Valvular Heart Disease and Pregnancy

  • Eric V. Krieger
  • Karen K. Stout


The population of women with valvular disease who are of childbearing age continues to increase. Many will want to become pregnant or may present already pregnant, and in some cases, underlying valve disease will complicate pregnancy, increasing the risk for adverse outcomes for the mother and fetus. This chapter discusses the hemodynamic changes of pregnancy and the implications for patients with valve disease. Focus is on the physiology and outcomes of pregnancy with specific valve lesions. There is a discussion of particular issues that may be relevant in these patients, such as anticoagulation for mechanical valves and cardiac surgery during pregnancy. Issues to be addressed during labor and delivery are described. Ideally, women with valvular disease will present prior to pregnancy, allowing for preconceptual counseling. Thus, strategies to assess risk include currently available risk scores that can aid in counseling, regardless of specific valve abnormality.


Pregnancy Valvular disease Aortic stenosis Mitral stenosis Mitral regurgitation Aortic regurgitation Tetralogy of Fallot Mechanical valves Pregnancy risk score 


  1. 1.
    Easterling TR, Benedetti TJ, Schmucker BC, Millard SP. Maternal hemodynamics in normal and preeclamptic pregnancies: a longitudinal study. Obstet Gynecol. 1990;76:1061–9.PubMedGoogle Scholar
  2. 2.
    Robson SC, Dunlop W, Hunter S. Haemodynamic changes during the early puerperium. Br Med J (Clin Res Ed). 1987;294:1065.CrossRefGoogle Scholar
  3. 3.
    Meijboom LJ, Drenthen W, Pieper PG, Groenink M, van der Post JA, Timmermans J, Voors AA, Roos-Hesselink JW, van Veldhuisen DJ, Mulder BJ. Obstetric complications in Marfan syndrome. Int J Cardiol. 2006;110(1):53–9.PubMedCrossRefGoogle Scholar
  4. 4.
    Donnelly RT, Pinto NM, Kocolas I, Yetman AT. The immediate and long-term impact of pregnancy on aortic growth rate and mortality in women with Marfan syndrome. J Am Coll Cardiol. 2012;60:224–9.PubMedCrossRefGoogle Scholar
  5. 5.
    Mishra M, Chambers JB, Jackson G. Murmurs in pregnancy: an audit of echocardiography. BMJ. 1992;304:1413–4.PubMedCrossRefGoogle Scholar
  6. 6.
    Hunter S, Robson SC. Adaptation of the maternal heart in pregnancy. Br Heart J. 1992;68:540–3.PubMedCrossRefGoogle Scholar
  7. 7.
    Otto CM. The practice of clinical echocardiography. Philadelphia: Saunders/Elsevier; 2007.Google Scholar
  8. 8.
    Silversides CK, Colman JM, Sermer M, Farine D, Siu SC. Early and intermediate-term outcomes of pregnancy with congenital aortic stenosis. Am J Cardiol. 2003;91:1386–9.PubMedCrossRefGoogle Scholar
  9. 9.
    Grossman W, McLaurin LP. Diastolic properties of the left ventricle. Ann Intern Med. 1976;84:316–26.PubMedCrossRefGoogle Scholar
  10. 10.
    Hameed A, Karaalp IS, Tummala PP, Wani OR, Canetti M, Akhter MW, Goodwin I, Zapadinsky N, Elkayam U. The effect of valvular heart disease on maternal and fetal outcome of pregnancy. J Am Coll Cardiol. 2001;37:893–9.PubMedCrossRefGoogle Scholar
  11. 11.
    Arias F, Pineda J. Aortic stenosis and pregnancy. J Reprod Med. 1978;20:229–32.PubMedGoogle Scholar
  12. 12.
    Bonow RO, Carabello BA, Chatterjee K, de Leon Jr AC, Faxon DP, Freed MD, Gaasch WH, Lytle BW, Nishimura RA, O’Gara PT, O’Rourke RA, Otto CM, Shah PM, Shanewise JS. 2008 focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (writing committee to revise the 1998 guidelines for the management of patients with valvular heart disease). Endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. J Am Coll Cardiol. 2008;52:e1–142.PubMedCrossRefGoogle Scholar
  13. 13.
