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Yousuf MS, Ali MQ, Ahmed SS, Naqvi HI, Siddiqui K, Samad K. Challenges and strategies regarding anaesthetic management of twin pregnancy undergoing redo aortic valve replacement. Int J Surg Case Rep 2024; 122:110176. [PMID: 39153337 PMCID: PMC11378167 DOI: 10.1016/j.ijscr.2024.110176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2024] [Revised: 08/09/2024] [Accepted: 08/13/2024] [Indexed: 08/19/2024] Open
Abstract
INTRODUCTION AND IMPORTANCE Redo aortic valve replacement in twin pregnancy presents significant challenges because of the elevated risks for both maternal and fetal health. Mortality rates range from 12 % to 21 % in specialised centres, with previous cardiac surgeries further elevating the risk. Pregnancy complicates cardiac surgery, with fetal mortality rates as high as 16-33 %. PRESENTATION OF CASE A 31-year-old woman, 15 weeks pregnant with twins and with a history of mechanical aortic valve replacement, presented with worsening breathlessness and grade III dyspnoea. Echocardiography revealed severe valve obstruction, necessitating redo-aortic valve replacement and posterior aortic root enlargement. Despite intraoperative challenges, including ventricular fibrillation and postoperative heart block, she underwent successful surgery and pacemaker implantation, with both mother and fetuses remaining stable. DISCUSSION Optimal timing of surgery is crucial, considering fetal developmental vulnerability in the first trimester and maternal cardiac workload in the third trimester. Second-trimester risks are comparable to non-pregnant patients. A limited understanding of fetal-placental perfusion during bypass necessitates cautious management strategies, with emerging techniques like pulsatile perfusion showing promise. Anaesthesia selection prioritises fetal safety while monitoring fetal distress during surgery remains challenging. To achieve successful outcomes for both mother and babies in a twin pregnancy undergoing a redo aortic valve replacement, careful timing, appropriate surgical techniques, and meticulous perioperative care are essential. CONCLUSION A multidisciplinary approach is crucial for managing twin pregnancy following redo aortic valve surgery. Careful planning, close monitoring, and specialised surgical and anaesthetic techniques are key to minimising risks to both mother and fetus.
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Affiliation(s)
- Muhammad Saad Yousuf
- Department of Anaesthesiology, The Aga Khan University Hospital, P.O Box 3500, Stadium Road, Karachi 74800, Pakistan.
| | - Misbah Qurban Ali
- Department of Anaesthesiology, The Aga Khan University Hospital, P.O Box 3500, Stadium Road, Karachi 74800, Pakistan
| | - Syed Shabbir Ahmed
- Department of Anaesthesiology, The Aga Khan University Hospital, P.O Box 3500, Stadium Road, Karachi 74800, Pakistan
| | - Hamid Iqil Naqvi
- Department of Anaesthesiology, The Aga Khan University Hospital, P.O Box 3500, Stadium Road, Karachi 74800, Pakistan
| | - Khalid Siddiqui
- Department of Anaesthesiology, The Aga Khan University Hospital, P.O Box 3500, Stadium Road, Karachi 74800, Pakistan
| | - Khalid Samad
- Department of Anaesthesiology, The Aga Khan University Hospital, P.O Box 3500, Stadium Road, Karachi 74800, Pakistan
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Campello E, Bucciarelli P, Catalani F, Erba N, Squizzato A, Poli D. Anticoagulant Therapy in Pregnant Women with Mechanical Heart Valves: Italian Federation of Centers for Diagnosis and Surveillance of the Antithrombotic Therapies (FCSA) Position Paper. Thromb Haemost 2024; 124:695-708. [PMID: 38744424 PMCID: PMC11259494 DOI: 10.1055/a-2325-5658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Accepted: 02/18/2024] [Indexed: 05/16/2024]
Abstract
The management of anticoagulant therapy in pregnant women with mechanical heart valves (MHVs) is difficult and often challenging even for clinicians experienced in the field. These pregnancies, indeed, are burdened with higher rates of complications for both the mother and the fetus, compared to those in women without MHVs. The maternal need for an optimal anticoagulation as provided by vitamin K antagonists is counterbalanced by their teratogen effect on the embryo and fetus. On the other hand, several concerns have been raised about the efficacy of heparins in pregnant women with MHVs, considering the high risk of thrombotic complications in these patients. Therefore, numerous clinical issues about the management of pregnant women with MHVs remain unanswered, such as the selection of the best anticoagulant agent, the optimal anticoagulation levels to be achieved and maintained, and the evaluation of long-term effects for both the mother and the fetus. Based on a comprehensive review of the current literature, the Italian Federation of the Centers for the Diagnosis and the Surveillance of the Antithrombotic Therapies (FCSA) proposes experience-based suggestions and expert opinions. Particularly, this consensus document aims at providing practical guidance for clinicians dealing with pregnant women with MHVs, to optimize maternal and fetal outcomes while guaranteeing adequate anticoagulation. Finally, FCSA highlights the need for the creation of multidisciplinary teams experienced in the management of pregnant women with MHVs during pregnancy, delivery, and postpartum, in order to better deal with such complex clinical issues and provide a comprehensive counseling to these patients.
