Cardiomyopathy and pregnancy

Maternal and neonatal outcomes in pregnant women undergoing cardiac surgery: a systematic review and meta-analysis

OBJECTIVE

Cardiac diseases that require surgical intervention present a unique challenge during pregnancy and may affect both maternal and neonatal outcomes. This systematic review and meta-analysis aimed to evaluate maternal and neonatal outcomes in pregnant females undergoing cardiac surgery.

METHODS

A comprehensive manual and electronic search was conducted in PubMed, EMBASE, Cochrane Library, and Web of Sciences databases for studies published up to 31st May 2024. Eligible studies were required to report maternal and neonatal outcomes of women who underwent cardiac surgery during pregnancy. Random-effects meta-analysis was conducted to estimate pooled maternal and neonatal mortality proportions, and the results were presented as risk ratios (RR) with 95% confidence intervals (CIs).

RESULTS

Seventeen studies met the inclusion criteria, comprising a total sample size of 196 pregnant women who underwent cardiac surgery. Cardiac surgery during pregnancy was significantly (p < 0.001) linked to increased maternal and neonatal mortality, with pooled RR of 4.9% (CI: 2.1%-7.6%) and 26.5% (CI: 19.7%-33.4%), respectively.

CONCLUSION

This study highlights the significant risks associated with cardiac surgery during pregnancy, such as increased risk of maternal and neonatal mortality and higher incidence of preterm labor. Our findings underscore the importance of specialized care and multidisciplinary management for pregnant women with cardiac conditions. Further research is warranted to identify strategies for risk mitigation and improved outcomes in this vulnerable population.

Maternal heart failure: state-of-the-art review

Pregnancy is a period of substantial changes to the body's normal physiology, and the failure to adapt to these changes can lead to life-threatening pathology, particularly involving the cardiovascular system. In comparison to pre-pregnancy physiology, pregnant women have increased blood volume and physical demands which exert increased stress on the heart. This is important to consider in women with and without previously diagnosed cardiovascular disease, as the physiologic changes during pregnancy and postpartum can lead to sudden decompensation. The management of heart failure is particularly important as it remains the most common cardiovascular complication during pregnancy and is associated with substantial maternal and fetal morbidity and mortality. This is especially true in patients with pre-existing heart failure, who should receive counseling before conception and in certain cases be advised against pregnancy. For these reasons, healthcare professionals must be well-versed in the different strategies of diagnosis, management, treatment, and monitoring. This review will outline the pathophysiology, diagnostics, management, and general approach to heart failure in pregnant patients.

Heart disease in pregnancy and adverse outcomes: an umbrella review

Background

Heart disease in pregnancy encompasses both congenital heart disease and maternal-acquired heart disease, both of which are associated with an increased risk of various adverse outcomes for mothers and their offspring.

Objective

The objective of the study was to review and summarize the evidence regarding the association between heart disease in pregnancy and adverse outcomes in mothers and their offspring.

Data sources

A comprehensive search was conducted in Embase, PubMed, Web of Science, and the Cochrane Database of Systematic Reviews from inception to March 2024. The protocol for this review was registered in PROSPERO (CRD42024519144).

Study eligibility criteria

This review included systematic reviews and meta-analyses that examined the association between heart disease in pregnancy and adverse outcomes for mothers and their offspring.

Study appraisal and synthesis methods

Data were independently extracted by two reviewers. The quality of the systematic reviews and meta-analyses was assessed using the A Measurement Tool to Assess Systematic Reviews 2 (AMSTAR2), while Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) was used to evaluate the strength of the evidence for each outcome.

Results

A total of 12 meta-analyses and systematic reviews were included, which documented 156 adverse outcomes for mothers and 65 adverse outcomes for offspring. Evidence was found for both primary and secondary adverse outcomes. Adverse outcomes for mothers were death, cardiac events (cardiac arrest, heart failure, surgery, arrhythmia, anesthesia or sedation, endocarditis, mitral regurgitation, myocardial infarction, NYHA III-IV, restenosis, syncope, and others), pulmonary events (respiratory failure, pulmonary edema, and respiratory support), embolism, cerebrovascular events, postpartum hemorrhage, arterial events, delivery mode, and hospital stay. Adverse outcomes for offspring were death, pregnancy loss, growth restriction, low birth weight, preterm birth, recurrence, and uncertainty. No publication bias was detected using Egger's test. The overall AMSTAR 2 confidence rating for the included meta-analyses and systematic reviews was moderate. The majority (55.3%) of the evidence evaluated by GRADE was of low quality, while the remaining outcomes were categorized as having "very low"-quality evidence.

Conclusion

Current evidence links heart disease during pregnancy to adverse maternal outcomes, including death and cardiac, pulmonary, and cerebrovascular events, as well as increased mortality risk for offspring. Many meta-analyses in this field have limitations that raise concerns about their validity, highlighting the need for high-quality prospective studies.

Pregnancy-Related Cardiovascular Diseases: A Radiological Overview

Pregnancy induces significant hemodynamic changes, and cardiovascular diseases (CVDs) are one of the leading causes of non-obstetric maternal morbidity and mortality during pregnancy or the postpartum period in developed countries. The effective diagnosis and management of CVDs in pregnant women require a thorough evaluation that considers the health of both the mother and the fetus. Imaging plays a pivotal role in this evaluation, offering essential insights into the most significant pregnancy-related CVDs. However, due to concerns about fetal exposure, the use of contrast agents and radiation exposure must be carefully managed. Following to the principle of "As Low As Reasonably Achievable" (ALARA), strategies to minimize these risks are crucial for ensuring patient safety while maintaining diagnostic accuracy. This review highlights the contribution of cardiovascular imaging techniques, particularly computed tomography (CT) and magnetic resonance imaging (MRI), in the assessment of common pregnancy-related CVDs, and outlines strategies to reduce radiation exposure and limit contrast agent use when feasible, aiming to increase radiologists' awareness of this crucial topic.

Peripartum management of cardiac arrhythmias: a narrative review

Cardiac arrhythmias are responsible for a significant portion of cardiovascular disease among pregnant people. As the incidence of arrhythmias in pregnancy continues to increase, anesthesiologists who care for obstetric patients should be experts managing arrhythmias in pregnancy. This article examines the most common arrhythmias encountered in pregnancy, including risk factors, diagnosis, and management strategies. Peripartum monitoring and labor analgesia recommendations are discussed. Additionally, management of cardioversion, management of pacemakers and implantable cardioverter-defibrillators, and advanced cardiac life support in the setting of pregnancy is reviewed.

Cardiac physiology and pathophysiology in pregnancy

Cardiovascular disease is the leading indirect cause of maternal morbidity and mortality, accounting for nearly one third of maternal deaths during pregnancy. The burden of cardiovascular disease in pregnancy is increasing, as are the incidence of maternal morbidity and mortality. Normal physiologic adaptations to pregnancy, including increased cardiac output and plasma volume, may unmask cardiac conditions, exacerbate previously existing conditions, or create de novo complications. It is important for care providers to understand the normal physiologic changes of pregnancy and how they may impact the care of patients with cardiovascular disease. This review outlines the physiologic adaptions during pregnancy and their pathologic implications for some of the more common cardiovascular conditions in pregnancy.

Incident stroke in individuals with peripartum cardiomyopathy

BACKGROUND

Peripartum cardiomyopathy (PPCM), a form of heart failure with reduced ejection fraction (HFrEF) that occurs during the final month of pregnancy through the first 5 months postpartum, is associated with heightened risk for maternal morbidity and mortality. Stroke is a common complication of HFrEF but there is limited data on the incidence of stroke in PPCM.

METHODS

Using statewide, nonfederal administrative data from 2000 to 2015, we analyzed age-adjusted risk of stroke within 3 years after PPCM-associated pregnancies.