    Khairy P, Ouyang DW, Fernandes SM, Lee-Parritz A, Economy KE, Landzberg MJ. Pregnancy outcomes in women with congenital heart disease. Circulation. 2006;113:517–24.PubMedCrossRefGoogle Scholar
  14. 14.
    Drenthen W, Pieper PG, Roos-Hesselink JW, van Lottum WA, Voors AA, Mulder BJ, van Dijk AP, Vliegen HW, Yap SC, Moons P, Ebels T, van Veldhuisen DJ. Outcome of pregnancy in women with congenital heart disease: a literature review. J Am Coll Cardiol. 2007;49:2303–11.PubMedCrossRefGoogle Scholar
  15. 15.
    Yap SC, Drenthen W, Pieper PG, Moons P, Mulder BJ, Mostert B, Vliegen HW, van Dijk AP, Meijboom FJ, Steegers EA, Roos-Hesselink JW. Risk of complications during pregnancy in women with congenital aortic stenosis. Int J Cardiol. 2008;126:240–6.PubMedCrossRefGoogle Scholar
  16. 16.
    Drenthen W, Boersma E, Balci A, Moons P, Roos-Hesselink JW, Mulder BJ, Vliegen HW, van Dijk AP, Voors AA, Yap SC, van Veldhuisen DJ, Pieper PG. Predictors of pregnancy complications in women with congenital heart disease. Eur Heart J. 2010;31:2124–32.PubMedCrossRefGoogle Scholar
  17. 17.
    Siu SC, Sermer M, Colman JM, Alvarez AN, Mercier LA, Morton BC, Kells CM, Bergin ML, Kiess MC, Marcotte F, Taylor DA, Gordon EP, Spears JC, Tam JW, Amankwah KS, Smallhorn JF, Farine D, Sorensen S. Prospective multicenter study of pregnancy outcomes in women with heart disease. Circulation. 2001;104:515–21.PubMedCrossRefGoogle Scholar
  18. 18.
    Tzemos N, Silversides CK, Colman JM, Therrien J, Webb GD, Mason J, Cocoara E, Sermer M, Siu SC. Late cardiac outcomes after pregnancy in women with congenital aortic stenosis. Am Heart J. 2009;157:474–80.PubMedCrossRefGoogle Scholar
  19. 19.
    Tzemos N, Silversides CK, Carasso S, Rakowski H, Siu SC. Effect of pregnancy on left ventricular motion (twist) in women with aortic stenosis. Am J Cardiol. 2008;101:870–3.PubMedCrossRefGoogle Scholar
  20. 20.
    Immer FF, Bansi AG, Immer-Bansi AS, McDougall J, Zehr KJ, Schaff HV, Carrel TP. Aortic dissection in pregnancy: analysis of risk factors and outcome. Ann Thorac Surg. 2003;76:309–14.PubMedCrossRefGoogle Scholar
  21. 21.
    McKellar SH, MacDonald RJ, Michelena HI, Connolly HM, Sundt 3rd TM. Frequency of cardiovascular events in women with a congenitally bicuspid aortic valve in a single community and effect of pregnancy on events. Am J Cardiol. 2011;107:96–9.PubMedCrossRefGoogle Scholar
  22. 22.
    Oskoui R, Lindsay Jr J. Aortic dissection in women <40years of age and the unimportance of pregnancy. Am J Cardiol. 1994;73:821–3.PubMedCrossRefGoogle Scholar
  23. 23.
    Lewin MB, Otto CM. The bicuspid aortic valve: adverse outcomes from infancy to old age. Circulation. 2005;111:832–4.PubMedCrossRefGoogle Scholar
  24. 24.
    Garg V. Molecular genetics of aortic valve disease. Curr Opin Cardiol. 2006;21:180–4.PubMedCrossRefGoogle Scholar
  25. 25.
    Gerber IL, Stewart RA, Legget ME, West TM, French RL, Sutton TM, Yandle TG, French JK, Richards AM, White HD. Increased plasma natriuretic peptide levels reflect symptom onset in aortic stenosis. Circulation. 2003;107:1884–90.PubMedCrossRefGoogle Scholar
  26. 26.
