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Wiens EJ, Kawa K, Kass M, Shah AH. Impact of biological sex on valvular heart disease, interventions, and outcomes. Can J Physiol Pharmacol 2024. [PMID: 38427984 DOI: 10.1139/cjpp-2023-0390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/03/2024]
Abstract
Valvular heart disease (VHD) is common, affecting >14% of individuals aged >75, and is associated with morbidity, including heart failure and arrhythmia, and risk of early mortality. Increasingly, important sex differences are being found between males and females with VHD. These sex differences can involve the epidemiology, pathophysiology, presentation, diagnosis, and outcomes of the disease. Females are often disadvantaged, and female sex has been shown to be associated with delayed diagnosis and inferior outcomes in various forms of VHD. In addition, the unique pathophysiologic state of pregnancy is associated with increased risk for maternal and fetal morbidity and mortality in many forms of VHD. Therefore, understanding and recognizing these sex differences, and familiarity with the attendant risks of pregnancy and management of pregnant females with VHD, is of great importance for any primary care or cardiovascular medicine practitioner caring for the female patient. This review will outline sex differences in aortic, mitral, pulmonic, and tricuspid VHD, with particular focus on differences in pathophysiology, clinical presentation, and outcomes. In addition, the pathophysiology and management implications of pregnancy will be discussed.
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Affiliation(s)
- Evan J Wiens
- Department of Critical Care Medicine, University of Alberta, Edmonton, AB, Canada
| | - Kristal Kawa
- College of Nursing, University of Manitoba, Winnipeg, MB, Canada
| | - Malek Kass
- Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada
- Section of Cardiology, Department of Internal Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Ashish H Shah
- Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada
- Section of Cardiology, Department of Internal Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada
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2
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Pande SN, Yavana Suriya J, Ganapathy S, Pillai AA, Satheesh S, Mondal N, Harichandra Kumar KT, Silversides C, Siu SC, D'Souza R, Keepanasseril A. Validation of Risk Stratification for Cardiac Events in Pregnant Women With Valvular Heart Disease. J Am Coll Cardiol 2023; 82:1395-1406. [PMID: 37758434 DOI: 10.1016/j.jacc.2023.07.023] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 07/13/2023] [Accepted: 07/21/2023] [Indexed: 10/03/2023]
Abstract
BACKGROUND Most risk stratification tools for pregnant patients with heart disease were developed in high-income countries and in populations with predominantly congenital heart disease, and therefore, may not be generalizable to those with valvular heart disease (VHD). OBJECTIVES The purpose of this study was to validate and establish the clinical utility of 2 risk stratification tools-DEVI (VHD-specific tool) and CARPREG-II-for predicting adverse cardiac events in pregnant patients with VHD. METHODS We conducted a cohort study involving consecutive pregnancies complicated with VHD admitted to a tertiary center in a middle-income setting from January 2019 to April 2022. Individual risk for adverse composite cardiac events was calculated using DEVI and CARPREG-II models. Performance was assessed through discrimination and calibration characteristics. Clinical utility was evaluated with Decision Curve Analysis. RESULTS Of 577 eligible pregnancies, 69 (12.1%) experienced a component of the composite outcome. A majority (94.7%) had rheumatic etiology, with mitral regurgitation as the predominant lesion (48.2%). The area under the receiver-operating characteristic curve was 0.884 (95% CI: 0.844-0.923) for the DEVI and 0.808 (95% CI: 0.753-0.863) for the CARPREG-II models. Calibration plots suggested that DEVI score overestimates risk at higher probabilities, whereas CARPREG-II score overestimates risk at both extremes and underestimates risk at middle probabilities. Decision curve analysis demonstrated that both models were useful across predicted probability thresholds between 10% and 50%. CONCLUSIONS In pregnant patients with VHD, DEVI and CARPREG-II scores showed good discriminative ability and clinical utility across a range of probabilities. The DEVI score showed better agreement between predicted probabilities and observed events.
