RESUMEN
Pulmonary artery catheters are a useful tool for hemodynamic monitoring in high-risk patients during surgery and while in intensive care. However, there are major risks inherent to the device, and with modern day technology, their routine use has decreased. We discuss the need for routine insertion of pulmonary artery catheters in cardiac surgery. We also present a case of a left ventricular assist device implantation complicated by serious pulmonary hemorrhage due to pulmonary artery catheter insertion, highlighting the potentially life-threatening risks involved.
Asunto(s)
Procedimientos Quirúrgicos Cardíacos/métodos , Cateterismo de Swan-Ganz/métodos , Monitorización Hemodinámica/métodos , Monitoreo Intraoperatorio/métodos , HumanosRESUMEN
Ischemic rupture of the anterolateral papillary muscle is uncommon due to its dual blood supply. It usually follows an ischemic event involving branches of the left circumflex or left anterior descending arteries. We present a case of a patient admitted with an acute inferior wall myocardial infarction and an isolated distal right coronary artery occlusion. Acute mitral regurgitation with rupture of the anterolateral papillary muscle was diagnosed on the fifth post-infarction day. The patient underwent mitral valve replacement and coronary artery bypass grafting to the posterior descending artery. We conclude that anterolateral papillary muscle rupture may also result from an isolated right coronary lesion.
Asunto(s)
Rotura Cardíaca Posinfarto/cirugía , Insuficiencia de la Válvula Mitral/cirugía , Infarto del Miocardio/cirugía , Puente de Arteria Coronaria , Electrocardiografía , Resultado Fatal , Humanos , Masculino , Persona de Mediana Edad , Válvula MitralRESUMEN
BACKGROUND: The involvement of mitochondria in pathological states, such as neurodegenerative diseases, sepsis, stroke, and cancer, are well documented. Monitoring of nicotinamide adenine dinucleotide (NADH) fluorescence in vivo as an intracellular oxygen indicator was established in 1950 to 1970 by Britton Chance and collaborators. We use a multiparametric monitoring system enabling assessment of tissue vitality. In order to use this technology in clinical practice, the commercial developed device, the CritiView (CRV), is tested in animal models as well as in patients. METHODS AND RESULTS: The new CRV enables the optical monitoring of four different parameters, representing the energy balance of various tissues in vivo. Mitochondrial NADH is measured by surface fluorometry/reflectometry. In addition, tissue microcirculatory blood flow, tissue reflectance and oxygenation are measured as well. The device is tested both in vitro and in vivo in a small animal model and in preliminary clinical trials in patients undergoing vascular or open heart surgery. In patients, the monitoring is started immediately after the insertion of a three-way Foley catheter (urine collection) to the patient and is stopped when the patient is discharged from the operating room. The results show that monitoring the urethral wall vitality provides information in correlation to the surgical procedure performed.
Asunto(s)
Flujometría por Láser-Doppler/métodos , Mitocondrias/fisiología , Monitoreo Intraoperatorio/instrumentación , Monitoreo Intraoperatorio/métodos , Análisis de Varianza , Animales , Aneurisma de la Aorta Abdominal/metabolismo , Aneurisma de la Aorta Abdominal/patología , Aneurisma de la Aorta Abdominal/cirugía , Dióxido de Carbono/metabolismo , Procedimientos Quirúrgicos Cardíacos , Cuidados Críticos , Metabolismo Energético , Fluorometría , Gerbillinae , Humanos , Concentración de Iones de Hidrógeno , Modelos Lineales , Microcirculación , Mitocondrias/química , Modelos Biológicos , NAD/química , NAD/metabolismo , Oxígeno/metabolismo , Ratas , Espectroscopía Infrarroja Corta , Uretra/citología , Uretra/fisiologíaRESUMEN
Surgical treatment for the anomalous origin of the right coronary artery from the left coronary sinus remains a topic of debate. A 61-year-old male patient, presenting with a single episode of chest pain, was diagnosed with anomalous origin of the right coronary artery from the left coronary sinus. The patient underwent right internal mammary artery coronary bypass surgery without ligating the proximal right coronary artery. Postoperatively, his condition remained uncomplicated and asymptomatic. Sudden death rate is high even in asymptomatic patients therefore the condition be subjected to surgical treatment after diagnosis.
