Prosthetic Heart Valves and Pregnancy
2003; Lippincott Williams & Wilkins; Volume: 107; Issue: 9 Linguagem: Inglês
10.1161/01.cir.0000060806.86686.ec
ISSN1524-4539
AutoresLynne Hung, Shahbudin H. Rahimtoola,
Tópico(s)Cardiac Structural Anomalies and Repair
ResumoHomeCirculationVol. 107, No. 9Prosthetic Heart Valves and Pregnancy Free AccessReview ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessReview ArticlePDF/EPUBProsthetic Heart Valves and Pregnancy Lynne Hung, MD and Shahbudin H. Rahimtoola, MB, FRCP, MACP, MACC, DSc (Hon) Lynne HungLynne Hung From the Griffith Center, Division of Cardiovascular Medicine, Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles. and Shahbudin H. RahimtoolaShahbudin H. Rahimtoola From the Griffith Center, Division of Cardiovascular Medicine, Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles. Originally published11 Mar 2003https://doi.org/10.1161/01.CIR.0000060806.86686.ECCirculation. 2003;107:1240–1246In patients with prosthetic heart valves (PHV), pregnancy is associated with the risks of warfarin embryopathy in patients with mechanical PHV and of structural valve deterioration (SVD), both early and late, in patients with biological PHV.Mechanical ValvesWarfarinThe use of warfarin, particularly between the 6th and 12th weeks of pregnancy, is associated with an embryopathy, "warfarin embryopathy,"1,2 which is characterized by nasal hypoplasia and/or stippled epiphyses.3 Uncommon features, including central nervous system and eye abnormalities, may be due to warfarin exposure during the second and third trimester.3There is a wide range of the reported incidence of warfarin embryopathy (Table 1).3–18 Ten studies comprising 427 pregnancies reported the incidence was zero (Table 1). From the patient's point of view, the incidence per live birth may be more important; four recent (between 1994 and 99) studies reported an incidence of 3/189 (1.6%) live births7,9,17,18 (Table 1). One group has shown that the risk of warfarin embryopathy was extremely low in the 33 women who needed ≤5 mg of warfarin to maintain an adequate INR.14,18TABLE 1. Incidence of Warfarin EmbryopathyReferenceNo. of PregnanciesNo. of Live BabiesWarfarin EmbryopathyNo.% of Pregnancies*Review of the literature.†Same medical center.‡Same medical center.§Thirty-eight of 80 live births were examined.∥Excluding 128 patients in Salazar study because only 38 of 80 live births were examined, as well as all in the study by Wong et al because the number of pregnancies is not known.¶Excluding 80 live births in the study by Salazar et al because only 38 live births were examined.# Excluding 3 in the study by Salazar et al and 18 in the study by Wong et al.** Excluding 3 in the study by Salazar et al.Anticoagulation status uncertain or variable Ben-Ismail et al4534500 Chen et al545…00IV heparin followed by warfarin at times followed by IV heparin Larrea et al (group III)6211900 Salazar et al7†401600 Iturbe-Alessio et al (group I)8†231900 Sbarouni and Oakley9646200Warfarin throughout pregnancy or 2nd and 3rd trimesters Hall1*418350245.7 Larrea et al (groups I and II)6261727.6 Chong et al10452200 Salazar et al (group II)11†12880§32.3 Iturbe-Alessio et al (groups II and III)8†49351020 Pavenkumar et al1247…00 Sareli et al1350…24 Cotrufo et al14‡20…00 Born et al15403237.5 Wong et al16…2918… Hanania et al171045611 Sbarouni and Oakley9363200 Vitale et al18‡ ≤5 mg/d333300 >5 mg/d25628Total (pregnancies)1399∥…44#3.9Total (live babies)…779¶59**7.4The incidence of warfarin embryopathy will be lower with use of IV unfractionated heparin in the first 3 months (especially between the 6th to 12th weeks) of pregnancy; one review concluded that this strategy "eliminated the risk."19 IV unfractionated