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Affiliation(s)
- Elena Campello
- Department of Medicine, General Medicine and Thrombotic and Hemorrhagic Unit, University of Padova, Padova, Italy
| | - Paolo Bucciarelli
- Fondazione IRCCS Ca' Granda – Ospedale Maggiore Policlinico, A. Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy
| | - Filippo Catalani
- Department of Medicine, General Medicine and Thrombotic and Hemorrhagic Unit, University of Padova, Padova, Italy
| | | | - Alessandro Squizzato
- Research Center on Thromboembolic Disorders and Antithrombotic Therapies, ASST Lariana, University of Insubria, Como, Italy
| | - Daniela Poli
- Thrombosis Center, “Careggi” Hospital, Florence, Italy
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3
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Rizi SS, Wiens E, Hunt J, Ducas R. Cardiac physiology and pathophysiology in pregnancy. Can J Physiol Pharmacol 2024. [PMID: 38815593 DOI: 10.1139/cjpp-2024-0010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2024]
Abstract
Cardiovascular disease is the leading indirect cause of maternal morbidity and mortality, accounting for nearly one third of maternal deaths during pregnancy. The burden of cardiovascular disease in pregnancy is increasing, as are the incidence of maternal morbidity and mortality. Normal physiologic adaptations to pregnancy, including increased cardiac output and plasma volume, may unmask cardiac conditions, exacerbate previously existing conditions, or create de novo complications. It is important for care providers to understand the normal physiologic changes of pregnancy and how they may impact the care of patients with cardiovascular disease. This review outlines the physiologic adaptions during pregnancy and their pathologic implications for some of the more common cardiovascular conditions in pregnancy.
