Advertisement

State of the Art Management of Mechanical Heart Valves During Pregnancy

  • Shivani R. AggarwalEmail author
  • Katherine E. Economy
  • Anne M. Valente
Pregnancy and Cardiovascular Disease (N Scott, Section Editor)
Part of the following topical collections:
  1. Topical Collection on Pregnancy and Cardiovascular Disease

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.

Summary

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.

Keywords

Pregnancy Mechanical heart valves Valvular heart disease Congenital heart disease 

Notes

Compliance with Ethical Standards

Conflict of Interest

The authors declare that they have no conflicts of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

References and Recommended Reading

Papers of particular interest, published recently, have been highlighted as: • Of importance

  1. 1.
    Goldstein SA, Ward CC. Congenital and acquired valvular heart disease in pregnancy. Curr Cardiol Rep. 2017;19(10):96.  https://doi.org/10.1007/s11886-017-0910-6.CrossRefPubMedGoogle Scholar
  2. 2.
    Roeder HA, Kuller JA, Barker PC, James AH. Maternal valvular heart disease in pregnancy. Obstet Gynecol Surv. 2011;66(9):561–71.  https://doi.org/10.1097/OGX.0b013e318238605d.CrossRefPubMedGoogle Scholar
  3. 3.
    Sliwa K, Johnson MR, Zilla P, Roos-Hesselink JW. Management of valvular disease in pregnancy: a global perspective. Eur Heart J. 2015;36(18):1078–89.  https://doi.org/10.1093/eurheartj/ehv050.CrossRefPubMedGoogle Scholar
  4. 4.
    Sliwa K, Libhaber E, Elliott C, et al. Spectrum of cardiac disease in maternity in a low-resource cohort in South Africa. Heart. 2014;100(24):1967–74.  https://doi.org/10.1136/heartjnl-2014-306199.CrossRefPubMedPubMedCentralGoogle Scholar
  5. 5.
    Pezzella AT. Global aspects of cardiothoracic surgery with focus on developing countries. Asian Cardiovasc Thorac Ann. 2010;18(3):299–310.  https://doi.org/10.1177/0218492310370060.CrossRefPubMedGoogle Scholar
  6. 6.
    Ntiloudi D, Giannakoulas G, Parcharidou D, Panagiotidis T, Gatzoulis MA, Karvounis H. Adult congenital heart disease: a paradigm of epidemiological change. Int J Cardiol. 2016;218:269–74.  https://doi.org/10.1016/j.ijcard.2016.05.046.CrossRefPubMedGoogle Scholar
  7. 7.
    Muganyizi PS, Kidanto HL. Impact of change in maternal age composition on the incidence of caesarean section and low birth weight: analysis of delivery records at a tertiary hospital in Tanzania, 1999–2005. BMC Pregnancy Childbirth. 2009;9:30.  https://doi.org/10.1186/1471-2393-9-30.CrossRefPubMedPubMedCentralGoogle Scholar
  8. 8.
    Carolan M, Frankowska D. Advanced maternal age and adverse perinatal outcome: a review of the evidence. Midwifery. 2011;27(6):793–801.  https://doi.org/10.1016/j.midw.2010.07.006.CrossRefPubMedGoogle Scholar
  9. 9.
    • Vause S, Clarke B, Tower CL, Hay C, Knight M, UKOSS) obo. Pregnancy outcomes in women with mechanical prosthetic heart valves: a prospective descriptive population based study using the United Kingdom Obstetric Surveillance System (UKOSS) data collection system. BJOG. 2017;124(9):1411–9.  https://doi.org/10.1111/1471-0528.14478 In 2017, Vause et al published a population-based study from the UK showing an incidence of MHVs of 3.7 per 100 000 pregnancies. Their cohort was managed on LMWH throughout pregnancy. Of the 58 women with an MHV they followed through pregnancy, only 28% women had good maternal and fetal outcome. The maternal mortality was as high as 9% and there was a poor fetal outcome in 47% of the pregnancies.CrossRefPubMedGoogle Scholar
  10. 10.
