2. Medical History
• 20 years-old lady living in Tahiti
• 2006: Mitral valve repair + tricuspid annuloplasty in for
severe rheumatic mitral regurgitation
• 2010: mechanical valve replacement for recurrence of mitral
stenosis and mitral regurgitation
• Early 2012: Pregnancy. Vitamin K antagonists were
sustained throughout pregnancy including the first
trimester until the 36th week than was replaced by heparin.
• Mid-october 2012: delivery complicated by a severe
hemorrhage and anticoagulation was stopped for several
days
• In the following days, a large prosthetic thrombosis was
diagnosed during systematic transesophageal
echocardiography without any hemodynamic consequences.
• No changes after 2 weeks of correct anticoagulation +
aspirin and the patient was referred to our center for
surgery
3. Clinical and Transthoracic Echocardiographic
Examination at Arrival
• Perfectly tolerated 24 hours trip
• Physical examination
• Markedly overweight
• BP 117/75
• 2/6 diastolic murmur
• No sign of congestive heart failure
• ECG: sinus rhythm
• Transthoracic echocardiography
• Normal systolic function
• Increased mean transmitral gradient (14 mm hg) despite normal leaflets
motion
• Systolic pulmonary artery pressure: 40 mm Hg
5. LARGE OBSTRUCTIVE
PROSTHETIC THROMBOSIS
Normal mobility of both leaflets
(arrows) but unilateral
transprosthetic flow
6. 3D Transesophageal Echocardiography
Large thrombus
masking completely
the medial leaflet
(surgical view from
the left atrium, left
appendage (not
seen) on the right)
7. Management and Outcome
• The patient was operated on the next day
• Surgery confirmed the large prosthetic thrombosis
• A new mechanical valve (St Jude mitral n°25) was
implanted (no desire of any further pregnancy)
8. Take Home Message 1: Management of
Mechanical Valve Thrombosis
• Obstructive valve thrombosis should be suspected promptly
in any patient with any type of prosthetic valve, who
presents with recent dyspnea, embolic event or inadequate
anticoagulation
• The analysis of the risks and benefits of fibrinolysis should
be adapted to patient characteristics and local resources.
• Urgent or emergency valve replacement is recommended
for obstructive thrombosis in critically ill patients without
serious comorbidity
10. Take Home Message 2: Choice of valve
prosthesis
• Mechanical valves offer excellent hemodynamic
performance and long-term durability, but the need for
anticoagulation increases fetal and maternal mortality and
morbidity.
• Bioprosthetic valves also offer good hemodynamic
performance and are much less thrombogenic. Their use in
young women, however, is associated with a high risk of
structural valve deterioration, occurring in ≈50% of women
<30 years of age at 10 years post-implantation, and is
greater in the mitral position than in the aortic and tricuspid
position.
11. Take Home Message 3: Anticoagulation Regimen
During Pregnancy in patients with Mechanical Valve
• Pregnancy is associated with an increased maternal risk and
all anticoagulation regimens carry an increased risk of
miscarriage and of hemorrhagic complications, including
retroplacental bleeding leading to premature birth and fetal
death.
• The need for anticoagulation raises specific concerns
because of an increased risk of valve thrombosis, of
hemorrhagic complications, and of offspring complications.
12. Take Home Message 3: Anticoagulation Regimen
During Pregnancy in patients with Mechanical Valve
• First trimester:
• Continuation of oral anticoagulants throughout pregnancy should be considered,
after patient information and consent, when the warfarin dose is 5 mg daily (or
phenprocoumon ,3 mg or acenocoumarol ,2 mg daily) because the risk of
embryopathy is low (<3%), while oral anticoagulants are in large series the most
effective regimen to prevent valve thrombosis. [Recommendation Class IIa Level
of evidence C].
• Discontinuation of OAC between weeks 6 and 12 and replacement by adjusted-
dose unfractionated heparin (a PTT ≥2× control; in high risk patients applied as
intravenous infusion) or low molecular weight heparin twice daily (with dose
adjustment according to weight and target anti-Xa level 4–6 hours post-dose 0.8–
1.2 U/mL) should be considered in patients with a warfarin dose required of >5
mg/day (or phenprocoumon >3 mg/day or acenocoumarol >2mg/day).
[Recommendation Class IIa Level of evidence C].
• Discontinuation of OACs between weeks 6 and 12 and replacement by UFH or
LMWH under strict dose control (as described above) may be considered on an
individual basis in patients with warfarin dose required for therapeutic
anticoagulation <5 mg/day (or phenprocoumon <3 mg/day or acenocoumarol <2
mg/day). [Recommendation Class IIb Level of evidence C].
• Whatever the anticoagulation regimen, a weekly control is mandatory
13. Take Home Message 3: Anticoagulation Regimen
During Pregnancy in patients with Mechanical Valve
• Oral anticoagulants are recommended during the second and third
trimesters until the 36th week. [Recommendation Class I Level of
evidence C].
• Planned vaginal delivery is usually preferred, with prior switch to
heparin. A planned caesarean section may be considered as an
alternative, especially in patients with a high risk of valve
thrombosis, in order to keep the time without oral anticoagulants
as short as possible.
• Oral anticoagulants should be discontinued and dose-adjusted unfractionated
heparin (a PTT ≥2× control) or adjusted-dose low molecular weight heparin
(target anti-Xa level 4–6 hours post-dose 0.8-1.2 U/mL) started at the 36th week
of gestation. [Recommendation Class I Level of evidence C].
• Low molecular weight heparin should be replaced by intravenous unfractionated
heparin at least 36 hours before planned delivery. Unfractionated heparin should
be continued until 4–6 hours before planned delivery and restarted 4–6 hours after
delivery if there are no bleeding complications. [Recommendation Class I Level of
evidence C].
• If delivery starts while on oral anticoagulants , caesarean delivery is indicated.
[Recommendation Class I Level of evidence C].
14. Join the ESC Working Group
on Valvular Heart Disease
and take part in its
activities !
Membership is FREE!
