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Campello E, Bucciarelli P, Catalani F, Erba N, Squizzato A, Poli D. Anticoagulant Therapy in Pregnant Women with Mechanical Heart Valves: Italian Federation of Centers for Diagnosis and Surveillance of the Antithrombotic Therapies (FCSA) Position Paper. Thromb Haemost 2024. [PMID: 38744424 DOI: 10.1055/a-2325-5658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/16/2024]
Abstract
The management of anticoagulant therapy in pregnant women with mechanical heart valves (MHVs) is difficult and often challenging even for clinicians experienced in the field. These pregnancies, indeed, are burdened with higher rates of complications for both the mother and the fetus, compared to those in women without MHVs. The maternal need for an optimal anticoagulation as provided by vitamin K antagonists is counterbalanced by their teratogen effect on the embryo and fetus. On the other hand, several concerns have been raised about the efficacy of heparins in pregnant women with MHVs, considering the high risk of thrombotic complications in these patients. Therefore, numerous clinical issues about the management of pregnant women with MHVs remain unanswered, such as the selection of the best anticoagulant agent, the optimal anticoagulation levels to be achieved and maintained, and the evaluation of long-term effects for both the mother and the fetus. Based on a comprehensive review of the current literature, the Italian Federation of the Centers for the Diagnosis and the Surveillance of the Antithrombotic Therapies (FCSA) proposes experience-based suggestions and expert opinions. Particularly, this consensus document aims at providing practical guidance for clinicians dealing with pregnant women with MHVs, to optimize maternal and fetal outcomes while guaranteeing adequate anticoagulation. Finally, FCSA highlights the need for the creation of multidisciplinary teams experienced in the management of pregnant women with MHVs during pregnancy, delivery, and postpartum, in order to better deal with such complex clinical issues and provide a comprehensive counseling to these patients.
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Affiliation(s)
- Elena Campello
- Department of Medicine, General Medicine and Thrombotic and Hemorrhagic Unit, University of Padova, Padova, Italy
| | - Paolo Bucciarelli
- Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, A. Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy
| | - Filippo Catalani
- Department of Medicine, General Medicine and Thrombotic and Hemorrhagic Unit, University of Padova, Padova, Italy
| | | | - Alessandro Squizzato
- Research Center on Thromboembolic Disorders and Antithrombotic Therapies, ASST Lariana, University of Insubria, Como, Italy
| | - Daniela Poli
- Thrombosis Center, "Careggi" Hospital, Florence, Italy
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Liu JL, Wang Q, Qu DY. Postpartum quality of life and mental health in women with heart disease: Integrated clinical communication and treatment. World J Psychiatry 2024; 14:63-75. [PMID: 38327887 PMCID: PMC10845230 DOI: 10.5498/wjp.v14.i1.63] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 12/06/2023] [Accepted: 12/21/2023] [Indexed: 01/19/2024] Open
Abstract
BACKGROUND Postpartum quality of life (QoL) in women with heart disease has been neglected. AIM To improve clinical communication and treatment, we integrated medical data and subjective characteristics to study postpartum QoL concerns. METHODS The study assessed QoL 6 wk after birth using the 12-Item Short-Form Health Survey. The Edinburgh Postnatal Depression Scale, Cardiac Anxiety Questionnaire, European Heart Failure Self-Care Behavior Scale, and a self-designed questionnaire based on earlier research were also used to assess patient characteristics. Patient data were collected. Prediction models were created using multiple linear regression. RESULTS This retrospective study examined postpartum QoL in 105 cardiac patients. Postpartum QoL scores were lower (90.69 ± 13.82) than those of women without heart disease, with physical component scores (41.09 ± 9.91) lower than mental component scores (49.60 ± 14.87). Postpartum depression (33.3%), moderate anxiety (37.14%), pregnancy concerns (57.14%), offspring heart problems (57.14%), and life expectancy worries (48.6%) were all prevalent. No previous cardiac surgery, multiparity, higher sadness and cardiac anxiety, and fear of unfavorable pregnancy outcomes were strongly related to lower QoL (R2 = 0.525). CONCLUSION Postpartum QoL is linked to physical and mental health in women with heart disease. Our study emphasizes the need for healthcare workers to recognize the unique characteristics of these women while developing and implementing comprehensive management approaches during their maternity care.
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Affiliation(s)
- Jia-Lin Liu
- Department of Obstetrics and Gynecology, China Medical University, Shenyang 110122, Liaoning Province, China
| | - Qi Wang
- Department of Psychiatry, General Hospital of Northern Theater Command, Shenyang 110016, Liaoning Province, China
| | - Dong-Ying Qu
- Department of Obstetrics and Gynecology, General Hospital of Northern Theater Command, Shenyang 110016, Liaoning Province, China
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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.
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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
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Makhija N, Tayade S, Tilva H, Chadha A, Thatere U. Pregnancy After Cardiac Surgery. Cureus 2022; 14:e31133. [DOI: 10.7759/cureus.31133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Accepted: 11/05/2022] [Indexed: 11/07/2022] Open
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Pacheco LD, Saade G, Shrivastava V, Shree R, Elkayam U. Society for Maternal-Fetal Medicine Consult Series #61: Anticoagulation in pregnant patients with cardiac disease. Am J Obstet Gynecol 2022; 227:B28-B43. [PMID: 35337804 DOI: 10.1016/j.ajog.2022.03.036] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Pregnancy in individuals with a mechanical heart valve has been classified as very high risk because of a substantially increased risk of maternal mortality or severe morbidity. Lifelong therapeutic anticoagulation is a principal component of the medical management of mechanical heart valves to prevent valve thrombosis. Anticoagulation regimens indicated outside of pregnancy for patients with mechanical valves should be continued during pregnancy with the possibility of modifications based on the type of valve, the trimester of pregnancy, individual risk tolerance, and circumstances around the time of delivery. The purpose of this document is to provide recommendations regarding the management of anticoagulation for common cardiac conditions complicating pregnancy, including mechanical heart valves, atrial fibrillation, systolic heart failure, and congenital heart disease.
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Affiliation(s)
- Luis D Pacheco
- Society for Maternal-Fetal Medicine, 409 12 St. SW, Washington, DC 20024, USA.
| | - George Saade
- Society for Maternal-Fetal Medicine, 409 12 St. SW, Washington, DC 20024, USA.
| | - Vineet Shrivastava
- Society for Maternal-Fetal Medicine, 409 12 St. SW, Washington, DC 20024, USA.
| | - Raj Shree
- Society for Maternal-Fetal Medicine, 409 12 St. SW, Washington, DC 20024, USA.
| | - Uri Elkayam
- Society for Maternal-Fetal Medicine, 409 12 St. SW, Washington, DC 20024, USA.
