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Koziol KJ, Isath A, Aronow WS, Frishman W, Ranjan P. Cyanotic Congenital Heart Disease in Pregnancy: A Review of Pathophysiology and Management. Cardiol Rev 2024; 32:348-355. [PMID: 36716356 DOI: 10.1097/crd.0000000000000512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
The advancement of medical treatment and surgical technique, along with the invention of cardiopulmonary bypass, has allowed for long-term survival of patients with cyanotic congenital heart disease (CHD)-with many women with CHD now reaching child-bearing age and wishing to become pregnant. Pregnancy in these women is a major concern as the physiologic adaptations of pregnancy, including an increased circulating volume, increased cardiac output, reduced systemic vascular resistance, and decreased blood pressure, place a substantial load on the cardiovascular system. These changes are essential to meet the increased maternal and fetal metabolic demands and allow for sufficient placental circulation during gestation. However, in women with underlying structural heart conditions, they place an additional hemodynamic burden on the maternal body. Overall, with appropriate risk stratification, pre-conception counseling, and management by specialized cardiologists and high-risk obstetricians, most women with surgically corrected CHDs are expected to carry healthy pregnancies to term with optimization of both maternal and fetal risks. In this article, we describe the current understanding of 5 cyanotic CHDs-Tetralogy of Fallot, Transposition of the Great Arteries, Truncus Arteriosus, Ebstein's Anomaly, and Eisenmenger Syndrome-and explore the specific hemodynamic consequences, maternal and fetal risks, current guidelines, and outcomes of pregnancy in women with these conditions.
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Affiliation(s)
- Klaudia J Koziol
- From the New York Medical College, School of Medicine, Valhalla, NY
| | - Ameesh Isath
- Department of Cardiology, Westchester Medical Center, New York Medical College, Valhalla, NY
| | - Wilbert S Aronow
- From the New York Medical College, School of Medicine, Valhalla, NY
- Department of Cardiology, Westchester Medical Center, New York Medical College, Valhalla, NY
| | - William Frishman
- From the New York Medical College, School of Medicine, Valhalla, NY
- Department of Cardiology, Westchester Medical Center, New York Medical College, Valhalla, NY
| | - Pragya Ranjan
- From the New York Medical College, School of Medicine, Valhalla, NY
- Department of Cardiology, Westchester Medical Center, New York Medical College, Valhalla, NY
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2
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Pizula J, Devera J, Ng TMH, Yeung SL, Thangathurai J, Herrick N, Chatfield AJ, Mehra A, Elkayam U. Outcome of Pregnancy in Women With D-Transposition of the Great Arteries: A Systematic Review. J Am Heart Assoc 2022; 11:e026862. [PMID: 36444833 PMCID: PMC9851445 DOI: 10.1161/jaha.122.026862] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Background Information on maternal and fetal outcomes of pregnancy in women with D-transposition of the great arteries is limited. We conducted a systematic literature review on pregnancies in women with transposition of the great arteries after atrial and arterial switch operations to better define maternal and fetal risk. Methods and Results A systematic review was performed on studies between 2000 and 2021 that identified 676 pregnancies in 444 women with transposition of the great arteries. A total of 556 pregnancies in women with atrial switch operation were tolerated by most cases with low mortality (0.6%). Most common maternal complications, however, were arrhythmias (9%) and heart failure (8%) associated with serious morbidity in some patients. Worsening functional capacity, right ventricular function, and tricuspid regurgitation occurred in ≈20% of the cases. Rate of fetal and neonatal mortality was 1.4% and 0.8%, respectively, and rate of prematurity was 32%. A total of 120 pregnancies in women with arterial switch operation were associated with no maternal mortality, numerically lower rates of arrhythmias and heart failure (6% and 5%, respectively), significantly lower rate of prematurity (11%; P<0.001), and only 1 fetal loss. Conclusions Pregnancy is tolerated by most women with transposition of the great arteries and atrial switch operation with low mortality but important morbidity. Most common maternal complications were arrhythmias, heart failure, worsening of right ventricular function, and tricuspid regurgitation. There was also a high incidence of prematurity and increased rate of fetal loss and neonatal mortality. Outcome of pregnancy in women after arterial switch operations is more favorable, with reduced incidence of maternal complications and fetal outcomes similar to women without underlying cardiac disease.
