Patients with mechanical heart valves require lifelong anticoagulation to prevent thromboembolic complications. Pregnancy induces a hypercoagulable state, increasing the risk of those events. Although guidelines recommend anticoagulation with vitamin K antagonists (VKA), recent practice involves replacing VKA with low-molecular weight heparin (LMWH) to reduce fetal complications with an increase in maternal complications. This study aims to analyze outcomes in pregnant patients with mechanical heart valves anticoagulated with VKA or LMWH.

This was a retrospective case series of pregnant patients with mechanical heart valves referred to our tertiary care center from 2008 to 2024. Primary maternal outcomes were mortality and thromboembolic complications. Secondary outcomes were antepartum bleeding, cardiac events (arrhythmias, heart failure, non-thrombotic valvular dysfunction), postpartum hemorrhage. Fetal outcomes included live births and anticoagulant-related fetal anomalies, fetal intracranial bleeding, small for gestational age.

Among the eleven patients included based on chart review, four (36 %) received VKA peri-conceptionally and LMWH during pregnancy, three (27 %) received VKA throughout pregnancy, three (27 %) started LMWH preconceptionally and one (9 %) received LMWH in the first trimester and switched to VKA at 14 weeks (sequential regimen). Thromboembolic complications occurred in two patients receiving LMWH: one experienced valvular thrombosis and one non-valvular thrombosis. Seven pregnancies resulted in live births, three in termination of pregnancy and one ended in missed abortion. One fetal subdural hematoma occurred in a patient on sequential therapy at 26 weeks of pregnancy. No other major fetal anomalies related to anticoagulants were reported.

Our findings align with existing literature, indicating a higher incidence of maternal complications in women with mechanical heart valves receiving LMWH. Limited data on patients treated with VKA during pregnancy preclude definitive conclusions regarding its safety.

Accurate information on pregnancy outcomes in women with prosthetic heart valves (PHVs) is essential for preconception counseling and prenatal care. This study aims to determine the maternal and fetal outcomes in women with PHVs. A total of 138 pregnant women with PHVs admitted into a tertiary center between November 2007 and February 2020 were included in the study, and the data were analyzed retrospectively. Patients were divided into the mechanical heart valves (MHVs) group, 118 patients with MHVs, and the tissue heart valves (THVs) group, 20 patients with THVs. The 2 groups were compared. There was 1 maternal death in the MHV group patients (0.8%). There was no difference between the 2 groups regarding maternal mortality (P = 1.000), valve thrombosis (P = .376), and hemorrhagic events (P = .692). Only 66.9% of patients in the MHV group had a live birth compared to the live birth rate of 100% in the THV (P  = .002). Mechanical valve thrombosis (MVT) occurred in 3.2% of patients who used warfarin only; no MVT occurred in patients using a regimen called "sequential therapy", which utilizes low-molecular-weight heparin (LMWH) during the 1st trimester and warfarin during the 2nd and 3rd trimesters. MVT occurred in 33.3% of patients using LMWH throughout gestation (P < .001). The difference was statistically significant. Compared to patients using other regimens, the patients using the regimen of "warfarin only " was correlated with the highest rate of miscarriage (38.1%, 3.4%, and 16.7%, P < .001). Women with MHVs have a lower rate of live birth. The anticoagulation regimen of "sequential therapy" was superior to other regimens in terms of the weighted effects of regimens on maternal MVTs and fetal loss.

Heart valve replacement in children is fraught with long-term morbidity and mortality rates, largely because conventional implants lack the capacity to grow with the child. Partial heart transplantation presents a potential solution by transplanting only specific segments of a donor heart, thereby providing a living and growing heart valve implant. This approach harnesses the full spectrum of cardiac tissues, which, when freshly procured and supported by immunosuppression, can integrate as functional and potentially growth-capable tissue. This state-of-the-art review discusses the history and development of partial heart transplantation, its indications, recent clinical experiences, regulation, and future directions.

Pregnancy in women with a prosthetic heart valve is considered high risk, primarily due to the need for effective anticoagulation. However, data on the relationship between anticoagulation practices and pregnancy outcomes are very limited.

The Registry of Pregnancy and Cardiac disease is a global registry that prospectively enrolled pregnancies in women with a prosthetic heart valve between January 2018 and April 2023. Detailed data on anticoagulation, including dosage and monitoring, and cardiovascular, pregnancy, and perinatal outcomes were collected.

