1
|
Nappi F, Nenna A, Spadaccio C, Avtaar Singh SS, Almazil A, Acar C. The Use of the Cryopreserved Aortic Homograft for Aortic Valve Replacement: Is It Still an Option? J Cardiovasc Dev Dis 2023; 10:248. [PMID: 37367413 DOI: 10.3390/jcdd10060248] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Revised: 05/28/2023] [Accepted: 06/06/2023] [Indexed: 06/28/2023] Open
Abstract
The indications for cryopreserved allografts in aortic valve replacement are still debatable. We aim to identify factors influencing early and long-term durability of the aortic homograft and to define subgroups of patients with an improved long-term quality of life, survival, and freedom from structural valve degeneration (SVD). We evaluated our series of 210 patients who underwent allograft implantation with a retrospective cohort study design over a period of 20 years. Endpoints were overall mortality, cardiac mortality related to SVD, the incidence of SVD, reoperation, and a composite endpoint comprising major adverse cardiac and cerebrovascular events (MACCEs), which includes cardiac death both related and not related to SVD, subsequent aortic valve surgery, new or recurrent infection of implanted allograft, recurrent aortic regurgitation, rehospitalization for heart failure, an increase in New York Heart Association (NYHA) class of ≥1, or cerebrovascular events. The primary indication for surgery was endocarditis (48%), which was also a predisposing factor for increased cardiac mortality. Overall mortality was 32.4% with a 27% incidence of SVD and mortality associated with SVD of 13.8%. Reoperation occurred in 33.8% and MACCEs in 54.8%. Long-term NYHA functional class and echocardiographic parameters improved over time. Statistical analysis demonstrated that root replacement technique and adult age were protective factors for SVD. We found no statistically significant difference in the clinical outcomes analyzed between women of childbearing age who had children after surgery and the rest of the women. The cryopreserved allograft is still a valid option in aortic valve replacement, providing acceptable durability and clinical outcomes with optimal hemodynamic performance. SVD is influenced by the implantation technique. Women of childbearing age might have additional benefits from this procedure.
Collapse
Affiliation(s)
- Francesco Nappi
- Department of Cardiac Surgery, Centre Cardiologique du Nord, 93200 Saint Denis, France
| | - Antonio Nenna
- Department of Cardiovascular Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 00128 Roma, Italy
| | - Cristiano Spadaccio
- Cardiothoracic Surgery, Lancashire Cardiac Center, Blackpool Victoria Hospital, Blackpool FY3 8NP, UK
| | | | - Almothana Almazil
- Department of Cardiac Surgery, Centre Cardiologique du Nord, 93200 Saint Denis, France
| | - Christophe Acar
- Department of Cardiothoracic Surgery, Hôpital Pitié-Salpêtrière, Boulevard de Hôpital 47-83, 75013 Paris, France
| |
Collapse
|
2
|
Ng AP, Verma A, Sanaiha Y, Williamson CG, Afshar Y, Benharash P. Maternal and Fetal Outcomes in Pregnant Patients With Mechanical and Bioprosthetic Heart Valves. J Am Heart Assoc 2023; 12:e028653. [PMID: 37183876 DOI: 10.1161/jaha.122.028653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
Background Guidelines for choice of prosthetic heart valve in people of reproductive age are not well established. Although biologic heart valves (BHVs) have risk of deterioration, mechanical heart valves (MHVs) require lifelong anticoagulation. This study aimed to characterize the association of prosthetic valve type with maternal and fetal outcomes in pregnant patients. Methods and Results Using the 2008 to 2019 National Inpatient Sample, we identified all adult patients hospitalized for delivery with prior heart valve implantation. Multivariable regressions were used to analyze the primary outcome, major adverse cardiovascular events, and secondary outcomes, including maternal and fetal complications, length of stay, and costs. Among 39 871 862 birth hospitalizations, 4152 had MHVs and 874 had BHVs. Age, comorbidities, and cesarean birth rates were similar between patients with MHVs and BHVs. The presence of a prosthetic valve was associated with over 22-fold increase in likelihood of major adverse cardiovascular events (MHV: adjusted odds ratio, 22.1 [95% CI, 17.3-28.2]; BHV: adjusted odds ratio, 22.5 [95% CI, 13.9-36.5]) as well as increased duration of stay and hospitalization costs. However, patients with MHVs and BHVs had no significant difference in the odds of any maternal outcome, including major adverse cardiovascular events, hypertensive disease of pregnancy, and ante/postpartum hemorrhage. Similarly, fetal complications were more likely in patients with valve prostheses, including a 4-fold increase in odds of stillbirth, but remained comparable between MHVs and BHVs. Conclusions Patients hospitalized for delivery with prior valve replacement carry substantial risk of adverse maternal and fetal events, regardless of valve type. Our findings reveal comparable outcomes between MHVs and BHVs.
Collapse
Affiliation(s)
- Ayesha P Ng
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery David Geffen School of Medicine at UCLA Los Angeles CA USA
| | - Arjun Verma
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery David Geffen School of Medicine at UCLA Los Angeles CA USA
| | - Yas Sanaiha
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery David Geffen School of Medicine at UCLA Los Angeles CA USA
| | - Catherine G Williamson
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery David Geffen School of Medicine at UCLA Los Angeles CA USA
| | - Yalda Afshar
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology David Geffen School of Medicine at UCLA Los Angeles CA USA
- Molecular Biology Insitute University of California Los Angeles CA USA
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Cardiac Surgery David Geffen School of Medicine at UCLA Los Angeles CA USA
| |
Collapse
|
3
|
Bai C, Wu H, Wu W, Feng P, Nie M, Zhao L, Meng F. Anticoagulation for mechanical heart valves during pregnancy: A case report and a literature review. Medicine (Baltimore) 2022; 101:e32550. [PMID: 36596070 PMCID: PMC9803450 DOI: 10.1097/md.0000000000032550] [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] [Indexed: 12/31/2022] Open
Abstract
RATIONALE Most previous treatment guidelines for pregnant women with mechanical heart valves recommend that low molecular weight heparin (LMWH) should be applied once every 12 hours and only as required to reach peak anti-Xa levels of approximately 1.0 to 1.2 IU/mL, but it is commonly associated with subtherapeutic trough levels, consequently with an inadequate level of anticoagulation. Our case report here together with a literature review suggests that dose-adjusted (Target trough anti-Xa levels of 0.6 to 0.7 IU/mL and with peak anti-Xa levels of around 1.0 to 1.2 IU/mL or < 1.5 IU/mL) LMWH should be given thrice daily throughout pregnancy. In addition, the findings of this rare case indicate that a combination of LMWH and warfarin is effective in the treatment of small thromboses in pregnancy. PATIENT CONCERNS In the 1st trimester of pregnancy, a 28-year old pregnant female with a mechanical valve had a significant increase in the aortic valve flow rate and suspected mechanical valve thrombosis. DIAGNOSES The peak velocity of the pregnant female aortic mechanical valve increased, and mechanical valve thrombosis was suspected. INTERVENTIONS We adjusted the enoxaparin sodium dose every 12 hours to 1 injection every 8 hours, with a total daily dose of 160 mL. Based on the original application of LMWH, warfarin (3 mg/day) was recommended. OUTCOMES The pregnant woman delivered a live baby by cesarean section, and the peak flow velocity of the mechanical valve in the aortic position was reduced to nearly equivalent to the patient's pre-pregnancy status. The mother and the baby were in good health at the time of discharge. LESSONS LMWH is administered twice daily, and anti-Xa trough levels are mostly in a subtherapeutic state, which may lead to insufficient anticoagulation and thrombosis. Dose-adjusted LMWH thrice daily throughout pregnancy is the recommended treatment for pregnant women with mechanical heart valves. The combination of LMWH and warfarin exhibited good efficacy for the treatment of small thromboses.
