kenya, 30100.
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Abstract
Valvular heart disease is a major public health issue. The prevalence of valvular heart disease is expected to increase due to an aging population. Valve dysfunction manifests as valve stenosis, regurgitation, or both due to various etiologies. Valve repair and replacement are the main treatment options for severe valve dysfunction. Valve replacement is achieved by using either a mechanical or a bioprosthetic valve. Mechanical valves are more durable but require lifelong anticoagulation with associated complications. Bioprosthetic valves usually require anticoagulation only transiently after implantation but are less durable and degenerate more rapidly. In this article, we discuss antithrombotic regimens in persons after valve operations. We discuss general issues and antithrombotic recommendations for patients undergoing surgical bioprosthetic valve replacement, mechanical valve replacement (including different regimens for different positions and types of mechanical valves), mitral valve repair, and transcatheter aortic valve replacement. In addition, we discuss the antithrombotic management of patients in special circumstances, including patients with mechanical valves who have recurrent bleeding or thrombotic events, patients with mechanical valves undergoing surgery, and pregnant women with mechanical valves.
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Singh A, Panghal A, Prasad R, Mishra OP. A Case of Coumarin Embryopathy After in Utero Exposure to Acenocoumarol. JOURNAL OF FETAL MEDICINE 2018. [DOI: 10.1007/s40556-018-0182-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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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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Anticoagulation for the Pregnant Patient with a Mechanical Heart Valve, No Perfect Therapy: Review of Guidelines for Anticoagulation in the Pregnant Patient. Case Rep Cardiol 2017; 2017:3090273. [PMID: 29359052 PMCID: PMC5735605 DOI: 10.1155/2017/3090273] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Revised: 09/18/2017] [Accepted: 10/25/2017] [Indexed: 12/22/2022] Open
Abstract
Heart valve replacement with a mechanical valve requires lifelong anticoagulation. Guidelines currently recommend using a vitamin K antagonist (VKA) such as warfarin. Given the teratogenic effects of VKAs, it is often favorable to switch to heparin-derived therapies in pregnant patients since they do not cross the placenta. However, these therapies are known to be less effective anticoagulants subjecting the pregnant patient to a higher chance of a thrombotic event. Guidelines currently recommend pregnant women requiring more than 5 mg a day of warfarin be switched to alternative therapy during the first trimester. This case report highlights a patient who was switched to alternative therapy during her first pregnancy and suffered a devastating cerebrovascular accident (CVA). Further complicating her situation was during a subsequent pregnancy; this patient continued warfarin use during the first trimester and experienced multiple transient ischemic attacks (TIAs). This case highlights the increased risk of thrombotic events in pregnant patients with mechanical valves. It also highlights the difficulty of providing appropriate anticoagulation for the pregnant patient who has experienced thrombotic events on multiple anticoagulants.
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Bianca I, Geraci G, Gulizia MM, Egidy Assenza G, Barone C, Campisi M, Alaimo A, Adorisio R, Comoglio F, Favilli S, Agnoletti G, Carmina MG, Chessa M, Sarubbi B, Mongiovì M, Russo MG, Bianca S, Canzone G, Bonvicini M, Viora E, Poli M. Consensus Document of the Italian Association of Hospital Cardiologists (ANMCO), Italian Society of Pediatric Cardiology (SICP), and Italian Society of Gynaecologists and Obstetrics (SIGO): pregnancy and congenital heart diseases. Eur Heart J Suppl 2017; 19:D256-D292. [PMID: 28751846 PMCID: PMC5526477 DOI: 10.1093/eurheartj/sux032] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
The success of cardiac surgery over the past 50 years has increased numbers and median age of survivors with congenital heart disease (CHD). Adults now represent two-thirds of patients with CHD; in the USA alone the number is estimated to exceed 1 million. In this population, many affected women reach reproductive age and wish to have children. While in many CHD patients pregnancy can be accomplished successfully, some special situations with complex anatomy, iatrogenic or residual pathology are associated with an increased risk of severe maternal and fetal complications. Pre-conception counselling allows women to come to truly informed choices. Risk stratification tools can also help high-risk women to eventually renounce to pregnancy and to adopt safe contraception options. Once pregnant, women identified as intermediate or high risk should receive multidisciplinary care involving a cardiologist, an obstetrician and an anesthesiologist with specific expertise in managing this peculiar medical challenge. This document is intended to provide cardiologists working in hospitals where an Obstetrics and Gynecology Department is available with a streamlined and practical tool, useful for them to select the best management strategies to deal with a woman affected by CHD who desires to plan pregnancy or is already pregnant.