heparin use in the last 2 weeks of pregnancy is associated with a reduced risk of hemorrhage during delivery and the neonatal period in the mother, as well as in the baby, because warfarin crosses the placenta, and therefore, the fetus/baby is anticoagulated. To reduce the latter complication, some have suggested elective caesarian section in the 38th week of pregnancy.17,18An earlier study reported the incidence of abortion and stillbirths in these patients was higher than in the population;6 in a subsequent study the incidence was similar.9Subcutaneous HeparinThe recommendation for use of subcutaneous heparin in pregnancy by Ginsberg et al is based on: (1) its value in patients with angina and myocardial infarction20; and (2) a study of 100 pregnancies in 77 women.21 In 98 of the 100 pregnancies, heparin therapy was given for prevention or treatment of thromboembolism, and in 2/100 pregnancies it was given for women with PHV.21 Oakley has criticized this recommendation.22 The incidence of thromboembolism on heparin therapy during pregnancy in patients with a mechanical prosthesis is 4 times greater than in those treated with oral anticoagulants.17 Two studies from the same institution documented mechanical PHV thrombosis with subcutaneous heparin.7,8 In one study, 2/23 (8.7%) patients had massive valve thrombosis.8 In the other study, in 22 pregnant7 patients with mechanical valves, one had a cerebral embolus and 3 (14%) died, one from gastrointestinal bleeding and 2 with thrombosed PHV. Subcutaneous heparin does not improve fetal outcome and increases maternal mortality.Low-Molecular-Weight HeparinThere are no good data at the present time documenting the benefits for the use of low-molecular-weight heparin in patients with PHV.Case reports of thrombosed PHV with the use of low-molecular-weight heparin have been reported.23 The FDA24 has issued additions to the warnings and precautions sections of the Lovenox (enoxaparin sodium) product labeling. These warnings point out:This product (a low-molecular-weight heparin) is not recommended for thrombotic prophylaxis in patients with PHV;Cases of PHV thrombosis and of maternal and fetal deaths have been reported with use of this drug;Furthermore, in pregnant women who received this drug, both teratogenic and nonteratogenic effects have been reported.Biological ValvesBioprostheses (Heterografts)Operative mortality at initial PHV insertion was 4.3%.27Pregnancy in women with a bioprosthesis is associated with SVD; the incidence may average 24% during or shortly after pregnancy9,11,15,17,25 (Table 2). After bioprosthetic PHV valve replacement, the incidence of SVD at 10 years was 55 to 76%; the incidence of PHV-related re-operation was 60 to 80%26,27 (Table 3). The incidence of SVD in those who were subsequently pregnant versus those who were not was 76.7±14% versus 25.8±8.5% (P<0.05) in one study26 and 55.3±8.2% versus 45.7±4.8% (P=NS) in another.27 The issue is not similar rates of SVD in women with or without subsequent pregnancy. An important issue is the very high rate of bioprosthetic SVD in people aged 16 to 40 years at the time of PHV implantation: ≈50% at 10 years and 90% at 15 years (Figure).28 Furthermore, SVD begins 2 to 3 years after PHV implantation in this age group (Figure). The mortality of re-operation is 3.8% to 8.7%.26,27TABLE 2. Bioprostheses and Pregnancy: Early SVDReferenceNo. of PatientsEarly SVDCommentsNo.%*Porcine valves.