title: Pregnancy in Women With a Mechanical Heart Valve: Data of the European Society of Cardiology Registry of Pregnancy and Cardiac Disease (ROPAC).
abstract: BACKGROUND
  Pregnant women with a mechanical heart valve (MHV) are at a heightened risk of a thrombotic event, and their absolute need for adequate anticoagulation puts them at considerable risk of bleeding and, with some anticoagulants, fetotoxicity.
  
  
  RESULTS
  Within the prospective, observational, contemporary, worldwide Registry of Pregnancy and Cardiac disease (ROPAC), we describe the pregnancy outcome of 212 patients with an MHV. We compare them with 134 patients with a tissue heart valve and 2620 other patients without a prosthetic valve. Maternal mortality occurred in 1.4% of the patients with an MHV, in 1.5% of patients with a tissue heart valve (P=1.000), and in 0.2% of patients without a prosthetic valve (P=0.025). Mechanical valve thrombosis complicated pregnancy in 10 patients with an MHV (4.7%). In 5 of these patients, the valve thrombosis occurred in the first trimester, and all 5 patients had been switched to some form of heparin. Hemorrhagic events occurred in 23.1% of patients with an MHV, in 5.1% of patients with a tissue heart valve (P<0.001), and in 4.9% of patients without a prosthetic valve (P<0.001). Only 58% of the patients with an MHV had a pregnancy free of serious adverse events compared with 79% of patients with a tissue heart valve (P<0.001) and 78% of patients without a prosthetic valve (P<0.001). Vitamin K antagonist use in the first trimester compared with heparin was associated with a higher rate of miscarriage (28.6% versus 9.2%; P<0.001) and late fetal death (7.1% versus 0.7%; P=0.016).
  
  
  CONCLUSIONS
  Women with an MHV have only a 58% chance of experiencing an uncomplicated pregnancy with a live birth. The markedly increased mortality and morbidity warrant extensive prepregnancy counseling and centralization of care.
authors.affiliation: From Department of Cardiology, Erasmus University Medical Center, Rotterdam, The Netherlands (I.M.v.H., J.W.R.-H., T.P.E.R., E.B.); EURObservational Research Programme, European Society of Cardiology, Sophia Antipolis, France (J.W.R.-H.); Department of Obstetrics and Prenatal Medicine, Center for Obstetrics and Gynecology, University Bonn Medical School, Germany (W.M.M.); Heart Institute, Kaplan Medical Center, Rehovot, Israel (S.G.); Hebrew University, Jerusalem, Israel (S.G.); Department of Cardiology, Medical University Vienna, Austria (H.G.); Department of Cardiology, Medical University of Lodz, Poland (M.L.); Department of Cardiology, University of Medical Sciences, Poznan, Poland (O.T.); Heart and Vascular Institute, Cleveland Clinic, Abu Dhabi, United Arab Emirates (W.A.A.M.); Department of Cardiology, Gottsegen György Hungarian Institute of Cardiology, Budapest, Hungary (H.O.B.); Department of Cardiology, Faculty of Medicine, Cairo University Hospital, Egypt (Z.A.); Division of Adult Congenital and Valvular Heart Disease, Department of Cardiovascular Medicine, University Hospital Muenster, Germany (H.B.); Department of Obstetrics, Imperial College School of Medicine, Chelsea and Westminster Hospital, London, UK (M.R.J.); and Department of Cardiology, Norwich Medical School, University of East Anglia, UK (R.H.).
authors.forename: Iris M
authors.initials: IM
authors.lastname: van Hagen
authors.affiliation: From Department of Cardiology, Erasmus University Medical Center, Rotterdam, The Netherlands (I.M.v.H., J.W.R.-H., T.P.E.R., E.B.); EURObservational Research Programme, European Society of Cardiology, Sophia Antipolis, France (J.W.R.-H.); Department of Obstetrics and Prenatal Medicine, Center for Obstetrics and Gynecology, University Bonn Medical School, Germany (W.M.M.); Heart Institute, Kaplan Medical Center, Rehovot, Israel (S.G.); Hebrew University, Jerusalem, Israel (S.G.); Department of Cardiology, Medical University Vienna, Austria (H.G.); Department of Cardiology, Medical University of Lodz, Poland (M.L.); Department of Cardiology, University of Medical Sciences, Poznan, Poland (O.T.); Heart and Vascular Institute, Cleveland Clinic, Abu Dhabi, United Arab Emirates (W.A.A.M.); Department of Cardiology, Gottsegen György Hungarian Institute of Cardiology, Budapest, Hungary (H.O.B.); Department of Cardiology, Faculty of Medicine, Cairo University Hospital, Egypt (Z.A.); Division of Adult Congenital and Valvular Heart Disease, Department of Cardiovascular Medicine, University Hospital Muenster, Germany (H.B.); Department of Obstetrics, Imperial College School of Medicine, Chelsea and Westminster Hospital, London, UK (M.R.J.); and Department of Cardiology, Norwich Medical School, University of East Anglia, UK (R.H.). j.roos@erasmusmc.nl.
