Mechanical Heart Valves in Pregnancy

Study Questions:

What is the use and impact of the different anticoagulation regimes in women with a mechanical heart valve?

Methods:

Within the prospective, observational, contemporary, worldwide Registry Of Pregnancy And Cardiac disease (ROPAC), the investigators describe the pregnancy outcome of 212 patients with a mechanical heart valve (MHV). Univariable logistic regression analyses were used to assess associations between subgroups and outcome, followed by multivariable logistic regression to adjust for potential confounders.

Results:

The investigators compared 212 patients with a MHV to 134 patients with a tissue heart valve (THV) and 2,620 other patients without a prosthetic valve (NoPHV). Maternal mortality occurred in 1.4% of the MHV patients, in 1.5% of THV patients (p = 1.000), and in 0.2% of NoPHV patients (p = 0.025). Mechanical valve thrombosis complicated pregnancy in 10 (4.7%) MHV patients; in five of them the valve thrombosis occurred in the first trimester, and all five had been switched to some form of heparin. Hemorrhagic events occurred in 23.1% of MHV patients, in 5.1% of THV patients (p < 0.001), and in 4.9% of NoPHV patients (p < 0.001). Only 58% of the MHV patients had a pregnancy free of serious adverse events, versus 79% of THV patients (p < 0.001) and 78% of NoPHV patients (p < 0.001). Vitamin K antagonist use in the first trimester compared with heparin was associated with a higher rate of miscarriage (28.6% vs. 9.2%, p < 0.001) and late fetal death (7.1% vs. 0.7%, p = 0.016).

Conclusions:

The authors concluded that women with a MHV have only a 58% chance of experiencing an uncomplicated pregnancy with live birth.

Perspective:

This registry study reports that serious complications occurred in over 40% of pregnancies in women with a MHV, which is significantly higher compared to other groups of cardiac patients. Current anticoagulation regimes differ widely and, when considering the outcome for both mother and fetus, none is clearly superior. It would seem prudent that women with a MHV be counseled about the potential consequences of pregnancy and receive extensive guidance and care throughout pregnancy, delivery, and the postpartum period from a specialized multidisciplinary team.

Clinical Topics: Anticoagulation Management, Congenital Heart Disease and Pediatric Cardiology, Valvular Heart Disease, Congenital Heart Disease, CHD and Pediatrics and Prevention, CHD and Pediatrics and Quality Improvement

Keywords: Abortion, Spontaneous, Anticoagulants, Delivery, Obstetric, Fetal Death, Heart Defects, Congenital, Heart Valve Diseases, Heparin, Live Birth, Logistic Models, Maternal Mortality, Postpartum Period, Pregnancy Outcome, Registries, Thrombosis, Vitamin K


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