    Lim P, Monin JL, Monchi M, Garot J, Pasquet A, Hittinger L, Vanoverschelde JL, Carayon A, Gueret P. Predictors of outcome in patients with severe aortic stenosis and normal left ventricular function: role of B-type natriuretic peptide. Eur Heart J. 2004;25:2048–53.PubMedCrossRefGoogle Scholar
  27. 27.
    Patel S, Grayburn PA, High ST, Rosnes J, Choi JW. Usefulness of serial brain natriuretic peptide measurements for managing aortic valve stenosis in pregnancy. Proc (Bayl Univ Med Cent). 2009;22:226–9.Google Scholar
  28. 28.
    Resnik JL, Hong C, Resnik R, Kazanegra R, Beede J, Bhalla V, Maisel A. Evaluation of B-type natriuretic peptide (BNP) levels in normal and preeclamptic women. Am J Obstet Gynecol. 2005;193:450–4.PubMedCrossRefGoogle Scholar
  29. 29.
    Lao TT, Adelman AG, Sermer M, Colman JM. Balloon valvuloplasty for congenital aortic stenosis in pregnancy. Br J Obstet Gynaecol. 1993;100:1141–2.PubMedCrossRefGoogle Scholar
  30. 30.
    Myerson SG, Mitchell AR, Ormerod OJ, Banning AP. What is the role of balloon dilatation for severe aortic stenosis during pregnancy? J Heart Valve Dis. 2005;14:147–50.PubMedGoogle Scholar
  31. 31.
    John AS, Gurley F, Schaff HV, Warnes CA, Phillips SD, Arendt KW, Abel MD, Rose CH, Connolly HM. Cardiopulmonary bypass during pregnancy. Ann Thorac Surg. 2011;91:1191–6.PubMedCrossRefGoogle Scholar
  32. 32.
    Edouard DA, Pannier BM, London GM, Cuche JL, Safar ME. Venous and arterial behavior during normal pregnancy. Am J Physiol. 1998;274:H1605–12.PubMedGoogle Scholar
  33. 33.
    Marcus FI, Ewy GA, O’Rourke RA, Walsh B, Bleich AC. The effect of pregnancy on the murmurs of mitral and aortic regurgitation. Circulation. 1970;41:795–805.PubMedCrossRefGoogle Scholar
  34. 34.
    Lesniak-Sobelga A, Tracz W, KostKiewicz M, Podolec P, Pasowicz M. Clinical and echocardiographic assessment of pregnant women with valvular heart diseases – maternal and fetal outcome. Int J Cardiol. 2004;94:15–23.PubMedCrossRefGoogle Scholar
  35. 35.
    Walters BNJ, Redman CWG. Treatment of severe pregnancy-associated hypertension with the calcium-antagonist nifedipine. Br J Obstet Gynaecol. 1984;91:330–6.PubMedCrossRefGoogle Scholar
  36. 36.
    Silversides CK, Colman JM, Sermer M, Siu SC. Cardiac risk in pregnant women with rheumatic mitral stenosis. Am J Cardiol. 2003;91:1382–5.PubMedCrossRefGoogle Scholar
  37. 37.
    Chadha DS, Karthikeyan G, Goel K, Malani SK, Seth S, Singh S, Dhall A, Bhargava B. N-terminal pro-BNP plasma levels before and after percutaneous transvenous mitral commissurotomy for mitral stenosis. Int J Cardiol. 2010;144:238–40.PubMedCrossRefGoogle Scholar
  38. 38.
    Iltumur K, Karabulut A, Yokus B, Yavuzkir M, Taskesen T, Toprak N. N-terminal proBNP plasma levels correlate with severity of mitral stenosis. J Heart Valve Dis. 2005;14:735–41.PubMedGoogle Scholar
  39. 39.
    Hameed AB, Chan K, Ghamsary M, Elkayam U. Longitudinal changes in the b-type natriuretic peptide levels in normal pregnancy and postpartum. Clin Cardiol. 2009;32:E60–2.PubMedCrossRefGoogle Scholar
  40. 40.
