2018 ESC Guidelines for the management of cardiovascular diseases during pregnancy

Pregnancy and Congenital Heart Disease: A Brief Review of Risk Assessment and Management

Cardiac disease is a leading cause of morbidity and mortality in pregnant women. An increased prevalence of the cardiovascular disease has been found in women of childbearing age, in which the responsibility of the treating physician extends to the mother and to the unborn fetus. As a result, care of these high-risk pregnant women with cardiovascular disease including those with congenital heart disease (CHD) require a team approach including specialists in maternal-fetal medicine, adult congenital cardiology, and obstetrical anesthesia. The human body undergoes significant amounts of physiological changes during this period of time and the underlying cardiac disease can affect both the mother and the fetus. Today, most female children born with CHD will reach childbearing age. For many women with complex CHD, carrying a pregnancy has a moderate to high risk for both the mother and her fetus. This chapter will review the epidemiology, risk factors, clinical presentation including common signs and symptoms, physiological changes in pregnancy, and the medical approach including cardiac medications, percutaneous interventions, and surgical procedures for pregnant women with CHD.

Pulmonary Hypertension in Pregnancy

Pulmonary hypertension in pregnancy carries a high maternal and fetal morbidity, and mortality. In recent times, there has been significant progress in the field of pulmonary vascular disease with a better understanding of the disease and novel targeted therapies, which have ultimately resulted in improved outcomes. In addition, the development of an individualized and multidisciplinary approach to the management of pulmonary hypertension during pregnancy is essential for improved outcomes.

Evaluation and Diagnostic Testing

The evaluation of cardiovascular disease in pregnancy is challenging due to overlaps between cardiac and normal pregnancy symptomatology, as well as concerns about the potential impact, if any, of imaging studies on fetal development. We discuss here an approach to the evaluation of the pregnant cardiac patient and review the safety and utility of available diagnostic tests, including labs, electrocardiogram, echocardiography, stress testing, computed tomography, magnetic resonance imaging, and cardiac catheterization. Importantly, the majority of standard imaging studies can be safely performed in pregnancy, and a high index of suspicion must be maintained when evaluating pregnant patients, especially those with preexisting cardiovascular disease.

Cardiovascular Diseases in Women: Policies and Practices Around the Globe to Achieve Gender Equity in Cardiac Health

The women's global health agenda has recently been reformulated to address more accurately cardiovascular disease (CVD) prevention, diagnosis, and treatment. The aim of the present work was to review the global and national policies and practices that address sex equality in health with a focus on CVDs in women. Scientific databases and health organizations' websites that presented/discussed policies and initiative targeting to enhance a sex-centered approach regarding general health and/or specifically cardiac health care were reviewed in a systematic way. In total, 61 relevant documents were selected. The selected policies and initiatives included position statements, national action plans, evidence-based guidelines, guidance/recommendations, awareness campaigns, regulations/legislation, and state-of-the art reports by national/international projects and conferences. The target audiences of large stakeholders (eg, American Heart Association, European Society of Cardiology, Centers for Disease Control and Prevention) were female citizens, health professionals, and researchers. Much as policy-makers have recognized the sex/gender gap in the CVD field, there is still much to be done. Thereby, tailor-made strategies should be designed, evaluated, and delivered on a global and most importantly a national basis to achieve gender equity with regard to CVDs.

Cardiomyopathies in Pregnancy: Etiologies and Management Strategies

The cardiomyopathies are a diverse group of disorders characterized by structural abnormalities of heart muscle, many of which have a genetic component. They are associated with substantial morbidity and mortality in pregnancy. We review the distinct forms of cardiomyopathy (dilated, hypertrophic, and functional) which can be seen during pregnancy, discuss complications associated with each distinct group such as heart failure, arrhythmias, and transmission to offspring, and address management strategies for stable and unstable patients.

Thromboembolic complications in adult congenital heart disease: the knowns and the unknowns

Despite impressive improvement in long-term survival, adults with congenital heart disease (CHD) remain exposed to a significant cardiovascular morbidity over lifetime. Thromboembolic events (TE) are a major issue. Specific anatomic groups have been shown a particular high risk of TE, including cyanotic heart disease and Fontan circulation. Many intercurrent clinical factors add a substantial risk such as intracardiac medical devices, atrial arrhythmia, endocarditis, or pregnancy. Nevertheless, what is unknown exceeds what is known, especially regarding the management of this heterogenous patient population. Anticoagulation decision should always be individualized weighing balanced with the alternative risk of hemorrhagic complications. In this review, we aim to synthetize existing literature on TE in adults with CHD, discuss management issues, highlight gaps in knowledge, and intend to suggest high priority research.

Peripartum Cardiomyopathy: Management Strategies for Pregnancy Termination

Some women have underlying cardiovascular disease that leads to increased morbidity and mortality with pregnancy. These women may choose to terminate a pregnancy rather than face this increased risk. The optimal approach for pregnancy termination in women with cardiomyopathy is not well defined. We present two women with peripartum cardiomyopathy, both modified World Health Organization (mWHO) class IV and with elevated Cardiac Disease in Pregnancy (CARPREG II) pregnancy risk stratification scores who are at the highest risk for pregnancy continuation. Both underwent induced abortion, although the procedure was performed in very different settings. These cases illustrate factors that influence the mode and setting of pregnancy termination performance.

Interventional Cardiology and Catheter-Based Interventions in Pregnancy

Cardiovascular disease is the leading cause of maternal mortality worldwide and has been increasing in prevalence over the last several decades. Pregnancy is associated with significant hemodynamic changes that can overwhelm the maternal cardiovascular reserve, and may exacerbate previously asymptomatic cardiovascular disease. Complications associated with these may cause substantial harm to both the mother and the fetus, and the management of these conditions is often challenging. Numerous novel treatments and interventions have demonstrated the safety and efficacy of managing these conditions outside of pregnancy. However, there are little data regarding their use in the pregnant population. In this review, we describe the common cardiovascular diseases encountered during pregnancy and discuss their management strategies, with a particular focus on the role of percutaneous, catheter-based therapeutic interventions.

Peripartum cardiomyopathy with preeclampsia in a parturient: A case report with literature review

Peripartum cardiomyopathy (PPCM) is a rare disease of unknown cause that affects women of childbearing age. A high index of suspicion should be maintained in the pregnant and peripartum woman who presents with sudden cardiac decompensation without any prior history of cardiac disease. The diagnosis can be confirmed with echocardiographic evidence of global left ventricular dysfunction. Timely diagnosis and institution of therapy for heart failure can avoid adverse outcomes in a parturient with PPCM. In this case report, we describe the management of primigravida presenting to the hospital's emergency department with acute cardiac failure and respiratory distress due to PPCM. The case also highlights that though preeclampsia and PPCM are two separate entities, these can coexist in the same parturient due to the common pathophysiological mechanism. In the review, the recommended medical management of heart failure in PPCM with the “BOARD” (Bromocriptine, Oral heart failure drugs, Anticoagulants, Vasorelaxing agents, and Diuretics) scheme is discussed.

