Prosthetic Heart Valves Differential Diagnoses

Updated: Jan 03, 2022
  • Author: Kirtivardhan Vashistha, MBBS; Chief Editor: Richard A Lange, MD, MBA  more...
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DDx

Diagnostic Considerations

Other conditions to consider in patients with prosthetic heart valves include the following:

  • Hemolytic anemia

  • Thromboembolic disease

  • Cardiac conduction disturbances

Prepare patients with acute primary valve failure and severe hemodynamic compromise for surgery as quickly as possible. Delays in surgery to pursue diagnostic testing result in increased mortality.

Consider prosthetic valve endocarditis (PVE) in any patient with a prosthetic valve and a fever.

Pregnancy

Women with mechanical heart valves are considered very high risk for maternal mortality and morbidity in the setting of pregnancy, even classified by the World Health Organization as risk category III. One should consider a preconception transthoracic echocardiogram (TTE) to assess valvular function, ventricular function, and pulmonary artery pressures. If abnormalities are found, then preconception interventions may be beneficial to reduce risks during pregnancy. [12]

Pregnant women are at higher risk of valvular thrombosis due to being in a hypercoagulable state. It is important to discuss with the patient the risks and benefits of the anticoagulation strategies in pregnancy to determine the best strategy moving forward. [12]

For women with mechanical prosthetic valves, anticoagulation is recommended with frequent monitoring throughout the pregnancy. If therapeutic anticoagulation cannot be achieved or maintained, these women should be counseled against pregnancy. Vitamin K antagonists (VKAs), such as warfarin, are associated with the lowest maternal complications but the highest risk of miscarriage, fetal death, and congenital abnormalities, particularly when taken during the first trimester. Although low molecular-weight heparin (LMWH) is not teratogenic, it is associated with an increased risk of maternal thrombotic events. [12]

There is no perfect strategy for anticoagulation in pregnant women with mechanical prosthetic valves. The therapy strategies are as follows: continue warfarin throughout the pregnancy, switch to LMWH and use throughout the pregnancy, or use LMWH during the first trimester and warfarin during the second and third trimesters. [12]

At least 1 week before planned delivery, pregnant women on a VKA should be switched to twice daily dosing of LMWH or intravenous unfractionated heparin (UFH). Pregnant women should be switched off LMWH to UFH 36 hours before planned vaginal delivery. UFH should be stopped at least 6 hours prior to vaginal delivery. If labor occurs while the woman is therapeutic on a VKA, reversal of VKA prior to cesarean delivery is important. [12]

Differential Diagnoses