Planned vaginal delivery and cardiovascular morbidity in pregnant women with heart disease

2024 AHA/ACC/AMSSM/HRS/PACES/SCMR Guideline for the Management of Hypertrophic Cardiomyopathy: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines

AIM

The "2024 AHA/ACC/AMSSM/HRS/PACES/SCMR Guideline for the Management of Hypertrophic Cardiomyopathy" provides recommendations to guide clinicians in the management of patients with hypertrophic cardiomyopathy.

METHODS

A comprehensive literature search was conducted from September 14, 2022, to November 22, 2022, encompassing studies, reviews, and other evidence on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. Additional relevant studies, published through May 23, 2023, during the guideline writing process, were also considered by the writing committee and added to the evidence tables, where appropriate.

STRUCTURE

Hypertrophic cardiomyopathy remains a common genetic heart disease reported in populations globally. Recommendations from the "2020 AHA/ACC Guideline for the Diagnosis and Treatment of Patients With Hypertrophic Cardiomyopathy" have been updated with new evidence to guide clinicians.

2024 AHA/ACC/AMSSM/HRS/PACES/SCMR Guideline for the Management of Hypertrophic Cardiomyopathy: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines

AIM

The "2024 AHA/ACC/AMSSM/HRS/PACES/SCMR Guideline for the Management of Hypertrophic Cardiomyopathy" provides recommendations to guide clinicians in the management of patients with hypertrophic cardiomyopathy.

METHODS

A comprehensive literature search was conducted from September 14, 2022, to November 22, 2022, encompassing studies, reviews, and other evidence on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. Additional relevant studies, published through May 23, 2023, during the guideline writing process, were also considered by the writing committee and added to the evidence tables, where appropriate.

STRUCTURE

Hypertrophic cardiomyopathy remains a common genetic heart disease reported in populations globally. Recommendations from the "2020 AHA/ACC Guideline for the Diagnosis and Treatment of Patients With Hypertrophic Cardiomyopathy" have been updated with new evidence to guide clinicians.

Maternal Morbidity According to Mode of Delivery Among Pregnant Patients With Pulmonary Hypertension

BACKGROUND

Patients with pulmonary hypertension have a high risk of maternal morbidity and mortality. It is unknown if a trial of labor carries a lower risk of morbidity in these patients compared to a planned cesarean delivery. The objective of this study was to examine the association of delivery mode with severe maternal morbidity events during delivery hospitalization among patients with pulmonary hypertension.

METHODS

This retrospective cohort study used the Premier inpatient administrative database. Patients delivering ≥25 weeks gestation from January 1, 2016, to September 30, 2020, and with pulmonary hypertension were included. The primary analysis compared intended vaginal delivery (ie, trial of labor) to intended cesarean delivery (intention to treat analysis). A sensitivity analysis was conducted comparing vaginal delivery to cesarean delivery (as treated analysis). The primary outcome was nontransfusion severe maternal morbidity during the delivery hospitalization. Secondary outcomes included blood transfusion (4 or more units) and readmission to the delivery hospital within 90 days from discharge from delivery hospitalization.

RESULTS

The cohort consisted of 727 deliveries. In the primary analysis, there was no difference in nontransfusion morbidity between intended vaginal delivery and intended cesarean delivery groups (adjusted odds ratio [aOR], 0.75; 95% confidence interval [CI], 0.49-1.15). In secondary analyses, intended cesarean delivery was not associated with blood transfusion (aOR, 0.71; 95% CI, 0.34-1.50) or readmission within 90 days (aOR, 0.60; 95% CI, 0.32-1.14). In the sensitivity analysis, cesarean delivery was associated with a 3-fold higher risk of nontransfusion morbidity compared to vaginal delivery (aOR, 2.64; 95% CI, 1.54-3.93), a 3-fold higher risk of blood transfusion (aOR, 3.06; 95% CI, 1.17-7.99), and a 2-fold higher risk of readmission within 90 days (aOR, 2.20; 95% CI, 1.09-4.46) compared to vaginal delivery.

CONCLUSIONS

Among pregnant patients with pulmonary hypertension, a trial of labor was not associated with a higher risk of morbidity compared to an intended cesarean delivery. One-third of patients who required an intrapartum cesarean delivery had a morbidity event, demonstrating the increased risk of adverse events in this group.

Care for the Obstetric Patient with Complex Cardiac Disease

The prevalence of cardiac disease-related maternal morbidity and mortality is on the rise in the United States. To ensure safe management of pregnancy in patients with cardiovascular disease, pre-delivery evaluation by a multidisciplinary Pregnancy Heart Team should occur. Appropriate anesthetic, cardiac, and obstetric care are essential. Risk stratification tools evaluate the etiology and severity of cardiovascular disease to determine the appropriate hospital type and location for delivery and anesthetic management. Intrapartum hemodynamic monitoring may need to be intensified, and neuraxial analgesia and anesthesia are generally appropriate. The anesthesiologist must be prepared for obstetric and cardiac emergencies.