Secondary hyperparathyroidism is associated with postpartum blood pressure in preeclamptic women and normal pregnancies

BACKGROUND

Preeclampsia has been associated with features of secondary hyperparathyroidism. In this study, we examine the relationships of calcium metabolism with blood pressure (BP) in preeclamptic women and in a control group of normal (NORM) pregnancies in the postpartum.

METHODS

Sixty-three consecutive preeclamptic women (age 35 ± 6 years) were studied 4 weeks after delivery. We collected clinical and lab information on pregnancy and neonates and measured plasma and urinary calcium and phosphate, plasma parathyroid hormone (PTH) and 25-hydroxy vitamin D [25(OH)D], and performed 24-h ambulatory BP monitoring. BP and calcium metabolism of 51 preeclamptic were compared with 17 NORM pregnant women that matched for age, race, and postpartum BMI.

RESULTS

25(OH)D deficiency (<10 ng/ml) was found in 3% of preeclamptic women, insufficiency (10-30 ng/ml) in 67%, and NORM values (31-100 ng/ml) in the remaining 30%. Elevated plasma PTH (≥79 pg/ml) was found in 24% of preeclamptic women who had 25(OH)D plasma levels of 21.4 ± 8.3 ng/ml. In these women, PTH levels was independently associated with 24-h SBP and DBP and daytime and night-time DBP. Prevalence of nondippers and reverse dippers was elevated (75% and 33%, respectively). No associations between calcium metabolism and neonates' characteristics of preeclamptic women were observed. Prevalence of vitamin D deficiency and insufficiency and of elevated plasma PTH levels were comparable in matched groups. Considering preeclamptic women and matched controls as a whole group, office SBP and DBP levels were associated with PTH independently of preeclampsia and other confounders.

CONCLUSION

Features of secondary hyperparathyroidism are common in the postpartum. Preeclampsia and increased PTH levels were both independent factors associated with increased BP after delivery, and both might affect the future cardiovascular risk of these women.

Update on Prevention and Management of Rheumatic Heart Disease

Rheumatic heart disease (RHD) remains the most common cause of cardiovascular morbidity and mortality globally in children and young adults. This article focuses on prevention and management of RHD. Pregnancy can unmask previously undiagnosed RHD and poses high risk for mother and fetus. Management of anticoagulation is important. Definitive catheter and surgical intervention are the only treatments that can improve outcomes of patients with moderate or severe RHD. Access to intervention remains very limited in RHD endemic regions. There are ongoing global efforts to increase awareness, public policy adoption, and greater access to treatment.

Management of hypertension in pregnancy

Hypertensive diseases of pregnancy remain a leading cause of maternal and neonatal morbidity and mortality. Therefore, we sought to review the management of these conditions in pregnancy. In this review we discuss the most updated definitions, different antihypertensives, delivery recommendations and overall goals of management, including their effects on uteroplacental perfusion. We also highlight different medical situations where one antihypertensive may be preferable over others.

Valvular Heart Disease in Pregnancy

The number of reproductive age women with valvular heart disease is rising and accounts for one third of all heart disease among pregnant women. Severe, symptomatic left-sided cardiac lesions, particularly mitral and aortic stenosis, and mechanical heart valves, are associated with adverse maternal and fetal outcomes. Decreasing maternal and fetal risk requires shared decision-making among patients and the heart team, consisting of obstetricians, maternal-fetal medicine subspecialists, and cardiologists.

Acute aortic dissection during pregnancy: Trials and tribulations

BACKGROUND

Type A acute aortic dissection (TAAD) during pregnancy is a life-threatening event for both the mother and the unborn baby. Pregnancy has been recognized as an independent risk factor for TAAD, postulated to be due to physiological changes that cause hyperdynamic circulation. This review seeks to outline the current controversies around this unique group.

METHODS

A comprehensive literature search was carried out across large databases to assimilate relevant papers regarding acute aortic dissection in pregnant women.

RESULTS

The presentation can be atypical in many cases and further concern from clinicians of fetal radiation exposure can result in missed or delayed diagnoses. Investigation via the quickest form of imaging, whether computed tomography, magnetic resonance imaging, or transesophageal echocardiography, should be carried out promptly due to the high risk of mortality. Surgical management of TAAD in pregnancy revolves primarily around the decision to deliver the fetus concomitantly or to perform the aortic repair with the fetus in utero.

CONCLUSIONS

Management of this group includes rapid and dynamic assessment without delay. From conception to postpartum, there are multiple stages in which to manage these women. Challenges in carrying out management in the form of operative techniques and cardiopulmonary bypass place the fetus at risk and must be approached with caution, particularly as there is little evidence-base for many of these decisions. Further research into reducing maternal and fetal mortality is necessary.

Repetitive out of hospital cardiac arrests following pregnancy: a case report of an unfortunate presentation of mitral annular disjunction

BACKGROUND

Mitral annular disjunction (MAD) is an under-recognized cause of arrhythmic sudden cardiac death, especially in young women. The relation between MAD and the occurrence of arrhythmia during pregnancy has not yet been explored. We would like to stress the importance of careful echocardiographic examination and the vulnerable peripartum period.

CASE SUMMARY

A 29-year-old woman survived an out of hospital cardiac arrest 4 months after delivery of her first child. The diagnosis was not clear and an implantable cardioverter-defibrillator (ICD) as secondary prevention was implanted. Her second pregnancy and delivery were uneventful. The 12-lead electrocardiogram demonstrated sinus rhythm with right bundle branch block, ventricular extra systoles (premature ventricular contractions), and a right superior axis, i.e. origin in the inferolateral basal left ventricle. Transthoracic 2D echocardiography showed myxomatous mitral valve disease with moderate mitral valve insufficiency with normal left and right heart dimensions and function. However, 4 weeks after delivery she experienced a sudden syncope at home. Implantable cardioverter-defibrillator reading revealed primary ventricular fibrillation, induced by a ventricular premature beat (VPB), terminated with a successful ICD shock. A frame-by-frame echocardiographic analysis of the mitral valve using biplane echocardiographic analysis allowed diagnosis of MAD with detachment of the root of the annulus from the posterolateral ventricular myocardium during systole.

