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Montanaro C, Boyle S, Wander G, Johnson MR, Roos-Hesselink JW, Patel R, Rafiq I, Silversides CK, Gatzoulis MA. Pregnancy in patients with the Fontan operation. Eur J Prev Cardiol 2024; 31:1336-1344. [PMID: 38669446 DOI: 10.1093/eurjpc/zwae157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2024] [Revised: 04/03/2024] [Accepted: 04/22/2024] [Indexed: 04/28/2024]
Abstract
Improved survival rates for patients with a Fontan circulation has allowed more women with this complex cardiac physiology to contemplate pregnancy. However, pregnancy in women with a Fontan circulation is associated with a high risk of adverse maternal and foetal outcomes, high rates of miscarriage, and preterm delivery. Factors associated with a successful pregnancy outcome are younger age, normal body weight, absence of significant functional limitation, no Fontan-related complications, and well-functioning single ventricle physiology. Appropriate care with timely preconception counselling and regular, frequent clinical reviews by a multidisciplinary team based at a tertiary centre improves the chance of a successful pregnancy. Empowerment of patients with education on their specific congenital cardiac condition and its projected trajectory helps them make informed choices regarding their health, reproductive choices, and assists them to achieve their life goals.
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Affiliation(s)
- Claudia Montanaro
- Adult Congenital Heart Centre and National Centre for Pulmonary Hypertension, Royal Brompton Hospital, Guy's and St Thomas's NHS Foundation Trust, Sydney Street, London SW3 6NP, UK
- National Heart and Lung Institute, Imperial College, Dovehouse St, London, SW3 6LY, UK
| | - Siobhan Boyle
- Adult Congenital Heart Centre and National Centre for Pulmonary Hypertension, Royal Brompton Hospital, Guy's and St Thomas's NHS Foundation Trust, Sydney Street, London SW3 6NP, UK
- Department of Cardiology, Logan Hospital, Queensland, Australia
| | - Gurleen Wander
- Obstetrics and Gynaecology Department, Chelsea and Westminster Hospital, 369 Fulham Road, London SW10 9NH, UK
| | - Mark R Johnson
- National Heart and Lung Institute, Imperial College, Dovehouse St, London, SW3 6LY, UK
- Obstetrics and Gynaecology Department, Chelsea and Westminster Hospital, 369 Fulham Road, London SW10 9NH, UK
| | | | - Roshni Patel
- National Heart and Lung Institute, Imperial College, Dovehouse St, London, SW3 6LY, UK
- Obstetrics and Gynaecology Department, Chelsea and Westminster Hospital, 369 Fulham Road, London SW10 9NH, UK
| | - Isma Rafiq
- Adult Congenital Heart Centre and National Centre for Pulmonary Hypertension, Royal Brompton Hospital, Guy's and St Thomas's NHS Foundation Trust, Sydney Street, London SW3 6NP, UK
| | - Candice K Silversides
- Congenital Cardiac Centre for Adults, Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
| | - Michael A Gatzoulis
- Adult Congenital Heart Centre and National Centre for Pulmonary Hypertension, Royal Brompton Hospital, Guy's and St Thomas's NHS Foundation Trust, Sydney Street, London SW3 6NP, UK
- National Heart and Lung Institute, Imperial College, Dovehouse St, London, SW3 6LY, UK
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2
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Venkatesh P, Lin JP, Nguyen A, Rezkalla J, Moore JP. Predictors of arrhythmia during pregnancy in adults with congenital heart disease. Int J Cardiol 2023; 386:37-44. [PMID: 37178799 DOI: 10.1016/j.ijcard.2023.05.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Revised: 04/24/2023] [Accepted: 05/10/2023] [Indexed: 05/15/2023]
Abstract
BACKGROUND Risk prediction of arrhythmia during pregnancy in adult congenital heart disease (ACHD) patients is currently lacking, and the impact of preconception catheter ablation on future antepartum arrhythmia has not been studied. METHODS We conducted a single-center, retrospective cohort study of pregnancies in ACHD patients. Clinically significant arrhythmia events during pregnancy were described, predictors of arrhythmia were analyzed, and a risk score devised. The impact of preconception catheter ablation on antepartum arrhythmia was assessed. RESULTS The study included 172 pregnancies in 137 patients. Arrhythmia events occurred in 25 (15%) of pregnancies, with 64% of events occurring in the second trimester and sustained supraventricular tachycardia being the most common rhythm. Univariate predictors of arrhythmia were history of tachyarrhythmia (OR 20.33, 95% CI 6.95-59.47, p < 0.001, Fontan circulation (OR 11.90, 95% CI 2.60-53.70, p < 0.001), baseline physiologic class C/D (OR 3.72, 95% CI 1.54-9.01, p = 0.002) and history of multiple valve interventions (OR 3.10, 95% CI 1.20-8.20, p = 0.017). Three risk factors (excluding multiple valve interventions) were used to formulate a risk score, with a cutoff of ≥2 points predicting antepartum arrhythmia with sensitivity and specificity of 84%. While recurrence of the index arrhythmia was not observed following successful catheter ablation, preconception ablation did not impact odds of antepartum arrhythmia. CONCLUSIONS We provide a novel risk stratification scheme for predicting antepartum arrhythmia in ACHD patients. The role of contemporary preconception catheter ablation in risk reduction needs further refinement with multicenter investigation.
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Affiliation(s)
- Prashanth Venkatesh
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, United States of America.
| | - Jeannette P Lin
- Ahmanson/UCLA Adult Congenital Heart Disease Center, Department of Medicine, University of California, Los Angeles, Los Angeles, CA, United States of America; UCLA Cardio-Obstetrics Program, Department of Medicine, University of California, Los Angeles, Los Angeles, CA, United States of America
| | - Amanda Nguyen
- David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, United States of America
| | - Joshua Rezkalla
- Department of Cardiology, Mayo Clinic, Rochester, MN, United States of America
| | - Jeremy P Moore
- Ahmanson/UCLA Adult Congenital Heart Disease Center, Department of Medicine, University of California, Los Angeles, Los Angeles, CA, United States of America; UCLA Cardiac Arrhythmia Center, Department of Medicine, University of California, Los Angeles, Los Angeles, CA, United States of America
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3
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Wander G, van der Zande JA, Patel RR, Johnson MR, Roos-Hesselink J. Pregnancy in women with congenital heart disease: a focus on management and preventing the risk of complications. Expert Rev Cardiovasc Ther 2023; 21:587-599. [PMID: 37470417 DOI: 10.1080/14779072.2023.2237886] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 07/14/2023] [Indexed: 07/21/2023]
Abstract
INTRODUCTION Congenital heart disease (CHD) is the most common cardiac disorder in pregnancy in the western world (around 80%). Due to improvements in surgical interventions more women with CHD are surviving to adulthood and choosing to become pregnant. AREAS COVERED Preconception counseling, antenatal management of CHDs and strategies to prevent maternal and fetal complications.Preconception counseling should start early, before the transition to adult care and be offered to both men and women. It should include the choice of contraception, lifestyle modifications, pre-pregnancy optimization of cardiac state, the chance of the child inheriting a similar cardiac lesion, the risks to the mother, and long-term prognosis. Pregnancy induces marked physiological changes in the cardiovascular system that may precipitate cardiac complications. Risk stratification is based on the underlying cardiac disease and data from studies including CARPREG, ZAHARA, and ROPAC. EXPERT OPINION Women with left to right shunts, regurgitant lesions, and most corrected CHDs are at lower risk and can be managed in secondary care. Complex CHD, including systemic right ventricle need expert counseling in a tertiary center. Those with severe stenotic lesions, pulmonary artery hypertension, and Eisenmenger's syndrome should avoid pregnancy, be given effective contraception and managed in a tertiary center if pregnancy does happen.
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Affiliation(s)
- Gurleen Wander
- Imperial College London, Chelsea and Westminster Hospital, London, UK
| | - Johanna A van der Zande
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Roshni R Patel
- Imperial College London, Chelsea and Westminster Hospital, London, UK
| | - Mark R Johnson
- Imperial College London, Chelsea and Westminster Hospital, London, UK
| | - Jolien Roos-Hesselink
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
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Halpern DG, Penfield CA, Feinberg JL, Small AJ. Reproductive Health in Congenital Heart Disease: Preconception, Pregnancy, and Postpartum. J Cardiovasc Dev Dis 2023; 10:jcdd10050186. [PMID: 37233153 DOI: 10.3390/jcdd10050186] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Revised: 04/20/2023] [Accepted: 04/21/2023] [Indexed: 05/27/2023] Open
Abstract
The prevalence of congenital heart disease (CHD) in pregnancy is rising due to the improved survival of patients with CHD into childbearing age. The profound physiological changes that occur during pregnancy may worsen or unmask CHD, affecting both mother and fetus. Successful management of CHD during pregnancy requires knowledge of both the physiological changes of pregnancy and the potential complications of congenital heart lesions. Care of the CHD patient should be based on a multidisciplinary team approach beginning with preconception counseling and continuing into conception, pregnancy, and postpartum periods. This review summarizes the published data, available guidelines and recommendations for the care of CHD during pregnancy.
