1
|
Tated RCP, Maheta D, Agrawal SP, Frishman WH, Aronow WS. Ischemic Heart Disease in Pregnancy: Current Understanding and Management Strategies. Cardiol Rev 2024:00045415-990000000-00310. [PMID: 39140736 DOI: 10.1097/crd.0000000000000774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/15/2024]
Abstract
Ischemic heart disease (IHD) during pregnancy poses a rare but significant risk to maternal and fetal health, with global incidence rates ranging from 0.7 to 10 cases per 100,000 pregnancies. This review synthesizes current literature on the epidemiology, pathophysiology, clinical presentation, diagnosis, management, and outcomes of IHD in pregnancy. Pregnancy-related IHD encompasses various conditions, including coronary artery disease, spontaneous coronary artery dissection, myocardial infarction with nonobstructive coronary arteries, coronary embolism, and coronary vasospasm. The pathophysiology is multifactorial, involving hemodynamic changes, hormonal influences, and increased hypercoagulability. Clinical presentation may mimic typical pregnancy symptoms, necessitating a high index of suspicion for timely diagnosis. A multidisciplinary strategy is needed for management, taking into account the hazards to the mother and fetus while also taking drug safety and procedural treatments such coronary artery bypass grafting and percutaneous coronary intervention into account. Careful observation and timely management are necessary for complications such as cardiogenic shock, arrhythmias, and thromboembolic events following myocardial infarction. With advancements in treatment techniques and early discovery, the prognosis has improved, although maternal mortality is still a worry. For the purpose of improving results and directing future research endeavors, knowledge and comprehension of IHD during pregnancy are essential.
Collapse
Affiliation(s)
| | - Darshilkumar Maheta
- From the Department of Public Health, New York Medical College, Valhalla, NY
| | - Siddharth Pravin Agrawal
- Department of Internal Medicine, New York Medical College/Landmark Medical Center, Woonsocket, RI
| | | | - Wilbert S Aronow
- Department of Cardiology and Medicine, Westchester Medical Center and New York Medical College, Valhalla, NY
| |
Collapse
|
2
|
Trajkovski AV, Reiner K, Džaja N, Mamić G, Mažar M, Peršec J, Gluncic V, Lukic A. Anesthetic management for cesarean section in two parturient with ascending aortic aneurysm: a case-based discussion. BMC Anesthesiol 2024; 24:169. [PMID: 38711027 PMCID: PMC11071247 DOI: 10.1186/s12871-024-02553-2] [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: 11/09/2023] [Accepted: 04/30/2024] [Indexed: 05/08/2024] Open
Abstract
BACKGROUND The anesthetic management of parturients with ascending aortic aneurysm for cesarean section can be particularly challenging, primarily because of increased risk for aortic dissection or aneurysm rupture. CASE PRESENTATION We present some aspects of the anesthetic management of two parturients with ascending aortic aneurysm for cesarean sections; amongst, the use of remifentanil with its effects on patient and newborn. We emphasize the importance of a cardio-obstetric team in the context of preoperative planning of such patients. Also, we reviewed some literature on the anesthetic management with its effect on peri-operative hemodynamic stability. CONCLUSION Maintaining hemodynamic stability is paramount in the prevention of the rupture or dissection of ascending aortic aneurysm during labor of parturient.