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Affiliation(s)
- Swaraj Nandini Pande
- Department of Obstetrics and Gynaecology, Jawaharlal Institute of Post-graduate Medical Education and Research (JIPMER), Puducherry, India
| | - J Yavana Suriya
- Department of Obstetrics and Gynaecology, Jawaharlal Institute of Post-graduate Medical Education and Research (JIPMER), Puducherry, India
| | - Sachit Ganapathy
- Department of Biostatistics, Jawaharlal Institute of Post-graduate Medical Education and Research (JIPMER), Puducherry, India
| | - Ajith Ananthakrishna Pillai
- Department of Cardiology, Jawaharlal Institute of Post-graduate Medical Education and Research (JIPMER), Puducherry, India
| | - Santhosh Satheesh
- Department of Cardiology, Jawaharlal Institute of Post-graduate Medical Education and Research (JIPMER), Puducherry, India
| | - Nivedita Mondal
- Department of Neonatology, Jawaharlal Institute of Post-graduate Medical Education and Research (JIPMER), Puducherry, India
| | - K T Harichandra Kumar
- Department of Biostatistics, Jawaharlal Institute of Post-graduate Medical Education and Research (JIPMER), Puducherry, India
| | - Candice Silversides
- Division of Cardiology, University of Toronto Pregnancy and Heart Disease Program, Mount Sinai and Toronto General Hospitals, University of Toronto, Toronto, Ontario, Canada
| | - Samuel C Siu
- Division of Cardiology, University of Toronto Pregnancy and Heart Disease Program, Mount Sinai and Toronto General Hospitals, University of Toronto, Toronto, Ontario, Canada; Division of Cardiology, University of Western Ontario, London, Ontario, Canada
| | - Rohan D'Souza
- Department of Obstetrics and Gynaecology and Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Anish Keepanasseril
- Department of Obstetrics and Gynaecology, Jawaharlal Institute of Post-graduate Medical Education and Research (JIPMER), Puducherry, India.
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3
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Halpern DG, Penfield CA, Feinberg JL, Small AJ. Reproductive Health in Congenital Heart Disease: Preconception, Pregnancy, and Postpartum. J Cardiovasc Dev Dis 2023; 10:jcdd10050186. [PMID: 37233153 DOI: 10.3390/jcdd10050186] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Revised: 04/20/2023] [Accepted: 04/21/2023] [Indexed: 05/27/2023] Open
Abstract
The prevalence of congenital heart disease (CHD) in pregnancy is rising due to the improved survival of patients with CHD into childbearing age. The profound physiological changes that occur during pregnancy may worsen or unmask CHD, affecting both mother and fetus. Successful management of CHD during pregnancy requires knowledge of both the physiological changes of pregnancy and the potential complications of congenital heart lesions. Care of the CHD patient should be based on a multidisciplinary team approach beginning with preconception counseling and continuing into conception, pregnancy, and postpartum periods. This review summarizes the published data, available guidelines and recommendations for the care of CHD during pregnancy.
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Affiliation(s)
- Dan G Halpern
- NYU Adult Congenital Heart Disease Program, Leon H. Charney Division of Cardiology, NYU Grossman School of Medicine and NYU Langone Health, New York, NY 10016, USA
| | - Christina A Penfield
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, NYU Grossman School of Medicine and NYU Langone Health, New York, NY 10016, USA
| | - Jodi L Feinberg
- NYU Adult Congenital Heart Disease Program, Leon H. Charney Division of Cardiology, NYU Grossman School of Medicine and NYU Langone Health, New York, NY 10016, USA
| | - Adam J Small
- NYU Adult Congenital Heart Disease Program, Leon H. Charney Division of Cardiology, NYU Grossman School of Medicine and NYU Langone Health, New York, NY 10016, USA
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4
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Curtis SL, Belham M, Bennett S, James R, Harkness A, Gamlin W, Thilaganathan B, Giorgione V, Douglas H, Carroll A, Kitt J, Colebourn C, Ribeiro I, Fairbairn S, Augustine DX, Robinson S, Thorne SA. Transthoracic Echocardiographic Assessment of the Heart in Pregnancy-a position statement on behalf of the British Society of Echocardiography and the United Kingdom Maternal Cardiology Society. Echo Res Pract 2023; 10:7. [PMID: 37076874 PMCID: PMC10116662 DOI: 10.1186/s44156-023-00019-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Accepted: 03/30/2023] [Indexed: 04/21/2023] Open
Abstract
Pregnancy is a dynamic process associated with profound hormonally mediated haemodynamic changes which result in structural and functional adaptations in the cardiovascular system. An understanding of the myocardial adaptations is important for echocardiographers and clinicians undertaking or interpreting echocardiograms on pregnant and post-partum women. This guideline, on behalf of the British Society of Echocardiography and United Kingdom Maternal Cardiology Society, reviews the expected echocardiographic findings in normal pregnancy and in different cardiac disease states, as well as echocardiographic signs of decompensation. It aims to lay out a structure for echocardiographic scanning and surveillance during and after pregnancy as well as suggesting practical advice on scanning pregnant women.