In total, 613 pregnancies were included of which 411 pregnancies were in women with a mechanical valve and 202 were in women with a biological valve. The chance of an uncomplicated pregnancy with a live birth in women with a mechanical valve was 54%, compared with 79% in women with a biological valve (P < .001). Thromboembolic and haemorrhagic complications most frequently occurred when low-molecular weight heparin (LMWH)-based regimens were used. Valve thrombosis occurred in 24 (6%) women, and a prosthetic valve in mitral position was associated with valve thrombosis (odds ratio 3.3; 95% confidence interval 1.9-8.0). A thromboembolic event occurred in 12 (10%) women with anti-Xa monitoring and in 9 (21%) women without (P = .060). Foetal death occurred in 20% of all pregnancies.

More favourable outcomes were found in women with a biological valve compared with a mechanical valve. In women with a mechanical valve, the use of LMWH was associated with an increased risk of thromboembolic complications. A mitral prosthetic valve was identified as a predictor for valve thrombosis. The benefit could not be confirmed nor refuted, in terms of reduced thromboembolic events, from using anti-Xa level monitoring in women on LMWH.

Anticoagulant therapy prevents thrombosis and thromboembolic events in patients with mechanical heart valves. Bridging anticoagulation around the time of birth represents a unique challenge. Few retrospective reviews or case series exist examining peripartum outcomes with bridging anticoagulation.

Review of peripartum and postpartum anticoagulation management, with a focus on postpartum complications.

Design: case series, single centre.

Royal Brisbane and Women's Hospital, Australia between 1 January, 2000, and 1 August, 2022.

all pregnant women with mechanical heart valves (any type) who birthed.

intrapartum and postpartum haemorrhage, thrombosis, thromboembolic complications, cardiac events, readmission, and maternal death.

There were 18 women, with 23 births. Sixteen births were via caesarean section (70%). Fourteen women (61%) experienced at least one significant haemorrhagic complication, one woman required a peripartum hysterectomy, one woman experienced atrial fibrillation, and one had a valvular thromboembolic complication. No maternal cerebral thromboses or maternal deaths were recorded.

Women with mechanical heart valves who undergo bridging anticoagulation are associated with significant maternal morbidity. Most postpartum haemorrhagic complications were associated with bridging unfractionated heparin infusions in the first postnatal week. Bridging anticoagulation practices varied widely. Ongoing pooled data are required to inform evidence-based guidelines for postpartum anticoagulation management.

Managing pregnancies in patients with prosthetic heart valves presents challenges including recurrent arrhythmia, bleeding, thrombosis, and infection. We present a woman with valvular heart disease and paroxysmal atrial arrhythmias who died after pregnancy and examine how Maternal Mortality Review Committees address areas to improve maternal outcomes.

The aim of the present study was to review maternal and fetal outcomes in pregnant women with prosthetic heart valves.

A retrospective record review of pregnant women with prosthetic heart valves on anticoagulation was performed at the Specialist Cardiac Antenatal Clinic, Johannesburg South Africa from 2015 to 2023.

Fifty pregnancies with mechanical heart valves and three with tissue valves, on anticoagulation for comorbid atrial fibrillation were identified. The majority were of African ethnicity at a mean age of 33 ± 6 years. Anti-Xa adjusted enoxaparin was commenced at 10.5 ± 5.6 weeks' gestation until delivery in 48 (90.6%) pregnancies and warfarin was continued in five (9.4%) pregnancies. The live birth rates on enoxaparin and warfarin were 56.3% (95% confidence interval [CI]: 42.3-69.3) and 20.0% (95% CI: 2.0-64.0), respectively. There were 12 (22.6%) miscarriages at a mean of 11.3 ± 3.7 weeks' gestation, four (7.5%) intrauterine fetal deaths on warfarin and two (3.8%) warfarin embryopathy/fetopathy. The rates of antepartum/secondary postpartum bleeding and primary postpartum bleeding were 29.4% (95% CI: 18.6-43.1) and 5.9% (95% CI: 1.4-16.9), respectively. Maternal complications included anemia (n = 11, 20.8%), arrhythmia (n = 2, 3.8%), heart failure (n = 2, 3.8%) and paravalvular leak (n = 2, 3.8%). There was one (1.9%) mitral valve thrombosis and one (1.9%) stuck valve in pregnancies who defaulted warfarin prior to pregnancy. There were no maternal deaths.

Multidisciplinary management of pregnant women with prosthetic heart valves with anti-Xa adjusted low molecular weight heparin throughout pregnancy represents an effective anticoagulation option for low-middle-income countries.

The choice of valve prosthesis in women planning a pregnancy is still controversial. The durability of biological prostheses and the characteristic thrombogenic of mechanical prostheses are limitations to the pregnancy's successful Objectives: To study the pregnancy success rate after valve prosthesis implantation, and identify the variables related to maternal outcomes.

Prospective study with 78 pregnant women with bovine pericardial prosthesis (Group BP) and 50 with a mechanical prosthesis (Group MP), who received prior guidance on the risks of pregnancy. The pregnancy success rate was considered in the absence of complications cardiac, obstetric and/or fetal complications.