Collapse
Affiliation(s)
- Chunqiang Bai
- Department of Ultrasonography, The Affiliated Hospital of Chengde Medical University, Chengde, China
- * Correspondence: Chunqiang Bai, Department of Ultrasonography, The Affiliated Hospital of Chengde Medical University, Chengde 067000, China (e-mail: bcqlunwen2@163)
| | - Haiying Wu
- Department of Obstetrics, The Affiliated Hospital of Chengde Medical University, Chengde, China
| | - Wenying Wu
- Department of Ultrasonography, The Affiliated Hospital of Chengde Medical University, Chengde, China
| | - Peiming Feng
- Department of Ultrasonography, The Affiliated Hospital of Chengde Medical University, Chengde, China
| | - Minghui Nie
- Department of Ultrasonography, The Affiliated Hospital of Chengde Medical University, Chengde, China
| | - Li Zhao
- Department of Ultrasonography, The Affiliated Hospital of Chengde Medical University, Chengde, China
| | - Fanyue Meng
- Department of MEC Ultrasound, Chengde Center Hospital, The Second Affiliated to Chengde Medical University, Chengde, China
| |
Collapse
|
4
|
Malempati AR, Palanki SSG, Dixit N. A Study of Fertility and Pregnancy Outcomes in Women after Surgery for Valvular Heart Disease. INDIAN JOURNAL OF CARDIOVASCULAR DISEASE IN WOMEN 2022. [DOI: 10.25259/mm_ijcdw_459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Objectives:
Chronic Rheumatic Heart Disease (CRHD)is a common condition in India. CRHD accounts for a majority of heart valve surgery, including those in the younger age group. These young women almost traditionally get married in a country like India, and the social pressure to bear children is tremendous. Anticoagulation and the postoperative state of the patient itself can be a risk factor for maternal and fetal outcomes. There is very little data available for the same in India.
Materials and Methods:
In this study, 100 cases were studied retrospectively to study the fertility patterns after valvular heart surgery including fetal outcomes. This study was conducted at Nizam’s Institute of Medical Sciences, Hyderabad in which pregnancy, anticoagulation, maternal and fetal outcomes were studied.
Results:
A total of 63 patients conceived after surgery (pregnancy rate = 63%/ failure rate =37%) (p=0.001). Fetal loss occurred in 6 of the pregnancies, due to spontaneous abortion (n=3) and medical abortion (n=3). Parity, associated conditions and age did not affect the outcome. During pregnancy, 28 patients switched to UF heparin, 31 stayed on warfarin, 4 did not take any anticoagulation. Fetal loss was observed in 3 patients on Warfarin during pregnancy and 3 on UF heparin. Maternal loss was observed in 4 patients out of which 2 were on Warfarin, 1 on unfractionated UF heparin and 1 did not take any anticoagulation during pregnancy. In comparison, warfarin and UF heparin had similar fetal outcomes.
Conclusion:
The study recorded good outcomes irrespective of type of prosthesis and anticoagulation.
Collapse
Affiliation(s)
- Amaresh Rao Malempati
- Department of Cardiothoracic Surgery, Nizams Institute of Medical Sciences, Punjagutta, Hyderabad, India,
| | - Surya Satya Gopal Palanki
- Department of Cardiothoracic Surgery, Nizams Institute of Medical Sciences, Punjagutta, Hyderabad, India,
| | - Nikhil Dixit
- Department of Cardiothoracic Surgery, Nizams Institute of Medical Sciences, Punjagutta, Hyderabad, India,
| |
Collapse
|
5
|
Bouhout I, Kalfa D, Shah A, Goldstone AB, Harrington J, Bacha E. Surgical Management of Complex Aortic Valve Disease in Young Adults: Repair, Replacement, and Future Alternatives. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2022; 25:28-37. [PMID: 35835514 DOI: 10.1053/j.pcsu.2022.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 03/17/2022] [Accepted: 04/29/2022] [Indexed: 11/11/2022]
Abstract
The ideal aortic valve substitute in young adults remains unknown. Prosthetic valves are associated with a suboptimal survival and carry a significant risk of valve-related complications in young patients, mainly reinterventions with tissue valves and, thromboembolic events and major bleeding with mechanical prostheses. The Ross procedure is the only substitute that restores a survival curve similar to that of a matched general population, and permits a normal life without functional limitations. Though the risk of reintervention is the Achilles' heel of this procedure, it is very low in patients with aortic stenosis and can be mitigated in patients with aortic regurgitation by tailored surgical techniques. Finally, the Ozaki procedure and the transcatheter aortic valve implantation are seen by many as future alternatives but lack evidence and long-term follow-up in this specific patient population.
Collapse
Affiliation(s)
- Ismail Bouhout
- Division of Cardiothoracic and Vascular Surgery, Department of Surgery, Columbia University, New York, New York
| | - David Kalfa
- Division of Cardiothoracic and Vascular Surgery, Department of Surgery, Columbia University, New York, New York
| | - Amee Shah
- Division of Pediatric Cardiology, Department of Pediatrics, Columbia University, New York, New York
| | - Andrew B Goldstone
- Division of Cardiothoracic and Vascular Surgery, Department of Surgery, Columbia University, New York, New York
| | - Jamie Harrington
- Division of Pediatric Cardiology, Department of Pediatrics, Columbia University, New York, New York
| | - Emile Bacha
- Division of Cardiothoracic and Vascular Surgery, Department of Surgery, Columbia University, New York, New York.
| |
Collapse
|
6
|
Lindley KJ, Bairey Merz CN, Asgar AW, Bello NA, Chandra S, Davis MB, Gomberg-Maitland M, Gulati M, Hollier LM, Krieger EV, Park K, Silversides C, Wolfe NK, Pepine CJ. Management of Women With Congenital or Inherited Cardiovascular Disease From Pre-Conception Through Pregnancy and Postpartum: JACC Focus Seminar 2/5. J Am Coll Cardiol 2021; 77:1778-1798. [PMID: 33832605 DOI: 10.1016/j.jacc.2021.02.026] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 01/19/2021] [Accepted: 02/12/2021] [Indexed: 01/15/2023]
Abstract
Maternal morbidity and mortality continue to rise in the United States, with cardiovascular disease as the leading cause of maternal deaths. Congenital heart disease is now the most common cardiovascular condition encountered during pregnancy, and its prevalence will continue to grow. In tandem with these trends, maternal cardiovascular health is becoming increasingly complex. The identification of women at highest risk for cardiovascular complications is essential, and a team-based approach is recommended to optimize maternal and fetal outcomes. This document, the second of a 5-part series, will provide practical guidance from pre-conception through postpartum for cardiovascular conditions that are predominantly congenital or heritable in nature, including aortopathies, congenital heart disease, pulmonary hypertension, and valvular heart disease.
Collapse
Affiliation(s)
- Kathryn J Lindley
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, USA.
| | - C Noel Bairey Merz
- Barbra Streisand Women's Heart Center, Cedars-Sinai Smidt Heart Institute, Los Angeles, California, USA
| | - Anita W Asgar
- Division of Cardiology, Institut de Cardiologie de Montreal, Universite de Montreal, Montreal, Quebec, Canada
| | - Natalie A Bello
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York, New York, USA
| | - Sonal Chandra
- Division of Cardiology, Rush University Medical Center, Chicago, Illinois, USA
| | - Melinda B Davis
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Mardi Gomberg-Maitland
- George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Martha Gulati
- Department of Medicine (Cardiology), University of Arizona-Phoenix, Phoenix, Arizona, USA
| | - Lisa M Hollier
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas, USA
| | - Eric V Krieger
- Seattle Adult Congenital Heart Service, University of Washington School of Medicine, Seattle, Washington, USA
| | - Ki Park
- Cardiovascular Medicine, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Candice Silversides
- Division of Cardiology, University of Toronto Pregnancy and Heart Disease Program, Mount Sinai Hospital and University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Natasha K Wolfe
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Carl J Pepine
- Cardiovascular Medicine, University of Florida College of Medicine, Gainesville, Florida, USA
| | | |
Collapse
|
7
|
Abstract
Importance Mechanical heart valves (MHVs) pose significant thrombogenic risks to pregnant women and their fetuses, yet the choice of anticoagulation in this clinical setting remains unclear. Various therapeutic strategies carry distinct risk profiles that must be considered when making the decision about optimal anticoagulation. Objective We sought to review existing data and offer recommendations for the anticoagulation of pregnant women with MHVs, as well as management of anticoagulation in the peripartum period. Evidence Acquisition We performed a literature review of studies examining outcomes in pregnant women receiving systemic anticoagulation for mechanical valves, and also reviewed data on the safety profiles of various anticoagulant strategies in the setting of pregnancy. Results Warfarin has been shown to increase rates of embryopathy and fetal demise, although it has traditionally been the favored anticoagulant in this setting. Low-molecular-weight heparin, when dosed appropriately with close therapeutic monitoring, has been shown to be safe for both mother and fetus. Conclusions We favor the use of low-molecular-weight heparin with appropriate dosing and monitoring for the anticoagulation of pregnant women with MHVs. Data suggest that this approach minimizes the thrombotic risk associated with the valve while also providing safe and effective anticoagulation that can be easily managed in the peripartum period.
