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Ceuppens AS, De Meester P, Van De Bruaene A, Voigt JU, Van Calsteren K, Budts W, Troost E. Aorta pathology and pregnancy-related risks in adult congenital cardiac disease: does the aorta dilate during pregnancy? Obstet Med 2024; 17:41-46. [PMID: 38660320 PMCID: PMC11037198 DOI: 10.1177/1753495x231156851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 01/20/2023] [Indexed: 04/26/2024] Open
Abstract
Background Aortic dilatation and pregnancy are major concerns in women with aortopathy (AOP). This single-centre retrospective analysis focuses on the evolution of aortic diameters during and after pregnancy in women with Marfan syndrome (MS), Turner syndrome (TS) and bicuspid aortic valve (BAV) aortopathy. Methods and results Thirty-eight women who had one or more single pregnancies were included. The ascending aorta was measured during pregnancy and postpartum. During pregnancy, a significant increase of diameters of the sinus aortae (median 1.4 mm; [-1.3; 3.8]) and ascending aorta (median 2.1 mm; [0.0; 4.0]) was noted. Systemic hypertension gives dilation of the aorta, but it did not influence the overall trajectory during pregnancy. Conclusion Significant aortic dilatation is noted during pregnancy in women with underlying AOP, even persisting in the long term. Pre-existing systemic hypertension is associated with larger aortic diameters prior to pregnancy. More research on a larger study population however is needed.
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Affiliation(s)
| | - Pieter De Meester
- Congenital and Structural Cardiology, University Hospitals Leuven, Belgium
- Department of Cardiovascular Sciences, KU Leuven – University of Leuven, Belgium
| | - Alexander Van De Bruaene
- Congenital and Structural Cardiology, University Hospitals Leuven, Belgium
- Department of Cardiovascular Sciences, KU Leuven – University of Leuven, Belgium
| | - Jens-Uwe Voigt
- Department of Cardiovascular Sciences, KU Leuven – University of Leuven, Belgium
- Department of Cardiovascular Diseases, University Hospitals Leuven, Belgium
| | | | - Werner Budts
- Congenital and Structural Cardiology, University Hospitals Leuven, Belgium
- Department of Cardiovascular Sciences, KU Leuven – University of Leuven, Belgium
- Department of Cardiovascular Diseases, University Hospitals Leuven, Belgium
| | - Els Troost
- Congenital and Structural Cardiology, University Hospitals Leuven, Belgium
- Department of Cardiovascular Sciences, KU Leuven – University of Leuven, Belgium
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Galian-Gay L, Pijuan-Domenech A, Cantalapiedra-Romero J, Serrano B, Goya M, Maiz N, Casellas M, Manrique S, Suàrez-Edo E, Miranda-Barrio B, Gordon Ramirez B, Teixidó-Turà G, Gutierrez-Moreno L, González-Fernández V, Dux-Santoy L, Guala A, Evangelista A, Dos-Subirà L, Rodriguez-Palomares JF, Ferreira-Gonzalez I. Pregnancy-related aortic complications in women with bicuspid aortic valve. Heart 2023:heartjnl-2022-322328. [PMID: 37147129 DOI: 10.1136/heartjnl-2022-322328] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Accepted: 04/05/2023] [Indexed: 05/07/2023] Open
Abstract
OBJECTIVES To describe the aortic-related risks associated with pregnancy in women with bicuspid aortic valve (BAV) and to evaluate changes in aortic diameter in pregnancy. METHODS Prospective observational study of patients with BAV from a single-site registry of pregnant women with structural heart disease between 2013 and 2020. Cardiac, obstetric and neonatal outcomes were studied. An assessment of aortic dimensions was performed during pregnancy by two-dimensional echocardiography. Aortic diameters were measured at the annulus, root, sinotubular junction and maximum ascending aorta diameter, and the largest diameter was used. Measurements of the aorta were made using the end-diastolic leading edge-to-leading edge convention. RESULTS Forty-three women (32.9 years, IQR 29.6-35.3) with BAV were included: 9 (20.9%) had repaired aortic coarctation; 23 (53.5%) had moderate or severe aortic valve disease; 5 (11.6%) had a bioprosthetic aortic valve; and 2 (4.7%) had a mechanical prosthetic aortic valve. Twenty (47.0%) were nulliparous. The mean aortic diameter in the first trimester was 38.5 (SD 4.9) mm, and that in the third trimester was 38.4 (SD 4.8) mm. Forty (93.0%) women had an aortic diameter of <45 mm; 3 (7.0%) had 45-50 mm; and none had >50 mm. Three women (6.9%) with BAV presented cardiovascular complications during pregnancy or the postpartum period (two prosthetic thrombosis and one heart failure). No aortic complications were reported. There was a small but significant increase in aortic diameter during pregnancy (third trimester vs first trimester, 0.52 (SD 1.08) mm; p=0.03). Obstetric complications appeared in seven (16.3%) of pregnancies, and there were no maternal deaths. Vaginal non-instrumental delivery was performed in 21 (51.2%) out of 41 cases. There were no neonatal deaths, and the mean newborn weight was 3130 g (95% CI 2652 to 3380). CONCLUSIONS Pregnancy in BAV women had a low rate of cardiac complications with no aortic complications observed in a small study group. Neither aortic dissection nor need for aortic surgery was reported. A low but significant aortic growth was observed during pregnancy. Although requiring follow-up, the risk of aortic complications in pregnant women with BAV and aortic diameters of <45 mm at baseline is low.
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Affiliation(s)
- Laura Galian-Gay
- Department of Cardiology, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | | | - Javier Cantalapiedra-Romero
- Integrated Vall d'Hebron - Sant Pau Adult Congenital Heart Disease Unit, Department of Cardiology, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Berta Serrano
- Department of Obstetrics and Gynaecology, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Maria Goya
- Obstetrics, Maternal Fetal Medicine, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Nerea Maiz
- Department of Obstetrics and Gynaecology, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Manel Casellas
- Department of Obstetrics and Gynaecology, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Susana Manrique
- Department of Anesthesiology, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Elena Suàrez-Edo
- Department of Anesthesiology, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | | | - Blanca Gordon Ramirez
- Department of Cardiology, Hospital Universitari Vall d'Hebron, Barcelona, Spain
- Integrated Vall d'Hebron - Sant Pau Adult Congenital Heart Disease Unit, Department of Cardiology, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Gisela Teixidó-Turà
- Department of Cardiology, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | | | | | - Lydia Dux-Santoy
- Department of Cardiology, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Andrea Guala
- Department of Cardiology, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Arturo Evangelista
- Department of Cardiology, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Laura Dos-Subirà
- Adult Congenital Heart Disease Unit, Hospital Vall d'Hebron, Barcelona, Spain
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Wang X, Liu X, Liao E, Ge N, Hu Y. Pregnancy complicated with aortic dissection: Two cases report. Medicine (Baltimore) 2022; 101:e31487. [PMID: 36343070 PMCID: PMC9646651 DOI: 10.1097/md.0000000000031487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
RATIONALE This study aims to investigate the characteristics of pregnancy complicated with aortic dissection (AD), diagnosis and treatment plan, and maternal and infant outcomes. PATIENT CONCERNS Two pregnant women suffered persistent back pain were admitted to Hubei Maternal and Child Health Hospital from December 2019 to December 2020. DIAGNOSIS Pregnant women with chest and back pain and especially hypertension should be highly suspected of AD. However, to confirm diagnosis results, laboratory tests such as D-dimer, fibrinogen and white blood cells, and even some Special examination, cardiac ultrasound, computed tomographic angiography (CTA), magnetic resonance angiography (MRA), are required. Early diagnosis and intervention can improve maternal and infant outcomes. INTERVENTIONS Cesarean sections were performed in both patients. Case 1 underwent thoracic aortic stent implantation one day after the onset of AD symptoms. Case 2 received endovascular repair of AD 4 days after the onset of AD symptoms. OUTCOMES In these two cases, good maternal and infant outcomes were obtained through effective early identification and treatment. LESSONS AD is characterized with an acute onset, and the rates of misdiagnosis and missed diagnosis are high, which seriously endangers the life of mother and child. Hypertension is one of the high-risk factors causing AD. Good maternal and infant outcomes can be achieved by early identification, multidisciplinary collaboration and timely cardiac surgical intervention.
