2018 ESC Guidelines for the management of cardiovascular diseases during pregnancy

Cardiac arrhythmias in pregnant women: need for mother and offspring protection

Cardiac arrhythmias are the most common cardiac complication reported in pregnant women with and without structural heart disease (SHD); they are more frequent among women with SHD, such as cardiomyopathy and congenital heart disease (CHD). While older studies had indicated supraventricular tachycardia as the most common tachyarrhythmia in pregnancy, more recent data indicate an increase in the frequency of arrhythmias, with atrial fibrillation (AF) emerging as the most frequent arrhythmia in pregnancy, attributed to an increase in maternal age, cardiovascular risk factors and CHD in pregnancy. Importantly, the presence of any tachyarrhythmia during pregnancy may be associated with adverse maternal and fetal outcomes, including death. Thus, both the mother and the offspring need to be protected from such consequences. The use of antiarrhythmic drugs (AADs) depends on clinical presentation and on the presence of underlying SHD, which requires caution as it promotes pro-arrhythmia. In hemodynamically compromised women, electrical cardioversion is successful and safe to both mother and fetus. Use of beta-blockers appears quite safe; however, caution is advised when using other AADs, while no AAD should be used, if at all possible, during the first trimester when organogenesis takes place. Regarding the anticoagulation regimen in patients with AF, warfarin should be substituted with heparin during the first trimester, while direct oral anticoagulants are not indicated given the lack of data in pregnancy. Finally, for refractory arrhythmias, ablation and/or device implantation can be performed with current techniques in pregnant women, when needed, using minimal exposure to radiation. All these issues and relevant current guidelines are herein reviewed.

Maternal near-miss surveillance, Namibia

Objective

To analyse and improve the Namibian maternity care system by implementing maternal near-miss surveillance during 1 October 2018 and 31 March 2019, and identifying the challenges and benefits of such data collection.

Methods

From the results of an initial feasibility study, we adapted the World Health Organization’s criteria defining a maternal near miss to the Namibian health-care system. We visited most (27 out of 35) participating facilities before implementation and provided training on maternal near-miss identification and data collection. We visited all facilities at the end of the surveillance period to verify recorded data and to give staff the opportunity to provide feedback.

Findings

During the 6-month period, we recorded 37 106 live births, 298 maternal near misses (8.0 per 1000 live births) and 23 maternal deaths (62.0 per 100 000 live births). We observed that obstetric haemorrhage and hypertensive disorders were the most common causes of maternal near misses (each 92/298; 30.9%). Of the 49 maternal near misses due to pregnancies with abortive outcomes, ectopic pregnancy was the most common cause (36/298; 12.1%). Fetal or neonatal outcomes were poor; only 50.3% (157/312) of the infants born to maternal near-miss mothers went home with their mother.

Conclusion

Maternal near-miss surveillance is a useful intervention to identify within-country challenges, such as lack of access to caesarean section or hysterectomy. Knowledge of these challenges can be used by policy-makers and programme managers in the development of locally tailored targeted interventions to improve maternal outcome in their setting.

Prevention of Venous Thromboembolism during Pregnancy and the Puerperium with a Special Focus on Women with Hereditary Thrombophilia or Prior VTE-Position Paper of the Working Group in Women's Health of the Society of Thrombosis and Haemostasis (GTH)

Venous thromboembolism (VTE) is a major cause of maternal morbidity during pregnancy and the postpartum period. Because there is a lack of adequate study data, management strategies for the prevention of VTE during pregnancy have mainly been deduced from case-control and observational studies and extrapolated from recommendations for non-pregnant patients. The decision for or against pharmacologic thromboprophylaxis must be made on an individual basis weighing the risk of VTE against the risk of adverse side effects such as severe bleeding complications. A comprehensive, multidisciplinary approach is often essential as the clinical scenario is made more complex by the specific obstetric context, especially in the peripartum period. As members of the Working Group in Women's Health of the Society of Thrombosis and Haemostasis (GTH), we summarize the evidence from the available literature and aim to establish a more uniform strategy for VTE risk assessment and thromboprophylaxis in pregnancy and the puerperium. In this document, we focus on women with hereditary thrombophilia, prior VTE and the use of anticoagulants that can safely be applied during pregnancy and the lactation period.

Anesthesia for Pregnant Women with Pulmonary Hypertension

Despite advances in the therapy for pulmonary hypertension over the past decades, the prognosis of pregnant patients with pulmonary hypertension remains poor, with high maternal mortality. This poses a particular challenge for the mother and her medical team. In the present review, the authors have updated the classification and definition of pulmonary hypertension, summarized the current knowledge with regard to perioperative management and anesthesia considerations for these patients, and stressed the importance of a "pregnancy heart team" to improve long-term outcomes of pregnant women with pulmonary hypertension.

Anesthetic management of women with heart failure during pregnancy: a retrospective cohort study

BACKGROUND

The incidence of heart failure among pregnant women with pre-existing cardiac disease is quoted as 13%, with 10% requiring hospitalization. There is limited literature on heart failure in the pregnant population. The study objective was to describe the etiology and management of women hospitalized in our institution for heart failure during pregnancy.