Collapse
|
8
|
Hutt E, Desai MY. Management of valvular heart disease in the pregnant patient. Expert Rev Cardiovasc Ther 2020; 18:495-501. [PMID: 32717159 DOI: 10.1080/14779072.2020.1797490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Among cardiovascular disease in pregnancy, valvular heart disease remains a prevalent cause of maternal and fetal morbidity. The physiological changes of pregnancy can lead to decompensation of known or silent valvular heart disease. This poses a challenge to both physicians and patients in determining the best timing and management of valvular disease in the pre and post conception settings. This condition requires specific care to minimize both maternal and fetal morbidity and mortality. AREAS COVERED In this article, we review the recommended management of valvular heart disease in pregnancy, which include stenotic lesions, regurgitant lesions and prosthetic valves. EXPERT OPINION Overall, left sided stenotic lesions are poorly tolerated and require intervention prior to pregnancy in cases of severe or symptomatic stenosis. Regurgitant lesions, isolated right sided lesions and bioprosthetic valves are better tolerated. Mechanical valves pose a challenging scenario given the high risk for valve thrombosis which must be balanced with the risk of bleeding and fetal embryopathy. Shared decision making is primordial in choosing the anticoagulant strategy during pregnancy in patients with mechanical valves.
Collapse
Affiliation(s)
- Erika Hutt
- Department of Cardiovascular Medicine, Cleveland Clinic Foundation , Cleveland, OH, USA
| | - Milind Y Desai
- Department of Cardiovascular Medicine, Cleveland Clinic Foundation , Cleveland, OH, USA
| |
Collapse
|
9
|
Kayatta MO, Leshnower BG, McPherson L, Binongo JN, Lasanajak Y, Chen EP. Valve-Sparing Root Replacement Provides Excellent Midterm Outcomes for Bicuspid Valve Aortopathy. Ann Thorac Surg 2019; 107:499-504. [DOI: 10.1016/j.athoracsur.2018.08.011] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Revised: 07/06/2018] [Accepted: 08/13/2018] [Indexed: 12/01/2022]
|
10
|
Mazine A, El-Hamamsy I, Verma S, Peterson MD, Bonow RO, Yacoub MH, David TE, Bhatt DL. Ross Procedure in Adults for Cardiologists and Cardiac Surgeons. J Am Coll Cardiol 2018; 72:2761-2777. [DOI: 10.1016/j.jacc.2018.08.2200] [Citation(s) in RCA: 92] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Accepted: 08/19/2018] [Indexed: 01/07/2023]
|
11
|
Outcomes and Long-term Effects of Pregnancy in Women With Biologic and Mechanical Valve Prostheses. Am J Cardiol 2018; 122:1738-1744. [PMID: 30449326 DOI: 10.1016/j.amjcard.2018.07.020] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Revised: 07/19/2018] [Accepted: 07/23/2018] [Indexed: 11/20/2022]
Abstract
The optimal choice of prosthetic heart valve for women of child-bearing age is not well established. We conducted this retrospective cohort study to compare pregnancy outcomes and maternal mortality and morbidity, including long-term valve reoperation, between women with biologic and mechanical valve replacements. Women ≤50 years of age with prosthetic heart valve implantation and subsequent pregnancy in California, New Jersey, and New York State between 1990 to 2015 were identified using mandatory state inpatient databases. Average follow-up time was 9.4 years (SD 6.7 years). Of 11,930 women who underwent 14,017 valve replacements, pregnancies in 417 women with 241 biologic valves, and 217 mechanical valves were identified. Women with mechanical prostheses experienced significantly higher rates of pregnancy loss, with almost 2/3 of pregnancies ending in either spontaneous or induced abortion, and hemorrhage and thromboembolic events during delivery. Delivery was a significant risk factor for reoperation for both biologic (hazard ratio 2.5, 95% confidence interval 1.6 to 3.8 after time-dependent propensity matching) and mechanical (hazard ratio 2.3, 95% confidence interval 1.3 to 4.1 after time-dependent propensity matching) prostheses. Half of reoperations in women with mechanical valves who experienced pregnancy occurred within 1 year after delivery, and most were associated with mitral valve thrombosis. In conclusion, pregnancy accelerates time to reoperation for both biologic and mechanical prostheses. Mechanical valves are at particular risk for near-term valve failure after delivery, and compared with bioprostheses, are associated with higher rates of adverse events during pregnancy.
Collapse
|
12
|
Irani RA, Santa-Ines A, Elder RW, Lipkind HS, Paidas MJ, Campbell KH. Postpartum anticoagulation in women with mechanical heart valves. Int J Womens Health 2018; 10:663-670. [PMID: 30498374 PMCID: PMC6207249 DOI: 10.2147/ijwh.s177547] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Women with mechanical heart valves (MHV) requiring anticoagulation (AC) are at high risk for hemorrhagic complications. Despite guidelines to manage antenatal and peripartum AC, there are few evidence-based recommendations to guide the initiation of postpartum AC. We reviewed our institutional experience of pregnant women with MHV to lay the groundwork for recommendations of immediate postpartum AC therapy. Study design This descriptive retrospective cohort used ICD-9 and -10 codes to identify pregnant women with MHV on AC at the Yale-New Haven Hospital from 2007 to 2018. All identified patients were confirmed by chart review. Delivery hospitalization and the immediate postpartum AC management were reviewed. Maternal complications recorded were postpartum hemorrhage, transfusion, wound hematoma, intra-abdominal bleeding, stroke, valve thrombosis, and death. Further, immediate neonatal outcomes were detailed. Results Forty-two pregnant women with nonnative heart valves were identified during the study period. From those pregnant women, nine had an MHV and were anticoagulated throughout gestation. Of 19 total pregnancies, 14 met the inclusion criteria. The median gestational age of the delivered pregnancies was early term (37w2d). Nine deliveries were via cesarean (64%). The median time to restart AC after birth was 6 hours. After six deliveries (43%), AC was initiated ≤6 hours postpartum. Hemorrhagic complications occurred in six cases (43%), including wound and intra-abdominal hematomas. Four cases (29%) required blood transfusion. No maternal strokes, thrombotic events, or deaths were recorded. Five (38.5%) neonates required admission to the neonatal intensive care unit. Conclusion MHV in pregnancy was rare but was associated with significant maternal morbidity, particularly postpartum hemorrhagic complications. We noted significant variability in the timing of restarting postpartum AC and in the selected agents. Pooled institutional data and an interdisciplinary approach are recommended to minimize competing risks and sequelae of valve thrombosis and obstetrical hemorrhage and, thereby, to optimize maternal outcomes and develop evidence-based guidelines for postpartum AC management.
Collapse
Affiliation(s)
- Roxanna A Irani
- Department of Obstetrics, Gynecology and Reproductive Sciences, Section of Maternal-Fetal Medicine, Yale University School of Medicine, New Haven, CT, USA,
| | - Ann Santa-Ines
- Department of Pediatrics, Section of Pediatric Cardiology, Adult Congenital Heart Program, Yale University School of Medicine, New Haven, CT, USA
| | - Robert W Elder
- Department of Pediatrics, Section of Pediatric Cardiology, Adult Congenital Heart Program, Yale University School of Medicine, New Haven, CT, USA
| | - Heather S Lipkind
- Department of Obstetrics, Gynecology and Reproductive Sciences, Section of Maternal-Fetal Medicine, Yale University School of Medicine, New Haven, CT, USA,
| | - Michael J Paidas
- Department of Obstetrics, Gynecology and Reproductive Sciences, Section of Maternal-Fetal Medicine, Yale University School of Medicine, New Haven, CT, USA,
| | - Katherine H Campbell
- Department of Obstetrics, Gynecology and Reproductive Sciences, Section of Maternal-Fetal Medicine, Yale University School of Medicine, New Haven, CT, USA,
| |
Collapse
|
13
|
Doenst T. Prinzipien und Perspektiven der Mitralklappenchirurgie. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2018. [DOI: 10.1007/s00398-018-0210-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
|
14
|
Ouzounian M, Mazine A, David TE. The Ross procedure is the best operation to treat aortic stenosis in young and middle-aged adults. J Thorac Cardiovasc Surg 2017. [PMID: 28625775 DOI: 10.1016/j.jtcvs.2017.03.156] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- Maral Ouzounian
- Peter Munk Cardiac Centre, Division of Cardiac Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada.
