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Levy AM, Saling MM, Anderson JFI. Frequency and extent of cognitive complaint following adult civilian mild traumatic brain injury: a systematic review and meta-analysis. BRAIN IMPAIR 2023; 24:309-332. [PMID: 38167200 DOI: 10.1017/brimp.2022.19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE Cognitive symptoms are associated with return to work, healthcare use and quality of life after mild traumatic brain injury (mTBI). Additionally, while overall 'post-concussion' symptoms are often present at similar levels in mTBI and control groups, cognitive complaints may be specifically elevated in mTBI. A systematic review and meta-analysis was conducted to investigate the frequency and extent of cognitive complaints following adult civilian mTBI, and compare it to the frequency and extent of complaints in control populations (PROSPERO: CRD42020151284). METHOD This review included studies published up to March 2022. Thirteen studies were included in the systematic review, and six were included in the meta-analysis. Data extraction and quality assessment were conducted by two independent reviewers. RESULTS Cognitive complaints are common after mTBI, although reported rates differed greatly across studies. Results suggested that mTBI groups report cognitive complaints to a significantly greater extent than control groups (Hedges' g = 0.85, 95% CI 0.31-1.40, p = .0102). Heterogeneity between studies was high (τ2 = 0.20, 95% CI 0.04-1.58; I2 = 75.0%, 95% CI 43.4%-89.0%). Between-group differences in symptom reporting were most often found when healthy rather than injured controls were employed. CONCLUSIONS Cognitive complaints are consistently reported after mTBI, and are present at greater levels in mTBI patients than in controls. Despite the importance of these complaints, including in regards to return to work, healthcare use and quality of life, there has been limited research in this area, and heterogeneity in research methodology is common.
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Affiliation(s)
- Arielle M Levy
- Melbourne School of Psychological Sciences, The University of Melbourne, Parkville, VIC3010, Australia
| | - Michael M Saling
- Melbourne School of Psychological Sciences, The University of Melbourne, Parkville, VIC3010, Australia
| | - Jacqueline F I Anderson
- Melbourne School of Psychological Sciences, The University of Melbourne, Parkville, VIC3010, Australia
- Psychology Department, The Alfred Hospital, Melbourne, VIC3004, Australia
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2
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Interdisciplinary Methods for Zoonotic Tissue Acellularization for Natural Heart Valve Substitute of Biomimetic Materials. MATERIALS 2022; 15:ma15072594. [PMID: 35407927 PMCID: PMC9000896 DOI: 10.3390/ma15072594] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 03/14/2022] [Accepted: 03/29/2022] [Indexed: 02/04/2023]
Abstract
The goal of this work was to create a bioactive tissue-based scaffold using multi-disciplinary engineering materials and tissue engineering techniques. Materials & methods: Physical techniques such as direct laser interference lithography and proton radiation were selected as alternative methods of enzymatic and chemical decellularization to remove cells from a tissue without degradation of the extracellular matrix nor its protein structure. This study was an attempt to prepare a functional scaffold for cell culture from tissue of animal origin using new physical methods that have not been considered before. The work was carried out under full control of the histological and molecular analysis. Results & conclusions: The most important finding was that the physical methods used to obtain the decellularized tissue scaffold differed in the efficiency of cell removal from the tissue in favour of the laser method. Both the laser method and the proton method exhibited a destructive effect on tissue structure and the genetic material in cell nuclei. This effect was visible on histology images as blurred areas within the cell nucleus. The finite element 3D simulation of decellularization process of the three-layer tissue of animal origin sample reflected well the mechanical response of tissue described by hyperelastic material models and provided results comparable to the experimental ones.