†Mainly porcine and few other biological valves.Born et al1520420†Needed re-operation during pregnancy or in puerperiumBartolotti et al257229* 10 years are from Ross's group (Table 4).35–38 The freedom from autograft replacement ranged from 48.5±13.7% at 19 years to 85% at 20 years; the most likely explanation for this wide range is selection of patients reported in these 4 studies. In the series from only the National Heart Hospital:38TABLE 4. Ross Procedure by D.N. RossYear of Publication and Reference198835199136199237199738Values are expressed as n, range, or mean±SD, as indicated.*Unique pioneer series from the National Heart Hospital.†In operative survivors, ie, excluding operative mortality.Entry into studies Years1967 to 19861967 to 19911969 to 19911967 to 1984 Hospitals4121* Clinics111…No. of patients241339339151Age, y, range9 to 603.5 to 60 6011 to 52Operative mortality6.6%7.4%7.4%13%Longest follow-up18y 7m24 y24 y26 yTotal patient years1130398637742752Survival57.3±9.6% at 19 years80% at 20 years80% at 20 years61% at 20 years†Freedom from autograft replacement48.5±13.7% at 19 years85% at 20 years85% at 20 years75% at 20 yearsOperative mortality was 13%In operative survivors (ie, excluding operative mortality), late mortality was 40.5% and actuarially determined mortality at 15 and 20 years was 25% and 39%, respectivelyActuarially determined freedom from autograft replacement was 75% at 20 years.ConclusionsMechanical ValvesPatients with mechanical valves need close monitoring of warfarin therapy during pregnancy. Substitution of warfarin with IV unfractionated heparin in the first 6 to 12 weeks and last 2 weeks of pregnancy is associated with a low rate of warfarin embryopathy and of bleeding in the mother and baby. The initiation of heparin therapy is clinically most feasible and practical at 4 to 6 weeks of pregnancy. Women who need ≤5 mg of warfarin are probably at low risk for fetal warfarin embryopathy and may be able to receive warfarin throughout pregnancy, but more data are needed.Subcutaneous heparin and low molecular weight heparin cannot be recommended at the present time in such patients.Biological ValvesBioprostheses have a risk of early SVD during or shortly after the end of pregnancy. Moreover, at 10 years there is a high rate of SVD (55% to 77%) and of valve-related re-operation (60% to 80%).Both men and women aged 16 to 40 years at time of bioprosthetic PHV implantation are at risk of SVD, which begins 2 to 3 years after valve replacement; at 10 to 15 years, the rate of SVD is very high (50% to 90%).One has to balance the risks of SVD and its consequences to the mother and family in those who receive a bioprosthetic PHV versus the small risk of warfarin embryopathy in the fetus in those women who receive a mechanical PHV.There are no data in patients who had received a homograft.More data are needed in patients who have had the pulmonary autograft procedure according to the Ross principle.If anticoagulation is needed the use of LMWH is of concern because the FDA has cited the occurrence of both teratogenic and non-teratogenic effects with use of LMWH.24 More data, including randomized trials, are needed.Management StrategiesThe management of young women with VHD who are contemplating a future pregnancy, the choice of PHV if one is necessary, and the management of such patients during pregnancy are outlined in algorithms 1 to 6. Patients with aortic or mitral regurgitation (AR and MR, respectively) can cope with the volume load of pregnancy better than patients with severe valve stenosis because the reduction of systemic vascular resistance during pregnancy favors a reduction of aortic or mitral regurgitation. The volume load associated with pregnancy is not well tolerated in the presence of a severe valve stenosis (aortic stenosis as valve area ≤1.0 cm2; ≤0.6 cm2/m2) or mitral stenosis (mitral valve area ≤1.0 cm2). Download figureDownload PowerPointAlgorithm 1. Download figureDownload PowerPointAlgorithm 2. Download figureDownload PowerPointAlgorithm 3. Download figureDownload PowerPointAlgorithm 4. Download figureDownload PowerPointAlgorithm 5. Download figureDownload PowerPointAlgorithm 6. FootnotesCorrespondence to S.H. Rahimtoola, MD, Distinguished Professor, University of Southern California, 2025 Zonal Ave, Los Angeles, CA 90033. References 1 Hall JG. Embryopathy associated with oral anticoagulant therapy. Birth Defects. 