RESULTS

PPCM was associated with a greater than 4-fold increased risk of pregnancy-related stroke (aHR 4.7, 95% CI: 3.0-7.5). This risk was highest at the time of PPCM diagnosis but remained elevated in the first postpartum year.

CONCLUSION

Our findings confirm the strong association between PPCM and stroke, with risk that persists throughout and after the peripartum period.

The role of fibrosis in cardiomyopathies: An opportunity to develop novel biomarkers of disease activity

Cardiomyopathies encompass a spectrum of heart disorders with diverse causes and presentations. Fibrosis stands out as a shared hallmark among various cardiomyopathies, reflecting a common thread in their pathogenesis. This prevalent fibrotic response is intricately linked to the consequences of dysregulated extracellular matrix (ECM) remodeling, emphasizing its significance in the development and progression the disease. This review explores the ECM involvement in various cardiomyopathies and its impact on myocardial stiffness and fibrosis. Additionally, we discuss the potential of ECM fragments as early diagnosis, prognosis, and risk stratification. Biomarkers deriving from turnover of collagens and other ECM proteins hold promise in clinical applications. We outline current clinical management, future directions, and the potential for personalized ECM-targeted therapies with specific focus on microRNAs. In summary, this review examines the role of the fibrosis in cardiomyopathies, highlighting the potential of ECM-derived biomarkers in improving disease management with implications for precision medicine.

Management of Friedreich Ataxia-Associated Cardiomyopathy in Pregnancy: A Review of the Literature

A major manifestation of Friedreich ataxia (FRDA) is cardiomyopathy, caused by mitochondrial proliferation in myocytes. Because the lifespan for patients with FRDA improves with better treatment modalities, more patients are becoming pregnant, meaning that more medical providers must know how to care for this population. This report provides a review of the literature on multidisciplinary management of pregnant patients with FRDA and cardiomyopathy from preconception through lactation. A cardio-obstetrics team, including cardiology, anesthesiology, and obstetrics, should be involved for this entire period. All patients should be counseled on pregnancy risk using elements of existing stratification systems, and contraception should be discussed, highlighting the safety of intrauterine devices. Electrocardiogram should be obtained at baseline and each trimester, looking for atrial arrhythmias and ST-segment changes, as should transthoracic echocardiogram, with a focus on left ventricular ejection fraction-which is typically normal in FRDA cardiomyopathy-and relative wall thickness and global longitudinal strain-which tend to decrease as cardiomyopathy progresses. Brain natriuretic peptide is also a helpful marker to detect adverse events. If heart failure develops, it should be treated like any other etiology of heart failure during pregnancy. Atrial arrhythmias should be treated with β blockers or electrical cardioversion and anticoagulation, as necessary. Most patients with FRDA can deliver vaginally, and neuraxial analgesia is recommended during labor because of the risks associated with general anesthesia. Breastfeeding is encouraged, even for those taking cardiac medications.

Continuous Spinal Anesthesia for Labor Analgesia and Cesarean Delivery in a Parturient With Familial Dilated Cardiomyopathy: A Case Report

We report a case of successful continuous spinal anesthesia (CSA) for labor analgesia and cesarean delivery in a patient with familial dilated cardiomyopathy (DCM). A 33-year-old pregnant woman diagnosed with DCM was scheduled for a vaginal delivery under labor analgesia. An accidental intrathecal catheter was placed, and labor analgesia was provided by CSA. The vaginal delivery was converted to a cesarean delivery, and an intrathecal catheter was used for transition, which avoided hemodynamic changes and allowed the patient to safely undergo cesarean delivery. CSA is a reliable and rapidly titratable technique that provides excellent analgesia without hemodynamic changes in patients with DCM undergoing labor analgesia and subsequent cesarean delivery.

Contraception and Cardiovascular Effects: What Should the Cardiologist Know?

PURPOSE OF REVIEW

Cardiovascular disease (CVD) is the leading cause of death in women. This review highlights contraceptive options and their effects on the cardiovascular system (CVS). It provides guidance to cardiologists to make informed decisions regarding the safety of contraceptive use and cardiovascular risk stratification in the care of women of childbearing age.

RECENT FINDINGS

Approximately 44% of American women live with some type of CVD. Many women use hormonal contraception during their lifetime. It is imperative that cardiologists have a robust understanding of the forms of contraception in current use and their cardiovascular effects. This contemporary review provides a comprehensive summary of available contraceptive methods to practicing cardiologists and aims to be used as a resource to guide cardiovascular specialists on contraception in the context of cardiovascular disease.

Epidemiological features and mortality risk factors of peripartum cardiomyopathy in a group of Sub-Saharan African population

BACKGROUND

Peripartum cardiomyopathy (PPCM) is a rare cause of heart failure occurring during pregnancy. Its prevalence seems more frequent in Africa but its epidemiological, clinical and evolutionary particularities remain unknown. This study aimed to evaluate the epidemiological features and mortality risk factors of PPCM.

MATERIAL AND METHOD

We conducted a retrospective cross-sectional study over 38 months (January 2018 to March 2021) in 3 hospitals in the city of Douala(Cameroon). We included all patients with heart failure between the last month of pregnancy and 5 months after delivery without an identified cause. Were excluded, files not containing data on echocardiography, patients with heart failure without dilation or with LVEF≥ 45% and patients with a history of heart disease of known aetiology. Chi² tests and binary logistic regression were used for data analysis; the survival curve according to Kaplan Meier was drawn for the evolution. The threshold of significance was set at 0.05.

RESULTS

A total of 2102 medical records of women with heart failure were searched. In these records, a total of 59 patients showed signs of peripartum heart failure and only 29 fulfilled the inclusion criteria. From a socio-demographic point of view, the average age was 29 ± 7 years and 51.7% of patients were over 30 years old. Among these patients, 79.3% of patients lived in urban areas and 10.3% of patients had a low socio-economic level. The hospital frequency of PPCM was 1.3%. Clinically, primiparous and pauciparous women were the most affected; the diagnosis was made after more than a month of progression in 65.5% of patients. Dyspnea was present in all patients. In addition, 89.7% of patients had a left ventricular end-diastolic diameter ≥ 62 m, 48.3 % had a left ventricular ejection fraction (LVEF) between 30% and 45%, and 51.7% had an LVEF < 30%. The associated mortality rate was 27.7%. The only prognostic factor independently associated with mortality was age < 30 years.

CONCLUSION

The frequency of PPCM is relatively low in Cameroonian urban settings. Moreover, its diagnosis is generally delayed and it induces high mortality. Its occurrence in a woman under the age of 30 is a factor of poor prognosis.

Cardiac Complications of Pregnancy in Desmoplakin Cardiomyopathy

We present the course of 4 pregnancies in 3 women with desmoplakin cardiomyopathy, with a focus on changes in left ventricular ejection fraction and N-terminal pro-B-type natriuretic peptide levels from the prepregnancy period through the postpartum period, as well as maternal cardiac, obstetric, and neonatal outcomes. (Level of Difficulty: Advanced.).

ACC/AHA/HFSA 2022 and ESC 2021 guidelines on heart failure comparison

The 2022 American College of Cardiology/American Heart Association/Heart Failure Society of America (ACC/AHA/HFSA) and the 2021 European Society of Cardiology (ESC) both provide evidence-based guides for the diagnosis and treatment of heart failure (HF). In this review, we aimed to compare recommendations suggested by these guidelines highlighting the differences and latest evidence mentioned in each of the guidelines. While the staging of HF depends on left ventricular ejection fraction, the Universal Definition of HF, suggested in 2021, is described in 2022 ACC/AHA/HFSA guidelines. Both guidelines recommend invasive and non-invasive tests to diagnose. Despite being identical in the backbone, some differences exist in medical therapy and devices, which can be partially attributed to the recent trials published that are presented in the American guidelines. The recommendation of implantable cardioverter defibrillator for prevention in HF with reduced ejection fraction (HFrEF) patients, made by ACC/AHA/HFSA guidelines, is among the bold differences. It seems that ACC/AHA/HFSA guidelines emphasize the quality of life, cost-effectiveness, and optimization of care given to patients. On the other hand, the ESC guidelines provide recommendations for certain comorbidities. This comparison can guide clinicians in choosing the proper approach for their own settings and the writing committees in addressing the differences in order to have better consistency in future guidelines.

