Immediate and long-term follow-up of percutaneous balloon mitral valvuloplasty in pregnant patients with rheumatic mitral stenosis

A study of Clinical Profile and in Hospital Outcomes of patients undergoing Percutaneous Transvenous Mitral Commissurotomy at a Tertiary Care Center of Nepal

Introduction

Rheumatic heart disease (RHD), is a common cause of mitral stenosis (MS) in developing nations. As per current recommendation, Percutaneous Transvenous Mitral Commissurotomy (PTMC) is advised as a Class IA (I-Class Of Recommendation, COR; A-Level Of Evidence, LOE) indication in patients with symptomatic severe mitral stenosis. We aim to examine the clinical profile and in-hospital results of PTMC for mitral stenosis.

Methods

A cross-sectional retrospective study was conducted at Manmohan Cardiothoracic Vascular and Transplant Center from April 2020 to May 2022. A structured questionnaire was used to collect the data and ethical approval for conducting the study was taken from the Institutional Review Committee (IRC) of Institute of Medicine (IOM). The data was collected in Microsoft Excel (Ver. 2013). For statistical analysis, SPSS 21 (IBM Corp. Released 2012. IBM SPSS Statistics for Windows, Version 21.0. Armonk, NY: IBM Corp.) Association was measured using a parametric and non-parametric test (depending upon the distribution of data) and p value < 0.05 was considered significant.

Results

A total of 104 patients who met the inclusion criteria underwent PTMC during the study period. The mean age group of the patient was 41.7 ± 12.5 years, of which 23 (22.1%) were males and 81 (78.9%) were females. Mean mitral valve area prior to PTMC was 0.98 ± 0.19 mm2 that increased to 1.69 ± 0.19 mm2 after the procedure and it was statistically significant (p=<0.001). The post PTMC MVA varied with PTMC Wilkin's score with less than or equal to 8 having favorable outcomes.

Conclusion

Successful PTMC is highly influenced by the patients' increasing age, valve morphology (calcification, thickness, mobility), Left atrial dimensions, Pre PTMC mitral valve area, Degree of Baseline mitral regurgitation. Post procedure development of MR is usually well tolerated but rarely be severe enough requiring surgical valve replacement.

Managing Rheumatic Heart Disease in Pregnancy: A Practical Evidence-Based Multidisciplinary Approach

Rheumatic heart disease (RHD) remains a leading cause of mortality and morbidity in pregnant patients in low- to middle-income countries. Apart from the clinical challenges, these areas face poor infrastructure and resources to allow for early detection, with many women presenting to medical services for the first time when they deteriorate clinically during the pregnancy. The opportunity for preconception counselling and planning may thus be lost. It is ideal for all women to be seen before conception and risk-stratified according to their clinical state and pathology. The role of the cardio-obstetrics team has emerged over the past decade with the aim of a seamless transition to and from the appropriate levels of care during pregnancy. Severe symptomatic mitral and aortic valve stenoses portend the greatest risk to both mother and fetus. In mitral stenosis, beta-blockers are the cornerstone of therapy and only a small number of patients require balloon valvuloplasty. Regurgitant lesions mostly require diuretics alone for the treatment of heart failure. The mode of delivery is usually vaginal; caesarean section is performed in those with obstetrical indications or in cases with severe stenosis and a poor clinical state. The postpartum period presents a second high-risk period for maternal adverse events, with heart failure and arrhythmias being the most frequent. This review aims to provide a practical evidence-based multi-disciplinary approach to the management of women with RHD in pregnancy.

Percutaneous mitral commissurotomy in women with asymptomatic severe mitral stenosis before pregnancy

OBJECTIVES

Performing percutaneous mitral commissurotomy (PMC) in the women with asymptomatic severe mitral stenosis (MS) who plan a pregnancy is recommended. However the data regarding this recommendation is limited in the literature. We aimed to investigate maternal and fetal outcomes of women with asymptomatic severe MS who underwent PMC before a planned pregnancy.