1965; 12: 133–140.Google Scholar2 Sahul WL, Emery H, Hall JG. Chondrodysplasia punctata and maternal warfarin use during pregnancy. Am J Dis Child. 1975; 129: 360–362.MedlineGoogle Scholar3 Hall JAG, Paul RM, Wilson KM. Maternal and fetal sequelae of anticoagulation during pregnancy. Am J Med. 1980; 68: 122–140.CrossrefMedlineGoogle Scholar4 Ben-Ismail M, Fekih M, Taktak M, et al. Prostheses Valvulaires Cardiaques et Grossesse. Arch Mal Coeur. 1979; 2: 192–194.Google Scholar5 Chen WWC, Chau CS, Lee PK, et al. Pregnancy in patients with prosthetic heart-valves: an experience with 45 pregnancies. Q J Med. 1982; 51: 358–365.MedlineGoogle Scholar6 Larrea JL, Nunez L, Reque JA, et al. Pregnancy and mechanical valve prosthesis: a high-risk situation for the mother and the fetus. Ann Thorac Surg. 1983; 36: 459–463.CrossrefMedlineGoogle Scholar7 Salazar E, Izaguirre R, Verdejo J, et al. Failure of adjusted doses of subcutaneous heperin to prevent thrombo-embolic phenomena in pregnant patients with mechanical cardiac valve prosthesis. J Am Coll Cardiol. 1996; 27: 1698–1703.CrossrefMedlineGoogle Scholar8 Iturbe-Alessio I, del Carmen Fonseca M, Mutchinik O, et al. Risks of anticoagulant therapy in pregnant women with artificial heart valves. N Engl J Med. . 1986; 315: 1390–1393.CrossrefMedlineGoogle Scholar9 Sbarouni E, Oakley CM. Outcome of pregnancy in women with valve prosthesis. Br Heart J. 1994; 71: 196–201.CrossrefMedlineGoogle Scholar10 Chong MKB, Harvey D, Deswiet M. Follow-up study of children whose mothers were treated with warfarin during pregnancy. Br J Obs Gynae. 1984; 91: 1070–1073.CrossrefMedlineGoogle Scholar11 Salazar E, Zajarias A, Gutierrez N, et al. The problem of cardiac valve prosthesis, anticoagulant, and pregnancy. Circulation. 1984; 70 (suppl 1): 169–177.Google Scholar12 Pavunkumar P, Venugopal P, Kaul U, et al. Pregnancy in patients with prosthetic cardiac valve. a 10-year experience. Scand J Thorac Cardiovasc Surg. 1988; 22: 19–22.CrossrefMedlineGoogle Scholar13 Sareli P, England MJ, Berk MR, et al. Maternal and fetal sequelae of anticoagulation during pregnancy in patients with mechanical heart-valve prostheses. J Am Coll Cardiol. 1989; 63: 1462–1465.CrossrefGoogle Scholar14 Cotrufo M, de Luca TSL, Calabro R, et al. Coumadin anticoagulation during pregnancy in patients with mechanical valve prostheses. Eur J Cardiothorac Surg. 1991; 5: 300–305.CrossrefMedlineGoogle Scholar15 Born D, Martinez EE, Almeida PAM, et al. Pregnancy in patients with prosthetic heart valves: the effects of anticoagulation on mother, fetus, and neonate. Am Heart J. 1992; 124: 413–417.CrossrefMedlineGoogle Scholar16 Wong V, Cheng CH, Chan KC. Fetal and neonatal outcome of exposure to anticoagulants during pregnancy. Am J Med Genet. 1993; 45: 17–21.CrossrefMedlineGoogle Scholar17 Hanania G, Thomas D, Michel PL, et al. Pregnancy in patients with valvular prostheses-retrospective cooperative study in France (155 cases). J Arch Mal Coeur Vaiss. 1994; 87: 429–437.Google Scholar18 Vitale N, Feo MD, DeSanto LS, et al. Dose-dependent fetal complications of warfarin in pregnant women with mechanical heart valves. J Am Coll Cardiol. 1999; 33: 1637–1641.CrossrefMedlineGoogle Scholar19 Chan WC, Anand S, Ginsberg JS. Anticoagulation of pregnant women with mechanical valves: a systemic review of the literature. Arch Int Med. 2000; 160: 191–196.CrossrefMedlineGoogle Scholar20 Ginsberg JS, Barron WM. Pregnancy and prosthetic heart valves. Lancet. 