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Affiliation(s)
- Innocenzo Bianca
- Pediatric Cardiology Unit, Maternity and Neonatal Department, ARNAS Garibaldi, Catania, Italy
| | - Giovanna Geraci
- Cardiology Department, PO Cervello, Az. Osp. Riuniti Villa Sofia-Cervello, Via Trabucco, 180, 90146 Palermo, Italy
| | - Michele Massimo Gulizia
- Cardiology Department, Ospedale Garibaldi-Nesima, Azienda di Rilievo Nazionale e Alta Specializzazione ‘Garibaldi’, Catania, Italy
| | - Gabriele Egidy Assenza
- Pediatric Cardiology and Adult Congenital Heart Program, Azienda Ospedaliera-Universitaria Sant’Orsola-Malpighi, Bologna, Itlay
| | - Chiara Barone
- Genetics Unit, Maternity and Neonatal Department, ARNAS Garibaldi, Catania, Italy
| | - Marcello Campisi
- Pediatric Cardiology Unit, Maternity and Neonatal Department, ARNAS Garibaldi, Catania, Italy
| | - Annalisa Alaimo
- Pediatric Cardiology Department, PO Di Cristina, ARNAS Civico, Palermo, Italy
| | - Rachele Adorisio
- Pediatric Cardiology Department, Ospedale Pediatrico Bambino Gesù, Roma, Italy
| | - Francesca Comoglio
- SCDU 2, Dipartimento di Scienze Chirurgiche (Surgical Sciences Department), Università di Torino, Italy
| | - Silvia Favilli
- Pediatric Cardiology Department, Azienda-Ospedalliero-Universitaria Meyer, Firenze, Italy
| | - Gabriella Agnoletti
- Pediatric Cardiology Department, Ospedale Regina Margherita, Città della Salute e della Scienza, Torino, Italy
| | - Maria Gabriella Carmina
- Cardiology Department, PO Cervello, Az. Osp. Riuniti Villa Sofia-Cervello, Via Trabucco, 180, 90146 Palermo, Italy
| | - Massimo Chessa
- Pediatric and Adult Congenital Heart Centre, IRCCS-Policlinico San Donato Milanese San Donato Milanese (MI), Italy
| | - Berardo Sarubbi
- Pediatric Cardiology and Cardiology SUN, Seconda Università di Napoli, AORN dei Colli, Ospedale Monaldi, Napoli, Italy
| | - Maurizio Mongiovì
- Pediatric Cardiology Department, PO Di Cristina, ARNAS Civico, Palermo, Italy
| | - Maria Giovanna Russo
- Pediatric Cardiology and Cardiology SUN, Seconda Università di Napoli, AORN dei Colli, Ospedale Monaldi, Napoli, Italy
| | - Sebastiano Bianca
- Genetics Unit, Maternity and Neonatal Department, ARNAS Garibaldi, Catania, Italy
| | - Giuseppe Canzone
- Women and Children Health Department, Ospedale S. Cimino, Termini Imerese (PA), Italy
| | - Marco Bonvicini
- Pediatric Cardiology and Adult Congenital Heart Program, Azienda Ospedaliera-Universitaria Sant’Orsola-Malpighi, Bologna, Itlay
| | - Elsa Viora
- Echography and Prenatal Diagnosis Centre, Obstetrics and Gynaecology Department, Città della Salute e della Scienza di Torino, Italy
| | - Marco Poli
- Intensive Cardiac Therapy Department, Ospedale Sandro Pertini, Roma, Italy
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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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Davis MB. Pregnancy and Heart Disease Updates: Current Knowledge and Future Directions. CURRENT CARDIOVASCULAR RISK REPORTS 2015. [DOI: 10.1007/s12170-015-0478-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Basu S, Aggarwal P, Kakani N, Kumar A. Low-dose maternal warfarin intake resulting in fetal warfarin syndrome: In search for a safe anticoagulant regimen during pregnancy. ACTA ACUST UNITED AC 2015; 106:142-7. [PMID: 26389802 DOI: 10.1002/bdra.23435] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2015] [Revised: 07/22/2015] [Accepted: 08/04/2015] [Indexed: 01/13/2023]
Abstract
BACKGROUND Fetal exposure to maternal ingestion of warfarin is known to produce certain dysmorphic features in the neonate, known as fetal warfarin syndrome (FWS). There is a general consensus that maternal intake of warfarin at a daily dose of 5 mg or less is safe both for the infant and the mother. METHODS We report four cases of FWS born to mothers with rheumatic heart disease on warfarin prophylaxis during pregnancy at a dose less than 5 mg/day. RESULTS Along with typical facial features of FWS and multiple epiphyseal stippling in skeletal x-ray, Case 1 had Dandy-Walker malformation and Case 2 had laryngo-tracheomalacia and patent ductus arteriosus. CONCLUSION We emphasize the need for optimizing the choice and dosage schedule of anticoagulants during pregnancy, least harmful for the mother and her developing fetus.