| | - Amine Mazine
- Peter Munk Cardiac Centre, Division of Cardiac Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Tirone E David
- Peter Munk Cardiac Centre, Division of Cardiac Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
15
|
Kyo S, Imanaka K, Masuda M, Miyata T, Morita K, Morota T, Nomura M, Saiki Y, Sawa Y, Sueda T, Ueda Y, Yamazaki K, Yozu R, Iwamoto M, Kawamoto S, Koyama I, Kudo M, Matsumiya G, Orihashi K, Oshima H, Saito S, Sakamoto Y, Shigematsu K, Taketani T, Komuro I, Takamoto S, Tei C, Yamamoto F. Guidelines for Perioperative Cardiovascular Evaluation and Management for Noncardiac Surgery (JCS 2014) ― Digest Version ―. Circ J 2017; 81:245-267. [DOI: 10.1253/circj.cj-66-0135] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
|
16
|
Desborough MJR, Pavord S, Hunt BJ. Management of direct oral anticoagulants in women of childbearing potential: guidance from the SSC of the ISTH: comment. J Thromb Haemost 2017; 15:194-195. [PMID: 27565128 DOI: 10.1111/jth.13484] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Accepted: 08/22/2016] [Indexed: 11/30/2022]
Affiliation(s)
- M J R Desborough
- NHS Blood and Transplant, John Radcliffe Hospital, Oxford, UK
- Oxford Clinical Research in Transfusion Medicine, Nuffield Division of Clinical Laboratory Sciences, University of Oxford, Oxford, UK
| | - S Pavord
- Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - B J Hunt
- Thrombosis & Thrombophilia, Guy's & St Thomas' NHS Foundation Trust, Oxford, UK
| |
Collapse
|
17
|
Cohen H, Arachchillage DR, Middeldorp S, Beyer-Westendorf J, Abdul-Kadir R. Management of direct oral anticoagulants in women of childbearing potential: guidance from the SSC of the ISTH: reply. J Thromb Haemost 2017; 15:195-197. [PMID: 27732766 DOI: 10.1111/jth.13535] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- H Cohen
- Department of Haematology, University College London Hospitals NHS Foundation Trust, London, UK
- Department of Haematology, Haemostasis Research Unit, University College London, London, UK
| | - D R Arachchillage
- Department of Haematology, University College London Hospitals NHS Foundation Trust, London, UK
| | - S Middeldorp
- Department of Vascular Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - J Beyer-Westendorf
- Center for Vascular Medicine and Department of Medicine III, University Hospital 'Carl Gustav Carus', Technische Universität Dresden, Dresden, Germany
| | - R Abdul-Kadir
- Department of Obstetrics and Gynaecology, University College London, London, UK
- Katharine Dormandy Haemophilia Centre and Thrombosis Unit, The Royal Free Hospital NHS Foundation Trust, London, UK
- Department of Obstetrics and Gynaecology, The Royal Free Hospital NHS Foundation Trust, London, UK
| |
Collapse
|
18
|
Khader KAAM, Saad AS, Abdelshafy M. Pregnancy Outcome in Women with Mechanical Prosthetic Heart Valves Treated with Unfractionated Heparin (UFH) or Enoxaparin. J Obstet Gynaecol India 2016; 66:321-6. [PMID: 27486276 PMCID: PMC4958066 DOI: 10.1007/s13224-015-0678-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2014] [Accepted: 02/16/2015] [Indexed: 10/23/2022] Open
Abstract
OBJECTIVE This study was carried out to determine the maternal (including thromboembolic and hemorrhagic complications) and fetal outcomes (including miscarriage, stillbirth, baby death, and live birth) in women with mechanical heart valves managed with therapeutic doses of unfractionated heparin (UFH) versus enoxaparin during pregnancy. METHODS This is a prospective comparative, nonrandomized study. Pregnant women with mechanical heart valves presenting to high-risk pregnancy unit of Benha University Hospital, Egypt were treated with UFH 15,000 U/12 h versus enoxaparin (Clexane) 1 mg/kg SC/12 h during pregnancy and the results were analyzed. RESULTS 40 pregnant women were included in the study. In 20 pregnant women, anticoagulation was with UFH, and 20 pregnant women received enoxaparin. One (3 %) thrombotic complication occurred with enoxaparin treatment. Noncompliance or subtherapeutic levels contributed to this outcome in this case. Antenatal hemorrhage occurred in 4 (10 %) and postpartum hemorrhagic complications in 5 (12.5 %) pregnancies. Of the 32 pregnant women who continued after 20 weeks' gestation, 100 % (17/17) of the women taking predominantly UFH had a surviving infant compared with 93 % (14/15) of the women taking primarily enoxaparin (p = 0.25). One intrauterine fetal death occurred in the enoxaparin group. There was no significant difference in the live birth rates between the two groups (p = 0.31). CONCLUSIONS Compliance with therapeutic dose of UFH during pregnancy in women with mechanical heart valves is associated with a low risk of valve thrombosis and good fetal outcomes, but meticulous monitoring is essential.
Collapse
Affiliation(s)
- Khalid Abd Aziz Mohamad Khader
- Benha Faculty of Medicine and Benha University Hospital, Benha University, Egypt, El Qulyobia Governorate, El Sadat Street, Benha City, Egypt
| | - Ahmed Samy Saad
- Benha Faculty of Medicine and Benha University Hospital, Benha University, Egypt, El Qulyobia Governorate, El Sadat Street, Benha City, Egypt
| | - Mohammed Abdelshafy
- Benha Faculty of Medicine and Benha University Hospital, Benha University, Egypt, El Qulyobia Governorate, El Sadat Street, Benha City, Egypt
| |
Collapse
|
19
|
Mazine A, David TE, Rao V, Hickey EJ, Christie S, Manlhiot C, Ouzounian M. Long-Term Outcomes of the Ross Procedure Versus Mechanical Aortic Valve Replacement: Propensity-Matched Cohort Study. Circulation 2016; 134:576-85. [PMID: 27496856 DOI: 10.1161/circulationaha.116.022800] [Citation(s) in RCA: 109] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2016] [Accepted: 07/01/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND The ideal aortic valve substitute in young and middle-aged adults remains unknown. We sought to compare the long-term outcomes of patients undergoing the Ross procedure and those receiving a mechanical aortic valve replacement (AVR). METHODS From 1990 to 2014, 258 patients underwent a Ross procedure and 1444 had a mechanical AVR at a single institution. Patients were matched into 208 pairs through the use of a propensity score. Mean age was 37.2±10.2 years, and 63% were male. Mean follow-up was 14.2±6.5 years. RESULTS Overall survival was equivalent (Ross versus AVR: hazard ratio, 0.91, 95% confidence interval, 0.38-2.16; P=0.83), although freedom from cardiac- and valve-related mortality was improved in the Ross group (Ross versus AVR: hazard ratio, 0.22; 95% confidence interval, 0.034-0.86; P=0.03). Freedom from reintervention was equivalent after both procedures (Ross versus AVR: hazard ratio, 1.86; 95% confidence interval, 0.76-4.94; P=0.18). Long-term freedom from stroke or major bleeding was superior after the Ross procedure (Ross versus AVR: hazard ratio, 0.09; 95% confidence interval, 0.02-0.31; P<0.001). CONCLUSIONS Long-term survival and freedom from reintervention were comparable between the Ross procedure and mechanical AVR. However, the Ross procedure was associated with improved freedom from cardiac- and valve-related mortality and a significant reduction in the incidence of stroke and major bleeding. In specialized centers, the Ross procedure represents an excellent option and should be considered for young and middle-aged adults undergoing AVR.