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3
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Pacheco LD, Saade G, Shrivastava V, Shree R, Elkayam U. Society for Maternal-Fetal Medicine Consult Series #61: Anticoagulation in pregnant patients with cardiac disease. Am J Obstet Gynecol 2022; 227:B28-B43. [PMID: 35337804 DOI: 10.1016/j.ajog.2022.03.036] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Pregnancy in individuals with a mechanical heart valve has been classified as very high risk because of a substantially increased risk of maternal mortality or severe morbidity. Lifelong therapeutic anticoagulation is a principal component of the medical management of mechanical heart valves to prevent valve thrombosis. Anticoagulation regimens indicated outside of pregnancy for patients with mechanical valves should be continued during pregnancy with the possibility of modifications based on the type of valve, the trimester of pregnancy, individual risk tolerance, and circumstances around the time of delivery. The purpose of this document is to provide recommendations regarding the management of anticoagulation for common cardiac conditions complicating pregnancy, including mechanical heart valves, atrial fibrillation, systolic heart failure, and congenital heart disease.
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Affiliation(s)
- Luis D Pacheco
- Society for Maternal-Fetal Medicine, 409 12 St. SW, Washington, DC 20024, USA.
| | - George Saade
- Society for Maternal-Fetal Medicine, 409 12 St. SW, Washington, DC 20024, USA.
| | - Vineet Shrivastava
- Society for Maternal-Fetal Medicine, 409 12 St. SW, Washington, DC 20024, USA.
| | - Raj Shree
- Society for Maternal-Fetal Medicine, 409 12 St. SW, Washington, DC 20024, USA.
| | - Uri Elkayam
- Society for Maternal-Fetal Medicine, 409 12 St. SW, Washington, DC 20024, USA.
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4
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Erba N, Gatti S, Hassan SAA, Langer M, Chatenoud L, Portella G, Baiocchi R. Pregnancy Outcomes in Women With Mechanical Valve Prostheses Using Vitamin K Antagonist Therapy: The Experience of the Salam Centre for Cardiac Surgery in Sudan. Front Pediatr 2022; 10:918547. [PMID: 35899137 PMCID: PMC9309277 DOI: 10.3389/fped.2022.918547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 06/17/2022] [Indexed: 11/14/2022] Open
Abstract
Pregnancy and childbirth on anticoagulants after mechanical heart valve replacement present a high risk of complications for both mother and baby. On top of pregnancy worsening the mother's cardiac function, anticoagulant therapy itself is a crucial problem. A safe and effective anticoagulation regimen for both mother and fetus is not possible. The most effective drugs for preventing valve thrombosis are VKAs, whose dosage needs to be adjusted with frequent INR checks. Moreover, VKAs can have embryopathic and teratogenic action. Patients in follow-up and anticoagulant treatment at the Salam Centre for Cardiac Surgery in Sudan live spread out over a large area where transport to the Center is generally difficult; pregnancy treatment has, therefore, been adapted to the limitations of reality. Pregnancy is discouraged and contraception and therapeutic abortion are recommended, but this guidance frequently goes unheeded. Here we describe maternal and fetal outcomes in 307 consecutive pregnancies recorded by staff at the oral anticoagulant clinic (OAC) from April 2017 to November 2021. Out of 307 pregnancies, there were 15 maternal deaths (4.9%), 24 thrombotic events (7.8%) and 22 major bleedings (7.2%). Fifty pregnancies (16.3%) were terminated by therapeutic abortion. Only 47.6% of pregnancies had good maternal and neonatal outcomes. Data clearly show that, due to the complexity of pregnancy in women with mechanical heart valves and the scarcity of tertiary healthcare services in the area where patients live, maternal mortality is at an unacceptable level and requires a structured, multi-disciplinary intervention.