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Affiliation(s)
- Stephanie L Curtis
- University Hospitals Bristol and Weston NHS Trust, Bristol Heart Institute, Marlborough Street, Bristol, BS2 8HW, UK.
| | - Mark Belham
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Sadie Bennett
- University Hospitals of North Midlands, Stoke-On-Trent, UK
| | - Rachael James
- University Hospitals Sussex NHS FT, Brighton, UK
- United Kingdom's Maternal Cardiology Society, London, UK
| | - Allan Harkness
- East Suffolk and North Essex NHS Foundation Trust, Essex, UK
| | - Wendy Gamlin
- North West Heart Centre, Wythenshawe Hospital, Manchester, UK
| | | | | | | | | | - Jamie Kitt
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | | | - Isabel Ribeiro
- University Hospitals Bristol and Weston NHS Trust, Bristol Heart Institute, Marlborough Street, Bristol, BS2 8HW, UK
| | - Sarah Fairbairn
- University Hospitals Bristol and Weston NHS Trust, Bristol Heart Institute, Marlborough Street, Bristol, BS2 8HW, UK
| | - Daniel X Augustine
- Royal United Hospitals Bath NHS Foundation Trust, Bath, UK
- Department for Health, University of Bath, Bath, UK
| | | | - Sara A Thorne
- University Health Network Toronto, Toronto General Hospital & Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
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5
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Thakkar A, Hameed AB, Makshood M, Gudenkauf B, Creanga AA, Malhamé I, Grandi SM, Thorne SA, D'Souza R, Sharma G. Assessment and Prediction of Cardiovascular Contributions to Severe Maternal Morbidity. JACC. ADVANCES 2023; 2:100275. [PMID: 37560021 PMCID: PMC10410605 DOI: 10.1016/j.jacadv.2023.100275] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 01/30/2023] [Accepted: 02/03/2023] [Indexed: 08/11/2023]
Abstract
Severe maternal morbidity (SMM) refers to any unexpected outcome directly related to pregnancy and childbirth that results in both short-term delivery complications and long-term consequences to a women's health. This affects about 60,000 women annually in the United States. Cardiovascular contributions to SMM including cardiac arrest, arrhythmia, and acute myocardial infarction are on the rise, probably driven by changing demographics of the pregnant population including more women of extreme maternal age and an increased prevalence of cardiometabolic and structural heart disease. The utilization of SMM prediction tools and risk scores specific to cardiovascular disease in pregnancy has helped with risk stratification. Furthermore, health system data monitoring and reporting to identify and assess etiologies of cardiovascular complications has led to improvement in outcomes and greater standardization of care for mothers with cardiovascular disease. Improving cardiovascular disease-related SMM relies on a multipronged approach comprised of patient-level identification of risk factors, individualized review of SMM cases, and validation of risk stratification tools and system-wide improvements in quality of care. In this article, we review the epidemiology and cardiac causes of SMM, we provide a framework of risk prediction clinical tools, and we highlight need for organization of care to improve outcomes.
