ARTIFICIAL VALVE PROSTHESIS

Management:

 the handling of anticoagulant therapy in pregnant women with prosthetic heart valves is controversial and should be managed
by specialists;
 vitamin K antagonists (VKAs) should be avoided between weeks 6 and 12 and from the middle of the third trimester until
delivery; ( Vitamin K antagonistsincrease the risk of embryopathy, whereasthe use of unfractionated heparin has
beenassociated with an increased thromboembolicrisk for the mother.)
 treatments with unfractionated heparin or low-molecular-weight heparin throughout pregnancy are optional, but need to be
monitored very closely by measurement of relevant coagulation parameters;
 the different treatment strategies, with all consequent risks and benefits, should be carefully discussed with any pregnant
woman before any final decision of therapeutic strategy is taken.

Diseases that may lead to artificial valve prosthesis

valvular heart disease

 aortic stenosis
 mitral stenosis
 aortic regurgitation or insufficiency
 mitral regurgitation or insufficiency
 mixed aortic stenosis and regurgitation
 mixed mitral stenosis and regurgitation
 mitral valve prolapsed
 aortic valve prolapsed

Prosthetic heart valves can be classified as mechanical or biological

 Mechanical valves are those that are manufactured entirely from man made materials; these valves typically have a tilting
disk or bileaflet design and are composed of carbon alloys.

 Biological valves are composed primarily of material that originated as living tissue, including porcine aortic valves, valves
manufactured from bovine pericardium, valves transplanted from other human beings (homografts), and autografts from
the patient.

Prosthetic heart valves are associated with a variety of complications:

 Structural deterioration, particularly with bioprosthetic valves

 Valve obstruction due to thrombosis or pannus formation
 Thromboembolism (the blockage of a blood vessel by a thrombus carried through the bloodstream from its site of
formation.)
 Bleeding
 Endocarditis and other infections
 ventricular systolic dysfunction, which may be preexisting
 Hemolytic anemia
 re-operation or death.

These affect patients at a rate of 5% per year over their lifetimes [1,2]. Prosthetic valve obstruction may be caused by
thrombus formation or pannus ingrowth, or a combination of both

These complications plus replacement of a prosthetic heart valve will be reviewed here. Issues related to the monitoring of patients
with prosthetic valves are discussed separately.

There are five main issues for managing and advising the healthy patient with a prosthetic heart valve:

 Antithrombotic therapy to prevent valve thrombosis and thromboembolism

 Evaluation of valve function
 Endocarditis prophylaxis
 Safety of exercise
 Pregnancy

Pregnancy outcome in women with cardiac valve prosthesis

Twenty-one pregnancies in 16 women who conceived after cardiac valve replacement were reviewed. Oral anticoagulants were
discontinued before conception or as soon as possible for subcutaneous heparin treatment (8000–14000 IU every 8–12 h) and
resumed in the second trimester until the last period of pregnancy when oral anticoagulants were replaced again by heparin. No
therapeutic abortion was performed. The spontaneous abortion rate was found to be 14.3% (3/21). Preterm delivery (<- 37 weeks)
and low birth weight babies (< 2500 g) were 29.4% (5/17) and 35.3% (6/17), respectively, significantly more frequent than those of
the control group (P < 0.02 and P < 0.0005). No significant statistical difference was found when the rate of spontaneous abortion
[14.3% (3/21)] and the rate of fetal growth retardation [11.8% (2/17)] were compared with the control group. The majority of
thromboembolic events (6/7) occurred during heparin regimen in three mothers; one of them subsequently died. No coumarin
embryopathy was observed and the physical and mental development in the 16 surviving children was good. This study confirms: (1)
the increased rate of preterm delivery and infants weighing < 2500 g; (2) the increased risk of maternal thrombosis related to
heparin use; and (3) the good follow-up in the surviving children.

Pregnancy increases the risk of each of the aforementioned complications. The risk of pregnancy in women with a valve prosthesis is
multifactorial. Potential problems may be related to an increased haemodynamic load, hypercoagulable state of pregnancy, and risk
to the fetus due to anticoagulants. It should be noted that significant changes in the levels of coagulation factors increase the risk of
thrombosis during gestation.

Pregnant patients with mechanical valve prostheses have an obligate need for anticoagulation. While some have suggested that
warfarin is an acceptable anticoagulant, most would advise avoidance, particularly in the first trimester, as warfarin is teratogenic
and crosses the placenta. Some others have advocated the use of warfarin throughout pregnancy, despite increased fetal
teratogenictiy, with the risk perhaps lessened if the warfarin dose is < 5 mg/day. Nonetheless this approach is still controversial,
despite the fact that the teratogenic effects of warfarin have been over-emphasized [10]. Heparin does not cross the placenta and is
generally considered safer. Its longer-term use, however, is complicated by sterile abscesses, osteoporosis, thrombocytopenia, and
ble-eding.

Management of pregnant women with mechanical heart valve prosthesis: thromboprophylaxis with low molecular weight
heparin.

INTRODUCTION: Pregnancy increases the risk of mechanical heart valve (MHV) thrombosis. Warfarin is protective, but implies risks
to the fetus. Unfractionated heparin (UFH) is less effective but does not harm the fetus. In general, anticoagulation is more stable
and predictable with low molecular weight heparin (LMWH) than with UFH. METHOD: Retrospective study of 12 pregnancies with
MHV; 6 in aortic, 4 in mitral, and 2 in both positions, treated with therapeutic doses of subcutaneous LMWH twice daily throughout
pregnancy. Doses were adjusted using anti-Xa monitoring. The frequency of thrombo-embolism with various anticoagulation
regimes was calculated based on a literature review. RESULTS: Median LMWH dose was 15500 IU/24 h, range 10000-20000 IU/24 h;
median dose 257 IU/kg/24 h. Median peak LMWH in blood plasma ranged 0.54-0.92 anti-Xa U/mL. Thromboembolism developed in
two women with aortic MHV despite LMWH levels in target range. One had systemic embolic episodes; in the other woman valve
thrombosis was successfully thrombolysed. Both had initially received subtherapeutic doses. Thrombo-embolism was not observed
in ten pregnancies treated as recommended. The pregnancies resulted in thirteen healthy babies; eight delivered by Cesarean
section. Bleeding occurred in two women after Cesarean section due to preeclampsia. CONCLUSION: Treatment with adjusted
therapeutic doses of LMWH was successful in 10 of 12 pregnancies, and was not associated with fetal complications.
Thromboembolism occurred in two pregnancies, possibly attributed to subtherapeutic doses of LMWH during the initial 3 weeks.
Compared to UFH prophylaxis, therapeutic doses of LMWH appears to be more efficacious.