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Affiliation(s)
- Nicoletta Erba
- Emergency ONG ONLUS, Milan, Italy.,Federazione Centri per la Diagnosi Della Trombosi e la Sorveglianza Delle Terapie Antitrombotiche (FCSA), Milan, Italy
| | | | | | - Martin Langer
- Emergency ONG ONLUS, Milan, Italy.,Università Degli Studi, Milan, Italy
| | - Liliane Chatenoud
- Laboratory of Clinical Epidemiology, Department of Public Health, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
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5
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Abstract
Heart failure (HF) remains the most common major cardiovascular complication arising in pregnancy and the postpartum period. Mothers who develop HF have been shown to experience an increased risk of death as well as a variety of adverse cardiac and obstetric outcomes. Recent studies have demonstrated that the risk to neonates is significant, with increased risks in perinatal morbidity and mortality, low Apgar scores, and prolonged neonatal intensive care unit stays. Information on the causal factors of HF can be used to predict risk and understand timing of onset, mortality, and morbidity. A variety of modifiable, nonmodifiable, and obstetric risk factors as well as comorbidities are known to increase a patient's likelihood of developing HF, and there are additional elements that are known to portend a poorer prognosis beyond the HF diagnosis. Multidisciplinary cardio‐obstetric teams are becoming more prominent, and their existence will both benefit patients through direct care and increased awareness and educate clinicians and trainees on this patient population. Detection, access to care, insurance barriers to extended postpartum follow‐up, and timely patient counseling are all areas where care for these women can be improved. Further data on maternal and fetal outcomes are necessary, with the formation of State Maternal Perinatal Quality Collaboratives paving the way for such advances.
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Affiliation(s)
- Rachel A Bright
- Division of Cardiovascular Medicine Department of Medicine State University of New YorkStony Brook University Medical CenterRenaissance School of Medicine Stony Brook NY
| | - Fabio V Lima
- Division of Cardiology Warren Alpert Medical School of Brown University and Lifespan Cardiovascular Institute Providence RI
| | - Cecilia Avila
- Department of Obstetrics, Gynecology and Reproductive Medicine Stony Brook University Medical Center Stony Brook NY
| | - Javed Butler
- Department of Medicine University of Mississippi Jackson MS
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2020 ACC/AHA guideline for the management of patients with valvular heart disease: A report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Thorac Cardiovasc Surg 2021; 162:e183-e353. [PMID: 33972115 DOI: 10.1016/j.jtcvs.2021.04.002] [Citation(s) in RCA: 68] [Impact Index Per Article: 22.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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7
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Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F, Jneid H, Krieger EV, Mack M, McLeod C, O'Gara PT, Rigolin VH, Sundt TM, Thompson A, Toly C. 2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2021; 143:e72-e227. [PMID: 33332150 DOI: 10.1161/cir.0000000000000923] [Citation(s) in RCA: 522] [Impact Index Per Article: 174.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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8
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Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F, Jneid H, Krieger EV, Mack M, McLeod C, O'Gara PT, Rigolin VH, Sundt TM, Thompson A, Toly C. 2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2021; 77:e25-e197. [PMID: 33342586 DOI: 10.1016/j.jacc.2020.11.018] [Citation(s) in RCA: 721] [Impact Index Per Article: 240.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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9
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Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F, Jneid H, Krieger EV, Mack M, McLeod C, O'Gara PT, Rigolin VH, Sundt TM, Thompson A, Toly C. 2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2021; 143:e35-e71. [PMID: 33332149 DOI: 10.1161/cir.0000000000000932] [Citation(s) in RCA: 320] [Impact Index Per Article: 106.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
AIM This executive summary of the valvular heart disease guideline provides recommendations for clinicians to diagnose and manage valvular heart disease as well as supporting documentation to encourage their use. METHODS A comprehensive literature search was conducted from January 1, 2010, to March 1, 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, Cochrane, Agency for Healthcare Research and Quality Reports, and other selected database relevant to this guideline. Structure: Many recommendations from the earlier valvular heart disease guidelines have been updated with new evidence and provides newer options for diagnosis and treatment of valvular heart disease. This summary includes only the recommendations from the full guideline which focus on diagnostic work-up, the timing and choice of surgical and catheter interventions, and recommendations for medical therapy. The reader is referred to the full guideline for graphical flow charts, text, and tables with additional details about the rationale for and implementation of each recommendation, and the evidence tables detailing the data considered in developing these guidelines.