Mode of delivery and peripartum outcome in women with heart disease according to the ESC guidelines: an Italian multicenter study

INTRODUCTION

The European Society of Cardiology (ESC) guidelines (GL) provide indications on the mode of delivery in women with heart disease. However available data suggests that the rate of Cesarean Delivery (CD) is high and widely variable among such patients. In this study, we aimed to investigate the degree of adherence to the ESC recommendations among women delivering in four tertiary maternity services in Italy and how this affects the maternal and neonatal outcomes.

MATERIAL AND METHODS

Retrospective multicenter cohort study including pregnant women with heart disease who gave birth between January 2014 and July 2020. Composite adverse maternal outcome (CAM) was defined by the occurrence of one or more of the following: major postpartum hemorrhage, thrombo-embolic or ischemic event, de novo arrhythmia, heart failure, endocarditis, aortic dissection, need for re-surgery, sepsis, maternal death. Composite Adverse Neonatal outcome (CAN) was defined as cord arterial pH <7.00, APGAR <7 at 5 min, admission to the intensive care unit, and neonatal death. We compared the incidence of CAM and CAN between the cases with planned delivery in accordance (group "ESC consistent") or in disagreement (group "ESC not consistent") with the ESC GL.

RESULTS

Overall, 175 women and 181 liveborn were included. A higher frequency of CAN was found when delivery was not planned accordingly to the ESC guidelines [("ESC consistent" 9/124 (7.2%) vs "ESC not consistent" 13/57 (22.8%) p = 0.002 OR 3.74 (CI 95% 1.49-9.74) , while the occurrence of CAM was comparable between the two groups. At logistic regression analysis, the gestational age at delivery was the only parameter independently associated with the occurrence of CAN (p = 0.006).

CONCLUSION

Among pregnant women with heart disease, deviating from the ESC guidelines scheduling cesarean delivery does not seem to improve maternal outcomes and it is associated with worse perinatal outcomes, mainly due to lower gestational age at birth.

Severe Maternal Morbidity According to Mode of Delivery Among Pregnant Patients With Cardiomyopathies

BACKGROUND

Women with cardiomyopathies are at risk for pregnancy complications. The optimal mode of delivery in these patients is guided by expert opinion and limited small studies.

OBJECTIVES

The objective of this study is to examine the association of delivery mode with severe maternal morbidity events during delivery hospitalization and readmissions among patients with cardiomyopathies.

METHODS

The Premier inpatient administrative database was used to conduct a retrospective cohort study of pregnant patients with a diagnosis of a cardiomyopathy. Utilizing a target trial emulation strategy, the primary analysis compared outcomes among patients exposed to intended vaginal delivery vs intended cesarean delivery (intention to treat). A secondary analysis compared outcomes among patients who delivered vaginally vs by cesarean (as-treated). Outcomes examined were nontransfusion severe maternal morbidity during the delivery hospitalization, blood transfusion, and readmission.

RESULTS

The cohort consisted of 2,921 deliveries. In the primary analysis (intention to treat), there was no difference in nontransfusion morbidity (adjusted OR [aOR]: 1.17; 95% CI: 0.91-1.51), blood transfusion (aOR: 1.27; 95% CI: 0.81-1.98), or readmission (aOR: 1.03; 95% CI: 0.73-1.44) between intended vaginal delivery and intended cesarean delivery. In the as-treated analysis, cesarean delivery was associated with a 2-fold higher risk of nontransfusion morbidity (aOR: 2.44; 95% CI: 1.85-3.22) and blood transfusion (aOR: 2.26; 95% CI: 1.34-3.81) when compared with vaginal delivery.

CONCLUSIONS

In patients with cardiomyopathies, a trial of labor does not confer a higher risk of maternal morbidity, blood transfusion, or readmission compared with planned cesarean delivery.

Maternal cardiac disease and perinatal outcomes in a single tertiary care center

OBJECTIVE

Maternal mortality in the U.S. has increased, with a substantial contribution from maternal cardiac disease. As a result of improved childhood survival, more women with congenital heart disease are reaching reproductive age leading to a growing high-risk obstetric population. We sought to determine the obstetrical and neonatal outcomes of women with maternal cardiac disease, including acquired cardiovascular disease and congenital heart disease.

METHODS

We studied a retrospective cohort study of women that delivered from 2008 to 2013 (N = 9026). Singleton pregnancies without preexisting conditions were established as the unexposed group for this study. Maternal and neonatal outcomes were compared between the unexposed group (N = 7277) and women exposed to maternal (acquired or congenital) cardiac disease (N = 139) as well as only congenital heart disease (N = 85). Statistical comparisons used univariate/multivariable logistic and linear regression analysis controlling for confounders with p < .05 and 95% confidence intervals indicating statistical significance.