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Affiliation(s)
- Aarti Thakkar
- Division of Cardiology, Department of Medicine, Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Afshan B. Hameed
- Department of Obstetrics & Gynecology, Department of Medicine, University of California-Irvine, Irvine, California, USA
| | - Minhal Makshood
- Division of Cardiology, Department of Medicine, Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Brent Gudenkauf
- Division of Cardiology, Department of Medicine, Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Andreea A. Creanga
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Department of Gynecology and Obstetrics, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Isabelle Malhamé
- Division of General Internal Medicine, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
- Center for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Sonia M. Grandi
- Child Health Evaluative Sciences Program, The Hospital for Sick Children, Toronto, Ontario, Canada
- Division of Epidemiology, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Sara A. Thorne
- Division of Cardiology, Pregnancy & Heart Disease Program, Mount Sinai Hospital & University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Rohan D'Souza
- Departments of Obstetrics & Gynaecology and Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Garima Sharma
- Division of Cardiology, Department of Medicine, Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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6
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Pawar SJ, Anjankar VP, Anjankar A, Adnan M. Cardiopulmonary Arrest During Pregnancy: A Review Article. Cureus 2023; 15:e35219. [PMID: 36968940 PMCID: PMC10032350 DOI: 10.7759/cureus.35219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 02/20/2023] [Indexed: 02/22/2023] Open
Abstract
Massive pulmonary embolism (PE) is an uncommon but severe complication of pregnancy or during the first few weeks after giving birth. Our intention was to thoroughly analyze the information available to its management methods. Significant bleeding of mother survival and early deliveries in fetal survivals were having hemorrhage and were having key outcomes. We found 127 severe PE cases that have had at least one form of treatment (at least 83% big; 23% with cardiac arrest). The 83 women who received thrombolysis had a 94% (95%) survival rate. Cardiac arrest in pregnancy is uncommon, although maintaining current competency can be challenging. While maternal mortality rates have decreased globally over the past 25 years, they have increased in the United States. The intricacy of the maternal mortality issue is a result of a number of clinical and socioeconomic problems such as unequal healthcare access, racial and ethnic disparities, maternal comorbidities, and bias in epidemiologic ascertainment. The importance of doctors being prepared to react to a potential maternal cardiac arrest in any situation where they are providing treatment for pregnant women is highlighted by the rise in maternal mortality. For the treatment of maternal cardiac arrest, an interdisciplinary team with expertise in both the maternal resuscitation procedure and the physiological changes that take place during pregnancy is necessary. Additionally offered are basic and advanced cardiac life support protocols. Techniques to remove obstacles like aortocaval compression that could impair the effectiveness of resuscitation should be used.
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7
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Park K, Bortnick AE, Lindley KJ, Sintek M, Sethi S, Choi C, Davis MB, Walsh MN, Voeltz M, Bello NA, Saw J, Ahmed MM, Smilowitz NR, Vidovich MI. Interventional Cardiac Procedures and Pregnancy. JOURNAL OF THE SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY & INTERVENTIONS 2022; 1:100427. [PMID: 39131483 PMCID: PMC11307807 DOI: 10.1016/j.jscai.2022.100427] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 07/05/2022] [Accepted: 07/11/2022] [Indexed: 08/13/2024]
Abstract
As the average maternal age advances with increasing concurrent cardiovascular disease risk factors, more women are entering pregnancy with or at risk for various cardiovascular conditions. Although rare, pregnant patients may require various cardiac interventions in the catheterization laboratory. An understanding of indications for intervention in pregnant patients with conditions such as myocardial infarction, severe valvular disease, and cardiogenic shock is critical to optimizing both fetal and maternal outcomes. This document highlights the most common cardiovascular conditions that may be encountered during pregnancy that may require intervention and highlights indications for intervention and periprocedural considerations to facilitate favorable maternal and fetal outcomes.
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Affiliation(s)
- Ki Park
- North Florida/South Georgia Veterans Health System, Malcom Randall VA Medical Center, Gainesville, Florida
- Division of Cardiovascular Medicine, University of Florida College of Medicine, Gainesville, Florida