Asunto(s)
Anomalías de los Vasos Coronarios/cirugía , Anastomosis Interna Mamario-Coronaria/métodos , Angiografía Coronaria , Humanos , Masculino , Persona de Mediana EdadRESUMEN
Fever of unknown origin is rare as a primary presentation of aortic dissection. We describe a 69-year-old female presenting with a sustained fever. A diagnosis of chronic type A aortic dissection was established by computed tomography. Replacements of the ascending aorta and part of the aortic arch were performed. Ten days after the operation, the patient had recurrent pyrexia. A large effusion in the left pleural cavity was found. After puncture aspiration and antibiotic treatment, she recovered. She was doing well at the 5(1/2)-year follow-up.
Asunto(s)
Aneurisma de la Aorta/complicaciones , Disección Aórtica/complicaciones , Fiebre de Origen Desconocido/etiología , Anciano , Disección Aórtica/diagnóstico por imagen , Disección Aórtica/cirugía , Aneurisma de la Aorta/diagnóstico por imagen , Aneurisma de la Aorta/cirugía , Implantación de Prótesis Vascular/métodos , Enfermedad Crónica , Femenino , Humanos , Tomografía Computarizada por Rayos XRESUMEN
Aortic aneurysm is a rare cause of disseminated intravascular coagulopathy (DIC). We present the developmental course of DIC in a 70-year-old male patient who had a thoracoabdominal aortic aneurysm characterized by a progressive descending aortic aneurysm presenting as subcutaneous hemorrhage of acute onset. He was diagnosed as having aortic aneurysm-induced DIC. After adequate infusion of blood components, surgical repair of the descending aortic aneurysm was carried out successfully. The patient's bleeding tendency stopped dramatically in the early postoperative period as identified by clinical and laboratory findings. We concluded that the occurrence of DIC was due mainly to the progressive descending aortic aneurysm in the present patient and that surgical repair could be the definitive treatment of DIC in this setting.
Asunto(s)
Aorta Torácica/cirugía , Aneurisma de la Aorta/complicaciones , Coagulación Intravascular Diseminada/etiología , Enfermedad Aguda , Anciano , Aorta Torácica/diagnóstico por imagen , Aorta Torácica/patología , Aneurisma de la Aorta/diagnóstico , Aneurisma de la Aorta/cirugía , Implantación de Prótesis Vascular , Coagulación Intravascular Diseminada/patología , Coagulación Intravascular Diseminada/cirugía , Humanos , Imagen por Resonancia Magnética , Masculino , Tomografía Computarizada por Rayos X , Resultado del Tratamiento , Procedimientos Quirúrgicos VascularesRESUMEN
A 54-year-old male patient developed acute onset of chronic aortic dissection manifesting as primarily abdominal pain. A prompt diagnosis was made and urgent surgery was carried out successfully under profound hypothermic circulatory arrest. Prompt surgery is mandatory for such patients in order to prevent abrupt rupture. The awareness of possible aortic dissection is the key point leading to an early diagnosis in patients with atypical presentations.
Asunto(s)
Aneurisma de la Aorta/diagnóstico , Disección Aórtica/diagnóstico , Dolor Abdominal/etiología , Disección Aórtica/complicaciones , Disección Aórtica/cirugía , Aneurisma de la Aorta/complicaciones , Aneurisma de la Aorta/cirugía , Enfermedad Crónica , Humanos , Masculino , Persona de Mediana EdadRESUMEN
OBJECTIVE: "Fast-track" pathways have been successfully used in low-risk, relatively young patients after all types of surgical procedures including cardiac surgery. An increase in the number of referrals of older patients for cardiac surgery prompted the present study on the use of a "fast-track" pathway in septuagenarians and octogenarians. Risk factors for the unsuccessful application of the "fast-track" pathway in these elderly patients were determined. DESIGN: A retrospective observational study. SETTING: A single tertiary-care, university-affiliated center. PARTICIPANTS: All 70-year-old or older patients undergoing cardiac surgery between January 1, 2004 and June 30, 2007 were included. Septuagenarians were compared with octogenarians. MEASUREMENTS AND MAIN RESULTS: During the 42-month period, 860 cardiac operations were performed on 576 septuagenarians and 284 octogenarians. The "fast-track" pathway was successful in 54.5% and 37.3%, respectively. On multiple logistic regression analyses, stroke, renal failure, and procedures other than primary isolated coronary artery bypass graft surgery were independently associated with failed early extubation, delayed intensive care unit discharge, and delayed hospital discharge in both groups. Infections and atrial fibrillation were independent risk factors for delayed hospital discharge in both groups and delayed intensive care unit discharge in the octogenarians. In the octogenarians only, congestive heart failure was an independent risk factor for failed early extubation, delayed intensive care unit discharge, and delayed hospital discharge. CONCLUSIONS: A "fast-track" pathway may be applied in selected septuagenarians and octogenarians. Age alone should not exclude consideration for "fast-track" management.