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Affiliation(s)
- Dan G Halpern
- NYU Adult Congenital Heart Disease Program, Leon H. Charney Division of Cardiology, NYU Grossman School of Medicine and NYU Langone Health, New York, NY 10016, USA
| | - Christina A Penfield
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, NYU Grossman School of Medicine and NYU Langone Health, New York, NY 10016, USA
| | - Jodi L Feinberg
- NYU Adult Congenital Heart Disease Program, Leon H. Charney Division of Cardiology, NYU Grossman School of Medicine and NYU Langone Health, New York, NY 10016, USA
| | - Adam J Small
- NYU Adult Congenital Heart Disease Program, Leon H. Charney Division of Cardiology, NYU Grossman School of Medicine and NYU Langone Health, New York, NY 10016, USA
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Stephens EH, Dearani JA, Overman DM, Deyle DR, Rose CH, Ashikhmina E, Jain CC, Miranda WR, Connolly HM. Pregnancy heart team: A lesion-specific approach. J Thorac Cardiovasc Surg 2022:S0022-5223(22)01356-3. [PMID: 36658028 DOI: 10.1016/j.jtcvs.2022.12.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Revised: 12/14/2022] [Accepted: 12/15/2022] [Indexed: 12/24/2022]
Affiliation(s)
- Elizabeth H Stephens
- Department of Cardiovascular Surgery, Mayo Clinic-Children's Minnesota Cardiovascular Collaborative, Rochester, Minn.
| | - Joseph A Dearani
- Department of Cardiovascular Surgery, Mayo Clinic-Children's Minnesota Cardiovascular Collaborative, Rochester, Minn
| | - David M Overman
- Children's Heart Clinic, Children's Minnesota, Mayo Clinic-Children's Minnesota Cardiovascular Collaborative, Minneapolis, Minn
| | - David R Deyle
- Department of Clinical Genomics, Mayo Clinic, Rochester, Minn; Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minn
| | - Carl H Rose
- Obstetrics and Gynecology, Mayo Clinic, Rochester, Minn
| | - Elena Ashikhmina
- Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minn
| | - C Charles Jain
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minn
| | | | - Heidi M Connolly
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minn
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McCabe M, An N, Aboulhosn J, Schwarzenberger J, Canobbio M, Vallera C, Hong R. Anesthetic management for the peripartum care of women with Fontan physiology. Int J Obstet Anesth 2021; 48:103210. [PMID: 34425324 DOI: 10.1016/j.ijoa.2021.103210] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 06/21/2021] [Accepted: 07/22/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND As outcomes for surgical palliation have improved, women with single ventricle congenital heart disease are surviving into their reproductive years and may become pregnant. The cardiovascular changes of pregnancy may stress the Fontan circulation and pose significant risk to the mother and fetus. METHODS Pregnant women with Fontan physiology were identified from the Ahmanson/UCLA Adult Congenital Heart Disease Center database. A total of 37 pregnancies were identified between 2000 and 2019. Twenty live births from 19 patients were reviewed and compared for cardiac history, obstetric history, anesthetic management and cardiovascular outcomes. RESULTS Median gestational age at delivery was 35 weeks. Ten of 20 births were by cesarean delivery. An epidural technique was used as the primary anesthetic for 19 deliveries and general anesthesia was used for one cesarean delivery. An arterial line was placed in the peripartum period for three deliveries. Central venous access was established in the peripartum period for one patient. The mean blood loss for cesarean deliveries was 626 mL (range 240-1200 mL). The mean net peri-operative intake/output was positive 93.5 mL. Three patients were briefly transferred to the intensive care unit postpartum for higher level monitoring and care. CONCLUSION Epidural anesthesia is safe and effective for both vaginal and cesarean deliveries. Judicious fluid management is critical in minimizing postpartum cardiovascular complications. Many patients do not require a higher level of care, invasive monitoring or central venous access during the peripartum period.
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Affiliation(s)
- M McCabe
- Loma Linda University, Department of Anesthesiology, Los Angeles, CA, USA
| | - N An
- UCLA, Department of Anesthesiology and Perioperative Medicine, CA, USA.
| | - J Aboulhosn
- Ahmanson/UCLA Adult Congenital Heart Disease Center, CA, USA
| | - J Schwarzenberger
- UCLA, Department of Anesthesiology and Perioperative Medicine, CA, USA
| | - M Canobbio
- Ahmanson/UCLA Adult Congenital Heart Disease Center, CA, USA
| | - C Vallera
- UCLA, Department of Anesthesiology and Perioperative Medicine, CA, USA
| | - R Hong
- UCLA, Department of Anesthesiology and Perioperative Medicine, CA, USA
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7
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Anesthetic considerations for Fontan circulation and pregnancy. Int Anesthesiol Clin 2021; 59:52-59. [PMID: 34029248 DOI: 10.1097/aia.0000000000000329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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8
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Grandfils S, Dewandre PY, Bonnet P, Radermecker MA, Nisolle M, Kridelka F, Emonts P. Pregnancy and delivery in a patient with a Fontan circulation and primary ciliary dyskinesia: A case report. J Gynecol Obstet Hum Reprod 2021; 50:102184. [PMID: 34119700 DOI: 10.1016/j.jogoh.2021.102184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 05/30/2021] [Accepted: 06/07/2021] [Indexed: 10/21/2022]
Abstract
A patient had primary ciliary dyskinesia with a complex cardiac malformation. As a child, she had benefited from a Fontan surgery to maintain a proper cardiac function. In such patients, whether it is safe to become pregnant is controversial. This case illustrates the possibility of carrying a pregnancy to term and providing a vaginal birth if a rigorous preconception consultation is performed to ensure care by a multidisciplinary specialized team, and the patient is properly informed of the risks.
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Affiliation(s)
- Sébastien Grandfils
- Department of Gynecology and Obstetrics. CHU of Liege, University Hospital of Liege, 600 Rue de Gaillarmont, Liege 4032, Belgium.
| | | | | | - Marc André Radermecker
- Department of Anatomy, University of Liege, Belgium; Department of cardiovascular surgery, CHU of Liege, Belgium
| | - Michelle Nisolle
- Department of Gynecology and Obstetrics, CHU of Liege - CHR de la Citadelle Liege, Belgium
| | - Frédéric Kridelka
- Department of Gynecology and Obstetrics. CHU of Liege, University Hospital of Liege, 600 Rue de Gaillarmont, Liege 4032, Belgium
| | - Patrick Emonts
- Department of Gynecology and Obstetrics. CHU of Liege, University Hospital of Liege, 600 Rue de Gaillarmont, Liege 4032, Belgium; Department of Gynecology and Obstetrics, CHU of Liege - CHR de la Citadelle Liege, Belgium
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9
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Pregnancy and Congenital Heart Disease: A Brief Review of Risk Assessment and Management. Clin Obstet Gynecol 2020; 63:836-851. [PMID: 33074980 DOI: 10.1097/grf.0000000000000579] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Cardiac disease is a leading cause of morbidity and mortality in pregnant women. An increased prevalence of the cardiovascular disease has been found in women of childbearing age, in which the responsibility of the treating physician extends to the mother and to the unborn fetus. As a result, care of these high-risk pregnant women with cardiovascular disease including those with congenital heart disease (CHD) require a team approach including specialists in maternal-fetal medicine, adult congenital cardiology, and obstetrical anesthesia. The human body undergoes significant amounts of physiological changes during this period of time and the underlying cardiac disease can affect both the mother and the fetus. Today, most female children born with CHD will reach childbearing age. For many women with complex CHD, carrying a pregnancy has a moderate to high risk for both the mother and her fetus. This chapter will review the epidemiology, risk factors, clinical presentation including common signs and symptoms, physiological changes in pregnancy, and the medical approach including cardiac medications, percutaneous interventions, and surgical procedures for pregnant women with CHD.
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10
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Kim YY, Levine LD, Partington SL, Patel PA, Ruckdeschel E, Senapati S, Gracia CR. Successful in vitro fertilization in women with Fontan physiology. J Assist Reprod Genet 2020; 37:3017-3023. [PMID: 33040295 DOI: 10.1007/s10815-020-01969-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 10/05/2020] [Indexed: 10/23/2022] Open
Abstract
PURPOSE Patients with single ventricle anatomy palliated with Fontan operation are at risk for thromboembolism, arrhythmia, and heart failure rendering pregnancy high risk or even contraindicated. Infertility and high rates of first trimester miscarriage are not uncommon. In vitro fertilization (IVF) with or without gestational surrogacy can be an option, but poses risks during ovarian stimulation, oocyte retrieval, and the post-procedural period. We present six cases of women with complex congenital heart disease status post Fontan operation who underwent successful IVF. METHODS Case series from a single-center tertiary care setting. RESULTS Indications for referral were cardiac or fertility concerns for pregnancy of the congenital cardiologist. One woman had mild volume overload after oocyte retrieval requiring furosemide and one experienced post-operative colitis. There were no thrombotic complications. CONCLUSIONS A multidisciplinary team-based approach can result in successful oocyte retrieval and IVF in women with complex congenital heart disease and Fontan physiology.
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Affiliation(s)
- Yuli Y Kim
- Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA. .,Division of Cardiology, Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA. .,Philadelphia Adult Congenital Heart Center, Penn Medicine & Children's Hospital of Philadelphia, 3400 Civic Center Boulevard, PCAM 2nd Floor E. Pavilion, Philadelphia, PA, 19104, USA.
| | - Lisa D Levine
- Maternal and Child Health Research Center, Department of Obstetrics and Gynecology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Sara L Partington
- Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.,Division of Cardiology, Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.,Philadelphia Adult Congenital Heart Center, Penn Medicine & Children's Hospital of Philadelphia, 3400 Civic Center Boulevard, PCAM 2nd Floor E. Pavilion, Philadelphia, PA, 19104, USA
| | - Prakash A Patel
- Department of Anesthesia and Critical Care, Hospital of the University of Pennsylvania, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Emily Ruckdeschel
- Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.,Division of Cardiology, Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.,Philadelphia Adult Congenital Heart Center, Penn Medicine & Children's Hospital of Philadelphia, 3400 Civic Center Boulevard, PCAM 2nd Floor E. Pavilion, Philadelphia, PA, 19104, USA
| | - Suneeta Senapati
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Clarisa R Gracia
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
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Keenahan LA, Poondla RK, Franklin WJ, Ermis PR, Ketwaroo P, Opina A, Gandhi M. Pulmonary Embolism After Vaginal Delivery in a Fontan Patient. JACC Case Rep 2020; 2:1713-1715. [PMID: 34317041 PMCID: PMC8311981 DOI: 10.1016/j.jaccas.2020.04.051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Accepted: 04/15/2020] [Indexed: 06/13/2023]
Abstract
The Fontan procedure was created to address the mixing of pulmonary and systemic venous return in patients with a single functional ventricle. The patient in this case with a Fontan repair experienced multiple pulmonary emboli 10 days post-partum. We outline management and recommendations when treating these patients. (Level of Difficulty: Beginner.).