CONCLUSION

Mitral annular disjunction is an under-recognized cause of arrhythmic sudden cardiac death. Biplane echocardiographic analysis of the mitral annulus can identify MAD and as such may help for risk stratification and sudden cardiac death prevention. Careful follow-up is necessary especially during pregnancy and the postpartum period.

Platypnea-orthodeoxia syndrome: an unusual cause of breathlessness in late pregnancy

A pregnant patient with shortness of breath and arterial oxygen desaturation is presented. The primary and tentative initial diagnosis was pulmonary embolism. Her desaturation and dyspnea were aggravated in the upright compared with the supine position. The minimal response to supplemental oxygen suggested right-to-left shunting, which was confirmed by echocardiography. Shunting was minimal in the supine and maximal in the upright position, leading to the diagnosis of platypnea-orthodeoxia syndrome. By two weeks postpartum the patient's symptoms had resolved and shunting was undetectable.

Prediction of adverse maternal outcomes of early severe preeclampsia

OBJECTIVES

Assess soluble FMS-like tyrosine kinase-1/placental growth factor ratio (sFlt-1/PlGF) diagnostic accuracy for predicting adverse maternal outcome in patients with early severe preeclampsia, and whether its predictive performance is superior to full preeclampsia integrated estimate of risk score (PIERS).

STUDY DESIGN

Prospective study enrolled patients with early severe preeclampsia (defined by American College of Obstetricians and Gynaecologists 2013 guidelines) admitted to the Clinic for Obstetrics and Gynaecology, Clinical Center of Serbia intensive care unit. Patients underwent delivery to terminate preeclampsia within 48 h of admission. PIERS was generated and blood samples taken at admission. Multiple pregnancies and gestational ages outside 24-34 weeks were excluded. sFlt-1 and PlGF serum concentrations were measured using Elecsys® assays and cobas e 601 analyser. Maternal complications were recorded for seven days post-delivery.

MAIN OUTCOME MEASURES

Diagnostic accuracy (sensitivity and specificity), and predictive performance (receiver operating characteristic area under curve [AUC]) vs. PIERS, of sFlt-1/PlGF for predicting adverse maternal outcome.

RESULTS

Of 89 patients enrolled, 61 were evaluable. Median frequency of adverse maternal outcomes within seven days of delivery was two. Median sFlt-1/PlGF and PIERS were 521·0 and 5·0%, respectively. sFlt-1/PlGF showed greater correlation with complication number than PIERS (Spearman's rho: 0·728 [p < 0·001] and 0·134 [p = 0·304], respectively). AUC for sFlt-1/PlGF and PIERS were 0·853 and 0·628, respectively. A 377·0 sFlt-1/PlGF cut-off was optimal for predicting complications (75·0% sensitivity; 92·3% specificity).

CONCLUSIONS

sFlt-1/PlGF correlated more closely with number of adverse maternal outcomes than PIERS, and was a superior predictor of maternal complications.

Comparison of risk stratification models for pregnancy in congenital heart disease

BACKGROUND

Pregnancy in women with congenital heart disease (CHD) is associated with increased risk for maternal cardiac complications. Several risk stratification models are used to predict adverse cardiac outcome in women with CHD who become pregnant. This study was set up as an exploratory study to provide a head-to-head comparison of the 4 most commonly used models: CARPREG, CARPREG II and ZAHARA risk scores and mWHO risk classification.

METHODS AND RESULTS

We randomly selected 100 women from the database of paediatric and congenital heart disease of the University Hospitals Leuven. Individual pregnancy risk scores were retrospectively calculated and summarized in a weighted average risk for each risk stratification model. To evaluate accuracy of each model, the weighted average risk was plotted against the actual observed number of "cardiac events" as defined in the respective risk models. Maternal adverse cardiac events occurred in 8% of our study population. Weighted average risks were plotted versus the observed number of events for each model: 10.1% versus 4.0% for CARPREG, 8.6% versus 5.0% for CARPREG II, 11.1% versus 8.0% for ZAHARA and 12.4% versus 8.0% for the mWHO classification.

CONCLUSION

All risk models overestimated maternal cardiac risk. The ZAHARA risk model appeared to be a closer reflection of maternal risk in our cohort of CHD patients. More research on a larger study population is needed.

Left atrial myocardial function and compliance in pre-eclampsia with preserved left ventricular systolic and diastolic function

Left atrial (LA) adaptive changes associated with pre-eclampsia (PE) have not been adequately addressed. This study aimed to evaluate the usefulness of LA myocardial function indices in detecting early cardiac alterations in PE. Using speckle tracking echocardiography (STE), LA volumetric and myocardial parameters were acquired in PE women with preserved left ventricular (LV) systolic and diastolic function based on standard criteria and normotensive controls. LA compliance was assessed by the ratio of reservoir strain (LASr) to the estimated LA pressure (E/e'). Subtle systolic and diastolic abnormalities were identified as LV global longitudinal strain < 17.8% and mitral tissue e' velocity < 7 cm/s septal or < 10 cm/s lateral, respectively. LASr/(E/e') was prior to other LA measurements in detecting early LA function changes in PE. The rate of LASr/(E/e') < 3 was significantly greater in the patients with subtle systolic impairments than those without (P < 0.05) in spite of similar proportion of LASr < 31% between them. Among PE women with subtle diastolic damages, the frequencies of anomaly and the values in both LASr/(E/e') and LASr were significantly different to those without (P < 0.05). Moreover, the rate of LASr/(E/e') < 3 was markedly higher than that of LASr < 31% in PE cases with subtle cardiac abnormalities (P < 0.05). In the setting of PE with preserved systolic and diastolic function, STE-derived LA strain and estimated LA compliance may be beneficial to identifying earlier cardiac alternations. LA compliance could outperform LASr in detecting cardiac anomalies earlier during a PE pregnancy with preserved LV performance.