METHODS

We retrospectively analysed the procedural, pregnancy related, and fetal outcomes of 33 consecutive women with severe asymptomatic MS, age 27.97 ± 2.86 years, who underwent PMC before a planned pregnancy between 2014 and 2019. The control group comprised of 66 pregnant women, age 29.09 ± 3.00 years, without a cardiac disease.

RESULTS

The PMC procedure was successful in all patients and no major complication occurred. There were no deaths, pulmonary oedema, heart failure, atrial fibrillation, and thromboembolism during pregnancy. Maternal arrhythmia (p < .001), deterioration in NYHA class (p = .08), and use of cardiovascular medication (p < .001) was significantly higher in the study group. Maternal hospitalisation (p = .435), preeclampsia (p = 1), abortus (p = 1), fetal death (p = 1), and preterm delivery (p = .746) was similar between groups. Birth weight was significantly lower in the PMC group 2890 g (229) vs 3120 g (255) <0.001, however small for gestational age newborns were similar between groups (p = .12).

CONCLUSIONS

PMC is safe in asymptomatic women with severe MS planning a future pregnancy. In selected patients with favourable valve anatomy PMC may improve maternal and fetal outcomes.

Rheumatic heart disease in pregnancy and neonatal outcomes: A systematic review and meta-analysis

Purpose

Associations between rheumatic heart disease (RHD) in pregnancy and fetal outcomes are relatively unknown. This study aimed to review rates and predictors of major adverse fetal outcomes of RHD in pregnancy.

Methods

Medline (Ovid), Pubmed, EMcare, Scopus, CINAHL, Informit, and WHOICTRP databases were searched for studies that reported rates of adverse perinatal events in women with RHD during pregnancy. Outcomes included preterm birth, intra-uterine growth restriction (IUGR), low-birth weight (LBW), perinatal death and percutaneous balloon mitral valvuloplasty intervention. Meta-analysis of fetal events by the New-York Heart Association (NYHA) heart failure classification, and the Mitral-valve Area (MVA) severity score was performed with unadjusted random effects models and heterogeneity of risk ratios (RR) was assessed with the I² statistic. Quality of evidence was evaluated using the GRADE approach. The study was registered in PROSPERO (CRD42020161529).

Findings

The search identified 5949 non-duplicate records of which 136 full-text articles were assessed for eligibility and 22 studies included, 11 studies were eligible for meta-analyses. In 3928 pregnancies, high rates of preterm birth (9.35%-42.97%), LBW (12.98%-39.70%), IUGR (6.76%-22.40%) and perinatal death (0.00%-9.41%) were reported. NYHA III/IV pre-pregnancy was associated with higher rates of preterm birth (5 studies, RR 2.86, 95%CI 1.54–5.33), and perinatal death (6 studies, RR 3.23, 1.92–5.44). Moderate /severe mitral stenosis (MS) was associated with higher rates of preterm birth (3 studies, RR 2.05, 95%CI 1.02–4.11) and IUGR (3 studies, RR 2.46, 95%CI 1.02–5.95).

Interpretation

RHD during pregnancy is associated with adverse fetal outcomes. Maternal NYHA III/IV and moderate/severe MS in particular may predict poor prognosis.

Percutaneous balloon mitral valvotomy during pregnancy: A systematic review and meta-analysis

INTRODUCTION

The objective of this study was to systematically review the maternal and fetal outcomes in pregnant women who underwent percutaneous balloon mitral valvuloplasty (PBMV) during pregnancy.

MATERIAL AND METHODS

A search was conducted on MEDLINE and Embase databases to identify studies published between 2000 and 2018 that reported on maternal and fetal outcomes following PBMV performed in pregnancy. Randomized controlled trials, cohort studies, case-control studies, cross-sectional studies and case series with four or more pregnancies in which PBMV was performed during pregnancy were included. Reference lists from relevant articles were also hand-searched for relevant citations. A successful procedure was defined as one where there was a reported improvement in the valve area or reduction in the mitral valve gradient. A random effects model was used to derive pooled estimates of various outcomes and the final estimates were reported as percentages with a 95% confidence interval (95% CI).