Asunto(s)
Procedimientos Quirúrgicos Cardiovasculares/efectos adversos , Cuidados Posoperatorios/efectos adversos , Complicaciones Posoperatorias/epidemiología , Insuficiencia del Tratamiento , Factores de Edad , Anciano , Anciano de 80 o más Años , Procedimientos Quirúrgicos Cardiovasculares/tendencias , Femenino , Humanos , Tiempo de Internación/tendencias , Masculino , Alta del Paciente/tendencias , Cuidados Posoperatorios/métodos , Cuidados Posoperatorios/tendencias , Complicaciones Posoperatorias/etiología , Estudios Retrospectivos , Factores de Riesgo , Factores de TiempoRESUMEN
BACKGROUND: As the shortcomings of the Bentall operation and its variants in the Marfan syndrome have become apparent, the recent cusp-sparing techniques (remodeling or reimplantation) bear promise of better mid-term and long-term outcomes. OBJECTIVE: To examine the results of aortic root surgery in patients with Marfan syndrome. METHODS: During the period March 1994 to September 2007, 220 patients underwent aortic valve-sparing surgery; 20 were Marfan patients (group 1) who were compared with another 20 Marfan patients undergoing composite aortic root replacement (group 2). Fourteen patients had aortic dissection and 26 had thoracic aortic aneurysm. There were 31 males and 9 females with a mean age of 37.9 +/- 13.8 years. In group 1, reimplantation was used in 13 patients, remodeling in 4, and aortic valve repair with sinotubular junction replacement in 3. In group 2, a mechanical valve conduit was used. Mean logistic Euroscore was 12.27 +/- 14.6% for the whole group, five of whom were emergent cases RESULTS: Group 2 had more previous cardiac procedures compared to group 1 (9 vs. 2, P = 0.03) and shorter cross-clamp time (122 +/- 27.1 vs. 153.9 +/- 23.7 minutes, P = 0.0004). Overall mortality was 10%. Early mortality was 10% in group 2 and 5% in group 1 (NS). Mean follow-up time was 25 months for group 2 and 53 months for group 1. Three patients were reoperated; all had undergone the remodeling. Five year freedom from reoperation and death was 86% and 90% in group 2 and 70% and 95% in group 1 (P = 0.6, P = 0.6), respectively. CONCLUSIONS: Late survival of patients with Marfan syndrome was similar in both groups. Root reconstruction tends towards a higher incidence of late reoperations if the remodeling technique is used. We now prefer to use the reimplantation technique.
Asunto(s)
Aorta Torácica , Aneurisma de la Aorta/cirugía , Disección Aórtica/cirugía , Válvula Aórtica , Procedimientos Quirúrgicos Cardíacos/métodos , Síndrome de Marfan/complicaciones , Adulto , Disección Aórtica/etiología , Disección Aórtica/patología , Aneurisma de la Aorta/etiología , Aneurisma de la Aorta/patología , Femenino , Estudios de Seguimiento , Humanos , Masculino , Síndrome de Marfan/mortalidad , Síndrome de Marfan/cirugía , Persona de Mediana Edad , Estudios Retrospectivos , Tasa de Supervivencia , Resultado del TratamientoRESUMEN
It has been claimed that neoaortic root dilatation or enlargement with aortic regurgitation is progressive until 11 years after an arterial switch operation. We report a case of neoaortic root dilatation onset occurring 18 years after operation and discuss the pathological features and the possible acting mechanisms.