Collapse
Affiliation(s)
- Ana Vuzdar Trajkovski
- Department of Anesthesiology, Perioperative Management and Intensive Care in Gynecology and Obstetrics, Clinic of Anesthesiology, Reanimatology, Intensive Care and Pain Therapy, University Clinical Hospital Centre Zagreb, Kišpatićeva 12, Zagreb, 10000, Croatia
| | - Krešimir Reiner
- Department of Anesthesiology, Perioperative Management and Intensive Care in Gynecology and Obstetrics, Clinic of Anesthesiology, Reanimatology, Intensive Care and Pain Therapy, University Clinical Hospital Centre Zagreb, Kišpatićeva 12, Zagreb, 10000, Croatia
| | - Nikolina Džaja
- Department of Anesthesiology, Perioperative Management and Intensive Care in Gynecology and Obstetrics, Clinic of Anesthesiology, Reanimatology, Intensive Care and Pain Therapy, University Clinical Hospital Centre Zagreb, Kišpatićeva 12, Zagreb, 10000, Croatia
| | - Gloria Mamić
- Department of Anesthesiology, Perioperative Management and Intensive Care in Gynecology and Obstetrics, Clinic of Anesthesiology, Reanimatology, Intensive Care and Pain Therapy, University Clinical Hospital Centre Zagreb, Kišpatićeva 12, Zagreb, 10000, Croatia
| | - Mirabel Mažar
- Department of Anesthesiology and Intensive Care in Cardiac and Vascular Surgery, Clinic of Anesthesiology, Reanimatology, Intensive Care and Pain Therapy, University Clinical Hospital Centre Zagreb, Kišpatićeva 12, Zagreb, 10000, Croatia
| | - Jasminka Peršec
- Clinic of Anesthesiology, Reanimatology and Intensive Care Medicine, University Clinical Hospital Dubrava, Avenija Gojka Šuška 6, Zagreb, 10000, Croatia
| | - Vicko Gluncic
- Department of Anesthesia, Advocate Illinois Masonic Medical Center, 836 W Wellington Ave, Chicago, IL, 60657, USA
| | - Anita Lukic
- Department of Anesthesia, Intensive Medicine, and Reanimation, Varazdin General Hospital, 1 I. Mestrovica Street, Varazdin, 42 000, Croatia.
- University North, Ul. 104. Brigade 3, Varazdin, 42 000, Croatia.
- Bjelovar University of Applied Sciences, Nursing Studies, 4 Eugena Kvaternika Square, Bjelovar, HR-43000, Croatia.
| |
Collapse
|
3
|
Nguyen AH, Murrin E, Moyo A, Sharma G, Sullivan SA, Maxwell GL, Kennedy JLW, Saad AF. Ischemic heart disease in pregnancy: a practical approach to management. Am J Obstet Gynecol MFM 2024; 6:101295. [PMID: 38278176 DOI: 10.1016/j.ajogmf.2024.101295] [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: 12/08/2023] [Accepted: 01/03/2024] [Indexed: 01/28/2024]
Abstract
Ischemic heart disease is a crucial issue during pregnancy. The term is composed of both preexisting conditions and acute coronary syndrome in pregnancy, including pregnancy-associated myocardial infarction, which can have a significant effect on maternal and fetal outcomes. This review provides a complete guide to managing ischemic heart disease in pregnant women, emphasizing the importance of multidisciplinary care and individualized treatment strategies. Cardiovascular disease, particularly ischemic heart disease, is now the leading cause of maternal mortality worldwide. Pregnancy introduces unique physiological changes that increase the risk of acute myocardial infarction, with pregnancy-associated myocardial infarction cases often associated with factors, such as advanced maternal age, chronic hypertension, and preexisting cardiovascular conditions. This review distinguishes between preexisting ischemic heart disease and pregnancy-associated myocardial infarction. It will emphasize the various etiologies of pregnancy-associated myocardial infarction, including coronary atherosclerosis and plaque rupture presenting as ST-elevation myocardial infarction, non-ST-elevation myocardial infarction, and other nonatherosclerotic causes, including spontaneous coronary artery dissection, vasospasm, and embolism. Our study discusses the practical management of ischemic heart disease in pregnancy, with a focus on preconception counseling, risk assessment, and tailored antenatal planning for women with preexisting ischemic heart disease. Moreover, this document focuses on the challenges of diagnosing cardiovascular disease, especially when presented with nonclassical risk factors and presentation. It provides insight into the appropriate diagnostic testing methods, such as electrocardiogram, cardiac biomarkers, and echocardiography. In addition, the review covers various treatment strategies, from medical management to more invasive procedures, including coronary angiography, percutaneous coronary intervention, and coronary artery bypass graft. Special attention is given to medication safety during pregnancy, including anticoagulation, beta-blockers, and antiplatelet agents. The complexities of delivery planning in women with ischemic heart disease are discussed, advocating for a multidisciplinary team-based approach and careful consideration of the timing and mode of delivery. Furthermore, the roles of breastfeeding and postpartum care are explored, emphasizing the long-term benefits and the suitability of various medications during lactation. Lastly, this review provides crucial insights into the management of ischemic heart disease in pregnancy, stressing the need for heightened awareness, prompt diagnosis, and tailored management to optimize maternal and fetal health outcomes.