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10
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Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F, Jneid H, Krieger EV, Mack M, McLeod C, O’Gara PT, Rigolin VH, Sundt TM, Thompson A, Toly C. 2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary. J Am Coll Cardiol 2021; 77:450-500. [DOI: 10.1016/j.jacc.2020.11.035] [Citation(s) in RCA: 272] [Impact Index Per Article: 90.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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11
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[Relevant aspects of the ESC guidelines for the management of cardiovascular diseases during pregnancy for obstetric anaesthesia (update 2018)]. Anaesthesist 2019; 68:461-475. [PMID: 31267159 DOI: 10.1007/s00101-019-0613-z] [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: 10/26/2022]
Abstract
The current update of the ESC (European Society of Cardiology) guidelines on managing cardiovascular diseases during pregnancy provides instructions for doctors in daily practice. Heart diseases are the most common reason for maternal death during pregnancy in western countries. Among other things, the following topics are dealt with: congenital heart disease, pulmonary hypertension, aortic and valvular diseases as well as arrhythmias and hypertensive disorders. Compared to the guidelines from 2011 some changes have been made regarding the recommendations to classify maternal risk according to the modified World Health Organization (mWHO) classification or in recommendations on anticoagulation for low-dose and high-dose requirements of vitamin K antagonists. The main focus of this summary of recent recommendations is the impact on the anesthesia management in order to provide responsible anesthesiologists with relevant background knowledge.
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12
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Georgiopoulos G, Tsiachris D, Kordalis A, Kontogiannis C, Spartalis M, Pietri P, Magkas N, Stefanadis C. Pharmacotherapeutic strategies for atrial fibrillation in pregnancy. Expert Opin Pharmacother 2019; 20:1625-1636. [PMID: 31136204 DOI: 10.1080/14656566.2019.1621290] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Georgios Georgiopoulos
- Department of Cardiology, Athens Medical Center, Athens, Greece
- Department of Clinical Therapeutics, Alexandra Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | | | | | - Christos Kontogiannis
- Department of Clinical Therapeutics, Alexandra Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Michael Spartalis
- Division of Cardiology, Onassis Cardiac Surgery Center, Athens, Greece
| | | | - Nikolaos Magkas
- 1stDepartment of Cardiology, Hippocration Hospital, National and Kapodistrian University of Athens, Athens, Greece
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13
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Maskell P, Burgess M, MacCarthy‐Ofosu B, Harky A. Management of aortic valve disease during pregnancy: A review. J Card Surg 2019; 34:239-249. [DOI: 10.1111/jocs.14039] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Revised: 03/01/2019] [Accepted: 03/05/2019] [Indexed: 12/15/2022]
Affiliation(s)
- Perry Maskell
- Department of Vascular SurgeryCountess of Chester HospitalChester England
| | - Mika Burgess
- Department of Obstetrics and GynaecologyYsbyty GwyneddBangor Wales
| | | | - Amer Harky
- Department of Vascular SurgeryCountess of Chester HospitalChester England
- School of MedicineUniversity of LiverpoolLiverpool England
- Department of Cardiothoracic SurgeryLiverpool Heart and ChestLiverpool UK
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14
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Abstract
A bicuspid aortic valve is not only a common congenital heart defect but also an enigmatic condition that can cause a large spectrum of diseases, such as aortic valve stenosis and severe heart failure in newborns whereas aortic dissection in adults. On the contrary, a bicuspid aortic valve can also occur with normal function throughout life and never need treatment. Numerous genetic mechanisms are involved in the abnormal cellular functions that may cause abnormal development of the aortic valve during early foetal life. As several chromosomal disorders are also associated with a bicuspid valve, there does not appear to be an apparent common trigger to the abnormal development of the aortic valve. The clinical care of the bicuspid aortic valve patient has been changed by a significant body of evidence that has improved the understanding of the natural history of the disease, including when to best intervene with valve replacement and when to provide prophylactic aortic root surgery. Moreover, as bicuspid valve disease is also part of various syndromes, we can identify high-risk patients in whom a bicuspid valve is much more unfavourable than in the normal population. This review provides an overview of all aspects of the bicuspid aortic valve condition and gives an updated perspective on issues from pathophysiology to clinical care of bicuspid aortic valve disease and associated aortic disease in asymptomatic, symptomatic, and pregnant patients, as well as our viewpoint on population screening.