2023 National Heart Center/Saudi Heart Association Focused Update of the 2019 Saudi Heart Association Guidelines for the Management of Heart Failure

Background

The burden of cardiovascular diseases is undeniable in local populations, who have high mortality rates and a young age of disease onset. A systematic review of emerging evidence and update of the Saudi Heart Association (SHA) 2019 heart failure (HF) guidelines was therefore undertaken.

Methodology

A panel of expert cardiologists reviewed recommendations of the 2019 guidelines following the Saudi Heart Association methodology for guideline recommendations. When needed, the panel provided updated and new recommendations endorsed by the national heart council that are appropriate for clinical practice and local resources in Saudi Arabia.

Recommendations and conclusion

The focused update describes the appropriate use of clinical assessment as well as invasive and non-invasive modalities for the classification and diagnosis of HF. The prevention of HF was emphasized by expanding on both primary and secondary prevention approaches. Pharmacological treatment of HF was supplemented with recommendations on newer therapies, such as SGLT-2 inhibitors. Recommendations were also provided on the management of patients with cardiovascular and non-cardiovascular co-morbidities, with a focus on cardio-oncology and pregnancy. Updated clinical algorithms were included in support of HF management in both the acute and chronic settings. The implementation of this focused update on HF management in clinical practice is expected to lead to improved patient outcomes by providing evidence-based comprehensive guidance for practitioners in Saudi Arabia.

Introducing and Implementing Genetic Assessment in Cardio-Obstetrics Clinical Practice: Clinical and Genetic Workup of Patients with Cardiomyopathy

Cardiovascular disease (CVD) during pregnancy varies significantly worldwide, influenced by factors such as access to healthcare, delayed diagnosis, causes, and risk factors. Our study sought to explore the spectrum of CVD present in pregnant women in the United Arab Emirates to better understand this population's unique needs and challenges. Central to our study is an emphasis on the importance of implementing a multidisciplinary approach that involves the collaboration of obstetricians, cardiologists, geneticists, and other healthcare professionals to ensure that patients receive comprehensive and coordinated care. This approach can also help identify high-risk patients and implement preventive measures to reduce the occurrence of adverse maternal outcomes. Furthermore, increasing awareness among women about the risk of CVD during pregnancy and obtaining detailed family histories can help in the early identification and management of these conditions. Genetic testing and family screening can also aid in identifying inherited CVD that can be passed down through families. To illustrate the significance of such an approach, we provide a comprehensive analysis of five women's cases from our retrospective study of 800 women. The findings from our study emphasize the importance of addressing maternal cardiac health in pregnancy and the need for targeted interventions and improvements in the existing healthcare system to reduce adverse maternal outcomes.

Perinatal outcomes in pregnancies complicated by maternal cardiomyopathy: a systematic review and meta-analysis

OBJECTIVE

This study aimed to systematically assess perinatal outcomes of pregnancies complicated by maternal cardiomyopathy.

DATA SOURCES

PubMed, Ovid Embase, Ovid MEDLINE, the Cochrane Library, and ClinicalTrials.gov were systematically searched from inception to August 25, 2022.

STUDY ELIGIBILITY CRITERIA

Observational cohort, case-control, and case-cohort studies in human populations were included if they reported predefined perinatal outcomes in pregnant women with cardiomyopathy (any subtype) and an appropriate control population (either pregnant women with no known cardiac disease or pregnant women with noncardiomyopathy cardiac disease).

METHODS

Of note, 2 reviewers independently assessed the articles for eligibility and risk of bias, and conflicts were resolved by a third reviewer. Data were extracted and synthesized according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses and Meta-analysis of Observational Studies in Epidemiology guidelines.

RESULTS

Here, 13 studies (representing 2,291,024 pregnancies) were eligible for inclusion. Perinatal death was more likely in neonates born to women with cardiomyopathy than in (1) neonates born to women with no cardiac disease (stillbirth: odds ratio, 20.82; 95% confidence interval, 6.68-64.95; I² = not available; P<.00001; neonatal mortality: odds ratio, 6.75; 95% confidence interval, 3.54-12.89; I²=0%; P<.00001) and (2) neonates born to women with other forms of cardiac disease (stillbirth: odds ratio, 3.75; 95% confidence interval, 1.86-7.59; I²=0%; P=.0002; neonatal mortality: odds ratio, 2.42; 95% confidence interval, 1.39-4.21; I²=0%; P=.002). Pregnancies affected by maternal cardiomyopathy were significantly more likely to result in preterm birth (odds ratio, 2.21; 95% confidence interval, 1.31-3.73; I²=77%; P=.003) and small-for-gestational-age neonates (odds ratio, 2.97; 95% confidence interval, 2.38-3.70; I²=47%; P<.00001), both major causes of short- and long-term morbidities, than pregnancies affected by other forms of cardiac disease.

CONCLUSION

There was an increased likelihood of adverse perinatal outcomes in pregnancies affected by maternal cardiomyopathy compared with both pregnancies affected by noncardiomyopathy cardiac disease and pregnancies without cardiac disease. Women with cardiomyopathy who plan to get pregnant should receive detailed counseling regarding these risks and have their pregnancies managed by experienced multidisciplinary teams that can provide close fetal monitoring and neonatology expertise.

Cardiovascular evaluation of pregnant women with hypertrophic cardiomyopathy

BACKGROUND

The effect of physiological circulatory changes during pregnancy on hypertrophic cardiomyopathy (HCM) has been reported with limited data. This study aimed to provide information regarding outcomes of pregnant women with HCM and to identify predictors of major adverse cardiac event (MACE).

METHODS

A total of 45 pregnancies with HCM were retrospectively reviewed. The primary endpoint was a MACE that occurred within an 8‑week period after delivery, including maternal death, heart failure (HF), syncope, and malignant ventricular arrhythmias (VAs). Baseline and outcome data were analyzed for all patients. Patients with and without MACE were compared, and patients with obstructive HCM were compared with those who had non-obstructive HCM. The study population was divided into two subgroups of patients having or not having an implantable cardioverter defibrillator implantation (ICD).

RESULTS

At least one MACE occurred in 11 patients (24.4%); six patients developed HF (13.3%), six had a ventricular tachyarrhythmia (13.3%), and two had syncope (4.4%). New York Heart Association functional class of ≥ II, presence of HF signs before pregnancy, increased left ventricular outflow tract (LVOT) gradient were significantly associated with MACE. Fatal VAs were seen during pregnancy in one of five HCM patients with ICD. In the ROC curve analysis, an LVOT gradient higher than 53.5 mm Hg predicted the presence of MACE with a sensitivity of 90.9% and a specificity of 73.5%. This study is the largest series in the literature representing pregnant women who had HCM and ICD.

CONCLUSION

The current data suggest that HF and high LVOT gradients are important risk factors for the development of cardiac complications.