Asunto(s)
Aneurisma de la Aorta Torácica/etiología , Procedimientos Quirúrgicos Cardíacos/métodos , Transposición de los Grandes Vasos/cirugía , Adulto , Aneurisma de la Aorta Torácica/diagnóstico por imagen , Aneurisma de la Aorta Torácica/cirugía , Insuficiencia de la Válvula Aórtica/diagnóstico por imagen , Insuficiencia de la Válvula Aórtica/etiología , Insuficiencia de la Válvula Aórtica/cirugía , Implantación de Prótesis Vascular/métodos , Implantación de Prótesis de Válvulas Cardíacas , Humanos , Masculino , Complicaciones Posoperatorias , Factores de Tiempo , Tomografía Computarizada por Rayos XRESUMEN
BACKGROUND: Over the past 20 years, a series of procedures have been designed to reconstruct the aortic root of patients with aortic insufficiency, in whom the pathology and hence, the surgery, spares the valve leaflets. The objective of this current study was to evaluate our midterm results comparing the reimplantation technique with the remodeling technique in patients with aortic regurgitation due to aortic dissection, aortic root and ascending aortic aneurysms. PATIENTS AND METHODS: During the years 1993 and 2006 we operated on 209 patients with aortic regurgitation secondary to dilatation of the aortic root or ascending aorta with or without aortic dissection. Mean age was 59 years (range 21-81 years), 69% of the patients were males; 91 patients had chronic aneurysm, while 118 patients presented with acute dissection. Thirty-nine patients had Marfan syndrome or it's form fruste. Post-operative follow-up (FU) was 82% complete (172 patients) with mean follow-up time of 66 months, and completion of FU was continued. RESULTS: Thirty-nine patients underwent the reimplantation technique, 89 patients underwent the remodeling technique. Twenty-five patients underwent only replacement of the ascending aorta on the level of the STJ, 11 patients had replacement of the ascending aorta and one sinus. In 45 of the cases bio-glue was used in addition to replacing the ascending aorta. Overall, 30 days mortality was 5.7% (12 patients out of 209). There was no difference in mortality rates among the groups of patients who underwent reimplantation (chronic aneurysm vs Acute dissection), but significantly higher mortality rate was observed among patients who had aortic dissection and underwent the remodeling technique compared to the same group of patients who underwent reimplantation (6.7% vs 1.1%, P < 0.025). It was also found that Marfan patients who had aortic dissection had significantly higher mortality rate when undergoing the remodeling technique (7.6% Vs 0%, p < 0.01). Recurrence of AI more than 2+ occurred in 11 patients, ten from the remodeling and one from the reimplantation group (P = 0.17). Among Marfan patients, recurrence of AI more than 2+ occurred in two patients, both underwent remodeling and both had dissection of the ascending aorta involving the sinuses of Valsalva. Reoperation due to Severe AI was needed for 8 patients, all from the remodeling group and all were non-Marfans. CONCLUSIONS: In acute dissection reimplantation provides better haemostasis and there may be more stable repair, both in Marfan and non-Marfan patients. In Marfans it seems that the reimplantation technique provides better long-term results.
Asunto(s)
Insuficiencia de la Válvula Aórtica/cirugía , Adulto , Anciano , Anciano de 80 o más Años , Disección Aórtica/cirugía , Aneurisma de la Aorta/cirugía , Insuficiencia de la Válvula Aórtica/mortalidad , Femenino , Estudios de Seguimiento , Humanos , Masculino , Síndrome de Marfan/complicaciones , Persona de Mediana Edad , Reoperación/estadística & datos numéricos , Estudios Retrospectivos , Análisis de Supervivencia , SobrevivientesRESUMEN
BACKGROUND: During the last decade new surgical techniques for mitral valve repair were developed. We have been using those techniques in order to widen the spectrum of patients eligible for MV repair. OBJECTIVES: To assess the operative and mid-term results a wide variety of surgical techniques. METHODS: From January 2004 through December 2006, 213 patients underwent MV repair in our institution. Valve pathology was degenerative in 123 patients (58%), ischemic in 37 (17%), showed annular dilatation in 25 (12%), endocarditis in 16 (8%), was rheumatic in 13 (6%), and due to other causes in 14 (7%). Preoperative New York Heart Association score was 2.35 +/- 0.85 and ejection fraction 53 +/- 12%. Isolated MV repair was performed in 90 patients (42%) and 158 concomitant procedures were done in 123 patients (58%). A wide variety of surgical techniques was used in order to increase the number of repairs compared to valve replacement. RESULTS: There were 7 in-hospital deaths (3.3%). NYHA class improved from 2.19 +/- 0.85 to 1.4 +/- 0.6, and freedom from reoperation was 100%. Echocardiography follow-up of patients with degenerative MV revealed that 93% of the patients (115/123) were free of mitral regurgitation greater than 2+ grade. In patients operated by a minimal invasive approach there were no conversions to stemotomy, no late deaths, none required reoperation, and 96% were free of MR greater than 2+ grade. The use of multiple surgical techniques enabled the repair of more than 80% of pure MR cases. CONCLUSIONS: MV repair provides good perioperative and mid-term results, and supports the preference for MV repair over replacement, when feasible. Multiple valve repair techniques tailored to different pathologies increases the feasibility of mitral repair.