Collapse
Affiliation(s)
- Amine Mazine
- From Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital and University of Toronto, Toronto, ON, Canada
| | - Tirone E David
- From Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital and University of Toronto, Toronto, ON, Canada
| | - Vivek Rao
- From Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital and University of Toronto, Toronto, ON, Canada
| | - Edward J Hickey
- From Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital and University of Toronto, Toronto, ON, Canada
| | - Shakira Christie
- From Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital and University of Toronto, Toronto, ON, Canada
| | - Cedric Manlhiot
- From Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital and University of Toronto, Toronto, ON, Canada
| | - Maral Ouzounian
- From Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital and University of Toronto, Toronto, ON, Canada.
| |
Collapse
|
20
|
Elkayam U, Singh H, Irani A, Akhter MW. Anticoagulation in Pregnant Women With Prosthetic Heart Valves. J Cardiovasc Pharmacol Ther 2016; 9:107-15. [PMID: 15309247 DOI: 10.1177/107424840400900206] [Citation(s) in RCA: 59] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Pregnancy is associated with an increased risk of thrombosis in women with mechanical prosthetic heart valves. Effective anticoagulation is therefore critical in such patients but remains problematic, since oral anticoagulation and both unfractionated and low-molecular-weight heparin may be associated with important fetal and maternal side effects. Purpose: To review information related to the use of anticoagulation with both warfarin and heparin and reassess the safety and efficacy of these therapies in pregnant women with mechanical prosthetic heart valves. Data source and selection: A MEDLINE search from 1966 to October 2003 for English and non-English language articles that reported the use of anticoagulation in pregnancy was conducted. Articles were included if they reported use of anticoagulation in pregnancy with emphasis on those that included women with mechanical prosthetic heart valves. Conclusions: Anticoagulation prophylaxis with both warfarin and heparin (unfractionated heparin and low-molecular-weight heparin) may be associated with important fetal and maternal side effects. Optional regimens for the treatment of low-risk and high-risk patients are proposed to minimize potential complications.
Collapse
Affiliation(s)
- Uri Elkayam
- Division of Cardiovascular Medicine, Department of Medicine, University of Southern California, Keck School of Medicine, Los Angeles, California 90033, USA.
| | | | | | | |
Collapse
|
21
|
Prosthetic heart valve selection in women of childbearing age with acquired heart disease: a case report. J Med Case Rep 2016; 10:51. [PMID: 26956734 PMCID: PMC4782379 DOI: 10.1186/s13256-016-0821-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2015] [Accepted: 01/30/2016] [Indexed: 11/12/2022] Open
Abstract
Background The problem of prosthetic heart valve selection in fertile women with acquired heart defects remains crucial in modern cardiology. Mechanical heart valves require lifelong indirect anticoagulant therapy, which has significant fetal toxicity and is unacceptable for women planning pregnancy. Bioprosthetic heart valves are the best choice for fertile women; however, their durability is limited, and reoperations are required. Case presentation We describe the clinical case of a 21-year-old Russian woman with infectious endocarditis who underwent heart valve replacement with an epoxy-treated mitral valve prosthesis. Conclusions Epoxy-treated bioprosthetic heart valves can be used without long-term anticoagulant therapy because of their optimal hemodynamic functional parameters. Moreover, their high thromboresistance and resistance to infection improve patients’ quality of life in their late postoperative period. We recommend these valves both in older persons and in young patients including women who are planning pregnancy.
Collapse
|
22
|
Kanhere AV, Kanhere VM. Pregnancy After Cardiac Surgery. J Obstet Gynaecol India 2016; 66:10-5. [PMID: 26924901 DOI: 10.1007/s13224-016-0841-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2015] [Accepted: 01/09/2016] [Indexed: 10/22/2022] Open
Abstract
Heart disease is one of the common, indirect obstetric causes of maternal death. Management of these cases may challenge the entire team providing care to the mother and fetus. Advances in cardiac surgery has improved quality of life and level of functioning of cardiovascular system of patients with congenital or acquired heart disease. These diseases complicate 0.1-4 % pregnancies. Maternal complications in the form of thromboembolic, hemorrhagic episode and heart failure may occur. The fetus is in danger of effects of oral anticoagulation therapy and other medications given to the patient in order to support cardiovascular system, intrauterine growth restriction and danger of hypoxia. In recent era, we are facing more pregnant patients with previous history of surgical correction of congenital or rheumatic heart disease. In this review, we have attempted to draw a management protocol of such patients based on the available literature and various international guidelines. In pregnant women with mechanical heart valves, recent data support warfarin use throughout pregnancy, followed by a switch to heparin and planned induction of labor. However, the complexity of this situation demands a cafeteria approach where the patient herself can choose from the available options that are supported by evidence-based information. Preconception counseling, evaluation and antenatal high-risk management protocol with the help of cardiologist and cardiac surgeon improves maternal and neonatal outcome.
Collapse
Affiliation(s)
- Anjali Vivek Kanhere
- Department of Obstetrics and Gynecology, Chirayu Medical College and Hospital, Bhopal-Indore Highway, Near Bairagarh, Bhopal, Bhopal, MP 462030 India
| | - Vivek Madhav Kanhere
- Department of Cardiothoracic Surgery, Chirayu Cardiac Center, Chirayu Medical College and Hospital, Bhopal, Bhopal-Indore Highway, Near Bairagarh, Bhopal, MP 462030 India
| |
Collapse
|
23
|
Ayad SW, Hassanein MM, Mohamed EA, Gohar AM. Maternal and Fetal Outcomes in Pregnant Women with a Prosthetic Mechanical Heart Valve. CLINICAL MEDICINE INSIGHTS-CARDIOLOGY 2016; 10:11-7. [PMID: 26884686 PMCID: PMC4750893 DOI: 10.4137/cmc.s36740] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2015] [Revised: 12/28/2015] [Accepted: 01/02/2016] [Indexed: 12/01/2022]
Abstract
BACKGROUND Pregnancy is associated with several cardiocirculatory changes that can significantly impact underlying cardiac disease. These changes include an increase in cardiac output, sodium, and water retention leading to blood volume expansion, and reductions in systemic vascular resistance and systemic blood pressure. In addition, pregnancy results in a hypercoagulable state that increases the risk of thromboembolic complications. OBJECTIVES The aim of this study is to assess the maternal and fetal outcomes of pregnant women with mechanical prosthetic heart valves (PHVs). METHODS This is a prospective observational study that included 100 pregnant patients with cardiac mechanical valve prostheses on anticoagulant therapy. The main maternal outcomes included thromboembolic or hemorrhagic complications, prosthetic valve thrombosis, and acute decompensated heart failure. Fetal outcomes included miscarriage, fetal death, live birth, small-for-gestational age, and warfarin embryopathy. The relationship between the following were observed:
– Maternal and fetal complications and the site of the replaced valve (mitral, aortic, or double) – Maternal and fetal complications and warfarin dosage (≤5 mg, >5 mg) – Maternal and fetal complications and the type of anticoagulation administered during the first trimester
RESULTS This study included 60 patients (60%) with mitral valve replacement (MVR), 22 patients (22%) with aortic valve replacement (AVR), and 18 patients (18%) with double valve replacement (DVR). A total of 65 patients (65%) received >5 mg of oral anticoagulant (warfarin), 33 patients (33%) received ≤5 mg of warfarin, and 2 patients (2%) received low-molecular-weight heparin (LMWH; enoxaparin sodium) throughout the pregnancy. A total of 17 patients (17%) received oral anticoagulant (warfarin) during the first trimester: 9 patients received a daily warfarin dose of >5 mg while the remaining 8 patients received a daily dose of ≤5 mg. Twenty-eight patients (28%) received subcutaneous (SC) heparin calcium and 53 patients (53%) received SC LMWH (enoxaparin sodium). Prosthetic valve thrombosis occurred more frequently in patients with MVR (P = 0.008). Postpartum hemorrhage was more common in patients with aortic valve prostheses than in patients with mitral valve prostheses (P = 0.005). The incidence of perinatal death was higher in patients with AVR (P = 0.014). The incidence of live birth was higher in patients with DVR (P = 0.012). The incidence of postpartum hemorrhage was higher in patients who received a daily dose of >5 mg of warfarin than in patients who received ≤5 mg of warfarin (P = 0.05). The incidence of spontaneous abortion was also higher in patients receiving >5 mg of warfarin (P ≤ 0.001), while the incidence of live births was higher in patients receiving ≤5 mg of warfarin (P = 0.008). There was a statistically significant difference between the anticoagulant received during the first trimester and cardiac outcomes. Specifically, patients on heparin developed more heart failure (P = 0.008), arrhythmias (P = 0.008), and endocarditis (P = 0.016). There was a statistically significant relationship between heparin shifts during the first trimester and spontaneous abortion (P = 0.003). CONCLUSION Warfarin use during the first trimester is safer for the mother but is associated with more fetal loss, especially in doses that exceed 5 mg. The incidence of maternal complications is greater in women who receive LMWH or unfractionated heparin during the first trimester, especially prosthetic valve thrombosis, although the fetal outcome is better because heparin does not cross the placenta.