Imaging of heart disease in women: review and case presentation

Cardiovascular diseases (CVD) remain the leading cause of mortality worldwide. Although major diagnostic and therapeutic advances have significantly improved the prognosis of patients with CVD in the past decades, these advances have less benefited women than age-matched men. Noninvasive cardiac imaging plays a key role in the diagnosis of CVD. Despite shared imaging features and strategies between both sexes, there are critical sex disparities that warrant careful consideration, related to the selection of the most suited imaging techniques, to technical limitations, and to specific diseases that are overrepresented in the female population. Taking these sex disparities into consideration holds promise to improve management and alleviate the burden of CVD in women. In this review, we summarize the specific features of cardiac imaging in four of the most common presentations of CVD in the female population including coronary artery disease, heart failure, pregnancy complications, and heart disease in oncology, thereby highlighting contemporary strengths and limitations. We further propose diagnostic algorithms tailored to women that might help in selecting the most appropriate imaging modality.

Phenotypic Disease Network-Based Multimorbidity Analysis in Idiopathic Cardiomyopathy Patients with Hospital Discharge Records

BACKGROUND

Idiopathic cardiomyopathy (ICM) is a rare disease affecting numerous physiological and biomolecular systems with multimorbidity. However, due to the small sample size of uncommon diseases, the whole spectrum of chronic disease co-occurrence, especially in developing nations, has not yet been investigated. To grasp the multimorbidity pattern, we aimed to present a multidimensional model for ICM and differences among age groups.

METHODS

Hospital discharge records were collected from a rare disease centre of ICM inpatients (n = 1036) over 10 years (2012 to 2021) for this retrospective analysis. One-to-one matched controls were also included. First, by looking at the first three digits of the ICD-10 code, we concentrated on chronic illnesses with a prevalence of more than 1%. The ICM and control inpatients had a total of 71 and 69 chronic illnesses, respectively. Second, to evaluate the multimorbidity pattern in both groups, we built age-specific cosine-index-based multimorbidity networks. Third, the associated rule mining (ARM) assessed the comorbidities with heart failure for ICM, specifically.

RESULTS

The comorbidity burden of ICM was 78% larger than that of the controls. All ages were affected by the burden, although those over 50 years old had more intense interactions. Moreover, in terms of disease connectivity, central, hub, and authority diseases were concentrated in the metabolic, musculoskeletal and connective tissue, genitourinary, eye and adnexa, respiratory, and digestive systems. According to the age-specific connection, the impaired coagulation function was required for raising attention (e.g., autoimmune-attacked digestive and musculoskeletal system disorders) in young adult groups (ICM patients aged 20-49 years). For the middle-aged (50-60 years) and older (≥70 years) groups, malignant neoplasm and circulatory issues were the main confrontable problems. Finally, according to the result of ARM, the comorbidities and comorbidity patterns of heart failure include diabetes mellitus and metabolic disorder, sleeping disorder, renal failure, liver, and circulatory diseases.

CONCLUSIONS

The main cause of the comorbid load is aging. The ICM comorbidities were concentrated in the circulatory, metabolic, musculoskeletal and connective tissue, genitourinary, eye and adnexa, respiratory, and digestive systems. The network-based approach optimizes the integrated care of patients with ICM and advances our understanding of multimorbidity associated with the disease.

Pregnancy in Women with Arrhythmogenic Left Ventricular Cardiomyopathy

BACKGROUND

In the last few years, a phenotypic variant of arrhythmogenic cardiomyopathy (ACM) labeled arrhythmogenic left ventricular cardiomyopathy (ALVC) has been defined and researched. This type of cardiomyopathy is characterized by a predominant left ventricular (LV) involvement with no or minor right ventricular (RV) abnormalities. Data on the specific risk and management of pregnancy in women affected by ALVC are, thus far, not available. We have sought to characterize pregnancy course and outcomes in women affected by ALVC through the evaluation of a series of childbearing patients.

METHODS

A series of consecutive female ALVC patients were analyzed in a cross-sectional, retrospective study. Study protocol included 12-lead ECG assessments, 24-h Holter ECG evaluations, 2D-echocardiogram tests, cardiac magnetic resonance assessments, and genetic analysis. Furthermore, the long-term disease course of childbearing patients was compared with a group of nulliparous ALVC women.

RESULTS

A total of 35 patients (mean age 45 ± 9 years, 51% probands) were analyzed. Sixteen women (46%) reported a pregnancy, for a total of 27 singleton viable pregnancies (mean age at first childbirth 30 ± 9 years). Before pregnancy, all patients were in the NYHA class I and none of the patients reported a previous heart failure (HF) episode. No significant differences were found between childbearing and nulliparous women regarding ECG features, LV dimensions, function, and extent of late enhancement. Overall, 7 patients (20%, 4 belonging to the childbearing group) experienced a sustained ventricular tachycardia and 2 (6%)-one for each group-showed heart failure (HF) episodes. The analysis of arrhythmia-free survival patients did not show significant differences between childbearing and nulliparous women.

CONCLUSIONS

In a cohort of ALVC patients without previous episodes of HF, pregnancy was well tolerated, with no significant influence on disease progression and degree of electrical instability. Further studies on a larger cohort of women with different degrees of disease extent and genetic background are needed in order to achieve a more comprehensive knowledge regarding the outcome of pregnancy in ALVC patients.

Cardiovascular Magnetic Resonance Imaging Patterns in Rare Cardiovascular Diseases

Rare cardiovascular diseases (RCDs) have low incidence but major clinical impact. RCDs' classification includes Class I-systemic circulation, Class II-pulmonary circulation, Class III-cardiomyopathies, Class IV-congenital cardiovascular diseases (CVD), Class V-cardiac tumors and CVD in malignancy, Class VI-cardiac arrhythmogenic disorders, Class VII-CVD in pregnancy, Class VIII-unclassified rare CVD. Cardiovascular Magnetic Resonance (CMR) is useful in the diagnosis/management of RCDs, as it performs angiography, function, perfusion, and tissue characterization in the same examination. Edema expressed as a high signal in STIRT2 or increased T2 mapping is common in acute/active inflammatory states. Diffuse subendocardial fibrosis, expressed as diffuse late gadolinium enhancement (LGE), is characteristic of microvascular disease as in systemic sclerosis, small vessel vasculitis, cardiac amyloidosis, and metabolic disorders. Replacement fibrosis, expressed as LGE, in the inferolateral wall of the left ventricle (LV) is typical of neuromuscular disorders. Patchy LGE with concurrent edema is typical of myocarditis, irrespective of the cause. Cardiac hypertrophy is characteristic in hypertrophic cardiomyopathy (HCM), cardiac amyloidosis (CA) and Anderson-Fabry Disease (AFD), but LGE is located in the IVS, subendocardium and lateral wall in HCM, CA and AFD, respectively. Native T1 mapping is increased in HCM and CA and reduced in AFD. Magnetic resonance angiography provides information on aortopathies, such as Marfan, Turner syndrome and Takayasu vasculitis. LGE in the right ventricle is the typical finding of ARVC, but it may involve LV, leading to the diagnosis of arrhythmogenic cardiomyopathy. Tissue changes in RCDs may be detected only through parametric imaging indices.

Next-Generation Sequencing Gene Panels in Inheritable Cardiomyopathies and Channelopathies: Prevalence of Pathogenic Variants and Variants of Unknown Significance in Uncommon Genes

The diffusion of next-generation sequencing (NGS)-based approaches allows for the identification of pathogenic mutations of cardiomyopathies and channelopathies in more than 200 different genes. Since genes considered uncommon for a clinical phenotype are also now included in molecular testing, the detection rate of disease-causing variants has increased. Here, we report the prevalence of genetic variants detected by using a NGS custom panel in a cohort of 133 patients with inherited cardiomyopathies (n = 77) or channelopathies (n = 56). We identified 82 variants, of which 50 (61%) were identified in genes without a strong or definitive evidence of disease association according to the NIH-funded Clinical Genome Resource (ClinGen; "uncommon genes"). Among these, 35 (70%) were variants of unknown significance (VUSs), 13 (26%) were pathogenic (P) or likely pathogenic (LP) mutations, and 2 (4%) benign (B) or likely benign (LB) variants according to American College of Medical Genetics (ACMG) classifications. These data reinforce the need for the screening of uncommon genes in order to increase the diagnostic sensitivity of the genetic testing of inherited cardiomyopathies and channelopathies by allowing for the identification of mutations in genes that are not usually explored due to a currently poor association with the clinical phenotype.