    Tanous D, Siu SC, Mason J, Greutmann M, Wald RM, Parker JD, Sermer M, Colman JM, Silversides CK. B-type natriuretic peptide in pregnant women with heart disease. J Am Coll Cardiol. 2010;56:1247–53.PubMedCrossRefGoogle Scholar
  41. 41.
    Wadelius M, Darj E, Frenne G, Rane A. Induction of cyp2d6 in pregnancy. Clin Pharmacol Ther. 1997;62:400–7.PubMedCrossRefGoogle Scholar
  42. 42.
    Esteves CA, Munoz JS, Braga S, Andrade J, Meneghelo Z, Gomes N, Maldonado M, Esteves V, Sepetiba R, Sousa JE, Palacios IF. Immediate and long-term follow-up of percutaneous balloon mitral valvuloplasty in pregnant patients with rheumatic mitral stenosis. Am J Cardiol. 2006;98:812–6.PubMedCrossRefGoogle Scholar
  43. 43.
    Zipes DP, Braunwald E. Braunwald’s heart disease : a textbook of cardiovascular medicine. Philadelphia: W.B. Saunders; 2005.Google Scholar
  44. 44.
    Hameed AB, Mehra A, Rahimtoola SH. The role of catheter balloon commissurotomy for severe mitral stenosis in pregnancy. Obstet Gynecol. 2009;114:1336–40.PubMedCrossRefGoogle Scholar
  45. 45.
    Ben Farhat M, Gamra H, Betbout F, Maatouk F, Jarrar M, Addad F, Tiss M, Hammami S, Chahbani I, Thaalbi R. Percutaneous balloon mitral commissurotomy during pregnancy. Heart. 1997;77:564–7.PubMedGoogle Scholar
  46. 46.
    Avila WS, Gouveia AM, Pomerantzeff P, Bortolotto MR, Grinberg M, Stolf N, Zugaib M. Maternal-fetal outcome and prognosis of cardiac surgery during pregnancy. Arq Bras Cardiol. 2009;93:9–14.PubMedGoogle Scholar
  47. 47.
    Greutmann M, Von Klemperer K, Brooks R, Peebles D, O’Brien P, Walker F. Pregnancy outcome in women with congenital heart disease and residual haemodynamic lesions of the right ventricular outflow tract. Eur Heart J. 2010;31:1764–70.PubMedCrossRefGoogle Scholar
  48. 48.
    Veldtman GR, Connolly HM, Grogan M, Ammash NM, Warnes CA. Outcomes of pregnancy in women with tetralogy of Fallot. J Am Coll Cardiol. 2004;44:174–80.PubMedCrossRefGoogle Scholar
  49. 49.
    Meijer JM, Pieper PG, Drenthen W, Voors AA, Roos-Hesselink JW, van Dijk AP, Mulder BJ, Ebels T, van Veldhuisen DJ. Pregnancy, fertility, and recurrence risk in corrected tetralogy of Fallot. Heart. 2005;91:801–5.PubMedCrossRefGoogle Scholar
  50. 50.
    Beauchesne LM, Warnes CA, Connolly HM, Ammash NM, Grogan M, Jalal SM, Michels VV. Prevalence and clinical manifestations of 22q11.2 microdeletion in adults with selected conotruncal anomalies. J Am Coll Cardiol. 2005;45:595–8.PubMedCrossRefGoogle Scholar
  51. 51.
    Rauch R, Hofbeck M, Zweier C, Koch A, Zink S, Trautmann U, Hoyer J, Kaulitz R, Singer H, Rauch A. Comprehensive genotype-phenotype analysis in 230 patients with tetralogy of Fallot. J Med Genet. 2010;47:321–31.PubMedCrossRefGoogle Scholar
  52. 52.