Successful pregnancy was achieved in 64 (50.0%) patients, not differing between groups (BP 56.4% vs MP 40.0% - p=0.103). The BP group had a higher cardiac events rate and prosthesis dysfunction (43.6% vs 16.0% p<0.001; 26.9% vs 2.0% p<0.001). The frequency of fetal losses (14.1% vs 24.0% p=0.165) and obstetric complications (28.2% vs 42% p=0.127) were not different between the BP and MP groups. The pre-existence of heart failure (odds ratio 8.5; 95% CI [1.4; 50.7]; p=0.019), atrial fibrillation (odds ratio 16.7; 95% CI [5.7; 49 .1]; p<0.001) and dysfunction of the biological prosthesis (odds ratio 12.6; 95% CI [3.0; 52.7]; p=0.001) were the variables predicting complications and/or deaths.

Patients with valve prostheses had low maternal-fetal success due to the complicating factors of valve disease, the limited structural survival of biological prostheses and the lack of anticoagulants to guarantee pregnancy. The choice of a prosthesis, whether biological or mechanical, should not be considered an isolated decision, but rather a consequence of a complex outcome of the heart disease.

Thrombosis is an important cause of morbidity and mortality worldwide. Pregnancy is a hypercoagulable state, and thrombotic complications in pregnancy are a major cause of maternal and fetal morbidity and mortality. Current guidelines support the selective use of aspirin, heparin, and warfarin in pregnant women. The decision to treat with antiplatelets and anticoagulants during pregnancy can be challenging, as these agents have numerous indications and contraindications, potential teratogenicity, and dosing considerations. Their use requires thoughtful discussion between patient and provider that balances therapeutic benefit versus maternal and fetal risks, while accounting for a safe delivery plan. Our aim is to provide a narrative review of the established and emerging indications of antiplatelets and anticoagulants, discuss their appropriate timing of administration, and consider their associated adverse fetal and maternal risks.

We here sought to assess thrombotic and hemorrhagic complications and associated risk factors during pregnancy, delivery, and postpartum in women with prosthetic heart valves (PHV).

The retrospective cohort study covered January 2011 to December 2022. The objective of the study was to assess the risk factors and frequency of thrombotic and hemorrhagic complications during pregnancy, delivery, and the postpartum period in women with PHV based on the experience of one perinatal center. We included 88 pregnancies with 77 prosthetic heart valves (PHV), which were divided into two groups, mechanical valve prostheses (MVP) (n = 64) and biological valve prosthesis (BVP) (n = 24). In the study we analyzed pregnancy outcomes, as well as thrombotic and hemorrhagic complication frequencies.

Of 88 pregnancies, 79 resulted in live births. In the MVP group, there were six miscarriages (9.4%) and two medical abortions (3.1%), including one due to Warfarin's teratogenic effects. No miscarriages were reported in the BVP group, but one fetal mortality case (4.2%) occurred. During pregnancy, 11 MVP cases (17.2%) experienced thrombotic complications. In the BVP group, one patient (4.2%) had transient ischemic attack (TIA). Two MVP cases required surgical valve repair during pregnancy, and one in the post-delivery stage was caused by thrombotic complications. Postpartum, two MVP cases had strokes, and in one MVP patient, pulmonary embolism was registered, while no thrombotic complications occurred in the BVP group. Hemorrhagic complications affected 15 MVP cases (17.9%) in the postpartum period. There were no registered cases of maternal mortality.

The effective control of anti-factor Xa activity reduced thrombotic events. However, the persistently high incidence of postpartum hemorrhagic complications suggests a need to reassess anticoagulant therapy regimens, lower target levels of anti-Xa, and reduce INR levels for discontinuing heparin bridge therapy. Despite the heightened mortality risk in MVP patients, our study cohort did not have any mortality cases, which contrasts with findings from other registries.

Cardiovascular disease is the leading indirect cause of maternal morbidity and mortality, accounting for nearly one third of maternal deaths during pregnancy. The burden of cardiovascular disease in pregnancy is increasing, as are the incidence of maternal morbidity and mortality. Normal physiologic adaptations to pregnancy, including increased cardiac output and plasma volume, may unmask cardiac conditions, exacerbate previously existing conditions, or create de novo complications. It is important for care providers to understand the normal physiologic changes of pregnancy and how they may impact the care of patients with cardiovascular disease. This review outlines the physiologic adaptions during pregnancy and their pathologic implications for some of the more common cardiovascular conditions in pregnancy.

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.

Optimal first-trimester anticoagulation is still challenging in pregnant women with mechanical heart valves (MHVs) requiring high-dose warfarin. This multicenter prospective study aims to determine the optimal anticoagulation regimens for pregnant patients with MHVs.