RESULTS

Pregnancies complicated by maternal cardiac disease were associated with increased odds of preterm birth (<34 weeks, <37 weeks), intrauterine growth restriction (IUGR), need for assisted vaginal delivery, maternal ICU admission, and prolonged maternal hospitalization (>7 d). Neonatal outcomes including small for gestational age and Apgar score <7 at 5 min were increased in the pregnancies complicated by maternal cardiac disease. When pregnancies complicated by congenital heart disease were analyzed as a sub-group of the cohort, the results were similar. There were increased odds of preterm birth (<37 weeks), early-term delivery, need for assisted vaginal delivery, and prolonged hospitalization. Neonatal outcomes were only significant for small for gestational age.

CONCLUSION

We observed that in a select cohort of pregnancies complicated by maternal cardiac diseases (acquired or congenital), there were significant increases of adverse perinatal outcomes. Therefore, a multidisciplinary approach including maternal-fetal medicine specialists, cardiologists, obstetric anesthesia, and dedicated ancillary support is imperative for optimal care of this high-risk obstetrics population.

2023 HRS expert consensus statement on the management of arrhythmias during pregnancy

This international multidisciplinary expert consensus statement is intended to provide comprehensive guidance that can be referenced at the point of care to cardiac electrophysiologists, cardiologists, and other health care professionals, on the management of cardiac arrhythmias in pregnant patients and in fetuses. This document covers general concepts related to arrhythmias, including both brady- and tachyarrhythmias, in both the patient and the fetus during pregnancy. Recommendations are provided for optimal approaches to diagnosis and evaluation of arrhythmias; selection of invasive and noninvasive options for treatment of arrhythmias; and disease- and patient-specific considerations when risk stratifying, diagnosing, and treating arrhythmias in pregnant patients and fetuses. Gaps in knowledge and new directions for future research are also identified.

Sex Differences in Thoracic Aortic Disease and Dissection: JACC Review Topic of the Week

Despite its higher prevalence among men, women with thoracic aortic aneurysm and dissection (TAAD) have lower rates of treatment and surgical intervention and often have worse outcomes. A growing number of women with TAAD also desire pregnancy, which can be associated with an increased risk of aortic complications. Understanding sex-specific differences in TAAD has the potential to improve care delivery, reduce disparities in treatment, and optimize outcomes for women with TAAD.

Mode of delivery and perinatal outcomes by modified World Health Organization classification of maternal cardiovascular risk in pregnancy

BACKGROUND

Cardiac disease is a leading cause of maternal morbidity and mortality in the United States, and an increasing number of patients with known cardiac disease are reaching childbearing age. Although guidelines indicate that cesarean deliveries should be reserved for obstetrical indications, rates of cesarean delivery among obstetrical patients with cardiovascular disease are higher than those of the general population.

OBJECTIVE

This study aimed to evaluate mode of delivery and perinatal outcomes among patients with low-risk and moderate to high-risk cardiac disease as defined by the modified World Health Organization classification of maternal cardiovascular risk.

STUDY DESIGN

We performed a retrospective cohort study of obstetrical patients with known cardiac disease, as defined by the modified World Health Organization cardiovascular classification categories in pregnancy, who underwent a perinatal transthoracic echocardiogram at a single academic medical center between October 1, 2017 and May 1, 2022. Demographics, clinical characteristics, and perinatal outcomes were collected. Comparisons were made between patients with low- (modified World Health Organization Class I) and moderate to high-risk (modified World Health Organization Class II-IV) cardiac disease using chi-square, Fisher exact, or Student t-tests. Cohen d tests were used to estimate the effect size between group means. Logistic regression models were used to evaluate the odds of vaginal and cesarean delivery in low- and moderate to high-risk groups.

RESULTS

A total of 108 participants were eligible for inclusion, with 41 participants in the low-risk cardiac group and 67 in the moderate to high-risk group. Participants had a mean age of 32.1 (±5.5) years at the time of delivery and a mean pregravid body mass index of 29.9 (±7.8) kg/m2. Chronic hypertension (13.9%) and a history of hypertensive disorder of pregnancy (14.9%) were the most common comorbid medical conditions. In total, 17.1% of the sample had a history of a cardiac event (eg, arrhythmia, heart failure, myocardial infarction). Rates of vaginal and cesarean deliveries were similar between the low- and moderate to high-risk cardiac groups. Patients in the moderate to high-risk cardiac group were more likely to be admitted to the intensive care unit during pregnancy (odds ratio, 7.8; P<.05) and experience severe maternal morbidity compared with patients in the low-risk cardiac group (P<.01). Mode of delivery was not associated with severe maternal morbidity in the higher-risk cardiac group (odds ratio, 3.2; P=.12). In addition, infants of mothers with higher-risk disease were more likely to be admitted to the neonatal intensive care unit (odds ratio, 3.6; P=.06) and have longer neonatal intensive care unit stays (P=.005).