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Anticoagulation of women with congenital heart disease during pregnancy. INTERNATIONAL JOURNAL OF CARDIOLOGY CONGENITAL HEART DISEASE 2021. [DOI: 10.1016/j.ijcchd.2021.100210] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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2020 ACC/AHA guideline for the management of patients with valvular heart disease: A report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Thorac Cardiovasc Surg 2021; 162:e183-e353. [PMID: 33972115 DOI: 10.1016/j.jtcvs.2021.04.002] [Citation(s) in RCA: 68] [Impact Index Per Article: 22.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F, Jneid H, Krieger EV, Mack M, McLeod C, O'Gara PT, Rigolin VH, Sundt TM, Thompson A, Toly C. 2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2021; 143:e72-e227. [PMID: 33332150 DOI: 10.1161/cir.0000000000000923] [Citation(s) in RCA: 509] [Impact Index Per Article: 169.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F, Jneid H, Krieger EV, Mack M, McLeod C, O'Gara PT, Rigolin VH, Sundt TM, Thompson A, Toly C. 2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2021; 77:e25-e197. [PMID: 33342586 DOI: 10.1016/j.jacc.2020.11.018] [Citation(s) in RCA: 713] [Impact Index Per Article: 237.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Dhillon SK, Edwards J, Wilkie J, Bungard TJ. High-Versus Low-Dose Warfarin-Related Teratogenicity: A Case Report and Systematic Review. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2019; 40:1348-1357. [PMID: 30390948 DOI: 10.1016/j.jogc.2017.11.020] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2017] [Revised: 11/06/2017] [Accepted: 11/07/2017] [Indexed: 11/27/2022]
Abstract
OBJECTIVE The optimal anticoagulant therapy during pregnancy in women with mechanical heart valves remains controversial. This study highlights a case of high-dose warfarin ingestion throughout pregnancy and performed a systematic review to assess rates of teratogenicity with high versus low warfarin dosing (≤5 mg daily). METHODS A literature search for all case reports and available literature was conducted in PubMed, Medline, and EMBASE up to December 2016 using medical subject heading terms "mechanical prosthetic valves," "pregnancy," "oral anticoagulants," "warfarin," "coumarins," "heparin, low-molecular-weight," and "thromboembolism." To be included, warfarin had to be administered anytime between 6 and 12 weeks of gestation with the dose being specified. The Newcastle-Ottawa Scale was used to assess quality of the cohort data. RESULTS The woman in the studied case received the highest reported warfarin doses throughout pregnancy (14.5-16.5 mg daily) and delivered a baby with no evidence of teratogenicity to the current age of 5 years. The study identified 23 case reports, with all demonstrating warfarin teratogenicity regardless of high-dose (n = 12) or low-dose (n = 11) warfarin. Twelve cohort studies identified a warfarin teratogenicity rate of 5.0%, with rates of 2.4% and 10.5% with low- and high-dose warfarin, respectively. Risk of bias was moderate (median Newcastle-Ottawa Scale score of 6) for all of the cohort studies. CONCLUSION Although a lower prevalence of warfarin-induced teratogenicity is reported with low-dose warfarin, a safe "cut-off" dose is misleading. Teratogenic risk with warfarin is unpredictable, mandating individual decisions regardless of the dose.
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Affiliation(s)
| | | | | | - Tammy J Bungard
- Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, AB.
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Aggarwal SR, Economy KE, Valente AM. State of the Art Management of Mechanical Heart Valves During Pregnancy. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2018; 20:102. [PMID: 30417314 DOI: 10.1007/s11936-018-0702-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
PURPOSE OF THE REVIEW To review the management of women with mechanical heart valves during pregnancy, from preconception counseling through delivery with a summary of the latest guidelines. RECENT FINDINGS The hypercoagulability of pregnancy combined with the imperfect choices of anticoagulant agents contribute to a high risk of complications in pregnant women with mechanical heart valves. Valve thrombosis remains a major concern, much of which occurs during the first trimester transition to heparin-based products. The safest method of anticoagulation, with the best balance of maternal and fetal risk, is use of low-dose vitamin K antagonists, but only if therapeutic anticoagulation can be achieved with warfarin doses of ≤ 5 mg/day. Management of mechanical heart valves in pregnancy remains fraught with difficult decisions involving balancing of maternal and fetal risks as well as a high risk of maternal and fetal complications. Preconception counseling and planning is imperative. A risk-benefit discussion with the patient will help guide the choice of anticoagulation and outline the plan for safe delivery options. A multidisciplinary approach to management is advisable with close follow-up and care in a tertiary center.
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Affiliation(s)
- Shivani R Aggarwal
- Department of Cardiology, Boston Children's Hospital, 300 Longwood Avenue, BCH 3215, Boston, MA, 02115, USA. .,Department of Medicine, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA.
| | - Katherine E Economy
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Anne M Valente
- Department of Cardiology, Boston Children's Hospital, 300 Longwood Avenue, BCH 3215, Boston, MA, 02115, USA.,Department of Medicine, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA
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Mennander AA. Stepping down from the ivory tower: Inviting the patient for mutual responsibility. J Thorac Cardiovasc Surg 2018; 156:1496-1497. [DOI: 10.1016/j.jtcvs.2018.04.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Accepted: 04/09/2018] [Indexed: 11/26/2022]
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Barakat M, Dvir D, Azadani AN. Fluid Dynamic Characterization of Transcatheter Aortic Valves Using Particle Image Velocimetry. Artif Organs 2018; 42:E357-E368. [DOI: 10.1111/aor.13290] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Revised: 03/27/2018] [Accepted: 05/01/2018] [Indexed: 01/01/2023]
Affiliation(s)
- Mohammed Barakat
- Department of Mechanical and Materials Engineering; University of Denver; Denver CO USA
| | - Danny Dvir
- Department of Medicine, Division of Cardiology; University of Washington; Seattle WA USA
| | - Ali N. Azadani
- Department of Mechanical and Materials Engineering; University of Denver; Denver CO USA
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Moreno Ruiz NL. Gestación y anticoagulación en válvula mecánica: un reto terapéutico. REVISTA COLOMBIANA DE CARDIOLOGÍA 2018. [DOI: 10.1016/j.rccar.2017.11.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022] Open
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Adam K. Pregnancy in Women with Cardiovascular Diseases. Methodist Debakey Cardiovasc J 2018; 13:209-215. [PMID: 29744013 DOI: 10.14797/mdcj-13-4-209] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Patients with cardiovascular disease represent a significant cohort at risk for complications during pregnancy. The normal physiologic changes of pregnancy could further compromise the hemodynamics of various cardiovascular conditions, resulting in clinical deterioration and even death. The fetus of a gravida with cardiovascular disease also has an increased risk of morbidity, including an increased risk of inherited cardiac genetic disorders, fetal growth restriction, and premature delivery. These complications also increase the risk for antenatal and perinatal mortality. Ideally, the management of a patient with cardiac disease who is considering pregnancy should start with pre-conception counseling that outlines the maternal and fetal complications associated with her particular cardiac disorder. The pregnancy is best managed by a dedicated team of specialists in maternal-fetal medicine, cardiology, cardiovascular surgery, anesthesiology, and neonatology, preferably in a tertiary care center.