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Affiliation(s)
- Xiaoli Wang
- Department of Obstetrics, Maternal and Child Health Hospital of Hubei Province, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xi Liu
- Department of Obstetrics, Maternal and Child Health Hospital of Hubei Province, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - E. Liao
- Department of Obstetrics, Maternal and Child Health Hospital of Hubei Province, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ning Ge
- Radiology Department, Maternal and Child Health Hospital of Hubei Province, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yaping Hu
- Department of Obstetrics, Maternal and Child Health Hospital of Hubei Province, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- * Correspondence: Yaping Hu, Department of Obstetrics, Maternal and Child Health Hospital of Hubei Province, Tongji Medical College, Huazhong University of Science and Technology, No. 745, Wuluo Road, Hongshan District, Wuhan 430070, China (e-mail: )
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4
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Muacevic A, Adler JR, Flores R, Peplinski B, Murray J, Jones T, Reyes P. Ascending Aortic Aneurysm With Dissection in the Second Trimester of Pregnancy. Cureus 2022; 14:e31805. [PMID: 36579203 PMCID: PMC9788786 DOI: 10.7759/cureus.31805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/22/2022] [Indexed: 11/24/2022] Open
Abstract
Aortic aneurysm in pregnancy is uncommon. A dissecting aortic aneurysm in pregnancy is less common. If present, a dissecting aortic aneurysm can lead to poor outcomes for both the mother and the fetus, including death. Swift recognition of the signs and symptoms of a dissecting aortic aneurysm can prevent a delay in diagnosis and possibly improve maternal-fetal outcomes. The report discusses a case of a pregnant patient who experienced a dissecting aortic aneurysm in the second trimester despite having none of the commonly associated risk factors. The evaluation, diagnosis, and surgical management of dissecting aortic aneurysm in pregnancy are discussed.
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Ruben-Castillo C, Mier Y Teran-Ellis S, Anaya-Ayala JE, Contreras-Jimenez E, Lopez-Peña G, Luna L, Arzola LH, Silerio E, Guerrero-Hernández M, Hinojosa CA. Complex and Successful Management of a Symptomatic Isolated Abdominal Aortic Aneurysm in a Pregnant Woman with Marfan Syndrome. Vasc Endovascular Surg 2022; 56:529-534. [PMID: 35452326 DOI: 10.1177/15385744221087820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Aortopathies associated to Marfan syndrome (MFS) are important causes of maternal death during pregnancy. We present a 27-year-old and 24-week pregnant MFS woman who arrived to the emergency department with increasing abdominal pain; an obstetric ultrasound showed an Abdominal Aortic Aneurysm (AAA), a multislice computed tomography angiography (CTA) confirmed and demonstrated a 7.3 centimeter (cm) infrarenal AAA without evidence of dissection. A multidisciplinary committee determined that an open repair would lead to a significantly high maternal-fetal morbidity and mortality. Although endovascular repair (EVAR) in MFS patients remains controversial, an urgent bridge therapy was considered to be the best option. She was transferred to the angiography suite for EVAR to prevent AAA rupture and ensure a satisfactory pregnancy. The patient and fetus presented no complications during the procedure and were discharged 3 days later. She continued her pregnancy without eventualities and an elective C-section was performed on week 36. A CTA imaging at 12 months revealed type 1A and 3 endoleaks, we decided to perform endograft explant and a definitive open repair, there were no complications during the procedure, the patient is currently asymptomatic. Our case illustrates a complex decision and management that successfully avoid morbidity and mortality of a MFS mother and her product; additionally, this experience reinforces the need for lifelong and close surveillance in these patients.
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Affiliation(s)
- Christopher Ruben-Castillo
- Department of Surgery, Section of Vascular Surgery and Endovascular Therapy, 42559Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Santiago Mier Y Teran-Ellis
- Department of Surgery, Section of Vascular Surgery and Endovascular Therapy, 42559Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Javier E Anaya-Ayala
- Department of Surgery, Section of Vascular Surgery and Endovascular Therapy, 42559Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Emmanuel Contreras-Jimenez
- Department of Surgery, Section of Vascular Surgery and Endovascular Therapy, 42559Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Gabriel Lopez-Peña
- Department of Surgery, Section of Vascular Surgery and Endovascular Therapy, 42559Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Lizeth Luna
- Department of Surgery, Section of Vascular Surgery and Endovascular Therapy, 42559Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Luis H Arzola
- Department of Surgery, Section of Vascular Surgery and Endovascular Therapy, 42559Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Ernesto Silerio
- Department of Surgery, Section of Vascular Surgery and Endovascular Therapy, 42559Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Manuel Guerrero-Hernández
- Department of Radiology, Section of Interventional Radiology, 42559Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Carlos A Hinojosa
- Department of Surgery, Section of Vascular Surgery and Endovascular Therapy, 42559Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
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6
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Russo M, Boehler-Tatman M, Albright C, David C, Kennedy L, Roberts AW, Shalhub S, Afifi R. Aortic dissection in pregnancy and the postpartum period. Semin Vasc Surg 2022; 35:60-68. [PMID: 35501042 DOI: 10.1053/j.semvascsurg.2022.02.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 02/16/2022] [Accepted: 02/16/2022] [Indexed: 01/18/2023]
Abstract
Pregnancy-associated aortic dissection (AD) is a rare event, with an incidence of 0.0004% per pregnancy. The work of the Aortic Dissection Collaborative identified pregnancy-associated AD as a high-priority topic, despite its rarity. The Pregnancy Working Group, which included physicians and patient stakeholders, performed a systematic literature review of pregnancy-associated AD from 1960 to 2021 and identified 6,333 articles through PubMed, OVID MEDLINE, Cochrane, Embase, CINAHL and Web of Science. The inclusion criterion was AD in pregnant populations and exclusion criteria were case reports, conference abstracts, and languages other than English. Assessment of full-text articles for eligibility after removal of duplicates from all databases yielded 68 articles to be included in the final review. Topics included were timing of AD in pregnancy, type of AD, and management considerations of pregnancy-associated AD. The Pregnancy Working Group identified gaps in knowledge and future areas of research for pregnancy-associated AD, including clinical management, mental health outcomes post AD, reproductive and genetic counseling, and contraception after AD. Future collaborative projects could be a multicenter, international registry for all pregnancy-associated AD to refine the risk factors, best practice and management of AD in pregnancy. In addition, future mixed methodology studies may be useful to explore social, mental, and emotional factors related to pregnancy-associated AD and to determine support groups' effect on anxiety and depression related to these events in the pregnancy and postpartum period.
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Affiliation(s)
- Melissa Russo
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Women and Infants Hospital, Providence, Warren Alpert Medical School of Brown University, Providence, RI
| | | | - Catherine Albright
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Washington Medical Center, Seattle, WA
| | - Carmen David
- Aortic Dissection Collaborative Patient Stakeholder Group, Bedford, TX
| | | | - Aaron W Roberts
- Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School at The University of Texas Health Science Center, Houston, TX
| | - Sherene Shalhub
- Division of Vascular Surgery, Department of Surgery, University of Washington School of Medicine, Seattle, WA
| | - Rana Afifi
- Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), 6400 Fannin Street, Suite #2850, Houston, TX 77030.
