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Wander G, Breviario S, Krishnathasan K, Patel RR, Habibi H, Li W, Johnson MR, Gatzoulis MA, Dimopoulos K, Rafiq I. Multifaceted Fontan Patients and Their Response to Pregnancy. JACC Case Rep 2023; 28:102136. [PMID: 38204530 PMCID: PMC10774892 DOI: 10.1016/j.jaccas.2023.102136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 10/23/2023] [Indexed: 01/12/2024]
Abstract
We present 4 patients with Fontan circulation who underwent successful pregnancies, albeit with complications that required close monitoring and timely intervention. Each Fontan patient presents with a unique clinical picture, making risk stratification challenging but all the more important.
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Affiliation(s)
- Gurleen Wander
- Chelsea and Westminster Hospital NHS Foundation Trust, Imperial College London, London, United Kingdom
| | - Susanna Breviario
- Royal Brompton Hospital, Guys and St Thomas NHS Foundation Trust, London, United Kingdom
| | - Kaushiga Krishnathasan
- Royal Brompton Hospital, Guys and St Thomas NHS Foundation Trust, London, United Kingdom
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Roshni R. Patel
- Chelsea and Westminster Hospital NHS Foundation Trust, Imperial College London, London, United Kingdom
| | - Hajar Habibi
- Royal Brompton Hospital, Guys and St Thomas NHS Foundation Trust, London, United Kingdom
| | - Wei Li
- Royal Brompton Hospital, Guys and St Thomas NHS Foundation Trust, London, United Kingdom
| | - Mark R. Johnson
- Chelsea and Westminster Hospital NHS Foundation Trust, Imperial College London, London, United Kingdom
| | - Michael A. Gatzoulis
- Royal Brompton Hospital, Guys and St Thomas NHS Foundation Trust, London, United Kingdom
| | - Konstantinos Dimopoulos
- Royal Brompton Hospital, Guys and St Thomas NHS Foundation Trust, London, United Kingdom
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Isma Rafiq
- Royal Brompton Hospital, Guys and St Thomas NHS Foundation Trust, London, United Kingdom
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2
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Kops SA, Strah DD, Andrews J, Klewer SE, Seckeler MD. Contemporary pregnancy outcomes for women with moderate and severe congenital heart disease. Obstet Med 2023; 16:17-22. [PMID: 37139503 PMCID: PMC10150298 DOI: 10.1177/1753495x211064458] [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: 09/30/2021] [Accepted: 11/16/2021] [Indexed: 11/15/2022] Open
Abstract
Background Women with congenital heart disease (CHD) are surviving into adulthood, with more undergoing pregnancy. Methods Retrospective review of the Vizient database from 2017-2019 for women 15-44 years old with moderate, severe or no CHD and vaginal delivery or caesarean section. Demographics, hospital outcomes and costs were compared. Results There were 2,469,117 admissions: 2,467,589 with no CHD, 1277 with moderate and 251 with severe CHD. Both CHD groups were younger than no CHD, there were fewer white race/ethnicity in the no CHD group and more women with Medicare in both CHD groups compared to no CHD. With increasing CHD severity there was an increase in length of stay, ICU admission rates and costs. There were also higher rates of complications, mortality and caesarean section in the CHD groups. Conclusion Pregnant women with CHD have more problematic pregnancies and understanding this impact is important to improve management and decrease healthcare utilization.