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Affiliation(s)
- Sriparna Basu
- Neonatology Unit, Department of Pediatrics, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
| | - Priyanka Aggarwal
- Neonatology Unit, Department of Pediatrics, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
| | - Neha Kakani
- Neonatology Unit, Department of Pediatrics, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
| | - Ashok Kumar
- Neonatology Unit, Department of Pediatrics, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
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Heart disease in pregnancy. Best Pract Res Clin Obstet Gynaecol 2015; 29:579-97. [DOI: 10.1016/j.bpobgyn.2015.04.002] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2014] [Revised: 04/03/2015] [Accepted: 04/05/2015] [Indexed: 12/29/2022]
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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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Sakr SA, Abdel-Shakour H, Ramadan MM. Successful fibrinolytic treatment of prosthetic heart valve thrombosis using streptokinase. Acta Clin Belg 2015; 70:159-66. [PMID: 25495280 DOI: 10.1179/2295333714y.0000000107] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
OBJECTIVES This study aims to evaluate the clinical outcome of fibrinolytic treatment of prosthetic valve thrombosis (PVT) with 'streptokinase' as a first line treatment for these cases. METHODS The study group was 20 consecutive patients (10 females) diagnosed with PVT. The protocol for streptokinase administration was either accelerated (intravenous infusion of 0.5 million IU over 30 minutes followed by 0.15 million IU/h) or conventional (intravenous infusion of 0.25 million IU over 30 minutes followed by 0.15 million IU/h). Success of fibrinolytic therapy was defined as complete restoration of valve function in the presence or absence of complications. RESULTS Eighteen patients (90%) had mitral PVT and two (10%) had aortic PVT. Thrombolytic therapy with streptokinase was successful in all but one case, with a total mortality of four cases (20%). In PVT episodes, before streptokinase therapy, the prosthetic valve areas (in all cases, mitral and aortic positions) were 0.82 ± 0.21, 0.83 ± 0.21, and 0.73 ± 0.18 cm²; and the peak and mean transvalvular gradients were 38.7 ± 16.7 and 25.4 ± 8.7, 34.1 ± 8.8 and 23.2 ± 5.4, and 80.0 ± 14.1 and 45.0 ± 7.1 mmHg, respectively. After streptokinase therapy, the prosthetic valve area and peak and mean transvalvular gradients improved significantly (for all cases, mitral and aortic positions: valve area 2.17 ± 0.58, 2.21 ± 0.61, and 1.85 ± 0.07 cm², peak gradient 18.7 ± 11.0, 16.4 ± 7.7, and 39.0 ± 18.4, and mean gradient 9.6 ± 7.1, 8.2 ± 5.3, and 22.0 ± 11.3 mmHg, respectively; paired t-test, P<0.001 for pre- versus post-streptokinase infusion for all variables). CONCLUSION Fibrinolytic therapy using streptokinase was an effective therapeutic strategy for the management of PVT and is a reasonable alternative to surgery.