METHODS

A retrospective cohort study investigated women who presented with heart failure in pregnancy between 2004 and 2017. Hospital records were interrogated using International Classification of Diseases v10 codes for heart failure. Patient characteristics, investigations, treatment, obstetric and anesthetic management, and maternal-fetal outcome data were collected and summarized using descriptive statistics.

RESULTS

One-hundred-and-twenty cases (in 93 122 deliveries) were identified across the 13-year period (antepartum heart failure 51%, postpartum heart failure 49%).The most common etiologies were pre-eclampsia (28%), cardiomyopathy (22%), and valvular heart disease (18%). Cesarean delivery occurred in 76% of cases (13% because of the maternal cardiac condition). Neuraxial techniques were used for most deliveries (cesarean 83%; vaginal 90%). For cesarean delivery, titrated epidural or general anesthesia was employed in 48% and 16%, respectively. Cardiac arrest occurred in two cases (1.7%) and 44% required coronary or intensive care unit admission.

CONCLUSIONS

The incidence of heart failure was 0.13% (1:776 deliveries). Pre-eclampsia was the leading cause but may have been historically under-acknowledged. Anesthetic and obstetrical decisions were tailored by means of multidisciplinary input, with cesarean delivery and regional anesthesia used in the majority. The postpartum period warrants heightened attention for these patients.

Real-world in-hospital outcomes and potential predictors of heart failure in primigravid women with heart disease in Southwestern China

Background

Little is known about the status of maternal, obstetric, and neonatal complications and the potential predictors of developing heart failure (HF) in mothers with underlying heart disease (HD) in Southwestern China.

Methods

The eligible records from the YiduCloud database from December 1, 2010 to December 31, 2019 were screened. The maternal clinical characteristics and the in-hospital outcomes were collected and compared in primigravid women with and without HD. The HD subtypes analyzed included valvular HD (VHD), cardiomyopathy, adult congenital HD (ACHD), pulmonary hypertension (PH), and other cardiac conditions.

Results

Among 45,067 primigravid women, 508 (1.1%) had HD, in which 207 (41%) had ACHD, 66 (13%) had VHD, 84 (17%) had cardiomyopathy, 7 (1%) had PH, and 144 (28%) had other cardiac diseases. The maternal cardiac events and the neonatal complications occurred in 28% and 23.3%, respectively, of women with HD and were predominant in the PH group. In multivariable regression, HF was associated with the New York Heart Association (NYHA) class ≥3 (OR = 15.9, 95% confidence interval [CI] = 2.5–99.7; P = 0.003), heart rate ≥ 100 bpm (OR = 3.8, 95% CI = 1.1–13.5; P = 0.036), ejection fraction ≤60% (OR = 6.4, 95% CI = 2.0–21.0; P = 0.002) and left ventricular end-diastolic diameter ≥ 50 mm (OR = 3.4, 95% CI = 1.1–11.2; P = 0.041) at the beginning of pregnancy.

Conclusions

Maternal and neonatal complications are higher in primigravid women with HD particularly in the PH group compared with primigravid women without HD. Women with HD should be guided on the potential predictors for HF and closely monitored during pregnancy to reduce maternal and neonatal complications.

A Pilot Study of the Maternal-Fetal Pharmacokinetics of Furosemide in Plasma, Urine, and Amniotic Fluid of Hypertensive Parturient Women Under Cesarean Section

The third trimester of pregnancy is related to physiological changes that can modify the process of absorption, distribution, metabolism, and excretion and, consequently, the efficacy and toxicity of drugs. However, little is known about furosemide pharmacokinetics and placental transfer in pregnancy. This study evaluated the maternal-fetal pharmacokinetics and distribution to amniotic fluid of furosemide in hypertensive parturient women under cesarean section. Twelve hypertensive parturient women under methyldopa (250 mg/8 h) and/or pindolol (10 mg/12 h) treatment received a 40-mg single oral dose of furosemide 1 to 10 hours before delivery by cesarean section. Blood and urine samples were collected for 12 hours after furosemide administration. At delivery, samples were obtained from maternal and umbilical cord blood (n = 8) to assess the transplacental transfer. Amniotic fluid (n = 4) was collected at the time of delivery. The following furosemide pharmacokinetic parameters were obtained as median (interquartile range): C_max , 403 ng/mL (229 to 715 ng/mL); T_max , 2.00 hours (1.50 to 4.83 hours); elimination half-life (t_1/2 ), 2.50 hours (1.77 to 2.97 hours); AUC_{0-12 h} , 1366 ng⋅h/mL (927 to 2531 ng⋅h/mL); AUC_0-∞ , 1580 ng⋅h/mL (1270 to 2881 ng⋅h/mL); CL/F 25.3 L/h (13.8 to 31.4 L/h); CLR, 2.50 L/h (1.77 to 2.97 L/h); CLNR, 22.7 L/h (12.1 to 25.6 L/h); and V_d /F 82.8 L (34.4 to 173 L). The transplacental transfer of furosemide was 0.43 (0.10 to 0.73), and the amniotic fluid concentration was 11.0 ng/mL (5.51 to 14.6 ng/mL). From a clinical point of view, these results suggest that substrates of uridine diphosphate-glucuronosyltransferase isoenzymes such as furosemide may have increased clearance during pregnancy and could require dose adjustment in this population.