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Affiliation(s)
- Shekoofeh Saboktakin Rizi
- Section of Cardiology, Department of Internal Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Evan Wiens
- Division of Cardiology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Jennifer Hunt
- Department of Obstetrics, Gynecology & Reproductive Science, University of Manitoba, Winnipeg, MB, Canada
| | - Robin Ducas
- Section of Cardiology, Department of Internal Medicine, University of Manitoba, Winnipeg, MB, Canada
- Department of Obstetrics, Gynecology & Reproductive Science, University of Manitoba, Winnipeg, MB, Canada
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4
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Tabrizi NS, Demos RA, Schumann R, Musuku SR, Shapeton AD. Neuraxial Anesthesia in Patients With Aortic Stenosis: A Systematic Review. J Cardiothorac Vasc Anesth 2024; 38:505-516. [PMID: 37880038 DOI: 10.1053/j.jvca.2023.09.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Revised: 09/10/2023] [Accepted: 09/21/2023] [Indexed: 10/27/2023]
Abstract
Neuraxial anesthesia (NA) has been contraindicated in patients with aortic stenosis (AS) due to concerns of sympathetic blockade and hemodynamic instability. These considerations are based on precautionary expert recommendations, supported by expected physiologic effects, but in the absence of any published scientific evidence. In light of the increasing elderly population and the prevalence of AS, this systematic review compiles available literature on NA in patients with AS to address the understanding of the anesthetic practice and safety in this population. Using a systematic approach, PubMed, Embase, and Web of Science were searched for studies of patients with AS who exclusively received NA. Primary outcomes included intraoperative and postoperative complications. Of 1,433 citations, 61 met full-text inclusion criteria, including 3,228 patients undergoing noncardiac (n = 3,146, 97.5%), obstetric (n = 69, 2.1%), and cardiac (n = 13, 0.4%) procedures. Significant data heterogeneity (local anesthetic dosing, intraoperative interventions, and measured outcomes) prevented formal metanalysis, but descriptive data are presented. Spinal block (n = 2,856, 88.5%) and epidural anesthesia (n = 397, 12.3%) were administered most frequently. Hypotension requiring vasopressors was the most common intraoperative complication-noncardiac (n = 16, 9.9%), obstetric (n = 6, 13.0%), and cardiac (n = 1, 7.7%)-with resolution in all patients and no reported intraoperative cardiovascular collapse or mortality. The relative risk of different AS severities remains unclear, and optimal medication dosing remains elusive. The authors' data suggested that NA may not be contraindicated in carefully selected patients with AS. The authors' results should inform the design of future prospective studies comparing NA and general anesthesia in patients with AS.
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Affiliation(s)
| | | | - Roman Schumann
- Department of Anesthesiology and Perioperative Medicine, Tufts University School of Medicine, Boston, MA
| | | | - Alexander D Shapeton
- Veterans Affairs Boston Healthcare System, Boston, MA; Department of Anesthesia, Critical Care and Pain Medicine, Tufts University School of Medicine, Boston, MA
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Carvalho TD, Freitas OGAD, Chalela WA, Hossri CAC, Milani M, Buglia S, Precoma DB, Falcão AMGM, Mastrocola LE, Castro I, Albuquerque PFD, Coutinho RQ, Brito FSD, Alves JDC, Serra SM, Santos MAD, Colombo CSSDS, Stein R, Herdy AH, Silveira ADD, Castro CLBD, Silva MMFD, Meneghello RS, Ritt LEF, Malafaia FL, Marinucci LFB, Pena JLB, Almeida AEMD, Vieira MLC, Stier Júnior AL. Brazilian Guideline for Exercise Test in the Adult Population - 2024. Arq Bras Cardiol 2024; 121:e20240110. [PMID: 38896581 DOI: 10.36660/abc.20240110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/21/2024] Open
Affiliation(s)
- Tales de Carvalho
- Clínica de Prevenção e Reabilitação Cardiosport, Florianópolis, SC - Brasil
- Universidade do Estado de Santa Catarina, Florianópolis, SC - Brasil
| | | | - William Azem Chalela
- Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (InCor-HCFMUSP), São Paulo, SP - Brasil
| | | | - Mauricio Milani
- Universidade de Brasília (UnB), Brasília, DF, Brasil
- Hasselt University, Hasselt - Bélgica
- Jessa Ziekenhuis, Hasselt - Bélgica
| | - Susimeire Buglia
- Instituto Dante Pazzanese de Cardiologia, São Paulo, SP - Brasil
| | | | - Andréa Maria Gomes Marinho Falcão
- Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (InCor-HCFMUSP), São Paulo, SP - Brasil
| | | | - Iran Castro
- Instituto de Cardiologia do Rio Grande do Sul, Porto Alegre, RS - Brasil
| | | | | | | | | | - Salvador Manoel Serra
- Instituto Estadual de Cardiologia Aloysio de Castro (IECAC), Rio de Janeiro, RJ - Brasil
| | - Mauro Augusto Dos Santos
- Instituto Nacional de Cardiologia do Rio de Janeiro, Rio de Janeiro, RJ - Brasil
- Linkcare Saúde, Rio de Janeiro, RJ - Brasil