authors.forename: Jolien W
authors.initials: JW
authors.lastname: Roos-Hesselink
authors.affiliation: From Department of Cardiology, Erasmus University Medical Center, Rotterdam, The Netherlands (I.M.v.H., J.W.R.-H., T.P.E.R., E.B.); EURObservational Research Programme, European Society of Cardiology, Sophia Antipolis, France (J.W.R.-H.); Department of Obstetrics and Prenatal Medicine, Center for Obstetrics and Gynecology, University Bonn Medical School, Germany (W.M.M.); Heart Institute, Kaplan Medical Center, Rehovot, Israel (S.G.); Hebrew University, Jerusalem, Israel (S.G.); Department of Cardiology, Medical University Vienna, Austria (H.G.); Department of Cardiology, Medical University of Lodz, Poland (M.L.); Department of Cardiology, University of Medical Sciences, Poznan, Poland (O.T.); Heart and Vascular Institute, Cleveland Clinic, Abu Dhabi, United Arab Emirates (W.A.A.M.); Department of Cardiology, Gottsegen György Hungarian Institute of Cardiology, Budapest, Hungary (H.O.B.); Department of Cardiology, Faculty of Medicine, Cairo University Hospital, Egypt (Z.A.); Division of Adult Congenital and Valvular Heart Disease, Department of Cardiovascular Medicine, University Hospital Muenster, Germany (H.B.); Department of Obstetrics, Imperial College School of Medicine, Chelsea and Westminster Hospital, London, UK (M.R.J.); and Department of Cardiology, Norwich Medical School, University of East Anglia, UK (R.H.).
authors.forename: Titia P E
authors.initials: TP
authors.lastname: Ruys
authors.affiliation: From Department of Cardiology, Erasmus University Medical Center, Rotterdam, The Netherlands (I.M.v.H., J.W.R.-H., T.P.E.R., E.B.); EURObservational Research Programme, European Society of Cardiology, Sophia Antipolis, France (J.W.R.-H.); Department of Obstetrics and Prenatal Medicine, Center for Obstetrics and Gynecology, University Bonn Medical School, Germany (W.M.M.); Heart Institute, Kaplan Medical Center, Rehovot, Israel (S.G.); Hebrew University, Jerusalem, Israel (S.G.); Department of Cardiology, Medical University Vienna, Austria (H.G.); Department of Cardiology, Medical University of Lodz, Poland (M.L.); Department of Cardiology, University of Medical Sciences, Poznan, Poland (O.T.); Heart and Vascular Institute, Cleveland Clinic, Abu Dhabi, United Arab Emirates (W.A.A.M.); Department of Cardiology, Gottsegen György Hungarian Institute of Cardiology, Budapest, Hungary (H.O.B.); Department of Cardiology, Faculty of Medicine, Cairo University Hospital, Egypt (Z.A.); Division of Adult Congenital and Valvular Heart Disease, Department of Cardiovascular Medicine, University Hospital Muenster, Germany (H.B.); Department of Obstetrics, Imperial College School of Medicine, Chelsea and Westminster Hospital, London, UK (M.R.J.); and Department of Cardiology, Norwich Medical School, University of East Anglia, UK (R.H.).