Postpartum blood pressure patterns in severe preeclampsia and normotensive pregnant women following abdominal deliveries: a cohort study

Objective: To determine blood pressure (BP) patterns in the immediate postpartum period in preeclampsia with severe features (sPE) and normotensive pregnant women who had cesarean deliveries (CD).Study design: The BP levels of two groups comprising 50 sPE and 90 normotensive pregnant women who had CD were measured before delivery and on days 0-3 postpartum at four time points (05:00, 08:00, 14:00, and 22:00). Soluble fms-like tyrosine kinase-1 (sFlt-1) and placental growth factor (PIGF) were measured in the maternal serum ≤48 h before delivery.Results: Antihypertensive therapy was administered to 98, 96, 82, 78, and 56% of sPE antepartum and on postpartum days 0-3, respectively. De novo postpartum hypertension (BP ≥ 140/90 mmHg) occurred in 24.4% (22/90) of the normotensive group but only one required antihypertensive therapy. The occurrence of de novo postpartum hypertension was associated with maternal weight before delivery ≥ 84.5 kg (relative risks (RR) 2.6, CI 95% 1.2-5.8, p = .017), and body mass index before delivery ≥ 33.3 kg/m2 (RR 2.9, CI 95% 1.3-6.4, p = .008). In sPE, the BP decreased between predelivery period and postpartum day 0. From days 1 to 3 postpartum, there was a continuous increase in the daily mean BPs in both groups, with average daily increments (systolic/diastolic) being 5.6/4.6 mmHg and 0.6/1.3 mmHg in the sPE and normotensive women, respectively. Patient's group and time had a significant effect on BP, p < .001. Overall, daily mean BPs were higher in the sPE than the normotensive group (p < .001). Perceived stress (p = .022), low birth weight (p = .002), 5 min Apgar score ≤ 6 (p < .001) were significantly higher in the sPE group. sFlt-1/PIGF ratio was high in the hypertensive groups: sPE versus normotensive group, p < .001; de novo postpartum hypertension versus normotensives group that remained normotensive, p = .102.Conclusion: Postpartum BP and antihypertensive requirements are important considerations in managing sPE and normotensive pregnancies. sPE is associated with increased maternal stress and poor perinatal outcomes.

Association of Pregnancy With Recurrence of Spontaneous Coronary Artery Dissection Among Women With Prior Coronary Artery Dissection

IMPORTANCE

Spontaneous coronary artery dissection (SCAD) is a notable cause of acute coronary syndrome in women of childbearing age.

OBJECTIVE

To test the hypothesis that pregnancy after SCAD is associated with recurrent SCAD.

DESIGN, SETTING, AND PARTICIPANTS

Three study designs were implemented: a case series of women with pregnancy after SCAD; a nested case-control study comparing patients with recurrent SCAD to matched controls without recurrent SCAD; and a cohort study. Women with SCAD who were of childbearing potential and enrolled into the Mayo Clinic SCAD Registry from August 30, 2011, to April 4, 2019, were included in the study. Patients with coronary dissections associated with iatrogenesis, trauma, or atherosclerosis were not enrolled.

EXPOSURES

Pregnancy after SCAD.

MAIN OUTCOMES AND MEASURES

The primary outcome was SCAD recurrence, defined as an acute coronary syndrome or cardiac arrest due to new SCAD. Other demographic measures collected included age, year of SCAD occurrence, and comorbidities.

RESULTS

The cohort included 636 women of childbearing potential. Twenty-three of those women had a total of 32 pregnancies after SCAD. The median (interquartile range) age of women with pregnancy after SCAD was 38 years (34-40 years), and 20 (87%) were White. In the nested case-control study, 92 cases of recurrent SCAD were matched to 158 controls. There was no significant difference in exposure to subsequent pregnancies in the women with recurrent SCAD as compared with matched controls (2 of 92 [2%] vs 13 of 158 [8%]; P = .06). In the overall cohort of 636 patients, recurrent SCAD was present in 122 patients with a Kaplan-Meier 5-year SCAD recurrence estimate of 14.8%. The Cox analysis showed no significant association between subsequent pregnancy and SCAD recurrence with a nonsignificant hazard ratio of 0.38 (95% CI, 0.09-1.6) when controlling for age at first SCAD, year of first SCAD, and fibromuscular dysplasia.

CONCLUSIONS AND RELEVANCE

This study found that most women tolerated pregnancy and lactation after SCAD without evidence for increased risk of SCAD recurrence when compared with women with a history of SCAD who did not experience pregnancy. Although this study is reassuring and indicates complex contributors to SCAD recurrence, the results need to be interpreted prudently because of study selection bias and the small total number of women who became pregnant after SCAD. The notable hemodynamic changes that occur with pregnancy and severe presentation of pregnancy-associated SCAD are reasons for concern when considering pregnancy after SCAD.

Hypertension During Pregnancy

PURPOSE OF REVIEW

Hypertensive disorders of pregnancy affect about 5-10% of pregnancies impacting maternal, fetal, and neonatal outcomes. We review the recent studies in this field and discuss the pathophysiology, diagnosis, and management of hypertension during pregnancy, as well as the short- and long-term consequences on the cardiovascular health of women.

RECENT FINDINGS

Although the American College of Cardiology/American Heart Association revised their guidelines for hypertension in the general population in 2017, hypertension during pregnancy continues to be defined as a systolic blood pressure (SBP) ≥ 140 mmHg and/or a diastolic blood pressure (DBP) ≥ 90 mmHg, measured on two separate occasions. The addition of stage 1 hypertension will increase the prevalence of hypertension during pregnancy, identifying more women at risk of preeclampsia; however, more research is needed before changing the BP goal because a lower target BP has a risk of poor placental perfusion. Women with chronic hypertension have a higher incidence of superimposed preeclampsia, cesarean section, preterm delivery before 37 weeks' gestation, birth weight less than 2500 g, neonatal unit admission, and perinatal death. They also have a higher risk of developing cardiovascular disease later in life. The guidelines recommend low-dose aspirin for women with moderate and high risk of preeclampsia. While treating pregnant women with hypertension, the effectiveness of the antihypertensive agent must be balanced with risks to the fetus. Hypertensive disorders of pregnancy should be appropriately and promptly recognized and treated during pregnancy. They should further be co-managed by the obstetrician and cardiologist to decrease the long-term negative impact on the cardiovascular health of women.

Rheumatic mitral stenosis in a 28-week pregnant woman treated by mitral valvuoplasty guided by low dose of radiation: a case report and brief overview

Rheumatic mitral stenosis is still a pathological condition that affects young patients and is an important cause of mortality. 2017-European Guidelines for the management of valvular heart disease suggest a percutaneous approach with a mitral commissurotomy for the treatment of symptomatic pregnant women. Mitral commissurotomy procedure involves radiation exposure that is incompatible with the pregnancy condition. In our case, we present percutaneous mitral commissurotomy (PMC) to a 28-week pregnant woman with a low-radiation dose and the use of transesophageal echocardiography. The woman presented with a mitral transvalvular mean gradient of 21.6 mmHg and with symptoms non-responsive to medical treatment. PMC was driven by a transesophageal echocardiographic probe. This case demonstrates the feasibility and safety of PMC in a pregnant woman with severe rheumatic mitral stenosis.

Women Living with Familial Hypercholesterolemia: Challenges and Considerations Surrounding Their Care

PURPOSE OF REVIEW

To highlight the gender-based differences in presentation and disparities in care for women with familial hypercholesterolemia (FH).