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Affiliation(s)
- Samantha A Kops
- Department of Pediatrics, University of Arizona, Tucson, AZ, USA
| | - Danielle D Strah
- Department of Pediatrics, University of Arizona, Tucson, AZ, USA
| | - Jennifer Andrews
- Department of Pediatrics (Cardiology), University of Arizona, Tucson, AZ, USA
| | - Scott E Klewer
- Department of Pediatrics (Cardiology), University of Arizona, Tucson, AZ, USA
| | - Michael D Seckeler
- Department of Pediatrics (Cardiology), University of Arizona, Tucson, AZ, USA
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Thompson SE, Prabhakar CRK, Creasey T, Stoll VM, Gurney L, Green J, Fox C, Morris RK, Thompson PJ, Thorne SA, Clift P, Hudsmith LE. Pregnancy outcomes in women following the Ross procedure. Int J Cardiol 2023; 371:135-139. [PMID: 36181953 DOI: 10.1016/j.ijcard.2022.09.069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Revised: 09/20/2022] [Accepted: 09/26/2022] [Indexed: 12/14/2022]
Abstract
INTRODUCTION The Ross procedure, where a pulmonary autograft (neoaorta) replaces the aortic valve, has excellent long-term outcomes in patients with congenital aortic valve disease. However, there are reports of neoaortic dilatation and dissection. An increasing number of women are wishing to become pregnant following the Ross procedure, but little is known about the occurrence and risks of neoaortic dilatation and complications in pregnancy. We investigated neoaorta function and outcomes in pregnancy following the Ross procedure. METHODS This retrospective study investigated women post-Ross procedure at a tertiary ACHD unit between 1997 and 2021. Imaging evaluated neoaortic root dimensions and regurgitation pre-, and post- pregnancy, compared with matched non-pregnant controls. Primary endpoints were change in neoaortic dimensions, degree of regurgitation and adverse maternal outcomes. RESULTS Nineteen pregnancies in 12 women were included. The mean change in neoaortic root diameter post-pregnancy was 1.8 mm (SD 3.4) (p = 0.017). There was no significant change in neoaortic dimensions in matched controls during follow-up. There were no cases of dissection, arrhythmia, acute coronary syndrome, or maternal mortality. Three deliveries were pre-term, including one emergency Caesarean section due to maternal cardiac decompensation, requiring aortic root replacement post-partum but there were no neonatal deaths. CONCLUSIONS Pregnancy following the Ross procedure is associated with neoaortic dilatation, and pregnancy is generally well tolerated. Although adverse maternal outcomes are uncommon, there are still rare cases of cardiac complications in and around the time of pregnancy. These findings emphasise the need for accessible pre-pregnancy counselling, risk stratification and careful surveillance through pregnancy by specialist cardio-obstetric multi-disciplinary teams.
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Affiliation(s)
- Sophie E Thompson
- Department of Adult Congenital Heart Disease, Queen Elizabeth Hospital, University Hospital, Birmingham, UK.
| | | | - Tristan Creasey
- Northwick Park Hospital, London North West University Healthcare NHS Trust, London, UK
| | - Victoria M Stoll
- Department of Adult Congenital Heart Disease, Queen Elizabeth Hospital, University Hospital, Birmingham, UK; Institute of Cardiovascular Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Leo Gurney
- Department of Maternal and Fetal Medicine, Birmingham Women's and Children's Hospital, Birmingham, UK
| | - Jennifer Green
- Department of Adult Congenital Heart Disease, Queen Elizabeth Hospital, University Hospital, Birmingham, UK
| | - Caroline Fox
- Department of Maternal and Fetal Medicine, Birmingham Women's and Children's Hospital, Birmingham, UK
| | - R Katie Morris
- Department of Maternal and Fetal Medicine, Birmingham Women's and Children's Hospital, Birmingham, UK; Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Peter J Thompson
- Department of Maternal and Fetal Medicine, Birmingham Women's and Children's Hospital, Birmingham, UK
| | - Sara A Thorne
- Division of Cardiology, Pregnancy & Heart Disease Program, Mount Sinai Hospital & University Health Network, University of Toronto, Canada
| | - Paul Clift
- Department of Adult Congenital Heart Disease, Queen Elizabeth Hospital, University Hospital, Birmingham, UK
| | - Lucy E Hudsmith
- Department of Adult Congenital Heart Disease, Queen Elizabeth Hospital, University Hospital, Birmingham, UK
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Herrick N, Al-Rousan T, Rodriguez C, Lee JH, Valente AM, Stone J, Ramos G, Asante-Boateng B, El-Said H, Moceri-Casas M, Alshawabkeh L. Priorities and Understanding of Pregnancy Among Women With Congenital Heart Disease: A Mixed-Methods Study. JACC. ADVANCES 2022; 1:100112. [PMID: 38939700 PMCID: PMC11198376 DOI: 10.1016/j.jacadv.2022.100112] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 08/09/2022] [Accepted: 08/11/2022] [Indexed: 06/29/2024]
Abstract