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Affiliation(s)
| | | | - Wayne J. Franklin
- Department of Cardiology, Phoenix Children’s Hospital, Phoenix, Arizona
| | - Peter R. Ermis
- Baylor College of Medicine, Houston, Texas
- Adult Congenital Heart Disease Program, Texas Children’s Hospital Houston, Texas
| | - Pamela Ketwaroo
- Baylor College of Medicine, Houston, Texas
- Department of Radiology, Texas Children’s Hospital, Houston, Texas
| | - Angeline Opina
- Baylor College of Medicine, Houston, Texas
- Adult Congenital Heart Disease Program, Texas Children’s Hospital Houston, Texas
| | - Manisha Gandhi
- Baylor College of Medicine, Houston, Texas
- Department of Obstetrics and Gynecology, Texas Children’s Pavilion for Women, Houston, Texas
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12
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Ishida S, Uchiyama A, Imai K, Kusuda S. Brain-type natriuretic peptide level in pregnant women with congenital heart disease predicts SGA offspring. Pediatr Int 2019; 61:1221-1226. [PMID: 31461203 DOI: 10.1111/ped.13997] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Revised: 05/17/2019] [Accepted: 06/25/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND Women with congenital heart disease (CHD) commonly experience complications related to CHD during pregnancy. The clinical features of neonates born to mothers with CHD, however, have not been fully investigated. The frequency of small for gestational age (SGA) is high in infants born to mothers with CHD, but the risk factors have not been examined sufficiently. Therefore, we analyzed the maternal features associated with SGA infants. METHODS AND RESULTS We enrolled pregnant women with repaired CHD and infants born to them at Tokyo Women's Medical University Hospital between April 2007 and March 2015. Eleven SGA (11%) and 91 non-SGA infants (89%) were included. On multivariate logistic regression, SGA infants were significantly more likely to be associated with a high maternal brain-type natriuretic peptide (BNP) level (OR, 6.7; 95%CI: 1.3-34.5; P = 0.02) and maternal single ventricle disease (OR, 8.4; 95%CI:1.4-51.8; P = 0.02) than were non-SGA infants. CONCLUSIONS The incidence of SGA infants born to mothers with CHD was not high in this study. High BNP and maternal single ventricle disease, however, are independent predictors of SGA in infants.
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Affiliation(s)
- Shuji Ishida
- Department of Neonatal Medicine, Maternal and Perinatal Center, Tokyo Women's Medical University, Tokyo, Japan
| | - Atsushi Uchiyama
- Department of Neonatal Medicine, Maternal and Perinatal Center, Tokyo Women's Medical University, Tokyo, Japan
| | - Ken Imai
- Department of Neonatal Medicine, Maternal and Perinatal Center, Tokyo Women's Medical University, Tokyo, Japan
| | - Satoshi Kusuda
- Department of Neonatal Medicine, Maternal and Perinatal Center, Tokyo Women's Medical University, Tokyo, Japan
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Bassaw B, Singh D, Chinnia J, Karan A, Ramsarran J. Uni-ventricular pregnancy: a case report in a low resource country. J OBSTET GYNAECOL 2019; 40:128-129. [PMID: 31607195 DOI: 10.1080/01443615.2019.1581751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Bharat Bassaw
- Faculty of Medical Sciences, University of the West Indies, St. Augustine Campus, St. Augustine, Trinidad and Tobago
| | - Dinesh Singh
- Mt. Hope Maternity Hospital, Champs Fleurs, Trinidad and Tobago
| | - Javed Chinnia
- Mt. Hope Maternity Hospital, Champs Fleurs, Trinidad and Tobago
| | - Abhinav Karan
- Mt. Hope Maternity Hospital, Champs Fleurs, Trinidad and Tobago
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14
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Afshar Y, Tan W, Jones WM, Canobbio M, Lin J, Reardon L, Lluri G, Aboulhosn J, Koos BJ. Maternal Fontan procedure is a predictor of a small-for-gestational-age neonate: a 10-year retrospective study. Am J Obstet Gynecol MFM 2019; 1:100036. [PMID: 33345800 DOI: 10.1016/j.ajogmf.2019.100036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2019] [Revised: 06/02/2019] [Accepted: 08/07/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Women with single ventricle cardiac physiologic condition who have undergone Fontan procedures are surviving well into reproductive age and historically have been discouraged from pregnancy, despite the paucity of data regarding maternal and neonatal outcomes. OBJECTIVE Our primary objective was to investigate, in a large cohort, the maternal and neonatal outcomes of pregnant women who have undergone the Fontan procedure and to understand maternal and neonatal sequelae of their pregnancies. STUDY DESIGN This single-center retrospective cohort study involves pregnant women with a Fontan palliation who delivered at UCLA Medical Center over a 10-year period (2007-2017). All pregnancies were evaluated for differences in maternal and neonatal characteristics. RESULTS We identified 37 distinct pregnancies in 24 women with a Fontan procedure. The physiologic pregnancy-related increase in cardiac output is blunted substantially in Fontan circulation. Third-trimester cardiac index positively correlated to birthweight z-score (R2=0.48; P=.038) but not to small for gestational age (R2=0.13; P=.339). The most common cardiac complications in pregnancies of >24 weeks gestation were sustained arrhythmia (37.5%) and decompensated heart failure (21%). The 37 pregnancies comprised 25 live births (67.6%), 1 fetal death (2.7%), 9 spontaneous abortions (24%), and 2 pregnancy terminations (5.4%). Of the live births, 60% were preterm at an average gestational age of 34.9±3.7 weeks. Newborn infants were delivered via cesarean in 53%, operative vaginal delivery in 28%, and spontaneous vaginal delivery in 20%. Forty percent of neonates were born small (<10th percentile) for gestational age; 44.0% of all neonates were admitted to the neonatal intensive care unit. CONCLUSION Women with a single ventricle and Fontan circulation can have a successful pregnancy, although they are at increased risk for arrhythmias and heart failure. The decreased cardiac reserve in these pregnancies blunts the normal increase in maternal cardiac output, which is associated with preterm delivery and small-for-gestational-age neonates. Further studies are needed to determine to what extent the impaired rise in maternal cardiac output reduces uteroplacental perfusion, placental exchange, fetal growth, and onset of parturition.
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Affiliation(s)
- Yalda Afshar
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, David Geffen School of Medicine, University of California, Los Angeles, CA.
| | - Weiyi Tan
- Ahmanson/UCLA Adult Congenital Heart Disease Center, Division of Cardiology, David Geffen School of Medicine, University of California, Los Angeles, CA
| | - William M Jones
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, David Geffen School of Medicine, University of California, Los Angeles, CA
| | - Mary Canobbio
- Ahmanson/UCLA Adult Congenital Heart Disease Center, Division of Cardiology, David Geffen School of Medicine, University of California, Los Angeles, CA
| | - Jeannette Lin
- Ahmanson/UCLA Adult Congenital Heart Disease Center, Division of Cardiology, David Geffen School of Medicine, University of California, Los Angeles, CA
| | - Leigh Reardon
- Ahmanson/UCLA Adult Congenital Heart Disease Center, Division of Cardiology, David Geffen School of Medicine, University of California, Los Angeles, CA
| | - Gentian Lluri
- Ahmanson/UCLA Adult Congenital Heart Disease Center, Division of Cardiology, David Geffen School of Medicine, University of California, Los Angeles, CA
| | - Jamil Aboulhosn
- Ahmanson/UCLA Adult Congenital Heart Disease Center, Division of Cardiology, David Geffen School of Medicine, University of California, Los Angeles, CA
| | - Brian J Koos
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, David Geffen School of Medicine, University of California, Los Angeles, CA
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15
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Rychik J, Atz AM, Celermajer DS, Deal BJ, Gatzoulis MA, Gewillig MH, Hsia TY, Hsu DT, Kovacs AH, McCrindle BW, Newburger JW, Pike NA, Rodefeld M, Rosenthal DN, Schumacher KR, Marino BS, Stout K, Veldtman G, Younoszai AK, d'Udekem Y. Evaluation and Management of the Child and Adult With Fontan Circulation: A Scientific Statement From the American Heart Association. Circulation 2019; 140:e234-e284. [PMID: 31256636 DOI: 10.1161/cir.0000000000000696] [Citation(s) in RCA: 407] [Impact Index Per Article: 81.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
It has been 50 years since Francis Fontan pioneered the operation that today bears his name. Initially designed for patients with tricuspid atresia, this procedure is now offered for a vast array of congenital cardiac lesions when a circulation with 2 ventricles cannot be achieved. As a result of technical advances and improvements in patient selection and perioperative management, survival has steadily increased, and it is estimated that patients operated on today may hope for a 30-year survival of >80%. Up to 70 000 patients may be alive worldwide today with Fontan circulation, and this population is expected to double in the next 20 years. In the absence of a subpulmonary ventricle, Fontan circulation is characterized by chronically elevated systemic venous pressures and decreased cardiac output. The addition of this acquired abnormal circulation to innate abnormalities associated with single-ventricle congenital heart disease exposes these patients to a variety of complications. Circulatory failure, ventricular dysfunction, atrioventricular valve regurgitation, arrhythmia, protein-losing enteropathy, and plastic bronchitis are potential complications of the Fontan circulation. Abnormalities in body composition, bone structure, and growth have been detected. Liver fibrosis and renal dysfunction are common and may progress over time. Cognitive, neuropsychological, and behavioral deficits are highly prevalent. As a testimony to the success of the current strategy of care, the proportion of adults with Fontan circulation is increasing. Healthcare providers are ill-prepared to tackle these challenges, as well as specific needs such as contraception and pregnancy in female patients. The role of therapies such as cardiovascular drugs to prevent and treat complications, heart transplantation, and mechanical circulatory support remains undetermined. There is a clear need for consensus on how best to follow up patients with Fontan circulation and to treat their complications. This American Heart Association statement summarizes the current state of knowledge on the Fontan circulation and its consequences. A proposed surveillance testing toolkit provides recommendations for a range of acceptable approaches to follow-up care for the patient with Fontan circulation. Gaps in knowledge and areas for future focus of investigation are highlighted, with the objective of laying the groundwork for creating a normal quality and duration of life for these unique individuals.