| | | | - Ricardo Stein
- Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS - Brasil
| | - Artur Haddad Herdy
- Clínica de Prevenção e Reabilitação Cardiosport, Florianópolis, SC - Brasil
| | - Anderson Donelli da Silveira
- Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS - Brasil
- Hospital de Clínicas de Porto Alegre, Porto Alegre, RS - Brasil
- Hospital Moinhos de Vento, Porto Alegre, RS - Brasil
| | - Claudia Lucia Barros de Castro
- Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ - Brasil
- CLINIMEX - Clínica de Medicina de Exercício, Rio de Janeiro, RJ - Brasil
| | | | | | - Luiz Eduardo Fonteles Ritt
- Escola Bahiana de Medicina e Saúde Pública, Salvador, BA - Brasil
- Instituto D'Or de Pesquisa e Ensino, Salvador, BA - Brasil
- Hospital Cárdio Pulmonar, Salvador, BA - Brasil
| | - Felipe Lopes Malafaia
- Hospital Samaritano Paulista, São Paulo, SP - Brasil
- UnitedHealth Group Brasil, São Paulo, SP - Brasil
| | - Leonardo Filipe Benedeti Marinucci
- Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (InCor-HCFMUSP), São Paulo, SP - Brasil
| | - José Luiz Barros Pena
- Faculdade Ciências Médicas de Minas Gerais, Belo Horizonte, MG - Brasil
- Hospital Felício Rocho, Belo Horizonte, MG - Brasil
| | | | - Marcelo Luiz Campos Vieira
- Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (InCor-HCFMUSP), São Paulo, SP - Brasil
- Hospital Israelita Albert Einstein, São Paulo, SP - Brasil
| | - Arnaldo Laffitte Stier Júnior
- Universidade Federal do Paraná (UFPR), Curitiba, PR - Brasil
- Secretaria Municipal de Saúde Curitiba, Curitiba, PR - Brasil
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Shankar A, Shrestha R, Sharma A, Rosu D, Hays JV, Agoston I. A Triple Threat: Takayasu Arteritis, Bicuspid Aortic Valve, and Triplets. JACC Case Rep 2023; 28:102135. [PMID: 38204558 PMCID: PMC10774908 DOI: 10.1016/j.jaccas.2023.102135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 10/23/2023] [Accepted: 10/30/2023] [Indexed: 01/12/2024]
Abstract
Takayasu arteritis is a vasculitis affecting women of reproductive age. Appropriate care of these patients requires a multidisciplinary approach and close monitoring. We present the case of a woman with a triplet gestation and Takayasu arteritis complicated by an ascending aortic aneurysm, aortic regurgitation, and bicuspid aortic valve.
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Affiliation(s)
- Aditi Shankar
- Division of Cardiology, Department of Medicine, University of Texas Health San Antonio, San Antonio, Texas, USA
| | - Ribesh Shrestha
- Division of Cardiology, Department of Medicine, University of Texas Health San Antonio, San Antonio, Texas, USA
| | - Aditi Sharma
- Division of Cardiology, Department of Medicine, University of Texas Health San Antonio, San Antonio, Texas, USA
| | - Daniela Rosu
- Division of Cardiology, Department of Medicine, University of Texas Health San Antonio, San Antonio, Texas, USA
| | - Janet V. Hays
- Division of Cardiology, Department of Medicine, University of Texas Health San Antonio, San Antonio, Texas, USA
| | - Ildiko Agoston
- Division of Cardiology, Department of Medicine, University of Texas Health San Antonio, San Antonio, Texas, USA
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Kanagala SG, Sawhney A, Parikh K, Gupta V, Mahmood T, Anamika FNU, Jain R, Garg N. Navigating the challenges of bicuspid aortic valve-aortopathy. Glob Cardiol Sci Pract 2023; 2023:e202327. [PMID: 38404628 PMCID: PMC10886853 DOI: 10.21542/gcsp.2023.27] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 08/12/2023] [Indexed: 02/27/2024] Open
Abstract
Bicuspid aortic valve (BAV) is a congenital heart defect that affects 0.5-2% of the general population with familial predominance. The modifications in hemodynamics and structure change at cellular level contribute to the dilation of aorta, resulting in bicuspid aortopathy, which can result in catastrophic aortic events. The American Heart Association recommends screening first-degree relatives of patients with bicuspid aortic valve and aortic root disease. BAV may or may not be associated with a syndrome, with the non-syndromic variety having a higher chance of predisposition to congenital and vascular abnormalities. Many genes have been implicated in the etiology of non-syndromic aortic aneurysm such as ACTA2, MYH11, FLNA, and SMAD3. Common diagnostic modalities include transthoracic echocardiography (TTE), transesophageal echocardiography (TEE), multi system computer tomography (MSCT), and cardiac MRI. Medical management reduces the rate of disease progression and surgical management is indicated based on the diameter of the ascending aorta, which differs in American and European guidelines. Our article aims to explore the current understanding of the pathophysiology, clinical aspects, and surgical management of bicuspid aortic valve disease. Additionally, we have included a discussion on the management of this condition in special populations, such as athletes and pregnant women, who require distinct treatment recommendations.