| | - Anna E. Bortnick
- Department of Medicine, Division of Cardiology, Maternal and Fetal Medicine-Cardiology Joint Program and Department of Medicine, Division of Geriatrics, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York
| | - Kathryn J. Lindley
- Cardiovascular Division, Department of Medicine, Washington University in St. Louis, St. Louis, Missouri
| | - Marc Sintek
- Cardiovascular Division, Department of Medicine, Washington University in St. Louis, St. Louis, Missouri
| | - Sanjum Sethi
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Calvin Choi
- North Florida/South Georgia Veterans Health System, Malcom Randall VA Medical Center, Gainesville, Florida
- Division of Cardiovascular Medicine, University of Florida College of Medicine, Gainesville, Florida
| | - Melinda B. Davis
- Division of Cardiology, VA Ann Arbor Healthcare System and University of Michigan, Ann Arbor, Michigan
| | | | - Michele Voeltz
- Northside Hospital Cardiovascular Institute, Atlanta, Georgia
| | - Natalie A. Bello
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Jacqueline Saw
- Division of Cardiology, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - Mustafa M. Ahmed
- Division of Cardiovascular Medicine, University of Florida College of Medicine, Gainesville, Florida
| | - Nathaniel R. Smilowitz
- Department of Medicine, Leon H. Charney Division of Cardiology, New York University School of Medicine, New York, New York
| | - Mladen I. Vidovich
- Department of Medicine, Division of Cardiology, University of Illinois, Chicago, Illinois
| | - American College of Cardiology Cardiovascular Disease in Women Committee and the Cardio-Obstetrics Work Group
- North Florida/South Georgia Veterans Health System, Malcom Randall VA Medical Center, Gainesville, Florida
- Division of Cardiovascular Medicine, University of Florida College of Medicine, Gainesville, Florida
- Department of Medicine, Division of Cardiology, Maternal and Fetal Medicine-Cardiology Joint Program and Department of Medicine, Division of Geriatrics, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York
- Cardiovascular Division, Department of Medicine, Washington University in St. Louis, St. Louis, Missouri
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
- Division of Cardiology, VA Ann Arbor Healthcare System and University of Michigan, Ann Arbor, Michigan
- St. Vincent Heart Center, Indianapolis, Indiana
- Northside Hospital Cardiovascular Institute, Atlanta, Georgia
- Division of Cardiology, Vancouver General Hospital, Vancouver, British Columbia, Canada
- Department of Medicine, Leon H. Charney Division of Cardiology, New York University School of Medicine, New York, New York
- Department of Medicine, Division of Cardiology, University of Illinois, Chicago, Illinois
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8
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Elkayam U, Bansal P, Mehra A. Catheter-Based Interventions for the Management of Valvular Heart Disease During Pregnancy. JACC. ADVANCES 2022; 1:100022. [PMID: 38939308 PMCID: PMC11198064 DOI: 10.1016/j.jacadv.2022.100022] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 03/01/2022] [Accepted: 03/09/2022] [Indexed: 06/29/2024]
Abstract
Pregnancy is associated with a significant increase in hemodynamic burden. These changes can lead to maternal morbidity and mortality as well as unfavorable fetal outcomes in patients with valvular heart disease and limited cardiac reserve. Mechanical interventions may be needed for the management of severe hemodynamic deterioration not responding to medical therapy. Catheter-based percutaneous interventions can provide an alternative therapy to surgery during pregnancy. The purpose of this article is to review indications, potential advantages, and limitations of catheter-based interventions for the management of women with valvular heart disease in pregnancy.
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Affiliation(s)
- Uri Elkayam
- Division of Cardiology, Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
- Department of Obstetrics and Gynecology, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Priya Bansal
- Division of Cardiology, Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Anil Mehra
- Division of Cardiology, Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
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Rivera FB, Magalong JV, Tantengco OA, Mangubat GF, Villafuerte MG, Volgman AS. Maternal and neonatal outcomes among pregnant women with cardiovascular disease in the Philippines: a retrospective cross-sectional study from 2015-2019. J Matern Fetal Neonatal Med 2022; 35:9922-9933. [PMID: 35634711 DOI: 10.1080/14767058.2022.2076590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