1994; 344: 1170–1172.CrossrefMedlineGoogle Scholar21 Ginsberg JS, Kowalchuk G, Hirsh J, et al. Heparin therapy during pregnancy-risks to the fetus and mother. Arch Int Med. 1989; 149: 2233–2236.CrossrefMedlineGoogle Scholar22 Oakley CM. Anticoagulants in pregnancy. Br Heart J. 1995; 74: 107–111.CrossrefMedlineGoogle Scholar23 Idir M, Madonna F, Rondant R. Collapse and massive pulmonary edema secondary to thrombosis of a mitral mechanical heart valve prosthesis during low-molecular weight- heparin therapy. J Heart Valve Dis. 1999; 8: 303–304.MedlineGoogle Scholar24 FDA Med Watch. Available at: http://www.fda.gov/medwatch. Accessed July 20, 2002.Google Scholar25 Bartolloti U, Milano A, Massucco A, et al. Pregnancy in patients with a porcine valve bioprosthesis. Am J Cardiol. 1982; 50: 1051–1054.CrossrefMedlineGoogle Scholar26 Badduke ER, Jamieson RE, Miyashima RT, et al. Pregnancy and childbearing in a population with biologic valvular prostheses. J Thorac Cardiovasc Surg. 1991; 102: 179–186.CrossrefMedlineGoogle Scholar27 Jamieson WRE, Miller DC, Akins CW, et al. Pregnancy and bioprosthesis: influence on structural valve deterioration. Ann Thorac Surg. 1995; 60: S282–S287.CrossrefMedlineGoogle Scholar28 Yun KL, Miller DC, Moore KA, et al. Durability of the Hancock MO bioprosthesis compared with the standard aortic valve bioprosthesis. Ann Thorac Surg. 1995; 60: 5221–228.Google Scholar29 Rahimtoola SH. Choice of prosthetic heart valve for adult patients. J Am Coll Cardiol. In press.Google Scholar30 Grunkemeier GL, Li H-H, Naftel DC, et al. Long-term performance of heart valve prosthesis. Curr Probl in Cardiol. 2000; 25: 73–156.CrossrefMedlineGoogle Scholar31 Ross DN. The pulmonary autograft: the Ross principle (or Ross procedural confusion). J Heart Valve Dis. 2000; 9: 174–175.MedlineGoogle Scholar32 Dore A, Sommerville J. Pregnancy in patients with pulmonary autograft valve replacement. Eur Heart J. 1997; 18: 1659–1662.CrossrefMedlineGoogle Scholar33 Choudhary SK, Mather A, Chandler H, et al. Aortic valve replacement with biological substitute. J Cardiac Surg. 1998; 13: 1–8.CrossrefMedlineGoogle Scholar34 Pieters FAA, Al-Halees 2, Hatle L, et al. Results of the Ross operation in rheumatic versus non-rheumatic aortic valve disease. J Heart Valve Dis. 2000; 9: 38–44.MedlineGoogle Scholar35 Matsuki O, Okita Y, Almeida RS, et al. Two decades experience with aortic valve replacement with pulmonary autograft. J Thoracic Cardiovasc Surg. 1988; 95: 705–711.CrossrefMedlineGoogle Scholar36 Ross D, Jackson M, Davies J. Pulmonary autograft aortic valve replacement: long-term results. J Cardiac Surg. 1991; 6 (suppl): 529–533.CrossrefMedlineGoogle Scholar37 Ross D, Jackson M, Davies J. The pulmonary autograft: a permanent aortic valve. Eur J Cardio-Thorac Surg. 1992; 6: 113–117.CrossrefMedlineGoogle Scholar38 Chambers JC, Somerville J, Stone S, et al. Pulmonary autograft procedure for aortic valve disease: long-term results of the pioneer series. Circulation. 1997; 96: 2206–2214.CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Lindley K, Bairey Merz C, Asgar A, Bello N, Chandra S, Davis M, Gomberg-Maitland M, Gulati M, Hollier L, Krieger E, Park K, Silversides C, Wolfe N and Pepine C (2021) Management of Women With Congenital or Inherited Cardiovascular Disease From Pre-Conception Through Pregnancy and Postpartum, Journal of the American College of Cardiology, 10.1016/j.jacc.2021.02.026, 77:14, (1778-1798), Online publication date: 1-Apr-2021. Edupuganti M and Vineela P (2021) A RETROSPECTIVE STUDY ON CARDIAC DISEASE IN PREGNANCY, PARIPEX INDIAN JOURNAL OF RESEARCH, 