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Affiliation(s)
| | - Aanchal Sawhney
- Department of Internal Medicine, Crozer Chester Medical Center, Pennsylvania, USA
| | | | - Vasu Gupta
- Dayanand Medical College and Hospital, Ludhiana, India
| | | | - FNU Anamika
- University College of Medical Sciences, New Delhi, India
| | - Rohit Jain
- Penn State Health Milton S Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Nikita Garg
- Department of Pediatrics, Southern Illinois University School of Medicine, Springfield, Illinois, USA
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Misra A, Porras MP, Rajendran A, Contreras J, Scott NS. Cardio-Obstetrics: A Focused Review. Curr Cardiol Rep 2023; 25:1065-1073. [PMID: 37540401 DOI: 10.1007/s11886-023-01928-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/18/2023] [Indexed: 08/05/2023]
Abstract
PURPOSE OF REVIEW Cardiovascular disease is the leading cause of maternal mortality in the USA. All cardiovascular care providers should have a foundational knowledge on the management of pregnant individuals with heart disease. This focused review touches on several key cardio-obstetric themes. RECENT FINDINGS Many individuals with cardiovascular disease can safely undergo pregnancy, but should have counseling preconception to optimize cardiac status. There are several cardiovascular conditions that are high risk for maternal mortality and morbidity. These individuals should be adequately counseled preconception and offered reliable birth control. The approach to a high-risk pregnant patient with cardiac disease is best managed by a multidisciplinary team to address potential maternal and fetal complications. Identification of at risk individuals can be estimated preconception with several risk scores. The development of risk scores to stratify and identify those at elevated risk during pregnancy is an area of continued research and development.
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Affiliation(s)
- Amrit Misra
- Department of Cardiology, Brigham and Women's Hospital, Boston, MA, USA
| | | | - Aardra Rajendran
- Department of Internal Medicine, John Hopkins University, Baltimore, MD, USA
| | - Johanna Contreras
- Department of Cardiology, Division of Advanced Heart Failure and Transplant, Icahn School of Medicine, Mount Sinai, New York City, NY, USA
| | - Nandita S Scott
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, 55 Fruit Street, Yawkey 5B, Boston, MA, 02114, USA.