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Affiliation(s)
- Jena Pizula
- Division of Cardiovascular Medicine, Department of MedicineUniversity of Southern CaliforniaLos AngelesCA
| | - Justin Devera
- Division of Cardiovascular Medicine, Department of MedicineUniversity of Southern CaliforniaLos AngelesCA
| | - Tien M. H. Ng
- Division of Cardiovascular Medicine, Department of MedicineUniversity of Southern CaliforniaLos AngelesCA,School of PharmacyUniversity of Southern CaliforniaLos AngelesCA
| | | | - Jenica Thangathurai
- Division of Cardiovascular Medicine, Department of MedicineUniversity of Southern CaliforniaLos AngelesCA
| | - Nichole Herrick
- Division of Cardiovascular Medicine, Department of MedicineUniversity of Southern CaliforniaLos AngelesCA
| | - Amy J. Chatfield
- School of PharmacyUniversity of Southern CaliforniaLos AngelesCA
| | - Anil Mehra
- Division of Cardiovascular Medicine, Department of MedicineUniversity of Southern CaliforniaLos AngelesCA
| | - Uri Elkayam
- Division of Cardiovascular Medicine, Department of MedicineUniversity of Southern CaliforniaLos AngelesCA,Department of Obstetrics and GynecologyUniversity of Southern CaliforniaLos AngelesCA
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3
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Engele LJ, Mulder BJM, Schoones JW, Kiès P, Egorova AD, Vliegen HW, Hazekamp MG, Bouma BJ, Jongbloed MRM. The Coronary Arteries in Adults after the Arterial Switch Operation: A Systematic Review. J Cardiovasc Dev Dis 2021; 8:jcdd8090102. [PMID: 34564120 PMCID: PMC8468869 DOI: 10.3390/jcdd8090102] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 08/19/2021] [Accepted: 08/21/2021] [Indexed: 01/11/2023] Open
Abstract
Coronary artery status in adults long after the arterial switch operation (ASO) is unclear. We conducted a systematic review to provide an overview of coronary complications during adulthood and to evaluate the value of routine coronary imaging in adults after ASO, in light of current guidelines. Articles were screened for the inclusion of adult ASO patients and data on coronary complications and findings of coronary imaging were collected. A total of 993 adults were followed with a median available follow-up of only 2.0 years after reaching adulthood. Myocardial ischemia was suspected in 17/192 patients (8.9%). The number of coronary interventions was four (0.4%), and coronary death was reported in four (0.4%) patients. A lack of ischemia-related symptoms cannot be excluded because innervation studies indicated deficient cardiac innervation after ASO, although data is limited. Anatomical high-risk features found by routine coronary computed tomography (cCT) included stenosis (4%), acute angle (40%), kinking (24%) and inter-arterial course (11%). No coronary complications were reported during pregnancy (n = 45), although, remarkably, four (9%) patients developed heart failure. The 2020 European Society of Cardiology (ESC) guidelines state that routine screening for coronary pathologies is questionable. Based on current findings and in line with the 2018 American ACC/AHA guidelines a baseline assessment of the coronary arteries in all ASO adults seems justifiable. Thereafter, an individualized coronary follow-up strategy is advisable at least until significant duration of follow-up is available.
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Affiliation(s)
- Leo J Engele
- Center for Congenital Heart Disease Amsterdam-Leiden (CAHAL), Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Heart Centre, Amsterdam UMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
- Netherlands Heart Institute, 3511 EP Utrecht, The Netherlands
| | - Barbara J M Mulder
- Center for Congenital Heart Disease Amsterdam-Leiden (CAHAL), Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Heart Centre, Amsterdam UMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
- Netherlands Heart Institute, 3511 EP Utrecht, The Netherlands
| | - Jan W Schoones
- Directorate of Research Policy, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
| | - Philippine Kiès
- Center for Congenital Heart Disease Amsterdam-Leiden (CAHAL), Department of Cardiology, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
| | - Anastasia D Egorova
- Center for Congenital Heart Disease Amsterdam-Leiden (CAHAL), Department of Cardiology, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
| | - Hubert W Vliegen
- Center for Congenital Heart Disease Amsterdam-Leiden (CAHAL), Department of Cardiology, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
| | - Mark G Hazekamp
- Center for Congenital Heart Disease Amsterdam-Leiden (CAHAL), Department of Cardiothoracic Surgery, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
| | - Berto J Bouma
- Center for Congenital Heart Disease Amsterdam-Leiden (CAHAL), Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Heart Centre, Amsterdam UMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
- Netherlands Heart Institute, 3511 EP Utrecht, The Netherlands
| | - Monique R M Jongbloed
- Center for Congenital Heart Disease Amsterdam-Leiden (CAHAL), Department of Cardiology, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
- Center for Congenital Heart Disease Amsterdam-Leiden (CAHAL), Department of Anatomy and Embryology, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
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4
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Hardee I, Wright L, McCracken C, Lawson E, Oster ME. Maternal and Neonatal Outcomes of Pregnancies in Women With Congenital Heart Disease: A Meta-Analysis. J Am Heart Assoc 2021; 10:e017834. [PMID: 33821681 PMCID: PMC8174159 DOI: 10.1161/jaha.120.017834] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Background With advances in the treatment of congenital heart disease (CHD), more women with CHD survive childhood to reach reproductive age. The objective of this study was to evaluate the maternal and neonatal outcomes of pregnancies among women with CHD in the modern era. Methods and Results We conducted a meta‐analysis of peer‐reviewed literature published January 2007 through June 2019. Studies were included if they reported on maternal or fetal mortality and provided data by CHD lesion. Meta‐analysis was performed using random effect regression modeling using Comprehensive Meta‐Analysis (v3). CHD lesions were categorized as mild, moderate, and severe to allow for pooling of data across studies. Of 2200 articles returned by our search, 32 met inclusion criteria for this study. Overall, the rate of neonatal mortality was 1%, 3.1%, and 3.5% in mild, moderate, and severe lesions, respectively. There were too few maternal deaths in any group to pool data. The rates of maternal and neonatal morbidity among women with CHD increase with severity of lesion. Specifically, rates of maternal arrhythmia and heart failure, cesarean section, preterm birth, and small for gestational age neonate are all markedly increased as severity of maternal CHD increases. Conclusions In the modern era, pregnancy in women with CHD typically has a successful outcome in both mother and child. However, as maternal CHD severity increases, so too does the risk of numerous morbidities and neonatal mortality. These findings may help in counseling women with CHD who plan to become pregnant, especially women with severe lesions.