    Warnes CA, Williams RG, Bashore TM, Child JS, Connolly HM, Dearani JA, del Nido P, Fasules JW, Graham Jr TP, Hijazi ZM, Hunt SA, King ME, Landzberg MJ, Miner PD, Radford MJ, Walsh EP, Webb GD, Smith Jr SC, Jacobs AK, Adams CD, Anderson JL, Antman EM, Buller CE, Creager MA, Ettinger SM, Halperin JL, Krumholz HM, Kushner FG, Lytle BW, Nishimura RA, Page RL, Riegel B, Tarkington LG, Yancy CW. ACC/AHA 2008 guidelines for the management of adults with congenital heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (writing committee to develop guidelines on the management of adults with congenital heart disease). Developed in collaboration with the American Society of Echocardiography, Heart Rhythm Society, International Society for Adult Congenital Heart Disease, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. J Am Coll Cardiol. 2008;52:e143–263.PubMedCrossRefGoogle Scholar
  53. 53.
    Oosterhof T, Tulevski II, Vliegen HW, Spijkerboer AM, Mulder BJ. Effects of volume and/or pressure overload secondary to congenital heart disease (tetralogy of Fallot or pulmonary stenosis) on right ventricular function using cardiovascular magnetic resonance and B-type natriuretic peptide levels. Am J Cardiol. 2006;97:1051–5.PubMedCrossRefGoogle Scholar
  54. 54.
    Drenthen W, Pieper PG, Roos-Hesselink JW, Schmidt AC, Mulder BJ, van Dijk AP, Vliegen HW, Sollie KM, Voors AA, Ebels T, van Veldhuisen DJ. Non-cardiac complications during pregnancy in women with isolated congenital pulmonary valvar stenosis. Heart. 2006;92:1838–43.PubMedCrossRefGoogle Scholar
  55. 55.
    Driscoll DJ, Michels VV, Gersony WM, Hayes CJ, Keane JF, Kidd L, Pieroni DR, Rings LJ, Wolfe RR, Weidman WH. Occurrence risk for congenital heart defects in relatives of patients with aortic stenosis, pulmonary stenosis, or ventricular septal defect. Circulation. 1993;87:I114–20.PubMedGoogle Scholar
  56. 56.
    Curtis SL, Marsden-Williams J, Sullivan C, Sellers SM, Trinder J, Scrutton M, Stuart AG. Current trends in the management of heart disease in pregnancy. Int J Cardiol. 2009;133:62–9.PubMedCrossRefGoogle Scholar
  57. 57.
    North RA, Sadler L, Stewart AW, McCowan LM, Kerr AR, White HD. Long-term survival and valve-related complications in young women with cardiac valve replacements. Circulation. 1999;99:2669–76.PubMedCrossRefGoogle Scholar
  58. 58.
    Yun KL, Craig Miller D, Moore KA, Scott Mitchell R, Oyer PE, Stinson EB, Robbins RC, Reitz BA, Shumway NE. Durability of the Hancock MO bioprosthesis compared with standard aortic valve bioprostheses. Ann Thorac Surg. 1995;60 Suppl 2:S221–8.PubMedCrossRefGoogle Scholar
  59. 59.
    Elkayam U, Bitar F. Valvular heart disease and pregnancy: part II: prosthetic valves. J Am Coll Cardiol. 2005;46:403–10.PubMedCrossRefGoogle Scholar
  60. 60.
    Jeejeebhoy FM. Prosthetic heart valves and management during pregnancy. Can Fam Physician. 2009;55:155–7.PubMedGoogle Scholar
  61. 61.
    Jamieson WR, Rosado LJ, Munro AI, Gerein AN, Burr LH, Miyagishima RT, Janusz MT, Tyers GF. Carpentier-Edwards standard porcine bioprosthesis: primary tissue failure (structural valve deterioration) by age groups. Ann Thorac Surg. 1988;46:155–62.PubMedCrossRefGoogle Scholar
  62. 62.
    Bach DS, Metras J, Doty JR, Yun KL, Dumesnil JG, Kon ND. Freedom from structural valve deterioration among patients aged < or = 60 years undergoing freestyle stentless aortic valve replacement. J Heart Valve Dis. 2007;16:649–55; discussion 656.PubMedGoogle Scholar
  63. 63.
    El Oakley R, Kleine P, Bach DS. Choice of prosthetic heart valve in today’s practice. Circulation. 2008;117:253–6.PubMedCrossRefGoogle Scholar
  64. 64.