RECENT FINDINGS

Women with FH experience specific barriers to care including underrepresentation in research, significant underappreciation of risk, and interrupted therapy during childbearing. National and international registry and clinical trial data show significant healthcare disparities for women with FH. Women with FH are less likely to be on guideline-recommended high-intensity statin medications and those placed on statins are more likely to discontinue them within their first year. Women with FH are also less likely to be on regimens including non-statin agents such as PCSK9 inhibitors. As a result, women with FH are less likely to achieve target low-density lipoprotein cholesterol (LDL-C) targets, even those with prior atherosclerotic cardiovascular disease (ASCVD). FH is common, under-diagnosed, and under-treated. Disparities of care are more pronounced in women than men. Additionally, FH weighs differently on women throughout the course of their lives starting from choosing contraceptives as young girls along with lipid-lowering therapy, timing pregnancy, choosing breastfeeding or resumption of therapy, and finally deciding goals of care during menopause. Early identification and appropriate treatment prior to interruptions of therapy for childbearing can lead to marked reduction in morbidity and mortality. Women access care differently than men and increasing awareness among all providers, especially cardio-obstetricians, may improve diagnostic rates. Understanding the unique challenges women with FH face is crucial to close the gaps in care they experience.

Cesarean delivery in a parturient with a left ventricular assist device

Left ventricular assist devices are implanted pumps designed to treat patients with heart failure, and in some cases, to be a bridge to transplantation for patients who qualify. The preconception presence of a left ventricular assist device is a relative contraindication to pregnancy. Few cases have been published regarding the anesthetic management of parturients with left ventricular assist devices. We present the care of a 24-year-old gravida seven, para two woman who presented for induction of labor at gestational age 34 and 6/7 weeks. Her medical history was significant for the presence of a left ventricular assist device, inserted due to heart failure associated with polysubstance abuse. To our knowledge, this is the first description of successful cesarean delivery under neuraxial anesthesia of a parturient with a left ventricular assist device.

Care of infants, children and adults with congenital heart disease

Congenital heart disease refers to an anatomical or physiological defect of the heart that is present at birth. Over the past three decades there have been significant advances in surgical, medical and nursing care for infants and children requiring cardiac surgery for congenital heart disease. This has meant that the number of adults with moderate and complex congenital heart disease now exceeds the number of children with the disease. This article details the background and diagnosis of congenital heart disease. It considers the implications for infants and children with congenital heart disease, as well as their parents, such as screening methods, risk factors, parental stress and psychosocial needs. This article also discusses the care of adults with congenital heart disease, including specialist monitoring and patient education.

Gender Differences in Patients Admitted to a Certified German Chest Pain Unit: Results from the German Chest Pain Unit Registry

INTRODUCTION

Gender-specific atypical clinical presentation in acute coronary syndrome and sex-specific outcomes in cardiovascular disease in women are well known. The aim of this study is to analyze possible differences between men and women presenting to certified German chest pain units (CPUs).

METHODS

Data from 13,900 patients derived from the German CPU registry were analyzed for gender differences in patient characteristics, cardiovascular disease manifestation, critical time intervals, treatment and prognosis.

RESULTS

A total of 37.8% of patients were female. Typical chest pain occurred more frequently in men, while atypical symptoms occurred more frequently in women. Female gender was associated with longer pre- and in-hospital time delays. Women were more often diagnosed with a nonischemic origin of pain. In a 3-month follow-up, there was no gender-specific difference in combined major adverse coronary and cerebrovascular events.

DISCUSSION/CONCLUSION

This study points out gender-specific differences in prehospital time intervals and a significantly higher percentage of atypical symptoms in suspected myocardial ischemia as well as more noncoronary diagnoses in women. Symptom awareness and a broader diagnostic workup in women are essential.

Be Healthe for Your Heart: A Pilot Randomized Controlled Trial Evaluating a Web-Based Behavioral Intervention to Improve the Cardiovascular Health of Women with a History of Preeclampsia

This pilot randomized controlled trial (RCT) aimed to determine the acceptability and preliminary efficacy of a web-based cardiovascular disease (CVD) prevention intervention for women following preeclampsia. Australian women with a recent history (≤4 years post diagnosis) of preeclampsia were randomized into two study arms: (1) Be Healthe for your Heart, a web-based behavioral intervention or; (2) Control, access to the National Heart Foundation website. Assessments were conducted at baseline, and after three months. Intervention acceptability and impact on absolute CVD 30-year risk score, CVD risk markers and health behaviors were assessed. Twenty-four of 31 (77.4%) women completed the three-month assessment. Eleven out of 13 intervention participants (84.6%) agreed/strongly agreed they were satisfied with the program, with a mean score of 4.2 ± 0.9 (maximum of five). There were no significant between or within group differences in absolute CVD risk, CVD risk markers or health behaviors from baseline to three months. Women with a history of preeclampsia were successfully recruited and retained and they reported high levels of acceptability with the Be Healthe for your Heart program. Further research is therefore needed from powered trials to determine the impact of web-based lifestyle interventions on CVD risk in this at-risk group.

Severe Cardiopulmonary Disease in a Parturient With Noonan Syndrome

Noonan syndrome is a relatively common genetic disorder and the second most common cause of congenital heart disease after trisomy 21. The spectrum of cardiac anomalies in Noonan syndrome typically involves pulmonary valve stenosis occasionally in conjunction with hypertrophic cardiomyopathy. Mitral valve involvement is a rare finding in Noonan syndrome and is most commonly associated with either mitral valve prolapse or abnormal valvular insertion causing left ventricular outflow tract obstruction. Patients with Noonan syndrome typically have preserved fertility and, given the success of cardiac surgery and medical management of heart failure in this population, are beginning to present more commonly as parturients in adulthood. Maternal physiologic changes during pregnancy introduce an added complexity to hemodynamic management and anesthetic considerations during labor and delivery. In this article, we present a case of a patient with Noonan syndrome with severe mitral stenosis, pulmonary valve insufficiency, and severe restrictive and obstructive pulmonary disease who presented preterm for delivery due to increased dyspnea at rest. Here we review the pathophysiology behind Noonan syndrome and peripartum management strategies in a patient with severe combined cardiac and pulmonary disease.