Sudden Cardiac Arrest in Athletes: A Primary Level of Prevention

Primary prevention of sudden cardiac arrest (SCA) refers to the use of pharmacological or interventional therapy and healthy lifestyle modifications to prevent sudden cardiac death (SCD) in patients who have not experienced symptomatic, life-threatening persistent ventricular tachycardia or ventricular fibrillation or SCA but are considered to be at a higher risk. This review provides an overview of the physiological heart changes and distinct electrical manifestations, the etiology of SCA, and screening methods and interventions for the prevention of SCA in athletes. The American College of Cardiology and the American Heart Association (AHA) Guidelines recommend screening with a 14-point history and physical examination. In most cases, a thorough clinical evaluation along with an ECG is sufficient for screening. Athletes with heart diseases leading to SCD are urged not to compete. Further decisions are taken following the European Society of Cardiology and the AHA's current workout recommendations. Early detection of cardiac disease allows for individualized risk evaluation and treatment, which has been shown to reduce mortality rates in athletes.

Maternal pregnancy outcomes in women with cardiomyopathy: a systematic review and meta-analysis

OBJECTIVE

This study aimed to systematically assess the impact of cardiomyopathy on maternal pregnancy outcomes.

DATA SOURCES

PubMed, Ovid Embase, Ovid MEDLINE, Cochrane Library, and ClinicalTrials.gov were systematically searched from inception to April 24, 2022.

STUDY ELIGIBILITY CRITERIA

Observational cohort, case-control, and case-cohort studies in human populations were included if they reported predefined maternal outcomes for pregnant women with cardiomyopathy (any subtype) and for an appropriate control population (pregnant women with no known heart disease or pregnant women with noncardiomyopathy heart disease).

METHODS

Two reviewers independently assessed the articles for eligibility and risk of bias, and conflicts were resolved by a third reviewer. Data were extracted and synthesized according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses and Meta-Analyses of Observational Studies in Epidemiology guidelines.

RESULTS

A total of 14 studies (n=57,539,306 pregnancies) were eligible for inclusion. Women with cardiomyopathy were more likely to deliver by cesarean delivery than women with no heart disease (odds ratio, 2.96; 95% confidence interval, 2.47-3.55; I2=95%; P≤.00001) or women with noncardiomyopathy heart disease (odds ratio, 1.90; 95% confidence interval, 1.62-2.22; I2=91%; P<.00001). Having cardiomyopathy conferred a greater risk for experiencing severe maternal adverse cardiovascular events during pregnancy when compared with not having any heart disease (odds ratio, 206.64; 95% confidence interval, 192.09-222.28; I2=73%; P<.0001) or having noncardiomyopathy heart disease (odds ratio, 7.09; 95% confidence interval; 6.08-8.27; I2=88%; P<.00001). In-hospital mortality was significantly higher among women with cardiomyopathy than among women with no heart disease (odds ratio, 126.67; 95% confidence interval, 43.01-373.07; I2=87%; P<.00001) or among women with noncardiomyopathy heart disease (odds ratio, 4.30; 95% confidence interval, 3.42-5.40; I2=0%; P<.00001).

CONCLUSION

Pregnant women with cardiomyopathy have increased risks for adverse maternal outcomes, including maternal death, when compared with both women with no heart disease and women with noncardiomyopathy heart disease. Our results highlight the importance of preconception risk assessments to allow for informed decision-making before pregnancy. Pregnancies affected by cardiomyopathy are high risk and should be managed by expert, multidisciplinary obstetrical and cardiology teams.

Reversible Cerebral Vasoconstriction Syndrome and Ischemic Stroke Secondary to Peripartum Cardiomyopathy - Report a Rare Case

Acute cardioembolic stroke is a rare presentation of peripartum cardiomyopathy. We present an unusual case of peripartum cardiomyopathy, that subsequently developed cardioembolic ischemic stroke and reversible cerebral vasospasms. 

A 26-year-old G1P1 caucasian woman presented to the emergency department 10 days after a spontaneous vaginal delivery with the clinical and physical presentation of acute heart failure. Brain natriuretic peptide (BNP) level was >8000 pg/mL. Transthoracic echocardiogram (TTE) demonstrated global left ventricular hypokinesis, reduced ejection fraction (EF) 22% with grade I diastolic dysfunction and apical thrombus. On hospital day two of her heart failure exacerbation admission, a code stroke was activated for aphasia and confusion. She received an IV tissue plasminogen activator (tPA) and underwent a mechanical thrombectomy. On hospital day three, she developed worsening of neurological symptoms, and a computed tomography (CT) angiogram revealed vasospasm in the region of the left middle cerebral artery (MCA), which subsequently resulted in nimodipine therapy. Furthermore, her hospital course was complicated by persistent hypotension, and with our concern for vasospasm that was noted in the CT angiogram instead of guideline-directed therapy for heart failure, digoxin was given to control heart rate and to improve cardiac output. Ultimately, her neurological symptoms improved, and she was discharged on hospital day 10.

This case highlights the combination of rare presentations - postpartum cardiomyopathy, ischemic stroke, and reversible cerebral vasospasms, which suggests that the time and size of the stroke are of the essence in terms of promptness of aggressive treatment.

A Case of Multidisciplinary Approach to Post-Radiotherapy Dilative Cardiomyopathy Undergoing Elective Cesarean Delivery: Anesthetic and Intensive Care Management

BACKGROUND

Cardiovascular diseases are the most common non-obstetric cause of maternal death. These cases became more common thanks to the improvement in cardiovascular therapies. A multidisciplinary team is necessary to manage these pregnancies.

CASE REPORT

A 32 years old women at the 25^th week of gestation for acute heart failure in pre-existing left ventricular dysfunction induced by radio-chemotherapy admitted to the Coronary Unit of IRCCS Policlinico Universitario Agostino Gemelli for worsening of dyspneic symptoms and anuria not responding to diuretic therapy. At the echocardiogram: ejection fraction 30%, enlarged left atrium, systolic pulmonary arterial pressure 38 mmHg, bilateral pleural effusion, bilateral diffused pulmonary B lines. A multidisciplinary team composed by cardiologists, gynecologists, anesthesiologists, cardiac surgeons, neonatologists and bioethicists decided for an elective cesarean delivery at the 27^th week of gestation in the hybrid cardio-thoracic operating theater. Anesthesia was provided by combined spinal-epidural technique under invasive continuous hemodynamic monitoring with the Edwards Lifesciences HemoSphere with Hypotension Prediction Index (HPI) and ForeSight technology (Edwards Lifesciences, Irvine, USA) through catheterization of the left radial artery. The femoral arteries were left available for extracorporeal circulation. Continuous norepinephrine infusion was started once liquor was collected in the spinal needle at a 0.1 mcg/kg/minute through a central line and was continued until the end of surgery. Fluid management consisted of a total of 200 ml of crystalloids. HPI values never reached alarm values (maximum value =10). The patient was discharged home on the 5^th day after delivery with good hemodynamic compensation. The baby was intubated at birth and then gradually weaned from mechanical ventilation, then discharged.