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7
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Rajasekaran P, Gandhi P, Idhrees M, Velayudhan BV. Aortic complications in pregnancy: the less remembered chapter—a narrative review. EXPLORATION OF MEDICINE 2021. [DOI: 10.37349/emed.2021.00060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Pregnancy increases the risk of common vascular events and also the rarer events like aortic dissection (AD)/aortic rupture and this is even more pronounced in patients with predisposing aortopathies. AD was found to occur in 0.0004% of all pregnancies, and it is more pronounced in patients with underlying connective tissue disorders. The normal hemodynamic changes on a weak aorta will lead to AD and/or rupture, more so with increase in the period of gestation. Hence the haemodynamic and hormonal changes during pregnancy make pregnancy itself a risk factor for AD. It is advised that women with Marfan syndrome who are planning pregnancy should go through prophylactic aortic repair if the diameter of the ascending aorta exceeds 4 cm. Pre-pregnancy counselling is very important in these patients and must include complete history taking, including family history, physical examination and advanced aortic imaging. There is a general consensus among various authors advising against surgery during pregnancy in stable patients due to increased maternal and fetal morbidity but it is justified if the condition is refractory to medical management or in life threatening stage like acute AD. Though the incidence of aortopathy in pregnancy is rare, there is a high maternal and fetal mortality associated with this condition.
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Affiliation(s)
- Preetha Rajasekaran
- Department of Obstetrics and Gynaecology, Vihaa Hospitals, Anna Nagar, Chennai-600102, India
| | - Praveena Gandhi
- Department of Obstetrics and Gynaecology PPN Hospital, Palani-624601, India
| | - Mohammed Idhrees
- Institute of Cardiac and Aortic Diseases, SIMS hospital, Chennai-600026, India
| | - Bashi V. Velayudhan
- Institute of Cardiac and Aortic Diseases, SIMS hospital, Chennai-600026, India
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8
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Campens L, Baris L, Scott NS, Broberg CS, Bondue A, Jondeau G, Grewal J, Johnson MR, Hall R, De Backer J, Roos-Hesselink JW. Pregnancy outcome in thoracic aortic disease data from the Registry Of Pregnancy And Cardiac disease. Heart 2021; 107:1704-1709. [PMID: 33468574 PMCID: PMC8522458 DOI: 10.1136/heartjnl-2020-318183] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Revised: 12/15/2020] [Accepted: 12/15/2020] [Indexed: 12/29/2022] Open
Abstract
Background Cardiovascular disease is the leading cause of death during pregnancy with thoracic aortic dissection being one of the main causes. Thoracic aortic disease is commonly related to hereditary disorders and congenital heart malformations such as bicuspid aortic valve (BAV). Pregnancy is considered a high risk period in women with underlying aortopathy. Methods The ESC EORP Registry Of Pregnancy And Cardiac disease (ROPAC) is a prospective global registry that enrolled 5739 women with pre-existing cardiac disease. With this analysis, we aim to study the maternal and fetal outcome of pregnancy in women with thoracic aortic disease. Results Thoracic aortic disease was reported in 189 women (3.3%). Half of them were patients with Marfan syndrome (MFS), 26% had a BAV, 8% Turner syndrome, 2% vascular Ehlers-Danlos syndrome and 11% had no underlying genetic defect or associated congenital heart defect. Aortic dilatation was reported in 58% of patients and 6% had a history of aortic dissection. Four patients, of whom three were patients with MFS, had an acute aortic dissection (three type A and one type B aortic dissection) without maternal or fetal mortality. No complications occurred in women with a history of aortic dissection. There was no significant difference in median fetal birth weight if treated with a beta-blocker or not (2960 g (2358–3390 g) vs 3270 g (2750–3570 g), p value 0.25). Conclusion This ancillary analysis provides the largest prospective data review on pregnancy risk for patients with thoracic aortic disease. Overall pregnancy outcomes in women with thoracic aortic disease followed according to current guidelines are good.
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Affiliation(s)
- Laurence Campens
- Department of Cardiology, Ghent University Hospital, Gent, Belgium
| | - Lucia Baris
- Cardiology Department, Erasmus Medical Center, Rotterdam, Netherlands
| | - Nandita S Scott
- Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Craig S Broberg
- Adult Congenital Heart Disease Program. Knight Cardiovascular Institute, Oregon Health & Sciences University, Portland, Oregon, USA
| | - Antione Bondue
- Department of Cardiology, CUB Hôpital Erasme, Université Libre de Bruxelles, Bruxelles, Brussels, Belgium
| | - Guillaume Jondeau
- Department of Cardiology, CRMR Syndrome de Marfan et Apparentés, Bichat-Claude Bernard Hospital, Université de Paris, INSERM U1148, Paris, France
| | - Jasmine Grewal
- Division of Cardiology, University of British Columbia, Pacific Adult Congenital Heart Disease Clinic, St Paul's Hospital, Vancouver, British Columbia, Canada
| | - Mark R Johnson
- Department of Metabolism, Digestion and Reproduction, Imperial College London, Chelsea and Westminster Hospital, London, UK
| | - Roger Hall
- Department of Cardiology, University of East Anglia, Faculty of Medicine, Norwich Research Park, Norwich, Norfolk, UK
| | - Julie De Backer
- Department of Cardiology, Ghent University Hospital, Gent, Belgium.,Center for Medical Genetics, Ghent University Hospital, Ghent, Belgium
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Chin JM, Bartholomew ML. Aortic aneurysm and dissection in pregnancy: A case report. Case Rep Womens Health 2020; 28:e00261. [PMID: 33083238 PMCID: PMC7554023 DOI: 10.1016/j.crwh.2020.e00261] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Revised: 09/26/2020] [Accepted: 09/30/2020] [Indexed: 11/29/2022] Open
Abstract
We describe a 24-year-old pregnant woman at 34 weeks of gestation who presented to a community hospital with sharp chest pain radiating to her back. She was found to have a 6 cm ascending aortic aneurysm despite not having any established risk factors. She was transported by air ambulance to a tertiary-care hospital. She delivered a live female neonate via cesarean delivery. Her postpartum course was notable for multiple episodes of chest pain and multiple imaging studies that were read as negative for aortic dissection. Definitive valve surgery was postponed by the cardiothoracic surgeons to allow for recovery from severe preeclampsia, treatment of endometritis, and due to concerns for uterine bleeding while on anticoagulation during cardiopulmonary bypass. She was eventually transferred to another hospital in another state for valve-sparing surgery. During transport, she developed a pulmonary embolism, and after arrival an aortic dissection was confirmed. She received a mechanical aortic valve replacement and the aneurysm was repaired. She returned home and recovered without complication. A gene panel revealed a heterozygous pathogenic variant of the Filamin A gene. Aortic aneurysms during pregnancy are rare, and aortic dissections are more rare. We recommend expeditious surgical treatment, a heightened index of suspicion, and testing for a genetic cause of aneurysm when diagnosed in a pregnant or postpartum woman with no known risk factors. Aortic aneurysm in pregnancy is rare and mortality is high. Genetic testing should be performed with a new diagnosis of aortic aneurysm. Multidisciplinary care is essential for aortic aneurysm in pregnancy.