CONCLUSION

There was no difference in mode of delivery by modified World Health Organization cardiac classification, and mode of delivery was not associated with risk of severe maternal morbidity. Despite the overall increased risk of morbidity in the higher-risk group, vaginal delivery should be considered as an option for certain patients with well-compensated cardiac disease. However, larger studies are needed to confirm these findings.

Mode of delivery among women with maternal cardiac disease

OBJECTIVE

To determine if maternal cardiac disease affects delivery mode and to investigate maternal morbidity.

STUDY DESIGN

Retrospective cohort study performed using electronic medical record data. Primary outcome was mode of delivery; secondary outcomes included indication for cesarean delivery, and rates of severe maternal morbidity.

RESULTS

Among 14,160 deliveries meeting inclusion criteria, 218 (1.5%) had maternal cardiac disease. Cesarean delivery was more common in women with maternal cardiac disease (adjusted odds ratio 1.63 [95% confidence interval 1.18-2.25]). Patients delivered by cesarean delivery in the setting of maternal cardiac disease had significantly higher rates of severe maternal morbidity, with a 24.38-fold higher adjusted odds of severe maternal morbidity (95% confidence interval: 10.56-54.3).

CONCLUSION

While maternal cardiac disease was associated with increased risk of cesarean delivery, most were for obstetric indications. Additionally, cesarean delivery in the setting of maternal cardiac disease is associated with high rates of severe maternal morbidity.

Prolonged labor and adverse cardiac outcomes in pregnant patients with congenital heart disease

BACKGROUND

Patients with congenital heart disease are at high risk for peripartum cardiac morbidity, yet data on the impact of duration of labor on cardiac outcomes are limited. Prolonged labor is a known risk factor for maternal morbidity, but the impact of prolonged labor on cardiac outcomes in patients with congenital heart disease has not been evaluated.

OBJECTIVE

This study aimed to evaluate the association between prolonged labor (≥24 hours) and adverse peripartum maternal cardiac outcomes in pregnant patients with congenital heart disease.

STUDY DESIGN

This was a retrospective cohort study of pregnant patients ≥18 years with congenital heart disease who received prenatal care and delivered at an academic institution between 1998 and 2020 with a singleton gestation. Pregnancies that ended <20 weeks' gestation and patients who underwent an outright cesarean delivery without exposure to labor were excluded. The primary outcome was a composite adverse maternal cardiac outcome that occurred intrapartum or up to 6 weeks postpartum, defined as the occurrence of 1 or more of the following events: heart failure or clinical volume overload requiring diuresis, pulmonary edema, arrhythmia requiring treatment, thromboembolic complications including deep vein thrombosis or pulmonary embolism, transient ischemic attack, stroke, endocarditis, myocardial infarction, aortic dissection, cardiac arrest, or cardiac death. Outcomes were compared between patients with prolonged labor (≥24 hours) and those without prolonged labor (<24 hours). An interaction between prolonged labor and cesarean delivery was evaluated.

RESULTS

A total of 229 patients were included. The median duration of labor was 14 hours, and 18% of patients labored for ≥24 hours. Overall, 11.8% experienced the composite cardiac outcome with a significantly higher rate in the prolonged labor group (22% vs 9.6%; P=.03). After adjusting for confounders, including nulliparity, labor induction, gestational age, and World Health Organization class, there was a 2.7-fold increase in the odds of the composite cardiac outcome for patients who experienced prolonged labor (adjusted odds ratio, 2.7; 95% confidence interval, 1.1-7.1). There was no significant difference in cardiac outcome between those who had a vaginal delivery and those who had a cesarean delivery during labor (10.0% vs 16.1%; P=.18). There was, however, a significant interaction between prolonged labor and cesarean delivery; after adjustment for confounders, patients who underwent a cesarean delivery after prolonged labor had a 6.8-fold increase in the odds of experiencing the composite cardiac outcome when compared with those who underwent a cesarean delivery without prolonged labor (30.8% vs 7.1%; adjusted odds ratio, 6.8; 95% confidence interval, 1.4-32.5), most commonly, heart failure or volume overload requiring diuresis.

CONCLUSION

In a cohort of pregnant patients with congenital heart disease, prolonged duration of labor ≥24 hours was significantly associated with an increased risk for an adverse peripartum cardiac outcome, especially among those who underwent a cesarean delivery after that time. These findings suggest that close attention should be paid to the duration of labor, and those who require a cesarean delivery after a prolonged labor should be monitored closely for signs of volume overload and other adverse cardiac events.

Reproductive Health in Congenital Heart Disease: Preconception, Pregnancy, and Postpartum

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.