Asunto(s)
Implantación de Prótesis de Válvulas Cardíacas/normas , Insuficiencia de la Válvula Mitral/cirugía , Guías de Práctica Clínica como Asunto , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Puente Cardiopulmonar , Ecocardiografía , Femenino , Estudios de Seguimiento , Implantación de Prótesis de Válvulas Cardíacas/métodos , Mortalidad Hospitalaria/tendencias , Humanos , Masculino , Persona de Mediana Edad , Insuficiencia de la Válvula Mitral/diagnóstico por imagen , Insuficiencia de la Válvula Mitral/mortalidad , Estudios Retrospectivos , Tasa de Supervivencia/tendencias , Resultado del TratamientoRESUMEN
We herein describe four modifications of graft construction in coronary bypass surgery, including composite left mammary arterial T graft, arterial-venous I, and U grafts, and coronary-coronary vein graft and discuss their indications.
Asunto(s)
Puente de Arteria Coronaria/métodos , Arterias Mamarias/trasplante , Anciano , Enfermedad de la Arteria Coronaria/patología , Enfermedad de la Arteria Coronaria/cirugía , Humanos , MasculinoRESUMEN
AIM: Assessing the impact of chest tube removal timing following a coronary artery bypass grafting surgery on the clinical outcome. METHODS: Eighty-three consecutive patients were randomly assigned to either have the chest tube removed 24 hours (Group A) or 48 hours (Group B) postoperatively. Chest tubes were removed on the condition that drainage was less than 100 cc for the last 8 hours. Pre- and postoperative data were analyzed. RESULTS: The following preoperative and intraoperative risk factors were more prevalent among Group A patients: previous MI (60.5% vs 40.7%, p = 0.11), previous CVA (9.1% vs 0%, p = 0.11), hypertension (72.7% vs 55.6%, p = 0.14), pump time (111.6 min vs 96.8 min, p = 0.07), and cross-clamp time (73.8 min vs 64.4 min, p = 0.07). Postoperatively, there was a lower demand for analgesics in Group A (2.1 times for 12 hours at 36 hours vs 3.6 p = 0.09), lower white blood cell count (10,947 at 48 hours vs 11,576, p = 0.39) a higher oxygen saturation (91.9% at 48 hours vs 88.9%, p = 0.07), higher expiratory volumes (594 mL at 36 hours vs 514 mL p = 0.08) and earlier mobilization (23% walking at 48 hours vs 4%, p = 0.01). Pleural effusion and atelectasis were less frequent in Group A in both chest X-rays (66% vs 73%, p = 0.6 and 64% vs 75%, p = 0.47, respectively) and CT scans (19% vs 41%, p = 0.1 and 84% vs 96%, p = 0.42, respectively). There was no difference between the two groups in the prevalence of serous wound discharge and the length of hospital stay and there were no reported cases of pneumonia throughout the study. CONCLUSION: In cases where no excessive drainage accumulates, early removal of the chest tubes was found to be a policy that improves the postoperative outcome and decreases the need for supportive treatment such as analgetics, physiotherapy, nurse care, and oxygen. This policy did not involve significant residual effusions.