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Affiliation(s)
- Jennifer M Chin
- University of Hawaii, Department of Obstetrics, Gynecology, and Women's Health, 1319 Punahou St, Ste 824, Honolulu, HI 96826, USA
| | - Marguerite L Bartholomew
- University of Hawaii, Department of Obstetrics, Gynecology, and Women's Health, 1319 Punahou St, Ste 824, Honolulu, HI 96826, USA
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10
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Rimmer L, Heyward-Chaplin J, South M, Gouda M, Bashir M. Acute aortic dissection during pregnancy: Trials and tribulations. J Card Surg 2020; 36:1799-1805. [PMID: 32996191 DOI: 10.1111/jocs.15068] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 09/08/2020] [Accepted: 09/09/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND Type A acute aortic dissection (TAAD) during pregnancy is a life-threatening event for both the mother and the unborn baby. Pregnancy has been recognized as an independent risk factor for TAAD, postulated to be due to physiological changes that cause hyperdynamic circulation. This review seeks to outline the current controversies around this unique group. METHODS A comprehensive literature search was carried out across large databases to assimilate relevant papers regarding acute aortic dissection in pregnant women. RESULTS The presentation can be atypical in many cases and further concern from clinicians of fetal radiation exposure can result in missed or delayed diagnoses. Investigation via the quickest form of imaging, whether computed tomography, magnetic resonance imaging, or transesophageal echocardiography, should be carried out promptly due to the high risk of mortality. Surgical management of TAAD in pregnancy revolves primarily around the decision to deliver the fetus concomitantly or to perform the aortic repair with the fetus in utero. CONCLUSIONS Management of this group includes rapid and dynamic assessment without delay. From conception to postpartum, there are multiple stages in which to manage these women. Challenges in carrying out management in the form of operative techniques and cardiopulmonary bypass place the fetus at risk and must be approached with caution, particularly as there is little evidence-base for many of these decisions. Further research into reducing maternal and fetal mortality is necessary.
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Affiliation(s)
- Lara Rimmer
- Vascular Surgery Department, Blackburn Hospital, East Lancashire Hospitals NHS Trust, Blackburn, UK
| | - Jessica Heyward-Chaplin
- Vascular Surgery Department, Blackburn Hospital, East Lancashire Hospitals NHS Trust, Blackburn, UK
| | - Matthew South
- Vascular Surgery Department, Blackburn Hospital, East Lancashire Hospitals NHS Trust, Blackburn, UK
| | - Mohamed Gouda
- Department of Vascular and Endovascular Surgery, Mataria Teaching Hospital, Cairo, Egypt
| | - Mohamad Bashir
- Vascular Surgery Department, Blackburn Hospital, East Lancashire Hospitals NHS Trust, Blackburn, UK
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11
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Herrman NWC, Hatton C, Fung C. Postpartum aortic dissection diagnosed by point-of-care ultrasound in the emergency department: A case study. Australas Emerg Care 2020; 23:193-195. [PMID: 32546393 DOI: 10.1016/j.auec.2020.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 04/05/2020] [Accepted: 04/21/2020] [Indexed: 10/24/2022]
Abstract
Aortic dissection is a rare but clinically significant cause of chest pain in the emergency department (ED). While classic risk factors include advanced age, male sex, and tobacco use, pregnancy is also an independent and easily overlooked risk factor. Aortic dissection carries both high maternal and fetal morbidity and mortality. Point-of-care ultrasound is increasingly employed in the ED and has been shown to be useful in the evaluation of abdominal aortic pathologies. We present a case in which abdominal aortic ultrasound was utilized in the diagnosis of an acute Stanford type B aortic dissection in a recently postpartum patient.
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Affiliation(s)
| | - Colman Hatton
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Christopher Fung
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, USA
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12
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Abstract
Inherited thoracic aortopathies denote a group of congenital conditions that predispose to disease of the thoracic aorta. Aortic wall weakness and abnormal aortic hemodynamic profiles predispose these patients to dilatation of the thoracic aorta, which is generally silent but can precipitate aortic dissection or rupture with devastating and often fatal consequences. Current strategies to assess the future risk of aortic dissection or rupture are based primarily on monitoring aortic diameter. However, diameter alone is a poor predictor of risk, with many patients experiencing dissection or rupture below current intervention thresholds. Developing tools that improve the risk assessment of those with aortopathy is internationally regarded as a research priority. A robust understanding of the molecular pathways that lead to aortic wall weakness is required to identify biomarkers and therapeutic targets that could improve patient management. Here, we summarize the current understanding of the genetically determined mechanisms underlying inherited aortopathies and critically appraise the available blood biomarkers, imaging techniques, and therapeutic targets that have shown promise for improving the management of patients with these important and potentially fatal conditions.
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Affiliation(s)
- Alexander J. Fletcher
- University of Edinburgh Centre for Cardiovascular Science, Royal Infirmary of Edinburgh, United Kingdom (A.J.F., M.B.J.S., D.E.N., N.L.W.)
| | - Maaz B.J. Syed
- University of Edinburgh Centre for Cardiovascular Science, Royal Infirmary of Edinburgh, United Kingdom (A.J.F., M.B.J.S., D.E.N., N.L.W.)
| | - Timothy J. Aitman
- Centre for Genomics and Experimental Medicine, MRC Institute of Genetics and Molecular Medicine, University of Edinburgh, United Kingdom (T.J.A.)
| | - David E. Newby
- University of Edinburgh Centre for Cardiovascular Science, Royal Infirmary of Edinburgh, United Kingdom (A.J.F., M.B.J.S., D.E.N., N.L.W.)
| | - Niki L. Walker
- University of Edinburgh Centre for Cardiovascular Science, Royal Infirmary of Edinburgh, United Kingdom (A.J.F., M.B.J.S., D.E.N., N.L.W.)
- Scottish Adult Congenital Heart Disease Service, Golden Jubilee National Hospital, Clydebank, Glasgow, United Kingdom (N.L.W.)
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Marfan Syndrome Versus Bicuspid Aortic Valve Disease: Comparative Analysis of Obstetric Outcome and Pregnancy-Associated Immediate and Long-Term Aortic Complications. J Clin Med 2020; 9:jcm9041124. [PMID: 32326432 PMCID: PMC7230569 DOI: 10.3390/jcm9041124] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 04/10/2020] [Accepted: 04/11/2020] [Indexed: 12/19/2022] Open
Abstract
Pregnancy poses a threat to women with aortopathy. Conclusive data on the obstetric and aortic outcome in this risk collective, especially when it comes to aortic complications in the long term, are still missing. This study offers a comparative analysis of pregnancy-associated outcome in 113 consecutive women with Marfan syndrome or bicuspid aortic valve disease, including 46 ever-pregnant and 37 never-pregnant women with Marfan syndrome, and 23 ever-pregnant and 7 never-pregnant females with bicuspid aortic valve disease. The overall obstetric outcome was comparable between ever-pregnant women with Marfan syndrome and with bicuspid aortic valve disease (p = 0.112). Pregnancy-associated aortic dissection occurred in two women with Marfan syndrome (3%) during a total of 62 completed pregnancies, whereas no single case of aortic event occurred in women with bicuspid aortic valve disease during a total of 36 completed pregnancies (p = 0.530). In the long-term follow-up, aortic dissection occurred in 21% of ever-pregnant women with Marfan syndrome, but in none of the women with bicuspid aortic valve disease (p = 0.022). Proximal aortic surgery was performed with similar frequency in ever-pregnant women with Marfan syndrome and with bicuspid aortic valve disease in the long term (p = 0.252). However, ever-pregnant women with Marfan syndrome were younger when surgery was performed (44 ± 9 vs. 59 ± 7 years; p = 0.041). In Marfan syndrome, long-term growth of the aorta was comparable between ever-pregnant and never-pregnant women. Pregnancy thus exhibited an increased immediate aortic risk only in women with Marfan syndrome, but not in women with bicuspid aortic valve disease. Previous pregnancy did not relate to an increased long-term risk of adverse aortic events in women with Marfan syndrome or with bicuspid aortic valve disease.
