It is recommended that pregnant women with an MHV are managed by the Pregnancy Heart Team.Guideline rec
Class ILevel CRec Table 19 · §12.5.3 · p.4534
Mechanical valve anticoagulation
Inputs
Output
Management of pregnant women with mechanical heart valves by the Pregnancy Heart Team
Class I
Figure 21 [FIG]Good control of anticoagulation with therapeutic INRs
No class printed
Figure 21 [FIG]Figure 21 starts from 'Good control of anticoagulation with therapeutic INRs'. Answer Q1 to see the printed options. Until then: The guideline does not specify this.
Doses for extremes of body weight, renal failure or twin pregnancy are not printed for women with MHVs. The guideline does not specify this.
Regular maternal cardiac ultrasound should be performed during pregnancy to assess valve function and rule out valve thrombosis. Imaging once per trimester will usually suffice unless there is pre-existing valve dysfunction or HF. Changes in valve gradient that exceed the usual increase due to changing cardiac output should be investigated. Symptoms such as new HF, embolic event, or syncope need urgent assessment.
No class printed§12.5.3.2.2, printed p4534 [TXT]
Valve thrombosis has a high maternal mortality. Its management is comparable with management in non-pregnant women. In a subacute setting, optimizing anticoagulation with UFH and re-establishing a therapeutic INR with VKA may be sufficient. Thrombolysis may be considered, especially in non-critically ill women, when surgery is not immediately available for critically ill women, and in right-sided prosthetic valve thrombosis. Urgent intervention is often required in acute thrombosis with obstruction or severe regurgitation.
No class printed§12.5.3.2.2, printed p4534 [TXT]
- Peak anti-factor Xa target: Table 11 prints 0.8–1.2 U/mL (4–6 h post administration); §5.2.1.2.1 prints 'between 1.0 and 1.2 U/mL' and §12.5.3.2.1 'between 1 and 1.2 IU/mL'. Working choice: Table 11, with the text range shown. [REVIEW]
- Table 10 prints 'High VKA dose to achieve required INR → Switch to LMWH'. Figure 21 prints 'Continue VKA' for high risk of valve thrombosis and 'Continuous i.v. UFH' for high risk with high VKA dose and/or no anti-factor Xa testing. Both are shown; the Pregnancy Heart Team decides.
- Tinzaparin: Table 11 prints '250 IU /kg (starting dose) then 175 IU/kg o.d.' (once daily) in a row whose other drugs are b.i.d., and §12.5.3.2.1 says LMWH 'twice daily'. Shown as printed. [REVIEW]
- Warfarin low-dose threshold is printed '≤5 mg of warfarin' without '/day' (Table 10 footnote f, §5.2.1.1).
- Figure 21 footnote b cites Section 4.5.7; the delivery text is Section 4.5.6.
- The project plan places aspirin in Figure 21; it is not in the figure. The text (§12.5.3.2.1) says the addition of low-dose ASA 'should be considered' in women with a very high thrombotic risk, with no class and no definition of 'very high'.
- Rec Table 4 (Class III, Level C) is 'DOACs are not recommended during pregnancy'. For lactation the guideline prints only text ('alternative drugs should be preferred to DOACs'), with no class.
- 2018 content is superseded (Supplement S1/S2); only 2025 wording is shown.
Educational summary of the 2025 ESC Guidelines. It does not replace clinical judgement or local protocol.