Anaesthetic Management and Peripartum Outcomes for Parturients With Valvular Heart Disease in a Tertiary Care Hospital of Pakistan

Introduction Parturients with valvular heart disease are at increased risk of maternal cardiac and neonatal complications. We aim to observe maternal cardiac complications in relation to the type of anaesthesia and mode of delivery as our primary objective and neonatal complications as the secondary outcomes. Methods We retrospectively reviewed all parturients with valvular heart disease undergoing delivery over a five-year period at the Aga Khan University Hospital, Karachi, Pakistan. to identify maternal cardiac and neonatal complications occurring during the peripartum period. Results Of 83 patients with valvular heart disease, 79.5% had rheumatic heart disease. Caesarian section (CS) was performed in 79.5% of patients and regional anaesthesia (RA) was given to 62.1%. Patients with cardiac risk index > 2 were delivered by CS and 64.5% received RA. One maternal and three neonatal deaths were reported with a complication event rate of 9.64% in parturients and 40.9% in neonates. Incidence of maternal cardiac events was one in 17 (5.8%) for vaginal deliveries versus seven in 66 (10.6 %) for CS. Maternal events for CS under RA was 5/66 (7.5 %) vs 2/66 (3%) under general anaesthesia. The incidence of peripartum maternal cardiac events when stratified by severity of cardiac disease was similar to a previously derived cardiac risk index for pregnant women with cardiac disease with no statistical difference in the adverse events rate from the estimated rates (p-value= 0.42). Conclusion Elective CS with RA was a common approach for high-risk parturients; however, the benefits cannot be ascertained. Despite low maternal and neonatal mortality, significant maternal cardiac and neonatal complications were observed.

Anesthetic Care of the Pregnant Patient With Cardiovascular Disease: A Scientific Statement From the American Heart Association

The pregnancy-related mortality rate in the United States is excessively high. The American Heart Association is dedicated to fighting heart disease and recognizes that cardiovascular disease, preexisting or acquired during pregnancy, is the leading cause of maternal mortality in the United States. Comprehensive scientific statements from cardiology and obstetrics experts guide the treatment of cardio-obstetric patients before, during, and after pregnancy. This scientific statement aims to highlight the role of specialized cardio-obstetric anesthesiology care, presenting a systematic approach to the care of these patients from the anesthesiology perspective. The anesthesiologist is a critical part of the pregnancy heart team as the perioperative physician who is trained to prevent or promptly recognize and treat patients with peripartum cardiovascular decompensation. Maternal morbidity is attenuated with expert anesthesiology peripartum care, which includes the management of neuraxial anesthesia, inotrope and vasopressor support, transthoracic echocardiography, optimization of delivery location, and consideration of advanced critical care and mechanical support when needed. Standardizing the anesthesiology approach to patients with high peripartum cardiovascular risk and ensuring that cardio-obstetrics patients have access to the appropriate care team, facilities, and advanced cardiovascular therapies will contribute to improving peripartum morbidity and mortality.

Contemporary pregnancy outcomes for women with moderate and severe congenital heart disease

Background

Women with congenital heart disease (CHD) are surviving into adulthood, with more undergoing pregnancy.

Methods

Retrospective review of the Vizient database from 2017-2019 for women 15-44 years old with moderate, severe or no CHD and vaginal delivery or caesarean section. Demographics, hospital outcomes and costs were compared.

Results

There were 2,469,117 admissions: 2,467,589 with no CHD, 1277 with moderate and 251 with severe CHD. Both CHD groups were younger than no CHD, there were fewer white race/ethnicity in the no CHD group and more women with Medicare in both CHD groups compared to no CHD. With increasing CHD severity there was an increase in length of stay, ICU admission rates and costs. There were also higher rates of complications, mortality and caesarean section in the CHD groups.

Conclusion

Pregnant women with CHD have more problematic pregnancies and understanding this impact is important to improve management and decrease healthcare utilization.

Main operating room deliveries for patients with high-risk cardiovascular disease

BACKGROUND

High-risk cardiovascular disease (CVD) prevalence in pregnant patients is increasing. Management of this complex population is not well studied, and little guidance is available regarding labour and delivery planning for optimal outcomes.

OBJECTIVE

We aimed to describe the process for and outcomes of our centre's experience with the main operating room (OR) caesarean deliveries for patients with high-risk CVD, including procedural and postpartum considerations.

STUDY DESIGN

We performed a retrospective evaluation of pregnant patients with high-risk CVD who delivered in the main OR at a large academic centre between January 2010 and March 2021. Patients were classified by CVD type: adult congenital heart disease, cardiac arrest, connective tissue disease with aortopathy, ischaemic cardiomyopathy, non-ischaemic cardiomyopathy or valve disease. We examined demographic, anaesthetic and procedure-related variables and in-hospital maternal and fetal outcomes. Multidisciplinary delivery planning was evaluated before and after formalising a cardio-obstetrics programme.