Background Many women with congenital heart disease (CHD) desire safe and successful pregnancies, but a significant proportion does not seek prepregnancy counseling. Objectives This study aims to distinguish the personal priorities and perceptions about pregnancy in this growing population. Methods Women aged 18 to 50 years with CHD were enrolled from 2 sites. Using a mixed-methods approach (Q-methodology), 179 participants sorted 23 statements representing a collection of views on pregnancy using priority forced ranking along a scale from "strongly agree" to "strongly disagree." Results Majority of women were between 25 and 29 years of age, had moderate or severely complex CHD, and were married. Five unique group identities were elucidated from patient responses. Group 1 was centered around a strong desire to start a family. Women in group 2 had significant anxiety, and their psychological wellbeing interfered with their decision to start a family. Women in group 3 were concerned about premature death; if they do have kids, they want to be alive to see them grow old. Women in group 4 had strong objections to termination. Group 5 valued health care engagement. Group identities were unrelated to CHD complexity and demographic factors such as age and marital status. Six differentiating statements were identified that help distinguish which group a woman aligns with. Conclusions Women with CHD have diverse priorities and values relating to pregnancy and heart disease. This study used a mixed-methods approach to provide a framework identifying several domains for targeted prepregnancy counseling in women with CHD.
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Affiliation(s)
- Nicole Herrick
- Adult Congenital Heart Disease Program, Division of Cardiovascular Medicine, University of California-San Diego, San Diego, California, USA
| | - Tala Al-Rousan
- Herbert Wertheim School of Public Health and Human Longevity, University of California-San Diego, San Diego, California, USA
| | - Carla Rodriguez
- Division of Cardiology, Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ji Hae Lee
- Division of Cardiology, Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Anne Marie Valente
- Division of Cardiology, Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Jordan Stone
- Reproductive Medicine Department, University of California-San Diego, San Diego, California, USA
| | - Gladys Ramos
- Reproductive Medicine Department, University of California-San Diego, San Diego, California, USA
| | - Bendelyn Asante-Boateng
- Adult Congenital Heart Disease Program, Division of Cardiovascular Medicine, University of California-San Diego, San Diego, California, USA
| | - Howaida El-Said
- Division of Pediatric Cardiology, Rady Children's Hospital and UC San Diego School of Medicine, San Diego, California, USA
| | - Maria Moceri-Casas
- Adult Congenital Heart Disease Program, Division of Cardiovascular Medicine, University of California-San Diego, San Diego, California, USA
| | - Laith Alshawabkeh
- Adult Congenital Heart Disease Program, Division of Cardiovascular Medicine, University of California-San Diego, San Diego, California, USA
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5
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Steiner JM, Lokken E, Bayley E, Pechan J, Curtin A, Buber J, Albright C. Cardiac and Pregnancy Outcomes of Pregnant Patients With Congenital Heart Disease According to Risk Classification System. Am J Cardiol 2021; 161:95-101. [PMID: 34635313 PMCID: PMC10686784 DOI: 10.1016/j.amjcard.2021.08.037] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2021] [Revised: 08/19/2021] [Accepted: 08/23/2021] [Indexed: 11/29/2022]
Abstract
Pregnancy risk assessment for patients with adult congenital heart disease (ACHD) must include physiologic and anatomic impacts. We aimed to determine whether maternal cardiac and pregnancy outcomes vary by disease severity defined according to the following 3 different classifications: ACHD anatomic severity, ACHD physiologic class, and modified World Health Organization (mWHO) class. Cardiac outcomes included a composite of arrhythmia, heart failure, stroke, and thromboembolism. Pregnancy outcomes included a composite of intrauterine growth restriction, preterm birth, preeclampsia, or postpartum hemorrhage. We employed generalized estimating equations to account for multiple pregnancies. Of the 245 pregnancies, 17.1% were preterm and 45.7% were cesarean deliveries. Cardiac hospitalizations occurred in 22.0% and arrhythmias in 12.7%. Cardiac outcomes tended to be more prevalent in people with more severe heart disease. Pregnancy outcomes were U-shaped or less prevalent in people with more severe disease. There was a 2.9-fold increased risk for the composite cardiac outcome for complex anatomy (adjusted incidence rate ratio 2.90, 95% confidence interval 1.08 to 7.81, p = 0.04), a 9.4-fold increased risk for physiologic class C or D (9.37, 1.28 to 68.79, p = 0.03), and a fourfold increased risk for mWHO class III or IV (3.99, 1.53 to 10.40, p = 0.005). There was a lower risk for the composite pregnancy outcome for mWHO class II or II to III (0.54, 0.36 to 0.79, p = 0.002) but no association with anatomy or physiology. In conclusion, physiologic class may be most accurately associated with adverse outcomes and therefore efforts to optimize hemodynamics before pregnancy may help to mitigate the risk.