PURPOSE Several studies link maternal cardiovascular disease (CVD) to maternal and fetal morbidity and mortality. This study describes the profile of maternal, obstetric, and neonatal outcomes among pregnant women with CVD in a tertiary hospital in the Philippines. It identifies the clinical and sociodemographic variables associated with these outcomes. MATERIALS AND METHODS A single-center, retrospective analysis of pregnant women admitted for delivery at the Philippine General Hospital from 2015 to 2019 was performed. Of these patients, pregnant women with CVD were identified as the cohort for this study. Data on clinical and sociodemographic factors, maternal major adverse cardiovascular events, neonatal adverse clinical events, and obstetric complications were collected. Logistic regression analysis was performed to determine the odds ratio for the risk factors for small-for-gestational-age (SGA) babies and preterm birth. RESULTS Among 30,053 delivery admissions in the Philippine General Hospital from 2015 to 2019, 293 (0.98%) pregnant women had CVD. Of the CVDs present in this cohort, congenital heart diseases (n = 119, 40.6%) were the most common, followed by rheumatic heart disease (n = 109, 37.2%). Maternal adverse events were rarely observed. Four women experienced symptomatic arrhythmias, two presented with worsening heart failure, three experienced thromboembolic events, and one had cerebrovascular infarction. There was no reported maternal death, cardiac arrest, shock, or acute renal failure. The majority (69.3%) of the women included in the study were delivered by spontaneous vaginal delivery and assisted vaginal delivery by vacuum or forceps; however, a significant portion of these women had undergone cesarean section. Almost all the study cohort delivered live births, with most neonates being delivered at 37-38 weeks gestational age (83.6%) and only 16.0% born preterm. However, a significant portion, a third of the neonates, were classified as having low birth weight. Around 17.4% of neonates born from gravidocardiac mothers were admitted neonatal intensive care unit. Conditions associated with preterm birth were low educational attainment, previous history of early neonatal death, maternal low ejection fraction, and abnormal maternal left ventricular geometry. The conditions associated with SGA babies were high gravidity and parity, a history of abortion/stillbirth, a history of previous cesarean section delivery, low ejection fraction, a history of multiple gestations, and higher BMI. CONCLUSION In this cohort study, adverse maternal outcomes were rarely observed. CVD in pregnancy is associated with an increased risk of preterm birth and SGA babies. We identified certain maternal conditions and sociodemographic factors associated with these outcomes. Despite having CVD, our study cohort had no mortality from the pregnancy.
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Affiliation(s)
- Frederick Berro Rivera
- Department of Medicine, University of the Philippines-Philippine General Hospital, Manila, Philippines
| | - John Vincent Magalong
- Department of Medicine, University of the Philippines-Philippine General Hospital, Manila, Philippines
| | | | | | - Mary Grace Villafuerte
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of the Philippines - Philippine General Hospital, Manila, Philippines
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10
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Cupido B, Zühlke L, Osman A, van Dyk D, Sliwa K. Managing Rheumatic Heart Disease in Pregnancy: A Practical Evidence-Based Multidisciplinary Approach. Can J Cardiol 2021; 37:2045-2055. [PMID: 34571164 DOI: 10.1016/j.cjca.2021.09.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 09/17/2021] [Accepted: 09/18/2021] [Indexed: 10/20/2022] Open
Abstract
Rheumatic heart disease (RHD) remains a leading cause of mortality and morbidity in pregnant patients in low- to middle-income countries. Apart from the clinical challenges, these areas face poor infrastructure and resources to allow for early detection, with many women presenting to medical services for the first time when they deteriorate clinically during the pregnancy. The opportunity for preconception counselling and planning may thus be lost. It is ideal for all women to be seen before conception and risk-stratified according to their clinical state and pathology. The role of the cardio-obstetrics team has emerged over the past decade with the aim of a seamless transition to and from the appropriate levels of care during pregnancy. Severe symptomatic mitral and aortic valve stenoses portend the greatest risk to both mother and fetus. In mitral stenosis, beta-blockers are the cornerstone of therapy and only a small number of patients require balloon valvuloplasty. Regurgitant lesions mostly require diuretics alone for the treatment of heart failure. The mode of delivery is usually vaginal; caesarean section is performed in those with obstetrical indications or in cases with severe stenosis and a poor clinical state. The postpartum period presents a second high-risk period for maternal adverse events, with heart failure and arrhythmias being the most frequent. This review aims to provide a practical evidence-based multi-disciplinary approach to the management of women with RHD in pregnancy.
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Affiliation(s)
- Blanche Cupido
- Division of Cardiology, Department of Medicine, Groote Schuur Hospital, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.