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16
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Abstract
The Fontan operation is a palliative surgical procedure for patients whose hearts cannot support a biventricular circulation. The haemodynamic changes that occur in pregnancy are particularly challenging for Fontan patients and the outcomes are variable. We present a case where fetal outcome was particularly poor despite a lack of high risk features pre-pregnancy.
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17
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Ephrem G, Hebson C, John A, Moore E, Jokhadar M, Ford R, Veldtman G, Dori Y, Gurvitz M, Kogon B, Kovacs A, Roswick M, McConnell M, Book WM, Rodriguez F. Frontiers in Fontan failure: Innovation and improving outcomes: A conference summary. CONGENIT HEART DIS 2018; 14:128-137. [PMID: 30343507 DOI: 10.1111/chd.12685] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Accepted: 09/14/2018] [Indexed: 12/24/2022]
Abstract
The initial "Frontiers in Fontan Failure" conference in 2015 in Atlanta, GA, provided an opportunity for experts in the field of pediatric cardiology and adult congenital heart disease to focus on the etiology, physiology, and potential interventions for patients with "Failing Fontan" physiology. Four types of "Fontan Failure" were described and then published by Dr Book et al. The acknowledgment that even Dr Fontan himself realized that the Fontan procedure "imposed a gradually declining functional capacity and premature late death after an initial period of often excellent palliation." The purpose of the second "Frontiers in Fontan Failure" was to further the discussion regarding new data and technologies as well as novel interventions. The 2017 "Frontiers in Fontan Failure: Innovation and Improving Outcomes" was sponsored by Children's Healthcare of Atlanta, Sibley Heart Center Cardiology, and Emory University School of Medicine. Future directions in the management of Fontan failure include further investigations into the risk of sudden cardiac death and how to properly prevent it, achievable interventions in modifying the Fontan physiology to treat or prevent late complications, and improved and refined algorithms in Fontan surveillance. Finally, further research into the interventional treatment of lymphatic-related complications hold the promise of marked improvement in the quality of life of advanced Fontan failure patients and as such should be encouraged and contributed to.
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Affiliation(s)
- Georges Ephrem
- Peter Munk Cardiac Centre, University Health Network, Toronto, Canada
| | - Camden Hebson
- Division of Cardiology, Department of Pediatrics, Children's of Alabama, Birmingham, Alabama
| | - Anitha John
- Division of Pediatric Cardiology, Children's National Health System, Washington, District of Columbia
| | - Estella Moore
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Maan Jokhadar
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Ryan Ford
- Division of Gastroenterology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Gruschen Veldtman
- Department of Cardiology, The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Yoav Dori
- Division of Cardiology, Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Michelle Gurvitz
- Boston Children's Hospital, Boston, Massachusetts.,Brigham and Women's Hospital, Boston, Massachusetts
| | - Brian Kogon
- Division of Pediatric Cardiothoracic Surgery, University of Mississippi Medical Center, Jackson, Mississippi
| | - Adrienne Kovacs
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon
| | | | - Michael McConnell
- Sibley Heart Center Cardiology, Emory University School of Medicine, Atlanta, Georgia
| | - Wendy M Book
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Fred Rodriguez
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia.,Sibley Heart Center Cardiology, Emory University School of Medicine, Atlanta, Georgia
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18
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Kay WA, Moe T, Suter B, Tennancour A, Chan A, Krasuski RA, Zaidi AN. Long Term Consequences of the Fontan Procedure and How to Manage Them. Prog Cardiovasc Dis 2018; 61:365-376. [PMID: 30236751 DOI: 10.1016/j.pcad.2018.09.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Accepted: 09/11/2018] [Indexed: 12/12/2022]
Abstract
In 1971, Fontan and Baudet described a surgical technique for successful palliation of patients with tricuspid atresia. Subsequently, this technique has been applied to treat most forms of functional single ventricles and has become the current standard of care for long-term palliation of all patients with single ventricle congenital heart disease. Since 1971, the Fontan procedure has undergone several variations. These patients require lifelong management including a thorough knowledge of their anatomic substrate, hemodynamic status, management of rhythm and ventricular function along with multi organ evaluation. As these patients enter middle age, there is increasing awareness regarding the long-term complications and mortality. This review highlights the long-term outcomes of the Fontan procedure and management of late sequelae.
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Affiliation(s)
- W Aaron Kay
- Indiana University School of Medicine, Krannert Institute of Cardiology, IN.
| | - Tabitha Moe
- University of Arizona School of Medicine, Phoenix, AZ.
| | - Blair Suter
- Indiana University School of Medicine, Departments of Medicine and Pediatrics, IN.
| | - Andrea Tennancour
- Indiana University School of Medicine, Krannert Institute of Cardiology, IN.
| | - Alice Chan
- Children's Hospital at Montefiore, Montefiore Medical Center, Albert Einstein College of Medicine, NY.
| | | | - Ali N Zaidi
- Children's Hospital at Montefiore, Montefiore Medical Center, Albert Einstein College of Medicine, NY.
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19
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Abstract
Survival rates and life expectancies for patients with congenital heart disease (CHD) have dramatically increased, and these patients are now reaching reproductive age. As they reproduce, questions pertaining to recurrent risk of disease and the impact on incidence rates have emerged. Recurrence rates for CHD have been estimated at 3% to 5%, although, due to the complex genetics underlying CHD, this range may represent an underestimation of the true risk. Debate still exists on whether the impact of recurrence of disease has been reflected in incidence rates. Although incidence rates have undoubtedly increased, the mechanism underlying this remains unclear; improved detection likely accounts for the majority of the observed increase; however, a true increase may be present simultaneously. Concurrently, certain factors, including improved fetal detection and elective terminations, infertility, increased rates of spontaneous abortion and intrauterine fetal demise in women with CHD, and folic acid supplementation, are leading to decreases in the incidence of CHD. It is likely that the full impact of improved survival and heritability of CHD on incidence rates remains to be seen and will likely be attenuated by other factors acting to decrease incidence.
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20
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Gestación tras cirugía de Fontan-Kreutzer. Rev Esp Cardiol (Engl Ed) 2018. [DOI: 10.1016/j.recesp.2017.03.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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21
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Garcia Ropero A, Baskar S, Roos Hesselink JW, Girnius A, Zentner D, Swan L, Ladouceur M, Brown N, Veldtman GR. Pregnancy in Women With a Fontan Circulation. Circ Cardiovasc Qual Outcomes 2018; 11:e004575. [DOI: 10.1161/circoutcomes.117.004575] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Accepted: 03/20/2018] [Indexed: 11/16/2022]
Affiliation(s)
- Alvaro Garcia Ropero
- Department of Cardiology, Instituto de Investigación Sanitaria-Fundación Jiménez Díaz, Madrid, Spain (A.G.R.)
| | - Shankar Baskar
- Heart Institute, Cincinnati Children’s Hospital Medical Center, OH (S.B. G.R.V., N.B.)
| | - Jolien W. Roos Hesselink
- Department of Cardiology, Erasmus Medical Center, Rotterdam, The Netherlands (J.W.R.H., N.B., G.R.V.)
| | - Andrea Girnius
- Department of Anesthesiology, University of Cincinnati, OH (A.G.)
| | - Dominica Zentner
- Department of Cardiology, Royal Melbourne Hospital and Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Parkville, Australia (D.Z.)
| | - Lorna Swan
- Department of Adult Congenital Heart Disease, Royal Brompton and Harefield NHS Foundation Trust, London, United Kingdom (L.S.)
| | - Magalie Ladouceur
- Department of Adult Congenital Heart Disease, Hôpital Européen Georges Pompidou, Assistance Publique–Hôpitaux de Paris (AP-HP), Paris Descartes University, Sorbonne Paris Cité, Paris Centre de Recherche Cardiovasculaire, INSERM U970, France (M.L.)
| | - Nicole Brown
- Heart Institute, Cincinnati Children’s Hospital Medical Center, OH (S.B. G.R.V., N.B.)
- Department of Cardiology, Erasmus Medical Center, Rotterdam, The Netherlands (J.W.R.H., N.B., G.R.V.)
| | - Gruschen R. Veldtman
- Heart Institute, Cincinnati Children’s Hospital Medical Center, OH (S.B. G.R.V., N.B.)
- Department of Cardiology, Erasmus Medical Center, Rotterdam, The Netherlands (J.W.R.H., N.B., G.R.V.)