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Affiliation(s)
| | - Erica Lokken
- Department of Obstetrics and Gynecology; Department of Global Health, University of Washington, Seattle, Washington
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6
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Case Challenge: Nulliparous Cardiac Challenges: A Diagnostic Case. J Nurse Pract 2021. [DOI: 10.1016/j.nurpra.2021.11.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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7
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Lammers AE, Diller GP, Lober R, Möllers M, Schmidt R, Radke RM, De-Torres-Alba F, Kaleschke G, Marschall U, Bauer UM, Gerß J, Enders D, Baumgartner H. Maternal and neonatal complications in women with congenital heart disease: a nationwide analysis. Eur Heart J 2021; 42:4252-4260. [PMID: 34638134 DOI: 10.1093/eurheartj/ehab571] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 06/23/2021] [Accepted: 08/24/2021] [Indexed: 01/27/2023] Open
Abstract
AIMS The aim of this study was to provide population-based data on maternal and neonatal complications and outcome in the pregnancies of women with congenital heart disease (CHD). METHODS AND RESULTS Based on administrative data from one of the largest German Health Insurance Companies (BARMER GEK, ∼9 million members representative for Germany), all pregnancies in women with CHD between 2005 and 2018 were analysed. In addition, an age-matched non-CHD control group was included for comparison and the association between adult CHD (ACHD) and maternal or neonatal outcomes investigated. Overall, 7512 pregnancies occurred in 4015 women with CHD. The matched non-CHD control group included 6502 women with 11 225 pregnancies. Caesarean deliveries were more common in CHD patients (40.5% vs. 31.5% in the control group; P < 0.001). There was no excess mortality. Although the maternal complication rate was low in absolute terms, women with CHD had a significantly higher rate of stroke, heart failure and cardiac arrhythmias during pregnancy (P < 0.001 for all). Neonatal mortality was low but also significantly higher in the ACHD group (0.83% vs. 0.22%; P = 0.001) and neonates to CHD mothers had low/extremely low birth weight or extreme immaturity (<0.001) or required resuscitation and mechanical ventilation more often compared to non-CHD offspring (P < 0.001 for both). On multivariate logistic regression maternal defect complexity, arterial hypertension, heart failure, prior fertility treatment, and anticoagulation with vitamin K antagonists emerged as significant predictors of adverse neonatal outcome (P < 0.05 for all). Recurrence of CHD was 6.1 times higher in infants to ACHD mothers compared to controls (P < 0.0001). CONCLUSIONS This population-based study illustrates a reassuringly low maternal mortality rate in a highly developed healthcare system. Nevertheless, maternal morbidity and neonatal morbidity/mortality were significantly increased in women with ACHD and their offspring compared to non-ACHD controls highlighting the need of specialized care and pre-pregnancy counselling.