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Affiliation(s)
- Isabel Hardee
- Department of Pediatrics University of Colorado School of Medicine Denver CO
| | - Lydia Wright
- Department of Pediatrics Emory University School of Medicine, Children's Healthcare of Atlanta Atlanta GA
| | - Courtney McCracken
- Department of Pediatrics Emory University School of Medicine, Children's Healthcare of Atlanta Atlanta GA
| | - Emily Lawson
- Woodruff Health Sciences Center Library Emory University Atlanta GA
| | - Matthew E Oster
- Department of Pediatrics Emory University School of Medicine, Children's Healthcare of Atlanta Atlanta GA
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5
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Tutarel O, Ramlakhan KP, Baris L, Subirana MT, Bouchardy J, Nemes A, Vejlstrup NG, Osipova OA, Johnson MR, Hall R, Roos-Hesselink JW. Pregnancy Outcomes in Women After Arterial Switch Operation for Transposition of the Great Arteries: Results From ROPAC (Registry of Pregnancy and Cardiac Disease) of the European Society of Cardiology EURObservational Research Programme. J Am Heart Assoc 2020; 10:e018176. [PMID: 33350866 PMCID: PMC7955508 DOI: 10.1161/jaha.120.018176] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Background In the past 3 decades, the arterial switch procedure has replaced the atrial switch procedure as treatment of choice for transposition of the great arteries. Although survival is superior after the arterial switch procedure, data on pregnancy outcomes are scarce and transposition of the great arteries after arterial switch is not yet included in the modified World Health Organization classification of maternal cardiovascular risk. Methods and Results The ROPAC (Registry of Pregnancy and Cardiac disease) is an international prospective registry of pregnant women with cardiac disease, part of the European Society of Cardiology EURObservational Research Programme. Pregnancy outcomes in all women after an arterial switch procedure for transposition of the great arteries are described. The primary end point was a major adverse cardiovascular event, defined as combined end point of maternal death, supraventricular or ventricular arrhythmias requiring treatment, heart failure, aortic dissection, endocarditis, ischemic coronary events, and thromboembolic events. Altogether, 41 pregnant women (mean age, 26.7±3.9 years) were included, and there was no maternal mortality. A major adverse cardiovascular event occurred in 2 women (4.9%): heart failure in one (2.4%) and ventricular tachycardia in another (2.4%). One woman experienced fetal loss, whereas no neonatal mortality was observed. Conclusions Women after an arterial switch procedure for transposition of the great arteries tolerate pregnancy well, with a favorable maternal and fetal outcome. During counseling, most women should be reassured that the risk of pregnancy is low. Classification as modified World Health Organization risk class II seems appropriate.
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Affiliation(s)
- Oktay Tutarel
- Department of Congenital Heart Disease and Paediatric Cardiology German Heart Centre MunichTechnical University of Munich School of MedicineTechnical University of Munich Germany.,DZHK (German Centre for Cardiovascular Research), partner site Munich Heart Alliance Munich Germany
| | - Karishma P Ramlakhan
- Department of Cardiology Erasmus University Medical Center Rotterdam the Netherlands
| | - Lucia Baris
- Department of Cardiology Erasmus University Medical Center Rotterdam the Netherlands
| | - Maria T Subirana
- Adult Congenital Heart Disease Unit Vall d'Hebrón-Sant Pau Barcelona Spain
| | - Judith Bouchardy
- Service of Cardiology University Hospital Lausanne and University of Lausanne Switzerland.,Service of Cardiology University of Geneva Switzerland
| | - Attila Nemes
- 2nd Department of Medicine and Cardiology Centre Medical Faculty Albert Szent-Györgyi Clinical Center University of Szeged Hungary
| | - Niels G Vejlstrup
- Department of Cardiology, Rigshospitalet Copenhagen University Hospital Copenhagen Denmark
| | - Olga A Osipova
- Department of Pregnancy Pathology Perinatal Centre of Belgorod Regional Clinical Hospital of St Iosaph Belgorod Russia.,Belgorod State University Belgorod Russia
| | - Mark R Johnson
- Department of Obstetric Medicine Imperial College London, Chelsea and Westminster Hospital London United Kingdom
| | - Roger Hall
- Department of Cardiology University of East Anglia Norwich United Kingdom
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6
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Abstract
Women with congenital heart disease are pursuing pregnancy in increasing numbers. Counseling about genetic transmission, medication management, maternal and fetal risks, and maternal longevity should be initiated well before pregnancy is considered. Although preconception medical and surgical optimization as well as coordinated multidisciplinary care throughout pregnancy decrease maternal and fetal risks, the rate of complications remains increased compared with the general population. Lesion-specific risk stratification and care throughout pregnancy further improve outcomes and decrease unnecessary interventions.
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Affiliation(s)
- Katherine B Salciccioli
- Adult Congenital Heart Disease, Department of Internal Medicine, University of Michigan, University of Michigan Congenital Heart Center, C.S. Mott Children's Hospital, 1540 East Hospital Drive, Ann Arbor, MI 48109-4204, USA
| | - Timothy B Cotts
- Adult Congenital Heart Disease, Department of Internal Medicine, University of Michigan, University of Michigan Congenital Heart Center, C.S. Mott Children's Hospital, 1540 East Hospital Drive, Ann Arbor, MI 48109-4204, USA; Adult Congenital Heart Disease, Department of Pediatrics, University of Michigan, University of Michigan Congenital Heart Center, C.S. Mott Children's Hospital, 1540 East Hospital Drive, Ann Arbor, MI 48109-4204, USA.