Diagnostic Angiograms and Percutaneous Coronary Interventions in Pregnancy

Cardiovascular disease is the leading indirect cause of maternal mortality in the UK. Pregnancy increases the risk of acute MI (AMI) by three- to fourfold secondary to the profound physiological changes that place an extra burden on the cardiovascular system. AMI is not always recognised in pregnancy and there is concern among both clinicians and patients regarding catheter-based interventions due to fears of foetal irradiation and risks to the foetus. This article evaluates the current state of knowledge on AMI in pregnancy with particular emphasis on pregnancy-associated spontaneous coronary artery dissection and percutaneous coronary intervention as the revascularisation procedure for AMI. Special considerations that must be made in patients requiring percutaneous coronary intervention for pregnancy-associated spontaneous coronary artery dissection and the current recommendations on arterial access, methods of minimising radiation and stent selection are discussed.

Warfarin-associated intracranial haemorrhage in pregnant woman with double mechanical valve replacement: a case presentation

BACKGROUND

Management of warfarin-associated major haemorrhage in prosthetic valve diseases is difficult as there is a fine line between haemorrhage and thrombosis. An individual's propensity towards thrombosis, such as pregnancy, makes this situation even more complicated. Cases like these are very rare in the literature.

CASE PRESENTATION

A 26 weeks pregnant, gravida two, para one, 35-year-old patient with prosthetic aortic and mitral valves presented to an external emergency clinic with clouding of consciousness. Her international normalised ratio(INR) was 8.9 at presentation. Brain MRI revealed a left subdural haematoma with no significant mass effect. Warfarin treatment was discontinued. On the second day of follow-up, she was referred to our centre for further evaluation of her clinical deterioration. She was haemodynamically stable on admission to the intensive care unit and followed up with a stable condition until the fourth day when she developed right eye drop and subsequent loss of consciousness. Her haematoma was surgically evacuated, and her condition improved. Eventually, she and a healthy newborn were discharged.

CONCLUSION

Intracranial haemorrhage during pregnancy is a relatively rare complication that requires a multidisciplinary management plan. Although the thrombogenic risk is high, it is vital to complete a reversal of warfarin anticoagulation in pregnant women with major bleeding.

Cardiovascular Considerations in Caring for Pregnant Patients: A Scientific Statement From the American Heart Association

Cardio-obstetrics has emerged as an important multidisciplinary field that requires a team approach to the management of cardiovascular disease during pregnancy. Cardiac conditions during pregnancy include hypertensive disorders, hypercholesterolemia, myocardial infarction, cardiomyopathies, arrhythmias, valvular disease, thromboembolic disease, aortic disease, and cerebrovascular diseases. Cardiovascular disease is the primary cause of pregnancy-related mortality in the United States. Advancing maternal age and preexisting comorbid conditions have contributed to the increased rates of maternal mortality. Preconception counseling by the multidisciplinary cardio-obstetrics team is essential for women with preexistent cardiac conditions or history of preeclampsia. Early involvement of the cardio-obstetrics team is critical to prevent maternal morbidity and mortality during the length of the pregnancy and 1 year postpartum. A general understanding of cardiovascular disease during pregnancy should be a core knowledge area for all cardiovascular and primary care clinicians. This scientific statement provides an overview of the diagnosis and management of cardiovascular disease during pregnancy.

Subendocardial stress in pre-eclampsia

A primigravida 26‐year‐old woman who had developed pre‐eclampsia with malignant hypertension at 30 weeks of gestation suffered acute myocardial infarction two days postpartum. Electrocardiogram demonstrated diffuse ST‐segment depression suggestive of subendocardial ischemia. Echocardiography demonstrated focal asymmetric left ventricular hypertrophy, with a characteristic “basal septal bulge”, and a left ventricular mid‐cavitary gradient of 51 mmHg. Coronary angiography revealed normal coronary arteries and vascular flow. Peripartum acute myocardial infarction is rare and portends a high mortality. However, to date, only one case of acute myocardial infarction associated with asymmetric left ventricular hypertrophy and pre‐eclampsia has been described in the literature.

Pregnancy and cardiac interventions: What are the optimal management options?

Cardiac disease is the leading cause of maternal mortality in the United Kingdom. Major causes of cardiac death in pregnant women include cardiomyopathies, myocardial infarction, ischemic heart disease, and aortic dissection. Uncorrected congenital heart disease and women who have had corrective or palliative surgery may have complicated pregnancies as well. Some women with significant cardiac disease are unable to meet the increased physiological demands of pregnancy. Of these, those who do not respond to medical treatment may require surgical correction such as coronary artery bypass grafting. The risk of cardiac operations for pregnant women is similar to that for nonpregnant women but the fetal mortality rate remains high. Contributing factors to high fetal mortality rates include timing, urgency of operation, and the fetal/fetoplacental response to cardiopulmonary bypass. The aim of this review is to summarize current evidence in utilizing the different management approaches of cardiac issues during pregnancy.

Mechanical heart valves and pregnancy: Issues surrounding anticoagulation. Experience from two obstetric cardiac centres

Background

Pregnant women with mechanical heart valves are at significant risk of obstetric/cardiac complications. This study compares the anticoagulation management in two obstetric cardiac centres.