Collapse
Affiliation(s)
- Sherif W Ayad
- Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | | | | | - Ahmed M Gohar
- Faculty of Medicine, Alexandria University, Alexandria, Egypt
| |
Collapse
|
24
|
Morimoto K, Hoashi T, Kagisaki K, Yoshimatsu J, Shiraishi I, Ichikawa H, Kobayashi J, Nakatani T, Yagihara T, Kitamura S, Fujita T. Impact of Ross Operation on Outcome in Young Female Adult Patients Wanting to Have Children. Circ J 2015; 79:1976-83. [PMID: 26118461 DOI: 10.1253/circj.cj-15-0410] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND The most appropriate valve substitute at aortic valve replacement (AVR) for young female adult patients wanting to have children is unclear. METHODS AND RESULTS Between 1992 and 2013, 12 consecutive female patients aged >18 (median, 22.5 years; range, 18-34 years) underwent Ross operation (Ross group). Between 1984 and 2013, 9 consecutive female patients aged >18 (median, 30 years; range, 22-39 years) underwent AVR with bioprosthesis (bioprosthesis group). There was 1 late mortality in the bioprosthesis group, due to prosthetic valve endocarditis (PVE). Freedom from reoperation for aortic valve at 15 years was 90.0% in the Ross group, and 57.1% in the bioprosthesis group (log-rank, P=0.098). One in the Ross group underwent reoperation for aortic regurgitation (AR), whereas 4 in the bioprosthesis group did so for aortic stenosis (AS) in 2, combined AS and AR in 1, and PVE in 1. Five patients in the Ross group and 3 in the bioprosthesis group had 7 and 4 uneventful pregnancies, respectively. AR progressed during the perinatal period in a total of 7 of 11 pregnancies. No AS was seen at discharge, after 5 years, or during pregnancy in the Ross group. CONCLUSIONS The long-term outcome of Ross operation for female patients wanting to have children is excellent. Although subclinical pulmonary autograft valve regurgitation during pregnancy was often observed, pulmonary autograft stenosis did not occur, therefore it would be an ideal option for patients wanting to have children.
Collapse
Affiliation(s)
- Kazuki Morimoto
- Department of Pediatric Cardiovascular Surgery, National Cerebral and Cardiovascular Center
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
25
|
Nappi F, Spadaccio C, Chello M, Lusini M, Acar C. Impact of Structural Valve Deterioration on Outcomes in the Cryopreserved Mitral Homograft Valve. J Card Surg 2014; 29:616-22. [DOI: 10.1111/jocs.12400] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Francesco Nappi
- Department of Cardiac Surgery; Centre Cardiologique du Nord; Paris France
| | - Cristiano Spadaccio
- Department of Cardiovascular Surgery; University Campus Bio-Medico of Rome; Italy
| | - Massimo Chello
- Department of Cardiovascular Surgery; University Campus Bio-Medico of Rome; Italy
| | - Mario Lusini
- Department of Cardiovascular Surgery; University Campus Bio-Medico of Rome; Italy
| | - Cristophe Acar
- Department of Thoracic and Cardiovascular Surgery Pitie-Salpetriere; Paris France
| |
Collapse
|
26
|
Affiliation(s)
- Michael Nanna
- Yale University School of Medicine and Yale New Haven Hospital, Department of Medicine, New Haven, CT (M.N.)
| | - Kathleen Stergiopoulos
- Division of Cardiovascular Disease, Department of Medicine, Stony Brook University Medical Center, Stony Brook, NY (K.S.)
| |
Collapse
|
27
|
Regitz-Zagrosek V, Gohlke-Bärwolf C, Iung B, Pieper PG. Management of cardiovascular diseases during pregnancy. Curr Probl Cardiol 2014; 39:85-151. [PMID: 24794710 DOI: 10.1016/j.cpcardiol.2014.02.001] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
The prevalence of cardiovascular diseases (CVDs) in women of childbearing age is rising. The successes in medical and surgical treatment of congenital heart disease have led to an increasing number of women at childbearing age presenting with problems of treated congenital heart disease. Furthermore, in developing countries and in immigrants from these countries, rheumatic valvular heart disease still plays a significant role in young women. Increasing age of pregnant women and increasing prevalence of atherosclerotic risk factors have led to an increase in women with coronary artery disease at pregnancy. Successful management of pregnancy in women with CVDs requires early diagnosis, a thorough risk stratification, and appropriate management by a multidisciplinary team of obstetricians, cardiologists, anesthesiologists, and primary care physicians. The following review is based on the recent European guidelines on the management of CVDs during pregnancy, which aim at providing concise and simple recommendations for these challenging problems.
Collapse
|
28
|
Basude S, Trinder J, Caputo M, Curtis SL. Pregnancy outcome and follow-up cardiac outcome in women with aortic valve replacement. Obstet Med 2014; 7:29-33. [PMID: 27512416 DOI: 10.1177/1753495x13514382] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES To compare the maternal, fetal and cardiac outcomes in women who have undergone aortic valve replacement. METHOD Retrospective observational study of all women with aortic valve replacement, who underwent a pregnancy (1998-2012). Maternal-, fetal- and valve-related cardiac outcomes were assessed. RESULTS Thirty-two pregnancies in 16 women with aortic valve replacement (nine bioprosthetic, six Ross and 17 mechanical) were evaluated. There were no adverse maternal events in the bioprosthetic and Ross groups but three in the mechanical group. Fetal loss rate was highest in the mechanical valve pregnancies (53%). One woman in the bioprosthetic group needed valve re-operation, and one woman in the mechanical valve group died. There was no difference in the change of Vmax over the follow-up between the valves (p = 0.25). CONCLUSIONS There was no difference in deterioration between aortic valve replacements during and after pregnancy. The highest risk of maternal and fetal complications occurred in the mechanical valve group.
Collapse
Affiliation(s)
- Snehalata Basude
- Department of Obstetrics, St Michaels Hospital, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Johanna Trinder
- Department of Obstetrics, St Michaels Hospital, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Massimo Caputo
- Bristol Heart Institute, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Stephanie L Curtis
- Bristol Heart Institute, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| |
Collapse
|
29
|
Abstract
The etiology of valvular heart diseases (VHD) has changed in the last 50 years in the industrialized countries. A significant reduction in the incidence of rheumatic fever and its sequelae, increase in life expectancy, recognition of new causes of VHD and advancement in technology are responsible for the metamorphosis of the etiology of VHD. Heritable disorders of connective tissue (marfan syndrome, Ehlers-Danlos syndrome, adult polycystic kidney disease, floppy mitral valve/mitral valve prolapse); congenital heart disease (bicuspid aortic valve); inflammatory/immunologic disorders (rheumatic fever, AIDS, Kawasaki disease, syphilis, seronegative spondyloarthropathies, systemic lupus erythematosus, antiphospholipid syndrome); endocardial disorders (nonbacteremic thrombotic endocarditis, infective endocarditis, endomyocardial fibroelastosis); myocardial dysfunction (ischemic heart disease, dilated cardiomyopathy, hypertrophic cardiomyopathy); diseases and disorders of other organs (chronic renal failure, carcinoid heart disease); aging (calcific aortic stenosis, mitral annular calcification); postinterventional valvular disease; drugs and physical agents are all clinical entities associated with VHD. It should be emphasized that VHDs still constitute a major health problem which will increase with the aging population.
Collapse
|
30
|
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.
Collapse
Affiliation(s)
- Sunil Mankad
- Mayo Clinic College of Medicine, 200 First Street SW, Gonda 6-402, Rochester, MN, 55905, USA,
| |
Collapse
|
31
|
Arabkhani B, Heuvelman HJ, Bogers AJJC, Mokhles MM, Roos-Hesselink JW, Takkenberg JJM. Does pregnancy influence the durability of human aortic valve substitutes? J Am Coll Cardiol 2012; 60:1991-2. [PMID: 23062538 DOI: 10.1016/j.jacc.2012.06.055] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2012] [Revised: 06/19/2012] [Accepted: 06/26/2012] [Indexed: 11/30/2022]
|
32
|
Abstract
“Clinical decisions and research programs ultimately depend on the reliable and valid measurement of adherence. Yet, 50 years of research in this field have not provided the data necessary to answer critical measurement questions.”.