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Steinberg ZL, Dominguez-Islas CP, Otto CM, Stout KK, Krieger EV. Maternal and Fetal Outcomes of Anticoagulation in Pregnant Women With Mechanical Heart Valves. J Am Coll Cardiol 2017; 69:2681-2691. [PMID: 28571631 PMCID: PMC5457289 DOI: 10.1016/j.jacc.2017.03.605] [Citation(s) in RCA: 92] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2016] [Revised: 03/26/2017] [Accepted: 03/28/2017] [Indexed: 01/18/2023]
Abstract
Background Anticoagulation for mechanical heart valves during pregnancy is essential to prevent thromboembolic events. Each regimen has drawbacks with regard to maternal or fetal risk. Objectives This meta-analysis sought to estimate and compare the risk of adverse maternal and fetal outcomes in pregnant women with mechanical heart valves who received different methods of anticoagulation. Methods Studies were identified using a Medline search including all publications up to June 5, 2016. Study inclusion required reporting of maternal death, thromboembolism, and valve failure, and/or fetal spontaneous abortion, death, and congenital defects in pregnant women treated with any of the following: 1) a vitamin K antagonist (VKA) throughout pregnancy; 2) low-molecular-weight heparin (LMWH) throughout pregnancy; 3) LMWH for the first trimester, followed by a VKA (LMWH and VKA); or 4) unfractionated heparin for the first trimester, followed by a VKA (UFH and VKA). Results A total of 800 pregnancies from 18 publications were included. Composite maternal risk was lowest with VKA (5%), compared with LMWH (16%; ratio of averaged risk [RAR]: 3.2; 95% confidence interval [CI]: 1.5 to 7.5), LMWH and VKA (16%; RAR: 3.1; 95% CI: 1.2 to 7.5), or UFH and VKA (16%; RAR: 3.1; 95% CI: 1.5 to 7.1). Composite fetal risk was lowest with LMWH (13%; RAR: 0.3; 95% CI: 0.1 to 0.8), compared with VKA (39%), LMWH and VKA (23%), or UFH and VKA (34%). No significant difference in fetal risk was observed between women taking ≤5 mg daily warfarin and those with an LMWH regimen (RAR: 0.9; 95% CI: 0.3 to 2.4). Conclusions VKA treatment was associated with the lowest risk of adverse maternal outcomes, whereas the use of LMWH throughout pregnancy was associated with the lowest risk of adverse fetal outcomes. Fetal risk was similar between women taking ≤5 mg warfarin daily and women treated with LMWH.
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Affiliation(s)
- Zachary L Steinberg
- Division of Cardiology, Department of Medicine, University of Washington School of Medicine, Seattle, Washington.
| | - Clara P Dominguez-Islas
- Medical Research Council Biostatistics Unit, School of Clinical Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Catherine M Otto
- Division of Cardiology, Department of Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Karen K Stout
- Division of Cardiology, Department of Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Eric V Krieger
- Division of Cardiology, Department of Medicine, University of Washington School of Medicine, Seattle, Washington
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Anticoagulation Therapy for Pregnant Women With Mechanical Prosthetic Heart Valves. J Am Coll Cardiol 2017; 69:2692-2695. [DOI: 10.1016/j.jacc.2017.04.034] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2017] [Accepted: 04/24/2017] [Indexed: 11/19/2022]
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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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Canobbio MM, Warnes CA, Aboulhosn J, Connolly HM, Khanna A, Koos BJ, Mital S, Rose C, Silversides C, Stout K. Management of Pregnancy in Patients With Complex Congenital Heart Disease: A Scientific Statement for Healthcare Professionals From the American Heart Association. Circulation 2017; 135:e50-e87. [PMID: 28082385 DOI: 10.1161/cir.0000000000000458] [Citation(s) in RCA: 215] [Impact Index Per Article: 30.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Today, most female children born with congenital heart disease will reach childbearing age. For many women with complex congenital heart disease, carrying a pregnancy carries a moderate to high risk for both the mother and her fetus. Many such women, however, do not have access to adult congenital heart disease tertiary centers with experienced reproductive programs. Therefore, it is important that all practitioners who will be managing these women have current information not only on preconception counseling and diagnostic evaluation to determine maternal and fetal risk but also on how to manage them once they are pregnant and when to refer them to a regional center with expertise in pregnancy management.
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20
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Chaux A, Gray RJ, Stupka JC, Emken MR, Scotten LN, Siegel R. Anticoagulant independent mechanical heart valves: viable now or still a distant holy grail. ANNALS OF TRANSLATIONAL MEDICINE 2016; 4:525. [PMID: 28149886 DOI: 10.21037/atm.2016.12.58] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Valvular heart disease remains a large public health problem for all societies; it attracts the attention of public health organizations, researchers and governments. Valve substitution is an integral part of the treatment for this condition. At present, the choice of valve prosthesis is either tissue or mechanical. Tissue valves have become increasingly popular in spite of unresolved problems with durability, hemodynamics, cost and need for anticoagulation therapy. As a consequence, mechanical valve innovation has virtually ceased; the last successful mechanical design is 25 years old. We postulate that with improved technology, knowledge and experience gained over the last quarter century, the best possible solution to the problem of valve substitution can be achieved with a mechanical valve that is anticoagulant independent, durable, hemodynamically and cost efficient. At present, it is possible to design, test and produce a valve that can accomplish these goals.
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Affiliation(s)
- Aurelio Chaux
- Visiting Scientist Cedars Sinai Medical Center Heart Institute, Los Angeles, CA, USA
| | - Richard J Gray
- Medical Director Tyler Heart Institute, Community Hospital of the Monterey Peninsula, CA, USA
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Kataoka G, Asano R, Sato A, Tatsuishi W, Nakano K. Outcomes of prosthetic valve replacement in women of child-bearing age. Surg Today 2016; 47:755-761. [PMID: 27838861 DOI: 10.1007/s00595-016-1445-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2016] [Accepted: 09/29/2016] [Indexed: 10/20/2022]
Abstract
PURPOSE The outcomes of pregnancy are more favorable for women with bioprostheses than for those with mechanical prostheses. However, bioprostheses are associated with a high reoperation rate in young women and it remains unclear whether these young women can give birth without any complications. We analyzed the outcomes of prosthetic valve replacement and investigated the effectiveness and problems associated with bioprostheses in women of child-bearing age in Japan. METHODS The subjects of this study were six consecutive young adult women aged under 40 years, who underwent prosthetic valve replacement between January 2007 and April 2016. RESULTS Bioprostheses were selected for four of these six women in consideration of their child-bearing age. Mechanical valves were selected for the other two women who underwent the Konno procedure and double valve replacement (AVR, MVR) in view of their high risk for reoperation. The cardiac operations, although without mortality or morbidity, were complex and some involved multi-time procedures. Three of the women with bioprostheses had uneventful term pregnancies. CONCLUSIONS These young women with bioprostheses were able to give birth safely; however, as multiple operations are often required, and bioprostheses may not be ideal for young women. Prosthetic valve selection for young women of child-bearing age requires adequate pregnancy counseling and long-term planning.
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Affiliation(s)
- Go Kataoka
- Department of Cardiovascular Surgery, Tokyo Women's Medical University, Medical Center East, 2-1-10, Nishiogu, Arakawa-ku, 116-8567, Tokyo, Japan.
| | - Ryota Asano
- Department of Cardiovascular Surgery, Tokyo Women's Medical University, Medical Center East, 2-1-10, Nishiogu, Arakawa-ku, 116-8567, Tokyo, Japan
| | - Atsuhiko Sato
- Department of Cardiovascular Surgery, Tokyo Women's Medical University, Medical Center East, 2-1-10, Nishiogu, Arakawa-ku, 116-8567, Tokyo, Japan
| | - Wataru Tatsuishi
- Department of Cardiovascular Surgery, Tokyo Women's Medical University, Medical Center East, 2-1-10, Nishiogu, Arakawa-ku, 116-8567, Tokyo, Japan
| | - Kiyoharu Nakano
- Department of Cardiovascular Surgery, Tokyo Women's Medical University, Medical Center East, 2-1-10, Nishiogu, Arakawa-ku, 116-8567, Tokyo, Japan
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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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23
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Alshawabkeh L, Economy KE, Valente AM. Anticoagulation During Pregnancy. J Am Coll Cardiol 2016; 68:1804-1813. [DOI: 10.1016/j.jacc.2016.06.076] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2016] [Revised: 05/24/2016] [Accepted: 06/06/2016] [Indexed: 12/22/2022]
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24
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Bhagra CJ, D'Souza R, Silversides CK. Valvular heart disease and pregnancy part II: management of prosthetic valves. Heart 2016; 103:244-252. [PMID: 27670966 DOI: 10.1136/heartjnl-2015-308199] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Catriona J Bhagra
- Division of Cardiology, University of Toronto Pregnancy and Heart Disease Program, Mount Sinai Hospital and University Health Network, Toronto, Ontario, Canada
| | - Rohan D'Souza
- Department of Obstetrics and Gynaecology, Division of Maternal and Fetal Medicine, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Candice K Silversides
- Division of Cardiology, University of Toronto Pregnancy and Heart Disease Program, Mount Sinai Hospital and University Health Network, Toronto, Ontario, Canada
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25
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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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26
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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.