Collapse
Affiliation(s)
- Andrew H Nguyen
- Department of Internal Medicine, Inova Fairfax Hospital, Falls Church, Virginia (Drs Nguyen and Moyo)
| | - Ellen Murrin
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Inova Fairfax Hospital, Falls Church, Virginia (Drs Murrin, Sullivan, and Saad)
| | - Axucillia Moyo
- Department of Internal Medicine, Inova Fairfax Hospital, Falls Church, Virginia (Drs Nguyen and Moyo)
| | - Garima Sharma
- Department of Cardiology, Inova Schar Heart and Vascular Institute, Falls Church, Virginia (Drs Sharma and Kennedy)
| | - Scott A Sullivan
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Inova Fairfax Hospital, Falls Church, Virginia (Drs Murrin, Sullivan, and Saad)
| | - George L Maxwell
- Department of Obstetrics and Gynecology, Inova Fairfax Hospital, Falls Church, Virginia (Dr Maxwell)
| | - Jamie L W Kennedy
- Department of Cardiology, Inova Schar Heart and Vascular Institute, Falls Church, Virginia (Drs Sharma and Kennedy)
| | - Antonio F Saad
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Inova Fairfax Hospital, Falls Church, Virginia (Drs Murrin, Sullivan, and Saad).
| |
Collapse
|
4
|
Kim JA, Kim SY, Virk HUH, Alam M, Sharma S, Johnson MR, Krittanawong C. Acute Myocardial Infarction in Pregnancy. Cardiol Rev 2024:00045415-990000000-00222. [PMID: 38411170 DOI: 10.1097/crd.0000000000000681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/28/2024]
Abstract
Pregnancy-associated myocardial infarction is an overall uncommon event, but can be associated with significant maternal and fetal morbidity and mortality. In contrast to myocardial infarction in the general nonpregnant population, the mechanism of pregnancy-associated myocardial infarction is most commonly due to nonatherosclerotic mechanisms such as coronary dissection, vasospasm, or thromboembolism. The diagnosis of pregnancy-associated myocardial infarction can be challenging, requiring a high index of suspicion for prompt recognition and management. Furthermore, the management of pregnancy-associated myocardial infarction can be complex due to maternal and fetal considerations and may vary based on the specific underlying mechanism of the myocardial infarction. This review aims to review the recent literature on pregnancy-associated myocardial infarction and summarize the epidemiology, mechanisms, diagnosis, and treatment strategies for this uncommon entity.
