Prosthetic Valve Thrombosis Presenting as an Acute Embolic Myocardial Infarction in a Pregnant Patient: Issues on Anticoagulation Regimens and Thrombolytic Therapy

Coronary Events in the Pregnant Patient: Who Is at Risk and How Best to Manage?

Coronary events in pregnancy are a rare but growing cause of maternal morbidity and mortality. Pregnancy presents unique challenges across a broad spectrum of disciplines and requires a multidisciplinary approach to optimise maternal and fetal outcomes. The early involvement of the "cardio-obstetrics" team in prepregnancy counselling, the antenatal period, delivery, and postpartum is vital to ensuring better outcomes for patients at high risk of coronary pathology. The overall risk for coronary events complicating pregnancy is increasing owing to a number of factors, including advancing maternal age and increases in traditional cardiac risk factors contributing to higher rates of maternal morbidity and mortality. The majority of pregnant women experiencing a coronary event do not have previous coronary disease, and the pathologic mechanisms involved are predominantly nonatherosclerotic. Diagnosis and management should follow standard guideline-based practices for acute coronary syndrome (ACS), including the use of diagnostic coronary angiography to guide percutaneous intervention when needed. Management of ACS should not be delayed to facilitate delivery, which can proceed following stent implantation and dual antiplatelet therapy. The timing and mode of delivery should be based on assessment of maternal and fetal status, but vaginal delivery is preferred when possible. This review aims to provide an overview of the major etiologies, risk factors, diagnoses, and management strategies for patients at risk of or presenting with coronary events in pregnancy.

Diagnostic Angiograms and Percutaneous Coronary Interventions in Pregnancy

Cardiovascular disease is the leading indirect cause of maternal mortality in the UK. Pregnancy increases the risk of acute MI (AMI) by three- to fourfold secondary to the profound physiological changes that place an extra burden on the cardiovascular system. AMI is not always recognised in pregnancy and there is concern among both clinicians and patients regarding catheter-based interventions due to fears of foetal irradiation and risks to the foetus. This article evaluates the current state of knowledge on AMI in pregnancy with particular emphasis on pregnancy-associated spontaneous coronary artery dissection and percutaneous coronary intervention as the revascularisation procedure for AMI. Special considerations that must be made in patients requiring percutaneous coronary intervention for pregnancy-associated spontaneous coronary artery dissection and the current recommendations on arterial access, methods of minimising radiation and stent selection are discussed.

Prosthetic thrombosis and coronary embolism during pregnancy: a delicate situation of antithrombotic therapy management

Mechanical heart valve thrombosis is not so rare in pregnant women because of the difficulties in managing anticoagulant treatment and the hypercoagulability state associated with pregnancy. Among the embolic complications of valve prosthetic thrombosis, the coronary embolism is rare, it requires an urgent pharmaco-invasive approach which must be adapted to this particular associated condition. We report the observation and the difficulties of managing antithrombotic therapy in a pregnant patient hospitalized for non-obstructive prosthetic valve thrombosis complicated by coronary embolism and resulting in ST elevation myocardial infarction.

Pregnancy in mothers with prosthetic heart valves

Prosthetic mechanical valves have a high risk condition for patients in pregnancy. The aim of this study was to evaluate the safety of pregnancy in mothers with prosthetic heart valves. In this cross sectional study, we compared incidence of thromboembolic attacks abortion and maternal and fetal complications in 19 patients with prosthetic heart valves. We reviewed medical records, also office visit and follow up of these women for 10 years. Between 10 years we studied 19 patients, 13 had mechanical heart valves with mean ages of 28.2 +/- 5.43, 4 cases with bioprosthetic valves with mean age of 25.4 +/- 4.12 and 2 cases of valve repaired 27.00 +/- 7.07. Seven women were uniparous 8 cases were in second pregnancy, one had 3rd and another one were gravid 4th. There was a mean interval between valve surgery and pregnancy of 7.65 +/- 6.07 (1-23) years. Dominant underling disease for valve replacement was rheumatic. In conclusion bridge anticoagulation during pregnancy is safe for mother and fetus in women with mechanical heart valves.

Acute Myocardial Infarction due to Coronary Artery Embolism in a Patient with Mechanical Aortic Valve Prosthesis

Previous cases of coronary embolism as a cause of myocardial infarction (MI) in association with prosthetic mechanical valves have been reported, but the fact that the patient was not aware of the importance of maintaining anticoagulation therapy is relevant in this case. A 16-year-old female was referred for primary coronary intervention due to subacute anterolateral ST elevation MI, after she decided to discontinue warfarin therapy three weeks before. Coronary angiography showed distal occlusion of the left anterior descending coronary artery with an image suggesting embolic material. Conventional echocardiography demonstrated akinesia of anteroseptal, inferior, and posterior segments of the left ventricle, with severe systolic dysfunction, beyond the intraventricular thrombus. The presence of mechanic aortic prosthesis and no anticoagulation therapy are highly suggestive of coronary embolism as the cause of MI. This case report confirms that patient education is vital in our struggle to prevent this complication in high-risk patients.

Fibrinolytic Therapy of Prosthetic Mitral Valve Thrombosis During Pregnancy: Three Case Reports and Review of the Literature

The incidence of prosthetic valve thrombosis (PVT), which is a life-threatening complication, increased during pregnancy because of the hypercoagulable state. Despite adequate anticoagulation, the incidence of PVT has been estimated as 4% to 14% during pregnancy. Prosthetic valve thrombosis occurring during pregnancy requires urgent therapy including fibrinolytic therapy, valve replacement, and surgical thrombectomy due to high mortality. Although surgery has traditionally been the standard procedure for treatment of PVT, fibrinolytic therapy may be used as first-line therapy according to data from the recent reports. Data about the fibrinolytic therapy is scarce and controversial in the setting of pregnancies complicated with PVT. Herein, we share the outcomes of 3 pregnant women complicated with PVT and treated with recombinant tissue-type plasminogen activator.