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Affiliation(s)
- Astrid Elisabeth Lammers
- Department of Cardiology III, Adult Congenital and Valvular Heart Disease, University Hospital Muenster, Albert-Schweitzer-Campus 1, 48149 Münster, Germany.,Department of Paediatric Cardiology, University Hospital Münster, Albert-Schweitzer-Campus 1, 48149 Münster, Germany
| | - Gerhard-Paul Diller
- Department of Cardiology III, Adult Congenital and Valvular Heart Disease, University Hospital Muenster, Albert-Schweitzer-Campus 1, 48149 Münster, Germany.,National Register for Congenital Heart Disease, Berlin, Germany
| | - Rieke Lober
- Department of Cardiology III, Adult Congenital and Valvular Heart Disease, University Hospital Muenster, Albert-Schweitzer-Campus 1, 48149 Münster, Germany
| | - Mareike Möllers
- Department of Gynecology and Obstetrics, University Hospital Münster, Albert-Schweitzer-Campus 1, 48149 Münster, Germany
| | - Renate Schmidt
- Department of Cardiology III, Adult Congenital and Valvular Heart Disease, University Hospital Muenster, Albert-Schweitzer-Campus 1, 48149 Münster, Germany
| | - Robert M Radke
- Department of Cardiology III, Adult Congenital and Valvular Heart Disease, University Hospital Muenster, Albert-Schweitzer-Campus 1, 48149 Münster, Germany
| | - Fernando De-Torres-Alba
- Department of Cardiology III, Adult Congenital and Valvular Heart Disease, University Hospital Muenster, Albert-Schweitzer-Campus 1, 48149 Münster, Germany
| | - Gerrit Kaleschke
- Department of Cardiology III, Adult Congenital and Valvular Heart Disease, University Hospital Muenster, Albert-Schweitzer-Campus 1, 48149 Münster, Germany
| | - Ursula Marschall
- Department of Medicine and Health Services Research, BARMER Health Insurance, Wuppertal, Germany
| | - Ulrike M Bauer
- National Register for Congenital Heart Disease, Berlin, Germany.,DZHK (Deutsches Zentrum für Herz-Kreislauf-Forschung), Berlin, Germany
| | - Joachim Gerß
- Department for Biostatistics, University Hospital Muenster, Albert-Schweitzer-Campus 1, 48149 Münster, Germany
| | - Dominic Enders
- Department for Biostatistics, University Hospital Muenster, Albert-Schweitzer-Campus 1, 48149 Münster, Germany
| | - Helmut Baumgartner
- Department of Cardiology III, Adult Congenital and Valvular Heart Disease, University Hospital Muenster, Albert-Schweitzer-Campus 1, 48149 Münster, Germany.,National Register for Congenital Heart Disease, Berlin, Germany
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8
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Puspa Pitaloka C, Secka A, Ernawati E, Sulistyono A, Juwono HT, Gumilar Dachlan E, Aditiawarman A. Characteristics shifting of heart disease in pregnancy: A report from low middle-income country. J Public Health Res 2021; 10:2137. [PMID: 34278766 PMCID: PMC8764548 DOI: 10.4081/jphr.2021.2137] [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: 01/25/2021] [Accepted: 05/13/2021] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Heart disease in pregnancy is one of the leading causes of maternal mortality and morbidity in developing countries. However, the characteristics of the disease vary between countries and regions. This study aimed to present the characteristics of pregnant women with heart disease in an economically advantageous region of a developing country. DESIGN AND METHODS A cross-sectional study was conducted using data from the Weekly Report of Obstetrics and Gynaecology Department to assess pregnant women with heart disease characteristics and pregnancy outcomes. A total sample of 69 pregnant women with heart disease regarding their gestational age was included in the study. Variables observed were maternal characteristics, heart disease's clinical parameters, and maternal and neonatal outcomes. Chi-square test was used to examine the different characteristics of congenital and acquired heart disease groups. RESULTS The prevalence of cardiac disease in pregnancy was 5.19%. Fifty-three point six percent of pregnant women with heart disease were suffered from congenital heart disease (CHD), while 46.4% were acquired heart disease (AHD). Most labor methods were Cesarean delivery, and 69.6% of women experienced cardiac complications. Maternal death was reported in 8.69% of cases. Four cases were CHD complicated by pulmonary hypertension, which leads to Eisenmenger syndrome. Two other cases were AHD complicated by Peripartum Cardiomyopathies. Although statistically insignificant, complications are more common in the AHD group than CHD. CONCLUSION Cardiac disease prevalence in pregnancy is considered high, with CHD as the most common case, which significantly differs from other developing countries.