Arrhythmias and Heart Failure in Pregnancy: A Dialogue on Multidisciplinary Collaboration

The prevalence of CVD in pregnant people is estimated to be around 1 to 4%, and it is imperative that clinicians that care for obstetric patients can promptly and accurately diagnose and manage common cardiovascular conditions as well as understand when to promptly refer to a high-risk obstetrics team for a multidisciplinary approach for managing more complex patients. In pregnant patients with CVD, arrhythmias and heart failure (HF) are the most common complications that arise. The difficulty in the management of these patients arises from variable degrees of severity of both arrhythmia and heart failure presentation. For example, arrhythmia-based complications in pregnancy can range from isolated premature ventricular contractions to life-threatening arrhythmias such as sustained ventricular tachycardia. HF also has variable manifestations in pregnant patients ranging from mild left ventricular impairment to patients with advanced heart failure with acute decompensated HF. In high-risk patients, a collaboration between the general obstetrics, maternal-fetal medicine, and cardiovascular teams (which may include cardio-obstetrics, electrophysiology, adult congenital, or advanced HF)—physicians, nurses and allied professionals—can provide the multidisciplinary approach necessary to properly risk-stratify these women and provide appropriate management to improve outcomes.

Pregnancy in women with dilated cardiomyopathy

Only a few studies describe the pathophysiology and outcomes of dilated cardiomyopathy (DCM) in pregnancy, which the authors aim to review here. DCM causes enlargement of the ventricles and reduced systolic function. Fluid overload and raised cardiac output in pregnancy may contribute to cardiac complications that lead to cardiac remodeling and heart failure, a common cause of maternal mortality. The risk of cardiac complications is higher in women with New York Heart Association class III and IV. Fetal and neonatal complications are common with coexisting obstetric risk factors. Hence, prepregnancy counseling and a multi-disciplinary approach are essential. Renin-angiotensin-aldosterone system blockers prevent cardiac remodeling but are teratogenic. Drugs, such as β-blockers to control cardiac remodeling, thiazide diuretics to reduce preload, hydralazine and nitrates to reduce afterload and digoxin to increase inotropy, are safe and should be used to manage DCM in pregnancy.

2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The "2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure" replaces the "2013 ACCF/AHA Guideline for the Management of Heart Failure" and the "2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure." The 2022 guideline is intended to provide patient-centric recommendations for clinicians to prevent, diagnose, and manage patients with heart failure.

METHODS

A comprehensive literature search was conducted from May 2020 to December 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from MEDLINE (PubMed), EMBASE, the Cochrane Collaboration, the Agency for Healthcare Research and Quality, and other relevant databases. Additional relevant clinical trials and research studies, published through September 2021, were also considered. This guideline was harmonized with other American Heart Association/American College of Cardiology guidelines published through December 2021. Structure: Heart failure remains a leading cause of morbidity and mortality globally. The 2022 heart failure guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with heart failure, with the intent to improve quality of care and align with patients' interests. Many recommendations from the earlier heart failure guidelines have been updated with new evidence, and new recommendations have been created when supported by published data. Value statements are provided for certain treatments with high-quality published economic analyses.

Transplantation of umbilical cord blood-derived mesenchymal stem cells as therapy for adriamycin induced-cardiomyopathy

Umbilical cord blood-derived mesenchymal stem cells (UCBMSCs) have been reported to possess cardioprotective effects in diseases. However, its effects on cardiomyopathy remain unclear. This study aimed to the therapeutic effects of UCBMSC transplantation on adriamycin (ADR)-induced cardiomyopathy. UCBMSCs isolated from human UCB were identified by detecting surface markers (CD29, CD90, CD34, and CD45) using flow cytometry. The effect of UCBMSCs on left ventricular end-diastolic dimension (LVEDD), left ventricular systolic end-diastolic diameter (LVESD), left ventricular ejection fraction (LVEF), and left ventricular fraction shortening (LVFS) were determined by echocardiography. Histological changes were observed by HE and Masson staining. The serum levels of collagen-I (Col-I), brain natriuretic peptide (BNP), aspartate aminotransferase (AST), lactate dehydrogenase (LDH), creatine kinase (CK), CK-MB, interleukin (IL)-6, IL-10, and tumor necrosis factor alpha (TNF-α) were measured by corresponding kits. The protein levels of IL-6, IL-10, and TNF-α were measured by Western blotting. The isolated UCBMSCs manifested the positive expression of CD29 and CD90, and the negative expression of CD34 and CD45. UCBMSC transplantation significantly reduced LVEDD and LVESD, and increased LVEF and LVFS in ADR-induced cardiomyopathy model rats. Cardiac injury and high collagen deposition in model rats were alleviated by UCBMSC treatment. Moreover, UCBMSCs decreased the serum levels of Col-I, BNP, AST, LDH, CK, CK-MB, IL-6, IL-10, and TNF-α in model rats. Overall, UCBMSCs exert the therapeutic effects on ADR-induced cardiomyopathy through recovering the myocadiac function and alleviating the inflammatory response.

2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure

AIM

The "2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure" replaces the "2013 ACCF/AHA Guideline for the Management of Heart Failure" and the "2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure." The 2022 guideline is intended to provide patient-centric recommendations for clinicians to prevent, diagnose, and manage patients with heart failure.

METHODS

A comprehensive literature search was conducted from May 2020 to December 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from MEDLINE (PubMed), EMBASE, the Cochrane Collaboration, the Agency for Healthcare Research and Quality, and other relevant databases. Additional relevant clinical trials and research studies, published through September 2021, were also considered. This guideline was harmonized with other American Heart Association/American College of Cardiology guidelines published through December 2021.

STRUCTURE

Heart failure remains a leading cause of morbidity and mortality globally. The 2022 heart failure guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with heart failure, with the intent to improve quality of care and align with patients' interests. Many recommendations from the earlier heart failure guidelines have been updated with new evidence, and new recommendations have been created when supported by published data. Value statements are provided for certain treatments with high-quality published economic analyses.

Identification of cardiomyopathy-related core genes through human metabolic networks and expression data

Background

Cardiomyopathy is a complex type of myocardial disease, and its incidence has increased significantly in recent years. Dilated cardiomyopathy (DCM) and ischemic cardiomyopathy (ICM) are two common and indistinguishable types of cardiomyopathy.

Results

Here, a systematic multi-omics integration approach was proposed to identify cardiomyopathy-related core genes that could distinguish normal, DCM and ICM samples using cardiomyopathy expression profile data based on a human metabolic network. First, according to the differentially expressed genes between different states (DCM/ICM and normal, or DCM and ICM) of samples, three sets of initial modules were obtained from the human metabolic network. Two permutation tests were used to evaluate the significance of the Pearson correlation coefficient difference score of the initial modules, and three candidate modules were screened out. Then, a cardiomyopathy risk module that was significantly related to DCM and ICM was determined according to the significance of the module score based on Markov random field. Finally, based on the shortest path between cardiomyopathy known genes, 13 core genes related to cardiomyopathy were identified. These core genes were enriched in pathways and functions significantly related to cardiomyopathy and could distinguish between samples of different states.

Conclusion

The identified core genes might serve as potential biomarkers of cardiomyopathy. This research will contribute to identifying potential biomarkers of cardiomyopathy and to distinguishing different types of cardiomyopathy.

Cardiovascular Diseases in Pregnancy - A Brief Overview

Even though, there have been many advances in maternal medical care and fertility treatments, the presence of cardiovascular disease has a significant impact on pregnancy. In pregnant women, several heart conditions, such as valvular heart disease, chronic hypertension, congenital heart defects and non-ischemic cardiomyopathies are linked to increased risk of fetal as well as maternal morbidity and mortality. To date, the management of the co-existing conditions of pregnancy and heart disease has been challenging. Therefore, in-depth information may be beneficial to tackle a difficult case scenario. Towards this end, this paper provides an overview of the recent updated knowledge of pregnancy-related cardiovascular diseases in women.