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7
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Stoll VM, Drury NE, Thorne S, Selman T, Clift P, Chong H, Thompson PJ, Morris RK, Hudsmith LE. Pregnancy Outcomes in Women With Transposition of the Great Arteries After an Arterial Switch Operation. JAMA Cardiol 2019; 3:1119-1122. [PMID: 30193342 DOI: 10.1001/jamacardio.2018.2747] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance A growing number of women are approaching childbearing age after arterial switch surgery for transposition of the great arteries. Prepregnancy counseling requires updated knowledge of the additional cardiovascular risks pregnancy poses for this cohort of women and the potential effect on their offspring; however, to our knowledge, this information is currently unknown. Objective To determine the pregnancy outcomes of women with transposition of the great arteries after an arterial switch operation, as well as the outcomes of their offspring. Design, Setting, and Participants This cohort study assessed women who had had arterial switch surgery from 1985 to the present and who were 16 years or older as of January 2018. All women with a previous arterial switch surgery for transposition of the great arteries with completed or ongoing pregnancy were included. Data were collected in a level 1 congenital cardiology center and joint obstetrics-cardiology clinic in Birmingham, United Kingdom. Exposures Patients were assessed before, during, and after pregnancy. Main Outcomes and Measures Adverse maternal cardiac events (arrhythmia, heart failure, aortic dissection, or acute coronary syndrome) and aortic root dilatation, aortic regurgitation, and left ventricular function before and after pregnancy were the main outcomes. Mode of delivery and fetal outcomes were considered secondary outcomes. Results A total of 25 pregnancies were identified in 15 women; 8 women had had 1 pregnancy, while 7 were multiparous. There were no adverse maternal cardiac events. Before pregnancy, 8 women (53%) had no aortic regurgitation, 1 (7%) had a trivial degree of regurgitation, 4 (26%) had mild regurgitation, and 2 (14%) had moderate regurgitation. After pregnancies, 1 woman (7%) had minor progression of aortic regurgitation. Five women (36%) had mild neoaortic root dilatation prepregnancy, but none developed progressive dilatation in the first year post-partum. A total of 24 pregnancies were completed by the end of the study, with all infants born alive and well. Nineteen modes of delivery were known; there were 7 cesarean deliveries (37%), of which 2 (11%) were recommended for aortic dilatation and 5 (26%) for obstetric indications or maternal choice. Conclusions and Relevance Pregnancy is well tolerated after arterial switch operation; no adverse maternal cardiac events or early progression of neoaortic root dilatation or aortic regurgitation were observed in this study. These results provide evidence to allow reassurance of women with previous arterial switch surgery who are planning pregnancies.
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Affiliation(s)
- Victoria M Stoll
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, United Kingdom.,Adult Congenital Heart Disease Unit, Queen Elizabeth Hospital, Birmingham, United Kingdom
| | - Nigel E Drury
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, United Kingdom.,Department of Paediatric Cardiac Surgery, Birmingham Children's Hospital, Birmingham, United Kingdom
| | - Sara Thorne
- Adult Congenital Heart Disease Unit, Queen Elizabeth Hospital, Birmingham, United Kingdom
| | - Tara Selman
- Department of Obstetrics, University Hospital Southampton, Southampton, United Kingdom
| | - Paul Clift
- Adult Congenital Heart Disease Unit, Queen Elizabeth Hospital, Birmingham, United Kingdom
| | - Hsu Chong
- Department of Obstetrics, Birmingham Women's Hospital, Birmingham, United Kingdom.,Institute of Metabolism and System's Research, University of Birmingham, Birmingham, United Kingdom
| | - Peter J Thompson
- Department of Obstetrics, Birmingham Women's Hospital, Birmingham, United Kingdom
| | - R Katie Morris
- Department of Obstetrics, Birmingham Women's Hospital, Birmingham, United Kingdom.,Institute of Metabolism and System's Research, University of Birmingham, Birmingham, United Kingdom
| | - Lucy E Hudsmith
- Adult Congenital Heart Disease Unit, Queen Elizabeth Hospital, Birmingham, United Kingdom
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8
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Pregnancy Outcomes in Women After the Arterial Switch Operation. Heart Lung Circ 2019; 29:1087-1092. [PMID: 31522930 DOI: 10.1016/j.hlc.2019.07.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Revised: 06/20/2019] [Accepted: 07/06/2019] [Indexed: 01/01/2023]
Abstract
BACKGROUND Pregnancy outcomes after the arterial switch operation (ASO) are rare. We sought to determine outcomes of ASO survivors who underwent pregnancy. METHODS Female patients who had an ASO and underwent pregnancy were identified from the congenital heart disease pregnancy clinic at The Royal Melbourne Hospital. All follow-up data were collected retrospectively by medical record review. RESULTS Eleven (11) women were identified as having undergone medical care during pregnancy, from the adult congenital database, at The Royal Melbourne Hospital. There were 17 successful pregnancies, and nine women have been followed post pregnancy. Of the 17 successful deliveries, eight were delivered by Caesarean section, seven were vaginal deliveries and two were instrumented vaginal deliveries. Of the eight Caesarean sections, five were emergency and three were elective. The indications for emergency Caesarean section were obstructed labour (n = 2), abnormal cardiotocography (n = 1), obstructed labour and abnormal cardiotocography (n = 1) and congestive cardiac failure (n = 1). There was one neonatal complication (respiratory distress requiring intubation) in a child born at 31 weeks. There were maternal obstetric complications in 10 patients. There were two maternal cardiac complications during pregnancy (heart failure and rapid atrial fibrillation/flutter). There was no change in left ventricular function post-pregnancy. There was progression of severity of neo-aortic valve regurgitation in two patients post pregnancy (trivial to mild and moderate-severe to severe respectively). CONCLUSION Pregnancy post ASO appears to be safe in the majority of women. Maternal cardiac complications are uncommon in patients without residual significant haemodynamic lesions, although maternal obstetric complications may be common.