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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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Fournet-Fayard A, Lebreton A, Ruivard M, Storme B, Godeau B, Bonnin M, Delabaere A, Gallot D. Prise en charge anténatale des patientes à risque d’hémorragie du post-partum (hors anomalies de l’insertion placentaire). ACTA ACUST UNITED AC 2014; 43:951-65. [DOI: 10.1016/j.jgyn.2014.09.024] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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Hirsch R. Should we offer a bioprosthetic valve to women of child-bearing age who need valve replacement? Interv Cardiol 2014. [DOI: 10.2217/ica.14.37] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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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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McLintock C. Thromboembolism in pregnancy: challenges and controversies in the prevention of pregnancy-associated venous thromboembolism and management of anticoagulation in women with mechanical prosthetic heart valves. Best Pract Res Clin Obstet Gynaecol 2014; 28:519-36. [PMID: 24814194 DOI: 10.1016/j.bpobgyn.2014.03.001] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2013] [Accepted: 03/03/2014] [Indexed: 12/19/2022]
Abstract
Thromboembolism in pregnancy is an important clinical issue. Despite identification of maternal and pregnancy-specific risk factors for development of pregnancy-associated venous thromboembolism, limited data are available to inform on optimal approaches for prevention. The relatively low overall prevalence of pregnancy-associated venous thromboembolism has prompted debate about the validity of recommendations, which are mainly based on expert opinion, and have resulted in an increased use of pharmacological thromboprophylaxis in pregnancy and postpartum. A pragmatic approach is required in the absence of more robust data. Anticoagulation management of pregnant women with mechanical prosthetic heart valves is particularly challenging. Continuation of therapeutic anticoagulation during pregnancy is essential to prevent valve thrombosis. Warfarin, the most effective anticoagulant, is associated with adverse fetal outcomes, including embryopathy and stillbirth. Fetal outcome is improved with therapeutic-dose low-molecular-weight heparin, but there may be more thromboembolic complications. More intensive anticoagulation, targeting higher trough anti-Xa levels, may reduce the risk of valve thrombosis.
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Affiliation(s)
- Claire McLintock
- National Women's Health, Auckland City Hospital, Auckland, New Zealand.
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Vause S, Clarke B. Risk stratification and hierarchy of antenatal care. Best Pract Res Clin Obstet Gynaecol 2014; 28:483-94. [PMID: 24726852 DOI: 10.1016/j.bpobgyn.2014.03.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2013] [Accepted: 03/11/2014] [Indexed: 10/25/2022]
Abstract
Cardiac disease is the leading cause of maternal death in the UK. The triennial maternal mortality reports have repeatedly highlighted failure to recognise the level of risk as a major contributing factor to the deaths of these women. Once the level of risk has been recognised, services then need to be organised in a way that supports the needs of the highest risk women, but avoids unnecessary intervention for women at lower risk. Risk scoring systems and lesion-specific indicators may help predict maternal and neonatal outcomes. Care can then be planned accordingly, to optimise the outcome for the woman and her baby.
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Affiliation(s)
- Sarah Vause
- St Mary's Hospital, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester M13 9WL, UK and Institute of Human Development, Faculty of Medical and Human Sciences, University of Manchester.