authors.forename: Waltraut M
authors.initials: WM
authors.lastname: Merz
authors.affiliation: From Department of Cardiology, Erasmus University Medical Center, Rotterdam, The Netherlands (I.M.v.H., J.W.R.-H., T.P.E.R., E.B.); EURObservational Research Programme, European Society of Cardiology, Sophia Antipolis, France (J.W.R.-H.); Department of Obstetrics and Prenatal Medicine, Center for Obstetrics and Gynecology, University Bonn Medical School, Germany (W.M.M.); Heart Institute, Kaplan Medical Center, Rehovot, Israel (S.G.); Hebrew University, Jerusalem, Israel (S.G.); Department of Cardiology, Medical University Vienna, Austria (H.G.); Department of Cardiology, Medical University of Lodz, Poland (M.L.); Department of Cardiology, University of Medical Sciences, Poznan, Poland (O.T.); Heart and Vascular Institute, Cleveland Clinic, Abu Dhabi, United Arab Emirates (W.A.A.M.); Department of Cardiology, Gottsegen György Hungarian Institute of Cardiology, Budapest, Hungary (H.O.B.); Department of Cardiology, Faculty of Medicine, Cairo University Hospital, Egypt (Z.A.); Division of Adult Congenital and Valvular Heart Disease, Department of Cardiovascular Medicine, University Hospital Muenster, Germany (H.B.); Department of Obstetrics, Imperial College School of Medicine, Chelsea and Westminster Hospital, London, UK (M.R.J.); and Department of Cardiology, Norwich Medical School, University of East Anglia, UK (R.H.).
authors.forename: Sorel
authors.initials: S
authors.lastname: Goland
authors.affiliation: From Department of Cardiology, Erasmus University Medical Center, Rotterdam, The Netherlands (I.M.v.H., J.W.R.-H., T.P.E.R., E.B.); EURObservational Research Programme, European Society of Cardiology, Sophia Antipolis, France (J.W.R.-H.); Department of Obstetrics and Prenatal Medicine, Center for Obstetrics and Gynecology, University Bonn Medical School, Germany (W.M.M.); Heart Institute, Kaplan Medical Center, Rehovot, Israel (S.G.); Hebrew University, Jerusalem, Israel (S.G.); Department of Cardiology, Medical University Vienna, Austria (H.G.); Department of Cardiology, Medical University of Lodz, Poland (M.L.); Department of Cardiology, University of Medical Sciences, Poznan, Poland (O.T.); Heart and Vascular Institute, Cleveland Clinic, Abu Dhabi, United Arab Emirates (W.A.A.M.); Department of Cardiology, Gottsegen György Hungarian Institute of Cardiology, Budapest, Hungary (H.O.B.); Department of Cardiology, Faculty of Medicine, Cairo University Hospital, Egypt (Z.A.); Division of Adult Congenital and Valvular Heart Disease, Department of Cardiovascular Medicine, University Hospital Muenster, Germany (H.B.); Department of Obstetrics, Imperial College School of Medicine, Chelsea and Westminster Hospital, London, UK (M.R.J.); and Department of Cardiology, Norwich Medical School, University of East Anglia, UK (R.H.).
authors.forename: Harald
authors.initials: H
authors.lastname: Gabriel
authors.affiliation: From Department of Cardiology, Erasmus University Medical Center, Rotterdam, The Netherlands (I.M.v.H., J.W.R.-H., T.P.E.R., E.B.); EURObservational Research Programme, European Society of Cardiology, Sophia Antipolis, France (J.W.R.-H.); Department of Obstetrics and Prenatal Medicine, Center for Obstetrics and Gynecology, University Bonn Medical School, Germany (W.M.M.); Heart Institute, Kaplan Medical Center, Rehovot, Israel (S.G.); Hebrew University, Jerusalem, Israel (S.G.); Department of Cardiology, Medical University Vienna, Austria (H.G.); Department of Cardiology, Medical University of Lodz, Poland (M.L.); Department of Cardiology, University of Medical Sciences, Poznan, Poland (O.T.); Heart and Vascular Institute, Cleveland Clinic, Abu Dhabi, United Arab Emirates (W.A.A.M.); Department of Cardiology, Gottsegen György Hungarian Institute of Cardiology, Budapest, Hungary (H.O.B.); Department of Cardiology, Faculty of Medicine, Cairo University Hospital, Egypt (Z.A.); Division of Adult Congenital and Valvular Heart Disease, Department of Cardiovascular Medicine, University Hospital Muenster, Germany (H.B.); Department of Obstetrics, Imperial College School of Medicine, Chelsea and Westminster Hospital, London, UK (M.R.J.); and Department of Cardiology, Norwich Medical School, University of East Anglia, UK (R.H.).