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22
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Tong C, Kiess M, Deyell MW, Qiu M, Orgad M, Rychel V, Claman A, Hardwick E, McCarthy B, Silversides CK, Grewal J. Impact of frequent premature ventricular contractions on pregnancy outcomes. Heart 2018; 104:1370-1375. [PMID: 29463610 DOI: 10.1136/heartjnl-2017-312624] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2017] [Revised: 01/16/2018] [Accepted: 01/26/2018] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES To determine cardiac and fetal/neonatal event rates among pregnant women with premature ventricular contractions (PVCs) and compare with control groups. METHODS Prospective case-control cohort study: 53 consecutive pregnancies in 49 women referred to the St. Paul's Hospital between 2010 and 2016 with PVC burden >1% in women without underlying cardiac disease. Maternal cardiac and fetal/neonatal outcomes were compared with two pregnant control groups: (1) supraventricular tachycardia (SVT) group of 53 women referred for a history of SVT/SVT in the current pregnancy and (2) low-risk group of 53 women with no cardiac disease. RESULTS The maximal PVC burden was 9.2% (range 1.1%-58.7%). Six of 53 (11%) pregnancies were complicated by a maternal cardiac event: heart failure n=1 and sustained ventricular tachycardia requiring therapy n=5 as compared with no cardiac events in both control groups. All women with an adverse event had a PVC burden >5%. Seven (13%) pregnancies were complicated by an adverse fetal and/or neonatal event and this was similar to the normal control group (5 (9%), P=0.45) and significantly less than the SVT group (16 (30%), P=0.03). The adverse fetal event was driven by small for gestational age neonates and preterm delivery. CONCLUSIONS In our cohort of pregnant women with a structurally normal heart and 'high' PVC burden, we found an adverse maternal event rate of 11%, and all events were successfully managed with medical therapy. The rate of adverse fetal events in the PVC group was similar to the normal control group.
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Affiliation(s)
- Calvin Tong
- Division of Cardiology, St Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Marla Kiess
- Division of Cardiology, St Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Marc William Deyell
- Division of Cardiology, St Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Michael Qiu
- Division of Cardiology, St Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Merav Orgad
- Division of Cardiology, St Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Valerie Rychel
- Department of Obstetrics and Gynecology, St Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Ariel Claman
- Division of Cardiology, St Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Emma Hardwick
- Division of Cardiology, St Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Beverly McCarthy
- Division of Cardiology, St Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Candice K Silversides
- Division of Cardiology, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Jasmine Grewal
- Division of Cardiology, St Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
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23
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Niwa K. Adult Congenital Heart Disease with Pregnancy. Korean Circ J 2018; 48:251-276. [PMID: 29625509 PMCID: PMC5889976 DOI: 10.4070/kcj.2018.0070] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Accepted: 03/06/2018] [Indexed: 12/17/2022] Open
Abstract
The number of women with congenital heart disease (CHD) at risk of pregnancy is growing because over 90% of them are grown-up into adulthood. The outcome of pregnancy and delivery is favorable in most of them provided that functional class and systemic ventricular function are good. Women with CHD such as pulmonary hypertension (Eisenmenger syndrome), severe left ventricular outflow stenosis, cyanotic CHD, aortopathy, Fontan procedure and systemic right ventricle (complete transposition of the great arteries [TGA] after atrial switch, congenitally corrected TGA) carry a high-risk. Most frequent complications during pregnancy and delivery are heart failure, arrhythmias, bleeding or thrombosis, and rarely maternal death. Complications of fetus are prematurity, low birth weight, abortion, and stillbirth. Risk stratification of pregnancy and delivery relates to functional status of the patient and is lesion specific. Medication during pregnancy and post-delivery (breast feeding) is a big concern. Especially prescribing medication with teratogenicity should be avoidable. Adequate care during pregnancy, delivery, and the postpartum period requires a multidisciplinary team approach with cardiologists, obstetricians, anesthesiologists, neonatologists, nurses and other related disciplines. Caring for a baby is an important issue due to temporarily pregnancy-induced cardiac dysfunction, and therefore familial support is mandatory especially during peripartum and after delivery. Timely pre-pregnancy counseling should be offered to all women with CHD to prevent avoidable pregnancy-related risks. Successful pregnancy is feasible for most women with CHD at relatively low risk when appropriate counseling and optimal care are provided.
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Affiliation(s)
- Koichiro Niwa
- Department of Cardiology, Cardiovascular Center, St. Luke's International Hospital, Tokyo, Japan. ,
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24
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Pregnancy outcomes in patients with a fontan circulation and proposal for a risk-scoring system: single centre experience. JOURNAL OF CONGENITAL CARDIOLOGY 2017. [DOI: 10.1186/s40949-017-0012-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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25
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Al Najashi KS, Mehdi S, Mohsin S, Atiyah M, Abdullah HA, Abdulhameed J, Al Zahrani AM. Four successful pregnancies in a patient with Fontan palliation and congenital heart disease: a case report. J Cardiothorac Surg 2017; 12:104. [PMID: 29183331 PMCID: PMC5706291 DOI: 10.1186/s13019-017-0678-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2017] [Accepted: 11/23/2017] [Indexed: 11/12/2022] Open
Abstract
Background Fontan is a palliative procedure in patients with single ventricle. Single ventricle supports systemic cardiac output and pulmonary blood flow is passively directed to the right pulmonary artery. Women with Fontan palliation are reported to have increased maternal risk during pregnancy. There are few reports of successful pregnancies in such cases. However data on these pregnancies is lacking, we consider this to be the first reported from kingdom of Saudi Arabia. Case presentation We present a 35-year-old woman from the Kingdom of Saudi Arabia who had Fontan surgery and who had four successful pregnancies and multiple miscarriages. She delivered live, low birth weight neonates. Conclusion This report provides an anecdotal evidence that pregnancy can be tolerated in an adequate Fontan patient with successful outcomes.
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Affiliation(s)
- Khalid S Al Najashi
- Prince Sultan Cardiac Center, PO Box 7897, 11159, Riyadh, Kingdom of Saudi Arabia.
| | - Syed Mehdi
- Prince Sultan Cardiac Center, PO Box 7897, 11159, Riyadh, Kingdom of Saudi Arabia
| | - Shazia Mohsin
- Prince Sultan Cardiac Center, PO Box 7897, 11159, Riyadh, Kingdom of Saudi Arabia
| | - Merna Atiyah
- Prince Sultan Cardiac Center, PO Box 7897, 11159, Riyadh, Kingdom of Saudi Arabia
| | - Hafez A Abdullah
- Prince Sultan Cardiac Center, PO Box 7897, 11159, Riyadh, Kingdom of Saudi Arabia
| | - Jassim Abdulhameed
- Prince Sultan Cardiac Center, PO Box 7897, 11159, Riyadh, Kingdom of Saudi Arabia
| | - Ahmed M Al Zahrani
- Prince Sultan Cardiac Center, PO Box 7897, 11159, Riyadh, Kingdom of Saudi Arabia
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26
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Mehta N, Mitta S. Fontan circulation and implications for future reproduction. Obstet Med 2017; 10:104-106. [PMID: 29051776 DOI: 10.1177/1753495x16676727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Accepted: 10/01/2016] [Indexed: 11/17/2022] Open
Abstract
This article summarizes and critiques four recent publications looking at preconception counseling, pregnancy outcomes, and cardiac complications in women with history of Fontan circulation. The Fontan procedure is a palliative strategy for single-ventricle type congenital heart disease and involves passive flow of venous return into the pulmonary circulation, bypassing the ventricles. Pregnancy in these patients is not without risk and preconception counseling and contraception practices vary widely. High rates of miscarriage, prematurity, and small-for-gestational-age babies are reported. Cardiac complications include mainly arrhythmias. Whether long-term prognosis in these patients is affected by pregnancy is not yet known.
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Affiliation(s)
- Niharika Mehta
- Department of Medicine, Warren Alpert Medical School of Brown University, Providence, RI, USA.,Division of Obstetric Medicine, Women and Infants Hospital of Rhode Island, Providence, RI, USA
| | - Srilakshmi Mitta
- Department of Medicine, Warren Alpert Medical School of Brown University, Providence, RI, USA.,Division of Obstetric Medicine, Women and Infants Hospital of Rhode Island, Providence, RI, USA
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27
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Abstract
The prevalence of pregnant women with cardiovascular heart disease is increasing. Transthoracic echocardiography is safe during pregnancy, and it is an important diagnostic tool in pregnant women with established heart disease in order to monitor ventricular and valvular anatomy and function. In addition, it can be used to delineate cardiac anatomy in complex congenital heart disease and help stratify maternal risk during pregnancy. This review will focus on the use of echocardiography in the diagnosis and management of pregnant women with common congenital lesions and with prosthetic valves.
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Affiliation(s)
- Meena Narayanan
- Division of Cardiology, Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Uri Elkayam
- Division of Cardiology, Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Tasneem Z Naqvi
- Division of Cardiology, Department of Medicine, College of Medicine, Mayo Clinic, CK27, 13400 E Shea Blvd, Scottsdale, AZ, 85259, USA.