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Wander G, van der Zande JA, Patel RR, Johnson MR, Roos-Hesselink J. Pregnancy in women with congenital heart disease: a focus on management and preventing the risk of complications. Expert Rev Cardiovasc Ther 2023; 21:587-599. [PMID: 37470417 DOI: 10.1080/14779072.2023.2237886] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 07/14/2023] [Indexed: 07/21/2023]
Abstract
INTRODUCTION Congenital heart disease (CHD) is the most common cardiac disorder in pregnancy in the western world (around 80%). Due to improvements in surgical interventions more women with CHD are surviving to adulthood and choosing to become pregnant. AREAS COVERED Preconception counseling, antenatal management of CHDs and strategies to prevent maternal and fetal complications.Preconception counseling should start early, before the transition to adult care and be offered to both men and women. It should include the choice of contraception, lifestyle modifications, pre-pregnancy optimization of cardiac state, the chance of the child inheriting a similar cardiac lesion, the risks to the mother, and long-term prognosis. Pregnancy induces marked physiological changes in the cardiovascular system that may precipitate cardiac complications. Risk stratification is based on the underlying cardiac disease and data from studies including CARPREG, ZAHARA, and ROPAC. EXPERT OPINION Women with left to right shunts, regurgitant lesions, and most corrected CHDs are at lower risk and can be managed in secondary care. Complex CHD, including systemic right ventricle need expert counseling in a tertiary center. Those with severe stenotic lesions, pulmonary artery hypertension, and Eisenmenger's syndrome should avoid pregnancy, be given effective contraception and managed in a tertiary center if pregnancy does happen.
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Affiliation(s)
- Gurleen Wander
- Imperial College London, Chelsea and Westminster Hospital, London, UK
| | - Johanna A van der Zande
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Roshni R Patel
- Imperial College London, Chelsea and Westminster Hospital, London, UK
| | - Mark R Johnson
- Imperial College London, Chelsea and Westminster Hospital, London, UK
| | - Jolien Roos-Hesselink
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
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Grashuis P, Khargi SD, Veen K, el Osrouti A, Bemelmans-Lalezari S, Cornette JM, Roos-Hesselink JW, Takkenberg JJ, Mokhles MM. Pregnancy outcomes in women with a mitral valve prosthesis: A systematic review and meta-analysis. JTCVS OPEN 2023; 14:102-122. [PMID: 37425470 PMCID: PMC10328972 DOI: 10.1016/j.xjon.2023.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 04/26/2023] [Accepted: 05/02/2023] [Indexed: 07/11/2023]
Abstract
Objectives To evaluate the ongoing debate concerning the choice of valve prosthesis for women requiring mitral valve replacement (MVR) and who wish to conceive. Bioprostheses are associated with risk of early structural valve deterioration. Mechanical prostheses require lifelong anticoagulation and carry maternal and fetal risks. Also, the optimal anticoagulation regimen during pregnancy after MVR remains unclear. Methods A systematic review and meta-analysis was conducted of studies reporting on pregnancy after MVR. Valve- and anticoagulation-related maternal and fetal risks during pregnancy and 30 days' postpartum were analyzed. Results Fifteen studies reporting 722 pregnancies were included. In total, 87.2% of pregnant women had a mechanical prosthesis and 12.5% a bioprosthesis. Maternal mortality risk was 1.33% (95% confidence interval [CI], 0.69-2.56), any hemorrhage risk 6.90% (95% CI, 3.70-12.88). Valve thrombosis risk was 4.71% (95% CI, 3.06-7.26) in patients with mechanical prostheses. 3.23% (95% CI, 1.34-7.75) of the patients with bioprostheses experienced early structural valve deterioration. Of these, the mortality was 40%. Pregnancy loss risk was 29.29% (95% CI, 19.74-43.47) with mechanical prostheses versus 13.50% (95% CI, 4.31-42.30) for bioprostheses. Switching to heparin during the first trimester demonstrated a bleeding risk of 7.78% (95% CI, 3.71-16.31) versus 4.08% (95% CI, 1.17-14.28) for women on oral anticoagulants throughout pregnancy and a valve thrombosis risk of 6.99% (95% CI, 2.08-23.51) versus 2.89% (95% CI, 1.40-5.94). Administration of anticoagulant dosages greater than 5 mg resulted in a risk of fetal adverse events of 74.24% (95% CI, 56.11-98.23) versus 8.85% (95% CI, 2.70-28.99) in ≤5 mg. Conclusions A bioprosthesis seems the best option for women of childbearing age who are interested in future pregnancy after MVR. If mechanical valve replacement is preferred, the favorable anticoagulation regimen is continuous low-dose oral anticoagulants. Shared decision-making remains priority when choosing a prosthetic valve for young women.