| | - Bernard Clarke
- Manchester Royal Infirmary, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Sciences Centre, Manchester M13 9WL and Institute of Cardiovascular Sciences, Faculty of Medical and Human Sciences, University of Manchester, UK
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Goland S, Schwartzenberg S, Fan J, Kozak N, Khatri N, Elkayam U. Monitoring of Anti-Xa in Pregnant Patients With Mechanical Prosthetic Valves Receiving Low-Molecular-Weight Heparin. J Cardiovasc Pharmacol Ther 2014; 19:451-6. [DOI: 10.1177/1074248414524302] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Objectives: We hypothesized that the guideline-recommended peak anti-Xa levels for pregnant women with mechanical prosthetic heart valves (MPHVs) receiving adjusted dose low-molecular-weight heparin (LMWH) are associated with subtherapeutic trough levels and consequently with an inadequate level of anticoagulation. Background: Low-molecular-weight heparin is often used for anticoagulation in pregnant women including those with MPHV. American College of Cardiology/American Heart Association guidelines recommend monitoring of plasma anti-Xa factor peak levels and adjustment of the dose to achieve peak levels of 0.7 to 1.2 U/mL. In spite of these recommendations, cases of valve thrombosis during pregnancy continue to occur. Methods and Results: We studied 30 pregnant patients receiving anticoagulation for various indications with adjusted dose LMWH given subcutaneously twice a day which had both trough and peak anti-Xa levels throughout pregnancy for a total of 187 paired determinations. The recommended peak anti-Xa levels (0.7-1.2 U/mL) were obtained in 123 (66%) of the measurements but in 80% of them, the trough levels were found to be subtherapeutic (<0.6 U/mL). Subtherapeutic trough levels were found in 8 (73%) of the 11 measurements with peak levels of 0.7 to 0.79 U/mL, 17 (74%) of the 23 of 0.8 to 0.89 U/mL, 21 (72%) of the 29 of 0.9 to 0.99 U/mL, and 28 (44%) of the 63 of 1.0 to 1.2 U/mL. There were 42 measurements with peak anti-Xa levels >1.2 U/mL and even in these cases, 13 (31%) of the trough levels were found to be subtherapeutic. Conclusions: Anticoagulation with adjusted dose LMWH aimed to achieve guideline-recommended peak levels of anti-Xa for patients with MPHVs is commonly associated with subtherapeutic trough levels. Routine measurement of trough anti-Xa levels is therefore advisable in women with MPHV treated with LMWH during pregnancy to assure adequate level of anticoagulation.
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Affiliation(s)
- Sorel Goland
- Heart Institute, Kaplan Medical Center, Affiliated to the Hebrew University and Hadassah Medical School, Jerusalem, Israel
| | - Shmuel Schwartzenberg
- Heart Institute, Kaplan Medical Center, Affiliated to the Hebrew University and Hadassah Medical School, Jerusalem, Israel
| | - John Fan
- Department of Medicine, Division of Cardiovascular Disease, University of Southern California, Los Angeles, CA, USA
- Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA, USA
| | - Natasha Kozak
- Heart Institute, Kaplan Medical Center, Affiliated to the Hebrew University and Hadassah Medical School, Jerusalem, Israel
| | - Nudrat Khatri
- Department of Medicine, Division of Cardiovascular Disease, University of Southern California, Los Angeles, CA, USA
- Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA, USA
| | - Uri Elkayam
- Department of Medicine, Division of Cardiovascular Disease, University of Southern California, Los Angeles, CA, USA
- Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA, USA
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Hassouna A, Allam H. Limited dose warfarin throughout pregnancy in patients with mechanical heart valve prosthesis: a meta-analysis. Interact Cardiovasc Thorac Surg 2014; 18:797-806. [PMID: 24595247 DOI: 10.1093/icvts/ivu009] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
The continuation of warfarin throughout pregnancy in patients with a mechanical valve prosthesis is a valid anticoagulation regimen, provided that warfarin dose does not exceed 5 mg/day. Two decades after being introduced, the efficacy and safety of this regimen merit evaluation. We performed a systematic review for cases published between January 1991 and January 2013. We compiled our prospective data on 55 pregnancies and calculated pooled estimates (95% confidence interval) of adverse foetal and maternal outcomes. Events were expressed as proportions of total pregnancies, except embryopathy and maternal death, which were related to the number of live births and number of patients, respectively. There were 494 eligible pregnancies reported in 11 studies. The rate of embryopathy was 0.9% (0.4-2.4%) and most of the 13.4% (8.4-24.7%) foetal losses were due to the 12.8% (7.7-22.7%) rate of spontaneous abortion. No maternal mortality was encountered (0-1.3%) but 0.6% (0.3-2%) prosthetic valve thrombosis, 1.8% (1.1-3.6%) total thromboembolic events and 3.4% (2-5.1%) major maternal bleeding events were recorded. Foetal loss, spontaneous abortions and foetal embryopathy dropped to 8.1% (2.9-13.7%), 7.3% (3.1-11.8%) and 0.6% (0.1-2.1%) among the 344 pregnancies (69.6%) observed in the 6 prospective studies (54.5%). Prosthetic valve thrombosis (0.6%; 01-2%), total thromboembolic (2.3%; 1.2-4.6%) and major bleeding events (2.9%; 1.8-6%) remained comparable with overall results. Foetal embryopathy and prosthetic valve thrombosis were not robust on sensitivity analysis, regardless of the study design. A prospective subgroup of 96 patients (19.4%) received smaller warfarin dose, through targeting a lower international normalized ratio (INR) between 1.5 and 2.5. The associated rate of foetal loss (2.1%; 0.5-6.9%) was significantly lower than that observed in the remaining patients targeting a higher INR between 2.5 and 3.5 (16.1%; 13.1-34.4%). Adverse maternal outcomes were also fewer but rates remained comparable. Limited dose warfarin throughout pregnancy was associated with improved foetal outcomes, without jeopardizing maternal safety. Foetal outcomes were better when patients were followed up prospectively or receiving smaller warfarin doses through targeting a lower INR than recommended (1.5-2.5). Large randomized controlled trials are mandatory to evaluate our findings.