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Affiliation(s)
- Kazuki Morimoto
- Department of Pediatric Cardiovascular Surgery, National Cerebral and Cardiovascular Center
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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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28
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van Hagen IM, Roos-Hesselink JW, Ruys TPE, Merz WM, Goland S, Gabriel H, Lelonek M, Trojnarska O, Al Mahmeed WA, Balint HO, Ashour Z, Baumgartner H, Boersma E, Johnson MR, Hall R. Pregnancy in Women With a Mechanical Heart Valve: Data of the European Society of Cardiology Registry of Pregnancy and Cardiac Disease (ROPAC). Circulation 2015; 132:132-42. [PMID: 26100109 DOI: 10.1161/circulationaha.115.015242] [Citation(s) in RCA: 198] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2015] [Accepted: 05/01/2015] [Indexed: 01/14/2023]
Abstract
BACKGROUND Pregnant women with a mechanical heart valve (MHV) are at a heightened risk of a thrombotic event, and their absolute need for adequate anticoagulation puts them at considerable risk of bleeding and, with some anticoagulants, fetotoxicity. METHODS AND RESULTS Within the prospective, observational, contemporary, worldwide Registry of Pregnancy and Cardiac disease (ROPAC), we describe the pregnancy outcome of 212 patients with an MHV. We compare them with 134 patients with a tissue heart valve and 2620 other patients without a prosthetic valve. Maternal mortality occurred in 1.4% of the patients with an MHV, in 1.5% of patients with a tissue heart valve (P=1.000), and in 0.2% of patients without a prosthetic valve (P=0.025). Mechanical valve thrombosis complicated pregnancy in 10 patients with an MHV (4.7%). In 5 of these patients, the valve thrombosis occurred in the first trimester, and all 5 patients had been switched to some form of heparin. Hemorrhagic events occurred in 23.1% of patients with an MHV, in 5.1% of patients with a tissue heart valve (P<0.001), and in 4.9% of patients without a prosthetic valve (P<0.001). Only 58% of the patients with an MHV had a pregnancy free of serious adverse events compared with 79% of patients with a tissue heart valve (P<0.001) and 78% of patients without a prosthetic valve (P<0.001). Vitamin K antagonist use in the first trimester compared with heparin was associated with a higher rate of miscarriage (28.6% versus 9.2%; P<0.001) and late fetal death (7.1% versus 0.7%; P=0.016). CONCLUSIONS Women with an MHV have only a 58% chance of experiencing an uncomplicated pregnancy with a live birth. The markedly increased mortality and morbidity warrant extensive prepregnancy counseling and centralization of care.
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Affiliation(s)
- Iris M van Hagen
- From Department of Cardiology, Erasmus University Medical Center, Rotterdam, The Netherlands (I.M.v.H., J.W.R.-H., T.P.E.R., E.B.); EURObservational Research Programme, European Society of Cardiology, Sophia Antipolis, France (J.W.R.-H.); Department of Obstetrics and Prenatal Medicine, Center for Obstetrics and Gynecology, University Bonn Medical School, Germany (W.M.M.); Heart Institute, Kaplan Medical Center, Rehovot, Israel (S.G.); Hebrew University, Jerusalem, Israel (S.G.); Department of Cardiology, Medical University Vienna, Austria (H.G.); Department of Cardiology, Medical University of Lodz, Poland (M.L.); Department of Cardiology, University of Medical Sciences, Poznan, Poland (O.T.); Heart and Vascular Institute, Cleveland Clinic, Abu Dhabi, United Arab Emirates (W.A.A.M.); Department of Cardiology, Gottsegen György Hungarian Institute of Cardiology, Budapest, Hungary (H.O.B.); Department of Cardiology, Faculty of Medicine, Cairo University Hospital, Egypt (Z.A.); Division of Adult Congenital and Valvular Heart Disease, Department of Cardiovascular Medicine, University Hospital Muenster, Germany (H.B.); Department of Obstetrics, Imperial College School of Medicine, Chelsea and Westminster Hospital, London, UK (M.R.J.); and Department of Cardiology, Norwich Medical School, University of East Anglia, UK (R.H.)
| | - Jolien W Roos-Hesselink
- From Department of Cardiology, Erasmus University Medical Center, Rotterdam, The Netherlands (I.M.v.H., J.W.R.-H., T.P.E.R., E.B.); EURObservational Research Programme, European Society of Cardiology, Sophia Antipolis, France (J.W.R.-H.); Department of Obstetrics and Prenatal Medicine, Center for Obstetrics and Gynecology, University Bonn Medical School, Germany (W.M.M.); Heart Institute, Kaplan Medical Center, Rehovot, Israel (S.G.); Hebrew University, Jerusalem, Israel (S.G.); Department of Cardiology, Medical University Vienna, Austria (H.G.); Department of Cardiology, Medical University of Lodz, Poland (M.L.); Department of Cardiology, University of Medical Sciences, Poznan, Poland (O.T.); Heart and Vascular Institute, Cleveland Clinic, Abu Dhabi, United Arab Emirates (W.A.A.M.); Department of Cardiology, Gottsegen György Hungarian Institute of Cardiology, Budapest, Hungary (H.O.B.); Department of Cardiology, Faculty of Medicine, Cairo University Hospital, Egypt (Z.A.); Division of Adult Congenital and Valvular Heart Disease, Department of Cardiovascular Medicine, University Hospital Muenster, Germany (H.B.); Department of Obstetrics, Imperial College School of Medicine, Chelsea and Westminster Hospital, London, UK (M.R.J.); and Department of Cardiology, Norwich Medical School, University of East Anglia, UK (R.H.).
