European Heart Journal Advance Access originally published online on August 20, 2007
European Heart Journal 2007 28(19):2419; doi:10.1093/eurheartj/ehm334
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Management of pregnant women with artificial heart valves: inconsistency in ESC publications
Department of Cardiology
RWTH Aachen University
Pauwelsstrasse 30
52074 Aachen
Germany
Tel: +49 241 8089669 Fax: +49 241 8082303 E-mail address: kmischke{at}ukaachen.de
I read with interest the ESC position paper on anticoagulants in heart disease.1 However, I was surprised by the succinct statement on anticoagulation in pregnant patients with artificial heart valves. Vitamin K antagonists increase the risk of embryopathy, whereas the use of unfractionated heparin has been associated with an increased thrombo-embolic risk for the mother. Experience with low molecular weight heparin is still limited.
The risk of warfarin embryopathy is probably dose-dependent.2 The current ESC guideline on management of valvular heart disease published in this journal in January 2007 therefore favours the use of warfarin during the first trimester if the dose is 
5 mg/24 h.3 This recommendation is in line with an older ESC consensus document published in 2003.4 The management of pregnant women with artificial heart valves using low molecular weight heparin proposed in the paper by De Caterina et al. deviates from these ESC guidelines without any further explanation. Interestingly, even the cited recommendations by Butchart et al.5 published in 2005 strongly favour the use of oral anticoagulation throughout pregnancy. However, the policy suggested in the ESC position paper by De Caterina et al. is in line with current AHA recommendations.6
The optimal management of pregnant women with artificial heart valves is discussed controversially and often poses a challenge to both physicians and patients involved. Because clinicians rely on guidelines and expert recommendations, it is important to establish consistency within publications by ESC task forces and working groups. However, in case of controversial opinions, these should be discussed.
References
- De Caterina R, Husted S, Wallentin L, Agnelli G, Bachmann F, Baigent C, Jespersen J, Kristensen SD, Montalescot G, Siegbahn A, Verheugt FW, Weitz J. Anticoagulants in heart disease: current status and perspectives. Eur Heart J (2007) 28:880–913.
[Free Full Text] - Vitale N, De Feo M, De Santo LS, Pollice A, Tedesco N, Cotrufo M. Dose-dependent fetal complications of warfarin in pregnant women with mechanical heart valves. J Am Coll Cardiol (1999) 33:1637–1641.
[Abstract/Free Full Text] - Vahanian A, Baumgartner H, Bax J, Butchart E, Dion R, Filippatos G, Flachskampf F, Hall R, Iung B, Kasprzak J, Nataf P, Tornos P, Torracca L, Wenink A. Guidelines on the management of valvular heart disease: The Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology. Eur Heart J (2007) 28:230–268.
[Free Full Text] - Expert consensus document on management of cardiovascular diseases during pregnancy. Eur Heart J (2003) 24:761–781.
[Free Full Text] - Butchart EG, Gohlke-Bärwolf C, Antunes MJ, Tornos P, De Caterina R, Cormier B, Prendergast B, Iung B, Bjornstad H, Leport C, Hall RJ, Vahanian A. Working Groups on Valvular Heart Disease, Thrombosis, and Cardiac Rehabilitation and Exercise Physiology, European Society of Cardiology. Recommendations for the management of patients after heart valve surgery. Eur Heart J (2005) 26:2463–2471.
[Abstract/Free Full Text] - Bonow RO, Carabello BA, Kanu C, de Leon AC, Faxon DP, Freed MD, Gaasch WH, Lytle BW, Nishimura RA, O'Gara PT, O'Rourke RA, Otto CM, Shah PM, Shanewise JS, Smith SC, Jacobs AK, Adams CD, Anderson JL, Antman EM, Faxon DP, Fuster V, Halperin JL, Hiratzka LF, Hunt SA, Lytle BW, Nishimura R, Page RL, Riegel B. ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (writing committee to revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): developed in collaboration with the Society of Cardiovascular Anesthesiologists: endorsed by the Society for Cardiovascular Angiography and Interventions and the Society of Thoracic Surgeons. Circulation (2006) 114:e84–e231.
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