RESULTS

Twenty-one observational studies reporting 745 pregnancies were included in the review, all of them having reported outcomes without a comparison group. Most of the studies fell into the low-risk category as determined using the Joanna Briggs Institute (JBI) critical appraisal checklist for case series. Most of the studies (86%) were reported from low- to middle-income countries and PBMV was mostly performed during the second trimester of pregnancy. Forty-three procedures (5.7%) were unsuccessful, nearly half (n = 19) of them reported among women with the severe subvalve disease (Wilkins subvalve score 3 or more). There were 11 maternal deaths among those with suboptimal valve anatomy (severe subvalve disease or Wilkin score >8). Mitral regurgitation was the most common cardiac complication (12.7%; 95% CI 7.3%-19.1%), followed by restenosis (2.4%; 95% CI 0.02%-7.2%). Pooled incidence of cesarean section was 12.1% (95% CI 3.6%-23.8%), preterm delivery 3.9% (95% CI 0.6%-9.0%), stillbirth 0.9% (95%CI 0.2%-2.2%) and low birthweight 5.4% (95% CI 0.2%-14.7%).

CONCLUSIONS

PBMV may be an effective and safe procedure for optimizing outcomes in pregnant women with mitral stenosis in the absence of severe subvalve disease.

Interventional Echocardiography of the MV: What the Interventionalist Wants to Know

The past 2 decades have seen a proliferation of transcatheter mitral valve (MV) therapies, which are less invasive and distinct from surgical MV repair or replacement. The commonly used MV transcatheter therapies include (1) percutaneous mitral balloon commissurotomy (PMBC) for rheumatic mitral stenosis; (2) edge-to-edge repair with the MitraClip for mitral regurgitation; (3) valve-in-valve implantation in bioprosthetic MV, native MV, or mitral ring; and (4) closure of paravalvular leaks (PVLs). This article will focus on the use of echocardiography in the diagnosis, patient selection, procedural guidance, and postprocedural follow-up for PMBC, with notes on the role of transesophageal echocardiography in transcatheter interventions for prosthetic valve degeneration and PVL closure.

Mechanical Mitral Valve Replacement during the 2nd Trimester of Pregnancy

We report the case of a 44-year-old pregnant woman who was diagnosed with symptomatic severe mitral stenosis that did not respond to optimal medical therapy and balloon valvuloplasty. After a multidisciplinary team discussion on the timing and risks of interventions and postoperative optimization of peripartum anticoagulation, the patient underwent mechanical mitral valve replacement during the 2nd trimester of pregnancy. The outcome was excellent for the mother and the infant. This case emphasizes the importance of a multidisciplinary approach in managing unusual cases.

Congenital and Acquired Valvular Heart Disease in Pregnancy

PURPOSE OF REVIEW

The number of pregnancies complicated by valvular heart disease is increasing. This review describes the hemodynamic effects of clinically important valvular abnormalities during pregnancy and reviews current guideline-driven management strategies.

RECENT FINDINGS

Valvular heart disease in women of childbearing age is most commonly caused by congenital abnormalities and rheumatic heart disease. Regurgitant lesions are well tolerated, while stenotic lesions are associated with a higher risk of pregnancy-related complications. Management of symptomatic disease during pregnancy is primarily medical, with percutaneous interventions considered for refractory symptoms. Most guidelines addressing the management of valvular heart disease during pregnancy are based on case reports and observational studies. Additional investigation is required to further advance the care of this growing patient population.

[Results of percutaneous mitral balloon commissurotomy in pregnant women about 12 cases]

INTRODUCTION

Mitral stenosis (MS) is the most common valvular heart disease revealed or exacerbated by pregnancy. Percutaneous mitral balloon commissurotomy (PMC) is currently the treatment of choice when mitral valve morphology is favorable.

AIM OF THE STUDY

The purpose of this study is to evaluate the immediate, medium and long term results of percutaneous mitral balloon commissurotomy in pregnant women with a severe symptomatic mitral stenosis despite medical treatment.

PATIENTS AND METHODS

It is a retrospective study including 12 pregnant patients diagnosed with severe mitral stenosis and hospitalized in the cardiology department of Habib Thameur hospital between 1994 and 2014. A clinical and ultrasonographic monitoring was performed for over 15 years.