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Affiliation(s)
- Cyntia Puspa Pitaloka
- Master Program of Public Health, Faculty of Public Health, Universitas Airlangga, Surabaya.
| | - Absa Secka
- Master Program of Public Health, Faculty of Public Health, Universitas Airlangga, Surabaya.
| | - Ernawati Ernawati
- Department of Obstetrics and Gynecology, Faculty of Medicine, Universitas Airlangga, Surabaya / Dr. Soetomo General Hospital; Department of Obstetrics and Gynaecology, Airlangga University Academic Hospital, Surabaya.
| | - Agus Sulistyono
- Department of Obstetrics and Gynecology, Faculty of Medicine, Universitas Airlangga, Surabaya / Dr. Soetomo General Hospital.
| | - Hermanto Tri Juwono
- Department of Obstetrics and Gynecology, Faculty of Medicine, Universitas Airlangga, Surabaya / Dr. Soetomo General Hospital.
| | - Erry Gumilar Dachlan
- Department of Obstetrics and Gynecology, Faculty of Medicine, Universitas Airlangga, Surabaya / Dr. Soetomo General Hospital.
| | - Aditiawarman Aditiawarman
- Department of Obstetrics and Gynecology, Faculty of Medicine, Universitas Airlangga, Surabaya / Dr. Soetomo General Hospital.
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Schwerzmann M, Goossens E, Gallego P, Kovacs AH, Moons P, Swan L, Tobler D, de Stoutz N, Gabriel H, Greutmann M, Roos-Hesselink JW, Sobanski PZ, Thomet C. Recommendations for advance care planning in adults with congenital heart disease: a position paper from the ESC Working Group of Adult Congenital Heart Disease, the Association of Cardiovascular Nursing and Allied Professions (ACNAP), the European Association for Palliative Care (EAPC), and the International Society for Adult Congenital Heart Disease (ISACHD). Eur Heart J 2021; 41:4200-4210. [PMID: 32862229 DOI: 10.1093/eurheartj/ehaa614] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Revised: 05/30/2020] [Accepted: 07/13/2020] [Indexed: 02/07/2023] Open
Abstract
Survival prospects in adults with congenital heart disease (CHD), although improved in recent decades, still remain below expectations for the general population. Patients and their loved ones benefit from preparation for both unexpected and predictable deaths, sometimes preceded by a prolonged period of declining health. Hence, advance care planning (ACP) is an integral part of comprehensive care for adults with CHD. This position paper summarizes evidence regarding benefits of and patients' preferences for ACP and provides practical advice regarding the implementation of ACP processes within clinical adult CHD practice. We suggest that ACP be delivered as a structured process across different stages, with content dependent upon the anticipated disease progression. We acknowledge potential barriers to initiate ACP discussions and emphasize the importance of a sensitive and situation-specific communication style. Conclusions presented in this article reflect agreed expert opinions and include both patient and provider perspectives.
