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Rizi SS, Wiens E, Hunt J, Ducas R. Cardiac physiology and pathophysiology in pregnancy. Can J Physiol Pharmacol 2024; 102:552-571. [PMID: 38815593 DOI: 10.1139/cjpp-2024-0010] [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: 06/01/2024]
Abstract
Cardiovascular disease is the leading indirect cause of maternal morbidity and mortality, accounting for nearly one third of maternal deaths during pregnancy. The burden of cardiovascular disease in pregnancy is increasing, as are the incidence of maternal morbidity and mortality. Normal physiologic adaptations to pregnancy, including increased cardiac output and plasma volume, may unmask cardiac conditions, exacerbate previously existing conditions, or create de novo complications. It is important for care providers to understand the normal physiologic changes of pregnancy and how they may impact the care of patients with cardiovascular disease. This review outlines the physiologic adaptions during pregnancy and their pathologic implications for some of the more common cardiovascular conditions in pregnancy.
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Affiliation(s)
- Shekoofeh Saboktakin Rizi
- Section of Cardiology, Department of Internal Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Evan Wiens
- Division of Cardiology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Jennifer Hunt
- Department of Obstetrics, Gynecology & Reproductive Science, University of Manitoba, Winnipeg, MB, Canada
| | - Robin Ducas
- Section of Cardiology, Department of Internal Medicine, University of Manitoba, Winnipeg, MB, Canada
- Department of Obstetrics, Gynecology & Reproductive Science, University of Manitoba, Winnipeg, MB, Canada
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2
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Liu H, Yang L, Chen CY, Qian SC, Ma LY, Diao YF, Wu XY, Wu SY, Dong ZQ, Shao YF, Zhang HJ, Sun LZ, Zhu JM, Zhang JR, Li H. Management strategies and outcomes in pregnancy-related acute aortic dissection: a multicentre cohort study in China. Heart 2024:heartjnl-2024-324009. [PMID: 39266045 DOI: 10.1136/heartjnl-2024-324009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Accepted: 08/27/2024] [Indexed: 09/14/2024] Open
Abstract
BACKGROUND Acute aortic dissection (AD) in pregnancy poses a lethal risk to both mother and fetus. However, well-established therapeutic guidelines are lacking. This study aimed to investigate clinical features, outcomes and optimal management strategies for pregnancy-related AD. METHODS We conducted a retrospective multicentre cohort study including 67 women with acute AD during pregnancy or within 12 weeks postpartum from three major cardiovascular centres in China between 2003 and 2021. Patient characteristics, management strategies and short-term outcomes were analysed. RESULTS Median age was 31 years, with AD onset at median 32 weeks gestation. Forty-six patients (68.7%) had type A AD, of which 41 underwent immediate surgery. Overall maternal mortality was 10.4% (7/67) and fetal mortality was 26.9% (18/67). Compared with immediate surgery, selective surgery was associated with higher risk of composite maternal and fetal death (adjusted RR: 12.47 (95% CI 3.26 to 47.73); p=0.0002) and fetal death (adjusted RR: 8.77 (95% CI 2.33 to 33.09); p=0.001). CONCLUSIONS Immediate aortic surgery should be considered for type A AD at any stage of pregnancy or postpartum. For pregnant women with AD before fetal viability, surgical treatment with the fetus in utero should be considered. Management strategies should account for dissection type, gestational age, and fetal viability. TRIAL REGISTRATION NUMBER NCT05501145.
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Affiliation(s)
- Hong Liu
- Department of Cardiovascular Surgery, the First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Liu Yang
- Department of Obstetrics and Gynecology, Fudan University Zhongshan Hospital, Shanghai, China
| | - Cui-Ying Chen
- Department of Obstetrics and Gynecology, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, China
| | - Si-Chong Qian
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Lu-Yao Ma
- Department of Cardiovascular Surgery, the First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Yi-Fei Diao
- Department of Cardiovascular Surgery, the First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Xiao-Yu Wu
- Department of Obstetrics and Gynecology, Fudan University Zhongshan Hospital, Shanghai, China
| | - Shu-Yan Wu
- Department of Obstetrics and Gynecology, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, China
| | - Zhi-Qiang Dong
- Department of Cardiovascular Surgery, Zhejiang Provincial People's Hospital (Affiliated People's Hospital), Hangzhou Medical College, Hangzhou, China
| | - Yong-Feng Shao
- Department of Cardiovascular Surgery, the First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Hong-Jia Zhang
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Li-Zhong Sun
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Jun-Ming Zhu
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Jia-Rong Zhang
- Department of Obstetrics and Gynecology, Fudan University Zhongshan Hospital, Shanghai, China
| | - Haiyang Li
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
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3
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Chauhan R, Balakrishnan I, Mishra K, Kumar V. Ruptured Aortic Aneurysm in Pregnancy, Anesthetic Management of Endovascular Procedure. Ann Card Anaesth 2024; 27:249-252. [PMID: 38963361 PMCID: PMC11315253 DOI: 10.4103/aca.aca_111_23] [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] [Received: 07/13/2023] [Revised: 12/15/2023] [Accepted: 12/18/2023] [Indexed: 07/05/2024] Open
Abstract
ABSTRACT Advanced pregnancy is associated with a higher risk of complicated aortopathies owing to the physiologic changes in pregnancy. The diagnosis can be elusive due to its rare incidence. The optimal treatment strategy is chosen based on the clinical condition of the patient, gestational age, and the severity of the aortic disease. A healthy young primigravida presented with acute chest pain in the early second trimester, diagnosed as a thoracic aortic aneurysm that had ruptured causing hemothorax. She underwent emergency endovascular repair under general anesthesia. Aortic disease should always be ruled out early in acute chest pain in pregnancy. Expeditious and strategic management helps improve maternal and fetal outcomes.
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Affiliation(s)
- Richa Chauhan
- Department of Anaesthesia and Intensive Care, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| | - Ira Balakrishnan
- Department of Anaesthesia and Intensive Care, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| | - Keshabanand Mishra
- Department of Anaesthesia and Intensive Care, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| | - Virendra Kumar
- Department of Anaesthesia and Intensive Care, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
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4
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Duarte VE, Richardson JN, Singh MN. The Impact of Pregnancy in Patients with Thoracic Aortic Disease: Epidemiology, Risk Assessment, and Management Considerations. Methodist Debakey Cardiovasc J 2024; 20:51-58. [PMID: 38495666 PMCID: PMC10941705 DOI: 10.14797/mdcvj.1371] [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] [Received: 02/20/2024] [Accepted: 02/23/2024] [Indexed: 03/19/2024] Open
Abstract
Thoracic aortic disease (TAD) poses substantial risks during pregnancy, particularly for women with genetic conditions such as Marfan syndrome, Loeys-Dietz syndrome, and vascular Ehlers-Danlos syndrome. This review examines the epidemiology, risk assessment, and management of TAD in pregnancy. Preconception counseling is vital considering the hereditary nature of TAD and potential pregnancy-related complications. Genetic testing and imaging surveillance aid in risk assessment. Medical management, including beta-blockade and strict blood pressure control, is essential throughout pregnancy. Surgical interventions may be necessary in certain cases. A multidisciplinary approach involving cardiologists, obstetricians, cardiac surgeons, anesthesiologists, and other specialists with expertise in cardio-obstetrics is essential for optimal outcomes. Patient education and shared decision-making play vital roles in navigating the complexities of TAD in pregnancy and improving maternal and neonatal outcomes.
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Affiliation(s)
- Valeria E. Duarte
- Houston Methodist DeBakey Heart & Vascular Center, Houston, Texas, US
- Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts, US
| | | | - Michael N. Singh
- Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts, US
- Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, US
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5
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Crosier R, Lopez Laporte MA, Unni RR, Coutinho T. Female-Specific Considerations in Aortic Health and Disease. CJC Open 2024; 6:391-406. [PMID: 38487044 PMCID: PMC10935703 DOI: 10.1016/j.cjco.2023.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 09/06/2023] [Indexed: 03/17/2024] Open
Abstract
The aorta plays a central role in the modulation of blood flow to supply end organs and to optimize the workload of the left ventricle. The constant interaction of the arterial wall with protective and deleterious circulating factors, and the cumulative exposure to ventriculoarterial pulsatile load, with its associated intimal-medial changes, are important players in the complex process of vascular aging. Vascular aging is also modulated by biomolecular processes such as oxidative stress, genomic instability, and cellular senescence. Concomitantly with well-established cardiometabolic and sex-specific risk factors and environmental stressors, arterial stiffness is associated with cardiovascular disease, which remains the leading cause of morbidity and mortality in women worldwide. Sexual dimorphisms in aortic health and disease are increasingly recognized and explain-at least in part-some of the observable sex differences in cardiovascular disease, which will be explored in this review. Specifically, we will discuss how biological sex affects arterial health and vascular aging and the implications this has for development of certain cardiovascular diseases uniquely or predominantly affecting women. We will then expand on sex differences in thoracic and abdominal aortic aneurysms, with special considerations for aortopathies in pregnancy.
