Maternal and Fetal Outcome After Cardiac Operations During Pregnancy: A Meta-Analysis

Infective Endocarditis Requiring Mitral Valve Replacement During Second Trimester of Pregnancy

Infective endocarditis requiring mitral valve replacement during pregnancy is a rare event. We present a case of infective endocarditis of the mitral valve during second trimester and report maternal and perinatal outcomes. Prompt identification and interdisciplinary treatment is crucial; maternal and fetal follow-up including serial fetal neurosonography is recommended.

Balancing Hemostasis With Thrombosis: A Challenging Case of Pregnancy With a Mechanical Mitral Valve

A 32-year-old pregnant woman with a mechanical mitral valve was admitted with vaginal bleeding and was found to have placenta previa. During her hospital stay, she developed acute valvular thrombosis. She underwent an emergency cesarean section followed by successful mechanical valve replacement.

Managing Pulmonary Embolism With Right Ventricular Thrombus in In Vitro Fertilization-Related Pregnancy: A Clinical Insight

This case study provides an insightful examination of the management of high-risk pulmonary embolism (PE) in a 27-year-old pregnant patient following in vitro fertilization (IVF). Overlapping symptoms of PE and typical pregnancy manifestations, coupled with concerns about radiation exposure from diagnostic imaging, presented unique diagnostic challenges. Despite the heightened risk of thrombosis during pregnancy and elevated D-dimer levels, a conservative approach was strategically employed. This involved therapeutic anticoagulation using low-molecular-weight heparin, leading to significant patient improvement without the need for invasive interventions. This case highlights the imperative for a judicious yet proactive approach in managing PE among pregnant patients, meticulously considering both maternal and fetal health risks.

Percutaneous debulking of tricuspid vegetations due to infectious endocarditis in pregnancy: a case report

Infective endocarditis is a rare but serious disease with increasing prevalence in women of childbearing age because of the opioid epidemic. Therefore, it is an increasingly frequent pregnancy complication. The gold standard of treatment is intravenous antibiotics with surgery reserved for refractory cases. However, pregnancy complicates decisions about the risk and timing of surgery. AngioVac represents a percutaneous alternative to surgical intervention. Here, we present a case of a 22-year-old G2P1001 woman with a history of intravenous drug use and infective endocarditis who continued to show signs and symptoms of septic pulmonary emboli despite management with intravenous antibiotics. The patient was deemed not to be a surgical candidate while pregnant and had an AngioVac procedure at 30 2/7 weeks of gestation with the removal of tricuspid vegetations. The patient was delivered via cesarean delivery at 32 5/7 weeks of gestation because of a nonreassuring fetal heart tracing. The patient's tricuspid valve was replaced on postpartum day 16. This case demonstrates that AngioVac can be safely used in the third trimester of pregnancy and may be considered in consultation with a multidisciplinary team for the management of infective endocarditis refractory to antibiotic treatment as an interim measure until surgery can be safely performed.

Contemporary Management of Cardiogenic Shock During Pregnancy

Cardiogenic shock is the most extreme cardiovascular disease state during pregnancy. Peripartum cardiomyopathy is the most common cause of cardiogenic shock toward the end of pregnancy and in the early postpartum period. Therapy for cardiogenic shock relies on appropriate phenotyping of shock etiology, severity and ventricular predominance, which are critical in the appropriate selection of medical and mechanical therapy. Mechanical circulatory support may be used as a bridge to recovery or as definitive therapy. Intra-aortic balloon pumps, percutaneous left ventricular assist devices and venoarterial extracorporeal circulatory devices have been successfully used in pregnancy and the postpartum period. The most commonly used mechanical therapy in the pregnant patient is extracorporeal membranous oxygenation circulatory support. The use of mechanical circulatory devices in peripartum cardiomyopathy has contributed to improved survival rates in recent years. Further efforts to identify the optimal mechanical circulatory support strategy for peripartum cardiomyopathy and cardiogenic shock in the peripartum period are needed.

Cardiovascular Complications of Pregnancy

The physiologic changes in pregnancy predispose the pregnant patient to a variety of potential cardiovascular complications. In this article, we discuss the major cardiovascular disorders of pregnancy and their management, highlight specific diagnostic challenges, and discuss new developments in the field. Topics covered in this article include venous thromboembolism, acute myocardial infarction, peripartum cardiomyopathy, and aortic dissection.