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Affiliation(s)
- Markus Schwerzmann
- Center for Congenital Heart Disease, University Hospital Inselspital, Department of Cardiology, University of Bern, Freiburgstrasse 15, 3010 Bern, Switzerland
| | - Eva Goossens
- Department of Public Health and Primary Care, KU Leuven, Kapucijnenvoer 35, box 7001, 3000 Leuven, Belgium.,Faculty of Medicine and Health Sciences, Centre for Research and Innovation in Care, Division of Nursing and Midwifery, University of Antwerp, Universiteitsplein 1, 2610 Antwerp, Belgium
| | - Pastora Gallego
- Department of Cardiology, Hospital Universitario Virgen del Rocio, Avenida Manuel Siurot s/n. 41013 Seville, Spain
| | - Adrienne H Kovacs
- Knight Cardiovascular Institute, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, UHN-62 Portland, Oregon, USA
| | - Philip Moons
- Department of Public Health and Primary Care, KU Leuven, Kapucijnenvoer 35, box 7001, 3000 Leuven, Belgium.,Institute of Health and Care Science, University of Gothenburg, Arvid Wallgrens Backe, Box 457, 405 30 Gothenburg, Sweden.,Department of Paediatrics and Child Health, University of Cape Town, Klipfrontein Road Mowbray, Cape Town 7700, South Africa
| | - Lorna Swan
- Division of Cardiology, Peter Munk Cardiac Centre; Toronto Congenital Cardiac Centre for Adults, University of Toronto, 585 University Avenue; Toronto ON M5G 2N2, Canada
| | - Daniel Tobler
- Department of Cardiology, University Hospital Basel, University of Basel, Petersgraben 44031 Basel, Switzerland
| | - Noémi de Stoutz
- European Society of Cardiology Patient Forum Representative, Member of "Cuore Matto" and Global ARCH, Dorfstrasse 64, 8126 Zumikon, Switzerland
| | - Harald Gabriel
- Department of Cardiology, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Matthias Greutmann
- Department of Cardiology, University Heart Center, Raemistrasse 100, 8091 Zurich, Switzerland
| | - Jolien W Roos-Hesselink
- Department of Cardiology, Erasmus MC, Erasmus University, P.O. Box 2040, 3000 CA Rotterdam, The Netherlands
| | - Piotr Z Sobanski
- Palliative Care Unit and Competence Center, Department of Internal Medicine, Hospital Schwyz, Waldeggstrasse 10, 6430 Schwyz, Switzerland
| | - Corina Thomet
- Center for Congenital Heart Disease, University Hospital Inselspital, Department of Cardiology, University of Bern, Freiburgstrasse 15, 3010 Bern, Switzerland.,Department of Public Health and Primary Care, KU Leuven, Kapucijnenvoer 35, box 7001, 3000 Leuven, Belgium
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10
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Ordoñez MV, Biglino G, Caputo M, Curtis SL. Pregnancy in the FONTAN palliation: physiology, management and new insights from bioengineering. JOURNAL OF CONGENITAL CARDIOLOGY 2021. [DOI: 10.1186/s40949-021-00058-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
AbstractFontan palliation for the single ventricle results in a challenging and delicate physiological state. At rest, the body adapts to a low cardiac output and high systemic venous pressure. However, when physiological demands increase, such as in the case of exercise or pregnancy, this delicate physiology struggles to adapt due to the inability of the heart to pump blood into the lungs and the consequent lack of augmentation of the cardiac output.Due to the advances in paediatric cardiology, surgery and intensive care, today most patients born with congenital heart disease reach adulthood. Consequently, many women with a Fontan circulation are becoming pregnant and so far data suggest that, although maternal risk is not high, the outcomes are poor for the foetus. Little is known about the reasons for this disparity and how the Fontan circulation adapts to the physiological demands of pregnancy.Here we review current knowledge about pregnancy in Fontan patients and explore the potential role of computational modelling as a means of better understanding this complex physiology in order to potentially improve outcomes, particularly for the foetus.
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11
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Abstract
Women with heart disease are at increased risk for maternal and fetal complications in pregnancy. Therefore, all women with heart disease should undergo evaluation and counseling, ideally before conception, or as early in pregnancy as possible. In this article we will review the role of risk assessment, the history of development of the cardiac risk prediction tools, and the role of current cardiac risk prediction tools.