Collapse
Affiliation(s)
- Jitae A Kim
- From the Department of Cardiology, University of Buffalo, New York, NY
| | - Sophie Y Kim
- Department of Obstetrics and Gynecology, Texas Tech University Health Sciences Center, El Paso, TX
| | - Hafeez Ul Hassan Virk
- Harrington Heart & Vascular Institute, Case Western Reserve University, University Hospitals Cleveland Medical Center, Cleveland, OH
| | - Mahboob Alam
- Division of Cardiology, The Texas Heart Institute, Baylor College of Medicine, Houston, TX
| | - Samin Sharma
- Cardiac Catheterization Laboratory of the Cardiovascular Institute, Mount Sinai Hospital, New York, NY
| | - Mark R Johnson
- Academic Department of Obstetrics and Gynaecology, Institute of Reproductive and Developmental Biology, Chelsea and Westminster Hospital, Imperial College London, London, UK; and
| | | |
Collapse
|
5
|
Brandstetter M, Neuner M, Dinges C, Hofstätter E, Wohlmuth C, Fazelnia C, Fischer T, Bogner G. Fetal Doppler monitoring during maternal open-heart surgery: Case report and key aspects of a multidisciplinary challenge. Eur J Obstet Gynecol Reprod Biol 2023; 287:63-66. [PMID: 37295346 DOI: 10.1016/j.ejogrb.2023.05.034] [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: 05/08/2023] [Accepted: 05/25/2023] [Indexed: 06/12/2023]
Abstract
CASE REPORT Herein we present the case of a 33-year nulliparous woman at 21 weeks of gestation with mitral valve vegetation resulting from infective endocarditis. Due to the mother's critical condition caused by consecutive thromboembolic events, surgery with cardiopulmonary bypass was indicated. During surgery the fetus was monitored by a specialized obstetrician who repetitively measured the Doppler indices of the umbilical artery, Ductus venosus and uterine artery. Right after CO2 was insufflated into the operating area, the Doppler monitoring showed an increased Pulsatility Index of the Umbilical artery right before fetal distress with bradycardia occurred. A subsequent maternal arterial blood gas analysis showed an acidosis with hypercapnia. Consequently, the CO2 insufflation was stopped and the gas flow on the Heart Lung Machine increased. After regaining homeostasis of acidosis, the Doppler Indices and fetal heart rate recovered. The remaining surgery and postoperative course were uneventful. At the 37 weeks of gestation a healthy boy was delivered by Cesarean section and at the age of two years, the neurodevelopment was assessed, which indicated normal development in mental cognition, language and motoric. This report presents a periodic Doppler examination of the maternal and fetal circulation during surgery on CPB while also discussing the possible impact of fetal monitoring in managing open cardiac surgery in pregnancy.
Collapse
Affiliation(s)
| | - Matthias Neuner
- Department of Anesthesiology, Paracelsus Medical University, Salzburg, Austria
| | - Christian Dinges
- Department of Heart Surgery, Paracelsus Medical University, Salzburg, Austria
| | - Edda Hofstätter
- Department of Neonatology, Paracelsus Medical University, Salzburg, Austria
| | - Christoph Wohlmuth
- Department of Obstetrics and Gynecology, Paracelsus Medical University, Salzburg, Austria
| | - Claudius Fazelnia
- Department of Obstetrics and Gynecology, Paracelsus Medical University, Salzburg, Austria
| | - Thorsten Fischer
- Department of Obstetrics and Gynecology, Paracelsus Medical University, Salzburg, Austria
| | - Gerhard Bogner
- Department of Obstetrics and Gynecology, Paracelsus Medical University, Salzburg, Austria.
| |
Collapse
|
6
|
Onofrei VA, Adam CA, Marcu DTM, Crisan Dabija R, Ceasovschih A, Constantin M, Grigorescu ED, Petroaie AD, Mitu F. Infective Endocarditis during Pregnancy-Keep It Safe and Simple! MEDICINA (KAUNAS, LITHUANIA) 2023; 59:medicina59050939. [PMID: 37241171 DOI: 10.3390/medicina59050939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Revised: 05/09/2023] [Accepted: 05/10/2023] [Indexed: 05/28/2023]
Abstract
The diagnosis of infective endocarditis (IE) during pregnancy is accompanied by a poor prognosis for both mother and fetus in the absence of prompt management by multidisciplinary teams. We searched the electronic databases of PubMed, MEDLINE and EMBASE for clinical studies addressing the management of infective endocarditis during pregnancy, with the aim of realizing a literature review ranging from risk factors to diagnostic investigations to optimal therapeutic management for mother and fetus alike. The presence of previous cardiovascular pathologies such as rheumatic heart disease, congenital heart disease, prosthetic valves, hemodialysis, intravenous catheters or immunosuppression are the main risk factors predisposing patients to IE during pregnancy. The identification of modern risk factors such as intracardiac devices and intravenous drug administration as well as genetic diagnostic methods such as cell-free deoxyribonucleic acid (DNA) next-generation sequencing require that these cases be addressed in multidisciplinary teams. Guiding treatment to eradicate infection and protect the fetus simultaneously creates challenges for cardiologists and gynecologists alike.