Possible roles of exercise and apelin against pregnancy complications

The prevalence of maternal obesity during pregnancy is associated with the risk of gestational diabetes, preeclampsia, and cardiomyopathy. Environmental factors such as active lifestyles and apelin may lead to beneficial changes. In rats, apelin and exercise (45 to 65% VO_2max for 6 to 9 weeks) during pregnancy increase brown adipose tissue (BAT) proteins such as Cidea, Elovl3, UCP1, PRDM16, and PGC-1α in males and females fetuses, while white adipose tissue (WAT) is reduced. In humans and animals, apelin and exercise stimulate the expression of the glucose transporters (GLUT1/2/4) in the muscle and adipose tissue through the PI3K/Akt and AMPK pathways. Hence, exercise and apelin may are known as regulators of energy metabolism and be anti-obesity and anti-diabetic properties. In mice, exercise also creates a short-term hypoxic environment in the pregnant mother, activating HIF-1, VEGF, and VEGFR, and increasing angiogenesis. Exercise and apelin also increase vasodilation, angiogenesis, and suppression of inflammation through the L-arginine/eNOS/NO pathway in humans. Exercise can stimulate the ACE2-Ang-(1-7)-Mas axis in parallel with inhibiting the ACE-Ang II-AT1 pathway. Exercise and apelin seem to prevent preeclampsia through these processes. In rats, moderate-intensity exercise (60 to 70% VO_2max for 8 weeks) and apelin/APJ also may prevent pathological hypertrophy in pregnancy by activating the PI3K/Akt/mTOR/p70S6K pathway, PI3k-Akt-ERK1/2-p70S6K pathway, and the anti-inflammatory cytokine IL-10. Since pre-clinical studies have been more on animal models, future research with scientific guidelines should pay more attention to human specimens. In future research, time factors such as the first, second, and third trimesters of pregnancy and the intensity and duration of exercise are important variables that should be considered to determine the optimal intensity and duration of exercise.

Tendência da mortalidade materna no Estado do Rio de Janeiro, Brasil, entre 2006 e 2018, segundo a classificação CID-MM

O objetivo foi analisar a tendência da razão de mortalidade materna (RMM) segundo a classificação CID-Mortalidade Materna (CID-MM) no Estado do Rio de Janeiro, Brasil, no período de 2006 a 2018. Foi realizado estudo de tendência temporal da RMM no Rio de Janeiro segundo tipo de óbito - direto ou indireto - e grupos de causas da classificação CID-MM, da Organização Mundial da Saúde (OMS). A RMM foi calculada com dados do Sistema de Informações sobre Mortalidade (SIM) e do Sistema de Informações sobre Nascidos Vivos (SINASC). As tendências foram estimadas pelo Joinpoint Regression Program. Dos 2.192 óbitos maternos no estado, 61% foram por causas diretas, 34% indiretas e 5% não especificadas. A tendência da RMM total e por causas diretas foi de declínio: 1,2% (IC95%: -2,3; -0,1) ao ano e 3,8% (IC95%: -4,9; -2,6) entre 2006 e 2015, respectivamente. Para causas diretas, segundo a CID-MM, o grupo 2 (causas hipertensivas) foi preponderante, mas houve declínio da eclâmpsia. Seguiram-se o grupo 5 (outras complicações, das quais se destacaram a categoria O90 e a subcategoria O90.3 - cardiomiopatia no puerpério) e o grupo 1 (gravidez que termina em aborto). As causas indiretas apresentaram estabilidade e a maioria pertencia à categoria O99 e suas subcategorias, relacionadas a doenças cardiovasculares e respiratórias. A RMM no Rio de Janeiro apresentou tendência de declínio entre 2006 e 2018, porém distante do recomendado pela OMS e com diferentes comportamentos entre as causas. A classificação CID-MM foi útil para identificar grandes grupos de causas, mas é preciso desagregar por subcategorias, para o adequado conhecimento da etiologia da morte materna.

miR-21 in Human Cardiomyopathies

miR-21 is a 22-nucleotide long microRNA that matches target mRNAs in a complementary base pairing fashion and regulates gene expression by repressing or degrading target mRNAs. miR-21 is involved in various cardiomyopathies, including heart failure, dilated cardiomyopathy, myocardial infarction, and diabetic cardiomyopathy. Expression levels of miR-21 notably change in both heart and circulation and provide cardiac protection after heart injury. In the meantime, miR-21 also tightly links to cardiac dysfunctions such as cardiac hypertrophy and fibrosis. This review focuses on the miR-21 expression pattern and its functions in diseased-heart and further discusses the feasibility of miR-21 as a biomarker and therapeutic target in cardiomyopathies.

Atypical presentation of cardiomyopathy in a case of maternal mortality that was demonstrated as hypovolemic shock

Periconceptional and prenatal care should be continued even during COVID-19 pandemics. Indeed, prevention and intervention programs for managing heart failure with aggressive resuscitation and invasive monitoring help to provide the best outcomes in cardiomyopathies. PPH may be associated with cardiac diseases and the resuscitation measures need modification to prevent maternal mortality.

Postpartum Respiratory Distress Due to Hypertension-Related Pulmonary Edema

We present the case of a 35-year-old female who presented to the emergency department (ED) shortly after undergoing a cesarean section with dyspnea. Her vitals on admission revealed hypertension, tachypnea, bradycardia, and suboptimal oxygen saturation. Physical examination was remarkable for crackles in the lower lung fields. Laboratory results revealed elevated lactate dehydrogenase (LDH), pro-B-type natriuretic peptide (pro-BNP), and D-dimer levels. A CT angiogram showed no pulmonary emboli, and an echocardiogram revealed a normal ejection fraction and no diastolic dysfunction. A chest X-ray was significant for pulmonary edema and vascular congestion. The patient was diagnosed with respiratory distress due to pulmonary edema that was secondary to hypertension. This unusual case report seeks to highlight the idea that elevated blood pressure in postpartum women should warrant careful monitoring, as its consequential manifestations may be lethal. Additionally, pulmonary edema secondary to hypertension should be considered as a differential in either postpartum or peripartum women who present with respiratory symptoms and elevated blood pressure.

Process of Care and a Practical Toolkit for Evaluating and Managing Arrhythmic Risk in the Cardiogenetic Pregnant Patient

Patients with inherited arrhythmia syndromes (IASs) and inherited cardiomyopathies (ICs) are periodically encountered in both general and specialist practices. These syndromes include long QT syndrome, catecholaminergic polymorphic ventricular tachycardia, Brugada syndrome, early repolarisation syndrome, and hypertrophic and arrhythmogenic cardiomyopathies. In general, the presence of an IAS or IC is not a contraindication to pregnancy, but does require additional expertise and patient engagement. In this review, we summarise the various pregnancy-related considerations in patients with IAS and IC, including the impact of physiologic/hemodynamic changes on heart failure progression or arrhythmia propensity, maternal and fetal pregnancy risk stratification, prenatal genetic testing, and the specialised care and monitoring required through pregnancy, labour, and delivery and into the postpartum period. Management of patients with IASs and IC during pregnancy and the postpartum period requires collaboration between patient and provider, with a shared understanding of the general safety and potential risks during the pregnancy and postpartum periods. Patients should be aware of the safety of various medications throughout pregnancy, and those with implantable cardioverter-defibrillators should be managed according to device guidelines. A peripartum care and delivery plan should be established, with multidisciplinary input from various specialists including obstetrics, cardiac obstetrics, and inherited arrhythmia specialists wherever appropriate.