| | - Titia P E Ruys
- From Department of Cardiology, Erasmus University Medical Center, Rotterdam, The Netherlands (I.M.v.H., J.W.R.-H., T.P.E.R., E.B.); EURObservational Research Programme, European Society of Cardiology, Sophia Antipolis, France (J.W.R.-H.); Department of Obstetrics and Prenatal Medicine, Center for Obstetrics and Gynecology, University Bonn Medical School, Germany (W.M.M.); Heart Institute, Kaplan Medical Center, Rehovot, Israel (S.G.); Hebrew University, Jerusalem, Israel (S.G.); Department of Cardiology, Medical University Vienna, Austria (H.G.); Department of Cardiology, Medical University of Lodz, Poland (M.L.); Department of Cardiology, University of Medical Sciences, Poznan, Poland (O.T.); Heart and Vascular Institute, Cleveland Clinic, Abu Dhabi, United Arab Emirates (W.A.A.M.); Department of Cardiology, Gottsegen György Hungarian Institute of Cardiology, Budapest, Hungary (H.O.B.); Department of Cardiology, Faculty of Medicine, Cairo University Hospital, Egypt (Z.A.); Division of Adult Congenital and Valvular Heart Disease, Department of Cardiovascular Medicine, University Hospital Muenster, Germany (H.B.); Department of Obstetrics, Imperial College School of Medicine, Chelsea and Westminster Hospital, London, UK (M.R.J.); and Department of Cardiology, Norwich Medical School, University of East Anglia, UK (R.H.)
| | - Waltraut M Merz
- From Department of Cardiology, Erasmus University Medical Center, Rotterdam, The Netherlands (I.M.v.H., J.W.R.-H., T.P.E.R., E.B.); EURObservational Research Programme, European Society of Cardiology, Sophia Antipolis, France (J.W.R.-H.); Department of Obstetrics and Prenatal Medicine, Center for Obstetrics and Gynecology, University Bonn Medical School, Germany (W.M.M.); Heart Institute, Kaplan Medical Center, Rehovot, Israel (S.G.); Hebrew University, Jerusalem, Israel (S.G.); Department of Cardiology, Medical University Vienna, Austria (H.G.); Department of Cardiology, Medical University of Lodz, Poland (M.L.); Department of Cardiology, University of Medical Sciences, Poznan, Poland (O.T.); Heart and Vascular Institute, Cleveland Clinic, Abu Dhabi, United Arab Emirates (W.A.A.M.); Department of Cardiology, Gottsegen György Hungarian Institute of Cardiology, Budapest, Hungary (H.O.B.); Department of Cardiology, Faculty of Medicine, Cairo University Hospital, Egypt (Z.A.); Division of Adult Congenital and Valvular Heart Disease, Department of Cardiovascular Medicine, University Hospital Muenster, Germany (H.B.); Department of Obstetrics, Imperial College School of Medicine, Chelsea and Westminster Hospital, London, UK (M.R.J.); and Department of Cardiology, Norwich Medical School, University of East Anglia, UK (R.H.)
| | - Sorel Goland
- From Department of Cardiology, Erasmus University Medical Center, Rotterdam, The Netherlands (I.M.v.H., J.W.R.-H., T.P.E.R., E.B.); EURObservational Research Programme, European Society of Cardiology, Sophia Antipolis, France (J.W.R.-H.); Department of Obstetrics and Prenatal Medicine, Center for Obstetrics and Gynecology, University Bonn Medical School, Germany (W.M.M.); Heart Institute, Kaplan Medical Center, Rehovot, Israel (S.G.); Hebrew University, Jerusalem, Israel (S.G.); Department of Cardiology, Medical University Vienna, Austria (H.G.); Department of Cardiology, Medical University of Lodz, Poland (M.L.); Department of Cardiology, University of Medical Sciences, Poznan, Poland (O.T.); Heart and Vascular Institute, Cleveland Clinic, Abu Dhabi, United Arab Emirates (W.A.A.M.); Department of Cardiology, Gottsegen György Hungarian Institute of Cardiology, Budapest, Hungary (H.O.B.); Department of Cardiology, Faculty of Medicine, Cairo University Hospital, Egypt (Z.A.); Division of Adult Congenital and Valvular Heart Disease, Department of Cardiovascular Medicine, University Hospital Muenster, Germany (H.B.); Department of Obstetrics, Imperial College School of Medicine, Chelsea and Westminster Hospital, London, UK (M.R.J.); and Department of Cardiology, Norwich Medical School, University of East Anglia, UK (R.H.)
| | - Harald Gabriel
- From Department of Cardiology, Erasmus University Medical Center, Rotterdam, The Netherlands (I.M.v.H., J.W.R.-H., T.P.E.R., E.B.); EURObservational Research Programme, European Society of Cardiology, Sophia Antipolis, France (J.W.R.-H.); Department of Obstetrics and Prenatal Medicine, Center for Obstetrics and Gynecology, University Bonn Medical School, Germany (W.M.M.); Heart Institute, Kaplan Medical Center, Rehovot, Israel (S.G.); Hebrew University, Jerusalem, Israel (S.G.); Department of Cardiology, Medical University Vienna, Austria (H.G.); Department of Cardiology, Medical University of Lodz, Poland (M.L.); Department of Cardiology, University of Medical Sciences, Poznan, Poland (O.T.); Heart and Vascular Institute, Cleveland Clinic, Abu Dhabi, United Arab Emirates (W.A.A.M.); Department of Cardiology, Gottsegen György Hungarian Institute of Cardiology, Budapest, Hungary (H.O.B.); Department of Cardiology, Faculty of Medicine, Cairo University Hospital, Egypt (Z.A.); Division of Adult Congenital and Valvular Heart Disease, Department of Cardiovascular Medicine, University Hospital Muenster, Germany (H.B.); Department of Obstetrics, Imperial College School of Medicine, Chelsea and Westminster Hospital, London, UK (M.R.J.); and Department of Cardiology, Norwich Medical School, University of East Anglia, UK (R.H.)
| | - Malgorzata Lelonek
- From Department of Cardiology, Erasmus University Medical Center, Rotterdam, The Netherlands (I.M.v.H., J.W.R.-H., T.P.E.R., E.B.); EURObservational Research Programme, European Society of Cardiology, Sophia Antipolis, France (J.W.R.-H.); Department of Obstetrics and Prenatal Medicine, Center for Obstetrics and Gynecology, University Bonn Medical School, Germany (W.M.M.); Heart Institute, Kaplan Medical Center, Rehovot, Israel (S.G.); Hebrew University, Jerusalem, Israel (S.G.); Department of Cardiology, Medical University Vienna, Austria (H.G.); Department of Cardiology, Medical University of Lodz, Poland (M.L.); Department of Cardiology, University of Medical Sciences, Poznan, Poland (O.T.); Heart and Vascular Institute, Cleveland Clinic, Abu Dhabi, United Arab Emirates (W.A.A.M.); Department of Cardiology, Gottsegen György Hungarian Institute of Cardiology, Budapest, Hungary (H.O.B.); Department of Cardiology, Faculty of Medicine, Cairo University Hospital, Egypt (Z.A.); Division of Adult Congenital and Valvular Heart Disease, Department of Cardiovascular Medicine, University Hospital Muenster, Germany (H.B.); Department of Obstetrics, Imperial College School of Medicine, Chelsea and Westminster Hospital, London, UK (M.R.J.); and Department of Cardiology, Norwich Medical School, University of East Anglia, UK (R.H.)