Collapse
Affiliation(s)
- Viviana Aursulesei Onofrei
- Department of Medical Specialties I, II, III and Preventive Medicine and Interdisciplinary, "Grigore T. Popa" University of Medicine and Pharmacy, University Street No. 16, 700115 Iasi, Romania
- "St. Spiridon" Clinical Emergency Hospital, Independence Boulevard No. 1, 700111 Iasi, Romania
| | - Cristina Andreea Adam
- Department of Medical Specialties I, II, III and Preventive Medicine and Interdisciplinary, "Grigore T. Popa" University of Medicine and Pharmacy, University Street No. 16, 700115 Iasi, Romania
- Cardiovascular Rehabilitation Clinic, Clinical Rehabilitation Hospital, Pantelimon Halipa Street No. 14, 700661 Iasi, Romania
| | - Dragos Traian Marius Marcu
- Department of Medical Specialties I, II, III and Preventive Medicine and Interdisciplinary, "Grigore T. Popa" University of Medicine and Pharmacy, University Street No. 16, 700115 Iasi, Romania
- Clinical Hospital of Pneumophthisiology Iași, Doctor Iosif Cihac Street No. 30, 700115 Iasi, Romania
| | - Radu Crisan Dabija
- Department of Medical Specialties I, II, III and Preventive Medicine and Interdisciplinary, "Grigore T. Popa" University of Medicine and Pharmacy, University Street No. 16, 700115 Iasi, Romania
- Clinical Hospital of Pneumophthisiology Iași, Doctor Iosif Cihac Street No. 30, 700115 Iasi, Romania
| | - Alexandr Ceasovschih
- Department of Medical Specialties I, II, III and Preventive Medicine and Interdisciplinary, "Grigore T. Popa" University of Medicine and Pharmacy, University Street No. 16, 700115 Iasi, Romania
- "St. Spiridon" Clinical Emergency Hospital, Independence Boulevard No. 1, 700111 Iasi, Romania
| | - Mihai Constantin
- Department of Medical Specialties I, II, III and Preventive Medicine and Interdisciplinary, "Grigore T. Popa" University of Medicine and Pharmacy, University Street No. 16, 700115 Iasi, Romania
- "St. Spiridon" Clinical Emergency Hospital, Independence Boulevard No. 1, 700111 Iasi, Romania
| | - Elena-Daniela Grigorescu
- Department of Medical Specialties I, II, III and Preventive Medicine and Interdisciplinary, "Grigore T. Popa" University of Medicine and Pharmacy, University Street No. 16, 700115 Iasi, Romania
| | - Antoneta Dacia Petroaie
- Department of Medical Specialties I, II, III and Preventive Medicine and Interdisciplinary, "Grigore T. Popa" University of Medicine and Pharmacy, University Street No. 16, 700115 Iasi, Romania
| | - Florin Mitu
- Department of Medical Specialties I, II, III and Preventive Medicine and Interdisciplinary, "Grigore T. Popa" University of Medicine and Pharmacy, University Street No. 16, 700115 Iasi, Romania
- Cardiovascular Rehabilitation Clinic, Clinical Rehabilitation Hospital, Pantelimon Halipa Street No. 14, 700661 Iasi, Romania
- Academy of Medical Sciences, Ion C. Brătianu Boulevard No. 1, 030167 Bucharest, Romania
- Academy of Romanian Scientists, Professor Dr. Doc. Dimitrie Mangeron Boulevard No. 433, 700050 Iasi, Romania
| |
Collapse
|
7
|