RESULTS

Of 25 deliveries, connective tissue disease (n=9, 36%) was the most common CVD type, followed by non-ischaemic cardiomyopathy (n=5, 20%). Scheduled deliveries that went as initially planned occurred for six patients (24%). Fourteen (56%) were unscheduled and urgent or emergent. Patients in modified WHO Class IV frequently underwent unscheduled, urgent deliveries (64%). Most deliveries were safely achieved with neuraxial regional anaesthesia (80%) and haemodynamic monitoring via arterial lines (88%). Postdelivery intensive care unit stays were common (n=18, 72%), but none required mechanical circulatory support. There were no in-hospital maternal or perinatal deaths; 60-day readmission rate was 16%. Some delivery planning was achieved for most patients (n=21, 84%); more planning was evident after establishing a cardio-obstetrics programme. Outcomes did not differ significantly by CVD group or delivery era.

CONCLUSIONS

Our experience suggests that short-term outcomes of pregnant patients with high-risk CVD undergoing main OR delivery are favourable. Multidisciplinary planning may support the success of these complex cases.

Reproductive Issues in Patients With the Fontan Operation

Patients with the Fontan operation have a unique circulation, with a limited ability to increase cardiac output, and high central venous pressure. They may have diastolic and/or systolic ventricular dysfunction, arrhythmias, thromboembolic complications, or multiorgan dysfunction. All of these factors contribute to reproductive issues, including menstrual irregularities, infertility, recurrent miscarriage, and complications during pregnancy. Although atrial arrhythmias are the most common cardiac complications during pregnancy, patients can develop heart failure and thromboembolic events. Obstetric bleeding, including postpartum hemorrhage, is common. In addition to maternal complications, adverse fetal and neonatal events, such as prematurity and low birthweight, are very common. Counselling about these reproductive issues should begin early. For those who become pregnant, care should be provided by a multidisciplinary cardio-obstetric team familiar with the specific issues and needs of the Fontan population. In this review, we discuss infertility, contraception, and pregnancy in patients with the Fontan operation.

Evaluation of Cardiac Function of Pregnant Women with High Blood Pressure during Gestation Period and Coupling of Hearts with Peripheral Vessels by Ultrasonic Cardiogram under Artificial Intelligence Algorithm

The research was aimed at analyzing the value of the optimized eXtreme Gradient Boosting (XGBoost) algorithm-based ultrasound cardiogram images in the diagnosis of pregnant hypertension patients. A total of 145 pregnant women (85 cases suffered from hypertension disease during pregnancy and 60 other normal women were healthy) were selected as the reference to the comparison and analysis of ultrasound cardiac function parameter, common carotid artery parameter, and the coupling relationship between hearts and cervical vessels of pregnant hypertension patients. The results demonstrated ultrasound cardiac function parameter of pregnant hypertension patients as follows. The maximum volume of the left atrium (LAVmax) was 35.65 mm, left ventricular end-systolic volume (LVESV) was 31.07 mm, and left ventricular end-diastolic volume (LVEDV) was 88.73 mm. All the above indexes were obviously higher than those of the normal control group (P < 0.05). Besides, intima-media thickness (IMT) of common carotid artery (465.84 μm), pulse wave velocity (PWV) (8.09 m/s), pressure of turning point 1 from isovolumic contraction phase to ejection phase (PT1) (126.5 mmHg), arterial enhancement pressure (AP) (6.14 mmHg), and arterial pressure enhancement index (8.58%) were all significantly higher than those of the normal control group (P < 0.05). In addition, the correlation between the coupling (E/A) of hearts and carotid artery of pregnant hypertension patients and PWV was not obvious (r = -0.08432, P > 0.05). The results of the research indicated that intima-media inside carotid artery of pregnant hypertension patients thickened obviously, and it became less elastic compared with that of normal healthy pregnant women. What is more, cardiac morphological changes were manifested mainly as the enlargement of the left atrial chamber and the thickening of the interventricular septum. Volume load and blood flow velocity both increased, and left ventricular diastolic function was damaged. XGBoost algorithm-based ultrasound cardiogram images could improve the diagnostic effects of hypertension during pregnancy effectively.

Sex Differences in Hypertrophic Cardiomyopathy: Interaction With Genetics and Environment

Purpose of Review

We explore the sex-specific interaction of genetics and the environment on the clinical course and outcomes of hypertrophic cardiomyopathy (HCM).

Recent Findings

Women account for approximately one-third of patients in specialist HCM centres and reported in observational studies. As a result, evidence informing clinical guideline recommendations is based predominantly on risk factors and outcomes seen in men. However, disease progression appears to be different between the sexes. Women present at a more advanced stage of disease, are older at diagnosis, have higher symptom burden, carry greater risk for heart failure and are at greater risk of mortality compared to men. Women are more likely to be gene-positive, while men are more likely to be gene-negative. The risk of sudden cardiac death and access to specialised care do not differ between the sexes.

Summary

Reporting sex-disaggregated results is essential to identify the mechanisms leading to sex differences in HCM.