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28
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Pregnancy After Fontan-Kreutzer Surgery. ACTA ACUST UNITED AC 2017; 71:583-584. [PMID: 28579257 DOI: 10.1016/j.rec.2017.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2016] [Accepted: 03/15/2017] [Indexed: 11/22/2022]
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29
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Bianca I, Geraci G, Gulizia MM, Egidy Assenza G, Barone C, Campisi M, Alaimo A, Adorisio R, Comoglio F, Favilli S, Agnoletti G, Carmina MG, Chessa M, Sarubbi B, Mongiovì M, Russo MG, Bianca S, Canzone G, Bonvicini M, Viora E, Poli M. Consensus Document of the Italian Association of Hospital Cardiologists (ANMCO), Italian Society of Pediatric Cardiology (SICP), and Italian Society of Gynaecologists and Obstetrics (SIGO): pregnancy and congenital heart diseases. Eur Heart J Suppl 2017; 19:D256-D292. [PMID: 28751846 PMCID: PMC5526477 DOI: 10.1093/eurheartj/sux032] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
The success of cardiac surgery over the past 50 years has increased numbers and median age of survivors with congenital heart disease (CHD). Adults now represent two-thirds of patients with CHD; in the USA alone the number is estimated to exceed 1 million. In this population, many affected women reach reproductive age and wish to have children. While in many CHD patients pregnancy can be accomplished successfully, some special situations with complex anatomy, iatrogenic or residual pathology are associated with an increased risk of severe maternal and fetal complications. Pre-conception counselling allows women to come to truly informed choices. Risk stratification tools can also help high-risk women to eventually renounce to pregnancy and to adopt safe contraception options. Once pregnant, women identified as intermediate or high risk should receive multidisciplinary care involving a cardiologist, an obstetrician and an anesthesiologist with specific expertise in managing this peculiar medical challenge. This document is intended to provide cardiologists working in hospitals where an Obstetrics and Gynecology Department is available with a streamlined and practical tool, useful for them to select the best management strategies to deal with a woman affected by CHD who desires to plan pregnancy or is already pregnant.
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Affiliation(s)
- Innocenzo Bianca
- Pediatric Cardiology Unit, Maternity and Neonatal Department, ARNAS Garibaldi, Catania, Italy
| | - Giovanna Geraci
- Cardiology Department, PO Cervello, Az. Osp. Riuniti Villa Sofia-Cervello, Via Trabucco, 180, 90146 Palermo, Italy
| | - Michele Massimo Gulizia
- Cardiology Department, Ospedale Garibaldi-Nesima, Azienda di Rilievo Nazionale e Alta Specializzazione ‘Garibaldi’, Catania, Italy
| | - Gabriele Egidy Assenza
- Pediatric Cardiology and Adult Congenital Heart Program, Azienda Ospedaliera-Universitaria Sant’Orsola-Malpighi, Bologna, Itlay
| | - Chiara Barone
- Genetics Unit, Maternity and Neonatal Department, ARNAS Garibaldi, Catania, Italy
| | - Marcello Campisi
- Pediatric Cardiology Unit, Maternity and Neonatal Department, ARNAS Garibaldi, Catania, Italy
| | - Annalisa Alaimo
- Pediatric Cardiology Department, PO Di Cristina, ARNAS Civico, Palermo, Italy
| | - Rachele Adorisio
- Pediatric Cardiology Department, Ospedale Pediatrico Bambino Gesù, Roma, Italy
| | - Francesca Comoglio
- SCDU 2, Dipartimento di Scienze Chirurgiche (Surgical Sciences Department), Università di Torino, Italy
| | - Silvia Favilli
- Pediatric Cardiology Department, Azienda-Ospedalliero-Universitaria Meyer, Firenze, Italy
| | - Gabriella Agnoletti
- Pediatric Cardiology Department, Ospedale Regina Margherita, Città della Salute e della Scienza, Torino, Italy
| | - Maria Gabriella Carmina
- Cardiology Department, PO Cervello, Az. Osp. Riuniti Villa Sofia-Cervello, Via Trabucco, 180, 90146 Palermo, Italy
| | - Massimo Chessa
- Pediatric and Adult Congenital Heart Centre, IRCCS-Policlinico San Donato Milanese San Donato Milanese (MI), Italy
| | - Berardo Sarubbi
- Pediatric Cardiology and Cardiology SUN, Seconda Università di Napoli, AORN dei Colli, Ospedale Monaldi, Napoli, Italy
| | - Maurizio Mongiovì
- Pediatric Cardiology Department, PO Di Cristina, ARNAS Civico, Palermo, Italy
| | - Maria Giovanna Russo
- Pediatric Cardiology and Cardiology SUN, Seconda Università di Napoli, AORN dei Colli, Ospedale Monaldi, Napoli, Italy
| | - Sebastiano Bianca
- Genetics Unit, Maternity and Neonatal Department, ARNAS Garibaldi, Catania, Italy
| | - Giuseppe Canzone
- Women and Children Health Department, Ospedale S. Cimino, Termini Imerese (PA), Italy
| | - Marco Bonvicini
- Pediatric Cardiology and Adult Congenital Heart Program, Azienda Ospedaliera-Universitaria Sant’Orsola-Malpighi, Bologna, Itlay
| | - Elsa Viora
- Echography and Prenatal Diagnosis Centre, Obstetrics and Gynaecology Department, Città della Salute e della Scienza di Torino, Italy
| | - Marco Poli
- Intensive Cardiac Therapy Department, Ospedale Sandro Pertini, Roma, Italy
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Collins RT, Chang D, Sandlin A, Goudie A, Robbins JM. National In-Hospital Outcomes of Pregnancy in Women With Single Ventricle Congenital Heart Disease. Am J Cardiol 2017; 119:1106-1110. [PMID: 28242012 DOI: 10.1016/j.amjcard.2016.12.015] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2016] [Revised: 12/15/2016] [Accepted: 12/15/2016] [Indexed: 02/01/2023]
Abstract
Most patients with single ventricle (SV) congenital heart disease are expected to survive to adulthood. Women with SV are often counseled against pregnancy; however, data on pregnancies in these women are lacking. We sought to evaluate in-hospital outcomes of pregnancy in women with SV. We used nationally representative data from the 1998 to 2012 National Inpatient Sample to identify women ≥18 years of age admitted to the hospital with International Classification of Diseases-9th Revision codes for an intrauterine pregnancy and a diagnosis of hypoplastic left heart syndrome, tricuspid atresia, or common ventricle. A matched comparison group without a diagnosis of congenital heart disease or pulmonary hypertension was identified from the database. National estimates of hospitalizations were calculated. Length of stay, hospital charges, and complications were analyzed and compared between groups. Charge data were adjusted to 2012 dollars. There were 282 admissions of pregnant women with SV (69% with deliveries) and 1,405 admissions in the control group (88% with deliveries). Vaginal delivery was more common in SV (74% vs 71%, p <0.001). Length of stay (4.1 ± 0.91 vs 2.8 ± 0.18 days, p <0.001) and charges ($30,787 ± 8,109 vs $15,536 ± 1,006, p <0.0001) were higher in the SV group. Complications occurred in most SV admissions and were more common in the SV group than in the control group. No deaths occurred. Cardiovascular complications occurred in 25% of pregnancy-related hospitalizations, although in-hospital pregnancy-related death is rare. Vaginal delivery is common in these patients. These data suggest that pregnancy and vaginal delivery can be tolerated in women with SV, although the risk for a cardiovascular event is significantly higher than in the general population.
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Affiliation(s)
- R Thomas Collins
- Department of Internal Medicine, The University of Arkansas for Medical Sciences, Little Rock, Arkansas; Department of Pediatrics, The University of Arkansas for Medical Sciences, Little Rock, Arkansas; Arkansas Children's Research Institute, The University of Arkansas for Medical Sciences, Little Rock, Arkansas.
| | - Di Chang
- Arkansas Children's Research Institute, The University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Adam Sandlin
- Department of Obstetrics and Gynecology, The University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Anthony Goudie
- Department of Pediatrics, The University of Arkansas for Medical Sciences, Little Rock, Arkansas; Arkansas Children's Research Institute, The University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - James M Robbins
- Department of Pediatrics, The University of Arkansas for Medical Sciences, Little Rock, Arkansas; Arkansas Children's Research Institute, The University of Arkansas for Medical Sciences, Little Rock, Arkansas
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Miner PD, Canobbio MM, Pearson DD, Schlater M, Balon Y, Junge KJ, Bhatt A, Barber D, Nickolaus MJ, Kovacs AH, Moons P, Shaw K, Fernandes SM. Contraceptive Practices of Women With Complex Congenital Heart Disease. Am J Cardiol 2017; 119:911-915. [PMID: 28087052 DOI: 10.1016/j.amjcard.2016.11.047] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Revised: 11/22/2016] [Accepted: 11/22/2016] [Indexed: 10/20/2022]
Abstract
Understanding the contraceptive practices of women with complex congenital heart disease (CHD) and providing them individualized contraception counseling may prevent adverse events and unplanned high-risk pregnancies. Given this, we sought to examine the contraceptive practices in women with CHD, describe adverse events associated with contraceptive use, and describe the provision of contraception counseling. Women >18 years were recruited from 2011 to 2014 from 9 adult CHD (ACHD) centers throughout North America. Subjects completed a 48-item questionnaire regarding contraceptive use and perceptions of contraception counseling, and a medical record review was performed. Of 505 subjects, median age was 33 (interquartile range 26 to 44) and 81% had CHD of moderate or great complexity. The majority (86%, 435 of 505) of the cohort had used contraception. The types included barrier methods (87%), oral contraception (OC) 84%, intrauterine device (18%), Depo-Provera (15%), vaginal ring (7%), patch (6%), hormonal implant (2%), Plan B (19%), and sterilization (16%). Overall OC use was not significantly different by CHD complexity. Women with CHD of great complexity were more likely to report a thrombotic event while taking OC than those with less complex CHD (9% vs 1%, p = 0.003). Contraception counseling by the ACHD team was noted by 43% of subjects. Unplanned pregnancy was reported by 25% with no statistical difference by CHD complexity. In conclusion, contraceptive practices of women with complex CHD are highly variable, and the prevalence of blood clots while taking OC is not insignificant while provision of contraception counseling by ACHD providers appears lacking.