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Clift PF, Cervi E. A review of thoracic aortic aneurysm disease. Echo Res Pract 2020; 7:R1-R10. [PMID: 32015897 PMCID: PMC6993256 DOI: 10.1530/erp-19-0049] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Accepted: 12/05/2019] [Indexed: 01/10/2023] Open
Abstract
Aortic diseases may be diagnosed after a long period of subclinical development or they may have an acute presentation. Acute aortic syndrome is often the first sign of the disease, which needs rapid diagnosis and decision making to reduce the extremely poor prognosis. Aortic dilatation is a well-recognised risk factor for acute events and can occur as a result of trauma, infection, or, most commonly, from an intrinsic abnormality in the elastin and collagen components of the aortic wall. Over the years it has become clear that a few monogenic syndromes are strongly associated with aneurysms and often dictate a severe presentation in younger patients while the vast majority have a multifactorial pathogenesis. Conventional cardiovascular risk factors and ageing play an important role. Management strategy is based on prevention consisting of regular follow-up with cross-sectional imaging, chemoprophylaxis of further dilatation with drugs proved to slow down the disease progression and preventative surgery when dimension exceeds internationally recognised cut-off values for aortic diameters and the risk of rupture/dissection is therefore deemed very high.
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Affiliation(s)
- Paul F Clift
- Department of Cardiology, University Hospital Birmingham, Birmingham, UK
| | - Elena Cervi
- Department of Cardiology, Great Ormond St Hospital, London, UK
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15
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Obstetric anesthesia management of the patient with cardiac disease. Int J Obstet Anesth 2019; 37:73-85. [DOI: 10.1016/j.ijoa.2018.09.011] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Revised: 09/09/2018] [Accepted: 09/19/2018] [Indexed: 02/06/2023]
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16
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Pourafkari L, Ghaffari S, Ahmadi M, Salehi R, Mazani S, Parizad R, Nader ND. Does multi-parity affect the size of the ascending thoracic aorta in women: a prospective cohort study. Curr Med Res Opin 2018; 34:1907-1912. [PMID: 29546781 DOI: 10.1080/03007995.2018.1451314] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
OBJECTIVE Aortic dissection is an uncommon and potentially fatal complication of pregnancy; however, the association of the number of pregnancies with the indexed and absolute size of the ascending aorta in patients without aortic aneurysm or connective tissue disorders is not well elucidated. RESEARCH DESIGN AND METHODS In this prospective observational study, women aged 18-80 years old undergoing transesophageal echocardiography in a university-affiliated echocardiography laboratory between 1 January 2015 and 1 September 2015 were enrolled. Indexed and absolute sizes of ascending aorta at the levels of annulus, root, sinotubular junction (STJ), proximal and arch were measured. Patients were grouped according to their gravida number into three classes (class I: ≤3, class II: 4-7, class III: ≥7). RESULTS Of 653 screened patients, 437 women were included (38.9% gravida class I, 44.3% gravida class II and 16.7% gravida class III). In univariate analysis, the number of pregnancies correlated with indexed diameters of the root (p < .001), STJ (p < .001) and the proximal ascending aorta (p < .001). Meanwhile, the number of pregnancies neither correlated with the annular diameter nor with the arch (p = .070 and p = .154, respectively). In multivariate analyses, the gravida class was among the independent predictors of the root size along with age, aortic insufficiency and the presence of congestive heart failure. CONCLUSION Gravida class was an independent predictor of aortic size at levels of the root, STJ and the proximal ascending aorta. The largest increase was observed at the level of the aortic root.
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Affiliation(s)
- Leili Pourafkari
- a Cardiovascular Research Center , Tabriz University of Medical Sciences , Tabriz , Iran
- b Department of Anesthesiology , University at Buffalo , Buffalo , NY , USA
| | - Samad Ghaffari
- a Cardiovascular Research Center , Tabriz University of Medical Sciences , Tabriz , Iran
| | - Mojan Ahmadi
- a Cardiovascular Research Center , Tabriz University of Medical Sciences , Tabriz , Iran
| | - Rezvaniye Salehi
- a Cardiovascular Research Center , Tabriz University of Medical Sciences , Tabriz , Iran
| | - Sarvin Mazani
- a Cardiovascular Research Center , Tabriz University of Medical Sciences , Tabriz , Iran
| | - Raziyeh Parizad
- a Cardiovascular Research Center , Tabriz University of Medical Sciences , Tabriz , Iran
| | - Nader D Nader
- b Department of Anesthesiology , University at Buffalo , Buffalo , NY , USA
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Keepanasseril A, Thendral N, Dorairajan G, Subbaih M, Pillai AA, Sai Chandran BV. Management of aortic aneurysm presenting during pregnancy: A case report. Obstet Med 2018; 13:37-40. [PMID: 32284731 DOI: 10.1177/1753495x18782627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Accepted: 05/18/2018] [Indexed: 11/15/2022] Open
Abstract
Aortic aneurysm in pregnancy is associated with higher risk of complications due to the stress induced by the physiologic changes in pregnancy. Many of the reports are concentrated on those with catastrophic outcomes or who underwent surgical repair during pregnancy/puerperium. We report a case of aortic aneurysm, who presented during the second trimester and had a successful pregnancy outcome, and discuss the various issues concerning the management during pregnancy.
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Affiliation(s)
- Anish Keepanasseril
- Department of Obstetrics & Gynaecology, Jawaharlal Institute of Post-graduate Medical Education & Research (JIPMER), Puducherry, India
| | - N Thendral
- Department of Obstetrics & Gynaecology, Jawaharlal Institute of Post-graduate Medical Education & Research (JIPMER), Puducherry, India
| | - Gowri Dorairajan
- Department of Obstetrics & Gynaecology, Jawaharlal Institute of Post-graduate Medical Education & Research (JIPMER), Puducherry, India
| | - Murali Subbaih
- Department of Obstetrics & Gynaecology, Jawaharlal Institute of Post-graduate Medical Education & Research (JIPMER), Puducherry, India
| | - Ajith Ananthakrishna Pillai
- Department of Cardiology, Jawaharlal Institute of Post-graduate Medical Education & Research (JIPMER), Puducherry, India
| | - B V Sai Chandran
- Department of Cardio-Thoracic & Vascular Surgery, Jawaharlal Institute of Post-graduate Medical Education & Research (JIPMER), Puducherry, India
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18
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Algeri P, Vergani P, Casati A, Achilli F. Thoracic aortic aneurism repair, during pregnancy, diagnosed thanks to heart examination at first antenatal visit, is a maternal and fetal safe option. Eur J Obstet Gynecol Reprod Biol 2018; 222:191-193. [PMID: 29398073 DOI: 10.1016/j.ejogrb.2018.01.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Revised: 01/16/2018] [Accepted: 01/17/2018] [Indexed: 11/30/2022]
Affiliation(s)
- P Algeri
- Department of Obstetrics and Gynecology, Foundation MBBM, University of Milano-Bicocca, Via Pergolesi 33, Monza, Monza e Brianza 20900, Italy; Cardiovascular Department, San Gerardo Hospital, Monza, Italy.