The Importance of Cardiovascular Risk Assessment and Pregnancy Heart Team in the Management of Cardiovascular Disease in Pregnancy

Pregnancy-related maternal morbidity and mortality is increasing because of complications from cardiovascular disease. Pregnancy results in physiologic changes that can adversely impact the cardiovascular system and lead to adverse pregnancy outcomes. A multidisciplinary pregnancy heart team is essential to safely navigate women with heart disease through pregnancy. This role of the pregnancy heart team is to offer preconception counseling, determine pregnancy risks and educate women about those risks, develop a comprehensive antenatal and delivery plan, and ensure appropriate postpartum follow-up. These steps are important to improve cardiovascular outcomes in pregnancy.

Perioperative Implications of the 2020 American Heart Association/American College of Cardiology Guidelines for the Diagnosis and Treatment of Patients with Hypertrophic Cardiomyopathy: A Focused Review

Hypertrophic cardiomyopathy is a complex disease with significant implications for patients and the physicians called upon to care for them during the perioperative period. In this article, the 2020 American Heart Association and American College of Cardiology clinical practice guidelines for the evaluation and management of pediatric and adult patients with hypertrophic cardiomyopathy are reviewed, with a particular focus on perioperative considerations for the anesthesiologist.

Impact of type of maternal cardiovascular disease on pregnancy outcomes among women managed in a multidisciplinary cardio-obstetrics program

BACKGROUND

Maternal cardiovascular disease complicates up to 4% of pregnancies in the United States. Knowledge regarding the impact of the cardiovascular disease category is limited.

OBJECTIVE

The purpose of this study was to compare the maternal and neonatal outcomes among women with different types of cardiovascular diseases managed in a multidisciplinary program.

STUDY DESIGN

This was a retrospective cohort study of patients with documented structural or functional cardiovascular disease who received care in a multidisciplinary program with maternal-fetal medicine and cardiology specialists at a single institution between March 2010 and November 2019. Women were categorized as having congenital heart disease, acquired heart disease, arrhythmias and channelopathies, or aortopathies. Women were excluded from the pregnancy outcome analysis if they never became pregnant or delivered at a different institution. The outcomes were analyzed according to the disease category using univariate techniques.

RESULTS

A total of 232 women with 253 pregnancies met the inclusion criteria for pregnancy outcome analysis. Of these, 77 (30.4%) had congenital heart disease, 63 (24.9%) had acquired heart disease, 94 (37.2%) had arrhythmias or channelopathies, and 19 (7.5%) had aortopathies. Obesity and hypertension were more common among women with acquired heart disease, and women with acquired heart disease and arrhythmias had higher Cardiac Disease in Pregnancy II scores. Most of the pregnancies had good maternal and neonatal outcomes. Preeclampsia occurred more commonly in women with acquired heart disease (27% among those with acquired heart disease vs 10.4% among those with congenital heart disease, 13.8% among those with arrhythmias or channelopathies, and 0% among those with aortopathies; P=.009). Indicated preterm birth was highest among women with acquired heart disease (15.9%). Significant postpartum arrhythmias occurred in 2.4% of women. Preconception counseling was underutilized.

CONCLUSION

Most women with preexisting cardiovascular disease experienced good pregnancy and neonatal outcomes when managed in a specialized, multidisciplinary program. Women with acquired heart disease were at highest risk for pregnancy complications such as preeclampsia and preterm birth.

Team-Based Care of Women With Cardiovascular Disease From Pre-Conception Through Pregnancy and Postpartum: JACC Focus Seminar 1/5

The specialty of cardio-obstetrics has emerged in response to the rising rates of maternal morbidity and mortality related to cardiovascular disease (CVD) during pregnancy. Women of childbearing age with or at risk for CVD should receive appropriate counseling regarding maternal and fetal risks of pregnancy, medical optimization, and contraception advice. A multidisciplinary cardio-obstetrics team should ensure appropriate monitoring during pregnancy, plan for labor and delivery, and ensure close follow-up during the postpartum period when CVD complications remain common. The hemodynamic changes throughout pregnancy and during labor and delivery should be considered with respect to the individual cardiac disease of the patient. The fourth trimester refers to the 12 weeks after delivery and is a key time to address contraception, mental health, cardiovascular risk factors, and identify any potential postpartum complications. Women with adverse pregnancy outcomes are at increased risk of long-term CVD and should receive appropriate education and longitudinal follow-up.

2020 AHA/ACC Guideline for the Diagnosis and Treatment of Patients With Hypertrophic Cardiomyopathy: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

This executive summary of the hypertrophic cardiomyopathy clinical practice guideline provides recommendations and algorithms for clinicians to diagnose and manage hypertrophic cardiomyopathy in adult and pediatric patients as well as supporting documentation to encourage their use.

METHODS

A comprehensive literature search was conducted from January 1, 2010, to April 30, 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, Agency for Healthcare Research and Quality reports, and other relevant databases.