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Affiliation(s)
- Rebecca Crosier
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | | | - Rudy R. Unni
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Thais Coutinho
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
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6
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McClure RS, Lindsay TF, Keir M, Bayne JP, Berry RF, Chu MWA, Chung JCY, Dagenais F, Ducas RA, Duncan A, Horne G, Klass D, Mongeon FP, Richer J, Rommens KL. The Aortic Team Model and Collaborative Decision Pathways for the Management of Complex Aortic Disease: Clinical Practice Update From the Canadian Cardiovascular Society/Canadian Society of Cardiac Surgeons/Canadian Society for Vascular Surgery/Canadian Association for Interventional Radiology. Can J Cardiol 2023; 39:1484-1498. [PMID: 37949520 DOI: 10.1016/j.cjca.2023.07.031] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 07/30/2023] [Accepted: 07/31/2023] [Indexed: 11/12/2023] Open
Abstract
Disease of the aortic arch, descending thoracic, or thoracoabdominal aorta necessitates dedicated expertise across medical, endovascular, and surgical specialties. Cardiologists, cardiac surgeons, vascular surgeons, interventional radiologists, and others have expertise and skills that aid in the management of patients with complex aortic disease. No specialty is uniformly expert in all aspects of required care. Because of this dispersion of expertise across specialties, an aortic team model approach to decision-making and treatment is advocated. A nonhierarchical partnership across specialties within an interdisciplinary aortic clinic ensures that all treatment options are considered and promotes shared decision-making between the patient and all aortic experts. Furthermore, regionalization of care for aortic disease of increased complexity assures that the breadth of treatment options is available and that favourable volume-outcome ratios for high-risk procedures are maintained. An awareness of best practice care pathways for patient referrals for preventative management, acute care scenarios, chronic care scenarios, and pregnancy might facilitate a more organized management schema for aortic disease across Canada and improve lifelong surveillance initiatives.
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Affiliation(s)
- R Scott McClure
- Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada.
| | - Thomas F Lindsay
- Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Michelle Keir
- Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Jason P Bayne
- Jewish General Hospital, McGill University, Montreal, Quebec, Canada
| | - Robert F Berry
- QEII Health Sciences Centre, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Michael W A Chu
- London Health Sciences Centre, Western University, London, Ontario, Canada
| | - Jennifer C-Y Chung
- Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Francois Dagenais
- Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Quebec City, Quebec, Canada
| | - Robin A Ducas
- St Boniface Hospital, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Audra Duncan
- London Health Sciences Centre, Western University, London, Ontario, Canada
| | - Gabrielle Horne
- QEII Health Sciences Centre, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Darren Klass
- Vancouver Coastal Health, University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Julie Richer
- University of Ottawa, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Kenton L Rommens
- Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
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7
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Misra A, Porras MP, Rajendran A, Contreras J, Scott NS. Cardio-Obstetrics: A Focused Review. Curr Cardiol Rep 2023; 25:1065-1073. [PMID: 37540401 DOI: 10.1007/s11886-023-01928-0] [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] [Accepted: 07/18/2023] [Indexed: 08/05/2023]
Abstract
PURPOSE OF REVIEW Cardiovascular disease is the leading cause of maternal mortality in the USA. All cardiovascular care providers should have a foundational knowledge on the management of pregnant individuals with heart disease. This focused review touches on several key cardio-obstetric themes. RECENT FINDINGS Many individuals with cardiovascular disease can safely undergo pregnancy, but should have counseling preconception to optimize cardiac status. There are several cardiovascular conditions that are high risk for maternal mortality and morbidity. These individuals should be adequately counseled preconception and offered reliable birth control. The approach to a high-risk pregnant patient with cardiac disease is best managed by a multidisciplinary team to address potential maternal and fetal complications. Identification of at risk individuals can be estimated preconception with several risk scores. The development of risk scores to stratify and identify those at elevated risk during pregnancy is an area of continued research and development.
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Affiliation(s)
- Amrit Misra
- Department of Cardiology, Brigham and Women's Hospital, Boston, MA, USA
| | | | - Aardra Rajendran
- Department of Internal Medicine, John Hopkins University, Baltimore, MD, USA
| | - Johanna Contreras
- Department of Cardiology, Division of Advanced Heart Failure and Transplant, Icahn School of Medicine, Mount Sinai, New York City, NY, USA
| | - Nandita S Scott
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, 55 Fruit Street, Yawkey 5B, Boston, MA, 02114, USA.
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8
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Fernandez Campos BA, Silversides CK. Marfan syndrome and pregnancy-related aortic complications: contemporary outcomes from two Spanish Marfan units. REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2022; 75:542-544. [PMID: 35339410 DOI: 10.1016/j.rec.2022.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 12/21/2021] [Indexed: 06/14/2023]
Affiliation(s)
- Beatriz Aldara Fernandez Campos
- University of Toronto, Division of Cardiology, Toronto Congenital Cardiac Centre for Adults, University Health Network and Mount Sinai Hospital, Toronto, Canada
| | - Candice K Silversides
- University of Toronto, Division of Cardiology, Toronto Congenital Cardiac Centre for Adults, University Health Network and Mount Sinai Hospital, Toronto, Canada.
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9
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Bhatt AB, Lantin-Hermoso MR, Daniels CJ, Jaquiss R, Landis BJ, Marino BS, Rathod RH, Vincent RN, Keller BB, Villafane J. Isolated Coarctation of the Aorta: Current Concepts and Perspectives. Front Cardiovasc Med 2022; 9:817866. [PMID: 35694677 PMCID: PMC9174545 DOI: 10.3389/fcvm.2022.817866] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Accepted: 03/21/2022] [Indexed: 12/02/2022] Open
Abstract
Current management of isolated CoA, localized narrowing of the aortic arch in the absence of other congenital heart disease, is a success story with improved prenatal diagnosis, high survival and improved understanding of long-term complication. Isolated CoA has heterogenous presentations, complex etiologic mechanisms, and progressive pathophysiologic changes that influence outcome. End-to-end or extended end-to-end anastomosis are the favored surgical approaches for isolated CoA in infants and transcatheter intervention is favored for children and adults. Primary stent placement is the procedure of choice in larger children and adults. Most adults with treated isolated CoA thrive, have normal daily activities, and undergo successful childbirth. Fetal echocardiography is the cornerstone of prenatal counseling and genetic testing is recommended. Advanced 3D imaging identifies aortic complications and myocardial dysfunction and guides individualized therapies including re-intervention. Adult CHD program enrollment is recommended. Longer follow-up data are needed to determine the frequency and severity of aneurysm formation, myocardial dysfunction, and whether childhood lifestyle modifications reduce late-onset complications.
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Affiliation(s)
- Ami B. Bhatt
- Departments of Internal Medicine and Pediatrics and Division of Cardiology, Harvard Medical School, Boston, MA, United States
| | - Maria R. Lantin-Hermoso
- Section of Cardiology, Department of Pediatrics, Baylor College of Medicine, Houston, TX, United States
| | - Curt J. Daniels
- Departments of Pediatrics and Internal Medicine, The Ohio State University Medical Center, Columbus, OH, United States
| | - Robert Jaquiss
- Department of Cardiovascular and Thoracic Surgery and Department of Pediatrics, UT Southwestern Medical Center, Dallas, TX, United States
| | - Benjamin John Landis
- Department of Pediatrics and Department of Medical and Molecular Genetics, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Bradley S. Marino
- Department of Pediatric Cardiology, Cleveland Clinic Children's, Cleveland, OH, United States
| | - Rahul H. Rathod
- Department of Pediatrics, Harvard Medical School, Boston, MA, United States
| | - Robert N. Vincent
- Department of Pediatrics, New York Medical College, Valhalla, NY, United States
| | - Bradley B. Keller
- Cincinnati Children's Heart Institute and the Department of Pediatrics, University of Cincinnati, Cincinnati, OH, United States
| | - Juan Villafane
- Cincinnati Children's Heart Institute and the Department of Pediatrics, University of Cincinnati, Cincinnati, OH, United States
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10
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Fernandez Campos BA, Silversides CK. Síndrome de Marfan y complicaciones aórticas en el embarazo. Resultados contemporáneos de dos unidades de Marfan españolas. Rev Esp Cardiol 2022. [DOI: 10.1016/j.recesp.2021.12.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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11
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He S, Huynh CA, Deng Y, Markan S, Nguyen A. Bicuspid Aortic Valve in Pregnancy Complicated by Aortic Valve Vegetation, Aortic Root Abscess, and Aortic Insufficiency. Cureus 2021; 13:e20209. [PMID: 35004029 PMCID: PMC8730475 DOI: 10.7759/cureus.20209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/06/2021] [Indexed: 11/30/2022] Open
Abstract
A 39-year-old patient presented to our Labor and Delivery unit with fever and nausea in the context of recent bacteriuria. She was found to be in sepsis due to an incidental bicuspid aortic valve (BAV) complicated by aortic valvular vegetations, severe aortic insufficiency, and aortic root abscess, requiring an emergent cesarean section. Three days after delivery, the patient successfully underwent a mechanical aortic valve replacement and root reconstruction. In this case report, medical, surgical, and anesthetic management of parturient patients with BAV are discussed. The management of this congenital valvulopathy and vasculopathy is complicated by the extensive hemodynamic and cardiovascular derangements that occur during pregnancy.
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Affiliation(s)
- Shan He
- Anesthesiology, Baylor College of Medicine, Houston, USA
| | | | - Yi Deng
- Anesthesiology, Baylor College of Medicine, Houston, USA
| | - Sandeep Markan
- Anesthesiology, Baylor College of Medicine, Houston, USA
| | - Anvinh Nguyen
- Anesthesiology, Baylor College of Medicine, Houston, USA
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12
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Abstract
Cardiovascular disease remains a major contributor to rising maternal morbidity and mortality. Both the pregnant woman and fetus are exposed to many potential complications as a result of the physiologic changes of pregnancy. These changes can exacerbate existing cardiac disease, as well as lead to the development of de novo issues during gestation, delivery, and the postnatal period. For women with preexisting cardiac disease, including congenital malformations, valvular disease, coronary artery disease, and aortopathies, it is crucial that they receive multidisciplinary evaluation, counseling, and optimization before conception, as well as close monitoring and medication management during pregnancy. Close monitoring is also essential for patients who develop cardiovascular complications such as preeclampsia, cardiomyopathy, congestive heart failure, coronary events, and arrhythmias during pregnancy. In addition, concerning disparities in maternal morbidity and mortality exist across many dimensions, in part because of the lack of uniformity of care in different treatment settings. Establishment of multidisciplinary cardio-obstetric teams including representatives from cardiology, anesthesia, obstetrics, maternal-fetal medicine, and specialized nursing has proven instrumental to delivering evidence-based and equitable care to high-risk patients. Multidisciplinary teams should work to guide these patients through the preconception, antepartum, delivery, and postpartum phases to ensure appropriate care for weeks to years after pregnancy.