Collapse
|
33
|
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]
|
34
|
Mazibuko B, Ramnarain H, Moodley J. An audit of pregnant women with prosthetic heart valves at a tertiary hospital in South Africa: a five-year experience. Cardiovasc J Afr 2012; 23:216-21. [PMID: 22614667 PMCID: PMC3721885 DOI: 10.5830/cvja-2012-022] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2010] [Accepted: 03/06/2012] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Cardiac disease in pregnancy is a common problem in under-resourced countries and a significant cause of maternal morbidity and mortality. A large proportion of patients with cardiac disease have prosthetic mechanical heart valve replacements, warranting prophylactic anticoagulation. AIM To evaluate obstetric outcomes in women with prosthetic heart valves in an under-resourced country. METHODS A retrospective chart review was performed of 61 pregnant patients with prosthetic valve prostheses referred to our tertiary hospital over a five-year period. RESULTS Sixty-one (6%) of 1 021 pregnant women with A diagnosis of cardiac disease had prosthetic heart valves. Fifty-nine had mechanical valves and were on prophylactic anticoagulation therapy, three had stopped their medication prior to pregnancy and two had bioprosthetic valves. There were forty-one (67%) live births, two (3%) early neonatal deaths, 12 (20%) miscarriages and six (10%) stillbirths. Maternal complications included mitral valve thrombosis (n = 4), atrial fibrillation (n = 8), infective endocarditis (n = 6), caesarean section wound haematomas (n = 7), broad ligament haematoma (n = 1) and warfarin embryopathy (n = 4). Haemorrhagic complications occurred in five patients and all five required blood transfusions. CONCLUSION Prophylactic anticoagulation with warfarin in patients with mechanical heart valve prostheses was associated with high rates of maternal and neonatal complications, including significant foetal wastage in the first and early second trimesters of pregnancy. Health professionals providing care for pregnant women with prosthetic heart valves must consistently advise on family planning matters, adherence to anticoagulation regimes and consider the use of prophylactic anticoagulant regimens other than warfarin, particularly during the first trimester of pregnancy.
Collapse
Affiliation(s)
- B Mazibuko
- Department of Obstetrics and Gynaecology, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | | | | |
Collapse
|
35
|
De Santo LS, Romano G, Della Corte A, D'Oria V, Nappi G, Giordano S, Cotrufo M, De Feo M. Mechanical Aortic Valve Replacement in Young Women Planning on Pregnancy. J Am Coll Cardiol 2012; 59:1110-5. [DOI: 10.1016/j.jacc.2011.10.899] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2011] [Revised: 10/25/2011] [Accepted: 10/31/2011] [Indexed: 11/30/2022]
|
36
|
Olivito S, Lalande S, Nappi F, Hammoudi N, D'Alessandro C, Fouret P, Acar C. Structural deterioration of the cryopreserved mitral homograft valve. J Thorac Cardiovasc Surg 2011; 144:313-20, 320.e1. [PMID: 21855094 DOI: 10.1016/j.jtcvs.2011.06.041] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2011] [Revised: 05/09/2011] [Accepted: 06/06/2011] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The aim of this study was to evaluate the long-term fate of the cryopreserved mitral homograft focusing on structural valve deterioration. METHODS Homograft replacement of the mitral valve was performed in 106 patients. The causes of mitral disease were rheumatic disease (n=75), endocarditis (n=24), and others (n=7). There were 40 partial homografts and 66 total homografts. RESULTS Mean follow-up was 9.3+4.7 years (up to 17.8 years). There were 5 early (<3 months) and 15 late deaths. There have been 5 early (<3 months) and 30 late reoperations. Five patients had endocarditis, and 5 patients had an ischemic/hemorrhagic event. Compared with baseline, follow-up echography showed progression of mitral regurgitation grade (from 0.4 to 1.3; P<.001) with stenosis (elevated gradient: from 3.9 to 7.0 mm Hg; P<.001) and decreased valve area (from 2.3 to 1.7 cm2, P<.001). Freedom from structural valve deterioration was 90%, 76%, and 65% at 5, 10, and 15 years, respectively. Structural valve deterioration was more frequent in total homografts (P=.018 vs partial homografts) and in case of pregnancy (P=.016 vs no pregnancy). Stenosis related to structural valve deterioration was more pronounced for age less than 40 years (P=.03) and ring size 30 mm or less (P=.002). Pathologic analysis of the explanted homografts almost invariably showed dense fibrosis with calcification and no cellularity. CONCLUSIONS Mitral homografting was accomplished with early echographic results similar to those of valve repair. Structural valve deterioration produced mixed stenosis with insufficiency, and its incidence was comparable to that of bioprostheses structural valve deterioration. An improvement in the preservation mode of valvular homografts is warranted.
Collapse
Affiliation(s)
- Silvio Olivito
- Department of Cardiac Surgery, Hôpital Pitié-Salpétrière, Paris, France
| | | | | | | | | | | | | |
Collapse
|
37
|
Font MÀ, Krupinski J, Arboix A. Antithrombotic medication for cardioembolic stroke prevention. Stroke Res Treat 2011; 2011:607852. [PMID: 21822469 PMCID: PMC3148601 DOI: 10.4061/2011/607852] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2010] [Revised: 03/02/2011] [Accepted: 03/27/2011] [Indexed: 01/28/2023] Open
Abstract
Embolism of cardiac origin accounts for about 20% of ischemic strokes. Nonvalvular atrial fibrillation is the most frequent cause of cardioembolic stroke. Approximately 1% of population is affected by atrial fibrillation, and its prevalence is growing with ageing in the modern world. Strokes due to cardioembolism are in general severe and prone to early recurrence and have a higher long-term risk of recurrence and mortality. Despite its enormous preventive potential, continuous oral anticoagulation is prescribed for less than half of patients with atrial fibrillation who have risk factors for cardioembolism and no contraindications for anticoagulation. Available evidence does not support routine immediate anticoagulation of acute cardioembolic stroke. Anticoagulation therapy's associated risk of hemorrhage and monitoring requirements have encouraged the investigation of alternative therapies for individuals with atrial fibrillation. New anticoagulants being tested for prevention of stroke are low-molecular-weight heparins (LMWH), unfractionated heparin, factor Xa inhibitors, or direct thrombin inhibitors like dabigatran etexilate and rivaroxaban. The later exhibit stable pharmacokinetics obviating the need for coagulation monitoring or dose titration, and they lack clinically significant food or drug interaction. Moreover, they offer another potential that includes fixed dosing, oral administration, and rapid onset of action. There are several concerns regarding potential harm, including an increased risk for hepatotoxicity, clinically significant bleeding, and acute coronary events. Therefore, additional trials and postmarketing surveillance will be needed.
Collapse
Affiliation(s)
- M. Àngels Font
- Institut d'Investigacions Biomèdiques de Bellvitge (IDIBELL), Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, 08907 Barcelona, Spain
- Department of Neurology, Hospital Sant Joan de Déu de Manresa (Fundació Althaia), Catalonia, 08243 Manresa, Spain
| | - Jerzy Krupinski
- Department of Neurology, Cerebrovascular Diseases Unit, Hospital Universitari Mútua de Terrassa, Catalonia, 08227 Terrassa, Spain
| | - Adrià Arboix
- Cerebrovascular Division, Department of Neurology, Hospital Universitari Sagrat Cor, University of Barcelona, C/Viladomat 288, Catalonia, 08029 Barcelona, Spain
| |
Collapse
|
38
|
Guidelines for perioperative cardiovascular evaluation and management for noncardiac surgery (JCS 2008)--digest version. Circ J 2011; 75:989-1009. [PMID: 21427501 DOI: 10.1253/circj.cj-88-0009] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
-
- Scientific Committee of the Japanese Circulation Society, 8th Floor CUBE OIKE Bldg., Karasuma Aneyakoji, Kyoto 604-8172, Japan.
| |
Collapse
|
39
|
Tillquist MN, Maddox TM. Cardiac crossroads: deciding between mechanical or bioprosthetic heart valve replacement. Patient Prefer Adherence 2011; 5:91-9. [PMID: 21448466 PMCID: PMC3063655 DOI: 10.2147/ppa.s16420] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2011] [Indexed: 11/23/2022] Open
Abstract
Nearly 15 million people in the United States suffer from either aortic or mitral valvular disease. For patients with severe and symptomatic valvular heart disease, valve replacement surgery improves morbidity and mortality outcomes. In 2009, 90,000 valve replacement surgeries were performed in the United States. This review evaluates the advantages and disadvantages of mechanical and bioprosthetic prosthetic heart valves as well as the factors for consideration in deciding the appropriate valve type for an individual patient. Although many caveats exist, the general recommendation is for patients younger than 60 to 65 years to receive mechanical valves due to the valve's longer durability and for patients older than 60 to 65 years to receive a bioprosthetic valve to avoid complications with anticoagulants. Situations that warrant special consideration include patient co-morbidities, the need for anticoagulation, and the potential for pregnancy. Once these characteristics have been considered, patients' values, anxieties, and expectations for their lifestyle and quality of life should be incorporated into final valve selection. Decision aids can be useful in integrating preferences in the valve decision. Finally, future directions in valve technology, anticoagulation, and medical decision-making are discussed.