| | - Liesl Zühlke
- Division of Cardiology, Department of Medicine, Groote Schuur Hospital, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa; Division of Paediatric Cardiology, Department of Paediatrics and Child Health, Red Cross Children's Hospital, Cape Town, South Africa; Cape Heart Institute, Department of Medicine, University of Cape Town, Cape Town, South Africa; The Deanery, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Ayesha Osman
- Department of Obstetrics and Gynaecology: Maternal Fetal Medicine Unit, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Dominique van Dyk
- Department of Anaesthesia and Perioperative Medicine, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa
| | - Karen Sliwa
- Division of Cardiology, Department of Medicine, Groote Schuur Hospital, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa; Cape Heart Institute, Department of Medicine, University of Cape Town, Cape Town, South Africa
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11
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Iop L, Iliceto S, Civieri G, Tona F. Inherited and Acquired Rhythm Disturbances in Sick Sinus Syndrome, Brugada Syndrome, and Atrial Fibrillation: Lessons from Preclinical Modeling. Cells 2021; 10:3175. [PMID: 34831398 PMCID: PMC8623957 DOI: 10.3390/cells10113175] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Revised: 11/03/2021] [Accepted: 11/09/2021] [Indexed: 12/12/2022] Open
Abstract
Rhythm disturbances are life-threatening cardiovascular diseases, accounting for many deaths annually worldwide. Abnormal electrical activity might arise in a structurally normal heart in response to specific triggers or as a consequence of cardiac tissue alterations, in both cases with catastrophic consequences on heart global functioning. Preclinical modeling by recapitulating human pathophysiology of rhythm disturbances is fundamental to increase the comprehension of these diseases and propose effective strategies for their prevention, diagnosis, and clinical management. In silico, in vivo, and in vitro models found variable application to dissect many congenital and acquired rhythm disturbances. In the copious list of rhythm disturbances, diseases of the conduction system, as sick sinus syndrome, Brugada syndrome, and atrial fibrillation, have found extensive preclinical modeling. In addition, the electrical remodeling as a result of other cardiovascular diseases has also been investigated in models of hypertrophic cardiomyopathy, cardiac fibrosis, as well as arrhythmias induced by other non-cardiac pathologies, stress, and drug cardiotoxicity. This review aims to offer a critical overview on the effective ability of in silico bioinformatic tools, in vivo animal studies, in vitro models to provide insights on human heart rhythm pathophysiology in case of sick sinus syndrome, Brugada syndrome, and atrial fibrillation and advance their safe and successful translation into the cardiology arena.
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Affiliation(s)
- Laura Iop
- Department of Cardiac Thoracic Vascular Sciences and Public Health, University of Padua, Via Giustiniani, 2, I-35124 Padua, Italy; (S.I.); (G.C.)
| | | | | | - Francesco Tona
- Department of Cardiac Thoracic Vascular Sciences and Public Health, University of Padua, Via Giustiniani, 2, I-35124 Padua, Italy; (S.I.); (G.C.)
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Minhas AS, Rahman F, Gavin N, Cedars A, Vaught AJ, Zakaria S, Resar J, Schena S, Schulman S, Zhao D, Hays AG, Michos ED. Cardiovascular and Obstetric Delivery Complications in Pregnant Women With Valvular Heart Disease. Am J Cardiol 2021; 158:90-97. [PMID: 34452683 PMCID: PMC8765669 DOI: 10.1016/j.amjcard.2021.07.038] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Revised: 07/10/2021] [Accepted: 07/16/2021] [Indexed: 10/20/2022]
Abstract
Women with valvular heart disease may be more likely to have adverse obstetric and cardiovascular complications during pregnancy. Most current recommendations focus on stenotic lesions with less guidance regarding regurgitant lesions. We aimed to compare adverse events at delivery for women with various stenotic and regurgitant valvular diseases. We used the 2016 to 2018 National Inpatient Sample data to compare demographics, comorbidities, and obstetric and cardiovascular complications during delivery hospitalizations. After adjusting for clinical and socioeconomic factors, logistic regression was performed to investigate associations between valvular disease and outcomes. Among >11.2 million deliveries, 20,349 were in women with valvular disease. Women with valvular disease were older, had longer length of stays, and higher costs associated with delivery. They had higher prevalence of underlying cardiovascular comorbidities compared with women without valvular disease (hypertension: 5.1 vs 0.25%; pulmonary hypertension: 7.0 vs <0.1%). At delivery, they had higher adjusted odds of obstetric events including preeclampsia and/or eclampsia (aOR 1.9 [1.8 to 2.2]) and intrapartum/postpartum hemorrhage (aOR 1.4 [1.2 to 1.6]), and cardiovascular events including peripartum cardiomyopathy (aOR 65 [53 to 78]), pulmonary edema (aOR 17 [13 to 22]), acute ischemic heart disease (aOR 19 [12 to 30]) and arrhythmias (aOR 22 [19 to 27]). There were valve lesion-specific differences in the magnitude of risk but both stenotic and regurgitant lesions were associated with elevated risk of cardiovascular complications. In conclusion, pregnant women with stenotic and regurgitant valvular disease have a greater burden of cardiovascular comorbidities and increased odds of obstetric and cardiovascular events at delivery. These women may benefit from specialized care from a Cardio-Obstetrics team.