Methods

Retrospective case-note review from Chelsea and Westminster/Royal Brompton Hospitals (CR) and Erasmus Medical Centre (EMC). Main outcome measure was mechanical heart valve thrombosis.

Results

Nineteen pregnancies from CR and 25 pregnancies from EMC were included. Most women were on low-molecular-weight heparin (LMWH) throughout pregnancy at CR, whereas at EMC most had LMWH in the first trimester and vitamin K antagonists in subsequent trimesters. Peak anti-factor Xa were performed monthly at CR, levels 0.39-1.51 IU/mL (mean 0.82 IU/mL). Anticoagulation management peri-partum was inconsistent. Delivery was mainly by caesarean section at CR (74%) and vaginal delivery at EMC (64%). No maternal deaths and only one mechanical heart valve thrombosis at CR. Two mechanical heart valve thromboses and one maternal death at EMC.

Conclusion

Peri-partum anticoagulation strategies, anticoagulation monitoring and mode of delivery inconsistencies reported.

Contemporary clinical updates on the prevention of future cardiovascular disease in women who experience adverse pregnancy outcomes

Adverse pregnancy outcomes including hypertensive disorders of pregnancy and gestational diabetes are significant causes of maternal mortality. There is substantial evidence of an association between adverse events during pregnancy and long-term maternal cardiovascular risk. It is therefore important to understand the role of risk modification prior to, during, and after pregnancy to reduce adverse outcomes. These efforts include risk assessment, routine screening for cardiovascular risk factors, and potential pharmacotherapeutic risk reduction. In this manuscript, we aim to highlight the current evidence in the areas of cardiovascular risk assessment and risk modification, and the role for potential risk reduction therapies before, during, and after pregnancy.

Proximity to risk-appropriate perinatal hospitals for pregnant women with congenital heart defects in New York state

BACKGROUND

Women with congenital heart defects (CHDs) experiencing pregnancies require specialized delivery care and extensive monitoring that may not be available at all birthing hospitals. In this study, we examined proximity to, and delivery at, a hospital with an appropriate level of perinatal care for pregnant women with CHDs and evaluated predictors of high travel distance to appropriate care. Appropriate care was defined as Level 3 perinatal hospitals and Regional Perinatal Centers (RPCs).

METHODS

Inpatient delivery records for women with CHD in New York State (NYS) between 2008 and 2013 were obtained. Driving time and transit time were calculated between the pregnant woman's residence and the actual delivery hospital as well as the closest Level 3 or RPC hospital using Geographic Information Systems (GIS). Linear and logistic regression models evaluated predictors of high distance to, and utilization of, appropriate delivery care respectively.

RESULTS

From 2008 to 2013, there were 909 deliveries in a NYS hospital by women with CHDs. Approximately 75% of women delivered at a Level 3 or RPC hospital. Younger women, those who reside in rural and smaller urban areas, and those who are non-Hispanic White had a greater drive time to an appropriate care facility. After adjustment for geographic differences, racial/ethnic minorities and poor women were less likely to deliver at an appropriate delivery care center.

CONCLUSIONS

Although most women with CHDs in NYS receive appropriate delivery care, there are some geographic and socio-demographic differences that require attention to ensure equitable access.

Pregnancy Outcomes in Patients With Heart Disease in China

To analyze pregnancy outcomes of patients with heart disease in a single center and to explore the risk factors of adverse outcomes. One thousand thirty-three pregnant women with heart disease were retrospectively included from 2010 to 2017. We collected data of maternal, obstetric, and fetal outcomes. Among 1,086 pregnancies, 295 (27.1%) with congenital heart disease, 244 (22.5%) with rheumatic heart disease, 387 (35.6%) with arrhythmia, and 55 (5.1%) with cardiomyopathy. There were 8 (0.7%) maternal deaths. Risk factors of mortality were New York Heart Association (NYHA) classification IV (p <0.001), cardiac surgery during pregnancy (p <0.001), and general anesthesia (p <0.001). Maternal cardiac complications occurred in 6.7% of women, with most in the cardiomyopathy (26.0%) and rheumatic heart disease (32.9%) groups. Multivariate logistic regression modeling was used to analyze the potential risk factors. NYHA classification III and IV independently predicted worse maternal outcomes. Peripartum intensive care unit admission rate was 10.2%. Admission to intensive care unit was associated with NYHA classification II/III/IV, modified World Health Organization (mWHO) classification II-III/III/IV, and cardiac surgery during pregnancy. In conclusion, pregnancy with heart disease is at higher risk of complications for both women and neonates. In our findings, maternal morbidity is associated with NYHA classification and mWHO classification.

Solely MRI-Guided Cardiac Catheterization for Assessment of Pulmonary Hypertension in a Pregnant Lady with Undiagnosed Congenital Heart Disease

Pregnancy in women with complex congenital heart disease (CHD) can be poorly tolerated. Amongst pregnant women with CHD and pulmonary hypertension (PH), the mortality rate can be as high as 30%. Cardiac catheterization procedures for assessment of haemodynamics and pulmonary vascular resistance (PVR) are often required in this patient population for risk stratification. However, during the first few weeks of pregnancy, this should better be avoided due to the known adverse effects of the ionizing radiation to the immature fetus. In this setting, a solely MRI-guided catheterization may present as a better alternative.