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Affiliation(s)
- Susan Mcilvaine
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.,Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Loryn Feinberg
- Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Melissa Spiel
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.,Department of Obstetrics, Gynecology, and Reproductive Biology, Harvard Medical School, Boston, MA
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13
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Souza-Paula E, Polonio LCC, Zochio GP, da Silva KP, Kushima H, Dias-Junior CA. Anticontractile Effect of Perivascular Adipose Tissue But Not of Endothelium Is Enhanced by Hydrogen Sulfide Stimulation in Hypertensive Pregnant Rat Aortae. J Cardiovasc Pharmacol 2021; 76:715-729. [PMID: 32976209 DOI: 10.1097/fjc.0000000000000917] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Perivascular adipose tissue (PVAT) modulates the vascular tone. Hydrogen sulfide (H2S) is synthetized by cystathionine gamma-lyase (CSE) in brown PVAT. Modulation of vascular contractility by H2S is, in part, adenosine triphosphate (ATP)-sensitive potassium channels dependent. However, the role of PVAT-derived H2S in hypertensive pregnancy (HTN-Preg) is unclear. Therefore, we aimed to examine the involvement of H2S in the anticontractile effect of PVAT in aortae from normotensive and hypertensive pregnant rats. To this end, phenylephrine-induced contractions in the presence and absence of PVAT and endothelium in aortae from normotensive pregnant (Norm-Preg) and HTN-Preg rats were investigated. Maternal blood pressure, fetal-placental parameters, angiogenesis-related biomarkers, and H2S levels were also assessed. We found that circulating H2S is elevated in hypertensive pregnancy associated with angiogenic imbalance, fetal and placental growth restrictions, which revealed that there is H2S pathway activation. Moreover, under stimulated H2S formation PVAT, but not endothelium, reduced phenylephrine-induced contractions in aortae from HTN-Preg rats. Also, H2S synthesis inhibitor abolished anticontractile effects of PVAT and endothelium. Furthermore, anticontractile effect of PVAT, but not of endothelium, was eliminated by ATP-sensitive potassium channels blocker. In accordance, increases in H2S levels in PVAT and placenta, but not in aortae without PVAT, were also observed. In conclusion, anticontractile effect of PVAT is lost, at least in part, in HTN-Preg aortae and PVAT effect is ATP-sensitive potassium channels dependent in normotensive and hypertensive pregnant rat aortae. PVAT but not endothelium is responsive to the H2S stimulation in hypertensive pregnant rat aortae, implying a key role for PVAT-derived H2S under endothelial dysfunction.
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Affiliation(s)
- Edileia Souza-Paula
- Department of Pharmacology, Biosciences Institute of Botucatu, Sao Paulo State University (UNESP), Botucatu, Sao Paulo, Brazil
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14
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Rommens KL, Sandhu HK, Miller CC, Cecchi AC, Prakash SK, Saqib NU, Charlton-Ouw KM, Milewicz DM, Estrera AL, Safi HJ, Afifi RO. In-hospital outcomes and long-term survival of women of childbearing age with aortic dissection: results from a single-center database. J Vasc Surg 2021; 74:1135-1142.e1. [PMID: 33864828 DOI: 10.1016/j.jvs.2021.03.028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Accepted: 03/14/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVE In the present study, we defined the outcomes and effects of pregnancy in a cohort of women of childbearing age with acute aortic dissection (AAD). METHODS We reviewed our database of AAD to identify all eligible female patients. Women aged <45 years were included. Data on pregnancy timing with respect to the occurrence of dissection, the demographic data, dissection extent, dissection treatment, dissection-related outcomes, overall maternal and fetal mortality, and genetic testing results were analyzed. RESULTS A total of 62 women aged <45 years had presented to us with AAD from 1999 to 2017. Of the 62 women, 37 (60%) had had a history of pregnancy at AAD. Of these 37 patients, 10 (27%) had had a peripartum aortic dissection, defined as dissection during pregnancy or within 12 months postpartum. Of the 10 AADs, 5 were type A and 5 were type B. Three patients had presented with AAD during pregnancy (one in the second and two in the third trimester). Five patients (50%) had developed AAD in the immediate postpartum period (within 3 months) and two (20%) in the late postpartum period. For the immediate postpartum AADs (<3 months), four of the five patients delivered via cesarean section. Of these 10 peripartum AADs, 3 (30%) had occurred in patients with known Marfan syndrome. In-hospital mortality for those with peripartum AAD was 10% (1 of 10). Fetal mortality was 20% (2 of 10). CONCLUSIONS The frequency of aortic dissection in women of childbearing age at our institution was low. However, pregnancy might increase the risk of those young women genetically predisposed to dissection events. From these data, this risk appears to be greatest in the immediate postpartum period, even for those who undergo cesarean section. Close clinical and radiographic surveillance is required for all women with suspected aortopathy, especially in the third trimester and early postpartum period.
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Affiliation(s)
- Kenton L Rommens
- Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Houston, Tex
| | - Harleen K Sandhu
- Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Houston, Tex
| | - Charles C Miller
- Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Houston, Tex
| | - Alana C Cecchi
- Division of Medical Genetics, Department of Internal Medicine, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Houston, Tex
| | - Siddharth K Prakash
- Division of Medical Genetics, Department of Internal Medicine, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Houston, Tex; Division of Cardiology, Department of Internal Medicine, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Houston, Tex
| | - Naveed U Saqib
- Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Houston, Tex
| | - Kristofer M Charlton-Ouw
- Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Houston, Tex
| | - Dianna M Milewicz
- Division of Medical Genetics, Department of Internal Medicine, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Houston, Tex
| | - Anthony L Estrera
- Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Houston, Tex
| | - Hazim J Safi
- Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Houston, Tex
| | - Rana O Afifi
- Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Houston, Tex.
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16
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Shalhub S, Wallace S, Okunbor O, Newhall K. Genetic aortic disease epidemiology, management principles, and disparities in care. Semin Vasc Surg 2021; 34:79-88. [PMID: 33757640 DOI: 10.1053/j.semvascsurg.2021.02.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Patients with syndromic and nonsyndromic heritable aortopathies (also known as genetic aortic disease) are a heterogeneous group of patients who present at younger ages with more rapid growth of aortic aneurysms and/or increased frequency of dissections compared with patients with atherosclerotic aortopathies. In this review, we describe the etiology, epidemiology, and appropriate care delivery for these conditions at each stage of management. Within each section, we discuss sex, gender, and race differences and highlight disparities in care and knowledge. We then discuss the role of the vascular team throughout the cycle of care and the evolving inclusion of patient input in research. This understanding is essential to the creation of effective health care policies that support equitable, appropriate, and patient-centered clinical practices.
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Affiliation(s)
- Sherene Shalhub
- Division of Vascular Surgery, Department of Surgery, University of Washington School of Medicine, 1959 NE Pacific Street, Box 356410, Seattle, WA 98195.
| | - Stephanie Wallace
- Division of Vascular Surgery, Department of Surgery, University of Washington School of Medicine, 1959 NE Pacific Street, Box 356410, Seattle, WA 98195
| | - Osa Okunbor
- Division of Vascular Surgery, Department of Surgery, University of Washington School of Medicine, 1959 NE Pacific Street, Box 356410, Seattle, WA 98195
| | - Karina Newhall
- Division of Vascular Surgery, Department of Surgery, University of Washington School of Medicine, 1959 NE Pacific Street, Box 356410, Seattle, WA 98195
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Rimmer L, Mellor S, Harky A, Gouda M, Bashir M. Pernicious pregnancy: Type B aortic dissection in pregnant women. J Card Surg 2021; 36:1232-1240. [PMID: 33533078 DOI: 10.1111/jocs.15354] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Revised: 09/22/2020] [Accepted: 10/14/2020] [Indexed: 12/29/2022]
Abstract
BACKGROUND Type B aortic dissection (TBAD) occurs seldomly, particularly in pregnancy, but has disastrous consequences for both mother and fetus. The focus of immediate surgical repair of type A aortic dissection due to higher mortality of patients is less clear in its counterpart, TBAD, in which management is controversial and debated. This article collates knowledge so far on this rare event during pregnancy. METHODS A comprehensive literature search was performed in PubMed, Scopus, Google Scholar, Embase, and Medline. Key search terms included "type B aortic dissection," "pregnancy," and corresponding synonyms. Non-English papers were excluded. RESULTS Risk factors for TBAD include aortic wall stress due to hypertension, previous cardiac surgery, structural abnormalities (bicuspid aortic valve, aortic coarctation), and connective tissue disorders. In pregnancy, pre-eclampsia is a cause of increased aortic wall stress. Management of this condition is often conservative, but this is dependent on a number of factors, including gestation, cardiovascular stability of the patient, and symptomology. In most cases, a cesarean section before intervention is carried out unless certain indications are present. CONCLUSIONS Due to a scarce number of cases across the decades, it is difficult to determine which management is optimal. The gold-standard management of TBAD has traditionally been the medical treatment for uncomplicated cases and open surgery for those needing urgent intervention, but with the advent of techniques, such as thoracic endovascular aortic repair, the management of these group of patients continues to develop.