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15
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Aggarwal SR, Economy KE, Valente AM. State of the Art Management of Mechanical Heart Valves During Pregnancy. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2018; 20:102. [PMID: 30417314 DOI: 10.1007/s11936-018-0702-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
PURPOSE OF THE REVIEW To review the management of women with mechanical heart valves during pregnancy, from preconception counseling through delivery with a summary of the latest guidelines. RECENT FINDINGS The hypercoagulability of pregnancy combined with the imperfect choices of anticoagulant agents contribute to a high risk of complications in pregnant women with mechanical heart valves. Valve thrombosis remains a major concern, much of which occurs during the first trimester transition to heparin-based products. The safest method of anticoagulation, with the best balance of maternal and fetal risk, is use of low-dose vitamin K antagonists, but only if therapeutic anticoagulation can be achieved with warfarin doses of ≤ 5 mg/day. Management of mechanical heart valves in pregnancy remains fraught with difficult decisions involving balancing of maternal and fetal risks as well as a high risk of maternal and fetal complications. Preconception counseling and planning is imperative. A risk-benefit discussion with the patient will help guide the choice of anticoagulation and outline the plan for safe delivery options. A multidisciplinary approach to management is advisable with close follow-up and care in a tertiary center.
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Affiliation(s)
- Shivani R Aggarwal
- Department of Cardiology, Boston Children's Hospital, 300 Longwood Avenue, BCH 3215, Boston, MA, 02115, USA. .,Department of Medicine, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA.
| | - Katherine E Economy
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Anne M Valente
- Department of Cardiology, Boston Children's Hospital, 300 Longwood Avenue, BCH 3215, Boston, MA, 02115, USA.,Department of Medicine, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA
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16
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Regitz-Zagrosek V, Roos-Hesselink JW, Bauersachs J, Blomström-Lundqvist C, Cífková R, De Bonis M, Iung B, Johnson MR, Kintscher U, Kranke P, Lang IM, Morais J, Pieper PG, Presbitero P, Price S, Rosano GMC, Seeland U, Simoncini T, Swan L, Warnes CA. 2018 ESC Guidelines for the management of cardiovascular diseases during pregnancy. Eur Heart J 2018; 39:3165-3241. [PMID: 30165544 DOI: 10.1093/eurheartj/ehy340] [Citation(s) in RCA: 1100] [Impact Index Per Article: 183.3] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
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Viaris de Lesegno B, Nelson-Piercy C. Advances in the management of cardiovascular disease during pregnancy. Future Cardiol 2018; 14:269-272. [PMID: 29932743 DOI: 10.2217/fca-2018-0033] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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18
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Jha N, Jha AK, Chand Chauhan R, Chauhan NS. Maternal and Fetal Outcome After Cardiac Operations During Pregnancy: A Meta-Analysis. Ann Thorac Surg 2018; 106:618-626. [PMID: 29660361 DOI: 10.1016/j.athoracsur.2018.03.020] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Revised: 03/06/2018] [Accepted: 03/06/2018] [Indexed: 01/11/2023]
Abstract
BACKGROUND In the past, cardiac surgical procedures during pregnancy have been associated with a high risk of adverse maternal and fetal outcomes. Therefore, this meta-analysis of more recent studies was done to assess the fetomaternal risk after cardiac operations during pregnancy using cardiopulmonary bypass. METHODS The MEDLINE, Embase, and Cochrane library were searched to find studies from January 1, 1990, to July 31, 2016, without language restriction. We selected studies that included at least 4 women to report fetomaternal outcomes after a cardiac operation using cardiopulmonary bypass during pregnancy. Two authors independently extracted data from the selected studies. The studies were assessed for methodological qualities using the Newcastle-Ottawa Scale. The primary outcomes included maternal death and any pregnancy loss. The secondary outcomes were maternal complications and neonatal complications. Primary analysis calculated absolute risks and 95% confidence intervals (CIs) for pregnancy outcomes using the DerSimonian-Laird random effects model. Heterogeneity was assessed by I2 statistic and visual plot. RESULTS Ten studies, including 154 women, were eligible for inclusion in this study. The patients underwent cardiac operations during pregnancy involving cardiopulmonary bypass. As calculated per 100 pregnancies, the pooled unadjusted estimate of maternal mortality was 11.2 (95% CI, 6.8 to 17.8), pregnancy loss was 33.1 (95% CI, 25.1 to 41.2), maternal complications were 8.8 (95% CI, 2.8 to 24.2), and neonatal complications were 10.8 (95% CI, 4.2 to 25.2). The risks of preterm labor and cesarean delivery were 28 per 100 pregnancies (95% CI, 15.6 to 45) and 33.8 per 100 pregnancies (95% CI, 19.1 to 52.4), respectively. CONCLUSIONS The fetomaternal mortality and morbidity after a cardiac operation during pregnancy are higher than that reported in the earlier literature (PROSPERO No. CRD42016047093).