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Affiliation(s)
- Anum S Minhas
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland.
| | - Faisal Rahman
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Nicole Gavin
- Department of Maternal Fetal Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Ari Cedars
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Arthur Jason Vaught
- Department of Maternal Fetal Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Sammy Zakaria
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jon Resar
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Stefano Schena
- Division of Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Steven Schulman
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Di Zhao
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Allison G Hays
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Erin D Michos
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland; The Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Grewal J, Windram J, Bottega N, Sermer M, Spears D, Silversides C, Siu SC, Swan L. Canadian Cardiovascular Society: Clinical Practice Update on Cardiovascular Management of the Pregnant Patient. Can J Cardiol 2021; 37:1886-1901. [PMID: 34217807 DOI: 10.1016/j.cjca.2021.06.021] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 06/24/2021] [Accepted: 06/28/2021] [Indexed: 11/29/2022] Open
Abstract
The number of women of childbearing age with cardiovascular disease (CVD) is growing due to increased survival of children with congenital heart disease (CHD). More women are also becoming pregnant at an older age, which is associated with increased co-morbidities including hypertension, diabetes and acquired CVD. Over the last decade the field of cardio-obstetrics has significantly advanced with the development of multidisciplinary cardio-obstetric programs (COPs) to address the increasing burden of CVD in pregnancy. With the introduction of formal COPs, pregnancy outcomes in women with heart disease have improved. COPs provide preconception counseling, antenatal and postpartum cardiac surveillance, labor and delivery planning. Pre-pregnancy counseling by a COP should be offered to women with suspected CVD who are of child bearing age. In those women who present while pregnant, counseling should be performed by a COP as early as possible in pregnancy. The purpose of counseling is to reduce the risk of pregnancy to the mother and fetus whenever possible. This is done through accurate maternal and fetal risk stratification, optimizing cardiac lesions, reviewing safety of medications in pregnancy, and making a detailed plan for the pregnancy, labor and delivery. This Clinical Practice Update highlights the COP approach to pre-pregnancy counseling, risk stratification, and management of commonly encountered cardiac conditions through pregnancy. We highlight "red flags" that should trigger a more timely assessment by a COP. We also describe the approach to some of the cardiac emergencies that the care provider may encounter in a pregnant woman.
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Affiliation(s)
- Jasmine Grewal
- Division of Cardiology, St.Paul's Hospital, University of British Columbia, Vancouver, B.C., Canada.
| | - Jonathan Windram
- Department of Cardiology, Mazankowski Heart Institute, University of Alberta, Edmonton, AB, Canada
| | - Natalie Bottega
- Department of Cardiology, Royal Victoria Hospital-Glen Site, McGill University, Montréal, QC, Canada
| | - Mathew Sermer
- Department of Obstetrics and Gynaecology, Mount Sinai Hospital, University of Toronto, Toronto ON
| | - Danna Spears
- Division of Cardiology, University Health Network, Toronto General Hospital, Toronto, Ontario, Canada
| | - Candice Silversides
- Division of Cardiology, University Health Network, Toronto General Hospital, Toronto, Ontario, Canada; Division of Cardiology Department of Medicine Mount Sinai Hospital and University Health NetworkUniversity of Toronto Canada
| | - Samuel C Siu
- Division of Cardiology Department of Medicine Mount Sinai Hospital and University Health NetworkUniversity of Toronto Canada; Maternal Cardiology Program Division of Cardiology Department of Medicine Schulich School of Medicine and Dentistry London Ontario Canada
| | - Lorna Swan
- Division of Cardiology, University Health Network, Toronto General Hospital, Toronto, Ontario, Canada; Division of Cardiology Department of Medicine Mount Sinai Hospital and University Health NetworkUniversity of Toronto Canada
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14
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McAnulty J. Heart Valve Regurgitation in Pregnancy: Risks Related to the Company It Keeps. J Am Coll Cardiol 2021; 77:2665-2666. [PMID: 34045023 DOI: 10.1016/j.jacc.2021.04.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Accepted: 04/08/2021] [Indexed: 10/01/2022]
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