authors.forename: Malgorzata
authors.initials: M
authors.lastname: Lelonek
authors.affiliation: From Department of Cardiology, Erasmus University Medical Center, Rotterdam, The Netherlands (I.M.v.H., J.W.R.-H., T.P.E.R., E.B.); EURObservational Research Programme, European Society of Cardiology, Sophia Antipolis, France (J.W.R.-H.); Department of Obstetrics and Prenatal Medicine, Center for Obstetrics and Gynecology, University Bonn Medical School, Germany (W.M.M.); Heart Institute, Kaplan Medical Center, Rehovot, Israel (S.G.); Hebrew University, Jerusalem, Israel (S.G.); Department of Cardiology, Medical University Vienna, Austria (H.G.); Department of Cardiology, Medical University of Lodz, Poland (M.L.); Department of Cardiology, University of Medical Sciences, Poznan, Poland (O.T.); Heart and Vascular Institute, Cleveland Clinic, Abu Dhabi, United Arab Emirates (W.A.A.M.); Department of Cardiology, Gottsegen György Hungarian Institute of Cardiology, Budapest, Hungary (H.O.B.); Department of Cardiology, Faculty of Medicine, Cairo University Hospital, Egypt (Z.A.); Division of Adult Congenital and Valvular Heart Disease, Department of Cardiovascular Medicine, University Hospital Muenster, Germany (H.B.); Department of Obstetrics, Imperial College School of Medicine, Chelsea and Westminster Hospital, London, UK (M.R.J.); and Department of Cardiology, Norwich Medical School, University of East Anglia, UK (R.H.).
authors.forename: Olga
authors.initials: O
authors.lastname: Trojnarska
authors.affiliation: From Department of Cardiology, Erasmus University Medical Center, Rotterdam, The Netherlands (I.M.v.H., J.W.R.-H., T.P.E.R., E.B.); EURObservational Research Programme, European Society of Cardiology, Sophia Antipolis, France (J.W.R.-H.); Department of Obstetrics and Prenatal Medicine, Center for Obstetrics and Gynecology, University Bonn Medical School, Germany (W.M.M.); Heart Institute, Kaplan Medical Center, Rehovot, Israel (S.G.); Hebrew University, Jerusalem, Israel (S.G.); Department of Cardiology, Medical University Vienna, Austria (H.G.); Department of Cardiology, Medical University of Lodz, Poland (M.L.); Department of Cardiology, University of Medical Sciences, Poznan, Poland (O.T.); Heart and Vascular Institute, Cleveland Clinic, Abu Dhabi, United Arab Emirates (W.A.A.M.); Department of Cardiology, Gottsegen György Hungarian Institute of Cardiology, Budapest, Hungary (H.O.B.); Department of Cardiology, Faculty of Medicine, Cairo University Hospital, Egypt (Z.A.); Division of Adult Congenital and Valvular Heart Disease, Department of Cardiovascular Medicine, University Hospital Muenster, Germany (H.B.); Department of Obstetrics, Imperial College School of Medicine, Chelsea and Westminster Hospital, London, UK (M.R.J.); and Department of Cardiology, Norwich Medical School, University of East Anglia, UK (R.H.).
authors.forename: Wael Abdulrahman
authors.initials: WA
authors.lastname: Al Mahmeed
authors.affiliation: From Department of Cardiology, Erasmus University Medical Center, Rotterdam, The Netherlands (I.M.v.H., J.W.R.-H., T.P.E.R., E.B.); EURObservational Research Programme, European Society of Cardiology, Sophia Antipolis, France (J.W.R.-H.); Department of Obstetrics and Prenatal Medicine, Center for Obstetrics and Gynecology, University Bonn Medical School, Germany (W.M.M.); Heart Institute, Kaplan Medical Center, Rehovot, Israel (S.G.); Hebrew University, Jerusalem, Israel (S.G.); Department of Cardiology, Medical University Vienna, Austria (H.G.); Department of Cardiology, Medical University of Lodz, Poland (M.L.); Department of Cardiology, University of Medical Sciences, Poznan, Poland (O.T.); Heart and Vascular Institute, Cleveland Clinic, Abu Dhabi, United Arab Emirates (W.A.A.M.); Department of Cardiology, Gottsegen György Hungarian Institute of Cardiology, Budapest, Hungary (H.O.B.); Department of Cardiology, Faculty of Medicine, Cairo University Hospital, Egypt (Z.A.); Division of Adult Congenital and Valvular Heart Disease, Department of Cardiovascular Medicine, University Hospital Muenster, Germany (H.B.); Department of Obstetrics, Imperial College School of Medicine, Chelsea and Westminster Hospital, London, UK (M.R.J.); and Department of Cardiology, Norwich Medical School, University of East Anglia, UK (R.H.).