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Affiliation(s)
- Ahmed Hassouna
- Department of Cardiothoracic Surgery, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Hemat Allam
- Department of Complementary Medicine, National Research Center, Giza, Egypt
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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. 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 2014; 129:e521-643. [PMID: 24589853 DOI: 10.1161/cir.0000000000000031] [Citation(s) in RCA: 884] [Impact Index Per Article: 88.4] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Lawley CM, Lain SJ, Algert CS, Ford JB, Figtree GA, Roberts CL. Prosthetic heart valves in pregnancy: a systematic review and meta-analysis protocol. Syst Rev 2014; 3:8. [PMID: 24444192 PMCID: PMC3913632 DOI: 10.1186/2046-4053-3-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2013] [Accepted: 01/06/2014] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Advances in surgical technique, prosthetic heart valve design, and anticoagulation have contributed to an overall improvement in morbidity and mortality in women with heart valve prostheses as well as increased feasibility of pregnancy. Previous work investigating the pregnancies of women with prosthetic valves has been directed largely toward understanding the influence of anticoagulation regimen. There has been little investigation on maternal and infant outcomes. The objective of this systematic review will be to assess the outcomes of pregnancy in women with heart valve prostheses in contemporary populations. METHODS/DESIGN A systematic search of Medline, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and the Cochrane Library will be undertaken. Article titles and abstracts will be evaluated by two reviewers for potential relevance. Studies that include pregnancies occurring from 1995 onwards and where there are six or more pregnancies in women with heart valve prostheses included in the study population will be reviewed for potential inclusion. Primary outcomes of interest will be mortality (maternal and perinatal). Secondary outcomes will include other pregnancy outcomes. No language restrictions will be applied. Methodological quality and heterogeneity of studies will be assessed. Data extraction from identified articles will be undertaken by two independent reviewers using a uniform template. Meta-analyses will be performed to ascertain risk of adverse events and, where numbers are sufficient, by type of prosthesis and location as well as other subgroup analyses. DISCUSSION Estimates of the risk of adverse events in recent pregnancies of women with heart valve prosthesis will provide better information for counselling and decision making. Given the improvements in prognosis of heart valve prosthesis recipients and the paucity of definitive data regarding optimal pregnancy management for these women, review of this topic is pertinent. REVIEW REGISTRATION This protocol has been registered with the international prospective register of systematic reviews (PROSPERO) as number CRD42013006187, accessible online at http://www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42013006187#.Utk7qNJ9Lf8.
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Affiliation(s)
- Claire M Lawley
- Clinical Population Perinatal Health Research Group, The Kolling Institute, University of Sydney at Royal North Shore Hospital, Herbert Street, St Leonards, New South Wales 2065, Australia.