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Canobbio MM, Warnes CA, Aboulhosn J, Connolly HM, Khanna A, Koos BJ, Mital S, Rose C, Silversides C, Stout K. Management of Pregnancy in Patients With Complex Congenital Heart Disease: A Scientific Statement for Healthcare Professionals From the American Heart Association. Circulation 2017; 135:e50-e87. [PMID: 28082385 DOI: 10.1161/cir.0000000000000458] [Citation(s) in RCA: 233] [Impact Index Per Article: 33.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Today, most female children born with congenital heart disease will reach childbearing age. For many women with complex congenital heart disease, carrying a pregnancy carries a moderate to high risk for both the mother and her fetus. Many such women, however, do not have access to adult congenital heart disease tertiary centers with experienced reproductive programs. Therefore, it is important that all practitioners who will be managing these women have current information not only on preconception counseling and diagnostic evaluation to determine maternal and fetal risk but also on how to manage them once they are pregnant and when to refer them to a regional center with expertise in pregnancy management.
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The Long-Term Management of Children and Adults with a Fontan Circulation: A Systematic Review and Survey of Current Practice in Australia and New Zealand. Pediatr Cardiol 2017; 38:56-69. [PMID: 27787594 DOI: 10.1007/s00246-016-1484-6] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2016] [Accepted: 10/15/2016] [Indexed: 01/28/2023]
Abstract
Although long-term survival is now the norm, Fontan patients face significant morbidity and premature mortality. Wide variation exists in long-term Fontan management. With an aim of improving their long-term management, we conducted a systematic review to identify best available evidence and gaps in knowledge for future research focus. We also surveyed cardiologists in Australia and New Zealand managing Fontan patients, to determine the alignment of current local practice with best available evidence. A systematic review was conducted using strict search criteria (PRISMA guidelines), pertaining to long-term Fontan management. All adult congenital and paediatric cardiologists registered with The Australia and New Zealand Fontan Registry were invited to respond to an online survey. Reasonable quality evidence exists for non-inferiority of aspirin over warfarin for thromboprophylaxis in standard-risk Fontan patients. No strong evidence is currently available for the routine use of ACE inhibitors, beta blockers or pulmonary vasodilators. Little evidence exists regarding optimal arrhythmia treatment, exercise restriction/prescription, routine fenestration closure, elective Fontan conversion and screening/management of liver abnormalities. Although pregnancy is generally well tolerated, there are high rates of miscarriage and premature delivery. Thirty-nine out of 78 (50 %) cardiologists responded to the survey. Heterogeneity in response was demonstrated with regard to long-term anti-coagulation, other medication use, fenestration closure and pregnancy and contraception counselling. Substantial gaps in our knowledge remain with regard to the long-term management of Fontan patients. This is reflected in the survey of cardiologists managing these patients. We have identified a number of key areas for future research.
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Clift P, Celermajer D. Managing adult Fontan patients: where do we stand? Eur Respir Rev 2016; 25:438-450. [PMID: 27903666 PMCID: PMC9487559 DOI: 10.1183/16000617.0091-2016] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2016] [Accepted: 10/13/2016] [Indexed: 01/10/2023] Open
Abstract
The Fontan operation is performed as a palliative procedure to improve survival in infants born with a functionally univentricular circulation. The success of the operation is demonstrated by a growing adult Fontan population that exists with this unique physiology. Late follow-up has demonstrated expected and unexpected sequelae, and has shown multisystem effects of this circulation. This review discusses the challenges of managing the late complications in terms of understanding this unique physiology and the innovative therapeutic interventions that are being investigated. The challenge remains to maintain quality of life for adult survivors, as well as extending life expectancy. Innovative solutions are required to meet the challenges of the Fontan circulation faced in adult lifehttp://ow.ly/XTSm305oH8b
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Zentner D, Kotevski A, King I, Grigg L, d'Udekem Y. Fertility and pregnancy in the Fontan population. Int J Cardiol 2016; 208:97-101. [DOI: 10.1016/j.ijcard.2016.01.180] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2015] [Revised: 12/07/2015] [Accepted: 01/11/2016] [Indexed: 10/22/2022]
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Hemodynamically Significant Congenital Cardiac Lesions in Pregnancy. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2016; 18:35. [PMID: 26994615 DOI: 10.1007/s11936-016-0451-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OPINION STATEMENT The incidence of congenital cardiac disease among reproductive-aged women is increasing. Understanding the unique physiology of pregnancy and the postpartum period is critical to helping women achieve successful pregnancy outcomes. Risk assessment models estimate the cardiac, obstetric, and neonatal risks a woman may face and influence the conversations regarding pregnancy and contraception management. This review focuses on some of the most common congenital cardiac lesion encountered during pregnancy, as well as key aspects of antepartum, intrapartum, and postpartum care for these women. A multidisciplinary team, with Maternal-Fetal Medicine, Cardiology and Obstetric Anesthesiology specialists, is critical to the care of these patients.
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Hebson C, Saraf A, Book WM. Risk Assessment and Management of the Mother with Cardiovascular Disease. Clin Perinatol 2016; 43:1-22. [PMID: 26876118 DOI: 10.1016/j.clp.2015.11.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Chronic medical conditions account for most nonobstetrical pregnancy-related maternal complications. Preconception counseling of women with cardiovascular disease can be aided by an understanding of cardiovascular physiology in pregnancy and risk scores to guide management.
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Affiliation(s)
- Camden Hebson
- Department of Medicine, The Sibley Heart Center, Emory University School of Medicine, 1365 Clifton Road Northeast, Clinic A, 2nd Floor, Cardiology, Atlanta, GA 30322, USA; Department of Pediatrics, The Sibley Heart Center, Emory University School of Medicine, 1365 Clifton Road Northeast, Clinic A, 2nd Floor, Cardiology, Atlanta, GA 30322, USA
| | - Anita Saraf
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, 1365 Clifton Road Northeast, Atlanta, GA 30322, USA
| | - Wendy M Book
- Division of Cardiology, Department of Medicine, Emory Adult Congenital Heart Center, Emory University School of Medicine, 1365 Clifton Road Northeast, Clinic A, 2nd Floor, Cardiology, Atlanta, GA 30322, USA.
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Cauldwell M, Von Klemperer K, Uebing A, Swan L, Steer PJ, Babu-Narayan SV, Gatzoulis MA, Johnson MR. A cohort study of women with a Fontan circulation undergoing preconception counselling. Heart 2016; 102:534-40. [DOI: 10.1136/heartjnl-2015-308788] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2015] [Accepted: 12/15/2015] [Indexed: 11/04/2022] Open
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Abstract
Most women with known congenital heart disease can have successful pregnancy, labor, and delivery. Preconception assessment is essential in understanding anatomy, repairs, and current physiology, all of which can influence risk in pregnancy. With that foundation, a multidisciplinary cardio-obstetric team can predict and prepare for complications that may occur with superimposed hemodynamic changes of pregnancy. Individuals with Eisenmenger syndrome, pulmonary hypertension, cyanosis, significant left heart obstruction, ventricular dysfunction, or prior major cardiac event are among the highest risk for complications.
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40
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Pundi KN, Pundi K, Johnson JN, Dearani JA, Bonnichsen CR, Phillips SD, Canobbio MC, Driscoll DJ, Cetta F. Contraception Practices and Pregnancy Outcome in Patients after Fontan Operation. CONGENIT HEART DIS 2015; 11:63-70. [DOI: 10.1111/chd.12291] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/28/2015] [Indexed: 11/27/2022]
Affiliation(s)
- Kavitha N. Pundi
- Division of Pediatric Cardiology; Mayo Clinic; Rochester Minn USA
| | - Krishna Pundi
- Division of Cardiovascular Diseases; Mayo Clinic; Rochester Minn USA
| | - Jonathan N. Johnson
- Division of Pediatric Cardiology; Mayo Clinic; Rochester Minn USA
- Division of Cardiovascular Surgery; Mayo Clinic; Rochester Minn USA
| | | | | | | | - Mary C. Canobbio
- Ahmanson/UCLA Adult Congenital Heart Disease Center; University of California; Los Angeles Calif USA
| | | | - Frank Cetta
- Division of Pediatric Cardiology; Mayo Clinic; Rochester Minn USA
- Division of Cardiovascular Surgery; Mayo Clinic; Rochester Minn USA
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Abstract
Because of the growing population of patients with congenital heart disease (CHD), most maternal cardiac disease is now congenital in origin. For women with complex CHD, pregnancy poses an increased risk for both the mother, with complications of arrhythmias and heart failure being the most common, and the baby, with a higher chance of miscarriage, intrauterine growth retardation, and the need for early delivery. Pre-pregnancy counseling must be performed by cardiologists who have expertise in both CHD and pregnancy, with a detailed clinical assessment of the patient and the current hemodynamic situation, including echocardiography and an exercise test. In each case the approach must be individualized with consideration of the risks in each case. In some cases, such as Eisenmenger syndrome, pregnancy is contraindicated. Optimum outcomes in these complex patients are achieved when a multidisciplinary approach is used, involving maternal-fetal medicine specialists, cardiologists with expertise in CHD and obstetric anesthesia.
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Gouton M, Nizard J, Patel M, Sassolas F, Jimenez M, Radojevic J, Mathiron A, Amedro P, Barre E, Labombarda F, Vaksmann G, Chantepie A, Le Gloan L, Ladouceur M. Maternal and fetal outcomes of pregnancy with Fontan circulation: A multicentric observational study. Int J Cardiol 2015; 187:84-9. [DOI: 10.1016/j.ijcard.2015.03.344] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2015] [Accepted: 03/21/2015] [Indexed: 10/23/2022]
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43
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Pinto C, Vettukattil JJ, Haw MP. Postpartum Pulmonary Embolism in a Patient With Fontan Circulation. World J Pediatr Congenit Heart Surg 2015; 6:317-9. [DOI: 10.1177/2150135114568786] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Pregnancy is typically not recommended in patients with Fontan circulation. Although patients are well aware of the risks for the mother and fetus, an increasing number opt to become pregnant. The higher rate of survival into adulthood post-Fontan procedure is a likely factor as a result of improved management of single ventricle anatomy. Postpartum thromboembolism is a known complication, but its prevalence and management are not clearly defined. We present a case of massive pulmonary embolism two weeks postpartum in a patient with double inlet left ventricle palliated with lateral tunnel Fontan.