All women were allocated to one of three treatment options during first trimester including lone low-molecular-weight heparin (LMWH), combination of LMWH + 2.5 mg warfarin, and LMWH+4 mg warfarin. Primary maternal outcome included a combination of death, thromboembolism, severe bleeding, and need for treatment of mechanical valve thrombosis (MVT). Any fetal loss was determined as primary fetal outcome.

The study included 78 pregnancies in 65 women with MHVs. Primary maternal outcome rate was 44%, 12.5%, 3.5%, respectively. The rates of primary maternal outcome (44 vs 3.5%, P < .001), obstructive MVT (16 vs 0%, P = .04), MVT requiring treatment (28 vs 0%, P = .003), and cerebral embolism (24 vs 3.4%, P = .041) were found to be significantly higher in lone LMWH group compared to LMWH + 4 mg warfarin group. Moreover, the rates of primary maternal outcome (12.5 vs 44%, P = .015) and treatment for MHV thrombus (4.2 vs 28%, P = .049) were significantly lower in LMWH + 2.5 mg warfarin group compared to lone LMWH group. The incidences of fetal loss were 8 (32%) in the lone LMWH group, 8 (33.3%) in LMWH + 2.5 mg warfarin group, and 11 (37.9%) in LMWH + 4 mg warfarin group (P = .890 for 3-group).Warfarin related-embryopathy was not observed in any case.

The combined anticoagulation strategy of LMWH plus low-dose warfarin during the first trimester of pregnancy may result in less maternal complications with comparable fetal outcomes in patients with MHVs.

Low-molecular-weight heparin (LMWH) is thought to be safer for the fetus, however it is suspected to be less protective for the mother. To solve this dilemma, the authors suggested a novel anticoagulation strategy in pregnant women with prosthetic valves. Seventy-eight pregnancies of 65 women (median age 32 [27-35] years) were included in the study. A combination of LMWH and a reduced dose warfarin were associated with low rates of thrombus-related complications in pregnant patients with mechanical heart valves.

The purpose was to evaluate pregnancy outcomes and risk factors associated with fetal complications in Chinese pregnant women with mechanical heart valves (MHVs) taking low-dose warfarin, aiming to fill in the research gap of this area.

Between June 2010 and Aug 2023, 122 patients with MHVs who had 151 pregnancies and received warfarin throughout pregnancy were included. We compared them with 302 paired pregnancies without warfarin treatment. Binary logistic regression analyses were performed to explore risk predictors of fetal complications.

Pregnancy loss rate was 37.1 % in women taking warfarin, compared to only 4.6 % for those without warfarin exposure in pregnancy (RR = 8.00, 95 % CI: 4.61-13.90). In pregnant women with MHVs, there were 34 spontaneous abortions, 22 stillbirths and 1 neonatal malformation. In the first, second and third pregnant trimesters of women with MHVs, fetal complication incidences were 19.2 %, 9.9 % and 8.0 %, respectively. 86.0 % of fetal complications occurred in women taking a warfarin dose ≤5 mg/d, accounting for 94.0 % of the total population. The newborns' birth weight, gestational age and 1-minute Apgar score were significantly lower in pregnancies treated with warfarin compared to those without warfarin exposure. Only 2.0 % of postpartum hemorrhage and no thrombosis or maternal mortality data were collected in pregnant women on warfarin in this study.

Most Chinese pregnant women take a warfarin daily dose ≤5 mg and they might have only around 60 % chance of giving birth to a live baby without maternal complications.

Valvular heart disease is a common cause of peripartum cardiovascular morbidity and mortality. The hemodynamic changes of pregnancy and their impact on preexisting valvular lesions are described in this paper. Tools for calculation of maternal and fetal risk during pregnancy are also discussed. The pathophysiology and management of valvular lesions, both obstructive and regurgitant, are then described, followed by discussion of mechanical and bioprosthetic valve complications during pregnancy.

A 32-year-old pregnant woman with a mechanical mitral valve was admitted with vaginal bleeding and was found to have placenta previa. During her hospital stay, she developed acute valvular thrombosis. She underwent an emergency cesarean section followed by successful mechanical valve replacement.

The "2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation" provides recommendations to guide clinicians in the treatment of patients with atrial fibrillation.

A comprehensive literature search was conducted from May 12, 2022, to November 3, 2022, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. Additional relevant studies, published through November 2022, during the guideline writing process, were also considered by the writing committee and added to the evidence tables, where appropriate.

Atrial fibrillation is the most sustained common arrhythmia, and its incidence and prevalence are increasing in the United States and globally. Recommendations from the "2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" and the "2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing atrial fibrillation and thromboembolic risk assessment, anticoagulation, left atrial appendage occlusion, atrial fibrillation catheter or surgical ablation, and risk factor modification and atrial fibrillation prevention have been developed.