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Affiliation(s)
- Nivedita Jha
- Department of Obstetrics and Gynecology, Pondicherry Institute of Medical Sciences, Puducherry, India
| | - Ajay Kumar Jha
- Department of Anesthesiology and Critical Care, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India.
| | - Ramesh Chand Chauhan
- Department of Community and Family Medicine, All India Institute of Medical Sciences, Bhubaneswar, India
| | - Neelima Singh Chauhan
- Department of Obstetrics and Gynecology, Pondicherry Institute of Medical Sciences, Puducherry, India
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19
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D'Souza R, Ostro J, Shah PS, Silversides CK, Malinowski A, Murphy KE, Sermer M, Shehata N. Anticoagulation for pregnant women with mechanical heart valves: a systematic review and meta-analysis. Eur Heart J 2018; 38:1509-1516. [PMID: 28329059 PMCID: PMC5429939 DOI: 10.1093/eurheartj/ehx032] [Citation(s) in RCA: 109] [Impact Index Per Article: 18.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2016] [Accepted: 02/13/2017] [Indexed: 12/21/2022] Open
Abstract
Aims To review maternal and foetal outcomes in women with mechanical heart valves (MHVs) treated with vitamin-K antagonists (VKAs), first-trimester heparin followed by VKAs (sequential treatment), low molecular weight heparin (LMWH) and unfractionated heparin (UFH) during pregnancy, in order to inform practice. Methods and results Medline, Embase and Central were searched from inception until February 2016. Two reviewers independently screened 1786 titles, reviewed 110 full-texts and extracted data and assessed risk-of-bias from 46 articles. Pooled incidence (95% confidence intervals) was calculated for maternal and foetal outcomes. Included studies had a moderate or high risk-of-bias. With VKAs, sequential treatment and LMWH, maternal mortality occurred in 0.9% (0.4–1.4), 2.0% (0.8–3.1) and 2.9% (0.2–5.7), thromboembolic complications in 2.7% (1.4–4.0), 5.8% (3.8–7.7) and 8.7% (3.9–13.4), livebirths in 64.5% (48.8–80.2), 79.9% (74.3–85.6) and 92.0% (86.1–98.0) and anticoagulant-related foetal/neonatal adverse events (embryopathy or foetopathy) in 2.0% (0.3–3.7), 1.4% (0.3–2.5) and 0%, respectively. When UFH is used throughout pregnancy, 11.2% (2.8–19.6) suffered thromboembolic complications. Foetal loss and adverse events occurred with first-trimester warfarin doses ≤ 5 mg/day, although there were more livebirths [83.6% (75.8–91.4) vs. 43.9% (32.8–55.0)] and fewer foetal anomalies [2.3% (0.7–4.0) vs. 12.4% (3.3–21.6)] with lower doses than with warfarin > 5 mg/day. Conclusions VKAs are associated with fewest maternal complications but also with fewest livebirths. Sequential treatment does not eliminate anticoagulant-related foetal/neonatal adverse events. LMWH is associated with the highest number of livebirths. The safety of UFH throughout pregnancy and first-trimester warfarin ≤ 5 mg/day remains unconfirmed.