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Affiliation(s)
- Candida Pinto
- Congenital Heart Center, Helen DeVos Children’s Hospital of Spectrum Health, Grand Rapids, MI, USA
| | - Joseph J. Vettukattil
- Congenital Heart Center, Helen DeVos Children’s Hospital of Spectrum Health, Grand Rapids, MI, USA
| | - Marcus P. Haw
- Congenital Heart Center, Helen DeVos Children’s Hospital of Spectrum Health, Grand Rapids, MI, USA
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Corticelli A, Grimaldi M, Marasini M, Croci F, Trifiletti V, Bonfiglio M, Delfino R, Cinque E, Saltarini M. Experience of two consecutive pregnancies after Fontan connection: anesthesiology and obstetrical aspects. CASE REPORTS IN PERINATAL MEDICINE 2015. [DOI: 10.1515/crpm-2014-0019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Abstract
We report a case of two consecutive pregnancies in a patient where a Fontan connection, a cardiac procedure used since 1971 to provide palliation for patients that cannot support a biventricular circulation was used. Here we analyze the anesthesiological and obstetrical aspects particularly regarding some cardiovascular problems that occurred during the pregnancy and delivery.
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Affiliation(s)
- Alberto Corticelli
- Department of Obstetrics and Gynaecology, ASL4 Chiavarese, Lavagna, Genoa, Italy
| | - Maura Grimaldi
- Department of Obstetrics and Gynaecology, ASL4 Chiavarese, Lavagna, Genoa, Italy
| | | | - Francesco Croci
- Department of Cardiology, ASL4 Chiavarese, Lavagna, Genoa, Italy
| | - Valeria Trifiletti
- University of Genoa, Internal Medicine, San Martino Hospital, Genoa, Italy
| | - Monica Bonfiglio
- Department of Anesthesiology, ASL4 Chiavarese, Lavagna, Genoa, Italy
| | - Riccarda Delfino
- Department of Anesthesiology, ASL4 Chiavarese, Lavagna, Genoa, Italy
| | - Enrico Cinque
- Department of Anesthesiology, ASL4 Chiavarese, Lavagna, Genoa, Italy
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Abstract
Due to advances in paediatric congenital heart surgery, there are a growing number of women with congenital heart disease (CHD) reaching childbearing age. Pregnancy, however, is associated with haemodynamic stresses which can result in cardiac decompensation in women with CHD. Many women with CHD are aware of their cardiac condition prior to pregnancy, and preconception counselling is an important aspect of their care. Preconception counselling allows women to make informed pregnancy decisions, provides an opportunity for modifications of teratogenic medications and, when necessary, repair of cardiac lesions prior to pregnancy. Less commonly, the haemodynamic changes of pregnancy unmask a previously unrecognised heart lesion. In general, pregnancy outcomes are favourable for women with CHD, but there are some cardiac lesions that carry high risk for both the mother and the baby, and this group of women require care by an experienced multidisciplinary team. This review discusses preconception counselling including contraception, an approach to risk stratification and management recommendations in women with some common CHDs.
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Affiliation(s)
- Rohan D'Souza
- Division of Maternal and Fetal Medicine, Department of Obstetrics & Gynaecology, University of Toronto, Mount Sinai Hospital, Toronto, Canada
| | - Mathew Sermer
- Division of Maternal and Fetal Medicine, Department of Obstetrics & Gynaecology, University of Toronto, Mount Sinai Hospital, Toronto, Canada
- Obstetric Medicine Program, Division of Cardiology, Department of Medicine, University of Toronto, Mount Sinai Hospital and University Health Network, Canada
| | - Candice K Silversides
- Division of Maternal and Fetal Medicine, Department of Obstetrics & Gynaecology, University of Toronto, Mount Sinai Hospital, Toronto, Canada
- Obstetric Medicine Program, Division of Cardiology, Department of Medicine, University of Toronto, Mount Sinai Hospital and University Health Network, Canada
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Tiouririne M, de Souza DG, Beers KT, Yemen TA. Anesthetic Management of Parturients With a Fontan Circulation. Semin Cardiothorac Vasc Anesth 2015; 19:203-9. [DOI: 10.1177/1089253214566887] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Parturients with Fontan physiology provide unique and complex challenges to anesthesiologists. Such challenges include the maintenance of a perfect balance between preload, pulmonary vascular resistance, afterload, and cardiac output in a setting of a single ventricle physiology. The physiological changes of pregnancy add additional burden to an already “fragile” physiology, making the anesthetic management for labor and/or cesarean delivery even more complex. Understanding the impact of these changes on the Fontan physiology and the effect of anesthetic choices on this dyad (pregnancy–Fontan) is an imperative prior to caring for these patients. In an effort to determine how these patients are best managed for labor and/or cesarean delivery, we have reviewed the literature examining the peripartum anesthetic management of parturients with Fontan circulation and have identified 27 case reports.
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Gribaa R, Slim M, Ouali S, Neffati E, Remadi F, Boughzela E. Four successful pregnancies in a woman after Fontan palliation: a case report. J Med Case Rep 2014; 8:350. [PMID: 25335555 PMCID: PMC4209458 DOI: 10.1186/1752-1947-8-350] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2014] [Accepted: 08/18/2014] [Indexed: 11/30/2022] Open
Abstract
Introduction A Fontan operation is performed to provide palliation for patients with many forms of highly complex congenital heart disease that cannot support a biventricular circulation. Increasing numbers of women who have undergone these connections in childhood are now reaching their childbearing years, and some are becoming pregnant. The low flow and fixed cardiac output of a Fontan circulation poses several problems during pregnancy. Case presentation We report the case of four successful pregnancies in a 31-year-old Tunisian woman with congenital tricuspid atresia after Fontan operation. Her pregnancies resulted in delivery of four healthy neonates. Her clinical status remained unchanged. Conclusions This case suggests that patients after adequate Fontan palliation could complete pregnancy without long-term cardiac sequelae. Intensive care should be provided with specialists, including a neonatologist, anesthesiologist and cardiologist.
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Affiliation(s)
| | - Mehdi Slim
- Department of Cardiology, Sahloul University Hospital, Sousse, Tunisia.
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48
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Abstract
The population of adults with CHD continues to expand,and thus the number of women with CHD who contemplate pregnancy or become pregnant is also growing. Mothers with low-risk defects can be managed by general cardiologist,whereas those with more complex defects should be managed by or with the assistance of ACHD cardiologists. It is important to acknowledge that all patients with CHD may have unique anatomy or physiology, despite their classification as having a simple, moderate, or complex defect. As such, clinicians evaluating these patients should have adequate knowledge and expertise when assessing patient's risk for pregnancy,when performing imaging or hemodynamic studies, and when managing these patients during pregnancy. The American Board of Medical Specialties has recently recognized ACHD as a subspecialty of cardiovascular disease to treat the specialized needs of these patients in adulthood. ACHD experts can provide expertise in the management of specific defects or lesions, imaging techniques, prepregnancy risk assessment,and can manage these patients or comanage them with other medical providers during their pregnancy. Because many of these ACHD patients are lost to follow-up in adulthood, pregnancy represents a time when these patients seek medical care(and for some, represents a time of vulnerability and increased risk). This represents an opportunity to establish or reestablish care with ACHD specialists and to reestablish continuing long-term care for their CHD. Pregnancy also provides an opportunity to create partnerships between primary care physicians,adult cardiologists, and ACHD specialists to provide optimal care for these women throughout their lives.
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Affiliation(s)
- M Elizabeth Brickner
- From the University of Texas Southwestern Medical Center, Division of Cardiology, Dallas.
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49
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Grewal J, Silversides CK, Colman JM. Pregnancy in women with heart disease: risk assessment and management of heart failure. Heart Fail Clin 2014; 10:117-29. [PMID: 24275299 DOI: 10.1016/j.hfc.2013.09.014] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Heart disease, present in 0.5% to 3% of pregnant women, is an important cause of morbidity and the leading cause of death among pregnant women in the developed world. Certain heart conditions are associated with an increased risk of heart failure during pregnancy or the postpartum period; for these conditions, management during pregnancy benefits from multidisciplinary care at a center with expertise in pregnancy and heart disease. This article focuses on cardiac risks and management strategies for women with acquired and congenital heart disease who are at increased risk of heart failure during pregnancy.
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Affiliation(s)
- Jasmine Grewal
- University of British Columbia Cardiac Obstetrics Clinic and Pacific Adult Congenital Heart Clinic, Division of Cardiology, St. Paul's Hospital, University of British Columbia, Room 344-1081, Burrard Street, Vancouver, British Columbia V6Z 1Y6, Canada.
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Abstract
Cardiac disease in pregnancy is a challenging health care problem. The number of cases and their complexity is increasing, such that heart disease is now the leading cause of maternal mortality in developed countries. Numerically, women with congenital heart disease (CHD) make up the majority of cases and although maternal mortality is infrequent, a good outcome is only achieved though meticulous care, which starts pre-pregnancy and continues for months after the pregnancy has ended. All women with CHD should be assessed and counseled before pregnancy and carefully monitored during pregnancy, the delivery and in the puerperium. In most cases, pregnancy is well tolerated but in some conditions, such as pulmonary hypertension or severe dilatation of the aorta, pregnancy is extremely high risk and should be advised against.
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Affiliation(s)
- J W Roos-Hesselink
- Department of Cardiology, Erasmus Medical Center, Office Ba 583a, Postbus 2040, 3000 CA, Rotterdam, Netherlands.
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