The "2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Patients With Atrial Fibrillation" provides recommendations to guide clinicians in the treatment of patients with atrial fibrillation.

A comprehensive literature search was conducted from May 12, 2022, to November 3, 2022, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. Additional relevant studies, published through November 2022, during the guideline writing process, were also considered by the writing committee and added to the evidence tables, where appropriate.

Atrial fibrillation is the most sustained common arrhythmia, and its incidence and prevalence are increasing in the United States and globally. Recommendations from the "2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" and the "2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing atrial fibrillation and thromboembolic risk assessment, anticoagulation, left atrial appendage occlusion, atrial fibrillation catheter or surgical ablation, and risk factor modification and atrial fibrillation prevention have been developed.

As a result of the ongoing opioid epidemic, physicians have encountered increasing rates of drug-use-related native tricuspid valve infective endocarditis (DU-TVIE), a complex multi-faceted disease that is best managed by interdisciplinary teams. Despite the large number of patients with DU-TVIE, there is little data to support the optimal treatment strategy with respect to medical and surgical therapy. The recent introduction of percutaneous mechanical aspiration of tricuspid valve vegetations has added another treatment modality that is also of uncertain benefit. Here we review the literature on the management of DU-TVIE and highlight the multi-step treatment approach developed by the multidisciplinary endocarditis team at the University of Kentucky.

Asymptomatic severe aortic stenosis (AS) during pregnancy remains challenging; however, the postponement of surgery with the possibility of valvuloplasty as a bridge therapy seems reasonable. Our case showed that despite physiological changes during pregnancy, the aortic valve defect did not worsen, which allowed us to avoid dilemmas related to anticoagulation on artificial valve.

A 31-year-old woman, with a bicuspid aortic aorta, post-aortic valvulotomy, was listed for cardiac surgery because of severe aortic stenosis. However, the operation was postponed due to procreation plans. During the pregnancy and delivery, we did not observe neither deterioration of symptoms nor changes of echocardiographic parameters. Subsequent monthly echocardiographic studies did not reveal a significant increase of peak and mean aortic gradient.Presented case reports showed that despite physiological changes associated with pregnancy, the aortic valve defect did not worsen, which allowed to avoid dilemmas related to anticoagulation on artificial valves.

A dramatic rise in cardiac output with a decrease in afterload are the hallmark of hemodynamic variations induced by normal pregnancy, which requires significant cardiac adaptation. Females with rheumatic mitral valve disease who have had a mitral valve replacement in the past are increasingly choosing to become pregnant. Hypercoagulability of pregnancy, problems with anticoagulant therapy along with hemodynamic changes in pregnancy increase the risk of cardiac complications in this subset. There is a paucity of research on the management of problems in patients with cardiac prosthetic valves. We present a case of primigravida with a history of mitral valve replacement, presenting with a stuck valve.

•Pregnancy is a pro-thrombotic state•Pregnancy with a mechanical heart valve has high risk of stuck vale despite adequate anti-coagulation•Management of such high-risk cases must be carried out at a tertiary care center with all facilities•Multi-disciplinary approach is required to deal with pregnant women with mechanical heart valve.

Rheumatic heart disease [RHD] is the most prevalent cause of valvular heart disease in the world, outstripping degenerative aortic stenosis numbers fourfold. Despite this, global resources are firmly aimed at improving the management of degenerative disease. Reasons remain complex and include lack of resources, expertise, and overall access to valve interventions in developing nations, where RHD is most prevalent. Is it time to consider less invasive alternatives to conventional valve surgery? Several anatomical and pathological differences exist between degenerative and rheumatic valves, including percutaneous valve landing zones. These are poorly documented and may require dedicated solutions when considering percutaneous intervention. Percutaneous balloon mitral valvuloplasty (PBMV) is the treatment of choice for severe mitral stenosis (MS) but is reserved for patients with suitable valve anatomy without significant mitral regurgitation (MR), the commonest lesion in RHD. Valvuloplasty also rarely offers a durable solution for patients with rheumatic aortic stenosis (AS) or aortic regurgitation (AR). MR and AR pose unique challenges to successful transcatheter valve implantation as landing zone calcification, so central in docking transcatheter aortic valves in degenerative AS, is often lacking. Surgery in young RHD patients requires mechanical prostheses for durability but morbidity and mortality from both thrombotic complications and bleeding on Warfarin remains excessively high. Also, redo surgery rates are high for progression of aortic valve disease in patients with prior mitral valve replacement (MVR). Transcatheter treatments may offer a solution to anticoagulation problems and address reoperation in patients with prior MVR or failing ventricles, but would have to be tailored to the rheumatic environment. The high prevalence of MR and AR, lack of calcification and other unique anatomical challenges remain. Improvements in tissue durability, the development of novel synthetic valve leaflet materials, dedicated delivery systems and docking stations or anchoring systems to securely land the transcatheter devices, would all require attention. We review the epidemiology of RHD and discuss anatomical differences between rheumatic valves and other pathologies with a view to transcatheter solutions. The shortcomings of current RHD management, including current transcatheter treatments, will be discussed and finally we look at future developments in the field.