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Farr SL, Downing KF, Ailes EC, Gurvitz M, Koontz G, Tran EL, Alverson CJ, Oster ME. Receipt of American Heart Association-Recommended Preconception Health Care Among Privately Insured Women With Congenital Heart Defects, 2007-2013. J Am Heart Assoc 2019; 8:e013608. [PMID: 31510829 PMCID: PMC6818013 DOI: 10.1161/jaha.119.013608] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Background Our objective was to estimate receipt of preconception health care among women with congenital heart defects (CHD), according to 2017 American Heart Association recommendations, as a baseline for evaluating recommendation implementation. Methods and Results Using 2007 to 2013 IBM MarketScan Commercial Databases, we identified women with CHD diagnosis codes ages 15 to 44 years who became pregnant and were enrolled in health insurance for ≥11 months in the year before estimated conception. We assessed documentation of complete blood count, electrolytes, thyroid‐stimulating hormone, liver function, ECG, comprehensive echocardiogram, and exercise stress test, using procedural codes, and outpatient prescription claims for US Food and Drug Administration category D and X cardiac‐related medications. Differences were examined according to CHD severity, age, region of residence, year of conception, and documented encounters at obstetric and cardiology practices. We found 2524 pregnancies among 2003 women with CHD (14.4% severe CHD). In the 98.3% of women with a healthcare encounter in the year before conception, <1% received all and 22.6% received no American Heart Association–recommended tests or assessments (range: 54.4% for complete blood count to 3.1% for exercise stress test). Women with the highest prevalence of receipt of recommended care were 35 to 44 years old, pregnant in 2012 to 2013, or had a documented obstetric or cardiology encounter in the year before conception (P<0.05 for all). In 9.0% of pregnancies, ≥1 prescriptions for US Food and Drug Administration category D or X cardiac‐related medications were filled in the year before conception. Conclusions A low percentage of women with CHD received American Heart Association–recommended preconception health care in the year before conception.
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Affiliation(s)
- Sherry L Farr
- National Center on Birth Defects and Developmental Disabilities Centers for Disease Control and Prevention Atlanta GA
| | - Karrie F Downing
- National Center on Birth Defects and Developmental Disabilities Centers for Disease Control and Prevention Atlanta GA
| | - Elizabeth C Ailes
- National Center on Birth Defects and Developmental Disabilities Centers for Disease Control and Prevention Atlanta GA
| | | | | | - Emmy L Tran
- National Center on Birth Defects and Developmental Disabilities Centers for Disease Control and Prevention Atlanta GA.,Oak Ridge Institute for Science and Education Oak Ridge TN
| | - C J Alverson
- National Center on Birth Defects and Developmental Disabilities Centers for Disease Control and Prevention Atlanta GA
| | - Matthew E Oster
- National Center on Birth Defects and Developmental Disabilities Centers for Disease Control and Prevention Atlanta GA.,Children's Healthcare of Atlanta Emory University School of Medicine Atlanta GA
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Foeller ME, Foeller TM, Druzin M. Maternal Congenital Heart Disease in Pregnancy. Obstet Gynecol Clin North Am 2018; 45:267-280. [PMID: 29747730 DOI: 10.1016/j.ogc.2018.01.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Congenital heart disease comprises most maternal cardiac diseases in pregnancy and is an important cause of maternal, fetal, and neonatal morbidity and mortality worldwide. Pregnancy is often considered a high-risk state for individuals with structural heart disease as a consequence of a limited ability to adapt to the major hemodynamic changes associated with pregnancy. Preconception counseling and evaluation are of utmost importance, as pregnancy is contraindicated in certain cardiac conditions. Pregnancy can be safely accomplished in most individuals with careful risk assessment before conception and multidisciplinary care throughout pregnancy and the postpartum period.
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Affiliation(s)
- Megan E Foeller
- Obstetrics and Gynecology, Stanford University, Stanford Hospital, 300 Pasteur Drive, Room G302, 5317, Stanford, CA 94305-5317, USA.
| | - Timothy M Foeller
- Internal Medicine, Stanford Health Care-ValleyCare, 5555 West Positas Boulevard, 1 West Hospitalist Room 1, Pleasanton, CA 94588, USA
| | - Maurice Druzin
- Obstetrics and Gynecology, Stanford University, Stanford Hospital, 300 Pasteur Drive, Room G302, 5317, Stanford, CA 94305-5317, USA
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