Pitfield AF, Bedard A, Bashir J, Bruce S, Augoustides JG, Cormican DS, Marchant BE, Fernando RJ. Anesthetic Management for Cardiac Surgery During Pregnancy Complicated by Postoperative Threatened Abortion. J Cardiothorac Vasc Anesth 2023; 37:158-166. [PMID: 36319562 DOI: 10.1053/j.jvca.2022.09.098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2022] [Accepted: 09/28/2022] [Indexed: 11/06/2022]
Affiliation(s)
| | | | - Jamil Bashir
- University of British Columbia, Vancouver, BC, Canada
| | - Simon Bruce
- Department of Anesthesia, Providence Health Care, University of British Columbia, Vancouver, BC, Canada
| | - John G Augoustides
- Cardiovascular and Thoracic Division, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Daniel S Cormican
- Divisions of Cardiothoracic Anesthesiology & Critical Care Medicine, Anesthesiology Institute, Allegheny Health Network, Pittsburgh, PA
| | - Bryan E Marchant
- Department of Anesthesiology, Cardiothoracic and Critical Care Sections, Wake Forest School of Medicine, Medical Center Boulevard, Winston Salem, NC
| | - Rohesh J Fernando
- Department of Anesthesiology, Cardiothoracic Section, Wake Forest School of Medicine, Medical Center Boulevard, Winston Salem, NC.
| |
Collapse
|
8
|
Zaleski KL, Blazey MH, Carabuena JM, Economy KE, Valente AM, Nasr VG. Perioperative Anesthetic Management of the Pregnant Patient With Congenital Heart Disease Undergoing Cardiac Intervention: A Systematic Review. J Cardiothorac Vasc Anesth 2022; 36:4483-4495. [PMID: 36195521 DOI: 10.1053/j.jvca.2022.09.001] [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: 06/13/2022] [Revised: 08/29/2022] [Accepted: 09/01/2022] [Indexed: 11/11/2022]
Abstract
Maternal congenital heart disease is increasingly prevalent, and has been associated with a significantly increased risk of maternal, obstetric, and neonatal complications. For patients with CHD who require cardiac interventions during pregnancy, there is little evidence-based guidance with regard to optimal perioperative management. The periprocedural management of pregnant patients with congenital heart disease requires extensive planning and a multidisciplinary teams-based approach. Anesthesia providers must not only be facile in the management of adult congenital heart disease, but cognizant of the normal, but significant, physiologic changes of pregnancy.
Collapse
Affiliation(s)
- Katherine L Zaleski
- Department of Anesthesiology, Critical Care, and Pain Medicine-Boston Children's Hospital, Harvard Medical School, Boston, MA
| | | | - Jean M Carabuena
- Department of Anesthesiology, Perioperative and Pain Medicine-Brigham and Women's Hospital, Harvard Medical School, Boston MA
| | - Katherine E Economy
- Division of Maternal-Fetal Medicine, Brigham, and Women's Hospital, Harvard Medical School, Boston, MA
| | - Anne M Valente
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Viviane G Nasr
- Department of Anesthesiology, Critical Care, and Pain Medicine-Boston Children's Hospital, Harvard Medical School, Boston, MA.