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Affiliation(s)
- Lara Rimmer
- Vascular Surgery Department, Royal Blackburn Teaching Hospital, Blackburn, UK
| | - Sophie Mellor
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Amer Harky
- Liverpool Heart and Chest Hospital NHS Foundation Trust, Liverpool, UK
| | - Mohamed Gouda
- Vascular & Endovascular Surgery, Mataria Teaching Hospital, Cairo, Egypt
| | - Mohamad Bashir
- Vascular Surgery Department, Royal Blackburn Teaching Hospital, Blackburn, UK
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18
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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: 25] [Impact Index Per Article: 8.3] [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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Pfaller B, Sathananthan G, Grewal J, Mason J, D'Souza R, Spears D, Kiess M, Siu SC, Silversides CK. Preventing Complications in Pregnant Women With Cardiac Disease. J Am Coll Cardiol 2020; 75:1443-1452. [PMID: 32216913 DOI: 10.1016/j.jacc.2020.01.039] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Accepted: 01/13/2020] [Indexed: 12/28/2022]
Abstract
BACKGROUND Pregnancy can lead to complications in women with heart disease, and these complications can be life threatening. Understanding serious complications and how they can be prevented is important. OBJECTIVES The primary objectives were to determine the incidence of serious cardiac events (SCEs) in pregnant women with heart disease, whether they were preventable, and their impact on fetal and neonatal outcomes. Serious obstetric events were also examined. METHODS A prospectively assembled cohort of 1,315 pregnancies in women with heart disease was studied. SCEs included cardiac death or arrest, ventricular arrhythmias, congestive heart failure or arrhythmias requiring admission to an intensive care unit, myocardial infarction, stroke, aortic dissection, valve thrombosis, endocarditis, and urgent cardiac intervention. The Harvard Medical Study criteria were used to adjudicate preventability. RESULTS Overall, 3.6% of pregnancies (47 of 1,315) were complicated by SCEs. The most frequent SCEs were cardiac death or arrest, heart failure, arrhythmias, and urgent interventions. Most SCEs (66%) occurred in the antepartum period. Almost one-half of SCEs (49%) were preventable; the majority of preventable SCEs (74%) were secondary to provider management factors. Adverse fetal and neonatal events were more common in pregnancies with SCEs compared with those without cardiac events (62% vs. 29%; p < 0.001). Serious obstetric events were less common (1.7%) and were primarily due to pre-eclampsia with severe features. CONCLUSIONS Pregnant women with heart disease are at risk for serious cardiac complications, and approximately one-half of all SCEs are preventable. Strategies to prevent serious cardiac complications in this high-risk cohort of women need to be developed.
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Affiliation(s)
- Birgit Pfaller
- Division of Cardiology, University of Toronto Pregnancy and Heart Disease Research Program, Toronto General and Mount Sinai Hospitals, Toronto, Ontario, Canada
| | - Gnalini Sathananthan
- Division of Cardiology, St. Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jasmine Grewal
- Division of Cardiology, St. Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jennifer Mason
- Division of Cardiology, University of Toronto Pregnancy and Heart Disease Research Program, Toronto General and Mount Sinai Hospitals, Toronto, Ontario, Canada
| | - Rohan D'Souza
- Department of Obstetrics & Gynecology, Division of Maternal-Fetal Medicine, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Danna Spears
- Division of Cardiology, University of Toronto Pregnancy and Heart Disease Research Program, Toronto General and Mount Sinai Hospitals, Toronto, Ontario, Canada
| | - Marla Kiess
- Division of Cardiology, St. Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Samuel C Siu
- Division of Cardiology, University of Western Ontario, London, Ontario, Canada
| | - Candice K Silversides
- Division of Cardiology, University of Toronto Pregnancy and Heart Disease Research Program, Toronto General and Mount Sinai Hospitals, Toronto, Ontario, Canada.
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Braverman AC, Mittauer E, Harris KM, Evangelista A, Pyeritz RE, Brinster D, Conklin L, Suzuki T, Fanola C, Ouzounian M, Chen E, Myrmel T, Bekeredjian R, Hutchison S, Coselli J, Gilon D, O'Gara P, Davis M, Isselbacher E, Eagle K. Clinical Features and Outcomes of Pregnancy-Related Acute Aortic Dissection. JAMA Cardiol 2020; 6:58-66. [PMID: 33052376 DOI: 10.1001/jamacardio.2020.4876] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Importance Women with aortopathy conditions are at risk for pregnancy-related aortic dissection, and these conditions may not be recognized until after the aortic dissection occurs. Objective To examine the clinical characteristics, imaging features, and outcomes in women with pregnancy-related acute aortic dissection. Design, Setting, and Participants A cohort study, comprising data from the International Registry of Acute Aortic Dissection (IRAD) (February 1, 1998, to February 28, 2018). The multicenter referral center study included 29 women with aortic dissection during pregnancy or less than 12 weeks post partum in IRAD from 1998 to 2018. Main Outcomes and Measures Clinical features of pregnancy-related aortic dissection to be studied included underlying aortopathy, aortic size, type of aortic dissection, timing of dissection, hypertension, and previous aortic surgery. Results A total of 29 women (mean [SD] age, 32 [6] years) had pregnancy-related aortic dissection, representing 0.3% of all aortic dissections and 1% of aortic dissection in women in the IRAD. Among women younger than 35 years, aortic dissection was related to pregnancy in 20 of 105 women (19%). Thirteen women (45%) had type A aortic dissection, and 16 women (55%) had type B. Aortic dissection onset was known in 27 women (93%): 15 during pregnancy, 4 in the first trimester, and 11 in the third trimester; 12 were post partum, occurring a mean (SD) of 12.5 (14) days post partum. At type A aortic dissection diagnosis, the mean (SD) aortic diameters were sinus of Valsalva, 54.5 (5) mm and ascending aorta, 54.7 (6) mm. At type B aortic dissection diagnosis, the mean (SD) descending aortic diameter was 32.5 (5) mm. Twenty women (69%) had an aortopathy condition or a positive family history: 13 women (65%) with Marfan syndrome, 2 women (10%) with Loeys-Dietz syndrome, 2 women (10%) with bicuspid aortic valves, 2 women (10%) with a family history of aortic disease, and 1 woman (5%) with familial thoracic aortic aneurysm. Aortopathy was not recognized until after aortic dissection in 47% of the women. Twenty-eight women (97%) survived aortic dissection hospitalization. Conclusions and Relevance Aortic dissection complicating pregnancy is rare. Most pregnancy-related aortic dissection is due to an aortopathy often not diagnosed until after aortic dissection. In this study, type A aortic dissections were associated with a dilated aorta, and type B aortic dissections often were not. Recognition of underlying conditions and risks for aortic dissection may improve management of pregnancy in women with aortopathy.
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Affiliation(s)
- Alan C Braverman
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Eric Mittauer
- Medical student, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Kevin M Harris
- Minneapolis Heart Institute at Abbott-Northwestern Hospital, Minneapolis, Minnesota
| | | | - Reed E Pyeritz
- Division of Translational Medicine and Human Genetics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Derek Brinster
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Health, New York, New York
| | - Lori Conklin
- Department of Anesthesiology, University of Virginia Medical School, Charlottesville
| | - Toru Suzuki
- Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom
| | - Christina Fanola
- Cardiovascular Division, Department of Medicine, University of Minnesota School of Medicine, Minneapolis
| | - Maral Ouzounian
- Department of Surgery University of Toronto, Toronto General Hospital, Toronto, Ontario, Canada
| | - Edward Chen
- Division of Cardiothoracic Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Truls Myrmel
- Department of Clinical Medicine, Tromsø University Hospital, Tromsø, Norway
| | | | - Stuart Hutchison
- Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Joseph Coselli
- Division of Cardiothoracic Surgery, Department of Baylor College of Medicine, Houston, Texas
| | - Dan Gilon
- Department of Cardiology, Hadassah University Medical Center, Jerusalem, Israel
| | - Patrick O'Gara
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.,Deputy Editor, JAMA Cardiology
| | - Melinda Davis
- Cardiovascular Division, Department of Medicine, University of Michigan School of Medicine, Ann Arbor
| | - Eric Isselbacher
- Cardiovascular Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Kim Eagle
- Cardiovascular Division, Department of Medicine, University of Michigan School of Medicine, Ann Arbor
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21
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Dawson A, LeMaire SA. Building on a genetic framework: Can we personalize the timing of surgical repair for patients with heritable thoracic aortic disease? J Thorac Cardiovasc Surg 2020; 160:901-905. [DOI: 10.1016/j.jtcvs.2020.01.121] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Revised: 01/28/2020] [Accepted: 01/30/2020] [Indexed: 12/13/2022]
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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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23
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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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24
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Avila WS, Alexandre ERG, Castro MLD, Lucena AJGD, Marques-Santos C, Freire CMV, Rossi EG, Campanharo FF, Rivera IR, Costa MENC, Rivera MAM, Carvalho RCMD, Abzaid A, Moron AF, Ramos AIDO, Albuquerque CJDM, Feio CMA, Born D, Silva FBD, Nani FS, Tarasoutchi F, Costa Junior JDR, Melo Filho JXD, Katz L, Almeida MCC, Grinberg M, Amorim MMRD, Melo NRD, Medeiros OOD, Pomerantzeff PMA, Braga SLN, Cristino SC, Martinez TLDR, Leal TDCAT. Brazilian Cardiology Society Statement for Management of Pregnancy and Family Planning in Women with Heart Disease - 2020. Arq Bras Cardiol 2020; 114:849-942. [PMID: 32491078 PMCID: PMC8386991 DOI: 10.36660/abc.20200406] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Affiliation(s)
- Walkiria Samuel Avila
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HC-FMUSP),São Paulo, SP - Brasil
| | | | - Marildes Luiza de Castro
- Hospital das Clínicas da Faculdade de Medicina da Universidade Federal de Minas gerais (UFMG),Belo Horizonte, MG - Brasil
| | | | - Celi Marques-Santos
- Universidade Tiradentes,Aracaju, SE - Brasil
- Hospital São Lucas, Rede D'Or Aracaju,Aracaju, SE - Brasil
| | | | - Eduardo Giusti Rossi
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HC-FMUSP),São Paulo, SP - Brasil
| | - Felipe Favorette Campanharo
- Universidade Federal de São Paulo (UNIFESP), Escola Paulista de Medicina (EPM),São Paulo, SP - Brasil
- Hospital Israelita Albert Einstein,São Paulo, SP - Brasil
| | | | - Maria Elizabeth Navegantes Caetano Costa
- Cardio Diagnóstico,Belém, PA - Brasil
- Centro Universitário Metropolitano da Amazônia (UNIFAMAZ),Belém, PA - Brasil
- Centro Universitário do Estado Pará (CESUPA),Belém, PA - Brasil
| | | | | | - Alexandre Abzaid
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HC-FMUSP),São Paulo, SP - Brasil
| | - Antonio Fernandes Moron
- Universidade Federal de São Paulo (UNIFESP), Escola Paulista de Medicina (EPM),São Paulo, SP - Brasil
| | | | - Carlos Japhet da Mata Albuquerque
- Instituto de Medicina Integral Professor Fernando Figueira (IMIP), Recife, PE – Brazil
- Hospital Barão de Lucena, Recife, PE – Brazil
- Hospital EMCOR, Recife, PE – Brazil
- Diagnósticos do Coração LTDA, Recife, PE – Brazil
| | | | - Daniel Born
- Universidade Federal de São Paulo (UNIFESP), Escola Paulista de Medicina (EPM),São Paulo, SP - Brasil
| | | | - Fernando Souza Nani
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HC-FMUSP),São Paulo, SP - Brasil
| | - Flavio Tarasoutchi
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HC-FMUSP),São Paulo, SP - Brasil
| | - José de Ribamar Costa Junior
- Hospital do Coração (HCor),São Paulo, SP - Brasil
- Instituto Dante Pazzanese de Cardiologia,São Paulo, SP - Brasil
| | | | - Leila Katz
- Instituto de Medicina Integral Professor Fernando Figueira (IMIP), Recife, PE – Brazil
| | | | - Max Grinberg
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HC-FMUSP),São Paulo, SP - Brasil
| | | | - Nilson Roberto de Melo
- Departamento de Obstetrícia e Ginecologia da Faculdade de Medicina da Universidade de São Paulo (USP), São Paulo, SP – Brazil
| | | | - Pablo Maria Alberto Pomerantzeff
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HC-FMUSP),São Paulo, SP - Brasil
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Nair GKK, Bhagra C, Sermer M, Silversides CK, Pfaller B. Pregnancy in a woman with a chronic descending thoracic aortic dissection. Obstet Med 2020; 14:102-104. [PMID: 34394719 DOI: 10.1177/1753495x19900410] [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: 08/26/2019] [Revised: 11/21/2019] [Accepted: 12/17/2019] [Indexed: 11/15/2022] Open
Abstract
Pregnancy increases aortic wall stress and, for a woman with a chronic dissection, this can lead to extension of the dissection, aortic rupture, and death. We report a pregnancy in a woman with a history of a chronic type B aortic dissection. As a child, she had repeat balloon dilation of aortic coarctation, and one of the procedures was complicated by an iatrogenic dissection at the dilation site. At the age of 27 years, she had a planned pregnancy.