RESULTS

Mean patients age was 31.5±4.4 years. All patients were in NYHA class III or IV despite medical treatment. Mitral regurgitation was rated as moderate in four cases. Functional improvement was observed in all cases immediately after the procedure. Mitral valve area increased from 1.02±0.5cm² averaged to 2±0.35cm². Mitral regurgitation increased in three cases and appeared in two cases. All patients delivered at term. Newborns were all healthy. Two of them had a low birth weight. On the long term follow-up (95.58±64.1 months), five patients had mitral restenosis: two had a surgical valve replacement and three underwent a second percutaneous mitral balloon commissurotomy.

CONCLUSION

The effectiveness of the percutaneous mitral balloon commissurotomy is clearly documented by clinical and echocardiographic evaluation. In the case of pregnancy, the goal is not so much to obtain an optimal result but to cause hemodynamic improvement authorizing the continuation of pregnancy and childbirth.

Pulmonary hypertension and pregnancy: the experience of a tertiary institution over 15 years

Background:

Pulmonary hypertension (PH) in pregnancy is associated with a high maternal mortality and morbidity and has been found to be as high as 30-56%.

Aim:

To review the management of such patients in a tertiary center over a 15 year period, as the current literature consists of a few case reports, a few small case series and 2 meta-analyses.

Materials and Methods:

A review of all patients admitted to our institution for management of PH in pregnancy between 1994 and February 2009 was undertaken. Cases were identified from the high-risk pregnancy database within the department of anesthesia and from the hospital medical records. Severity of PH, type of PH, NYHA functional status at presentation and delivery, mode of delivery, peripartum monitoring and APGAR scores were noted. Patients were reviewed by a multidisciplinary team and management planned accordingly.

Results:

19 eligible patients were identified. Patients who were significantly sick due to their PH were aggressively managed during pregnancy. Overall there was an improvement in NYHA functional status at the time of delivery. Epidural analgesia and anesthesia for labor and operatively delivery seem to be the ideal choice.

Conclusion:

Multidisciplinary approach is a key to the successful management of these patients. Secondary PH results in higher morbidity and mortality, in particular, older the age higher the maternal morbidity and mortality.

Percutaneous mitral commisurotomy during pregnancy - A report of two cases performed in a United Kingdom tertiary centre and a review of the literature

We report two cases of severe mitral stenosis where percutaneous mitral commisurotomy was performed within pregnancy. The first case involves an emergency procedure for a new diagnosis of severe mitral stenosis in a woman presenting with pulmonary oedema at 27 weeks' gestation. The second case is of a woman known to have mitral stenosis who underwent a semi-elective procedure for deterioration in symptoms. This procedure is not commonly performed in the United Kingdom because of low incidence of rheumatic heart disease. In addition, percutaneous mitral commisurotomy during pregnancy is rarely performed in the United Kingdom because of the improved healthcare system where majority of the women with moderate to severe mitral stenosis (even asymptomatic) will undergo planned interventions (percutaneous mitral commisurotomy or mitral valve surgery) before contemplating pregnancy. These cases highlight both the acute and chronic presentations of mitral stenosis and the impact pregnancy has on this condition. In addition, these cases show the importance of retaining skills in performing percutaneous mitral commisurotomy within our United Kingdom cardiologists.

Mitral balloon valvuloplasty during pregnancy:The long term up to 17 years obstetric outcome and childhood development

Background & Objectives : We report 17 years outcome of subsequent pregnancies of women with severe Mitral Stenosis (MS) who underwent Mitral Balloon Valvuloplasty (MBV) during pregnancy and the follow up of the children born of such pregnancies.

METHODS

Twenty three pregnant patients suffering from severe MS (NYHA-New York Heart Association class III/IV) who underwent MBV by Inoue balloon catheter technique during second trimester were enrolled. The study was performed between January 1992 and December 2008 at King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia, during which time, details about the obstetric outcome and childhood development were recorded. Mean follow up period was 10± 5.5 years (range 1-17 years).