Asunto(s)
Tubos Torácicos , Puente de Arteria Coronaria/instrumentación , Enfermedad de la Arteria Coronaria/cirugía , Remoción de Dispositivos , Cuidados Posoperatorios/métodos , Resultado del Tratamiento , Anciano , Drenaje/instrumentación , Femenino , Humanos , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias , Medición de Riesgo , Factores de TiempoRESUMEN
OBJECTIVE: A prospective double-blind randomized study undertaken to assess the effect of postoperative prophylactic "renal-dose" dopamine on post-coronary artery bypass grafting surgery's clinical outcome. METHODS: Eighty-five consecutive patients undergoing CABG operation were randomized to receive either 3-5 microg/kg/min dopamine (group D, n = 41) or saline as placebo (group P, n = 45) for 48 postoperative hours. Clinical outcome parameters were collected for four postoperative days. RESULTS: Preoperative and operative parameters were similar in both groups. Four patients from group P and none from group D reached an end-point of the study (oliguria, renal dysfunction) and received dopamine. Two patients from group P and none from group D needed an additional inotropic support. Mean arterial pressure values were similar during the first 24 hours after operation, but left atrial pressure values tended to be higher in group P (10 +/- 4 vs 7 +/- 3 mmH2O, p = 0.18). The mean pH was higher in group D at 8 hours after operation (7.38 +/- 0.2 vs 7.36 +/- 0.3, p = NS), due to higher bicarbonate levels (23 +/- 2 mmol/l vs 21 +/- 2, p = 0.49). The incidence of lung congestion in chest X-rays and CT scans was significantly higher in group P (50% vs 29%, p = 0.073 at 48 hours postoperatively). Room air blood O2 saturation and maximal expiratory volume tended to be higher in group D (at 72 hours after operation- 92 +/- 4 vs 90%+/- 5, p = 0.29 and 646 +/- 276 vs 485 ml +/- 206, p = 0.16, respectively). There was no statistical difference in urine output but the amount of furosemide given to patients in group P was significantly higher (during the first 8 hours 2.5 +/- 0.5 vs. 0.3 mg +/- 1.6, p = 0.07). Plasma creatinine levels were significantly lower in group D (at 24 hours 0.93 +/- 0.02 vs 1.05 mg/dL +/- 0.02, p = 0.02). Mobilization after surgery was faster in group D. CONCLUSIONS: Prophylactic dopamine administration after coronary artery bypass grafting surgery improves patient hemodynamic and renal status, reduces the need for additional medical support (inotropes and furosemide) and thus, provides stable postoperative course.
Asunto(s)
Cardiotónicos/administración & dosificación , Puente de Arteria Coronaria , Enfermedad Coronaria/terapia , Dopamina/administración & dosificación , Riñón/efectos de los fármacos , Riñón/fisiología , Cuidados Posoperatorios , Anciano , Bicarbonatos/sangre , Biomarcadores/sangre , Biomarcadores/orina , Presión Sanguínea/fisiología , Enfermedad Coronaria/metabolismo , Enfermedad Coronaria/fisiopatología , Relación Dosis-Respuesta a Droga , Método Doble Ciego , Femenino , Estudios de Seguimiento , Volumen Espiratorio Forzado/fisiología , Humanos , Israel , Riñón/metabolismo , Masculino , Persona de Mediana Edad , Oxígeno/sangre , Estudios Prospectivos , Resultado del TratamientoRESUMEN
The treatment of women in childbearing age with a mechanical heart valve is a challenge for the medical staff. Warfarin (Coumadin) is considered to be a safe and effective anticoagulant for patients with prosthetic heart valves. However, treatment during pregnancy poses many difficulties, especially during the first trimester, due to its ability to cross the placenta and its associated fetotoxicity. Treatment with heparin during the first trimester decreases the rate of embryopathy, but increases maternal morbidity and mortality. Warfarin therapy throughout pregnancy, which is common mainly in Europe, carries low rates of maternal complications and roughly six percent of embryopathy. Several studies compared warfarin treatment throughout pregnancy versus treatment with heparin during the first trimester. The relationship between daily warfarin doses and the rate of embryopathy was recently investigated. We report two cases of pregnant women with mechanical heart valves who were treated with heparin during the first trimester. Both underwent an emergency replacement of the prosthetic valve during the eighth week of pregnancy. In this article, we review the literature regarding anticoagulation therapy in pregnant women with prosthetic heart valves; the comparison between treatment with warfarin throughout pregnancy and heparin in the first trimester; and the relation of daily warfarin doses with the rate of embryopathy. The two case reports demonstrate the common approach for therapy and the danger within it. In the discussion we present a new approach for treating pregnant women with prosthetic valve and guidelines for the medical staff.