Anesthetic management of a parturient with Shone's syndrome -a case report with review of literature

BACKGROUND

Shone's syndrome is a rare complex congenital cardiac condition, characterized by a supra-valvular mitral ring, parachute deformity of the mitral valve, aortic stenosis, and coarctation of the aorta.

CASE

A 26-year-old parturient with partial Shone's syndrome presented to our delivery unit in pulmonary edema. She underwent a scheduled cesarean section performed under a combined spinal-epidural anesthetic at 33 weeks. She had multidisciplinary input from the cardiac, obstetric, and anesthetic teams, which led to a good outcome. A review of the five published case reports of Shone's syndrome in pregnancy is presented along with key findings.

CONCLUSIONS

Our case report and the review highlight the successful use of combined spinal-epidural anesthetic and provides guidance to the multidisciplinary team on the varied presentation and the optimum management of women with Shone's syndrome during the peripartum period.

Correlation Between Risk or Severity of Heart Failure and Outcome of Pregnancy

Background

The incidence of heart failure in pregnancy increases by 1–4% every year and causes 9% of maternal mortality worldwide. Determinant factors, characteristics, and risk factors influence the incidence of heart disease in pregnancy, so the early detection of determinant factors can reduce the incidence of heart disease in pregnancy. This study aimed to find the relationship between determinant factors of maternal and fetal outcomes with the severity of heart disease in pregnancy.

Methods

This was an observational cross-sectional analytical study. We used 342 cases of heart disease in pregnancy that were recorded in medical records at Dr. Hasan Sadikin Hospital, Bandung, Indonesia, from January 2014 to December 2018. The data were grouped based on the severity of heart disease according to the New York Heart Association (NYHA) classification. The relationship of maternal determinant factors with the severity of heart disease was analyzed based on the NYHA classification.

Results

Maternal occupation was significantly associated with a higher risk of NYHA class III–IV heart disease. Most of the patients with NYHA class III-IV were housewives. The severity of heart disease was also influenced by severe preeclampsia (p<0.05) as a risk factor. Maternal outcome with heart disease of severity NYHA class III–IV was worse than with NYHA class I–II. The risk of maternal death was higher, and the mother’s length of stay in hospital and her need for monitoring were also increased. There were no significant differences in the outcome of the fetus, but the incidence of fetal mortality increased in patients with heart disease severity III–IV.

Conclusion

Maternal determinant factors did not correlate with the severity of heart disease in pregnancy. Maternal outcomes were worse with increasing severity of heart disease. Fetal mortality was correlated with severity of heart disease but other outcomes were not affected.

Inherited Thoracic Aortic Disease: New Insights and Translational Targets

Inherited thoracic aortopathies denote a group of congenital conditions that predispose to disease of the thoracic aorta. Aortic wall weakness and abnormal aortic hemodynamic profiles predispose these patients to dilatation of the thoracic aorta, which is generally silent but can precipitate aortic dissection or rupture with devastating and often fatal consequences. Current strategies to assess the future risk of aortic dissection or rupture are based primarily on monitoring aortic diameter. However, diameter alone is a poor predictor of risk, with many patients experiencing dissection or rupture below current intervention thresholds. Developing tools that improve the risk assessment of those with aortopathy is internationally regarded as a research priority. A robust understanding of the molecular pathways that lead to aortic wall weakness is required to identify biomarkers and therapeutic targets that could improve patient management. Here, we summarize the current understanding of the genetically determined mechanisms underlying inherited aortopathies and critically appraise the available blood biomarkers, imaging techniques, and therapeutic targets that have shown promise for improving the management of patients with these important and potentially fatal conditions.

The evaluation of ventricular functions by speckle tracking echocardiography in preeclamptic patients

Preeclampsia is a maternal disorder of pregnancy characterized by concomitant increase in preload and afterload with end organ dysfunction. The aim of our study is to evaluate left ventricular (LV) and right ventricular (RV) functions with speckle tracking echocardiography in preeclamptic patients. Fifty-five preeclamptic (mean age: 30.7 ± 5.9 years) and 35 healthy pregnant women (mean age: 28.8 ± 5.7 years) of the same race, similar age and gestational week were consecutively included. The diagnosis of preeclampsia was based on the criteria proposed by the American College of Obstetricians and Gynecologists. LV and RV functions were assessed by both conventional and speckle tracking echocardiography after the 30th gestational week and at the postpartum 6th months. The preeclamptic patients had significantly larger left atrium, thicker interventricular septum, higher systolic pulmonary artery pressure and mitral E/e' ratio compared to controls during pregnancy while LV ejection fraction was similar. Preeclamptic patients had significantly lower LV and RV global longitudinal strain (GLS) during pregnancy compared to controls (- 18.0 ± 2.6% vs. - 19.8 ± 2.1% p = 0.001 and - 26.7 ± 3.3% vs. 28.9 ± 3.3% p = 0.002, respectively). In the postpartum period, while LVGLS values of preeclamptic patients increased significantly (- 18.0 ± 2.6% vs. - 20.4 ± 2.4% p < 0.001) and became similar to those of controls at the sixth month, the RVGLS decreased significantly (- 26.7 ± 3.3% vs. - 25.8 ± 2.7% p = 0.003) making the difference in RVGLS between the preeclamptic patients and controls more prominent. Preeclampsia may impair LV and RV function. Long-term follow up with larger sample is needed to determine the clinical relevance of the observed changes in strain.