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9
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Fabre-Gray A, Curtis S, Trinder J. Obstetric outcomes following atrial and arterial switch procedures for transposition of the great arteries (TGA) - A single, tertiary referral centre experience over 20 years. Obstet Med 2019; 13:125-131. [PMID: 33093864 DOI: 10.1177/1753495x19825964] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2018] [Accepted: 01/03/2019] [Indexed: 11/16/2022] Open
Abstract
Repair of transposition of the great arteries usually involves an atrial switch or arterial switch operation, which can complicate physiological adaptation to the demands of pregnancy and adversely affect the fetus. We retrospectively compared outcomes of 48 completed pregnancies in 23 women with surgically corrected transposition of the great arteries (38 atrial switch/10 arterial switch operation) under joint cardiac-obstetric care in our tertiary referral clinic between 1997 and 2017. Most women delivered vaginally (85%). The pre-term delivery rate was high (atrial switch 39%; arterial switch operation 40%). Small for gestational age occurred in 56% of babies, significantly more in the atrial switch group (66%) than arterial switch operation (20%), p = 0.013. Women with surgically corrected transposition of the great arteries wishing to become pregnant are at high risk of obstetric complications, primarily pre-term delivery and small for gestational age baby. They require more careful ultrasound surveillance beyond 36 weeks' gestation and/or may benefit from early induction of labour. Trial registration: Text/Not applicable.
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Affiliation(s)
- Anna Fabre-Gray
- Department of Maternal and Fetal Medicine, St Michael's Hospital, University Hospitals Bristol, Bristol, UK
| | - Stephanie Curtis
- Adult Congenital Heart Disease, University Hospitals Bristol, Bristol, UK.,Department of Maternal Medicine, University Hospitals Bristol, Bristol, UK
| | - Johanna Trinder
- Department of Maternal Medicine, University Hospitals Bristol, Bristol, UK.,Department of Obstetrics, University Hospitals Bristol, Bristol, UK
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Horiuchi C, Kamiya CA, Ohuchi H, Miyoshi T, Tsuritani M, Iwanaga N, Neki R, Niwa K, Kurosaki K, Ichikawa H, Ikeda T, Yoshimatsu J. Pregnancy outcomes and mid-term prognosis in women after arterial switch operation for dextro-transposition of the great arteries - Tertiary hospital experiences and review of literature. J Cardiol 2018; 73:247-254. [PMID: 30579805 DOI: 10.1016/j.jjcc.2018.11.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Revised: 11/03/2018] [Accepted: 11/10/2018] [Indexed: 10/27/2022]
Abstract
OBJECTIVE Arterial switch operation (ASO) for dextro-transposition of the great arteries (d-TGA) has gradually replaced the atrial switch operation and has become the standard operation. To date, the outcomes of pregnant women with d-TGA after this new operation have not been investigated. In this study, we investigated the impact of ASO on pregnant outcomes and mid-term prognosis in women with d-TGA and compared with the atrial switch operation through the literature review. METHODS AND RESULTS There were 20 pregnancies in 10 women with d-TGA after ASO and 6 resulted in abortion. Among 14 successful pregnancies in 10 women, 11 pregnancies achieved the term delivery and 3 pregnancies, including 1 twin pregnancy, resulted in preterm labor. Maternal cardiovascular events occurred in 4 (heart failure and arrhythmias in 3 and arrhythmia in 1), and all were controllable with medications. Risk factors for the peripartum cardiac events were older age at ASO and delivery, and higher concentration of brain natriuretic peptide (BNP) at first trimester (p<0.05). In 7-60 month-follow-up after delivery, no case showed deterioration of functional class and systemic ventricular function. According to the literature review, women after ASO demonstrated a better prognosis than those after the atrial switch operation. CONCLUSIONS The majority of women with d-TGA after ASO tolerated pregnancy and delivery well. The older age at ASO, an elderly pregnancy, and higher BNP levels at the first trimester were possibly risk factors of peripartum cardiovascular events among the group. The literature reviews and this study may indicate the advantage of systemic left ventricle compared with systemic right ventricle in long-term outcomes after delivery.
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Affiliation(s)
- Chinami Horiuchi
- Departments of Perinatology and Gynecology, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan; Departments of Obstetrics and Gynecology, Mie University School of Medicine, Mie, Japan.
| | - Chizuko A Kamiya
- Departments of Perinatology and Gynecology, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Hideo Ohuchi
- Departments of Pediatric Cardiology, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Takekazu Miyoshi
- Departments of Obstetrics and Gynecology, Mie University School of Medicine, Mie, Japan
| | - Mitsuhiro Tsuritani
- Departments of Perinatology and Gynecology, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Naoko Iwanaga
- Departments of Perinatology and Gynecology, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Reiko Neki
- Departments of Perinatology and Gynecology, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Koichiro Niwa
- Cardiovascular Center, St. Luke's International Hospital, Tokyo, Japan
| | - Kenichi Kurosaki
- Departments of Pediatric Cardiology, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Hajime Ichikawa
- Departments of Pediatric Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Tomoaki Ikeda
- Departments of Obstetrics and Gynecology, Mie University School of Medicine, Mie, Japan
| | - Jun Yoshimatsu
- Departments of Perinatology and Gynecology, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
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11
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Moe TG, Bardo DME. Long-term Outcomes of the Arterial Switch Operation for d-Transposition of the Great Arteries. Prog Cardiovasc Dis 2018; 61:360-364. [PMID: 30227186 DOI: 10.1016/j.pcad.2018.08.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Accepted: 08/22/2018] [Indexed: 12/16/2022]
Abstract
Dextrotransposition of the great arteries (d-TGA) is a relatively rare form of complex childhood congenital heart disease, which occurs in approximately 0.2 in 1000 live births (Long et al, 2010). The most common palliative procedure for this anatomy has become the arterial switch operation (ASO). We will review in this paper the evidence that is currently available regarding the clinical management following the ASO. Individuals with d-TGA who undergo ASO at a young age thus far have excellent long-term outcomes. Long-term complications for the ASO should be monitored for and patients should have routine follow-up with specialists in adult congenital heart disease.