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Affiliation(s)
- Govind Krishna Kumar Nair
- Division of Cardiology, University of Toronto, Pregnancy and Heart Disease Program, Sinai Health System, Toronto, Canada
| | - Catriona Bhagra
- Department of Cardiology, Cambridge University and Royal Papworth NHS Foundation Trusts, Cambridge, UK
| | - Mathew Sermer
- Department of Obstetrics & Gynecology, Division of Maternal Fetal Medicine, University of Toronto, Sinai Health System, Toronto, Canada
| | - Candice K Silversides
- Division of Cardiology, University of Toronto, Pregnancy and Heart Disease Program, Sinai Health System, Toronto, Canada
| | - Birgit Pfaller
- Division of Cardiology, University of Toronto, Pregnancy and Heart Disease Program, Sinai Health System, Toronto, Canada
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27
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Familial Aortopathies - State of the Art Review. Heart Lung Circ 2019; 29:607-618. [PMID: 32067919 DOI: 10.1016/j.hlc.2019.12.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Revised: 11/18/2019] [Accepted: 12/03/2019] [Indexed: 02/06/2023]
Abstract
Aortopathies are conditions that result in aortic dilatation, aneurysm formation and dissection. Familial aortopathies (perhaps better known as heritable thoracic aortic aneurysm and dissection, h-TAAD, as not all have a positive family history) are recognised to have an underlying genetic cause and affect the aorta, predisposing it to the above pathologies. These conditions can also affect the extra-aortic vasculature, particularly large elastic arteries and other body systems. Mutations in a number of genes have been associated with h-TAAD. However, not all affected families have a pathogenic gene variant identified-highlighting the importance of a three-generational family history and the likely role of both environmental factors and future gene discoveries in furthering knowledge. Survival has improved over the last few decades, essentially due to surgical intervention. The benefit of identifying affected individuals depends upon a regular surveillance program and timely referral for surgery before complications such as dissection. Further research is required to appreciate fully the effects of individual gene variants and improve evidence for prophylactic medical therapy, as well as to understand the effect of h-TAAD on quality of life and life choices, particularly around exercise and pregnancy, for affected individuals. This will be complemented by laboratory-based research that seeks to understand the tissue pathways that underlie development of arterial pathology, ideally providing targets for novel medical therapies and a means of non-invasively identifying individuals at increased vascular risk to reduce dissection, which remains a devastating life-threatening event.
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Kostadinovska B, Nikolic A, Slaveski D, Milojevic M. Acute aortic dissection in a patient with Marfan syndrome during advanced pregnancy. J Card Surg 2019; 35:499-502. [DOI: 10.1111/jocs.14408] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Beti Kostadinovska
- Department of Cardiac SurgeryAcibadem Sistina Hospital Skopje North Macedonia
| | - Aleksandar Nikolic
- Department of Cardiac SurgeryAcibadem Sistina Hospital Skopje North Macedonia
| | - Dimche Slaveski
- Department of Cardiac SurgeryAcibadem Sistina Hospital Skopje North Macedonia
| | - Milan Milojevic
- Department of Cardiac SurgeryAcibadem Sistina Hospital Skopje North Macedonia
- Department of Cardiothoracic SurgeryErasmus University Medical Center Rotterdam The Netherlands
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Chen SW, Zhong YL, Ge YP, Qiao ZY, Li CN, Zhu JM, Sun LZ. Successful repair of acute type A aortic dissection during pregnancy at 16 th gestational week with maternal and fetal survival: A case report and review of the literature. World J Clin Cases 2019; 7:2843-2850. [PMID: 31616701 PMCID: PMC6789399 DOI: 10.12998/wjcc.v7.i18.2843] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Revised: 08/21/2019] [Accepted: 08/26/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Aortic dissection during pregnancy is a rare but life-threatening event for mothers and fetuses. It often occurs in the third trimester of pregnancy and the postpartum period. Most patients have connective tissue diseases such as Marfan syndrome. Thus, the successful repair of a sporadic aortic dissection with maternal and fetal survival in the early second trimester is extremely rare.
CASE SUMMARY A 28-year-old woman without Marfan syndrome presented with chest pain at the 16th gestational week. Aortic computed tomographic angiography confirmed an acute type A aortic dissection (TAAD) with aortic arch and descending aorta involvement. Preoperative fetal ultrasound confirmed that the fetus was stable in the uterus. The patient underwent total arch replacement with a frozen elephant trunk using moderate hypothermic circulatory arrest with the fetus in situ. The patient recovered uneventfully and continued to be pregnant after discharge. At the 38th gestational week, she delivered a healthy female infant by cesarean section. After 2.5 years of follow-up, the patient is uneventful and the child’s development is normal.
CONCLUSION A fetus in the second trimester may have a high possibility of survival and healthy growth after aortic arch surgery.
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Affiliation(s)
- Su-Wei Chen
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
- Beijing Aortic Disease Center, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
- Beijing Institute of Heart, Lung, and Blood Vessel Diseases, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
- Beijing Engineering Research Center of Vascular Prostheses, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
| | - Yong-Liang Zhong
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
- Beijing Aortic Disease Center, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
- Beijing Institute of Heart, Lung, and Blood Vessel Diseases, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
- Beijing Engineering Research Center of Vascular Prostheses, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
| | - Yi-Peng Ge
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
- Beijing Aortic Disease Center, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
- Beijing Institute of Heart, Lung, and Blood Vessel Diseases, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
- Beijing Engineering Research Center of Vascular Prostheses, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
| | - Zhi-Yu Qiao
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
- Beijing Aortic Disease Center, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
- Beijing Institute of Heart, Lung, and Blood Vessel Diseases, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
- Beijing Engineering Research Center of Vascular Prostheses, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
| | - Cheng-Nan Li
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
- Beijing Aortic Disease Center, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
- Beijing Institute of Heart, Lung, and Blood Vessel Diseases, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
- Beijing Engineering Research Center of Vascular Prostheses, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
| | - Jun-Ming Zhu
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
- Beijing Aortic Disease Center, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
- Beijing Institute of Heart, Lung, and Blood Vessel Diseases, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
- Beijing Engineering Research Center of Vascular Prostheses, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
| | - Li-Zhong Sun
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
- Beijing Aortic Disease Center, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
- Beijing Institute of Heart, Lung, and Blood Vessel Diseases, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
- Beijing Engineering Research Center of Vascular Prostheses, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
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30
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Minsart AF, Mongeon FP, Laberge AM, Morin F, Dore A, Leduc L. Obstetric and cardiac outcomes in women with Marfan syndrome and an aortic root diameter ≤ 45mm. Eur J Obstet Gynecol Reprod Biol 2018; 230:68-72. [DOI: 10.1016/j.ejogrb.2018.09.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Revised: 08/10/2018] [Accepted: 09/10/2018] [Indexed: 01/16/2023]
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Foeller ME, Foeller TM, Druzin M. Maternal Congenital Heart Disease in Pregnancy. Obstet Gynecol Clin North Am 2018; 45:267-280. [PMID: 29747730 DOI: 10.1016/j.ogc.2018.01.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Congenital heart disease comprises most maternal cardiac diseases in pregnancy and is an important cause of maternal, fetal, and neonatal morbidity and mortality worldwide. Pregnancy is often considered a high-risk state for individuals with structural heart disease as a consequence of a limited ability to adapt to the major hemodynamic changes associated with pregnancy. Preconception counseling and evaluation are of utmost importance, as pregnancy is contraindicated in certain cardiac conditions. Pregnancy can be safely accomplished in most individuals with careful risk assessment before conception and multidisciplinary care throughout pregnancy and the postpartum period.