In patients with mechanical heart valve protheses, warfarin is usually recommended because of its exceptional anticoagulation effects. However, warfarin can cross the placenta, leading to teratogenicity and even catastrophic hemorrhage in the fetus. The present article describes a case of warfarin-associated fetal intracranial hemorrhage. The patient was a woman in her early 30s. At the age of 11 years, she had undergone aortic valve replacement (mechanical) for aortic regurgitation. Since then, she had been taking oral warfarin. During her pregnancy, her prothrombin time-international normalized ratio was maintained between 1.5 and 2.5. At 35 weeks of gestation, fetal ultrasonography revealed an intracranial mass in the left hemisphere. An emergency cesarean section was performed because fetal intracranial hemorrhage was suspected. A male infant was delivered with a 1- 5-, and 10-minute Apgar score of 1, 5, and 7, respectively. Cranial computed tomography revealed multiple hemorrhage sites with newly emerged bleeding spots. In patients with mechanical heart valve protheses, obstetricians face the dilemma of individual-patient differences and the difficulty of intensive monitoring of the coagulation parameters in the fetus. Tailor-made anticoagulation therapy and a more intensive ultrasonic monitoring strategy, even that involving regular magnetic resonance imaging, are necessary in these patients.

A pregnant woman with rheumatic heart disease always runs the risk of developing both thromboembolic and hemorrhagic symptoms, necessitating careful monitoring of her anticoagulation treatments both throughout pregnancy and after delivery. Postpartum haemorrhage, a hemorrhagic manifestation, can be challenging to control and presents a significant challenge when it comes to beginning anticoagulation after delivery. Thus, pregnancy in these patients is an extremely risky endeavour. Given that these women take anticoagulants, managing these women with artificial heart valves throughout pregnancy can be difficult. The diminished clotting ability in these women may be the cause of postpartum haemorrhage, and a multidisciplinary approach is necessary for a successful treatment. To manage this potentially fatal illness, a well-equipped institution with proper support systems is essential. We present a 23-year-old primigravida who was 39 weeks and three days pregnant and had a repaired aortic valve as well as a prosthetic mitral valve. She was taking warfarin to prevent clotting when she was pregnant.

The management of anticoagulation for mechanical heart valves (MHVs) during pregnancy posed a special challenge. Mechanical thrombectomy (MT) was the standard treatment for acute ischemic stroke (AIS) in anterior circulation with large vessel occlusion. However, the efficacy and safety of MT in the treatment of acute ischemic stroke in pregnancy were unknown.

A 29-year-old woman with MHVs in her first pregnancy at 7 weeks' gestation underwent MT because of a large occlusive thrombus in the end of the internal carotid artery despite therapeutic anticoagulation with low-molecular-weight heparin. This pregnant woman recovered well after MT with a modified rank score (mRS) of 0 at 90 days.

At present, there was no standard protocol of anticoagulation therapy for pregnant women with MHVs. Acute ischemic stroke with large vessel occlusion in pregnancy was rare, but could bring devastating consequences for both mother and infant. Our case report demonstrated that MT could be safe and effective in pregnancy.

Although not completely devoid of risk, pregnancy can be managed in virtually all patients affected by even the most complex forms of congenital heart disease. It is not however advisable in patients with any form of pulmonary arterial hypertension. Pregnancy is even manageable in patients with univentricular heart converted to Fontan circulation. A personalised risk stratification should be performed, and patients affected by advanced NYHA functional class appropriately warned of the potential risks. In this setting, metabolomics might represent a novel tool for use in conducting personalised risk stratification. All pregnancies, particularly those at higher risk, should be managed in a tertiary care centre capable of providing the necessary assistance to both the mother and infant. With a few rare exceptions, vaginal delivery is to be preferred over caesarean section due to the lower degree of maternal and foetal complications. The desire for motherhood, at times extreme in women with congenital heart disease, may often be accomplished, thus providing a ray of hope in the lives of these patients.

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.