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Affiliation(s)
- Tabitha G Moe
- Arizona Cardiology Group, 340 E Palm Lane Ste A175, Phoenix, AZ 85004, United States of America.
| | - Dianna M E Bardo
- Phoenix Children's Hospital, Radiology Dept., 1919 E Thomas Rd., Phoenix, AZ 85006, United States of America.
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12
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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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13
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Crean AM, Ahmed F, Motwani M. The Role of Radionuclide Imaging in Congenital Heart Disease. CURRENT CARDIOVASCULAR IMAGING REPORTS 2017. [DOI: 10.1007/s12410-017-9434-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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14
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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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15
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Abstract
OPINION STATEMENT Advances in cardiac surgical interventions in infancy and childhood have led to an increased number of women with congenital heart disease of childbearing age. For these women, individualized preconception counseling and pregnancy planning should be a vital component of their medical management, and presentation for obstetric care may even be an opportunity to re-establish cardiovascular care for patients who have been lost to follow-up. These patients have unique cardiovascular anatomy and physiology, which is dependent upon the surgical intervention they may have undergone during childhood or adolescence. These factors are associated with a variety of long-term complications, and the normal hemodynamic changes of pregnancy may unmask cardiac dysfunction and pose significant risk. Among three published risk assessment algorithms, the World Health Organization classification is the most sensitive in predicting maternal cardiovascular events in this population. Women with simple congenital heart defects generally tolerate pregnancy well and can be cared for in the community with careful monitoring. Conversely, women with complex congenital defects, with or without surgical repair and/or residual defects, should be managed in tertiary care centers under a multidisciplinary team of physicians experienced in adult congenital heart disease and high-risk obstetrics, who collaboratively participate in pregnancy planning, management, and care through childbirth and postpartum. Women who are cyanotic with oxygen saturation less than 85%, have significant pulmonary arterial hypertension of any cause, or have systemic ventricular dysfunction should be counseled to avoid pregnancy due to a very high risk of maternal and fetal mortality.
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Affiliation(s)
- Evin Yucel
- Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, MA, 02114, USA
| | - Doreen DeFaria Yeh
- Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, MA, 02114, USA. .,Adult Congenital Heart Disease Program, Massachusetts General Hospital, Division of Cardiology, Harvard Medical School, Boston, MA, USA.
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16
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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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17
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Update on the Management of Adults With Arterial Switch Procedure for Transposition of the Great Arteries. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2017; 19:4. [PMID: 28155117 DOI: 10.1007/s11936-017-0505-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OPINION STATEMENT The arterial switch operation (ASO) is now the most frequently performed surgical correction in individuals with dextro-transposition of the great arteries (D-TGA). Patients who undergo this procedure as neonates have overall good clinical outcomes yet continued clinical follow-up is important to evaluate for postoperative complications. In this group, the highest mortality is in the immediate postoperative period and is generally associated with reimplantation of the coronary arteries. As these patients live into adulthood, longitudinal follow-up for other ASO complications including neo-pulmonary stenosis, right ventricular outflow tract (RVOT) obstruction, or neo-aortic root dilation and resulting aortic insufficiency should be performed. In adults, extra care should be taken to identify and treat traditional cardiovascular risk factors as individuals with coronary obstruction may not present with typical anginal symptoms. Management of these patients should be performed in collaboration with an adult congenital heart center of excellence. This population offers a unique opportunity to provide timely feedback to adult congenital heart community of providers regarding late outcomes from surgical intervention and in the next decade will hopefully demonstrate a model for clinical feedback cycles in lifelong congenital care.
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18
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Pillutla P, Nguyen T, Markovic D, Canobbio M, Koos BJ, Aboulhosn JA. Cardiovascular and Neonatal Outcomes in Pregnant Women With High-Risk Congenital Heart Disease. Am J Cardiol 2016; 117:1672-1677. [PMID: 27055756 DOI: 10.1016/j.amjcard.2016.02.045] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2015] [Revised: 02/23/2016] [Accepted: 02/23/2016] [Indexed: 12/01/2022]
Abstract
Congenital heart disease (CHD) increases the risk of adverse maternal and neonatal outcomes. However, previous studies have included mainly women with low-risk features. A single-center, retrospective analysis of pregnant women with CHD was performed. Inclusion criteria were the following high-risk congenital lesions and co-morbidities: maternal cyanosis; New York Heart Association (NHYA) functional class >II; severe ventricular dysfunction; maternal arrhythmia, single ventricle (SV) physiology, severe left-sided heart obstruction and severe pulmonary arterial hypertension. Multivariate analyses for predictors of adverse maternal cardiovascular and neonatal outcomes were performed. Forty-three women reported 61 pregnancies. There were no maternal or neonatal deaths. Maternal cardiac (31%) and neonatal (54%) complications were frequent. The most frequent cardiac events were pulmonary edema, arrhythmia, and reduced NYHA class. Previous arrhythmia conferred a 12-fold increase in the odds of experiencing at least one major cardiac complication. Maternal SV physiology was an independent risk factor for low birth weight, risk of neonatal intensive care unit admission and lower gestational age. Maternal cyanosis and severe pulmonary arterial hypertension also predicted adverse neonatal outcomes. In conclusion, mothers without antepartum arrhythmia or functional incapacity are unlikely to experience arrhythmias or a decrease in NYHA class during pregnancy. In addition, SV physiology is a robust predictor of neonatal complications. Antepartum counseling and assessment of maternal fitness are crucial for the woman with CHD.