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Affiliation(s)
- Rohan D'Souza
- Department of Obstetrics and Gynaecology, Division of Maternal and Fetal Medicine, Mount Sinai Hospital, University of Toronto, 700 University Avenue, Toronto ON M5G 1Z5, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, 155 College Street, Toronto ON M5T 3M6, Canada
| | - Jackie Ostro
- Department of Medicine, Division of Hematology, University of Toronto, Toronto, Canada
| | - Prakesh S Shah
- Institute of Health Policy, Management and Evaluation, University of Toronto, 155 College Street, Toronto ON M5T 3M6, Canada.,Department of Paediatrics, Division of Neonatology, Mount Sinai Hospital, University of Toronto, 700 University Avenue, Toronto ON M5G 1Z5, Canada
| | - Candice K Silversides
- Department of Medicine, Division of Cardiology, Obstetric Medicine Program, Mount Sinai Hospital, University of Toronto, 700 University Avenue, Toronto ON M5G 1Z5, Canada
| | - Ann Malinowski
- Department of Obstetrics and Gynaecology, Division of Maternal and Fetal Medicine, Mount Sinai Hospital, University of Toronto, 700 University Avenue, Toronto ON M5G 1Z5, Canada
| | - Kellie E Murphy
- Department of Obstetrics and Gynaecology, Division of Maternal and Fetal Medicine, Mount Sinai Hospital, University of Toronto, 700 University Avenue, Toronto ON M5G 1Z5, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, 155 College Street, Toronto ON M5T 3M6, Canada
| | - Mathew Sermer
- Department of Obstetrics and Gynaecology, Division of Maternal and Fetal Medicine, Mount Sinai Hospital, University of Toronto, 700 University Avenue, Toronto ON M5G 1Z5, Canada
| | - Nadine Shehata
- Institute of Health Policy, Management and Evaluation, University of Toronto, 155 College Street, Toronto ON M5T 3M6, Canada.,Departments of Medicine and Laboratory Medicine and Pathobiology, Mount Sinai Hospital, Division of Hematology, Mount Sinai Hospital, University of Toronto, 700 University Avenue, Toronto ON M5G 1Z5, Canada
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Pregnancy after Prosthetic Aortic Valve Replacement: How Do We Monitor Prosthetic Valvular Function during Pregnancy? Case Rep Obstet Gynecol 2018; 2018:4935957. [PMID: 29581907 PMCID: PMC5822848 DOI: 10.1155/2018/4935957] [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: 09/06/2017] [Revised: 12/01/2017] [Accepted: 12/19/2017] [Indexed: 11/17/2022] Open
Abstract
Background With modern medicine, many women after structural heart repair are deciding to experience pregnancy. There is a need for further study to identify normal echocardiographic parameters to better assess prosthetic valvular function in pregnancy. In addition, a multidisciplinary approach is essential in managing pregnant patients with complex cardiac conditions. Case A 22-year-old nulliparous woman with an aortic valve replacement 18 months prior to her pregnancy presented to prenatal care at 20-week gestation. During her prenatal care, serial echocardiography showed a significant increase in the mean gradient across the prosthetic aortic valve. Multidisciplinary management and a serial echocardiography played an integral role in her care that resulted in a successful spontaneous vaginal delivery without complications. Conclusion Further characterization of the normal echocardiographic parameters in pregnant patients with prosthetic valves is critical to optimize prenatal care for this patient population. This case report is novel in that serial echocardiograms were obtained throughout prenatal care, which showed significant changes across the prosthetic aortic valve. Teaching Points (1) Further study is needed to identify normal echocardiographic parameters to best assess prosthetic valvular function in pregnancy. (2) Multidisciplinary management is encouraged to optimize prenatal care for women with prosthetic aortic valve replacements.