STRUCTURE

Many recommendations from the earlier hypertrophic cardiomyopathy guidelines have been updated with new evidence or a better understanding of earlier evidence. This summary operationalizes the recommendations from the full guideline and presents a combination of diagnostic work-up, genetic and family screening, risk stratification approaches, lifestyle modifications, surgical and catheter interventions, and medications that constitute components of guideline directed medical therapy. For both guideline-directed medical therapy and other recommended drug treatment regimens, the reader is advised to follow dosing, contraindications and drug-drug interactions based on product insert materials.

2020 AHA/ACC Guideline for the Diagnosis and Treatment of Patients With Hypertrophic Cardiomyopathy: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

Aim This executive summary of the hypertrophic cardiomyopathy clinical practice guideline provides recommendations and algorithms for clinicians to diagnose and manage hypertrophic cardiomyopathy in adult and pediatric patients as well as supporting documentation to encourage their use. Methods A comprehensive literature search was conducted from January 1, 2010, to April 30, 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, Agency for Healthcare Research and Quality reports, and other relevant databases. Structure Many recommendations from the earlier hypertrophic cardiomyopathy guidelines have been updated with new evidence or a better understanding of earlier evidence. This summary operationalizes the recommendations from the full guideline and presents a combination of diagnostic work-up, genetic and family screening, risk stratification approaches, lifestyle modifications, surgical and catheter interventions, and medications that constitute components of guideline directed medical therapy. For both guideline-directed medical therapy and other recommended drug treatment regimens, the reader is advised to follow dosing, contraindications and drug-drug interactions based on product insert materials.

Factors Related to Maternal Adverse Outcomes in Pregnant Women with Cardiac Disease in Low-resource Settings

Background: Cardiac disease is an important life-threatening complication during pregnancy. It is frequently seen in pregnant women living in resource-limited areas and often results in premature death. Aim: The aim of this hospital-based longitudinal study was to identify factors related to adverse maternal and neonatal outcomes in pregnant women with cardiac disease in low-resource settings. Methods: The study enrolled 91 pregnant women with congenital or acquired cardiac disease over a period of 2 years in Kenya. Results: Maternal and early neonatal deaths occurred in 12.2% and 12.6% of cases, respectively. The risk of adverse outcomes was significantly increased in those with pulmonary oedema (OR 11, 95% CI [2.3.52]; p=0.002) and arrhythmias (OR 16.9, 95% CI [2.5.113]; p=0.004). Limited access to care was significantly associated with adverse maternal outcomes (p≤0.001). Conclusion: Many factors contribute to adverse maternal and neonatal outcomes in pregnant women with cardiac disease. Access to comprehensive specialised care may help reduce cardiac-related complications during pregnancy.

Cardiovascular Considerations in Caring for Pregnant Patients: A Scientific Statement From the American Heart Association

Cardio-obstetrics has emerged as an important multidisciplinary field that requires a team approach to the management of cardiovascular disease during pregnancy. Cardiac conditions during pregnancy include hypertensive disorders, hypercholesterolemia, myocardial infarction, cardiomyopathies, arrhythmias, valvular disease, thromboembolic disease, aortic disease, and cerebrovascular diseases. Cardiovascular disease is the primary cause of pregnancy-related mortality in the United States. Advancing maternal age and preexisting comorbid conditions have contributed to the increased rates of maternal mortality. Preconception counseling by the multidisciplinary cardio-obstetrics team is essential for women with preexistent cardiac conditions or history of preeclampsia. Early involvement of the cardio-obstetrics team is critical to prevent maternal morbidity and mortality during the length of the pregnancy and 1 year postpartum. A general understanding of cardiovascular disease during pregnancy should be a core knowledge area for all cardiovascular and primary care clinicians. This scientific statement provides an overview of the diagnosis and management of cardiovascular disease during pregnancy.

Creating a Multidisciplinary Pregnancy Heart Team

PURPOSE OF REVIEW

Cardiovascular disease (CVD) is the leading cause of maternal death and cases of cardiovascular death are often associated with failure to provide timely risk-appropriate care. This review outlines considerations for creation of a team focused on the care of women with CVD during pregnancy and beyond.

RECENT FINDINGS

Improved outcomes for women with complex medical or obstetric conditions managed by a multidisciplinary care team inspired national guidelines advising the creation of a Pregnancy Heart Team for women with CVD in pregnancy. The recommendations from the European Society of Cardiology provide general guidance for risk-appropriate care without elaborating on the details of these specialized care teams. A Pregnancy Heart Team led by providers from cardiology, maternal-fetal medicine, obstetrics, obstetric anesthesia, pharmacy, and nursing support a holistic approach to patient care while facilitating opportunities for cross-disciplinary education. This team should focus on frequent antepartum risk stratification, multidisciplinary delivery planning, and comprehensive preconception and postpartum care. Available evidence suggests that a consistent and integrated approach to care for women with CVD in pregnancy has the potential to decrease severe maternal morbidity and mortality. The cost-effectiveness of this approach and the impact of this comprehensive care model on a woman's long-term cardiovascular health warrant future study.