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Affiliation(s)
- Priya Pillutla
- Division of Cardiology, Department of Medicine, Harbor-University of California, Los Angeles Medical Center, Torrance, California.
| | - Tina Nguyen
- Department of Obstetrics and Gynecology, Ronald Reagan University of California, Los Angeles Medical Center, Los Angeles, California
| | - Daniela Markovic
- Department of Biostatics, University of California Los Angeles, Los Angeles, California
| | - Mary Canobbio
- Ahmanson/UCLA ACHD Center Lecturer, University of California Los Angeles, School of Nursing, Los Angeles, California
| | - Brian J Koos
- Department of Obstetrics and Gynecology, Ronald Reagan University of California, Los Angeles Medical Center, Los Angeles, California
| | - Jamil A Aboulhosn
- Division of Cardiology, Department of Medicine, Ahmanson/University of California, Los Angeles Adult Congenital Heart Disease Center, Los Angeles, California
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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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20
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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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21
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Villafañe J, Lantin-Hermoso MR, Bhatt AB, Tweddell JS, Geva T, Nathan M, Elliott MJ, Vetter VL, Paridon SM, Kochilas L, Jenkins KJ, Beekman RH, Wernovsky G, Towbin JA. D-transposition of the great arteries: the current era of the arterial switch operation. J Am Coll Cardiol 2014; 64:498-511. [PMID: 25082585 DOI: 10.1016/j.jacc.2014.06.1150] [Citation(s) in RCA: 175] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2014] [Accepted: 06/20/2014] [Indexed: 01/25/2023]
Abstract
This paper aims to update clinicians on "hot topics" in the management of patients with D-loop transposition of the great arteries (D-TGA) in the current surgical era. The arterial switch operation (ASO) has replaced atrial switch procedures for D-TGA, and 90% of patients now reach adulthood. The Adult Congenital and Pediatric Cardiology Council of the American College of Cardiology assembled a team of experts to summarize current knowledge on genetics, pre-natal diagnosis, surgical timing, balloon atrial septostomy, prostaglandin E1 therapy, intraoperative techniques, imaging, coronary obstruction, arrhythmias, sudden death, neoaortic regurgitation and dilation, neurodevelopmental (ND) issues, and lifelong care of D-TGA patients. In simple D-TGA: 1) familial recurrence risk is low; 2) children diagnosed pre-natally have improved cognitive skills compared with those diagnosed post-natally; 3) echocardiography helps to identify risk factors; 4) routine use of BAS and prostaglandin E1 may not be indicated in all cases; 5) early ASO improves outcomes and reduces costs with a low mortality; 6) single or intramural coronary arteries remain risk factors; 7) post-ASO arrhythmias and cardiac dysfunction should raise suspicion of coronary insufficiency; 8) coronary insufficiency and arrhythmias are rare but are associated with sudden death; 9) early- and late-onset ND abnormalities are common; 10) aortic regurgitation and aortic root dilation are well tolerated; and 11) the aging ASO patient may benefit from "exercise-prescription" rather than restriction. Significant strides have been made in understanding risk factors for cardiac, ND, and other important clinical outcomes after ASO.
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Affiliation(s)
- Juan Villafañe
- Department of Pediatrics (Cardiology), University of Kentucky, Lexington, Kentucky.
| | | | - Ami B Bhatt
- Adult Congenital Heart Disease Program, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - James S Tweddell
- Cardiothoracic Surgery, Children's Hospital of Wisconsin, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Tal Geva
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Meena Nathan
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Martin J Elliott
- Department of Pediatric Cardiothoracic Surgery, The Great Ormond Street Hospital for Children, NHS Foundation Trust, London, United Kingdom
| | - Victoria L Vetter
- Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Stephen M Paridon
- Department of Exercise Physiology, Perlman School of Medicine, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Lazaros Kochilas
- University of Minnesota Children's Hospital, Minneapolis, Minnesota
| | - Kathy J Jenkins
- Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Robert H Beekman
- Division of Cardiology, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Gil Wernovsky
- The Heart Program, Miami Children's Hospital, Florida International University Herbert Wertheim College of Medicine, Miami, Florida
| | - Jeffrey A Towbin
- The Heart Institute, Division of Cardiology, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
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22
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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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23
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Abstract
Adults with congenital heart disease now form the largest group of women with cardiac disease becoming pregnant in the developed world. This is both a mark of impressive steps forward in the management of congenital heart disease and also a challenge to the medical community to develop systems of care that will best serve these women and their babies. Each woman with congenital heart disease presents a unique pattern of challenges for the cardiologist, obstetrician, and anesthesiologist, and their care should be tailored to deal with their individual circumstances. As this population of patients continues to grow, we must continue to learn and improve our diagnostic tools and management strategies to refine their care. This review intends to focus on reviewing the outcomes in this set of patients and also an approach to the assessment and the management of these patients, primarily for an audience of obstetricians, pediatricians, and anesthesiologists.
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Affiliation(s)
- Shaline Rao
- Division of Cardiology, Columbia University Medical Center, New York, NY
| | - Jonathan N Ginns
- Division of Cardiology, Columbia University Medical Center, New York, NY.
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Vause S, Clarke B. Risk stratification and hierarchy of antenatal care. Best Pract Res Clin Obstet Gynaecol 2014; 28:483-94. [PMID: 24726852 DOI: 10.1016/j.bpobgyn.2014.03.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2013] [Accepted: 03/11/2014] [Indexed: 10/25/2022]
Abstract
Cardiac disease is the leading cause of maternal death in the UK. The triennial maternal mortality reports have repeatedly highlighted failure to recognise the level of risk as a major contributing factor to the deaths of these women. Once the level of risk has been recognised, services then need to be organised in a way that supports the needs of the highest risk women, but avoids unnecessary intervention for women at lower risk. Risk scoring systems and lesion-specific indicators may help predict maternal and neonatal outcomes. Care can then be planned accordingly, to optimise the outcome for the woman and her baby.