Acute Coronary Syndrome and Ischemic Heart Disease in Pregnancy: Data From the EURObservational Research Programme-European Society of Cardiology Registry of Pregnancy and Cardiac Disease

Background The prevalence of ischemic heart disease (IHD) in women of child-bearing age is rising. Data on pregnancies however are scarce. The objective is to describe the pregnancy outcomes in these women. Methods and Results The European Society of Cardiology-EURObservational Research Programme ROPAC (Registry of Pregnancy and Cardiac Disease) is a prospective registry in which data on pregnancies in women with heart disease were collected from 138 centers in 53 countries. Pregnant women with preexistent and pregnancy-onset IHD were included. Primary end point were maternal cardiac events. Secondary end points were obstetric and fetal complications. There were 117 women with IHD, of which 104 had preexisting IHD. Median age was 35.5 years and 17.1% of women were smoking. There was no maternal mortality, heart failure occurred in 5 pregnancies (4.8%). Of the 104 women with preexisting IHD, 11 women suffered from acute coronary syndrome during pregnancy. ST-segment‒elevation myocardial infarction were more common than non‒ST-segment‒elevation myocardial infarction, and atherosclerosis was the most common etiology. Women who had undergone revascularization before pregnancy did not have less events than women who had not. There were 13 women with pregnancy-onset IHD, in whom non‒ST-segment‒elevation myocardial infarction was the most common. Smoking during pregnancy was associated with acute coronary syndrome. Caesarean section was the primary mode of delivery (55.8% in preexisting IHD, 84.6% in pregnancy-onset IHD) and there were high rates of preterm births (20.2% and 38.5%, respectively). Conclusions Women with IHD tolerate pregnancy relatively well, however there is a high rate of ischemic events and these women should therefore be considered moderate- to high-risk. Ongoing cigarette smoking is associated with acute coronary syndrome during pregnancy.

Pregnancy-Associated Myocardial Infarction: Prevalence, Causes, and Interventional Management

Pregnancy-associated myocardial infarction is a primary contributor to maternal cardiovascular morbidity and mortality. Specific attention to the cause of myocardial infarction, diagnostic evaluation, treatment strategies, and postevent care is necessary when treating women with pregnancy-associated myocardial infarction. This review summarizes the current knowledge, consensus statements, and essential nuances.

Pregnancy outcomes in women with dilated cardiomyopathy: Peripartum cardiovascular events predict post delivery prognosis

BACKGROUND

The number of pregnant women with dilated cardiomyopathy (DCM) is relatively small, and therefore their prognosis after pregnancy is unknown. This study aims to elucidate pregnancy outcomes among women with DCM, as well as the long-term prognosis after pregnancy.

METHODS

Thirty-five pregnancies and deliveries in 30 women, diagnosed with DCM before pregnancy, were retrospectively analyzed.

RESULTS

All women had a left ventricular ejection fraction (LVEF) over 30% and belonged to the New York Heart Association (NYHA) class I or II before pregnancy. The mean gestational age at delivery was 36 weeks with 15 (43%) preterm deliveries. Eight pregnancies (23%) were complicated by peripartum cardiac events including 1 ventricular arrhythmia, 6 heart failures, and 1 significant deterioration in LVEF requiring termination of pregnancy. NYHA class II, pre-pregnancy use of angiotensin-converting enzyme inhibitor/angiotensin II receptor blocker/diuretics, elevated brain natriuretic peptide (BNP), and advanced diastolic dysfunction assessed by Doppler echocardiography were defined as risk factors for cardiac events. Although the more severe cases took beta-blockers during pregnancy, the rates of cardiac events and decreasing LVEF did not differ significantly between those taking beta-blockers and those who were not. Values of LVEF decreased by almost 10% after the average 4-year post-delivery follow-up period. The long-term event-free survival was considerably worse among women with peripartum cardiac events than in those without (p<0.0001).

CONCLUSIONS

DCM women with pre-pregnancy LVEF over 30% tolerated pregnancy, but the rate of preterm delivery was high. Peripartum cardiovascular events occurred more often in women with NYHA class II, as well as those who received medications before and during pregnancy and showed more elevated BNP and advanced diastolic dysfunction before pregnancy. Beta-blockers likely allowed similar outcomes for DCM patients with lower initial LVEFs. Close monitoring later in life is required, particularly among the women with peripartum cardiac events.

Valvular Heart Disease in Pregnancy: Anticoagulation and the Role of Percutaneous Treatment

Valvular heart disease is present in about 1% of pregnancies, and it poses a management challenge as both fetal and maternal lives are at risk of complications. Pregnancy is associated with significant hemodynamic changes, which can compromise the cardiac status in women with underlying valvular disorders. Management of valvular heart diseases has undergone considerable innovation and advancement with newer techniques, approaches and devices being employed. The decision regarding the management of anticoagulation, especially in patients with prosthetic valves, raises distinct questions and challenges. In this review, we describe the management of common valvular heart diseases encountered during pregnancy, role of percutaneous catheter based therapeutic interventions, the importance of a team-based approach, and the challenges given existing gaps in the literature.

Management of Valvular Disease During Pregnancy: Evolving Role of Percutaneous Treatment

Valvular heart disease (VHD) is encountered in approximately 1% of pregnancies, significantly increasing both maternal and foetal risk. Rheumatic VHD remains the most common form in non-Western countries, whereas congenital heart disease dominates in the Western world. The risk of complications varies according to the type and severity of the underlying VHD. Moreover, pregnancy is a hypercoagulable state associated with increased risk of thromboembolism. The authors review the main VHDs encountered during pregnancy, and suggest management strategies based on the 2018 European Society of Cardiology recommendations for the management of pregnant women with VHD, providing an overview of classical and new transcatheter structural therapeutic options with a special focus on radiation exposure and anticoagulation drug management.

Early Onset Preeclampsia Diagnosis Prior to the 20th Week of Gestation in a Twin Pregnancy Managed via Selective Reduction of an Intrauterine Growth Restriction Fetus: A Case Report and Literature Review

A single, healthy, 44-year-old perimenopausal woman pursuing a pregnancy, employed donor embryos, resulting to a dichorionic diamniotic twin pregnancy. In the 18th week of gestation severe symptoms indicated early onset preeclampsia reporting severe hypertension (BP 180/90 mmHg), intense headaches and nausea as well as elevated 24-h urine protein levels (1.5 g/day). Concurrently diagnosis of an IUGR fetus was concluded. Standard pharmaceutical administration for treating preeclampsia was ordered. Persistence of symptoms indicated recommendation for pregnancy termination, however the patient opted against this. Selective embryo reduction was performed as the last resort prior to pregnancy termination. Following selective reduction the headaches and nausea were successfully subdued and the patient’s blood pressure was adjusted (mean BP 130/80 mmHg). This enabled further progression of pregnancy for an impressive 11 week-period, and a live birth on the 30th week. To conclude, only a few rare cases have been reported with diagnosis of early onset preeclampsia prior to the 20th week mark and none report live births. Albeit termination of pregnancy was recommended, the management of selective reduction of the IUGR fetus enabled successful treatment of preeclampsia coupled by a live birth of a healthy infant without any perinatal or postnatal complications reported.