| |
Collapse
|
9
|
O’Kelly AC, Ludmir J, Wood MJ. Acute Coronary Syndrome in Pregnancy and the Post-Partum Period. J Cardiovasc Dev Dis 2022; 9:jcdd9070198. [PMID: 35877560 PMCID: PMC9319853 DOI: 10.3390/jcdd9070198] [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: 05/31/2022] [Revised: 06/14/2022] [Accepted: 06/16/2022] [Indexed: 11/16/2022] Open
Abstract
Cardiovascular disease is the leading cause of maternal mortality in the United States. Acute coronary syndrome (ACS) is more common in pregnant women than in non-pregnant controls and contributes to the burden of maternal mortality. This review highlights numerous etiologies of chest discomfort during pregnancy, as well as risk factors and causes of ACS during pregnancy. It focuses on the evaluation and management of ACS during pregnancy and the post-partum period, including considerations when deciding between invasive and non-invasive ischemic evaluations. It also focuses specifically on the management of post-myocardial infarction complications, including shock, and outlines the role of mechanical circulatory support, including veno-arterial extracorporeal membrane oxygenation (VA-ECMO). Finally, it offers additional recommendations for navigating delivery in women who experienced pregnancy-associated myocardial infarction and considerations for the post-partum patient who develops ACS.
Collapse
|
10
|
Deedwania P, Dadhwal V, Sharma KA. Advanced Pregnancies With Valvular Heart Disease Requiring Peripartum Cardiac Intervention: Two Case Reports and Literature Review. Cureus 2022; 14:e22072. [PMID: 35308752 PMCID: PMC8920825 DOI: 10.7759/cureus.22072] [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] [Accepted: 02/09/2022] [Indexed: 11/05/2022] Open
Abstract
Cardiac interventions during advanced gestation carry a risk of maternal complications including mortality, along with the serious threat to the life of a viable fetus. However, with advancements in anesthesia and surgery techniques, cardiac interventions can be performed successfully during the peripartum period. We report two cases of decompensated severe valvular stenosis in the third trimester. One patient underwent balloon valvuloplasty followed by cesarean delivery. However, the other underwent a cesarean delivery followed by double valve replacement. Favorable maternal and fetal outcomes were achieved through peripartum interventions. Good fetomaternal outcomes can be obtained in women with severe valvular heart disease (VHD) presenting late in pregnancy. The decision for the timing of cardiac intervention in relation to cesarean section (CS) can vary from case-to-case basis.
Collapse
|
11
|
You Y, Liu S, Wu Z, Chen D, Wang G, Chen G, Pan Y, Zheng X. Cardiac surgery under cardiopulmonary bypass in pregnancy: report of four cases. J Cardiothorac Surg 2021; 16:268. [PMID: 34563221 PMCID: PMC8467144 DOI: 10.1186/s13019-021-01650-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2021] [Accepted: 08/29/2021] [Indexed: 12/11/2022] Open
Abstract
Background Open heart surgery during pregnancy is relatively rare at home and abroad, and there is a higher risk and probability of maternal and infant death. How to carry out heart valve replacement under cardiopulmonary bypass (CPB) under the premise of ensuring the safety of mother and child is the focus of attention at home and abroad. Case introduction We reported four cases of cardiac surgeries under CPB during pregnancy performed in our hospital from March 2020 to March 2021. Two of the patients continued their pregnancy after cardiac surgery under CPB. Three patients had infective endocarditis and the other one had an ascending aortic aneurysm. Three patients underwent heart valve placement with the mechanical mitral valve when the other one underwent Bentall surgery. The operations of four cases were all successful, and further follow-up evaluation of the pregnant women and fetuses showed no abnormalities. The patients' detailed information is shown in the following table. Conclusion Heart disease during pregnancy should be treated actively and proactively when the patient has obvious symptoms. Heart valve replacement under CPB will be the first choice, and this may become the primary surgical treatment for symptomatic heart disease during pregnancy.