| | - P Vergani
- Department of Obstetrics and Gynecology, Foundation MBBM, University of Milano-Bicocca, Via Pergolesi 33, Monza, Monza e Brianza 20900, Italy; Cardiovascular Department, San Gerardo Hospital, Monza, Italy
| | - A Casati
- Department of Obstetrics and Gynecology, Foundation MBBM, University of Milano-Bicocca, Via Pergolesi 33, Monza, Monza e Brianza 20900, Italy; Cardiovascular Department, San Gerardo Hospital, Monza, Italy
| | - F Achilli
- Department of Obstetrics and Gynecology, Foundation MBBM, University of Milano-Bicocca, Via Pergolesi 33, Monza, Monza e Brianza 20900, Italy; Cardiovascular Department, San Gerardo Hospital, Monza, Italy
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19
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Villard C, Hultgren R. Abdominal aortic aneurysm: Sex differences. Maturitas 2017; 109:63-69. [PMID: 29452784 DOI: 10.1016/j.maturitas.2017.12.012] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2017] [Revised: 12/11/2017] [Accepted: 12/12/2017] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Abdominal aortic aneurysm (AAA) predominantly affects an elderly male population. Even so, AAA appears more detrimental in women, who experience a higher risk of aneurysm rupture and a worse outcome after surgery than men. Why women are privileged from yet are worse off once affected has been attributed to an effect of sex hormones. This review summarizes the knowledge of sex differences in AAA and addresses the changes in the aneurysm wall from a gender perspective. METHOD Standard reporting guidelines set by the PRISMA Group were followed to identify studies examining AAA from a gender perspective. Relevant reports were identified using two electronic databases: PubMed and Web of Science. The systematic search was performed in two stages: firstly, using the terms AAA and gender/sex/women; and secondly, adding the terms "elastin", "collagen" and "vascular smooth muscle cells", in order to filter the search for studies relevant to our focus on the aneurysm wall. CONCLUSION Current studies support the theory that sex has an effect on aneurysm formation, yet are inconclusive about whether or not aneurysm formation is dependent on female/male sex hormones or a lack thereof. The studies in women are scarce and out of those most reports primarily address other end-points, which limit their ability to illuminate an effect of sex on aneurysm formation. The complexity of the human menstrual cycle and menopausal transition are difficult to mimic in animal models, which limit their applicability to AAA formation in humans.
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Affiliation(s)
- Christina Villard
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.
| | - Rebecka Hultgren
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Department of Vascular Surgery, Karolinska University Hospital, Stockholm, Sweden
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Abstract
OBJECTIVE To describe the demographic characteristics of women in Illinois who died from cardiovascular disease during pregnancy or up until 1 year postpartum, addressing specific etiologies, timing of death, proportion of potentially preventable mortality, and factors associated with preventability. METHODS This is a retrospective analysis from the Illinois Department of Public Health Maternal Mortality Review process using International Classification of Diseases, 9th Revision codes that attributed cardiovascular disease as the immediate or underlying cause of maternal death in Illinois from 2002 to 2011. We categorized the etiology of cardiovascular mortality, analyzed demographic factors associated with cardiovascular mortality in comparison with noncardiovascular causes, defined the relationship to pregnancy, and identified factors associated with preventability. RESULTS There were 636 deaths in Illinois from 2002 to 2011 of pregnant women or within 1 year postpartum. One hundred forty women (22.2%) died of cardiovascular causes, for a cardiovascular mortality rate of 8.2 (95% confidence interval 6.9-9.6) per 100,000 live births. Women with cardiovascular mortality were likely to be older and die postpartum. The most common etiologies were related to acquired cardiovascular disease (97.1%) as compared with congenital heart disease (2.9%). Cardiomyopathy was the most common etiology (n=39 [27.9%]), followed by stroke (n=32 [22.9%]), hypertensive disorders (n=18 [12.9%]), arrhythmias (n=15 [10.7%]), and coronary disease (n=13 [9.3%]). Nearly 75% of cardiac deaths were related to pregnancy as compared with 35.3% of noncardiac deaths. More than one fourth of cardiac deaths (28.1%) were potentially preventable, attributable primarily to health care provider and patient factors. CONCLUSION From 2002 to 2011, more than one fifth of maternal deaths in Illinois were attributed to cardiovascular disease such as cardiomyopathy. More than one fourth of these deaths were potentially preventable. Health care provider and patient factors were identified, which may be modifiable through education and intensive postpartum monitoring, which may diminish mortality. State maternal mortality reviews can identify opportunities for reducing maternal deaths.
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21
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Bianca I, Geraci G, Gulizia MM, Egidy Assenza G, Barone C, Campisi M, Alaimo A, Adorisio R, Comoglio F, Favilli S, Agnoletti G, Carmina MG, Chessa M, Sarubbi B, Mongiovì M, Russo MG, Bianca S, Canzone G, Bonvicini M, Viora E, Poli M. Consensus Document of the Italian Association of Hospital Cardiologists (ANMCO), Italian Society of Pediatric Cardiology (SICP), and Italian Society of Gynaecologists and Obstetrics (SIGO): pregnancy and congenital heart diseases. Eur Heart J Suppl 2017; 19:D256-D292. [PMID: 28751846 PMCID: PMC5526477 DOI: 10.1093/eurheartj/sux032] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
The success of cardiac surgery over the past 50 years has increased numbers and median age of survivors with congenital heart disease (CHD). Adults now represent two-thirds of patients with CHD; in the USA alone the number is estimated to exceed 1 million. In this population, many affected women reach reproductive age and wish to have children. While in many CHD patients pregnancy can be accomplished successfully, some special situations with complex anatomy, iatrogenic or residual pathology are associated with an increased risk of severe maternal and fetal complications. Pre-conception counselling allows women to come to truly informed choices. Risk stratification tools can also help high-risk women to eventually renounce to pregnancy and to adopt safe contraception options. Once pregnant, women identified as intermediate or high risk should receive multidisciplinary care involving a cardiologist, an obstetrician and an anesthesiologist with specific expertise in managing this peculiar medical challenge. This document is intended to provide cardiologists working in hospitals where an Obstetrics and Gynecology Department is available with a streamlined and practical tool, useful for them to select the best management strategies to deal with a woman affected by CHD who desires to plan pregnancy or is already pregnant.