    Holmes VA. Changes in haemostasis during normal pregnancy: does homocysteine play a role in maintaining homeostasis? Proc Nutr Soc. 2003;62(2):479–93.CrossRefGoogle Scholar
  11. 11.
    • van Hagen IM, Roos-Hesselink JW, Ruys TP, et al. 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(2):132–42.  https://doi.org/10.1161/CIRCULATIONAHA.115.015242 In 2015, Van Hagen et al published data from a prospective, observational, contemporary, worldwide Registry of Pregnancy and Cardiac disease describing the pregnancy outcome of 212 patients with an MHV compared to 134 patients with a tissue heart valve and 2620 without a prosthetic valve. Only 58% of the patients with an MHV had a pregnancy free of serious adverse events compared with 79% of patients with a bioprosthetic valve and 78% of patients without a prosthetic valve. There was a 4.7% rate of valve thrombosis, all occurring during the first trimester and half after switching to heparin. There was also a 23.1% rate of hemorrhagic events.CrossRefPubMedGoogle Scholar
  12. 12.
    Alshawabkeh L, Economy KE, Valente AM. Anticoagulation during pregnancy: evolving strategies with a focus on mechanical valves. J Am Coll Cardiol. 2016;68(16):1804–13.  https://doi.org/10.1016/j.jacc.2016.06.076.CrossRefPubMedGoogle Scholar
  13. 13.
    Siu SC, Sermer M, Colman JM, Alvarez AN, Mercier LA, Morton BC, et al. Prospective multicenter study of pregnancy outcomes in women with heart disease. Circulation. 2001;104(5):515–21.CrossRefGoogle Scholar
  14. 14.
    Drenthen W, Boersma E, Balci A, et al. Predictors of pregnancy complications in women with congenital heart disease. Eur Heart J. 2010;31(17):2124–32.  https://doi.org/10.1093/eurheartj/ehq200.CrossRefPubMedGoogle Scholar
  15. 15.
    Thorne S, MacGregor A, Nelson-Piercy C. Risks of contraception and pregnancy in heart disease. Heart. 2006;92(10):1520–5.  https://doi.org/10.1136/hrt.2006.095240.CrossRefPubMedPubMedCentralGoogle Scholar
  16. 16.
    • Silversides CK, Grewal J, Mason J, et al. Pregnancy outcomes in women with heart disease: The CARPREG II Study. J Am Coll Cardiol. 2018;71(21):2419–30.  https://doi.org/10.1016/j.jacc.2018.02.076 In 2018, Silversides et al published the latest risk stratification index based on their study of 1938 pregnancies including 43 (2.2%) women with MHV. Based on multivariate analysis, 10 independent predictors of primary maternal cardiac events were included in the final risk score. MHVs are heavily weighted in the score receiving 3 points, automatically increasing the calculated risk for for primary cardiac events during pregnancy in these women to 15% or more.CrossRefPubMedGoogle Scholar
  17. 17.
    Regitz-Zagrosek V, Blomstrom Lundqvist C, Borghi C, et al. ESC Guidelines on the management of cardiovascular diseases during pregnancy: the task force on the management of cardiovascular diseases during pregnancy of the European Society of Cardiology (ESC). Eur Heart J. 2011;32(24):3147–97.  https://doi.org/10.1093/eurheartj/ehr218.CrossRefPubMedGoogle Scholar
  18. 18.
    Economy KE, Valente AM. Mechanical heart valves in pregnancy: a sticky business. Circulation. 2015;132:79–81.CrossRefGoogle Scholar
  19. 19.
    Nishimura RA, Otto CM, Bonow RO, et al. 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 Thorac Cardiovasc Surg. 2014;148(1):e1–e132.  https://doi.org/10.1016/j.jtcvs.2014.05.014.CrossRefPubMedGoogle Scholar
  20. 20.
    Hall JG, Pauli RM, Wilson KM. Maternal and fetal sequelae of anticoagulation during pregnancy. Am J Med. 1980;68(1):122–40.CrossRefGoogle Scholar
  21. 21.
    Raivio KO, Ikonen E, Saarikoski S. Fetal risks due to warfarin therapy during pregnancy. Acta Paediatr Scand. 1977;66(6):735–9.CrossRefGoogle Scholar