authors.forename: Hajnalka Olga
authors.initials: HO
authors.lastname: Balint
authors.affiliation: From Department of Cardiology, Erasmus University Medical Center, Rotterdam, The Netherlands (I.M.v.H., J.W.R.-H., T.P.E.R., E.B.); EURObservational Research Programme, European Society of Cardiology, Sophia Antipolis, France (J.W.R.-H.); Department of Obstetrics and Prenatal Medicine, Center for Obstetrics and Gynecology, University Bonn Medical School, Germany (W.M.M.); Heart Institute, Kaplan Medical Center, Rehovot, Israel (S.G.); Hebrew University, Jerusalem, Israel (S.G.); Department of Cardiology, Medical University Vienna, Austria (H.G.); Department of Cardiology, Medical University of Lodz, Poland (M.L.); Department of Cardiology, University of Medical Sciences, Poznan, Poland (O.T.); Heart and Vascular Institute, Cleveland Clinic, Abu Dhabi, United Arab Emirates (W.A.A.M.); Department of Cardiology, Gottsegen György Hungarian Institute of Cardiology, Budapest, Hungary (H.O.B.); Department of Cardiology, Faculty of Medicine, Cairo University Hospital, Egypt (Z.A.); Division of Adult Congenital and Valvular Heart Disease, Department of Cardiovascular Medicine, University Hospital Muenster, Germany (H.B.); Department of Obstetrics, Imperial College School of Medicine, Chelsea and Westminster Hospital, London, UK (M.R.J.); and Department of Cardiology, Norwich Medical School, University of East Anglia, UK (R.H.).
authors.forename: Zeinab
authors.initials: Z
authors.lastname: Ashour
authors.affiliation: From Department of Cardiology, Erasmus University Medical Center, Rotterdam, The Netherlands (I.M.v.H., J.W.R.-H., T.P.E.R., E.B.); EURObservational Research Programme, European Society of Cardiology, Sophia Antipolis, France (J.W.R.-H.); Department of Obstetrics and Prenatal Medicine, Center for Obstetrics and Gynecology, University Bonn Medical School, Germany (W.M.M.); Heart Institute, Kaplan Medical Center, Rehovot, Israel (S.G.); Hebrew University, Jerusalem, Israel (S.G.); Department of Cardiology, Medical University Vienna, Austria (H.G.); Department of Cardiology, Medical University of Lodz, Poland (M.L.); Department of Cardiology, University of Medical Sciences, Poznan, Poland (O.T.); Heart and Vascular Institute, Cleveland Clinic, Abu Dhabi, United Arab Emirates (W.A.A.M.); Department of Cardiology, Gottsegen György Hungarian Institute of Cardiology, Budapest, Hungary (H.O.B.); Department of Cardiology, Faculty of Medicine, Cairo University Hospital, Egypt (Z.A.); Division of Adult Congenital and Valvular Heart Disease, Department of Cardiovascular Medicine, University Hospital Muenster, Germany (H.B.); Department of Obstetrics, Imperial College School of Medicine, Chelsea and Westminster Hospital, London, UK (M.R.J.); and Department of Cardiology, Norwich Medical School, University of East Anglia, UK (R.H.).
authors.forename: Helmut
authors.initials: H
authors.lastname: Baumgartner
authors.affiliation: From Department of Cardiology, Erasmus University Medical Center, Rotterdam, The Netherlands (I.M.v.H., J.W.R.-H., T.P.E.R., E.B.); EURObservational Research Programme, European Society of Cardiology, Sophia Antipolis, France (J.W.R.-H.); Department of Obstetrics and Prenatal Medicine, Center for Obstetrics and Gynecology, University Bonn Medical School, Germany (W.M.M.); Heart Institute, Kaplan Medical Center, Rehovot, Israel (S.G.); Hebrew University, Jerusalem, Israel (S.G.); Department of Cardiology, Medical University Vienna, Austria (H.G.); Department of Cardiology, Medical University of Lodz, Poland (M.L.); Department of Cardiology, University of Medical Sciences, Poznan, Poland (O.T.); Heart and Vascular Institute, Cleveland Clinic, Abu Dhabi, United Arab Emirates (W.A.A.M.); Department of Cardiology, Gottsegen György Hungarian Institute of Cardiology, Budapest, Hungary (H.O.B.); Department of Cardiology, Faculty of Medicine, Cairo University Hospital, Egypt (Z.A.); Division of Adult Congenital and Valvular Heart Disease, Department of Cardiovascular Medicine, University Hospital Muenster, Germany (H.B.); Department of Obstetrics, Imperial College School of Medicine, Chelsea and Westminster Hospital, London, UK (M.R.J.); and Department of Cardiology, Norwich Medical School, University of East Anglia, UK (R.H.).