Perioperative Anesthetic Management of the Pregnant Patient With Congenital Heart Disease Undergoing Cardiac Intervention: A Systematic Review

Maternal congenital heart disease is increasingly prevalent, and has been associated with a significantly increased risk of maternal, obstetric, and neonatal complications. For patients with CHD who require cardiac interventions during pregnancy, there is little evidence-based guidance with regard to optimal perioperative management. The periprocedural management of pregnant patients with congenital heart disease requires extensive planning and a multidisciplinary teams-based approach. Anesthesia providers must not only be facile in the management of adult congenital heart disease, but cognizant of the normal, but significant, physiologic changes of pregnancy.

The multidisciplinary management of a mechanical mitral valve thrombosis in pregnancy: a case report and review of the literature

Background

The management of anticoagulation for mechanical heart valves during pregnancy poses a unique challenge. Mechanical valve thrombosis is a devastating complication for which surgery is often the treatment of choice. However, cardiac surgery for prosthetic valve dysfunction in pregnant patients confers a high risk of maternofetal morbidity and mortality.

Case summary

A 39-year-old woman in her first pregnancy at 30 weeks gestation presented to hospital with a mechanical mitral valve thrombosis despite therapeutic anticoagulation with low-molecular-weight heparin. She underwent an emergent caesarean section followed immediately by a bioprosthetic mitral valve replacement. This occurred after careful planning and organization on the part of a large multidisciplinary team.

Discussion

A proactive, rather than reactive, approach to the surgical management of a mechanical valve thrombosis in pregnancy will maximize the chances of successful maternal and fetal outcomes.

Acute Myocardial Infarction in Pregnancy

Cardiovascular disease, and particularly ischemic heart disease, is a leading cause of maternal morbidity and mortality in high-income countries. The incidence of acute myocardial infarction (AMI) has been rising over the past two decades due to increasing maternal age and a higher prevalence of cardiovascular risk factors in the pregnant population. Causes of AMI in pregnancy are diverse and may require specific considerations for their diagnosis and management. In this narrative review, we provide an overview of physiologic changes, risk factors, and etiologies leading to AMI in pregnancy, as well as diagnostic tools, reperfusion strategies, and pharmacological treatments for this complex population. In addition, we outline considerations for labor and delivery planning and long-term follow-up of patients with AMI in pregnancy.

Aortic dissection in the first trimester; is it a dead end? A narrative review of recent articles

INTRODUCTION

Acute-type aortic dissection (AD) during pregnancy is considered a rare and potentially fatal complication for both mother and fetus. Although the definite treatment for an acute-type AD is considered to be open-heart surgery, the decision to perform such a surgery during pregnancy requires a multidisciplinary approach and carries significant risks.

METHODS

In the present review of the literature, we have discussed various challenges in the management of acute-type AD during pregnancy, including therapeutic approaches, choosing the preferred imaging modalities, surgical techniques, and medication challenges. We have also reported an 8-week pregnant woman with Marfan syndrome who presented with chest pain and was diagnosed with acute AD.

RESULTS

The patient underwent a Bentall operation and was discharged in good condition with her fetus alive. The medical team's various decisions during preoperative, operative, and postoperative treatments were discussed.

CONCLUSIONS

Type A AD is considered infrequent in the second and third trimester of pregnancy and rare in the first trimester. Performing a CMR study without contrast in stable patients can help evaluate the extension of the flap. Urgent surgery in the hands of a skilled surgeon may prove lifesaving for the mother while maximizing the likelihood of preserving the fetus.

Type A aortic dissection during in pregnancy: Confront without aversion or delay

Type A aortic dissection (TAAD) is a life-threatening clinical emergency requiring timely surgical intervention. Concomitant with pregnancy at any stage, it adds an additional level of complexity which mandates careful planning for the management strategy that will yield the optimal outcomes. It is life-threatening pathology to both the mother and fetus, with mortality rates of up to 30% and 50% reported, respectively. Safe imaging modalities that do not expose the fetus to radiation and contrast are recommended to reach an accurate diagnosis. In addition, meticulous multidisciplinary team planning is pivotal to ensure optimal outcomes are achieved through careful choice of surgical technique as well as strict control of medications. Although TAAD in pregnancy is associated with high mortality and morbidity to both the mother and her fetus, success in the treatment of this small subset of patients can certainly be achieved.