Specialists in Obstetric Haematology continue to be challenged by pregnant women with mechanical heart valves, who are at high risk of death or severe morbidity. Effective anticoagulation to reduce valve thrombosis inevitably increases risk of obstetric haemorrhage and fetal loss or harm, and difficult decisions need to be made. Lester and mulitdisciplinary colleagues on behalf of the British Society for Haematology review available evidence and provide comprehensive recommendations to guide management in this difficult area. Commentary on: Lester et al. British Society for Haematology guideline for anticoagulant management of pregnant individuals with mechanical heart valves. Br J Haematol 2023 (Online ahead of print). doi: https://doi.org/10.1111/bjh.18781.

The prevalence of congenital heart disease (CHD) in pregnancy is rising due to the improved survival of patients with CHD into childbearing age. The profound physiological changes that occur during pregnancy may worsen or unmask CHD, affecting both mother and fetus. Successful management of CHD during pregnancy requires knowledge of both the physiological changes of pregnancy and the potential complications of congenital heart lesions. Care of the CHD patient should be based on a multidisciplinary team approach beginning with preconception counseling and continuing into conception, pregnancy, and postpartum periods. This review summarizes the published data, available guidelines and recommendations for the care of CHD during pregnancy.

Pregnancy is a dynamic process associated with profound hormonally mediated haemodynamic changes which result in structural and functional adaptations in the cardiovascular system. An understanding of the myocardial adaptations is important for echocardiographers and clinicians undertaking or interpreting echocardiograms on pregnant and post-partum women. This guideline, on behalf of the British Society of Echocardiography and United Kingdom Maternal Cardiology Society, reviews the expected echocardiographic findings in normal pregnancy and in different cardiac disease states, as well as echocardiographic signs of decompensation. It aims to lay out a structure for echocardiographic scanning and surveillance during and after pregnancy as well as suggesting practical advice on scanning pregnant women.

The pregnancy-related mortality rate in the United States is excessively high. The American Heart Association is dedicated to fighting heart disease and recognizes that cardiovascular disease, preexisting or acquired during pregnancy, is the leading cause of maternal mortality in the United States. Comprehensive scientific statements from cardiology and obstetrics experts guide the treatment of cardio-obstetric patients before, during, and after pregnancy. This scientific statement aims to highlight the role of specialized cardio-obstetric anesthesiology care, presenting a systematic approach to the care of these patients from the anesthesiology perspective. The anesthesiologist is a critical part of the pregnancy heart team as the perioperative physician who is trained to prevent or promptly recognize and treat patients with peripartum cardiovascular decompensation. Maternal morbidity is attenuated with expert anesthesiology peripartum care, which includes the management of neuraxial anesthesia, inotrope and vasopressor support, transthoracic echocardiography, optimization of delivery location, and consideration of advanced critical care and mechanical support when needed. Standardizing the anesthesiology approach to patients with high peripartum cardiovascular risk and ensuring that cardio-obstetrics patients have access to the appropriate care team, facilities, and advanced cardiovascular therapies will contribute to improving peripartum morbidity and mortality.

More women with mechanical mitral valves (MMVs) are pursuing pregnancy. Guidelines exist for pregnancy anticoagulation, but they do not address individualized anticoagulation during delivery-a period of risk for bleeding, thrombosis, and anesthetic complications. This case series of parturients with MMVs highlights the challenges in, and the evidence and strategies for, treating these patients. (Level of Difficulty: Advanced.).

Women with single ventricle physiology after the Fontan procedure, despite numerous possible complications, can reach adulthood and give birth. Pregnancy poses a hemodynamic burden for distorted physiology of Fontan circulation, but according to the literature, it is usually well tolerated unless the patient is a "failing" Fontan. Our study aimed to assess maternal and fetal outcomes in patients after the Fontan procedure followed up in two tertiary Polish medical centers. We retrospectively evaluated all pregnancies in women after the Fontan procedure who were followed up between 1995-2022. During the study period, 15 women after the Fontan procedure had 26 pregnancies. Among 26 pregnancies, eleven ended with miscarriages, and 15 pregnancies resulted in 16 live births. Fetal complications were observed in 9 (56.3%) live births, with prematurity being the most common complication (n = 7, 43.8%). We recorded 3 (18.8%) neonatal deaths. Obstetrical complications were present in 6 (40%) out of 15 completed pregnancies-two (13.3%) cases of abruptio placentae, two (13.3%) pregnancies with premature rupture of membranes, and two (13.3%) patients with antepartum hemorrhage. There was neither maternal death nor heart failure decompensation during pregnancy. In two (13.3%) women, atrial arrhythmia developed. One (6.7%) patient in the second trimester developed ventricular arrhythmia. None of the patients suffered from systemic thromboembolism during pregnancy. Pregnancy in women after the Fontan procedure is well tolerated. However, it is burdened by a high risk of miscarriage and multiple obstetrical complications. These women require specialized care provided by both experienced cardiologists and obstetricians.