Heart Disease and Pregnancy: The Need for a Twenty-First Century Approach to Care…

Pregnancy and childbirth present a specific challenge to the maternal cardiovascular system. Pre-existing cardiac diseases, or cardiac diseases that occur during pregnancy, are associated with a significant risk of morbidity and mortality for both mother and baby. In recent decades, cardiac disease has emerged as a leading cause of maternal death in most high income countries, including Australia and New Zealand. The burden of cardiac disease in pregnancy is likely to be growing due to an increase in adult survivors with congenital heart disease embarking on pregnancy coupled with demographic shifts in the age and cardiovascular risk factors of women giving birth and the persisting high incidence of acute rheumatic fever in First Nations women. There is widespread consensus that the best obstetric and neonatal outcomes in women with cardiac disease are delivered by a strategy of carefully coordinated multidisciplinary care. Australia and New Zealand currently lack nationally agreed strategies for clinical practice and service delivery for women with heart disease in pregnancy. This state-of-the-art review summarises some of the key issues faced in relation to prevention, diagnosis, treatment and health service delivery in this patient group and concludes with suggested priorities for policy and research.

Pre-eclampsia with severe features: management of antihypertensive therapy in the postpartum period

Introduction

there is variance in both the types and combinations of antihypertensive drugs used for managing pre-eclampsia in the postpartum period. Knowledge of the most common and suitable single or combination antihypertensive drug therapies in the postpartum period will minimize harmful effects, promote adherence to medications, overcome any fears that lactating mothers may have about these drugs and will assist in healthcare planning. Objective: to determine the types of antihypertensive drug therapies used in managing pre-eclampsia with severe features (sPE) in the postpartum period in a regional hospital in South Africa.

Methods

fifty consecutively presenting pregnant women with sPE were followed up prospectively from the pre-delivery period (within 48 hours before delivery) until day 3 postpartum. The antihypertensive drug therapies administered to the participants were observed. Their blood pressures were measured daily at 04: 00, 08: 00, 14: 00 and 22: 00 hours.

Results

nifedipine was the commonest rapid-acting agent used for severe hypertension. Prepartum, 9 different combinations of antihypertensive drugs were prescribed; alpha-methyldopa was the commonest single long-acting agent used. Postpartum, the number of different drug combinations administered were 15, 18, 22 and 16 on days 0, 1, 2 and 3 respectively. Alpha-methyldopa was the commonest single agent used on postpartum days 0 - 2 while hydrochlorothiazide was the most frequently used single agent on postpartum day 3. Postpartum, the commonest combination therapy was alpha-methyldopa and amlodipine on day 0; alpha-methyldopa and amlodipine as a regimen as well as alpha-methyldopa, amlodipine and hydrochlorothiazide as another regimen on day 1; alpha-methyldopa and amlodipine on day 2; and many amlodipine-based regimens on day 3.

Conclusion

a variety of antihypertensive drug combinations were used in the postpartum period indicating the need for standardised guidelines; however, detailed studies are required to evaluate their efficacies completely.

Eisenmenger syndrome: diagnosis, prognosis and clinical management

Eisenmenger syndrome (ES) represents the most severe phenotype of pulmonary arterial hypertension (PAH) associated with congenital heart disease (CHD) and occurs in patients with large unrepaired shunts. Despite early detection of CHD and major advances in paediatric cardiac surgery, ES is still prevalent and requires a multidisciplinary approach by adult CHD experts in tertiary centres. Central cyanosis is the primary clinical manifestation leading to secondary erythrocytosis and various multiorgan complications that increase morbidity and affect quality of life. Close follow-up is needed to early diagnose and timely manage these complications. The primary goal of care is to maintain patients' fragile stability. Although the recent use of advanced PAH therapies has substantially improved functional capacity and increased life expectancy, long-term survival remains poor. Progressive heart failure, infectious diseases and sudden cardiac death comprise the main causes of death in patients with ES. Impaired exercise tolerance, decreased arterial oxygen saturation, iron deficiency, pre-tricuspid shunts, arrhythmias, increased brain natriuretic peptide, echocardiographic indices of right ventricular dysfunction and hospitalisation for heart failure predict mortality. Endothelin receptor antagonists are used as first-line treatment in symptomatic patients, while phosphodiesterase-5 inhibitors may be added. Due to the lack of evidence, current guidelines do not provide a clear therapeutic strategy regarding treatment escalation. Additional well-designed trials are required to assess the comparative efficacy of various PAH agents and the benefit of combination therapy. Finally, the development of a risk score is of utmost importance to guide clinical therapy.

Inherited cardiac arrhythmias

The main inherited cardiac arrhythmias are long QT syndrome, short QT syndrome, catecholaminergic polymorphic ventricular tachycardia and Brugada syndrome. These rare diseases are often the underlying cause of sudden cardiac death in young individuals and result from mutations in several genes encoding ion channels or proteins involved in their regulation. The genetic defects lead to alterations in the ionic currents that determine the morphology and duration of the cardiac action potential, and individuals with these disorders often present with syncope or a life-threatening arrhythmic episode. The diagnosis is based on clinical presentation and history, the characteristics of the electrocardiographic recording at rest and during exercise and genetic analyses. Management relies on pharmacological therapy, mostly β-adrenergic receptor blockers (specifically, propranolol and nadolol) and sodium and transient outward current blockers (such as quinidine), or surgical interventions, including left cardiac sympathetic denervation and implantation of a cardioverter-defibrillator. All these arrhythmias are potentially life-threatening and have substantial negative effects on the quality of life of patients. Future research should focus on the identification of genes associated with the diseases and other risk factors, improved risk stratification and, in particular for Brugada syndrome, effective therapies.

Reduced right ventricular function on cardiovascular magnetic resonance imaging is associated with uteroplacental impairment in tetralogy of Fallot

BACKGROUND

Maternal right ventricular (RV) dysfunction (measured by echocardiography) is associated with impaired uteroplacental circulation, however echocardiography has important limitations in the assessment of RV function. We therefore aimed to investigate the association of pre-pregnancy RV and left ventricular (LV) function measured by cardiovascular magnetic resonance with uteroplacental Doppler flow parameters in pregnant women with repaired Tetralogy of Fallot (ToF).

METHODS

Women with repaired ToF were examined, who had been enrolled in a prospective multicenter study of pregnant women with congenital heart disease. Clinical data and CMR evaluation before pregnancy were compared with uteroplacental Doppler parameters at 20 and 32 weeks gestation. In particular, pulsatility index (PI) of uterine and umbilical artery were studied.