Society for Maternal-Fetal Medicine Consult Series #61: Anticoagulation in pregnant patients with cardiac disease

Pregnancy in individuals with a mechanical heart valve has been classified as very high risk because of a substantially increased risk of maternal mortality or severe morbidity. Lifelong therapeutic anticoagulation is a principal component of the medical management of mechanical heart valves to prevent valve thrombosis. Anticoagulation regimens indicated outside of pregnancy for patients with mechanical valves should be continued during pregnancy with the possibility of modifications based on the type of valve, the trimester of pregnancy, individual risk tolerance, and circumstances around the time of delivery. The purpose of this document is to provide recommendations regarding the management of anticoagulation for common cardiac conditions complicating pregnancy, including mechanical heart valves, atrial fibrillation, systolic heart failure, and congenital heart disease.

Case Series: Video-Assisted Minimally Invasive Cardiac Surgery During Pregnancy

Surgical intervention is expected to improve maternal outcomes in pregnant patients with heart disease once the conservative treatment fails. For pregnant patients with heart disease, the risk of cardiac surgery under cardiopulmonary bypass (CPB) must be balanced due to the high fetal loss. The video-assisted minimally invasive cardiac surgery (MICS) has been progressively applied and shows advantages in non-pregnant patients over the years. We present five cases of pregnant women who underwent a video-assisted minimally invasive surgical approach for cardiac surgery and the management strategies. In conclusion, the video-assisted MICS is feasible and safe to pregnant patients, with good maternal and fetal outcomes under the multidisciplinary assessment and management.

Cardiac Surgery in Women in the Current Era: What Are the Gaps in Care?

Cardiovascular disease remains the leading cause of morbidity and mortality for women in United States and worldwide. One in 3 women dies from cardiovascular disease, and 45% of women >20 years old have some form of CVD. Historically, women have had higher morbidity and mortality after cardiac surgery. Sex influences pathogenesis, pathophysiology, presentation, postoperative complications, surgical outcomes, and survival. This review summarizes current cardiovascular surgery outcomes as they pertain to women. Specifically, this article seeks to address whether sex disparities in research, surgical referral, and outcomes still exist and to provide strategies to close these gaps. In addition, with the growing population of women of reproductive age with cardiovascular disease and cardiovascular risk factors, indications for cardiac surgery arise in pregnant women. The current review will also address the unique issues associated with this special population.

Pregnancy-Associated Myocardial Infarction: A Review of Current Practices and Guidelines

PURPOSE OF REVIEW

Pregnancy-associated myocardial infarction is a principal cause of cardiovascular disease with a steadily rising incidence of 4.98 AMI events/100,000 deliveries over the last four decades in the USA. It is also linked with significant maternal and fetal morbidity and mortality, with maternal case fatality rate ranging from 5.1 to 37%. The management of acute myocardial infarction can be challenging in pregnant patients since treatment modalities and medication use are limited by their safety during pregnancy.

RECENT FINDINGS

Limited guidelines exist regarding the management of pregnancy-associated myocardial infarction. Routinely used medications in myocardial infarction including angiotensin-converting enzyme inhibitors (ACEI), angiotensin receptor blockers (ARB), and statin therapy are contraindicated during pregnancy. Aspirin use is considered safe in pregnant women, but dual antiplatelet therapy and therapeutic anticoagulation can be associated with increased risk of maternal and fetal complications, and should only be used after a comprehensive benefit-to-risk assessment. The standard approach to revascularization requires additional caution in pregnant women. Percutaneous coronary intervention is generally considered safe but can be associated with high failure rates and poor outcomes depending on the etiology. Fibrinolytic therapy may have significant sequelae in pregnant patients, and hemodynamic management during surgery is complex and adds risk during pregnancy. Understanding the risks and benefits of the different treatment modalities available and their utility depending on the underlying etiology, encompassed with a multidisciplinary team approach, is vital to improve outcomes and minimize maternal and fetal complications.