Doppler gradients, valve area and ventricular function in pregnant women with aortic or pulmonary valve disease: Left versus right

OBJECTIVE

Little is known about the course of echocardiographic parameters used for the evaluation of valvular heart disease (VHD) during pregnancy, hampering interpretation of possible changes (physiological vs. pathophysiological). Therefore we studied the course of these parameters and ventricular function in pregnant women with aortic and pulmonary VHD.

METHODS

The cohort comprised 66 pregnant women enrolled in the prospective ZAHARA studies or evaluated by an identical protocol who had pulmonary VHD or aortic VHD (stenosis/prosthetic valve). The control group comprised 46 healthy pregnant women. Echocardiography was performed preconception, during pregnancy and 1 year postpartum. Peak gradient, mean gradient, aortic valve area (AVA)/effective orifice area (EOA), left ventricular ejection fraction (LVEF) and right ventricular function (RVF; TAPSE) were assessed.

RESULTS

Peak and mean gradients increased during pregnancy compared to preconception in women with aortic VHD and controls (p < 0.0125), but not in women with pulmonary VHD. AVA/EOA remained unchanged. Preconception and postpartum gradients were comparable in all groups. Mean LVEF was normal in pregnant women with VHD and controls. Mean TAPSE was lower (p < 0.001) in women with pulmonary VHD compared to women with aortic VHD and controls (<20 mm vs. ≥23 mm; p < 0.001). In women with pulmonary VHD a decrease of TAPSE was observed during pregnancy (p = 0.005).

CONCLUSION

Physiological changes during pregnancy lead to increased Doppler gradients in women with aortic VHD. This increase was not found in women with pulmonary VHD, probably caused by impaired RVF. Therefore, evaluation of RVF during pregnancy might be important to prevent underestimation of the degree of stenosis.

Dilated cardiomyopathies and non-compaction cardiomyopathy

Dilated cardiomyopathy (DCM) is the most common form of cardiomyopathy and one of the most common causes of heart failure. It is characterized by left or biventricular dilation and a reduced systolic function. The causes are manifold and range from myocarditis to alcohol and other toxins, to rheumatological, endocrinological, and metabolic diseases. Peripartum cardiomyopathy is a special form that occurs at the end of or shortly after pregnancy. Genetic mutations can be detected in approximately 30-50% of DCM patients. Owing to the growing possibilities of genetic diagnostics, increasingly more triggering variants and hereditary mechanisms emerge. This is particularly important with regard to risk stratification for patients with variants with an increased risk of arrhythmias. Patient prognosis is determined by the occurrence of heart failure and arrhythmias. In addition to the treatment of the underlying disease or the elimination of triggering harmful toxins, therapy consists in guideline-directed heart failure treatment including drug and device therapy.

Good at heart: Developing a tertiary perinatal cardiac service; the first eight years of experience

BACKGROUND

Maternal cardiac disease is the most common cause of indirect maternal death, and women with pre-existing cardiac disease have complex medical, obstetric and anaesthetic requirements. Our hospital commenced a multidisciplinary perinatal cardiac service in 2009 to optimise outcomes in women with cardiac disease.

AIM

To assess the maternal and perinatal outcomes of women referred to the clinic to evaluate clinical practice and inform future service provision.

MATERIALS AND METHODS

This is a single-centre retrospective study of women referred to the perinatal cardiac service between 2009-2016. Data collected included: demographic details; cardiac diagnosis; pregnancy outcomes, including anaesthetic and delivery complications, and admission to intensive care unit (ICU)/high dependency unit (HDU).

RESULTS

One hundred and fifty-two women were referred for care in 165 pregnancies. Congenital heart disease was the most common indication for referral (35%), followed by maternal cardiac arrhythmia (26%) and valvular disease (18%). The perinatal mortality rate was 2%, median gestational age at delivery was 38 weeks 4 days, fetal growth restriction (customised birthweight <10th centile) was 9% although 25 (17%) pregnancies resulted in preterm birth, 36% of which were spontaneous and 64% were iatrogenic. Maternal outcomes were favourable and there were no maternal deaths. However, 51% of women required a caesarean section, and 23% who achieved a live birth required ICU/HDU admission.

CONCLUSION

This study confirmed that women with cardiac disease are at increased risk of preterm birth, and high acuity in the peripartum period but otherwise good maternal and perinatal outcomes. An integrated multidisciplinary perinatal cardiac service can optimise perinatal outcomes in these women.