Collapse
Affiliation(s)
| | - Thomas M Maddox
- VA Eastern Colorado Health Care System, and Department of Medicine (Cardiology), University of Colorado Denver, Denver, CO, USA
- Correspondence: Thomas M Maddox, Cardiology (111B), Denver VA Medical Center, 1055 Clermont Street, Denver, CO 80220, USA, Tel +1 (303) 370-7569, Fax +1 (303) 370-7580, Email
| |
Collapse
|
40
|
McLintock C. Anticoagulant therapy in pregnant women with mechanical prosthetic heart valves: no easy option. Thromb Res 2011; 127 Suppl 3:S56-60. [DOI: 10.1016/s0049-3848(11)70016-0] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
|
41
|
Rahimtoola SH. Choice of prosthetic heart valve in adults an update. J Am Coll Cardiol 2010; 55:2413-26. [PMID: 20510209 DOI: 10.1016/j.jacc.2009.10.085] [Citation(s) in RCA: 237] [Impact Index Per Article: 16.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2009] [Revised: 10/23/2009] [Accepted: 10/27/2009] [Indexed: 11/16/2022]
Abstract
In the last 7 years, more data have reconfirmed that patients' comorbid conditions are very important factors determining patient outcomes. Prosthetic heart valves (PHVs) that require aortic root replacement in the absence of aortic root disease are associated with poorer outcomes. For the vast majority of patients, the choice of PHV is between a mechanical valve and a stented bioprosthesis. The choice is largely dependent upon the age of the patient at the time of PHV implantation and on which complication the patient wants to avoid: specifically, anticoagulation therapy and its complications with the mechanical valve, and structural valve deterioration with a bioprosthesis. Data on the pros and cons of the choices and exceptions to the rules are discussed, and a new algorithm is developed.
Collapse
Affiliation(s)
- Shahbudin H Rahimtoola
- Griffith Center, Division of Cardiovascular Medicine, Department of Medicine, LAC+USC Medical Center, Keck School of Medicine at University of Southern California, Los Angeles, California 90033, USA.
| |
Collapse
|
42
|
Abstract
Mitral stenosis is one of the more commonly seen valve lesions encountered in pregnancy. The pathophysiologic implications, management strategies, and a comprehensive review of literature over the past 20 years for optimal timing of catheter balloon commissurotomy during pregnancy are discussed. Mechanical relief of obstruction is indicated for cases of severe symptomatic mitral stenosis in pregnancy refractory to medical therapy. Catheter balloon commissurotomy is the procedure of choice in a select group of these patients with suitable valve morphology.
Collapse
|
43
|
Abstract
Mechanical heart valve thrombosis during pregnancy is a challenging condition. We present a pregnant patient with stuck mechanical mitral valve. During the 36th week of pregnancy, she was admitted to our emergency clinic because of aggravated dyspnea, tachypnea, and cyanosis. Echocardiography revealed stuck mechanical valve in mitral position and she was diagnosed with acute left ventricular heart failure due to mechanical valve thrombosis. Reoperative mitral valve replacement was performed in emergency conditions immediately following Cesarean section. She and her baby were discharged 11 days after surgery without complications.
Collapse
Affiliation(s)
- Askin A Korkmaz
- Department of Cardiovascular Surgery, Sema Hospital, Istanbul, Turkey.
| | | | | | | | | |
Collapse
|
44
|
Abstract
Patients with mechanical valve prostheses require a lifelong anticoagulant treatment. The combined use of Warfarin and low-dose aspirin appears to reduce the risk of valve thrombosis and systemic embolism at a low risk of bleeding. The management of women with prosthetic heart valves during pregnancy poses a particular challenge, as there are no available controlled clinical trials to provide guidelines for effective antithrombotic therapy. Oral anticoagulants, such as Warfarin, cause foetal embryopathy; unfractionated heparin and low-molecular-weight heparin have been reported to be ineffective in preventing thromboembolic complications. This article discusses the available data and the most recent guidelines in the antithrombotic management of patients with prosthetic valves, and antithrombotic therapy in various clinical situations such as pregnant women with prosthetic heart valves, and patients with prosthetic heart valves undergoing noncardiac surgery.
Collapse
Affiliation(s)
- Ha Mohamed
- Department of Medicine, Division of Cardiology, Regina General Hospital. Regina, SK, Canada
| |
Collapse
|
45
|
Abstract
Pregnancy in women with mechanical valve prostheses has a high maternal complication rate including valve thrombosis and death. Coumarin derivatives are relatively safe for the mother with a lower incidence of valve thrombosis than un-fractionated and low-molecular-weight heparin, but carry the risk of embryopathy, which is probably dose-dependent. The different anticoagulation regimens are discussed in this review. When valve thrombosis occurs during pregnancy, thrombolysis is the preferable therapeutic option. Bioprostheses have a more favourable pregnancy outcome than mechanical prostheses but due to the high re-operation rate in young women they do not constitute the ideal alternative. When women with native valve stenosis need pre-pregnancy intervention, mitral balloon valvuloplasty is the best option in mitral stenosis, while the Ross operation or homograft implantation may be the preferable surgical regimen in aortic stenosis. (Neth Heart J 2008;16:406-11.).
Collapse
Affiliation(s)
- P.G. Pieper
- Thorax Centre, Department of Cardiology, University Medical Center Groningen, Groningen, the Netherlands
| | - A. Balci
- Thorax Centre, Department of Cardiology, University Medical Center Groningen, Groningen, the Netherlands
| | - A.P. Van Dijk
- Department of Cardiology, Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands
| |
Collapse
|
46
|
Bonow RO, Carabello BA, Chatterjee K, de Leon AC, Faxon DP, Freed MD, Gaasch WH, Lytle BW, Nishimura RA, O'Gara PT, O'Rourke RA, Otto CM, Shah PM, Shanewise JS, Nishimura RA, Carabello BA, Faxon DP, Freed MD, Lytle BW, O'Gara PT, O'Rourke RA, Shah PM. 2008 focused update incorporated into the ACC/AHA 2006 guidelines 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 (Writing Committee to revise the 1998 guidelines for the management of patients with valvular heart disease). Endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. J Am Coll Cardiol 2008; 52:e1-142. [PMID: 18848134 DOI: 10.1016/j.jacc.2008.05.007] [Citation(s) in RCA: 1058] [Impact Index Per Article: 66.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
|
47
|
Bonow RO, Carabello BA, Chatterjee K, de Leon AC, Faxon DP, Freed MD, Gaasch WH, Lytle BW, Nishimura RA, O'Gara PT, O'Rourke RA, Otto CM, Shah PM, Shanewise JS. 2008 Focused update incorporated into the ACC/AHA 2006 guidelines 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 (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation 2008; 118:e523-661. [PMID: 18820172 DOI: 10.1161/circulationaha.108.190748] [Citation(s) in RCA: 698] [Impact Index Per Article: 43.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
|
48
|
|
49
|
The Diagnosis and Management of Chronic Rheumatic Heart Disease—An Australian Guideline. Heart Lung Circ 2008; 17:271-89. [DOI: 10.1016/j.hlc.2007.12.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2007] [Revised: 11/30/2007] [Accepted: 12/03/2007] [Indexed: 11/22/2022]
|
50
|
|