Collapse
Affiliation(s)
- Youhao You
- Thoracic and Cardiovascular Surgery, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Shenghua Liu
- Thoracic and Cardiovascular Surgery, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China.
| | - Zhaohong Wu
- Thoracic and Cardiovascular Surgery, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Dunjin Chen
- Obstetrics and Gynecology Department, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Gefei Wang
- Thoracic and Cardiovascular Surgery, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Gangdong Chen
- Thoracic and Cardiovascular Surgery, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Youguang Pan
- Thoracic and Cardiovascular Surgery, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Xing Zheng
- Thoracic and Cardiovascular Surgery, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China
| |
Collapse
|
12
|
Pregnancy-Associated Myocardial Infarction: A Review of Current Practices and Guidelines. Curr Cardiol Rep 2021; 23:142. [PMID: 34410528 DOI: 10.1007/s11886-021-01579-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/10/2021] [Indexed: 12/12/2022]
Abstract
PURPOSE OF REVIEW Pregnancy-associated myocardial infarction is a principal cause of cardiovascular disease with a steadily rising incidence of 4.98 AMI events/100,000 deliveries over the last four decades in the USA. It is also linked with significant maternal and fetal morbidity and mortality, with maternal case fatality rate ranging from 5.1 to 37%. The management of acute myocardial infarction can be challenging in pregnant patients since treatment modalities and medication use are limited by their safety during pregnancy. RECENT FINDINGS Limited guidelines exist regarding the management of pregnancy-associated myocardial infarction. Routinely used medications in myocardial infarction including angiotensin-converting enzyme inhibitors (ACEI), angiotensin receptor blockers (ARB), and statin therapy are contraindicated during pregnancy. Aspirin use is considered safe in pregnant women, but dual antiplatelet therapy and therapeutic anticoagulation can be associated with increased risk of maternal and fetal complications, and should only be used after a comprehensive benefit-to-risk assessment. The standard approach to revascularization requires additional caution in pregnant women. Percutaneous coronary intervention is generally considered safe but can be associated with high failure rates and poor outcomes depending on the etiology. Fibrinolytic therapy may have significant sequelae in pregnant patients, and hemodynamic management during surgery is complex and adds risk during pregnancy. Understanding the risks and benefits of the different treatment modalities available and their utility depending on the underlying etiology, encompassed with a multidisciplinary team approach, is vital to improve outcomes and minimize maternal and fetal complications.
Collapse
|
13
|
Hussey H, Hussey P, Meng ML. Peripartum considerations for women with cardiac disease. Curr Opin Anaesthesiol 2021; 34:218-225. [PMID: 33935168 PMCID: PMC8610034 DOI: 10.1097/aco.0000000000000992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW The aim of this review of cardiac disease in pregnancy is to delineate current best practices and highlight emerging themes in the literature. RECENT FINDINGS Cardiovascular disease is the leading cause of death among pregnant women in the United States. Many clinicians and institutions have developed care pathways to approach care in these high-risk patients including highly coordinated multidisciplinary teams. The diagnosis of pulmonary hypertension is the greatest risk factor for an adverse event in pregnant women. Vaginal delivery, with good neuraxial anesthesia, is usually the preferred mode of delivery in women with cardiac disease, although the rate of cesarean delivery is higher among women with heart disease. SUMMARY The leading cause of morbidity and mortality in pregnant women is cardiac disease. Preconception counseling is useful for optimizing patients for pregnancy and setting appropriate expectations about care and outcomes. Ensuring that women are cared for in centers with appropriate multidisciplinary resources is key for improving outcomes for cardio-obstetric patients.
Collapse
Affiliation(s)
- Hanna Hussey
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Patrick Hussey
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Marie-Louise Meng
- Department of Anesthesiology, Duke University, Durham, North Carolina, USA
| |
Collapse
|
14
|
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.
Collapse
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
| |
Collapse
|
15
|
Raveenthiran S, Harky A. Marfan syndrome, aortic dissection, and pregnancy-the triple combination. J Card Surg 2020; 35:2118. [PMID: 32652727 DOI: 10.1111/jocs.14788] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 05/15/2020] [Indexed: 12/12/2022]
Affiliation(s)
| | - Amer Harky
- School of Medicine, University of Liverpool, Liverpool, UK.,Department of Cardiothoracic Surgery, Liverpool Heart and Chest, Liverpool, UK
| |
Collapse
|