Marfan Syndrome Versus Bicuspid Aortic Valve Disease: Comparative Analysis of Obstetric Outcome and Pregnancy-Associated Immediate and Long-Term Aortic Complications

Pregnancy poses a threat to women with aortopathy. Conclusive data on the obstetric and aortic outcome in this risk collective, especially when it comes to aortic complications in the long term, are still missing. This study offers a comparative analysis of pregnancy-associated outcome in 113 consecutive women with Marfan syndrome or bicuspid aortic valve disease, including 46 ever-pregnant and 37 never-pregnant women with Marfan syndrome, and 23 ever-pregnant and 7 never-pregnant females with bicuspid aortic valve disease. The overall obstetric outcome was comparable between ever-pregnant women with Marfan syndrome and with bicuspid aortic valve disease (p = 0.112). Pregnancy-associated aortic dissection occurred in two women with Marfan syndrome (3%) during a total of 62 completed pregnancies, whereas no single case of aortic event occurred in women with bicuspid aortic valve disease during a total of 36 completed pregnancies (p = 0.530). In the long-term follow-up, aortic dissection occurred in 21% of ever-pregnant women with Marfan syndrome, but in none of the women with bicuspid aortic valve disease (p = 0.022). Proximal aortic surgery was performed with similar frequency in ever-pregnant women with Marfan syndrome and with bicuspid aortic valve disease in the long term (p = 0.252). However, ever-pregnant women with Marfan syndrome were younger when surgery was performed (44 ± 9 vs. 59 ± 7 years; p = 0.041). In Marfan syndrome, long-term growth of the aorta was comparable between ever-pregnant and never-pregnant women. Pregnancy thus exhibited an increased immediate aortic risk only in women with Marfan syndrome, but not in women with bicuspid aortic valve disease. Previous pregnancy did not relate to an increased long-term risk of adverse aortic events in women with Marfan syndrome or with bicuspid aortic valve disease.

Infective Endocarditis in a Third Trimester Pregnant Woman: Team Work Is the Best Option

Infective endocarditis in pregnancy may have a misleading presentation and carries a high-risk of complications for both the mother and her infant. When urgent valve surgery is required, the fetal risk relative to cardiopulmonary bypass is challenging requiring a multidisciplinary management. We report the case of a pregnant woman with infective endocarditis on a bicuspid aortic valve who was successfully treated by a 2-step strategy including cardiac surgery. (Level of Difficulty: Intermediate.)

Genetic testing for aortopathies: primer for the nongeneticist

PURPOSE OF REVIEW

Although the majority of thoracic aortic aneurysms and dissections (TAD) in the overall population are mainly related to arterial hypertension and atherosclerosis, Heritable Thoracic Aortic Disease (HTAD) are increasingly recognized, especially in younger individuals. As fatal events in the setting of HTAD are preventable with timely detection and appropriate management, this review aims to provide an overview of the genetic basis of HTAD and practical recommendations for genetic evaluation in this setting.

RECENT FINDINGS

Thanks in part to a number of important efforts to set up (inter)national networks and consortia for collecting clinical and genetic data from patients with these rare disorders, significant progress has been made in understanding the natural evolution of these disorders. These insights are now starting to enable the development of recommendations for the management of these patients.In addition, pathogenic variants in a number of new genes have been identified in HTAD patients. On the basis of more extensive genetic screening in cohorts of patients with TAD, it is becoming clear that there is no strict boundary between syndromal and nonsyndromal HTAD entities. It is, therefore, important to at least consider genetic evaluation, not only for patients presenting with syndromic forms but also for more isolated TAD.Finally, there are indications that we will -- up to a certain point -- soon be able to draw up a more precise policy for individual patients, based on the underlying genetic defects SUMMARY: Genetic evaluation in (young) patients with both syndromic and nonsyndromic forms of HTAD should be considered and is helpful for the development of more precise medicine.

Hypertrophic cardiomyopathy: an updated review on diagnosis, prognosis, and treatment

Hypertrophic cardiomyopathy (HCM) represents a phenotype of left ventricular hypertrophy unexplained by abnormal loading conditions. The definition is based on clinical criteria; however, there are numerous underlying etiologic factors. The MOGE(S) classification provides a standardized approach for multimodal characterization of HCM. HCM is associated with increased morbidity and mortality, and especially the assessment of the risk of sudden cardiac death is of paramount importance. In this review, we summarize essential knowledge and recently published data on clinical presentation, diagnosis, genetic analyses, differential diagnosis, prognosis, and treatment options that are necessary for understanding and management of HCM.

Pregnancy-associated cardiac dysfunction and the regulatory role of microRNAs

Many crucial cardiovascular adaptations occur in the body during pregnancy to ensure successful gestation. Maladaptation of the cardiovascular system during pregnancy can lead to complications that promote cardiac dysfunction and may lead to heart failure (HF). About 12% of pregnancy-related deaths in the USA have been attributed to HF and the detrimental effects of cardiovascular complications on the heart can be long-lasting, pre-disposing the mother to HF later in life. Indeed, cardiovascular complications such as gestational diabetes mellitus, preeclampsia, gestational hypertension, and peripartum cardiomyopathy have been shown to induce cardiac metabolic dysfunction, oxidative stress, fibrosis, apoptosis, and diastolic and systolic dysfunction in the hearts of pregnant women, all of which are hallmarks of HF. The exact etiology and cardiac pathophysiology of pregnancy-related complications is not yet fully deciphered. Furthermore, diagnosis of cardiac dysfunction in pregnancy is often made only after clinical symptoms are already present, thus necessitating the need for novel diagnostic and prognostic biomarkers. Mounting data demonstrates an altered expression of maternal circulating miRNAs during pregnancy affected by cardiovascular complications. Throughout the past decade, miRNAs have become of growing interest as modulators and biomarkers of pathophysiology, diagnosis, and prognosis in cardiac dysfunction. While the association between pregnancy-related cardiovascular complications and cardiac dysfunction or HF is becoming increasingly evident, the roles of miRNA-mediated regulation herein remain poorly understood. Therefore, this review will summarize current reports on pregnancy-related cardiovascular complications that may lead to cardiac dysfunction and HF during and after pregnancy in previously healthy women, with a focus on the pathophysiological role of miRNAs.