| | - Olga Trojnarska
- From Department of Cardiology, Erasmus University Medical Center, Rotterdam, The Netherlands (I.M.v.H., J.W.R.-H., T.P.E.R., E.B.); EURObservational Research Programme, European Society of Cardiology, Sophia Antipolis, France (J.W.R.-H.); Department of Obstetrics and Prenatal Medicine, Center for Obstetrics and Gynecology, University Bonn Medical School, Germany (W.M.M.); Heart Institute, Kaplan Medical Center, Rehovot, Israel (S.G.); Hebrew University, Jerusalem, Israel (S.G.); Department of Cardiology, Medical University Vienna, Austria (H.G.); Department of Cardiology, Medical University of Lodz, Poland (M.L.); Department of Cardiology, University of Medical Sciences, Poznan, Poland (O.T.); Heart and Vascular Institute, Cleveland Clinic, Abu Dhabi, United Arab Emirates (W.A.A.M.); Department of Cardiology, Gottsegen György Hungarian Institute of Cardiology, Budapest, Hungary (H.O.B.); Department of Cardiology, Faculty of Medicine, Cairo University Hospital, Egypt (Z.A.); Division of Adult Congenital and Valvular Heart Disease, Department of Cardiovascular Medicine, University Hospital Muenster, Germany (H.B.); Department of Obstetrics, Imperial College School of Medicine, Chelsea and Westminster Hospital, London, UK (M.R.J.); and Department of Cardiology, Norwich Medical School, University of East Anglia, UK (R.H.)
| | - Wael Abdulrahman Al Mahmeed
- From Department of Cardiology, Erasmus University Medical Center, Rotterdam, The Netherlands (I.M.v.H., J.W.R.-H., T.P.E.R., E.B.); EURObservational Research Programme, European Society of Cardiology, Sophia Antipolis, France (J.W.R.-H.); Department of Obstetrics and Prenatal Medicine, Center for Obstetrics and Gynecology, University Bonn Medical School, Germany (W.M.M.); Heart Institute, Kaplan Medical Center, Rehovot, Israel (S.G.); Hebrew University, Jerusalem, Israel (S.G.); Department of Cardiology, Medical University Vienna, Austria (H.G.); Department of Cardiology, Medical University of Lodz, Poland (M.L.); Department of Cardiology, University of Medical Sciences, Poznan, Poland (O.T.); Heart and Vascular Institute, Cleveland Clinic, Abu Dhabi, United Arab Emirates (W.A.A.M.); Department of Cardiology, Gottsegen György Hungarian Institute of Cardiology, Budapest, Hungary (H.O.B.); Department of Cardiology, Faculty of Medicine, Cairo University Hospital, Egypt (Z.A.); Division of Adult Congenital and Valvular Heart Disease, Department of Cardiovascular Medicine, University Hospital Muenster, Germany (H.B.); Department of Obstetrics, Imperial College School of Medicine, Chelsea and Westminster Hospital, London, UK (M.R.J.); and Department of Cardiology, Norwich Medical School, University of East Anglia, UK (R.H.)
| | - Hajnalka Olga Balint
- From Department of Cardiology, Erasmus University Medical Center, Rotterdam, The Netherlands (I.M.v.H., J.W.R.-H., T.P.E.R., E.B.); EURObservational Research Programme, European Society of Cardiology, Sophia Antipolis, France (J.W.R.-H.); Department of Obstetrics and Prenatal Medicine, Center for Obstetrics and Gynecology, University Bonn Medical School, Germany (W.M.M.); Heart Institute, Kaplan Medical Center, Rehovot, Israel (S.G.); Hebrew University, Jerusalem, Israel (S.G.); Department of Cardiology, Medical University Vienna, Austria (H.G.); Department of Cardiology, Medical University of Lodz, Poland (M.L.); Department of Cardiology, University of Medical Sciences, Poznan, Poland (O.T.); Heart and Vascular Institute, Cleveland Clinic, Abu Dhabi, United Arab Emirates (W.A.A.M.); Department of Cardiology, Gottsegen György Hungarian Institute of Cardiology, Budapest, Hungary (H.O.B.); Department of Cardiology, Faculty of Medicine, Cairo University Hospital, Egypt (Z.A.); Division of Adult Congenital and Valvular Heart Disease, Department of Cardiovascular Medicine, University Hospital Muenster, Germany (H.B.); Department of Obstetrics, Imperial College School of Medicine, Chelsea and Westminster Hospital, London, UK (M.R.J.); and Department of Cardiology, Norwich Medical School, University of East Anglia, UK (R.H.)
| | - Zeinab Ashour
- From Department of Cardiology, Erasmus University Medical Center, Rotterdam, The Netherlands (I.M.v.H., J.W.R.-H., T.P.E.R., E.B.); EURObservational Research Programme, European Society of Cardiology, Sophia Antipolis, France (J.W.R.-H.); Department of Obstetrics and Prenatal Medicine, Center for Obstetrics and Gynecology, University Bonn Medical School, Germany (W.M.M.); Heart Institute, Kaplan Medical Center, Rehovot, Israel (S.G.); Hebrew University, Jerusalem, Israel (S.G.); Department of Cardiology, Medical University Vienna, Austria (H.G.); Department of Cardiology, Medical University of Lodz, Poland (M.L.); Department of Cardiology, University of Medical Sciences, Poznan, Poland (O.T.); Heart and Vascular Institute, Cleveland Clinic, Abu Dhabi, United Arab Emirates (W.A.A.M.); Department of Cardiology, Gottsegen György Hungarian Institute of Cardiology, Budapest, Hungary (H.O.B.); Department of Cardiology, Faculty of Medicine, Cairo University Hospital, Egypt (Z.A.); Division of Adult Congenital and Valvular Heart Disease, Department of Cardiovascular Medicine, University Hospital Muenster, Germany (H.B.); Department of Obstetrics, Imperial College School of Medicine, Chelsea and Westminster Hospital, London, UK (M.R.J.); and Department of Cardiology, Norwich Medical School, University of East Anglia, UK (R.H.)
| | - Helmut Baumgartner
- From Department of Cardiology, Erasmus University Medical Center, Rotterdam, The Netherlands (I.M.v.H., J.W.R.-H., T.P.E.R., E.B.); EURObservational Research Programme, European Society of Cardiology, Sophia Antipolis, France (J.W.R.-H.); Department of Obstetrics and Prenatal Medicine, Center for Obstetrics and Gynecology, University Bonn Medical School, Germany (W.M.M.); Heart Institute, Kaplan Medical Center, Rehovot, Israel (S.G.); Hebrew University, Jerusalem, Israel (S.G.); Department of Cardiology, Medical University Vienna, Austria (H.G.); Department of Cardiology, Medical University of Lodz, Poland (M.L.); Department of Cardiology, University of Medical Sciences, Poznan, Poland (O.T.); Heart and Vascular Institute, Cleveland Clinic, Abu Dhabi, United Arab Emirates (W.A.A.M.); Department of Cardiology, Gottsegen György Hungarian Institute of Cardiology, Budapest, Hungary (H.O.B.); Department of Cardiology, Faculty of Medicine, Cairo University Hospital, Egypt (Z.A.); Division of Adult Congenital and Valvular Heart Disease, Department of Cardiovascular Medicine, University Hospital Muenster, Germany (H.B.); Department of Obstetrics, Imperial College School of Medicine, Chelsea and Westminster Hospital, London, UK (M.R.J.); and Department of Cardiology, Norwich Medical School, University of East Anglia, UK (R.H.)