RESULTS

MBV was successful in all patients with improvement in their NYHA class to I/II. All patients were followed until term and had uneventful course after MBV. Twenty two (95.6%) patients delivered 23 babies including a twin birth. These children exhibited normal growth and development according to their age. Nineteen patients had further pregnancies and gave birth to 38 live & healthy babies with one still birth and no unfavorable maternal outcome. Of these, 97.4% were singleton pregnancies while 2.6% were twin pregnancies. Spontaneous abortions were recorded in 21.5% and there was one still birth (2.5%) and one ectopic pregnancy (2.5%). Conclusion : Mitral Balloon Valvuloplasty is a safe and useful procedure during pregnancy, with no short or long term adverse affects on the mothers and their obstetric future. The children born of subsequent pregnancies exhibited normal physical and mental development.

Percutaneous Mitral Valve Interventions

Percutaneous interventions for mitral valve disease represent both the oldest and the newest of catheter interventions. Balloon mitral valvuloplasty was among the first effective catheter therapies for valvular heart disease. The technique and device approach was initially reported by Inoue in 1982 and, remarkably, is virtually unchanged between then and now. Conversely, novel catheter therapies to repair mitral regurgitation are now in their infancy, with only the earliest human experience. This article details the spectrum of these therapies.

Percutaneous Mitral Balloon Valvuloplasty for Patients with Rheumatic Mitral Stenosis

Percutaneous balloon dilatation of stenotic cardiac valves is used for the treatment of pulmonic, mitral, aortic, and tricuspid stenosis. Percutaneous mitral balloon valvuloplasty (PMV) has been used successfully as an alternative to open or closed surgical mitral commissurotomy in the treatment of symptomatic rheumatic mitral stenosis. PMV produces good immediate hemodynamic outcome, low complication rates, and clinical improvement in the majority of patients. PMV is safe and effective and provides clinical and hemodynamic improvement in rheumatic mitral stenosis. PMV is the preferred form of therapy for relief of mitral stenosis for a selected group of patients with symptomatic mitral stenosis.

Treatment of valvular heart disease during pregnancy for improving maternal and neonatal outcome

BACKGROUND

Valvular heart disease constitutes the majority of all causes of heart disease in pregnancy. In the presence of valvular heart disease, the necessary haemodynamic changes of pregnancy might cause heart failure, leading to severe maternal and fetal morbidity and even mortality. Treatment of valvular heart disease is indicated when patients experience a deterioration of symptoms and in case of a severe valvular lesion. Whether medical therapy or interventional therapy is the optimal treatment for both mother and child is unclear.

OBJECTIVES

To assess effectiveness and adverse effects of the different treatment modalities of valvular heart disease in pregnancy to improve maternal and neonatal outcomes.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 March 2011), EMBASE (1980 to 23 March 2011) and the reference lists of background review articles.

SELECTION CRITERIA

Randomised controlled trials, quasi-randomised controlled and cluster-randomised controlled trials comparing medical therapy with percutaneous or surgical intervention for the treatment of valvular heart disease in pregnancy.

DATA COLLECTION AND ANALYSIS

We identified no (randomised) controlled trials to assess the effectiveness and adverse effects of the treatment of valvular heart disease in pregnancy.

MAIN RESULTS

There were no randomised controlled trials, quasi-randomised controlled trials or cluster-randomised trials identified from the search strategy.

AUTHORS' CONCLUSIONS

There is insufficient evidence to define the most effective treatment of valvular heart disease in pregnancy to improve maternal and neonatal outcomes.

Spectrum of cardiovascular findings during pregnancy and parturition at a tertiary referral center

AIM

To analyze the spectrum of cardiovascular diseases occurring during pregnancy and delivery at a tertiary referral center.

METHODS

All patients presenting at our institution with pre-existing or first diagnosis of cardiac disease were recruited. Cardiac and obstetric complications and maternal and neonatal outcomes were recorded.