authors.forename: Eric
authors.initials: E
authors.lastname: Boersma
authors.affiliation: From Department of Cardiology, Erasmus University Medical Center, Rotterdam, The Netherlands (I.M.v.H., J.W.R.-H., T.P.E.R., E.B.); EURObservational Research Programme, European Society of Cardiology, Sophia Antipolis, France (J.W.R.-H.); Department of Obstetrics and Prenatal Medicine, Center for Obstetrics and Gynecology, University Bonn Medical School, Germany (W.M.M.); Heart Institute, Kaplan Medical Center, Rehovot, Israel (S.G.); Hebrew University, Jerusalem, Israel (S.G.); Department of Cardiology, Medical University Vienna, Austria (H.G.); Department of Cardiology, Medical University of Lodz, Poland (M.L.); Department of Cardiology, University of Medical Sciences, Poznan, Poland (O.T.); Heart and Vascular Institute, Cleveland Clinic, Abu Dhabi, United Arab Emirates (W.A.A.M.); Department of Cardiology, Gottsegen György Hungarian Institute of Cardiology, Budapest, Hungary (H.O.B.); Department of Cardiology, Faculty of Medicine, Cairo University Hospital, Egypt (Z.A.); Division of Adult Congenital and Valvular Heart Disease, Department of Cardiovascular Medicine, University Hospital Muenster, Germany (H.B.); Department of Obstetrics, Imperial College School of Medicine, Chelsea and Westminster Hospital, London, UK (M.R.J.); and Department of Cardiology, Norwich Medical School, University of East Anglia, UK (R.H.).
authors.forename: Mark R
authors.initials: MR
authors.lastname: Johnson
authors.affiliation: From Department of Cardiology, Erasmus University Medical Center, Rotterdam, The Netherlands (I.M.v.H., J.W.R.-H., T.P.E.R., E.B.); EURObservational Research Programme, European Society of Cardiology, Sophia Antipolis, France (J.W.R.-H.); Department of Obstetrics and Prenatal Medicine, Center for Obstetrics and Gynecology, University Bonn Medical School, Germany (W.M.M.); Heart Institute, Kaplan Medical Center, Rehovot, Israel (S.G.); Hebrew University, Jerusalem, Israel (S.G.); Department of Cardiology, Medical University Vienna, Austria (H.G.); Department of Cardiology, Medical University of Lodz, Poland (M.L.); Department of Cardiology, University of Medical Sciences, Poznan, Poland (O.T.); Heart and Vascular Institute, Cleveland Clinic, Abu Dhabi, United Arab Emirates (W.A.A.M.); Department of Cardiology, Gottsegen György Hungarian Institute of Cardiology, Budapest, Hungary (H.O.B.); Department of Cardiology, Faculty of Medicine, Cairo University Hospital, Egypt (Z.A.); Division of Adult Congenital and Valvular Heart Disease, Department of Cardiovascular Medicine, University Hospital Muenster, Germany (H.B.); Department of Obstetrics, Imperial College School of Medicine, Chelsea and Westminster Hospital, London, UK (M.R.J.); and Department of Cardiology, Norwich Medical School, University of East Anglia, UK (R.H.).
authors.forename: Roger
authors.initials: R
authors.lastname: Hall
mesh_terms: D000328:Adult; D002309:Cardiology / Q000639:trends; D016208:Databases, Factual / Q000639:trends; D005060:Europe / Q000453:epidemiology; D005260:Female; D006331:Heart Diseases / Q000175:diagnosis / Q000401:mortality; D006350:Heart Valve Prosthesis / Q000639:trends; D006801:Humans; D009026:Mortality / Q000639:trends; D011247:Pregnancy; D011249:Pregnancy Complications, Cardiovascular / Q000175:diagnosis* / Q000401:mortality*; D011446:Prospective Studies; D012042:Registries; D012955:Societies, Medical / Q000639:trends; D055815:Young Adult
keywords: heart defects, congenital; heart valves; pregnancy; prostheses and implants; thrombosis