| | - Eric Boersma
- From Department of Cardiology, Erasmus University Medical Center, Rotterdam, The Netherlands (I.M.v.H., J.W.R.-H., T.P.E.R., E.B.); EURObservational Research Programme, European Society of Cardiology, Sophia Antipolis, France (J.W.R.-H.); Department of Obstetrics and Prenatal Medicine, Center for Obstetrics and Gynecology, University Bonn Medical School, Germany (W.M.M.); Heart Institute, Kaplan Medical Center, Rehovot, Israel (S.G.); Hebrew University, Jerusalem, Israel (S.G.); Department of Cardiology, Medical University Vienna, Austria (H.G.); Department of Cardiology, Medical University of Lodz, Poland (M.L.); Department of Cardiology, University of Medical Sciences, Poznan, Poland (O.T.); Heart and Vascular Institute, Cleveland Clinic, Abu Dhabi, United Arab Emirates (W.A.A.M.); Department of Cardiology, Gottsegen György Hungarian Institute of Cardiology, Budapest, Hungary (H.O.B.); Department of Cardiology, Faculty of Medicine, Cairo University Hospital, Egypt (Z.A.); Division of Adult Congenital and Valvular Heart Disease, Department of Cardiovascular Medicine, University Hospital Muenster, Germany (H.B.); Department of Obstetrics, Imperial College School of Medicine, Chelsea and Westminster Hospital, London, UK (M.R.J.); and Department of Cardiology, Norwich Medical School, University of East Anglia, UK (R.H.)
| | - Mark R Johnson
- From Department of Cardiology, Erasmus University Medical Center, Rotterdam, The Netherlands (I.M.v.H., J.W.R.-H., T.P.E.R., E.B.); EURObservational Research Programme, European Society of Cardiology, Sophia Antipolis, France (J.W.R.-H.); Department of Obstetrics and Prenatal Medicine, Center for Obstetrics and Gynecology, University Bonn Medical School, Germany (W.M.M.); Heart Institute, Kaplan Medical Center, Rehovot, Israel (S.G.); Hebrew University, Jerusalem, Israel (S.G.); Department of Cardiology, Medical University Vienna, Austria (H.G.); Department of Cardiology, Medical University of Lodz, Poland (M.L.); Department of Cardiology, University of Medical Sciences, Poznan, Poland (O.T.); Heart and Vascular Institute, Cleveland Clinic, Abu Dhabi, United Arab Emirates (W.A.A.M.); Department of Cardiology, Gottsegen György Hungarian Institute of Cardiology, Budapest, Hungary (H.O.B.); Department of Cardiology, Faculty of Medicine, Cairo University Hospital, Egypt (Z.A.); Division of Adult Congenital and Valvular Heart Disease, Department of Cardiovascular Medicine, University Hospital Muenster, Germany (H.B.); Department of Obstetrics, Imperial College School of Medicine, Chelsea and Westminster Hospital, London, UK (M.R.J.); and Department of Cardiology, Norwich Medical School, University of East Anglia, UK (R.H.)
| | - Roger Hall
- From Department of Cardiology, Erasmus University Medical Center, Rotterdam, The Netherlands (I.M.v.H., J.W.R.-H., T.P.E.R., E.B.); EURObservational Research Programme, European Society of Cardiology, Sophia Antipolis, France (J.W.R.-H.); Department of Obstetrics and Prenatal Medicine, Center for Obstetrics and Gynecology, University Bonn Medical School, Germany (W.M.M.); Heart Institute, Kaplan Medical Center, Rehovot, Israel (S.G.); Hebrew University, Jerusalem, Israel (S.G.); Department of Cardiology, Medical University Vienna, Austria (H.G.); Department of Cardiology, Medical University of Lodz, Poland (M.L.); Department of Cardiology, University of Medical Sciences, Poznan, Poland (O.T.); Heart and Vascular Institute, Cleveland Clinic, Abu Dhabi, United Arab Emirates (W.A.A.M.); Department of Cardiology, Gottsegen György Hungarian Institute of Cardiology, Budapest, Hungary (H.O.B.); Department of Cardiology, Faculty of Medicine, Cairo University Hospital, Egypt (Z.A.); Division of Adult Congenital and Valvular Heart Disease, Department of Cardiovascular Medicine, University Hospital Muenster, Germany (H.B.); Department of Obstetrics, Imperial College School of Medicine, Chelsea and Westminster Hospital, London, UK (M.R.J.); and Department of Cardiology, Norwich Medical School, University of East Anglia, UK (R.H.)
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Bian C, Qi X, Li L, Zhao J, Liu X. Anticoagulant management of pregnant women with mechanical heart valve replacement during perioperative period. Arch Gynecol Obstet 2015; 293:69-74. [PMID: 26048261 DOI: 10.1007/s00404-015-3768-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2014] [Accepted: 05/27/2015] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To investigate the morbidity of complications and pregnancy outcomes in women with mechanical heart valve replacement who received low-dose oral anticoagulation treatment with warfarin throughout the pregnancy, compare the prognosis and complications of patients who were treated with single oral warfarin treatment or the "bridging" therapy treatment, investigate the influence of using vitamin K1 before emergency cesarean section delivery on postoperative warfarin anticoagulant effect and to explore an appropriate anticoagulant regimen during perioperative period for pregnant women with mechanical heart valve replacement. METHOD 46 pregnant women with mechanical heart valve replacement who received low-dose oral anticoagulation treatment from October 2008 to October 2014 treated at West China Women's and Children's Hospital were retrospectively reviewed. Eight patients received emergency cesarean section (CS), while 38 patients received selective CS, in which 17 patients received single oral warfarin and 21 patients received "bridging" anticoagulation treatment during postoperative period. Morbidity of complications and the time to achieve the target INR after operation were compared. RESULTS The mechanical valves were at the mitral position in 35 (76.09 %) patients, at the aortic position in 2 (4.35 %) patient and at both the mitral and aortic position in 9 (19.57 %) patients. 46 full-term healthy babies were delivered and no maternal thromboembolic was observed during pregnancy. There was no significant difference of the amount of uterine bleeding between single oral warfarin group and "bridging" treatment group during postpartum period. In single oral warfarin group, one valve thrombosis was observed and led to sudden death. No periphery thrombosis, hematoma, general hemorrhage or other sign of over-anticoagulation was observed. The INR increased more slowly in the group who received emergency CS with preoperative application of vitamin K1 than other two groups. CONCLUSION The use of vitamin K1 preoperatively might result in warfarin resistance and discontinuation of warfarin therapy before selective CS might be more appropriate than application of vitamin K1. The "bridging" anticoagulation treatment which combines oral warfarin and subcutaneous LMWH might be more effective and safer than single oral warfarin therapy for patients with mechanical heart valve replacement during postoperative period, no matter selective or emergency CS. The safety of low-dose oral warfarin therapy throughout pregnancy is still under controversy.
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Affiliation(s)
- Ce Bian
- Department of Obstetrics and Gynecology, Sichuan Provincial Key Laboratory of Gynecologic Oncology, Key Laboratory of Obstetric and Gynecologic and Pediatric Diseases and Birth Defects of Ministry of Education, West China Women's and Children's Hospital, Sichuan University, Chengdu, 610041, Sichuan, People's Republic of China
| | - Xiaorong Qi
- Department of Obstetrics and Gynecology, Sichuan Provincial Key Laboratory of Gynecologic Oncology, Key Laboratory of Obstetric and Gynecologic and Pediatric Diseases and Birth Defects of Ministry of Education, West China Women's and Children's Hospital, Sichuan University, Chengdu, 610041, Sichuan, People's Republic of China
| | - Li Li
- Department of Obstetrics and Gynecology, Sichuan Provincial Key Laboratory of Gynecologic Oncology, Key Laboratory of Obstetric and Gynecologic and Pediatric Diseases and Birth Defects of Ministry of Education, West China Women's and Children's Hospital, Sichuan University, Chengdu, 610041, Sichuan, People's Republic of China
| | - Jitong Zhao
- Department of Obstetrics and Gynecology, Sichuan Provincial Key Laboratory of Gynecologic Oncology, Key Laboratory of Obstetric and Gynecologic and Pediatric Diseases and Birth Defects of Ministry of Education, West China Women's and Children's Hospital, Sichuan University, Chengdu, 610041, Sichuan, People's Republic of China
| | - Xinghui Liu
- Department of Obstetrics and Gynecology, Sichuan Provincial Key Laboratory of Gynecologic Oncology, Key Laboratory of Obstetric and Gynecologic and Pediatric Diseases and Birth Defects of Ministry of Education, West China Women's and Children's Hospital, Sichuan University, Chengdu, 610041, Sichuan, People's Republic of China.