RESULTS

Fifty-two pregnancies in 49 women, including three pregnancy terminations were analyzed. Cardiac lesions were congenital in 26 (53.1%) and acquired in nine (18.4%); six patients (12.2%) had cardiomyopathies, eight (16.3%) ar-rhythmic conditions. A total of 42 women (85.7%) had a pre-existing cardiac condition and seven (14.3%) presented with first manifestation. Overall 22 cardiac complications occurred: five in pregnancy, eight around parturition, nine during follow-up. They included >1 New York Heart Association functional class deterioration (n=5), congestive heart failure/cardiomyopathy (n=5), valve replacement (n=4), sustained arrhythmia (n=3), cerebral insult, aortic dissection, transplantation (one case each), and death (n=2). Mean gestational age at delivery was 36+6. The cesarean section rate was 77.5%; 31.6% were performed for cardiac indications. Obstetric complications happened in 23 pregnancies (46.9%). There was no perinatal loss; cardiac defects were diagnosed in 9.3% (n=5) of offspring.

CONCLUSION

Cardiovascular diseases occurring during pregnancy and parturition comprise a heterogeneous spectrum of conditions. Established scores aid in the identification of high-risk patients; however, in our series 14.3% women had been healthy previously.

Cardiac surgery in pregnancy

The need for cardiac surgery during pregnancy is rare. Only 1% to 4% of pregnancies are complicated by maternal cardiac disease and most of these can be managed with medical therapy and lifestyle changes. On occasion, whether owing to natural progression of the underlying cardiac disease or precipitated by the cardiovascular changes of pregnancy, cardiac surgical therapy must be considered. Cardiac surgery is inherently dangerous for both, the mother and fetus with mortality rates near 10% and 30%, respectively. For some conditions, percutaneous cardiac intervention offers effective therapy with far less risk to the mother and her fetus. For others, cardiac surgery, including procedures that mandate the use of cardiopulmonary bypass, must be entertained to save the life of the mother. Given the extreme risks to the fetus, if the patient is in the third trimester, strong consideration should be given to delivery before surgery involving cardiopulmonary bypass. At earlier gestational ages when this is not feasible, modifications to the perfusion protocol including higher flow rates, normothermic perfusion, pulsatile flow, and the use of intraoperative external fetal heart rate monitoring should be considered.

Advances in percutaneous treatment for adult valvular heart disease

Valvular heart disease occurs in 2-3% of the general population with an increase in prevalence with advancing age. The aetiology of valvular heart disease has evolved in recent decades with degenerative aortic and mitral valve disease supplanting rheumatic heart disease as a primary cause. The common valve lesions to be discussed in this article are aortic stenosis and mitral regurgitation. The traditional approach to calcific aortic stenosis when either symptoms or left ventricular impairment develops is surgical aortic valve replacement and it remains a treatment with excellent outcomes. In recent years there has been interest in less invasive approaches, including percutaneous and transapical aortic valve implantation. With refinements in technology these approaches are becoming a potential treatment option, primarily for high-risk patients who may otherwise be unsuitable for traditional open surgical treatment. Catheter-based approaches for mitral valve disease are also evolving. Mitral regurgitation may often be the result of mitral annular dilatation seen in patients with an enlarged left ventricle or left atrium. Percutaneous implantation of a constricting device in the coronary sinus, which lies in close proximity to the mitral annulus, results in a change to the geometry of the mitral valve and reduced regurgitation. Another technique in patients with degenerative mitral regurgitation is the endovascular edge-to-edge repair in which coaptation of the mitral valve leaflets can be improved with a percutaneously deployed clip. Small patient series indicate that these new techniques are promising. As such, advances in percutaneous interventional and surgical approaches have the potential to further improve outcomes for selected patients with valvular heart disease.

The role of catheter balloon commissurotomy for severe mitral stenosis in pregnancy

Mitral stenosis is one of the more commonly seen valve lesions encountered in pregnancy. The pathophysiologic implications, management strategies, and a comprehensive review of literature over the past 20 years for optimal timing of catheter balloon commissurotomy during pregnancy are discussed. Mechanical relief of obstruction is indicated for cases of severe symptomatic mitral stenosis in pregnancy refractory to medical therapy. Catheter balloon commissurotomy is the procedure of choice in a select group of these patients with suitable valve morphology.