We performed a clinical audit of maternal and fetal outcomes in pregnant women with valvular heart disease (VHD) from Portuguese-speaking African countries who were transferred for their care, during a twenty-year period, through a memorandum of agreement of international cooperation.

A retrospective analysis of 81 pregnancies in 45 patients with VHD (median age 24, interquartile range 22-29 years) from 2000 to 2020 was performed. The main outcome measures were maternal cardiovascular and fetal outcomes. History of rheumatic heart disease was present in 60 (74.1%) pregnancies. Most were in New York Heart Association (NYHA) functional class I or II; at the first evaluation, 35 (43.2%) were on cardiac medication and 49 (60.5%) were anticoagulated. Forty-eight pregnancies had at least one valvular prosthesis, including 38 mechanical heart valves. During pregnancy, deterioration in NYHA functional class occurred in 35 (42.0%), and eight (9.9%) patients required initiation or intensified cardiac medication. Mechanical valve thrombosis complicated four (4.9%) pregnancies, all cases on heparin, and resulted in one maternal death. Haemorrhagic complications happened in 7 (8.6%) anticoagulated patients, in the immediate postpartum or puerperal period. The 81 pregnancies resulted in 56 (69.1%) live births, while miscarriage and fetal malformations occurred in 19 (23.5%) and 12 (14.8%) pregnancies, respectively. In multivariate analysis, vitamin K antagonist therapy was the only independent predictor of an unsuccessful pregnancy (p = 0.048).

In a high-income country, successful pregnancy was possible with low rate of maternal events in women with VHD transferred from five low-middle income countries in Africa. The use of anticoagulation with a vitamin K antagonist was associated with an unsuccessful pregnancy.

Mechanical heart valves require long-term anticoagulation strategies to prevent valve thrombosis. Pregnant women with mechanical heart valves are especially susceptible to valve thrombosis, given their procoagulant state and the complexity of anticoagulation strategies during pregnancy. We describe a case of prosthetic valve thrombosis in a pregnant woman treated successfully with low-dose slow infusion of thrombolytic therapy.

A 23-year-old pregnant woman with a mechanical aortic valve on subcutaneous enoxaparin presented to the maternal cardiac clinic for a follow-up visit. Her physical exam was notable for a loud grade three crescendo decrescendo murmur and follow-up transthoracic echocardiography revealed peak and mean gradients of 87 and 58 mmHg, respectively. The Doppler velocity index (DVI) was 0.24 with an acceleration time of 130 ms. Fluoroscopy confirmed a stuck leaflet disk. Thrombolysis was performed using a low-dose ultra-slow infusion of thrombolytic therapy (1 mg/h of tissue-type plasminogen activator) with the restoration of normal valve function after 8 days. A repeat transthoracic echocardiography showed a decrease in the peak and mean gradients to 37 and 21 mmHg, respectively, with an improvement in the DVI to 0.53. Repeat fluoroscopy confirmed the opening of both leaflet disks.

Treatment options for mechanical aortic valve thrombosis are either slow-infusion, low-dose thrombolytic therapy or emergency surgery. The hypercoagulable state of pregnancy makes adequate anticoagulation, proper monitoring, and medication adherence even more critical to prevent valve thrombosis. Physicians should educate pregnant patients on anticoagulation strategies and participate in shared decision-making.

Pregnant individuals with pulmonary arterial hypertension (PAH) have significantly high risks of maternal and perinatal mortality. Profound changes in plasma volume, cardiac output and systemic vascular resistance can all increase the strain being placed on the right ventricle, leading to heart failure and cardiovascular collapse. Given the complex network of opposing physiological changes, strict contraception and reduction of hemodynamic fluctuations during pregnancy are important methods of minimizing the risk of maternal mortality and improving the outcomes following pregnancy. In this review, we discuss the recent research progress into pre-conception management and the various therapeutic strategies for pregnant individuals with PAH.

The management of anticoagulation for mechanical heart valves during pregnancy poses a unique challenge. Mechanical valve thrombosis is a devastating complication for which surgery is often the treatment of choice. However, cardiac surgery for prosthetic valve dysfunction in pregnant patients confers a high risk of maternofetal morbidity and mortality.

A 39-year-old woman in her first pregnancy at 30 weeks gestation presented to hospital with a mechanical mitral valve thrombosis despite therapeutic anticoagulation with low-molecular-weight heparin. She underwent an emergent caesarean section followed immediately by a bioprosthetic mitral valve replacement. This occurred after careful planning and organization on the part of a large multidisciplinary team.

A proactive, rather than reactive, approach to the surgical management of a mechanical valve thrombosis in pregnancy will maximize the chances of successful maternal and fetal outcomes.