    Gao G, Wu Y, Grunkemeier GL, Furnary AP, Starr A. Durability of pericardial versus porcine aortic valves. J Am Coll Cardiol. 2004;44:384–8.PubMedCrossRefGoogle Scholar
  65. 65.
    David TE. Ross procedure at the crossroads. Circulation. 2009;119:207–9.PubMedCrossRefGoogle Scholar
  66. 66.
    Bortolotti U, Milano A, Mazzucco A, Valfre C, Russo R, Valente M, Schivazappa L, Thiene G, Gallucci V. Pregnancy in patients with a porcine valve bioprosthesis. Am J Cardiol. 1982;50:1051–4.PubMedCrossRefGoogle Scholar
  67. 67.
    Badduke BR, Jamieson WR, Miyagishima RT, Munro AI, Gerein AN, MacNab J, Tyers GF. Pregnancy and childbearing in a population with biologic valvular prostheses. J Thorac Cardiovasc Surg. 1991;102:179–86.PubMedGoogle Scholar
  68. 68.
    Hanania G, Thomas D, Michel PL, Garbarz E, Age C, Millaire A, Acar J. Pregnancy and prosthetic heart valves: a French cooperative retrospective study of 155 cases. Eur Heart J. 1994;15:1651–8.PubMedGoogle Scholar
  69. 69.
    Cleuziou J, Horer J, Kaemmerer H, Teodorowicz A, Kasnar-Samprec J, Schreiber C, Lange R. Pregnancy does not accelerate biological valve degeneration. Int J Cardiol. 2010;145:418–21.PubMedCrossRefGoogle Scholar
  70. 70.
    Avila WS, Rossi EG, Grinberg M, Ramires JA. Influence of pregnancy after bioprosthetic valve replacement in young women: a prospective five-year study. J Heart Valve Dis. 2002;11:864–9.PubMedGoogle Scholar
  71. 71.
    Abildgaard U, Sandset PM, Hammerstrom J, Gjestvang FT, Tveit A. Management of pregnant women with mechanical heart valve prosthesis: thromboprophylaxis with low molecular weight heparin. Thromb Res. 2009;124:262–7.PubMedCrossRefGoogle Scholar
  72. 72.
    Vural KM, Ozatik MA, Uncu H, Emir M, Yurdagok O, Sener E, Tasdemir O. Pregnancy after mechanical mitral valve replacement. J Heart Valve Dis. 2003;12:370–6.PubMedGoogle Scholar
  73. 73.
    Salazar E, Izaguirre R, Verdejo J, Mutchinick O. Failure of adjusted doses of subcutaneous heparin to prevent thromboembolic phenomena in pregnant patients with mechanical cardiac valve prostheses. J Am Coll Cardiol. 1996;27:1698–703.PubMedCrossRefGoogle Scholar
  74. 74.
    Chan WS, Anand S, Ginsberg JS. Anticoagulation of pregnant women with mechanical heart valves: a systematic review of the literature. Arch Intern Med. 2000;160:191–6.PubMedCrossRefGoogle Scholar
  75. 75.
    Curtis SL, Trinder J, Stuart AG. Acute thrombosis of a prosthetic mitral valve in pregnancy in spite of adjusted-dose low-molecular-weight heparin and aspirin. J Heart Valve Dis. 2008;17:133–4.PubMedGoogle Scholar
  76. 76.
    McLintock C, McCowan LM, North RA. Maternal complications and pregnancy outcome in women with mechanical prosthetic heart valves treated with enoxaparin. BJOG. 2009;116:1585–92.PubMedCrossRefGoogle Scholar
  77. 77.
    Sillesen M, Hjortdal V, Vejlstrup N, Sorensen K. Pregnancy with prosthetic heart valves – 30 years’ nationwide experience in Denmark. Eur J Cardiothorac Surg. 2011;40:448–54.PubMedGoogle Scholar
  78. 78.
    Bates SM, Greer IA, Middeldorp S, Veenstra DL, Prabulos AM, Vandvik PO. VTE, thrombophilia, antithrombotic therapy, and pregnancy: antithrombotic therapy and prevention of thrombosis, 9th ed: American college of chest physicians evidence-based clinical practice guidelines. Chest. 2012;141:e691S–736.PubMedCrossRefGoogle Scholar
  79. 79.