Mitral valve disease in pregnancy: outcomes and management

Young women may have asymptomatic mitral valve disease which becomes unmasked during the haemodynamic stress of pregnancy. Rheumatic mitral stenosis is the most common cardiac disease found in women during pregnancy. The typical increased volume and heart rate of pregnancy are not well tolerated in patients with more than mild stenosis. Maternal complications of atrial fibrillation and congestive heart failure can occur, and are increased in patients with poor functional class and severe pulmonary artery hypertension. Patients can be diagnosed by echocardiography and symptoms treated with beta-1 antagonists and cautious diuresis. Patients with heart failure unresponsive to treatment can undergo percutaneous balloon mitral valvuloplasty. Labour and delivery goals include reducing tachycardia by adequate pain control and minimized volume shifts. Mitral valve regurgitation, even when severe, is usually very well tolerated in pregnancy as the increase in volume is offset by a decrease in vascular resistance. On the other hand, patients with left ventricular dysfunction, moderate pulmonary hypertension or NYHA functional class III-IV are at increased risk for heart failure and arrhythmias. They may need cautious diuresis and limitations on physical activity during pregnancy, as well as invasive haemodynamic monitoring for labour and delivery. Vaginal delivery is preferred and caesarean section reserved for obstetric indications.

Real-time 3-dimensional echocardiography in the operating room

Real-time 3-dimensional transesophageal echocardiography (RT-3D-TEE) represents a novel clinical and intuitively educational perioperative cardiovascular imaging modality. The development of RT-3D-TEE allows for live 3D imaging as it circumvents most of the disadvantages of reconstructive 3D methods. RT-3D-TEE will likely revolutionize perioperative assessment of complex 3D structures, such as the mitral valve (MV), as it provides important mechanistic insights into functional and ischemic mitral regurgitation. The MV is particularly suited to live RT-3D-TEE assessment because of the complex interrelationships among the valve, chordae, papillary muscles, and myocardial walls. The 3D en face view of the MV is in accordance with the surgical view and allows to illustrate the unique saddle shape of the MV annulus and to define and localize mitral leaflet lesions in MV prolapse, endocarditis, or congenital MV abnormalities, all potentially important in guiding surgical repair. RT-3D-TEE will soon be integrated into routine perioperative practice. Its unique ability of real-time acquisition, online rendering and cropping capabilities, accurate identification of the precise pathology and location of cardiac disease, together with its ability to promptly quantify 3D data sets using built-in software, will likely help in transitioning this modality into standard of care.

[Management of heart diseases in pregnancy: rheumatic and congenital heart disease, myocardial infarction and post partum cardiomyopathy]

Heart disease is present in 0.5-1% of all pregnancies. It is the leading non-obstetric cause of maternal mortality accounting for about 10-15% of all maternal death. Over the last decades the underlying cardiac disease has changed. Also new therapeutic options have been developed. In western industrial countries the incidence of acquired rheumatic heart disease has declined. In contrast, as a result of neonatal corrective or palliative surgery, congenital heart disease has become an increasing and challenging problem. Maternal older age and the increase in women's smoking habits amplify the likelihood of coronary artery disease. Multiple therapeutic options including percutaneous interventions are available and novel therapeutic concepts are emerging i.e. for peripartum cardiomyopathy. Management of pregnancy, labor and delivery requires accurate diagnosis of the underlying cardiac disorder. Hemodynamic changes physiologically occurring during pregnancy have a different impact depending on the type and severity of cardiac anomalies. Management of these patients requires teamwork of obstetricians, neonatologists, cardiologists, anesthetists and sometimes cardiac surgeons.

Pregnancy and adult congenital heart disease

Increasing numbers of women with complex congenital heart disease are reaching childbearing age. Pregnancy is a major issue in the management of adult congenital heart disease. Cardiac disease is one of the most common causes of maternal morbidity and mortality. Complications, such as growth retardation, preterm and premature birth and even fetal and neonatal mortality, are more frequent among children of women with congenital heart disease. The risk of complications is determined by the severity of the cardiac lesion, the presence of cyanosis, the maternal functional class and the use of anticoagulation. However, the pathophysiology of these complications is not completely understood and may be related to a diminished increase in cardiac output and/or endothelial dysfunction. The management of pregnant cardiac patients is based on limited clinical information. This article reviews pre-pregnancy counseling and management during pregnancy in patients with congenital heart disease.