  22. 22.
    Iturbe-Alessio I, Fonseca MC, Mutchinik O, Santos MA, Zajarias A, Salazar E. Risks of anticoagulant therapy in pregnant women with artificial heart valves. N Engl J Med. 1986;315(22):1390–3.  https://doi.org/10.1056/nejm198611273152205.CrossRefPubMedGoogle Scholar
  23. 23.
    Vitale N, De Feo M, De Santo LS, Pollice A, Tedesco N, Cotrufo M. Dose-dependent fetal complications of warfarin in pregnant women with mechanical heart valves. J Am Coll Cardiol. 1999;33(6):1637–41.CrossRefGoogle Scholar
  24. 24.
    Soma-Pillay P, Nene Z, Mathivha TM, Macdonald AP. The effect of warfarin dosage on maternal and fetal outcomes in pregnant women with prosthetic heart valves. Obstet Med. 2011;4(1):24–7.  https://doi.org/10.1258/om.2010.100067.CrossRefPubMedPubMedCentralGoogle Scholar
  25. 25.
    Castellano JM, Narayan RL, Vaishnava P, Fuster V. Anticoagulation during pregnancy in patients with a prosthetic heart valve. Nat Rev Cardiol. 2012;9(7):415–24.  https://doi.org/10.1038/nrcardio.2012.69.CrossRefPubMedGoogle Scholar
  26. 26.
    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(6):797–806.  https://doi.org/10.1093/icvts/ivu009.CrossRefPubMedGoogle Scholar
  27. 27.
    Richardson A, Shah S, Harris C, McCulloch G, Antoun P. Anticoagulation for the pregnant patient with a mechanical heart valve, no perfect therapy: review of guidelines for anticoagulation in the pregnant patient. Case Rep Cardiol. 2017;2017:3090273.  https://doi.org/10.1155/2017/3090273.CrossRefPubMedPubMedCentralGoogle Scholar
  28. 28.
    • Regitz-Zagrosek V, Roos-Hesselink JW, Bauersachs J, et al. 2018 ESC Guidelines for the management of cardiovascular diseases during pregnancy. Eur Heart J. 2018;39(34):3165–241.  https://doi.org/10.1093/eurheartj/ehy340 This comprehensive set of guidelines is an update to the prior version published in 2012, with new evidence on diagnsotic techniques, risk assessment and use of cardiovascular medications in pregnancy. This inclues recommendations for anticoagulation in women with vitamin K antagonist medication.CrossRefPubMedGoogle Scholar
  29. 29.
    Vandermeulen EP, Van Aken H, Vermylen J. Anticoagulants and spinal-epidural anesthesia. Anesth Analg. 1994;79(6):1165–77.CrossRefGoogle Scholar
  30. 30.
    Horlocker TT, Vandermeuelen E, Kopp SL, Gogarten W, Leffert LR, Benzon HT. Regional anesthesia in the patient receiving antithrombotic or thrombolytic therapy: American Society of Regional Anesthesia and Pain Medicine Evidence-Based Guidelines (Fourth Edition). Reg Anesth Pain Med. 2018;43(3):263–309.  https://doi.org/10.1097/aap.0000000000000763.CrossRefPubMedGoogle Scholar
  31. 31.
    Cousin B, Guglielminotti J, Iung B, Montravers P. Retrospective study of anaesthetic management of pregnancy patients with mechanical heart valve prosthesis and anticoagulants. Anaesth Crit Care Pain Med. 2017;37:225–31.  https://doi.org/10.1016/j.accpm.2017.08.005.CrossRefPubMedGoogle Scholar
  32. 32.
    Jha N, Jha AK, Chand Chauhan R, Chauhan NS. Maternal and fetal outcome after cardiac operations during pregnancy: a meta-analysis. Ann Thorac Surg. 2018;106(2):618–26.  https://doi.org/10.1016/j.athoracsur.2018.03.020.CrossRefPubMedGoogle Scholar
  33. 33.
    Sousa Gomes M, Guimaraes M, Montenegro N. Thrombolysis in pregnancy: a literature review. J Matern Fetal Neonatal Med. 2018:1–11.  https://doi.org/10.1080/14767058.2018.1434141.
  34. 34.
    Ozkan M, Cakal B, Karakoyun S, et al. Thrombolytic therapy for the treatment of prosthetic heart valve thrombosis in pregnancy with low-dose, slow infusion of tissue-type plasminogen activator. Circulation. 2013;128(5):532–40.  https://doi.org/10.1161/circulationaha.113.001145.CrossRefPubMedGoogle Scholar