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Affiliation(s)
- Innocenzo Bianca
- Pediatric Cardiology Unit, Maternity and Neonatal Department, ARNAS Garibaldi, Catania, Italy
| | - Giovanna Geraci
- Cardiology Department, PO Cervello, Az. Osp. Riuniti Villa Sofia-Cervello, Via Trabucco, 180, 90146 Palermo, Italy
| | - Michele Massimo Gulizia
- Cardiology Department, Ospedale Garibaldi-Nesima, Azienda di Rilievo Nazionale e Alta Specializzazione ‘Garibaldi’, Catania, Italy
| | - Gabriele Egidy Assenza
- Pediatric Cardiology and Adult Congenital Heart Program, Azienda Ospedaliera-Universitaria Sant’Orsola-Malpighi, Bologna, Itlay
| | - Chiara Barone
- Genetics Unit, Maternity and Neonatal Department, ARNAS Garibaldi, Catania, Italy
| | - Marcello Campisi
- Pediatric Cardiology Unit, Maternity and Neonatal Department, ARNAS Garibaldi, Catania, Italy
| | - Annalisa Alaimo
- Pediatric Cardiology Department, PO Di Cristina, ARNAS Civico, Palermo, Italy
| | - Rachele Adorisio
- Pediatric Cardiology Department, Ospedale Pediatrico Bambino Gesù, Roma, Italy
| | - Francesca Comoglio
- SCDU 2, Dipartimento di Scienze Chirurgiche (Surgical Sciences Department), Università di Torino, Italy
| | - Silvia Favilli
- Pediatric Cardiology Department, Azienda-Ospedalliero-Universitaria Meyer, Firenze, Italy
| | - Gabriella Agnoletti
- Pediatric Cardiology Department, Ospedale Regina Margherita, Città della Salute e della Scienza, Torino, Italy
| | - Maria Gabriella Carmina
- Cardiology Department, PO Cervello, Az. Osp. Riuniti Villa Sofia-Cervello, Via Trabucco, 180, 90146 Palermo, Italy
| | - Massimo Chessa
- Pediatric and Adult Congenital Heart Centre, IRCCS-Policlinico San Donato Milanese San Donato Milanese (MI), Italy
| | - Berardo Sarubbi
- Pediatric Cardiology and Cardiology SUN, Seconda Università di Napoli, AORN dei Colli, Ospedale Monaldi, Napoli, Italy
| | - Maurizio Mongiovì
- Pediatric Cardiology Department, PO Di Cristina, ARNAS Civico, Palermo, Italy
| | - Maria Giovanna Russo
- Pediatric Cardiology and Cardiology SUN, Seconda Università di Napoli, AORN dei Colli, Ospedale Monaldi, Napoli, Italy
| | - Sebastiano Bianca
- Genetics Unit, Maternity and Neonatal Department, ARNAS Garibaldi, Catania, Italy
| | - Giuseppe Canzone
- Women and Children Health Department, Ospedale S. Cimino, Termini Imerese (PA), Italy
| | - Marco Bonvicini
- Pediatric Cardiology and Adult Congenital Heart Program, Azienda Ospedaliera-Universitaria Sant’Orsola-Malpighi, Bologna, Itlay
| | - Elsa Viora
- Echography and Prenatal Diagnosis Centre, Obstetrics and Gynaecology Department, Città della Salute e della Scienza di Torino, Italy
| | - Marco Poli
- Intensive Cardiac Therapy Department, Ospedale Sandro Pertini, Roma, Italy
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Smith K, Gros B. Pregnancy-related acute aortic dissection in Marfan syndrome: A review of the literature. CONGENIT HEART DIS 2017; 12:251-260. [PMID: 28371362 DOI: 10.1111/chd.12465] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Revised: 03/08/2017] [Accepted: 03/10/2017] [Indexed: 11/25/2022]
Abstract
A well-established association exists between acute aortic dissection and pregnancy, particularly in women with Marfan syndrome. However, there is debate regarding appropriate management guidelines. In particular, there are differing opinions regarding when prophylactic aortic root repair should be recommended as well as the efficacy of beta blockers in this clinical scenario. The current study evaluated 10 years of published literature (2005-2015) in the PubMed/Medline database. Fifty articles, describing 72 cases of women who presented with aortic dissection in the antepartum or postpartum period were identified. Comparisons on demographic variables and clinical outcomes between cases of women with Marfan syndrome (n = 36) and without Marfan syndrome (n = 36) were conducted. There were no significant differences in demographics (age, gravidity, parity) between the Marfan and non-Marfan cases. Marfan patients presented with antepartum dissections significantly earlier in pregnancy than those without Marfan syndrome (P = .002). However, there were no significant difference between the 2 groups in maternal mortality, fetal mortality, or obstetric outcomes (mode of delivery and gestational age at delivery). Eight cases described events in Marfan women with an aortic root diameter ≤40 mm. Six events occurred in Marfan women who were managed with beta blockers. Current guidelines rely on aortic root diameter for stratification of Marfan women into risk categories, but we identified several cases that would be missed by these guidelines. Specifically, the existing literature suggest that women with Marfan syndrome should take precautions throughout pregnancy, rather than the third trimester.
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Affiliation(s)
| | - Bernard Gros
- University of Central Florida College of Medicine
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23
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De Backer J, Muiño-Mosquera L, Demulier L. Aortopathy. PREGNANCY AND CONGENITAL HEART DISEASE 2017. [DOI: 10.1007/978-3-319-38913-4_12] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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24
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Yalçın M, Ürkmez M, Tayfur KD, Yazman S. Postpartum aortic dissection in a patient without Marfan's syndrome. Turk J Obstet Gynecol 2016; 13:212-214. [PMID: 28913124 PMCID: PMC5558295 DOI: 10.4274/tjod.35336] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Accepted: 11/06/2016] [Indexed: 12/01/2022] Open
Abstract
Aortic dissection can occur in pregnancy or during the postpartum period without pre-existing disease and it is a rare but potentially life-threatening event. Herein, we present a young woman without Marfan’s syndrome who developed a postpartum ascending aortic dissection 5 days after cesarean section.
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Affiliation(s)
- Mihriban Yalçın
- Ordu State Hospital, Clinic of Cardiovascular Surgery, Ordu, Turkey
| | - Melih Ürkmez
- Ordu State Hospital, Clinic of Cardiovascular Surgery, Ordu, Turkey
| | | | - Serkan Yazman
- Ordu State Hospital, Clinic of Cardiovascular Surgery, Ordu, Turkey
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25
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Lansman SL, Goldberg JB, Kai M, Tang GHL, Malekan R, Spielvogel D. Aortic surgery in pregnancy. J Thorac Cardiovasc Surg 2016; 153:S44-S48. [PMID: 27431443 DOI: 10.1016/j.jtcvs.2016.06.015] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2016] [Revised: 05/05/2016] [Accepted: 06/11/2016] [Indexed: 02/03/2023]
Abstract
Pregnancy engenders changes in hemodynamics and the aortic wall that make a woman more susceptible to aortic dilatation and dissection. This is particularly true of women with aortic dilatation and an aortopathy, including the inherited fibrillinopathies, bicuspid aortic valve, and Turner syndrome. Women in these risk groups may be served best by undergoing elective aortic surgery before becoming pregnant. However, some women present during pregnancy with significant aortic dilatation, rapid expansion, or aortic dissection, and strategies to deal with these situations, while optimizing maternal and fetal outcomes, change as gestation progresses. This review summarizes the approaches to the management of aortic diseases and the conduct of aortic surgery in pregnancy.
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Affiliation(s)
- Steven L Lansman
- Westchester Medical Center, Valhalla, NY; Department of Surgery, Section of Cardiothoracic Surgery, New York Medical College, Valhalla, NY.
| | - Joshua B Goldberg
- Westchester Medical Center, Valhalla, NY; Department of Surgery, Section of Cardiothoracic Surgery, New York Medical College, Valhalla, NY
| | - Masashi Kai
- Westchester Medical Center, Valhalla, NY; Department of Surgery, Section of Cardiothoracic Surgery, New York Medical College, Valhalla, NY
| | - Gilbert H L Tang
- Westchester Medical Center, Valhalla, NY; Department of Surgery, Section of Cardiothoracic Surgery, New York Medical College, Valhalla, NY
| | - Ramin Malekan
- Westchester Medical Center, Valhalla, NY; Department of Surgery, Section of Cardiothoracic Surgery, New York Medical College, Valhalla, NY
| | - David Spielvogel
- Westchester Medical Center, Valhalla, NY; Department of Surgery, Section of Cardiothoracic Surgery, New York Medical College, Valhalla, NY
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26
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Ji J, Posenau JT, Lindley KJ, Braverman AC. Dissecting the Dilemma: Uncontrolled Hypertension in a Pregnant Patient. Am J Med 2016; 129:e1-3. [PMID: 26551983 DOI: 10.1016/j.amjmed.2015.09.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2015] [Accepted: 09/16/2015] [Indexed: 11/25/2022]
Affiliation(s)
- Joyce Ji
- Department of Internal Medicine, Washington University School of Medicine, St. Louis, Mo.
| | - J Trevor Posenau
- Department of Internal Medicine, Washington University School of Medicine, St. Louis, Mo; Cardiovascular Division, Washington University School of Medicine, St. Louis, Mo
| | - Kathryn J Lindley
- Department of Internal Medicine, Washington University School of Medicine, St. Louis, Mo; Cardiovascular Division, Washington University School of Medicine, St. Louis, Mo
| | - Alan C Braverman
- Department of Internal Medicine, Washington University School of Medicine, St. Louis, Mo; Cardiovascular Division, Washington University School of Medicine, St. Louis, Mo
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27
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Ahluwalia M, Parmacek MS, Sayani FA, Vallabhajosyula P. Nearly Missed: Postpartum Type B Aortic Dissection. Am J Med 2015; 128:1188-90. [PMID: 26264721 DOI: 10.1016/j.amjmed.2015.07.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2015] [Revised: 07/30/2015] [Accepted: 07/30/2015] [Indexed: 11/30/2022]
Affiliation(s)
- Monica Ahluwalia
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia.
| | - Michael S Parmacek
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Farzana A Sayani
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Prashanth Vallabhajosyula
- Department of Cardiovascular Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia
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28
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Du Pré BC, Van Laake LW, Velthuis BK, de Waal EEC, Buijsrogge MP, Hassink RJ. An exceptionally large coronary artery aneurysm in a formerly healthy young woman. Neth Heart J 2015; 23:609-10. [PMID: 26449243 PMCID: PMC4651965 DOI: 10.1007/s12471-015-0756-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- B C Du Pré
- Department of Cardiology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.,Department of Medical Physiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - L W Van Laake
- Department of Cardiology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - B K Velthuis
- Department of Radiology, University Medical Center, Utrecht, The Netherlands
| | - E E C de Waal
- Department of Anesthesiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - M P Buijsrogge
- Department of Cardiothoracic Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - R J Hassink
- Department of Cardiology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.