10.36106/paripex/2100520, (15-19), Online publication date: 15-Sep-2021. Valente A (2021) Pregnancy and Heart Disease Echocardiography in Pediatric and Congenital Heart Disease, 10.1002/9781119612858.ch43, (904-923), Online publication date: 27-Dec-2022. Carabello B (2020) Evidenced-Based and Practical Management of Real-World Valvular Heart Disease Valvular Heart Disease, 10.1007/978-1-4471-2840-3_13, (285-305), . Daughety M, Zilberman-Rudenko J, Shatzel J, McCarty O, Raghunathan V and DeLoughery T (2020) Management of Anticoagulation in Pregnant Women With Mechanical Heart Valves, Obstetrical & Gynecological Survey, 10.1097/OGX.0000000000000751, 75:3, (190-198), Online publication date: 1-Mar-2020. Hutt E and Desai M (2020) Management of valvular heart disease in the pregnant patient, Expert Review of Cardiovascular Therapy, 10.1080/14779072.2020.1797490, 18:8, (495-501), Online publication date: 2-Aug-2020. Kayatta M, Leshnower B, McPherson L, Binongo J, Lasanajak Y and Chen E (2019) Valve-Sparing Root Replacement Provides Excellent Midterm Outcomes for Bicuspid Valve Aortopathy, The Annals of Thoracic Surgery, 10.1016/j.athoracsur.2018.08.011, 107:2, (499-504), Online publication date: 1-Feb-2019. Mazine A, El-Hamamsy I, Verma S, Peterson M, Bonow R, Yacoub M, David T and Bhatt D (2018) Ross Procedure in Adults for Cardiologists and Cardiac Surgeons, Journal of the American College of Cardiology, 10.1016/j.jacc.2018.08.2200, 72:22, (2761-2777), Online publication date: 1-Dec-2018. Collier P (2018) OBSOLETE: Diseases of the Mitral Valve Reference Module in Biomedical Sciences, 10.1016/B978-0-12-801238-3.99707-1, . Doenst T (2018) Prinzipien und Perspektiven der MitralklappenchirurgiePrinciples and perspectives of mitral valve surgery, Zeitschrift für Herz-,Thorax- und Gefäßchirurgie, 10.1007/s00398-018-0210-5, 32:5, (352-360), Online publication date: 1-Oct-2018. Batra J, Itagaki S, Egorova N and Chikwe J (2018) Outcomes and Long-term Effects of Pregnancy in Women With Biologic and Mechanical Valve Prostheses, The American Journal of Cardiology, 10.1016/j.amjcard.2018.07.020, 122:10, (1738-1744), Online publication date: 1-Nov-2018. Mc Carthy L and Collier P (2018) Diseases of the Mitral Valve Encyclopedia of Cardiovascular Research and Medicine, 10.1016/B978-0-12-809657-4.99707-2, (98-106), . Ouzounian M, Mazine A and David T (2017) The Ross procedure is the best operation to treat aortic stenosis in young and middle-aged adults, The Journal of Thoracic and Cardiovascular Surgery, 10.1016/j.jtcvs.2017.03.156, 154:3, (778-782), Online publication date: 1-Sep-2017. Kyo S, Imanaka K, Masuda M, Miyata T, Morita K, Morota T, Nomura M, Saiki Y, Sawa Y, Sueda T, Ueda Y, Yamazaki K, Yozu R, Iwamoto M, Kawamoto S, Koyama I, Kudo M, Matsumiya G, Orihashi K, Oshima H, Saito S, Sakamoto Y, Shigematsu K, Taketani T, Komuro I, Takamoto S, Tei C and Yamamoto F (2017) Guidelines for Perioperative Cardiovascular Evaluation and Management for Noncardiac Surgery (JCS 2014) ― Digest Version ―, Circulation Journal, 10.1253/circj.CJ-66-0135, 81:2, (245-267), . Misfeld M, Charitos E and Sievers H (2017) Acquired Lesions of the Aortic Valve Cardiac Surgery, 10.1007/978-3-662-52672-9_24, (759-794), . Cohen H, Arachchillage D, Middeldorp S, Beyer-Westendorf J and Abdul-Kadir R (2016) Management of direct oral anticoagulants in women of childbearing potential: guidance from the SSC of the ISTH: reply, Journal of Thrombosis and Haemostasis, 10.1111/jth.13535, 15:1, (195-197), Online publication date: 1-Jan-2017. Desborough M, Pavord S and Hunt B (2016) Management of direct oral anticoagulants in women of childbearing potential: guidance from the SSC of the ISTH: comment, Journal of Thrombosis and