RESULTS

We studied 31 women; mean age 30 years, operated at early age. Univariable analyses showed that reduced RV ejection fraction (RVEF; P = 0.037 and P = 0.001), higher RV end-systolic volume (P = 0.004) and higher LV end-diastolic and end-systolic volume (P = 0.001 and P = 0.003, respectively) were associated with higher uterine or umbilical artery PI. With multivariable analyses (corrected for maternal age and body mass index), reduced RVEF before pregnancy remained associated with higher umbilical artery PI at 32 weeks (P = 0.002). RVEF was lower in women with high PI compared to women with normal PI during pregnancy (44% vs. 53%, p = 0.022). LV ejection fraction was not associated with uterine or umbilical artery PI.

CONCLUSIONS

Reduced RV function before pregnancy is associated with abnormal uteroplacental Doppler flow parameters. It could be postulated that reduced RV function on pre-pregnancy CMR (≤2 years) is a predisposing factor for impaired placental function in women with repaired ToF.

Comparison of Different Anticoagulation Regimens Regarding Maternal and Fetal Outcomes in Pregnant Patients With Mechanical Prosthetic Heart Valves (from the Multicenter ANATOLIA-PREG Registry)

Mechanical prosthetic heart valves (MPHVs) are highly thrombogenic, and a pregnancy-induced procoagulant status increases the risk of MPHV thrombosis. Despite numerous case reports, 2 major registries and meta-analyses/systematic reviews, optimal anticoagulation therapy during pregnancy remains controversial. The goal of this study was to evaluate different anticoagulation regimens in pregnant patients with MPHVs. The outcomes of anticoagulation regimens were assessed retrospectively in pregnant women (110 women; 155 pregnancies) with MPHVs. The study population was divided into 5 groups according to anticoagulation regimens used; high-dose warfarin (>5 mg/d) throughout pregnancy (group 1), low-dose warfarin (≤5 mg/d) throughout pregnancy (group 2), low molecular weight heparin (LMWH) throughout pregnancy (group 3), first trimester LMWH, 2nd and 3rd trimester warfarin (group 4), first 2 trimester LMWH, and 3rd trimester warfarin (group 5). Of 155 pregnancies, 55 (35%) resulted in fetal loss; whereas 41 (27%) cases with abortion (miscarriage and therapeutic) and 14 (9%) stillbirths occurred. The comparison of the groups showed that the whole abortion rates including therapeutic abortion were significantly higher in Group 1, and lower in groups 3 and 5 (p <0.001). However, miscarriage rates were similar between the groups. A total of 53 pregnancies (34%) suffered from prosthetic valves thrombosis (PVT) during pregnancy or in the postpartum period. Group 2 had significantly lower rates of PVT than the other groups (p <0.001). In conclusion, the current data suggests that there is no optimal therapy, and that all managements have advantages and disadvantages. Low-dose warfarin (≤5 mg/day) regimen with therapeutic international normalized ratio levels may provide effective maternal protection throughout pregnancy with acceptable fetal outcomes.

Pulmonary arterial hypertension: closing the gap in congenital heart disease

PURPOSE OF REVIEW

Pulmonary arterial hypertension associated with congenital heart disease (PAH-CHD) is a common association adversely affecting quality of life and survival in these patients. We provide herewith recent advances in the understanding and management of PAH-CHD.

RECENT FINDINGS

Significant progress has been made in disease-targeting therapy with pulmonary vasodilators for the treatment of Eisenmenger syndrome, the most severe form of PAH-CHD. Important gaps, however, still exist in the assessment and management of patients with PAH-CHD with systemic to pulmonary shunts. The choice of therapy, either interventional, medical, or both is an on-going dilemma that requires more long-term data. PAH after defect closure represents the most concerning subgroup of patients with the worst prognosis, requiring close follow-up and proactive disease-targeting therapy treatment. Small defects are not considered responsible for patients who have severe PAH and therefore, present different subgroup of patients similar to idiopathic PAH.

SUMMARY

Even with advances in diagnosis and treatment PAH-CHD remains a challenging field requiring lifelong follow-up and meticulous treatment in centres specialized in both CHD and PAH.

Cardiac Complications during Pregnancy Related to Parity in Women with Congenital Heart Disease

OBJECTIVE

To describe the frequency of cardiac complications during pregnancy related to parity in women with congenital heart defects.

METHODS

A retrospective tertiary single-center study at the Adult Congenital Heart Disease Centre that followed 307 women with congenital heart disease during the years 1997-2015 in Gothenburg, Sweden. Ma-ternal cardiac complications were noted for each pregnancy using medical and obstetric records. The CARPREG I and modified WHO (mWHO) risk classifications were used. Twin pregnancies, miscarriages before gestational week 13, and pregnancy terminations were excluded.

RESULTS

Five hundred seventy-one deliveries and 9 late miscarriages were analyzed. The mean parity was 1.74 per woman (range 1-8). Eighty-four (14.6%) maternal cardiac complications were experienced; arrhythmia (5.7%) and heart failure (4.4%) being the most prevalent, and there was 1 maternal death. Heart failure occurred during the first pregnancy in 12 women (3.9%), in the second pregnancy in 8 women (4.3%), and in the third pregnancy in 4 women (7.7%). CARPREG I and mWHO scores were associated with an increased risk of having a cardiac complication, while parity per se was not associated. The OR for having a maternally uneventful second pregnancy if the first pregnancy was without cardiac complications was 5.47 (95% CI 1.76-16.94) after controlling for CARPREG I and mWHO scores.

CONCLUSION

The risk of severe maternal cardiac complications during pregnancy in women with congenital heart disease is low. In this largest analysis to date with a focus on parity in 307 women, the risk classification predicts the maternal outcome more than parity per se. If the first pregnancy is uneventful, the OR is 5.5 for an uneventful second pregnancy if CARPREG I and mWHO scores remain unchanged.

Ebstein Anomaly in the Adult Patient

Ebstein anomaly is a congenital malformation involving primarily the tricuspid valve, with failure of delamination from the underlying myocardium and right ventricular myopathy. Echocardiography is diagnostic in most patients and demonstrates apical displacement of the septal leaflet and variable tethering of leaflet tissue to the right ventricular myocardium. Operative intervention is considered for exertional symptoms, progressive right ventricular enlargement, or right ventricular dysfunction. Tricuspid valve cone repair is the preferred surgical approach. Tricuspid valve replacement and bidirectional cavopulmonary shunt also are considered in patients with advanced disease. Pregnancy generally is well tolerated. Patients with Ebstein anomaly require lifelong follow-up.

Risk Assessment of the Cardiac Pregnant Patient

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.