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Affiliation(s)
- Megan E Foeller
- Obstetrics and Gynecology, Stanford University, Stanford Hospital, 300 Pasteur Drive, Room G302, 5317, Stanford, CA 94305-5317, USA.
| | - Timothy M Foeller
- Internal Medicine, Stanford Health Care-ValleyCare, 5555 West Positas Boulevard, 1 West Hospitalist Room 1, Pleasanton, CA 94588, USA
| | - Maurice Druzin
- Obstetrics and Gynecology, Stanford University, Stanford Hospital, 300 Pasteur Drive, Room G302, 5317, Stanford, CA 94305-5317, USA
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32
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Makatsariya A, Radetskaya L, Bitsadze V, Khizroeva J, Khamani N, Makatsariya N. Prenatal care and labor in patients with mesenchimal dysplasias (Marfan syndrome, Ehlers-Danlos syndrome, hereditary hemorrhagic telangiectasia). J Matern Fetal Neonatal Med 2018; 33:373-379. [PMID: 29938556 DOI: 10.1080/14767058.2018.1493102] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Background: Mesenchymal dysplasias or inherited connective tissue diseases are the group of diseases with deficiency of various components of connective tissue. Connective tissue disorders can affect different organs: skeleton, sight organ, skin, lungs, heart. But the most dangerous is vascular wall insufficiency leading to high risk of hemorrhage, especially during pregnancy and delivery due to hemodynamic and hormonal effects on the walls of the modified vessels.Aim: To evaluate the risk of complications during the pregnancy and delivery in patients with mesenchymal dysplasias.Study design: Fifty-six pregnancies in patients with mesenchymal dysplasias, including subclinical forms of diseases: 23 with Marfan syndrome (I group), 22 with Ehlers-Danlos syndrome (II group), and 11 with Osler-Weber-Rendu syndrome (hereditary hemorrhagic telangiectasia) (III group) of the age from 18 to 36. The study included retrospective analysis (for the period from 1993 to 2005) and prospective study. Results of study showed high risk of life-threatening complications during pregnancy and delivery, especially the risk of hemorrhage and cardiovascular complications. In all the patients, we observed the progression of bleeding or development of bleeding in new localizations (epistaxis in 27 patients, easy brushing in 22, skin and mucosa telangiectasia in 20, gastrointestinal bleedings in 4, hemoptysis in 4, hematomas for minor traumas in 14, conjunctivas hemorrhages in 5).Conclusion: The pathogenesis of bleeding in such patients has mixed pattern: besides vascular wall pathology coagulation deficiency plays some role. The preferred delivery method for such patients is caesarean section. Deep vaginal ruptures and serious hemorrhage accompany vaginal delivery.
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Affiliation(s)
- Alexander Makatsariya
- Obstetrics and Gynecology, I.M. Sechenov First Moscow State Medical University, Moscow, Russian Federation
| | - Lyudmila Radetskaya
- Obstetrics and Gynecology, I.M. Sechenov First Moscow State Medical University, Moscow, Russian Federation
| | - Viktoriya Bitsadze
- Obstetrics and Gynecology, I.M. Sechenov First Moscow State Medical University, Moscow, Russian Federation
| | - Jamilya Khizroeva
- Obstetrics and Gynecology, I.M. Sechenov First Moscow State Medical University, Moscow, Russian Federation
| | - Nadin Khamani
- Obstetrics and Gynecology, I.M. Sechenov First Moscow State Medical University, Moscow, Russian Federation
| | - Natalya Makatsariya
- Obstetrics and Gynecology, I.M. Sechenov First Moscow State Medical University, Moscow, Russian Federation
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33
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Rao P, Isselbacher EM. Preconception Counseling for Patients With Thoracic Aortic Aneurysms. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2018; 20:50. [PMID: 29749581 DOI: 10.1007/s11936-018-0640-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
PURPOSE OF THE REVIEW Acute aortic dissection is a potentially catastrophic cardiovascular emergency that is associated with a high mortality rate. Pregnancy, with its attendant hormonal and physiological changes, increases the risk of dissection in women with known thoracic aortic aneurysms. In this review, we highlight the importance of preconception counseling to help women with known thoracic aortic aneurysms better understand their risk of dissection and the heritable nature of thoracic aortic disease and its associated syndromes. RECENT FINDINGS The risk of aortic dissection during pregnancy differs according to the underlying etiology of thoracic aortic aneurysm and the degree of aortic dilatation at baseline. Guideline-specific management of women with thoracic aortic aneurysms in pregnancy reduces their risk of dissection. Management of pregnant women with thoracic aortic aneurysms requires an intensive multidisciplinary approach to maximize the chances of a successful outcome for both the mother and fetus. Preconception counseling provides an opportunity to optimize patients medically and to consider potential prophylactic aortic repair prior to pregnancy.
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Affiliation(s)
- Prashant Rao
- Massachusetts General Hospital, 55 Fruit St., YAW-5800, Boston, MA, 02114, USA
| | - Eric M Isselbacher
- Massachusetts General Hospital, 55 Fruit St., YAW-5800, Boston, MA, 02114, USA.
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34
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Ouzounian M, LeMaire SA. How can genetic diagnosis inform the decision of when to operate? J Vis Surg 2018; 4:68. [PMID: 29780714 DOI: 10.21037/jovs.2018.03.08] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2018] [Accepted: 03/07/2018] [Indexed: 12/16/2022]
Abstract
Genetic discovery for heritable thoracic aortic disease (HTAD) has been progressing at a brisk pace. Surgical management of thoracic aortic aneurysms and dissections has become more personalized, with genetic factors increasingly informing the decision of when to operate on patients. An improved understanding of genotype-phenotype correlations in patients with HTAD will ultimately lead to gene- and mutation-specific recommendations for surgical repair. Until more robust data from larger cohorts can inform our decisions, patients with HTAD should be seen by an aortic specialist for a tailored approach to elective surgical repair.
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Affiliation(s)
- Maral Ouzounian
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital, Toronto, Canada.,Department of Surgery, University of Toronto, Toronto, Canada
| | - Scott A LeMaire
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, and the Cardiovascular Research Institute, Baylor College of Medicine, Houston, Texas, USA.,Cardiovascular Surgery Service, The Texas Heart Institute, Houston, Texas, USA
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35
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Patel PA, Fernando RJ, MacKay EJ, Yoon J, Gutsche JT, Patel S, Shah R, Dashiell J, Weiss SJ, Goeddel L, Evans AS, Feinman JW, Augoustides JG. Acute Type A Aortic Dissection in Pregnancy-Diagnostic and Therapeutic Challenges in a Multidisciplinary Setting. J Cardiothorac Vasc Anesth 2018. [PMID: 29519602 DOI: 10.1053/j.jvca.2018.01.035] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- Prakash A Patel
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Rohesh J Fernando
- Cardiothoracic Section, Department of Anesthesiology, Wake Forest School of Medicine, Wake Forest University, Winston-Salem, NC
| | - Emily J MacKay
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Jeongae Yoon
- Cardiothoracic Anesthesiology, Department of Anesthesiology, Lewis School of Medicine, Temple University, Philadelphia, PA
| | - Jacob T Gutsche
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Saumil Patel
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Ronak Shah
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Jillian Dashiell
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Stuart J Weiss
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Lee Goeddel
- Divisions of Cardiac Anesthesia and Adult Critical Care, Department of Anesthesiology and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD
| | - Adam S Evans
- Department of Anesthesiology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Jared W Feinman
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - John G Augoustides
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.
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36
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Carvajal HG, Lindley KJ, Shah T, Brar AK, Barger PM, Billadello JJ, Eghtesady P. Impact of pregnancy on autograft dilatation and aortic valve function following the Ross procedure. CONGENIT HEART DIS 2017; 13:217-221. [PMID: 29250922 DOI: 10.1111/chd.12554] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Accepted: 11/06/2017] [Indexed: 11/28/2022]
Abstract
OBJECTIVE The effects of pregnancy on autograft dilatation and neoaortic valve function in patients with a Ross procedure have not been studied. We sought to evaluate the effect of pregnancy on autograft dilatation and valve function in these patients with the goal of determining whether pregnancy is safe after the Ross procedure. DESIGN A retrospective chart review of female patients who underwent a Ross procedure was conducted. PATIENTS Medical records for 51 patients were reviewed. Among the 33 patients who met inclusion criteria, 11 became pregnant after surgery and 22 did not. OUTCOME MEASURES Echocardiographic reports were used to record aortic root diameter and aortic insufficiency before, during, and after pregnancy. Patient's charts were reviewed for reinterventions and complications. Primary endpoints included reinterventions, aortic root dilation of ≥5 cm, aortic insufficiency degree ≥ moderate, and death. RESULTS There were 18 pregnancies carried beyond 20 weeks in 11 patients. There was no significant difference in aortic root diameter between nulliparous patients and parous patients prior to their first pregnancy (3.53 ± 0.44 vs 3.57 ± 0.69 cm, P = .74). There was no significant change in aortic root diameter after first pregnancy (3.7 ± 0.4 cm, P = .056) although there was significant dilatation after the second (4.3 ± 0.7 cm, P = .009) and third (4.5 ± 0.7 cm, P = .009) pregnancies. Freedom from combined endpoints was significantly higher for patients in the pregnancy group than those in the nonpregnancy group (P = .002). CONCLUSIONS Pregnancy was not associated with significantly increased adverse events in patients following the Ross procedure. Special care should be taken after the first pregnancy, as multiparity may lead to increased neoaortic dilatation.