Noncompaction Cardiomyopathy-History and Current Knowledge for Clinical Practice

Noncompaction cardiomyopathy (NCCM) has gained increasing attention over the past twenty years, but in daily clinical practice NCCM is still rarely considered. So far, there are no generally accepted diagnostic criteria and some groups even refuse to acknowledge it as a distinct cardiomyopathy, and grade it as a variant of dilated cardiomyopathy or a morphological trait of different conditions. A wide range of morphological variants have been observed even in healthy persons, suggesting that pathologic remodeling and physiologic adaptation have to be differentiated in cases where this spongy myocardial pattern is encountered. Recent studies have uncovered numerous new pathogenetic and pathophysiologic aspects of this elusive cardiomyopathy, but a current summary and evaluation of clinical patient management are still lacking, especially to avoid mis- and overdiagnosis. Addressing this issue, this article provides an up to date overview of the current knowledge in classification, pathogenesis, pathophysiology, epidemiology, clinical manifestations and diagnostic evaluation, including genetic testing, treatment and prognosis of NCCM.

Pregnancy in arrhythmogenic cardiomyopathy

Arrhythmogenic cardiomyopathy (AC) is a rare heart muscle disease with a genetic background and autosomal dominant mode of transmission. The clinical manifestation is characterized by ventricular arrhythmias (VA), heart failure (HF) and the risk of sudden cardiac death (SCD). Pregnancy in young female patients with AC represents a challenging condition for the life and family planning of young affected women. In addition to genetic mechanisms that influence the complex pathophysiology of AC, experimental and clinical data have confirmed the pathogenetic role of strenuous exercise and competitive sports in the early onset and rapid progression of AC symptoms and complications. Pregnancy and exercise share a number of physiological aspects of adaptation. In AC, both result in ventricular volume overload and myocardial stretch. Therefore, pregnancy has been postulated as a potential risk factor for HF, VA, SCD, and pregnancy-related obstetric complications in patients with AC. However, the available evidence on pregnancy in AC does not confirm this hypothesis. In most women with AC, pregnancies are well tolerated, uneventful, and follow a benign course. Pregnancy-related symptoms (VA, syncope, HF) and mortality, as well as obstetric complications, are uncommon in AC patients and range in the order of background populations and cohorts with AC and no pregnancy. The number of completed pregnancies is not associated with an acceleration of AC pathology or an increased risk of VA or HF during pregnancy and follow-up. Accordingly, there is no medical indication to advise against pregnancy in patients with AC. Preconditions include stability of rhythm and hemodynamics at baseline, as well as clinical follow-ups and the availability of multidisciplinary expert consultation during pregnancy and postpartum. Genetic counseling is recommended prior to pregnancy for all couples and their families affected by AC.

Intersection of Heart Failure and Pregnancy: Beyond Peripartum Cardiomyopathy

Heart failure (HF) is a leading cause of morbidity and mortality in pregnant women in the United States. Although peripartum cardiomyopathy is the most common diagnosis for pregnant women with HF, women with preexisting cardiomyopathies and systolic dysfunction are also at risk as the hemodynamic demands of pregnancy can lead to decompensation, arrhythmia, and rarely death. The differential diagnosis of HF in pregnancy is broad and includes Takotsubo or stress cardiomyopathy, exacerbation of a preexisting cardiomyopathy, such as familial cardiomyopathy, hypertrophic cardiomyopathy, arrhythmogenic right ventricular cardiomyopathy, or left ventricular noncompaction. This review will explore the implications of pregnancy in women with preexisting cardiomyopathies and de novo HF, risk assessment and preconception planning, decisions about contraception, the safety of HF medications and implantable cardioverter-defibrillators during pregnancy, pregnancy in women with left ventricular assist devices and following heart transplantation.

Management of Implantable Cardioverter-Defibrillators during Pregnancy-A Systematic Review

Background: With the advent of implantable cardioverter-defibrillator (ICD) technology in recent decades, patients with inherited or congenital cardiomyopathy have a greater chance of survival into adulthood. Women with ICDs in this group are now more likely to reach reproductive age. However, pregnancy represents a challenge for clinicians, as no guidelines for the treatment of pregnant women with an ICD are currently available. Methods: To analyze this issue, we performed a systematic screening of the literature using the keywords: pregnancy with ICD, lead fracture in pregnancy, lead thrombi in pregnancy, ventricular tachycardia in pregnancy, inappropriate shocks in pregnancy, ICD discharge in pregnancy and ICD shock in pregnancy. Of 1101 publications found, 27 publications were eligible for further analysis (four retrospective trials and 23 case reports). Results: According to physiological changes in pregnancy, resulting in an increase in heart rate and cardiac output, a vulnerability for malignant arrhythmias and device-related complications in ICD carriers might be suspected. While the literature is limited on this issue, maternal complications including arrhythmia burden with following ICD therapies, thromboembolic events and lead complications as well as inappropriate shock therapy have been reported. According to the limited available studies, associated risk seems not to be more frequent than in the general population and depends on the underlying cardiac pathology. Furthermore, worsening of heart failure and related cardiovascular disease have been reported with associated risk of preterm delivery. These observations are exaggerated by restricted applications of diagnostics and treatment due to the risk of fetal harm in this population. Conclusions: Due to limited data on management of ICDs during pregnancy, further scientific investigations are required. Consequently, careful risk assessment with individual risk evaluation and close follow ups with interdisciplinary treatment are recommended in pregnant ICD carriers.

Risk stratification and management of women with cardiomyopathy/heart failure planning pregnancy or presenting during/after pregnancy: a position statement from the Heart Failure Association of the European Society of Cardiology Study Group on Peripartum Cardiomyopathy

This position paper focusses on the pathophysiology, diagnosis and management of women diagnosed with a cardiomyopathy, or at risk of heart failure (HF), who are planning to conceive or present with (de novo or previously unknown) HF during or after pregnancy. This includes the heterogeneous group of heart muscle diseases such as hypertrophic, dilated, arrhythmogenic right ventricular and non-classified cardiomyopathies, left ventricular non-compaction, peripartum cardiomyopathy, Takotsubo syndrome, adult congenital heart disease with HF, and patients with right HF. Also, patients with a history of chemo-/radiotherapy for cancer or haematological malignancies need specific pre-, during and post-pregnancy assessment and counselling. We summarize the current knowledge about pathophysiological mechanisms, including gene mutations, clinical presentation, diagnosis, and medical and device management, as well as risk stratification. Women with a known diagnosis of a cardiomyopathy will often require continuation of drug therapy, which has the potential to exert negative effects on the foetus. This position paper assists in balancing benefits and detrimental effects.

Genetics of Peripartum Cardiomyopathy: Current Knowledge, Future Directions and Clinical Implications

Peripartum cardiomyopathy (PPCM) is a condition in which heart failure and systolic dysfunction occur late in pregnancy or within months following delivery. Over the last decade, genetic advances in heritable cardiomyopathy have provided new insights into the role of genetics in PPCM. In this review, we summarise current knowledge of the genetics of PPCM and potential avenues for further research, including the role of molecular chaperone mutations in PPCM. Evidence supporting a genetic basis for PPCM has emanated from observations of familial disease, overlap with familial dilated cardiomyopathy, and sequencing studies of PPCM cohorts. Approximately 20% of PPCM patients screened for cardiomyopathy genes have an identified pathogenic mutation, with TTN truncations most commonly implicated. As a stress-associated condition, PPCM may be modulated by molecular chaperones such as heat shock proteins (Hsps). Recent studies have led to the identification of Hsp mutations in a PPCM model, suggesting that variation in these stress-response genes may contribute to PPCM pathogenesis. Although some Hsp genes have been implicated in dilated cardiomyopathy, their roles in PPCM remain to be determined. Additional areas of future investigation may include the delineation of genotype-phenotype correlations and the screening of newly-identified cardiomyopathy genes for their roles in PPCM. Nevertheless, these findings suggest that the construction of a family history may be advised in the management of PPCM and that genetic testing should be considered. A better understanding of the genetics of PPCM holds the potential to improve treatment, prognosis, and family management.