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Tounsi A, Abid D, Louati D, Mallek S, Akrout M, Abid L, Abdennadher M, Frikha I, Chaabene K, Hentati M, Kammoun S. Anticoagulation in Pregnant Women with Mechanical Heart Valve Prostheses: 25-Year Experience at a Tertiary Care Hospital in a Developing Country. ACTA ACUST UNITED AC 2014. [DOI: 10.4236/wjcd.2014.46037] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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44
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Goland S, Zilberman L, Elkayam U. Clinical Considerations on Anticoagulation Management in Cardiovascular Diseases During Pregnancy. Drug Dev Res 2013. [DOI: 10.1002/ddr.21113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- Sorel Goland
- The Department of Cardiology; Kaplan Medical Center; Rehovot Israel
| | - Liaz Zilberman
- The Department of Cardiology; Kaplan Medical Center; Rehovot Israel
| | - Uri Elkayam
- Department of Medicine; Division of Cardiovascular Disease; University of Southern California; Los Angeles CA USA
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45
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Prokšelj K, Štalc M, Šajina Stritar B, Mohorko-Pleskovič P, Kozak M. Pregnancy in a patient with a bioprosthetic tricuspid valve. J OBSTET GYNAECOL 2013; 33:736-7. [PMID: 24127967 DOI: 10.3109/01443615.2013.816662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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46
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Casais P, Rolandi F. Prosthetic valve thrombosis in pregnancy: a promising treatment for a rare and mostly preventable complication. Circulation 2013; 128:481-2. [PMID: 23812181 DOI: 10.1161/circulationaha.113.004259] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Abstract
To assess the rate and type of maternal and infant complications among pregnant women receiving low-molecular-weight heparin (LMWH). Retrospective study of pregnant women on LMWH referred to two university hematology clinics from January 2001 to December 2010. We recorded the number of pregnancies, indication, dose and dose adjustments for LMWH, pregnancy outcomes (live births, maternal and infant complications) and side effects of LMWH. There were 89 pregnancies in 76 women. The most common indication for LMWH was a history of adverse outcome of pregnancy associated with thrombophilia. LMWH was adjusted in 75 and 45% of pregnancies in women on therapeutic and prophylactic doses, respectively. Live birth rate was 97%. There were 25 maternal and 11 infant complications. Side effects were minimal and included decreased bone mineral density and bleeding. LMWH use among pregnant women is associated with successful pregnancy outcomes. Although side effects were minimal, maternal and infant complications occurred in 28 and 12% of cases, respectively.
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Anticoagulant choices in pregnant women with mechanical heart valves: Balancing maternal and fetal risks – the difference the dose makes. Thromb Res 2013; 131 Suppl 1:S8-10. [DOI: 10.1016/s0049-3848(13)70010-0] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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49
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Abstract
OPINION STATEMENT With greater awareness and treatment of valvular heart disease, there are now an increasing number of patients with prosthetic heart valves. However, replacement of a diseased valve with a prosthetic valve creates the opportunity for new and unique complications that once diagnosed require specific treatments. Complications which may occur depend not only on the type of prosthesis but also are influenced by clinical factors that are important to understand and may affect treatment strategies. Tissue prostheses tend to deteriorate over time while mechanical prostheses require anticoagulation with its attendant risks. The rate of serious prosthetic heart valve complications is approximately 3 % per year. They include bleeding, systemic embolization, obstruction due to thrombus or pannus formation, patient-prosthesis mismatch, infective endocarditis, structural deterioration, prosthetic and peri-prosthetic regurgitation, and hemolysis. Importantly, the risk of prosthetic heart valve complications can be reduced by appropriate choices made at the time of surgery such as utilization of the correct prosthesis size and type. In addition, adherence to current guidelines for anticoagulation, endocarditis prophylaxis, and the timing of clinical and echocardiographic surveillance is also important to prevent complications. Should complications occur, rapid diagnosis, usually with echocardiography, is pivotal and can provide important hemodynamic as well as anatomic information critical to determining appropriate treatment and timing of surgical re-intervention if necessary. Optimal treatment of prosthetic heart valve complications remains a challenge and new treatment strategies continue to evolve.
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Affiliation(s)
- Sunil Mankad
- Mayo Clinic College of Medicine, 200 First Street SW, Gonda 6-402, Rochester, MN, 55905, USA,
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50
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Castellano JM, Narayan RL, Vaishnava P, Fuster V. Anticoagulation during pregnancy in patients with a prosthetic heart valve. Nat Rev Cardiol 2012; 9:415-24. [DOI: 10.1038/nrcardio.2012.69] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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