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Affiliation(s)
- Horacio G Carvajal
- Section of Pediatric Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA.,Faculty of Health Sciences, Universidad Anahuac Mexico Norte, Huixquilucan, Mexico
| | - Kathryn J Lindley
- Cardiovascular Division, Department of Internal Medicine, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
| | - Trupti Shah
- Section of Pediatric Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
| | - Anoop K Brar
- Section of Pediatric Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
| | - Philip M Barger
- Cardiovascular Division, Department of Internal Medicine, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
| | - Joseph J Billadello
- Cardiovascular Division, Department of Internal Medicine, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
| | - Pirooz Eghtesady
- Section of Pediatric Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
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37
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Jiménez-Altayó F, Siegert AM, Bonorino F, Meirelles T, Barberà L, Dantas AP, Vila E, Egea G. Differences in the Thoracic Aorta by Region and Sex in a Murine Model of Marfan Syndrome. Front Physiol 2017; 8:933. [PMID: 29187826 PMCID: PMC5694786 DOI: 10.3389/fphys.2017.00933] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Accepted: 11/03/2017] [Indexed: 12/27/2022] Open
Abstract
Marfan syndrome (MFS) is a hereditary disorder of the connective tissue that causes life-threatening aortic aneurysm, which initiates at the aortic root and can progress into the ascending portion. However, analysis of ascending aorta reactivity in animal models of MFS has remained elusive. Epidemiologic evidence suggests that although MFS is equally prevalent in men and women, men are at a higher risk of aortic complications than non-pregnant women. Nevertheless, there is no experimental evidence to support this hypothesis. The aim of this study was to explore whether there are regional and sex differences in the thoracic aorta function of mice heterozygous for the fibrillin 1 (Fbn1) allele encoding a missense mutation (Fbn1C1039G/+), the most common class of mutation in MFS. Ascending and descending thoracic aorta reactivity was evaluated by wire myography. Ascending aorta mRNA and protein levels, and elastic fiber integrity were assessed by qRT-PCR, Western blotting, and Verhoeff-Van Gieson histological staining, respectively. MFS differently altered reactivity in the ascending and descending thoracic aorta by either increasing or decreasing phenylephrine contractions, respectively. When mice were separated by sex, contractions to phenylephrine increased progressively from 3 to 6 months of age in MFS ascending aortas of males, whereas contractions in females were unchanged. Endothelium-dependent relaxation was unaltered in the MFS ascending aorta of either sex; an effect related to augmented endothelium-dependent hyperpolarization-type dilations. In MFS males, the non-selective cyclooxygenase (COX) inhibitor indomethacin prevented the MFS-induced enhancement of phenylephrine contractions linked to increased COX-2 expression. In MFS mice of both sexes, the non-selective nitric oxide synthase inhibitor L-NAME revealed negative feedback of nitric oxide on phenylephrine contractions, which was associated with upregulation of eNOS in females. Finally, MFS ascending aortas showed a greater number of elastic fiber breaks than the wild-types, and males exhibited more breaks than females. These results show regional and sex differences in Fbn1C1039G/+ mice thoracic aorta contractility and aortic media injuries. The presence of more pronounced aortic alterations in male mice provides experimental evidence to support that male MFS patients are at increased risk of suffering aortic complications.
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Affiliation(s)
- Francesc Jiménez-Altayó
- Departament de Farmacologia, de Terapèutica i de Toxicologia, Institut de Neurociències, Facultat de Medicina, Universitat Autònoma de Barcelona, Bellaterra, Spain
| | - Anna-Maria Siegert
- Departament de Biomedicina, Facultat de Medicina i Ciències de la Salut, Universitat de Barcelona, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain
| | - Fabio Bonorino
- Departament de Biomedicina, Facultat de Medicina i Ciències de la Salut, Universitat de Barcelona, Barcelona, Spain
| | - Thayna Meirelles
- Departament de Biomedicina, Facultat de Medicina i Ciències de la Salut, Universitat de Barcelona, Barcelona, Spain
| | - Laura Barberà
- Departament de Biomedicina, Facultat de Medicina i Ciències de la Salut, Universitat de Barcelona, Barcelona, Spain
| | - Ana P Dantas
- Institut Clínic del Tòrax, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain
| | - Elisabet Vila
- Departament de Farmacologia, de Terapèutica i de Toxicologia, Institut de Neurociències, Facultat de Medicina, Universitat Autònoma de Barcelona, Bellaterra, Spain
| | - Gustavo Egea
- Departament de Biomedicina, Facultat de Medicina i Ciències de la Salut, Universitat de Barcelona, Barcelona, Spain
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38
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Fetal and placental anatomy visualized with cinematic rendering from volumetric CT data. Radiol Case Rep 2017; 13:281-283. [PMID: 29487668 PMCID: PMC5826733 DOI: 10.1016/j.radcr.2017.09.028] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Revised: 09/22/2017] [Accepted: 09/25/2017] [Indexed: 11/23/2022] Open
Abstract
Avoiding unnecessary radiation exposure in children, including fetuses or embryos, is of paramount importance. However, emergent clinical situations will arise that necessitate the use of ionizing radiation-based modalities, such as computed tomography (CT), in this patient population. In such circumstances, the use of advanced visualization methods may provide optimum diagnostic utility. We present the case of a pregnant patient with Loeys-Dietz syndrome who was evaluated with CT angiography to rule out an acute aortic syndrome. The CT data from the fetus and placenta were reconstructed using the new cinematic rendering technique that allows for photorealistic display. The potential advantages of cinematic rendering relative to traditional volume rendering are discussed.
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39
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Wanga S, Hibender S, Ridwan Y, van Roomen C, Vos M, van der Made I, van Vliet N, Franken R, van Riel LA, Groenink M, Zwinderman AH, Mulder BJ, de Vries CJ, Essers J, de Waard V. Aortic microcalcification is associated with elastin fragmentation in Marfan syndrome. J Pathol 2017; 243:294-306. [PMID: 28727149 DOI: 10.1002/path.4949] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2016] [Revised: 06/17/2017] [Accepted: 07/06/2017] [Indexed: 12/20/2022]
Abstract
Marfan syndrome (MFS) is a connective tissue disorder in which aortic rupture is the major cause of death. MFS patients with an aortic diameter below the advised limit for prophylactic surgery (<5 cm) may unexpectedly experience an aortic dissection or rupture, despite yearly monitoring. Hence, there is a clear need for improved prognostic markers to predict such aortic events. We hypothesize that elastin fragments play a causal role in aortic calcification in MFS, and that microcalcification serves as a marker for aortic disease severity. To address this hypothesis, we analysed MFS patient and mouse aortas. MFS patient aortic tissue showed enhanced microcalcification in areas with extensive elastic lamina fragmentation in the media. A causal relationship between medial injury and microcalcification was revealed by studies in vascular smooth muscle cells (SMCs); elastin peptides were shown to increase the activity of the calcification marker alkaline phosphatase (ALP) and reduce the expression of the calcification inhibitor matrix GLA protein in human SMCs. In murine Fbn1C1039G/+ MFS aortic SMCs, Alpl mRNA and activity were upregulated as compared with wild-type SMCs. The elastin peptide-induced ALP activity was prevented by incubation with lactose or a neuraminidase inhibitor, which inhibit the elastin receptor complex, and a mitogen-activated protein kinase kinase-1/2 inhibitor, indicating downstream involvement of extracellular signal-regulated kinase-1/2 (ERK1/2) phosphorylation. Histological analyses in MFS mice revealed macrocalcification in the aortic root, whereas the ascending aorta contained microcalcification, as identified with the near-infrared fluorescent bisphosphonate probe OsteoSense-800. Significantly, microcalcification correlated strongly with aortic diameter, distensibility, elastin breaks, and phosphorylated ERK1/2. In conclusion, microcalcification co-localizes with aortic elastin degradation in MFS aortas of humans and mice, where elastin-derived peptides induce a calcification process in SMCs via the elastin receptor complex and ERK1/2 activation. We propose microcalcification as a novel imaging marker to monitor local elastin degradation and thus predict aortic events in MFS patients. Copyright © 2017 Pathological Society of Great Britain and Ireland. Published by John Wiley & Sons, Ltd.