    Bian C, Wei Q, Liu X. Influence of heart-valve replacement of warfarin anticoagulant therapy on perinatal outcomes. Arch Gynecol Obstet. 2012;285(2):347–51.PubMedCrossRefGoogle Scholar
  80. 80.
    Frewin R, Chisholm M. Anticoagulation of women with prosthetic heart valves during pregnancy. Br J Obstet Gynaecol. 1998;105:683–6.PubMedCrossRefGoogle Scholar
  81. 81.
    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;33:1637–41.PubMedCrossRefGoogle Scholar
  82. 82.
    Farquharson RG, Quenby S, Greaves M. Antiphospholipid syndrome in pregnancy: a randomized, controlled trial of treatment. Obstet Gynecol. 2002;100:408–13.PubMedCrossRefGoogle Scholar
  83. 83.
    Oran B, Lee-Parritz A, Ansell J. Low molecular weight heparin for the prophylaxis of thromboembolism in women with prosthetic mechanical heart valves during pregnancy. Thromb Haemost. 2004;92:747–51.PubMedGoogle Scholar
  84. 84.
    Barbour LA, Oja JL, Schultz LK. A prospective trial that demonstrates that dalteparin requirements increase in pregnancy to maintain therapeutic levels of anticoagulation. Am J Obstet Gynecol. 2004;191:1024–9.PubMedCrossRefGoogle Scholar
  85. 85.
    Caceres-Loriga FM, Perez-Lopez H, Morlans-Hernandez K, Facundo-Sanchez H, Santos-Gracia J, Valiente-Mustelier J, Rodiles-Aldana F, Marrero-Mirayaga MA, Betancourt BY, Lopez-Saura P. Thrombolysis as first choice therapy in prosthetic heart valve thrombosis. A study of 68 patients. J Thromb Thrombolysis. 2006;21:185–90.PubMedCrossRefGoogle Scholar
  86. 86.
    Lengyel M. Thrombolysis should be regarded as first-line therapy for prosthetic valve thrombosis in the absence of contraindications. J Am Coll Cardiol. 2005;45:325; author reply 326.PubMedCrossRefGoogle Scholar
  87. 87.
    Tong AT, Roudaut R, Ozkan M, Sagie A, Shahid MS, Pontes Junior SC, Carreras F, Girard SE, Arnaout S, Stainback RF, Thadhani R, Zoghbi WA. Transesophageal echocardiography improves risk assessment of thrombolysis of prosthetic valve thrombosis: results of the international pro-tee registry. J Am Coll Cardiol. 2004;43:77–84.PubMedCrossRefGoogle Scholar
  88. 88.
    Turrentine MA, Braems G, Ramirez MM. Use of thrombolytics for the treatment of thromboembolic disease during pregnancy. Obstet Gynecol Surv. 1995;50:534–41.PubMedCrossRefGoogle Scholar
  89. 89.
    Weiss BM, von Segesser LK, Alon E, Seifert B, Turina MI. Outcome of cardiovascular surgery and pregnancy: a systematic review of the period 1984–1996. Am J Obstet Gynecol. 1998;179:1643–53.PubMedCrossRefGoogle Scholar
  90. 90.
    Arnoni RT, Arnoni AS, Bonini RC, de Almeida AF, Neto CA, Dinkhuysen JJ, Issa M, Chaccur P, Paulista PP. Risk factors associated with cardiac surgery during pregnancy. Ann Thorac Surg. 2003;76:1605–8.PubMedCrossRefGoogle Scholar
  91. 91.
    Robertson JE, Silversides CK, Mah ML, Kulikowski J, Maxwell C, Wald RM, Colman JM, Siu SC, Sermer M. A contemporary approach to the obstetric management of women with heart disease. J Obstet Gynaecol Can. 2012;34:812–9.PubMedGoogle Scholar

Copyright information

© Springer-Verlag London 2014

Authors and Affiliations

  1. 1.Division of Cardiology, Department of Medicine and PediatricsUniversity of Washington/University of Washington Medical Center and Seattle Children’s HospitalSeattleUSA

Personalised recommendations