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29
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Reinhold SM, Lima B, Khalid A, Gonzalez-Stawinski GV, Stoler RC, Hall SA, Chamogeorgakis T. Heart transplantation in the Ehlers-Danlos syndrome. Proc AMIA Symp 2015; 28:492-3. [PMID: 26424951 PMCID: PMC4569234 DOI: 10.1080/08998280.2015.11929319] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
We describe a woman with Ehlers-Danlos syndrome and aortic aneurysm who experienced a myocardial infarction due to spontaneous left circumflex coronary artery dissection 3 weeks postpartum. She developed end-stage heart failure and subsequently underwent a successful orthotopic heart transplantation. To our knowledge, this is the first report of a heart transplant performed in an individual with Ehlers-Danlos syndrome.
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Affiliation(s)
- Stephanie M Reinhold
- Texas A&M Health Science Center College of Medicine (Reinhold); the Division of Cardiology (Khalid, Stoler, Hall) and the Department of Cardiovascular and Thoracic Surgery (Lima, Gonzalez-Stawinski, Chamogeorgakis), Baylor University Medical Center at Dallas and the Baylor Hamilton Heart and Vascular Hospital, Dallas, Texas
| | - Brian Lima
- Texas A&M Health Science Center College of Medicine (Reinhold); the Division of Cardiology (Khalid, Stoler, Hall) and the Department of Cardiovascular and Thoracic Surgery (Lima, Gonzalez-Stawinski, Chamogeorgakis), Baylor University Medical Center at Dallas and the Baylor Hamilton Heart and Vascular Hospital, Dallas, Texas
| | - Adnan Khalid
- Texas A&M Health Science Center College of Medicine (Reinhold); the Division of Cardiology (Khalid, Stoler, Hall) and the Department of Cardiovascular and Thoracic Surgery (Lima, Gonzalez-Stawinski, Chamogeorgakis), Baylor University Medical Center at Dallas and the Baylor Hamilton Heart and Vascular Hospital, Dallas, Texas
| | - Gonzalo V Gonzalez-Stawinski
- Texas A&M Health Science Center College of Medicine (Reinhold); the Division of Cardiology (Khalid, Stoler, Hall) and the Department of Cardiovascular and Thoracic Surgery (Lima, Gonzalez-Stawinski, Chamogeorgakis), Baylor University Medical Center at Dallas and the Baylor Hamilton Heart and Vascular Hospital, Dallas, Texas
| | - Robert C Stoler
- Texas A&M Health Science Center College of Medicine (Reinhold); the Division of Cardiology (Khalid, Stoler, Hall) and the Department of Cardiovascular and Thoracic Surgery (Lima, Gonzalez-Stawinski, Chamogeorgakis), Baylor University Medical Center at Dallas and the Baylor Hamilton Heart and Vascular Hospital, Dallas, Texas
| | - Shelley A Hall
- Texas A&M Health Science Center College of Medicine (Reinhold); the Division of Cardiology (Khalid, Stoler, Hall) and the Department of Cardiovascular and Thoracic Surgery (Lima, Gonzalez-Stawinski, Chamogeorgakis), Baylor University Medical Center at Dallas and the Baylor Hamilton Heart and Vascular Hospital, Dallas, Texas
| | - Themistokles Chamogeorgakis
- Texas A&M Health Science Center College of Medicine (Reinhold); the Division of Cardiology (Khalid, Stoler, Hall) and the Department of Cardiovascular and Thoracic Surgery (Lima, Gonzalez-Stawinski, Chamogeorgakis), Baylor University Medical Center at Dallas and the Baylor Hamilton Heart and Vascular Hospital, Dallas, Texas
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30
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Crawford JD, Hsieh CM, Schenning RC, Slater MS, Landry GJ, Moneta GL, Mitchell EL. Genetics, Pregnancy, and Aortic Degeneration. Ann Vasc Surg 2015; 30:158.e5-9. [PMID: 26381327 DOI: 10.1016/j.avsg.2015.06.100] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2015] [Revised: 06/04/2015] [Accepted: 06/16/2015] [Indexed: 12/24/2022]
Abstract
We present a case of familial thoracic aortic aneurysm and dissection (FTAAD) in a pregnant female. FTAAD is an inherited, nonsyndromic aortopathy resulting from several genetic mutations critical to aortic wall integrity have been identified. One such mutation is the myosin heavy chain gene (MYH11) which is responsible for 1-2% of all FTAAD cases. This mutation results in aortic medial degeneration, loss of elastin, and reticulin fiber fragmentation predisposing to TAAD. Aortic disease is more aggressive during pregnancy as a result of increased wall stress from hyperdynamic cardiovascular changes and estrogen-induced aortic media degeneration. Our patient was a 29-year-old G2P1 woman at 26 weeks gestation presenting with abdominal and back pain. Work-up revealed a 6.4-cm ascending aortic aneurysm with a type A dissection extending into all arch vessels, aortic coarctation at the isthmus, and a separate focal type B aortic dissection with visceral involvement. Surgical management included concomitant cesarean section with delivery of a live premature infant, tubal ligation, ascending aortic replacement with reconstruction of the arch vessels, and aortic valve resuspension. The type B dissection was managed medically without complication. This is the first reported case of aortic dissection in a patient with FTAAD/MYH11 mutation and pregnancy. This case highlights that FTAAD and pregnancy cause aortic degeneration via distinct mechanisms and that hyperdynamics of pregnancy increase aortic wall stress. Management of pregnancy associated with aortopathy requires early transfer to a tertiary center, careful investigation to identify familial aortopathy, fetal monitoring, and a multidisciplinary team approach.
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Affiliation(s)
- Jeffrey D Crawford
- Department of Surgery, Oregon Health and Science University, Portland, OR
| | - Cindy M Hsieh
- Department of Pathology, Oregon Health and Science University, Portland, OR
| | - Ryan C Schenning
- Department of Vascular and Interventional Radiology, Oregon Health and Science University, Portland, OR
| | - Matthew S Slater
- Division of Cardiac Surgery, Department of Surgery, Oregon Health and Science University, Portland, OR
| | - Gregory J Landry
- Division of Vascular Surgery, Oregon Health and Science University, Portland, OR
| | - Gregory L Moneta
- Division of Vascular Surgery, Oregon Health and Science University, Portland, OR
| | - Erica L Mitchell
- Department of Surgery, Oregon Health and Science University, Portland, OR; Division of Vascular Surgery, Oregon Health and Science University, Portland, OR.
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31
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Muiño Mosquera L, De Backer J. Managing aortic aneurysms and dissections during pregnancy. Expert Rev Cardiovasc Ther 2015; 13:703-14. [DOI: 10.1586/14779072.2015.1042862] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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