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Asian Cardiovasc Thorac Ann 2006;14:264
© 2006 Asia Publishing EXchange Ltd

LETTER TO EDITOR

MECHANICAL VALVES AND PREGNANCY: A CAVEAT

Zohair Al Halees, MD

King Faisal Heart Institute, King Faisal Specialist Hospital & Research Center, MBC #16, P.O. Box 3354, Riyadh 11211, Saudi Arabia, Tel.: 966 1 442 7470, Fax: 966 1 442 7482, Email: alhalees{at}kfshrc.edu.sa

This letter refers to the article, "Anticoagulation in Patients with Mechanical Valves During Pregnancy" by Muhammad A. Geelani, et.al. which appeared in the recent issue of the Asian Cardiovascular and Thaoracic Annals.1

The article deals with a problem we often encounter in our area as well: Young females in childbearing age requiring replacement. There is no clear consensus on the optimal type of valve prosthesis that should be implanted in these patients. Mechanical valve replacement requires long-term anticoagulation and since pregnancy is a natural hypercoagulable state, the warfarin monitoring intensity required may be higher than usual. Both warfarin and heparin have been used to anticoagulate pregnant women with mechanical valves, but neither represents an ideal therapy. This is demonstrated in many reports in literature. Warfarin embryopathy and fetal wastage, risk maternal thromboembolism, valve thrombosis, bleeding and death have all been reported.2,3

What is striking about this article is the almost perfect outcome; something we probably see for the first time in literature. A single institution experience of 250 pregnancies in 10 years in women with mechanical valves has got to be the largest reported. One of the largest series reported previously is that by Sbarouni and Oakley,4 214 pregnancies in women with a prosthetic heart valve was multi-institutional and actually the information was obtained by questionnaires rather than by follow-up!

Other striking features noted are:

  1. 150 patients took warfarin (group I) with almost perfect INR and surprisingly all are requiring not more than 5 mg of warfarin, the supposedly "safe" warfarin dose to avoid embryopathy.
  2. The very low incidence of maternal and fetus complications. Even the spontaneous abortion rate reported is lower than what is seen with pregnancy in matched groups of women without prosthetic heart valves.5

We encounter many difficulties following our patients with mechanical heart valves and keeping their INRs within the target range. Despite all our good intention and efforts, we probably cannot match the results reported. That is why we have been using alternate solutions like valve repairs and biological prosthesis. Knowing that our patients have many similar characteristics and social backgrounds to the patients in India, we find that the results reported are truly outstanding and almost too good!

REFERENCES:

  1. Geelani MA, Singh S, Verna A, Nagesh A, Betigeri V, Nigam M. Anticoagulation in Patients with Mechanical Valves During Pregnancy. Asian Cardiovasc Thorac Ann 2005;13:30–3.[Abstract/Free Full Text]

  2. Srivastava AK, Gupta AK, Singh AV, Husain T. Effect of Oral Anticoagulant During Pregnancy with Prosthetic Heart Valve. Asian Cardiovasc Thorac Ann 2002;10:306–9.[Abstract/Free Full Text]

  3. Salazar E, Izaguirre R, Verdejo J, Mutchinick O. Failure of adjusted doses subcutaneous heparin to prevent thromboembolic phenomena in pregnant patients with mechanical cardiac valve prosthesis. J Am Coll Cardiol 1996;27:1698–703.[Abstract]

  4. Sbarouni E, Oakley CM. Outcome of pregnancy in women with valve prostheses. Br Heart J 1994;71:196–201.[Abstract/Free Full Text]

  5. Ashour ZA, Shawky HA, Hassan Hussein M. Outcome of pregnancy in women with mechanical valves. Tex Heart Inst J 2000; 27:240–5.[Medline]





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