The regimen of adjusted doses of subcutaneous heparin used in this study is not effective to prevent thrombosis of mechanical valve prostheses during pregnancy. The use of heparin from the 6th to the 12th week of gestation does not decrease the high incidence of fetal wastage associated with anticoagulant therapy. Coumarin agents provide adequate protection against thromboembolism during pregnancy in patients with mechanical valve prostheses.

In an attempt to identify the best treatment for pregnant women with cardiac-valve prostheses who are receiving oral anticoagulants, we studied 72 pregnancies prospectively. In 23 pregnancies (Group I), the coumarin derivative acenocoumarol was discontinued and the patients received 5,000 U of subcutaneous heparin every 12 hours from the 6th to the 12th week of gestation, in 12 pregnancies (Group II), heparin was not substituted for the coumarin derivative until after the 7th week, and in 37 pregnancies, detected after the first trimester (Group III), the coumarin derivative was given throughout gestation. In most patients heparin was again substituted for the oral anticoagulant after the 38th week. Three mothers had thrombosis of a tilting-disk mitral prosthesis (two cases were fatal) during heparin treatment. No differences were found in the rates of spontaneous abortion in the three groups. Coumarin embryopathy occurred in 25 percent and 29.6 percent of the pregnancies in Groups II and III, respectively. We conclude that in the second and third trimesters of pregnancy, coumarin derivatives provide effective protection against thromboembolism while causing few fetopathic effects, but that these agents are contraindicated from the 6th to the 12th weeks of gestation. Low-dose heparin does not protect against prosthetic-valve thrombosis, and the possibility that a larger dose might be more effective requires further exploration.

No abstract

SummaryBackground: Aortic valvular disease is the most common valvular lesion among elderly patients. Because of changing demographics, it has become increasingly frequent. Aortic valve replacement (AVR) is the only effective treatment for aortic valvular disease.Hypothesis: This study was undertaken to evaluate the results of AVR in an elderly population.Methods: Data were retrospectively analyzed in 117 consecutive patients (mean age 73.8 years) who underwent AVR between 1991 and 2002.Results: Pure or predominant severe aortic stenosis was present in 108 patients. Nine patients had severe aortic regurgitation. Before valve replacement, 62.4% of the patients were in New York Heart Association (NYHA) functional class III-IV. A bioprosthesis was implanted in 62.4% of the patients, and 37.6% received a mechanical valve. Concomitant cardiac surgical procedures were performed in 25 patients (coronary artery bypass graft in 22, mitral valve replacement in 3). There were 17 deaths, giving a perioperative mortality rate of 14.5%. Multivariate logistic regression showed that repeat surgery for bleeding, prolonged cardiopulmonary bypass time, postoperative respiratory failure, and postoperative acute renal insufficiency were significant independent predictors of operative mortality. Of the 100 hospital survivors, 78 were followed for a mean of 42.9 months. There were six deaths during followup; only two of these were cardiac related. Five-year actuarial survival for all patients and for hospital survivors were 70 and 91.1%, respectively. One year post surgery, all patients were in NYHA functional class I-II.

HLickgroiinti: Pregnancy can cause life-threatening coniplications in women with mitral stenosis. Frequently. there is an urgent need to increase the mitral valve area mechanically. In selected cases, percutaneous initral balloon vulvotomy (PMBV) has emerged as a safe andeft'ective alternative to surgical commissurotom y. Hypotfwsis: The study evaluates the effects of PMRV by the Inoue technique in nine pregnant patients with severe symptomatic initral stenosis. Methods: The patients were in New York Heart Association (NY HA) functional class I1 to JV and had echocardiographic scores of< 8. The mean gestational age was 74.8 .+ 6.1 weeks. The patient's pelvic and abdominal regions were covered with a lead apron to protect the fetus from radiation. A stepwise dilatation technique was used. Fluoroscopy time was kept to 10 to 15 min. h'iw/ts: One patient developed severe niitral regurgitation requiring emergency valve replacement. The remaining eight patients showed marked immediate symptomatic and hemodynamic improvement. After dilatation. the transniitral pressure gradient decreased from 20.8 2 6.5 to 7.3 f I .4 mnHg (p = 0.00 I) and the calculated niitral valve area increased from 0.9 +. 0.1 to 1.8 +. 0.4 (p < 0.00 I). All patients had uneventful term deliveries of norinal babies. On follow-up they were in NYHA functional class I. Cow/usiom: Percutaneous mi tral balloon valvotomy is a safe and effective procedure for selected pregnant patients with severe initral stenosis. The procedure is well tolerated by the fetus. Severe mitral regurgitation requiring immediate surgery may occur occasionally. The possible harmful effects to the fetus from its exposure to radiation during PMBV are unknown.