Haemostasis, 10.1111/jth.13484, 15:1, (194-195), Online publication date: 1-Jan-2017. Khader K, Saad A and Abdelshafy M (2015) Pregnancy Outcome in Women with Mechanical Prosthetic Heart Valves Treated with Unfractionated Heparin (UFH) or Enoxaparin, The Journal of Obstetrics and Gynecology of India, 10.1007/s13224-015-0678-9, 66:5, (321-326), Online publication date: 1-Oct-2016. Barbarash L, Rutkovskaya N, Barbarash O, Odarenko Y, Stasev A and Uchasova E (2016) Prosthetic heart valve selection in women of childbearing age with acquired heart disease: a case report, Journal of Medical Case Reports, 10.1186/s13256-016-0821-y, 10:1, Online publication date: 1-Dec-2016. Mazine A, David T, Rao V, Hickey E, Christie S, Manlhiot C and Ouzounian M (2016) Long-Term Outcomes of the Ross Procedure Versus Mechanical Aortic Valve Replacement, Circulation, 10.1161/CIRCULATIONAHA.116.022800, 134:8, (576-585), Online publication date: 23-Aug-2016. Kanhere A and Kanhere V (2016) Pregnancy After Cardiac Surgery, The Journal of Obstetrics and Gynecology of India, 10.1007/s13224-016-0841-y, 66:1, (10-15), Online publication date: 1-Feb-2016. Ayad S, Hassanein M, Mohamed E and Gohar A (2016) Maternal and Fetal Outcomes in Pregnant Women with a Prosthetic Mechanical Heart Valve, Clinical Medicine Insights: Cardiology, 10.4137/CMC.S36740, 10, (CMC.S36740), Online publication date: 1-Jan-2016. Valente A (2016) Pregnancy and Heart Disease Echocardiography in Pediatric and Congenital Heart Disease, 10.1002/9781118742440.ch43, (815-833) Adilova L, Adamyan L, Lyashko E, Shifman E, Tyulkina E, Konisheva O, Lukina N and Lapochkina O (2015) The pregnancy in women with bioprosthetic heart valves, Problemy reproduktsii, 10.17116/repro2015213111-116, 21:3, (111), . Morimoto K, Hoashi T, Kagisaki K, Yoshimatsu J, Shiraishi I, Ichikawa H, Kobayashi J, Nakatani T, Yagihara T, Kitamura S and Fujita T (2015) Impact of Ross Operation on Outcome in Young Female Adult Patients Wanting to Have Children, Circulation Journal, 10.1253/circj.CJ-15-0410, 79:9, (1976-1983), . Herrey A, Cohen H and Walker F (2015) Antithrombotic Therapy for Cardiac Disorders in Pregnancy Disorders of Thrombosis and Hemostasis in Pregnancy, 10.1007/978-3-319-15120-5_10, (173-191), . Nanna M and Stergiopoulos K (2014) Pregnancy Complicated by Valvular Heart Disease: An Update, Journal of the American Heart Association, 3:3, Online publication date: 22-May-2014. Nappi F, Spadaccio C, Chello M, Lusini M and Acar C (2014) Impact of Structural Valve Deterioration on Outcomes in the Cryopreserved Mitral Homograft Valve, Journal of Cardiac Surgery, 10.1111/jocs.12400, 29:5, (616-622), Online publication date: 1-Sep-2014. Regitz-Zagrosek V, Gohlke-Ba¨rwolf C, Iung B and Pieper P (2014) Management of Cardiovascular Diseases During Pregnancy, Current Problems in Cardiology, 10.1016/j.cpcardiol.2014.02.001, 39:4-5, (85-151), Online publication date: 1-Apr-2014. Nappi F, Spadaccio C, Chello M, Lusini M and Acar C (2014) Long-Term Structural Valve Degeneration in Cryopreserved Mitral and Aortic Homograft: Is Pregnancy a Factor?, World Journal of Cardiovascular Diseases, 10.4236/wjcd.2014.46036, 04:06, (277-286), . Basude S, Trinder J, Caputo M and Curtis S (2014) Pregnancy outcome and follow-up cardiac outcome in women with aortic valve replacement, Obstetric Medicine, 10.1177/1753495X13514382, 7:1, (29-33), Online publication date: 1-Mar-2014. Deloughery T (2013) Anticoagulation for Atrial Fibrillation and Prosthetic Cardiac Valves Consultative Hemostasis and Thrombosis, 10.1016/B978-1-4557-2296-9.00047-6, (786-799), . Prapa S, Dimopoulos K, Shore D, Petrou M and Gatzoulis M (2013) Adult Congenital Heart Disease Pediatric Cardiac Surgery, 10.1002
Referência(s)