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Cauldwell M, Gatzoulis M, Steer P. Congenital heart disease and pregnancy: A contemporary approach to counselling, pre-pregnancy investigations and the impact of pregnancy on heart function. Obstet Med 2017; 10:53-57. [PMID: 28680462 DOI: 10.1177/1753495x16687905] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2016] [Accepted: 12/04/2016] [Indexed: 12/17/2022] Open
Abstract
Cardiac disease in pregnancy is a challenging clinical problem. The number of women pursuing pregnancy and the underlying complexity of their cardiac disease is increasing, such that heart disease is now the leading cause of maternal mortality in developed countries. Women with congenital heart disease make up the majority of these cases and although maternal mortality is infrequent, a good outcome is only achieved though meticulous multidisciplinary care, beginning with pre-pregnancy counselling. All women with congenital heart disease should be assessed and be referred for pre-conception counselling prior to pregnancy and should receive thorough clinical assessment prior to pregnancy. In some conditions, such as pulmonary hypertension or severe/progressive aortic dilatation, pregnancy is of very high risk and women should be made aware of such risks. In such circumstances, if women choose to proceed with pregnancy, it is paramount that they are cared for by multidisciplinary teams who have experience and expertise of managing such conditions to minimise risks and optimise outcome.
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Affiliation(s)
- Matthew Cauldwell
- Academic Department of Obstetrics and Gynaecology, Imperial College London, Chelsea and Westminster Hospital, London, UK
| | - Michael Gatzoulis
- Adult Congenital Heart Centre, The National Heart and Lung Institute, Imperial College London, Royal Brompton Hospital, London, UK
| | - Philip Steer
- Academic Department of Obstetrics and Gynaecology, Imperial College London, Chelsea and Westminster Hospital, London, UK
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Vause S, Clarke B, Tower CL, Hay CRM, Knight M. Pregnancy outcomes in women with mechanical prosthetic heart valves: a prospective descriptive population based study using the United Kingdom Obstetric Surveillance System (UKOSS) data collection system. BJOG 2016; 124:1411-1419. [DOI: 10.1111/1471-0528.14478] [Citation(s) in RCA: 66] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/09/2016] [Indexed: 11/28/2022]
Affiliation(s)
- S Vause
- Obstetric Directorate; St Mary's Hospital; Central Manchester University Hospitals NHS Foundation Trust; Manchester UK
- Institute of Human Development; Manchester Academic Health Science Centre; University of Manchester; Manchester UK
| | - B Clarke
- Manchester Heart Centre; Manchester Royal Infirmary; Central Manchester University Hospitals NHS Foundation Trust; Manchester UK
- Institute of Cardiovascular Sciences; Manchester Academic Health Science Centre; University of Manchester; Manchester UK
| | - CL Tower
- Obstetric Directorate; St Mary's Hospital; Central Manchester University Hospitals NHS Foundation Trust; Manchester UK
- Institute of Human Development; Manchester Academic Health Science Centre; University of Manchester; Manchester UK
| | - CRM Hay
- Department of Haematology; Manchester Royal Infirmary; Central Manchester University Hospitals NHS Foundation Trust; Manchester UK
- Institute of Cancer Sciences; Manchester Academic Health Science Centre; University of Manchester; Manchester UK
| | - M Knight
- National Perinatal Epidemiology Unit; University of Oxford; Oxford UK
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Reineke D, Gisler F, Englberger L, Carrel T. Mechanical versus biological aortic valve replacement strategies. Expert Rev Cardiovasc Ther 2016; 14:423-30. [DOI: 10.1586/14779072.2016.1133293] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Fischer T, Grab D, Grubert T, Hantschmann P, Kainer F, Kästner R, Kentenich C, Klockenbusch W, Lammert F, Louwen F, Mylonas I, Pildner von Steinburg S, Rath W, Schäfer-Graf UM, Schleußner E, Schmitz R, Steitz HO, Verlohren S. Maternale Erkrankungen in der Schwangerschaft. FACHARZTWISSEN GEBURTSMEDIZIN 2016. [PMCID: PMC7158353 DOI: 10.1016/b978-3-437-23752-2.00017-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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