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Sliwa K, Johnson MR, Zilla P, Roos-Hesselink JW. Management of valvular disease in pregnancy: a global perspective. Eur Heart J 2015; 36:1078-89. [DOI: 10.1093/eurheartj/ehv050] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2014] [Accepted: 02/09/2015] [Indexed: 11/14/2022] 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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Affiliation(s)
- Michael Nanna
- Yale University School of Medicine and Yale New Haven Hospital, Department of Medicine, New Haven, CT (M.N.)
| | - Kathleen Stergiopoulos
- Division of Cardiovascular Disease, Department of Medicine, Stony Brook University Medical Center, Stony Brook, NY (K.S.)
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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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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: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 2014; 129:2440-92. [PMID: 24589852 DOI: 10.1161/cir.0000000000000029] [Citation(s) in RCA: 1015] [Impact Index Per Article: 101.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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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: 867] [Impact Index Per Article: 86.7] [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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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. J Am Coll Cardiol 2014; 63:2438-88. [PMID: 24603191 DOI: 10.1016/j.jacc.2014.02.537] [Citation(s) in RCA: 1338] [Impact Index Per Article: 133.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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A Review of JACC Journal Articles on the Topic of Interventional Cardiology: 2011–2012. J Am Coll Cardiol 2013. [DOI: 10.1016/j.jacc.2013.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Pregnancy and heart disease: Time for a randomized controlled trial. Int J Cardiol 2013; 168:3149-51. [DOI: 10.1016/j.ijcard.2013.07.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2013] [Accepted: 07/01/2013] [Indexed: 11/21/2022]
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Abstract
PURPOSE OF REVIEW Heart disease is a leading cause of maternal death worldwide. In western countries, the principal causes of death from heart disease are myocardial infarction, cardiomyopathy and congenital heart disease, whereas in developing countries, rheumatic heart disease and its long-term consequences are more important. RECENT FINDINGS There are few prospective studies upon which to base the management of these complex cases. However, best practice includes the assessment of women prepregnancy by a multidisciplinary team, with the aim of optimizing the clinical state, changing therapy to avoid teratogenic treatments and advising the patient and her relatives about the potential risks and possible complications that may arise. During pregnancy, the multidisciplinary team should define the level of care/surveillance required in each case. Some women may be safely looked after in a peripheral hospital, whereas others may need to be seen by the multidisciplinary team in the tertiary centre at regular intervals along with close echocardiographic monitoring. SUMMARY The majority of women with preexisting heart disease can go through pregnancy safely, however, close attention to detail must be paid to avoid potential complications.
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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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Augoustides JGT. Breakthroughs in anticoagulation: advent of the oral direct factor Xa inhibitors. J Cardiothorac Vasc Anesth 2012; 26:740-5. [PMID: 22608466 DOI: 10.1053/j.jvca.2012.03.029] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2012] [Indexed: 11/11/2022]
Abstract
The oral direct factor Xa inhibitors include rivaroxaban and apixaban that recently have been evaluated comprehensively in multiple randomized clinical trials. Based on the efficacy and safety data from these trials, these novel anticoagulants are disseminating throughout clinical practice for thromboprophylaxis in major lower-extremity joint replacement, acute medical illness, atrial fibrillation, and acute coronary syndromes. The advantages of the xabans over vitamin K antagonists include no requirement for routine anticoagulation monitoring as well as a fast and reliable onset of action. The first perioperative limitation of the xabans is the lack of a routine coagulation test for monitoring their anticoagulant effect in scenarios, such as the timing of surgical procedures, the reversal of xaban-related bleeding, and the conduct of regional anesthesia. A second perioperative limitation is the lack of fully validated clinical reversal agents although prothrombin complex concentrate, recombinant factor VIIa, and factor X concentrate are options for xaban reversal in life-threatening bleeding scenarios. Given their clinical efficacy and advantages, further xabans are in clinical development, with edoxaban already in phase III clinical trials. Although the xabans have ushered in a new paradigm for clinical anticoagulation, further clinical trials are indicated to refine their clinical indications even further, such as anticoagulation for patients with mechanical heart valves.
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Affiliation(s)
- John G T Augoustides
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
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The Search for a Safe and Effective Anticoagulation Regimen in Pregnant Women With Mechanical Prosthetic Heart Valves⁎⁎Editorials published in the Journal of the American College of Cardiology reflect the views of the authors and do not necessarily represent the views of JACC or the American College of Cardiology. J Am Coll Cardiol 2012; 59:1116-8. [DOI: 10.1016/j.jacc.2011.12.018] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2011] [Revised: 12/14/2011] [Accepted: 12/20/2011] [Indexed: 11/19/2022]
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Dimitrova NA, Dimitrov GV, Bonow RO, Carabello BA, Erwin JP, Guyton RA, O’Gara PT, Ruiz CE, Skubas NJ, Sorajja P, Sundt TM, Thomas JD. Effect of electrical stimulus parameters on the development and propagation of action potentials in short excitable fibres. J Am Coll Cardiol 1988; 63:e57-185. [PMID: 2460319 DOI: 10.1016/j.jacc.2014.02.536] [Citation(s) in RCA: 1827] [Impact Index Per Article: 50.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Intracellular action potentials (IAPs) produced by short fibres in response to their electrical stimulation were analysed. IAPs were calculated on the basis of the Hodgkin-Huxley (1952) model by the method described by Joyner et al. (1978). Principal differences were found in processes of activation of short (semilength L less than 5 lambda) and long fibres under near-threshold stimulation. The shorter the fibre, the lower was the threshold value (Ithr). Dependence of the latency on the stimulus strength (Ist) was substantially non-linear and was affected by the fibre length. Both fibre length and stimulus strength influenced the IAP amplitude, the instantaneous propagation velocity (IPV) and the site of the first origin of the IAP (and, consequently, excitability of the short fibre membrane). With L less than or equal to 2 lambda and Ithr less than or equal to Ist less than or equal to 1.1Ithr, IPV could reach either very high values (so that all the fibre membrane fired practically simultaneously) or even negative values. The latter corresponded to the first origin of the propagated IAP, not at the site of stimulation but at the fibre termination or at a midpoint. The characters of all the above dependencies were unchanged irrespective of the manner of approaching threshold (variation of stimulus duration or its strength). Reasons for differences in processes of activation of short and long fibres are discussed in terms of electrical load and latency. Applications of the results to explain an increased jitter, velocity recovery function and velocity-diameter relationship are also discussed.
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Affiliation(s)
- N A Dimitrova
- CLBA, Centre of Biology, Bulgarian Academy of Sciences, Sofia
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