Valvular Heart Disease in Pregnancy

The number of reproductive age women with valvular heart disease is rising and accounts for one third of all heart disease among pregnant women. Severe, symptomatic left-sided cardiac lesions, particularly mitral and aortic stenosis, and mechanical heart valves, are associated with adverse maternal and fetal outcomes. Decreasing maternal and fetal risk requires shared decision-making among patients and the heart team, consisting of obstetricians, maternal-fetal medicine subspecialists, and cardiologists.

Pregnancy and cardiac interventions: What are the optimal management options?

Cardiac disease is the leading cause of maternal mortality in the United Kingdom. Major causes of cardiac death in pregnant women include cardiomyopathies, myocardial infarction, ischemic heart disease, and aortic dissection. Uncorrected congenital heart disease and women who have had corrective or palliative surgery may have complicated pregnancies as well. Some women with significant cardiac disease are unable to meet the increased physiological demands of pregnancy. Of these, those who do not respond to medical treatment may require surgical correction such as coronary artery bypass grafting. The risk of cardiac operations for pregnant women is similar to that for nonpregnant women but the fetal mortality rate remains high. Contributing factors to high fetal mortality rates include timing, urgency of operation, and the fetal/fetoplacental response to cardiopulmonary bypass. The aim of this review is to summarize current evidence in utilizing the different management approaches of cardiac issues during pregnancy.

Emergency Aortic Valve Replacement in a 12-Week Pregnant Patient

Urgent cardiac surgery was performed in a pregnant woman at 12 weeks of gestation for prosthetic valve thrombosis as result of noncompliance to anticoagulation. With this report we emphasize the importance of proper anticoagulation regimens and follow-up. (Level of Difficulty: Intermediate.)

A Dangerous Dilemma: Thrombus in Transit During Pregnancy

Pregnancy is associated with venous thromboembolism. Occasionally, thrombus can become entrapped across a patent foramen ovale, with risk of systemic embolism. This report presents a case of a pregnant woman who had thrombus in transit diagnosed by echocardiography, which was successfully removed by surgical thrombectomy. (Level of Difficulty: Intermediate.)

Peripartum Cardiomyopathy: Current Options for Treatment and Cardiovascular Support

Peripartum cardiomyopathy is a rare form of acute heart failure but the major cause of all deaths in pregnant patients with heart failure. Improved survival rates in recent years, however, emphasize the importance of early recognition and initiation of heart failure treatment. This article, therefore, attempts to raise awareness among cardiac and obstetric anesthesiologists as well as intensivists of this often fatal diagnosis. This review summarizes theories of the pathophysiology and outcome of peripartum cardiomyopathy. Based on the most recent literature, it further outlines diagnostic criteria and treatment options including medical management, mechanical circulatory support devices, and heart transplantation. Earlier recognition of this rare condition and a new generation of mechanical circulatory devices has contributed to the improved outcome. More frequently, patients in cardiogenic shock who fail medical management are successfully bridged to recovery on extracorporeal circulatory devices or survive with a long-lasting implantable ventricular assist device. The outcome of transplanted patients with peripartum cardiomyopathy, however, is worse compared to other recipients of heart transplants and warrants further investigation in the future.

State of the Art Management of Mechanical Heart Valves During Pregnancy

PURPOSE OF THE REVIEW

To review the management of women with mechanical heart valves during pregnancy, from preconception counseling through delivery with a summary of the latest guidelines.

RECENT FINDINGS

The hypercoagulability of pregnancy combined with the imperfect choices of anticoagulant agents contribute to a high risk of complications in pregnant women with mechanical heart valves. Valve thrombosis remains a major concern, much of which occurs during the first trimester transition to heparin-based products. The safest method of anticoagulation, with the best balance of maternal and fetal risk, is use of low-dose vitamin K antagonists, but only if therapeutic anticoagulation can be achieved with warfarin doses of ≤ 5 mg/day. Management of mechanical heart valves in pregnancy remains fraught with difficult decisions involving balancing of maternal and fetal risks as well as a high risk of maternal and fetal complications. Preconception counseling and planning is imperative. A risk-benefit discussion with the patient will help guide the choice of anticoagulation and outline the plan for safe delivery options. A multidisciplinary approach to management is advisable with close follow-up and care in a tertiary center.