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Affiliation(s)
- Shaynah Wanga
- Department of Medical Biochemistry, Academic Medical Centre Amsterdam, Amsterdam, The Netherlands.,Netherlands Heart Institute, Utrecht, The Netherlands.,Department of Cardiology, Academic Medical Centre Amsterdam, Amsterdam, The Netherlands
| | - Stijntje Hibender
- Department of Medical Biochemistry, Academic Medical Centre Amsterdam, Amsterdam, The Netherlands
| | - Yanto Ridwan
- Department of Molecular Genetics, Erasmus MC, Rotterdam, The Netherlands
| | - Cindy van Roomen
- Department of Medical Biochemistry, Academic Medical Centre Amsterdam, Amsterdam, The Netherlands
| | - Mariska Vos
- Department of Medical Biochemistry, Academic Medical Centre Amsterdam, Amsterdam, The Netherlands
| | - Ingeborg van der Made
- Department of Experimental Cardiology, Academic Medical Centre Amsterdam, Amsterdam, The Netherlands
| | - Nicole van Vliet
- Department of Molecular Genetics, Erasmus MC, Rotterdam, The Netherlands
| | - Romy Franken
- Department of Cardiology, Academic Medical Centre Amsterdam, Amsterdam, The Netherlands
| | - Luigi Amjg van Riel
- Department of Medical Biochemistry, Academic Medical Centre Amsterdam, Amsterdam, The Netherlands
| | - Maarten Groenink
- Department of Cardiology, Academic Medical Centre Amsterdam, Amsterdam, The Netherlands.,Department of Radiology, Academic Medical Centre Amsterdam, Amsterdam, The Netherlands
| | - Aeilko H Zwinderman
- Department of Clinical Epidemiology and Biostatistics, Academic Medical Centre Amsterdam, Amsterdam, The Netherlands
| | - Barbara Jm Mulder
- Department of Cardiology, Academic Medical Centre Amsterdam, Amsterdam, The Netherlands
| | - Carlie Jm de Vries
- Department of Medical Biochemistry, Academic Medical Centre Amsterdam, Amsterdam, The Netherlands
| | - Jeroen Essers
- Department of Molecular Genetics, Erasmus MC, Rotterdam, The Netherlands.,Department of Radiation Oncology, Department of Vascular Surgery, Erasmus MC, Rotterdam, The Netherlands
| | - Vivian de Waard
- Department of Medical Biochemistry, Academic Medical Centre Amsterdam, Amsterdam, The Netherlands
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Abstract
Marfan syndrome is a connective tissue disorder that can affect many organ systems. Affected patients present with orthopaedic manifestations of the syndrome during all phases of life. Pain caused by musculoskeletal abnormalities often requires definitive orthopaedic treatment. Orthopaedic surgeons must understand the phenotypes of Marfan syndrome so they can recognize when screening is warranted and can appropriately address the skeletal manifestations. Through medical advancements, patients with Marfan syndrome are living longer and more active lives. Knowledge of the latest diagnostic criteria for the disorder, as well as of advances in understanding the skeletal phenotype, clinical trials of medication therapy, and lifestyle considerations is important for orthopaedic surgeons who treat these patients because these clinicians often are the first to suspect Marfan syndrome and recommend screening.
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41
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Type A chronic aortic dissection with obesity and preeclampsia. ACTA ACUST UNITED AC 2017; 64:585-589. [PMID: 28666539 DOI: 10.1016/j.redar.2017.03.015] [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: 12/06/2016] [Revised: 03/02/2017] [Accepted: 03/19/2017] [Indexed: 11/22/2022]
Abstract
Aortic dissection is a potentially lethal disease whose incidence in pregnant women can be up to 100 times that of the remaining adult population. In most cases, it presents as typical chest pain. We report the case of a 37yo obese woman diagnosed with chronic type A aortic dissection documented by a radiological finding 10 months after delivery.
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Plowman RS, Javidan-Nejad C, Raptis CA, Katz DS, Mellnick VM, Bhalla S, Cornejo P, Menias CO. Imaging of Pregnancy-related Vascular Complications. Radiographics 2017; 37:1270-1289. [DOI: 10.1148/rg.2017160128] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- R. Scooter Plowman
- From the Department of Radiology, Mayo Clinic Arizona, Phoenix, Ariz (R.S.P., C.O.M.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (C.J.N., C.A.R., V.M.M., S.B.); Department of Radiology, NYU Winthrop Hospital, Mineola, NY (D.S.K.); Stony Brook University School of Medicine, Stony Brook, NY (D.S.K.); and Neuroradiology Section, Department of Radiology, Phoenix Children’s Hospital, Phoenix, Ariz (P.C.)
| | - Cylen Javidan-Nejad
- From the Department of Radiology, Mayo Clinic Arizona, Phoenix, Ariz (R.S.P., C.O.M.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (C.J.N., C.A.R., V.M.M., S.B.); Department of Radiology, NYU Winthrop Hospital, Mineola, NY (D.S.K.); Stony Brook University School of Medicine, Stony Brook, NY (D.S.K.); and Neuroradiology Section, Department of Radiology, Phoenix Children’s Hospital, Phoenix, Ariz (P.C.)
| | - Constantine A. Raptis
- From the Department of Radiology, Mayo Clinic Arizona, Phoenix, Ariz (R.S.P., C.O.M.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (C.J.N., C.A.R., V.M.M., S.B.); Department of Radiology, NYU Winthrop Hospital, Mineola, NY (D.S.K.); Stony Brook University School of Medicine, Stony Brook, NY (D.S.K.); and Neuroradiology Section, Department of Radiology, Phoenix Children’s Hospital, Phoenix, Ariz (P.C.)
| | - Douglas S. Katz
- From the Department of Radiology, Mayo Clinic Arizona, Phoenix, Ariz (R.S.P., C.O.M.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (C.J.N., C.A.R., V.M.M., S.B.); Department of Radiology, NYU Winthrop Hospital, Mineola, NY (D.S.K.); Stony Brook University School of Medicine, Stony Brook, NY (D.S.K.); and Neuroradiology Section, Department of Radiology, Phoenix Children’s Hospital, Phoenix, Ariz (P.C.)
| | - Vincent M. Mellnick
- From the Department of Radiology, Mayo Clinic Arizona, Phoenix, Ariz (R.S.P., C.O.M.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (C.J.N., C.A.R., V.M.M., S.B.); Department of Radiology, NYU Winthrop Hospital, Mineola, NY (D.S.K.); Stony Brook University School of Medicine, Stony Brook, NY (D.S.K.); and Neuroradiology Section, Department of Radiology, Phoenix Children’s Hospital, Phoenix, Ariz (P.C.)
| | - Sanjeev Bhalla
- From the Department of Radiology, Mayo Clinic Arizona, Phoenix, Ariz (R.S.P., C.O.M.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (C.J.N., C.A.R., V.M.M., S.B.); Department of Radiology, NYU Winthrop Hospital, Mineola, NY (D.S.K.); Stony Brook University School of Medicine, Stony Brook, NY (D.S.K.); and Neuroradiology Section, Department of Radiology, Phoenix Children’s Hospital, Phoenix, Ariz (P.C.)
| | - Patricia Cornejo
- From the Department of Radiology, Mayo Clinic Arizona, Phoenix, Ariz (R.S.P., C.O.M.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (C.J.N., C.A.R., V.M.M., S.B.); Department of Radiology, NYU Winthrop Hospital, Mineola, NY (D.S.K.); Stony Brook University School of Medicine, Stony Brook, NY (D.S.K.); and Neuroradiology Section, Department of Radiology, Phoenix Children’s Hospital, Phoenix, Ariz (P.C.)
| | - Christine O. Menias
- From the Department of Radiology, Mayo Clinic Arizona, Phoenix, Ariz (R.S.P., C.O.M.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (C.J.N., C.A.R., V.M.M., S.B.); Department of Radiology, NYU Winthrop Hospital, Mineola, NY (D.S.K.); Stony Brook University School of Medicine, Stony Brook, NY (D.S.K.); and Neuroradiology Section, Department of Radiology, Phoenix Children’s Hospital, Phoenix, Ariz (P.C.)
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Cardiovascular causes of maternal sudden death. Sudden arrhythmic death syndrome is leading cause in UK. Eur J Obstet Gynecol Reprod Biol 2017; 212:155-159. [DOI: 10.1016/j.ejogrb.2017.03.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2017] [Revised: 02/27/2017] [Accepted: 03/04/2017] [Indexed: 11/17/2022]
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44
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At the Heart of the Pregnancy: What Prenatal and Cardiovascular Genetic Counselors Need to Know about Maternal Heart Disease. J Genet Couns 2017; 26:669-688. [DOI: 10.1007/s10897-017-0081-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2016] [Accepted: 02/14/2017] [Indexed: 01/25/2023]
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45
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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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46
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47
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48
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Abstract
BACKGROUND Marfan syndrome is associated with morbidity and mortality due to aortic dilatation and dissection. Preventive aortic root replacement has been the standard treatment in Marfan syndrome patients with aortic dilatation. In this study, we present aortic event data from a nationwide Marfan syndrome cohort. METHOD The nationwide cohort of Danish Marfan syndrome patients was established from the Danish National Patient Registry and the Cause of Death Register, where we retrieved information about aortic surgery and dissections. We associated aortic events with age, sex, and Marfan syndrome diagnosis prior or after the first aortic event. RESULTS From the total cohort of 412 patients, 150 (36.4 %) had an aortic event. Fifty percent were event free at age 49.6. Eighty patients (53.3 %) had prophylactic surgery and seventy patients (46.7 %) a dissection. The yearly event rate was 0.02 events/year/patient in the period 1994-2014. Male patients had a significant higher risk of an aortic event at a younger age with a hazard ratio of 1.75 (CI 1.26-2.42, p = 0.001) compared with women. Fifty-three patients (12.9 %) were diagnosed with MFS after their first aortic event which primarily was aortic dissection [n = 44 (83.0 %)]. CONCLUSION More than a third of MFS patients experienced an aortic event and male patients had significantly more aortic events than females. More than half of the total number of dissections was in patients undiagnosed with MFS at the time of their event. This emphasizes that diagnosing MFS is lifesaving and improves mortality risk by reducing the risk of aorta dissection.
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49
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[Chest pain at 32 weeks' gestation: pregnancy-related spontaneous coronary artery dissection]. Anaesthesist 2016; 65:690-5. [PMID: 27484758 DOI: 10.1007/s00101-016-0209-9] [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: 04/28/2016] [Revised: 06/17/2016] [Accepted: 07/03/2016] [Indexed: 10/21/2022]
Abstract
A 32-year-old woman at 32 weeks gestation presented with cardiac arrest due to ventricular tachycardia following acute chest pain at home. After immediate defibrillation with return of spontaneous circulation (ROSC), an ST segment elevation myocardial infarction due to coronary artery dissection was confirmed. Two drug-eluting stents were implanted and she was placed on dual antiplatelet therapy (DAPT). The echocardiogram showed akinesis of the apex and anterior wall. The patients risk for stent thrombosis was considered high and therefore DAPT was continued until cesarean section at 35 weeks gestation. Intraoperatively she received two units of packed red blood cells, one platelet concentrate, 4 g fibrinogen and 2 g tranexamic acid. Left ventricular ejection fraction deteriorated 8 days after delivery and the patient developed congestive heart failure.
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50
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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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