  35. 35.
    Zimmerman J, Shotan A. Prosthetic valve endocarditis in pregnancy. Acta Obstet Gynecol Scand. 1984;63(8):731–2.CrossRefGoogle Scholar
  36. 36.
    Ayad SW, Hassanein MM, Mohamed EA, Gohar AM. Maternal and fetal outcomes in pregnant women with a prosthetic mechanical heart valve. Clin Med Insights Cardiol. 2016;10:11–7.  https://doi.org/10.4137/CMC.S36740.CrossRefPubMedPubMedCentralGoogle Scholar
  37. 37.
    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(11):1446–55.  https://doi.org/10.1111/1471-0528.13491.CrossRefPubMedGoogle Scholar
  38. 38.
    Bhagra CJ, D'Souza R, Silversides CK. Valvular heart disease and pregnancy part II: management of prosthetic valves. Heart. 2017;103(3):244–52.  https://doi.org/10.1136/heartjnl-2015-308199.CrossRefPubMedGoogle Scholar
  39. 39.
    Habib G, Lancellotti P, Antunes MJ, et al. 2015 ESC guidelines for the management of infective endocarditis: the task force for the management of infective endocarditis of the European Society of Cardiology (ESC). Endorsed by: European Association for Cardio-Thoracic Surgery (EACTS), the European Association of Nuclear Medicine (EANM). Eur Heart J. 2015;36(44):3075–128.  https://doi.org/10.1093/eurheartj/ehv319.CrossRefGoogle Scholar
  40. 40.
    Wilson W, Taubert KA, Gewitz M, et al. Prevention of infective endocarditis: guidelines from the American Heart Association: a guideline from the American Heart Association Rheumatic Fever, Endocarditis and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular sSurgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group. J Am Dent Assoc. 2007;138(6):739–45, 47-60.CrossRefGoogle Scholar
  41. 41.
    • 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(22):2681–91.  https://doi.org/10.1016/j.jacc.2017.03.605 In 2017, Steinberg et al published a meta-analysis of 800 pregnancies in women with MHVs on 4 different anticoagulation regimens – VKA alone, LMWH alone, LMWH then VKA or UFH then VKA. The composite maternal was lowest with VKA alone and composite fetal risk was lowest with LMWH alone. However, when compared with low dose VKA (≤5 mg warfarin/day) the fetal risk in women on LMWH was no different.CrossRefPubMedPubMedCentralGoogle Scholar
  42. 42.
    De Santo LS, Romano G, Della Corte A, et al. Mechanical aortic valve replacement in young women planning on pregnancy: maternal and fetal outcomes under low oral anticoagulation, a pilot observational study on a comprehensive pre-operative counseling protocol. J Am Coll Cardiol. 2012;59(12):1110–5.  https://doi.org/10.1016/j.jacc.2011.10.899.CrossRefPubMedGoogle Scholar
  43. 43.
    Puskas J, Gerdisch M, Nichols D, et al. Reduced anticoagulation after mechanical aortic valve replacement: interim results from the prospective randomized on-X valve anticoagulation clinical trial randomized Food and Drug Administration investigational device exemption trial. J Thorac Cardiovasc Surg. 2014;147(4):1202–10; discussion 10–1.  https://doi.org/10.1016/j.jtcvs.2014.01.004.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  • Shivani R. Aggarwal
    • 1
    • 2
    Email author
  • Katherine E. Economy
    • 3
  • Anne M. Valente
    • 1
    • 2
  1. 1.Department of CardiologyBoston Children’s HospitalBostonUSA
  2. 2.Department of Medicine, Division of Cardiovascular MedicineBrigham and Women’s HospitalBostonUSA
  3. 3.Department of Obstetrics and Gynecology, Division of Maternal Fetal MedicineBrigham and Women’s HospitalBostonUSA

Personalised recommendations