Detection and management of arrhythmias in peripartum cardiomyopathy

Peripartum cardiomyopathy (PPCM) is an idiopathic dilated cardiomyopathy, in which previously healthy women present with heart failure secondary to left ventricular (LV) systolic dysfunction during the last months of pregnancy or up to 5 months postpartum. PPCM occurs worldwide. The incidence seems to be increasing, possibly due to increasing awareness of the condition and diagnosis thereof. Women diagnosed with PPCM present with symptoms and signs of heart failure, thromboembolism or arrhythmia. Although the incidence of arrhythmias in this condition is not well documented, patients with PPCM often have rhythm disturbances. Indeed, life-threating arrhythmias contribute significantly to sudden cardiac death (SCD) in this population, especially when patients have poor systolic function. In this review, we summarize the evidence on atrial and ventricular arrhythmias in PPCM, as detected by various diagnostic modalities. Furthermore, we summarize the management of arrhythmias in PPCM, as recommended by contemporary guidelines.

Rheumatic heart disease: current status of diagnosis and therapy

Rheumatic heart disease (RHD) is the only preventable cardiovascular disease which causes significant morbidity and mortality particularly in low- and middle-income countries. Early clinical diagnosis is key, the updated Jones criteria increases the likelihood of diagnosis in endemic settings, including the echo diagnosis of sub-clinical carditis, polyarthralgia and monoarthritis as well as amended thresholds of minor criteria. The mainstay of rheumatic heart valve disease (RHVD) is a thorough clinical and echocardiographic investigation while severe disease is managed with medical, interventional and surgical treatment. In this report we detail some of the more recent epidemiological findings and focus on the diagnostic and interventional elements of the specific valve lesions. Finally, we discuss some of the recent efforts to improve medical and surgical management for this disease. As we are already more than a year from the historic 2018 World Heart Organization Resolution against Rheumatic Fever and Rheumatic Heart Disease, we advocate strongly for renewed efforts to prioritize this disease across the endemic regions of the world.

Effectiveness of Implanted Cardiac Rhythm Recorders With Electrocardiographic Monitoring for Detecting Arrhythmias in Pregnant Women With Symptomatic Arrhythmia and/or Structural Heart Disease: A Randomized Clinical Trial

Importance

Arrhythmias are an important cause of maternal morbidity and mortality but remain difficult to diagnose.

Objective

To compare implantable loop recorder (ILR) plus 24-hour Holter electrocardiographic (ECG) monitoring with standard 24-hour Holter ECG monitoring alone in terms of acceptability, ability to identify significant arrythmias, and effect on management and pregnancy outcome in women who were symptomatic or at high risk of arrythmia because of underlying structural heart disease.

Design, Setting, and Participants

This single-center, prospective randomized clinical trial recruited 40 consecutive patients from the Cardiac Disease and Maternity Clinic at Groote Schuur Hospital in Cape Town, South Africa. Pregnant patients with symptoms of arrhythmia and/or structural heart disease at risk of arrhythmia were included.

Intervention

Patients were randomized to standard care (SC; 24-hour Holter ECG monitoring [n = 20]) or standard care plus ILR (SC-ILR; 24-hour Holter ECG monitoring plus ILR [n = 20]). Only 17 consented to ILR insertion, and the 3 who declined ILR were allocated to the SC group.

Main Outcomes and Measures

Arrhythmias considered included atrial fibrillation, atrial flutter, premature ventricular complexes, supraventricular tachycardia, ventricular tachycardia, or ventricular fibrillation.

Results

Among the 40 women in this trial, the mean (SD) age was 28.4 (5.5) years. Holter monitoring detected arrhythmias in 3 of 23 patients (13%) in the SC group and 4 of 17 patients (24%) in the SC-ILR group compared with 9 of 17 patients (53%) patients who had arrhythmias detected by ILR. Seven patients (4 with supraventricular tachycardia, 1 with premature ventricular complexes, and 2 with paroxysmal atrial fibrillation recorded by ILR) did not have arrhythmias detected by 24-hour Holter monitoring. Three of these 7 patients (43%) had a change in management as a result of their ILR recordings. There were no maternal deaths. However, the SC group had a significantly lower mean (SD) gestational stage at delivery (35 [5] weeks vs 38 [2], P = .04).

Conclusions and Relevance

The ILR was better than 24-hour Holter monitoring in detecting arrhythmias, which led to a change in management for a significant proportion of patients. Our findings suggest that ILR may be beneficial for pregnant women at risk of arrhythmia.

Trial Registration

ClinicalTrials.gov Identifier: NCT02249195.