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Affiliation(s)
- Sarah Vause
- St Mary's Hospital, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester M13 9WL, UK and Institute of Human Development, Faculty of Medical and Human Sciences, University of Manchester.
| | - Bernard Clarke
- Manchester Royal Infirmary, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Sciences Centre, Manchester M13 9WL and Institute of Cardiovascular Sciences, Faculty of Medical and Human Sciences, University of Manchester, UK
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Regitz-Zagrosek V, Gohlke-Bärwolf C, Iung B, Pieper PG. Management of cardiovascular diseases during pregnancy. Curr Probl Cardiol 2014; 39:85-151. [PMID: 24794710 DOI: 10.1016/j.cpcardiol.2014.02.001] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
The prevalence of cardiovascular diseases (CVDs) in women of childbearing age is rising. The successes in medical and surgical treatment of congenital heart disease have led to an increasing number of women at childbearing age presenting with problems of treated congenital heart disease. Furthermore, in developing countries and in immigrants from these countries, rheumatic valvular heart disease still plays a significant role in young women. Increasing age of pregnant women and increasing prevalence of atherosclerotic risk factors have led to an increase in women with coronary artery disease at pregnancy. Successful management of pregnancy in women with CVDs requires early diagnosis, a thorough risk stratification, and appropriate management by a multidisciplinary team of obstetricians, cardiologists, anesthesiologists, and primary care physicians. The following review is based on the recent European guidelines on the management of CVDs during pregnancy, which aim at providing concise and simple recommendations for these challenging problems.
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27
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Affiliation(s)
- Alexander R Opotowsky
- Department of Cardiology, Boston Children's Hospital, and Department of Medicine, Brigham and Women's Hospital, Boston, MA
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28
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Chugh R. Management of Pregnancy in Women With Repaired CHD or After the Fontan Procedure. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2013; 15:646-62. [DOI: 10.1007/s11936-013-0263-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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29
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Arterial switch repair to transposition of great arteries: So far so good. Int J Cardiol 2012; 160:1-3. [DOI: 10.1016/j.ijcard.2012.01.079] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2012] [Accepted: 01/26/2012] [Indexed: 11/24/2022]
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Abstract
Advances in the surgical palliation and correction of congenital heart lesions have improved survival and increased the number of patients living into adulthood. Although pregnancy outcomes will be favorable for most patients with congenital heart disease, the cardiovascular challenges associated with pregnancy and delivery are best managed with a multidisciplinary approach during the puerperium. This review addresses the prevalence, physiology, risk assessment, peripartum complications, and anesthetic management of the pregnant patient with underlying congenital heart disease.
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Affiliation(s)
- Amy J Ortman
- University of Kansas Medical Center, Kansas City, KS 66160-7415, USA.
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31
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Guía de práctica clínica de la ESC para el tratamiento de las enfermedades cardiovasculares durante el embarazo. Rev Esp Cardiol 2012. [DOI: 10.1016/j.recesp.2011.11.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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33
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Abstract
PURPOSE OF REVIEW Transposition of the great arteries (TGA) is a complex congenital heart defect usually defined within the group of conotruncal defects. Some astonishing similarities between the spiral pattern of great arteries and the spiral pattern of snail shells and a possible common genetic mechanism of normal and abnormal anatomical aspects of the heart and shells are examined. RECENT FINDINGS The pulmonary vascular resistances in TGA and ventricular septal defect (VSD) need to be assessed before surgery, as they are the key factors for the success of the surgical procedure. A noninvasive method has been proposed to assess this key factor. A first series of the pregnancy outcomes in young women after arterial switch operation (ASO) is promising and encouraging for even better results. The systemic failing right ventricle (RV) is treated empirically using the same drugs and devices as for the failing left ventricle. The rationale for the treatment of ventricular failure, similar or different for predominantly right or left ventricle, is debated. The results of Rastelli operation are compared with those of the other surgical procedures for the treatment of TGA, VSD and pulmonary stenosis, namely reparation a l'ètage ventriculaire and Nikaidoh interventions. SUMMARY This review outlines some new aspects of the embryologic cardiac development and reveals astonishing similarities between heart and shells. A new diagnostic noninvasive method for measuring pulmonary vascular resistances, the pregnancy outcome of a first series of women operated by ASO, and the pharmacological and cardiac devices used in the failing systemic RV are presented. Finally, the review comments on the Rastelli operation as the 'gold standard' for TGA, VSD, and pulmonary stenosis.
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34
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Regitz-Zagrosek V, Blomstrom Lundqvist C, Borghi C, Cifkova R, Ferreira R, Foidart JM, Gibbs JSR, Gohlke-Baerwolf C, Gorenek B, Iung B, Kirby M, Maas AHEM, Morais J, Nihoyannopoulos P, Pieper PG, Presbitero P, Roos-Hesselink JW, Schaufelberger M, Seeland U, Torracca L. ESC Guidelines on the management of cardiovascular diseases during pregnancy: the Task Force on the Management of Cardiovascular Diseases during Pregnancy of the European Society of Cardiology (ESC). Eur Heart J 2011; 32:3147-97. [PMID: 21873418 DOI: 10.1093/eurheartj/ehr218] [Citation(s) in RCA: 935] [Impact Index Per Article: 71.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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35
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Roche SL, Silversides CK, Oechslin EN. Monitoring the Patient with Transposition of the Great Arteries: Arterial Switch Versus Atrial Switch. Curr Cardiol Rep 2011; 13:336-46. [DOI: 10.1007/s11886-011-0185-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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