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Affiliation(s)
- Pepijn Grashuis
- Department of Cardiothoracic Surgery, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - Shanti D.M. Khargi
- Department of Cardiothoracic Surgery, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - Kevin Veen
- Department of Cardiothoracic Surgery, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - Azzeddine el Osrouti
- Department of Cardiothoracic Surgery, Erasmus Medical Centre, Rotterdam, The Netherlands
| | | | - Jérôme M.J. Cornette
- Department of Obstetrics and Fetal Medicine, Erasmus Medical Centre, Rotterdam, The Netherlands
| | | | | | - Mostafa M. Mokhles
- Department of Cardiothoracic Surgery, Erasmus Medical Centre, Rotterdam, The Netherlands
- Department of Cardiothoracic Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
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Lima NDA, Patel DA, Sundaram N, de Castro RL, Huffman C, Diaz M, Linares ST, Melgar TA. Hospital admissions for mitral stenosis in pregnancy in the United States: a thirteen-year analysis. AMERICAN JOURNAL OF CARDIOVASCULAR DISEASE 2023; 13:10-20. [PMID: 36938518 PMCID: PMC10017922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Accepted: 01/28/2023] [Indexed: 03/21/2023]
Abstract
BACKGROUND Cardiac conditions are a significant cause of maternal morbidity and mortality, significantly exacerbated during the hemodynamic demands of pregnancy. Mitral stenosis in pregnancy (MSp) is rare in the USA however, it has a high risk for maternal complications. METHODS We aim to outline the burden of MSp hospitalizations nationally. A retrospective review of HCUP/NIS data from 2002-2014 was conducted. RESULTS There were 2014 weighted discharges for both pregnancy and mitral stenosis (MS). Patients diagnosed with MS had a more considerable mean cost per discharge than the comparison group. Pulmonary Hypertension (PH), Atrial Arrhythmias (AA), Stroke, and Heart Failure (HF) were respectively reported in 25.71%, 7.14%, 0.95%, and 19.28% of the discharges. Our study identified a low incidence of MS in the US over the 12-year period; no deaths were identified. CONCLUSION Our results substantiate MSp as a risk factor for PH, AA, HF, and stroke in pregnancy. Even though the mortality is low, it is essential that clinicians be aware of this diagnosis due to higher associated morbidity and costs.
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Affiliation(s)
- Neiberg de Alcantara Lima
- Division of Cardiology, Department of Internal Medicine-Wayne State University Detroit 48201, Michigan, USA
| | | | - Nikhil Sundaram
- Wayne State University School of Medicine Detroit 48201, Michigan, USA
| | | | - Cuyler Huffman
- Department of Statistics-Western Michigan University Homer Stryker MD School of Medicine Kalamazoo, Michigan, USA
| | - Mireya Diaz
- Department of Statistics-Western Michigan University Homer Stryker MD School of Medicine Kalamazoo, Michigan, USA
| | - Silvia Teresa Linares
- Department of Obstetrics and Gynecology-Western Michigan University Homer Stryker MD School of Medicine Kalamazoo, Michigan, USA
| | - Thomas A Melgar
- Departments of Pediatrics, Adolescent and Internal Medicine, Western Michigan University Homer Stryker MD School of Medicine Kalamazoo, Michigan, USA
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12
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Deedwania P, Dadhwal V, Sharma KA. Advanced Pregnancies With Valvular Heart Disease Requiring Peripartum Cardiac Intervention: Two Case Reports and Literature Review. Cureus 2022; 14:e22072. [PMID: 35308752 PMCID: PMC8920825 DOI: 10.7759/cureus.22072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/09/2022] [Indexed: 11/05/2022] Open
Abstract
Cardiac interventions during advanced gestation carry a risk of maternal complications including mortality, along with the serious threat to the life of a viable fetus. However, with advancements in anesthesia and surgery techniques, cardiac interventions can be performed successfully during the peripartum period. We report two cases of decompensated severe valvular stenosis in the third trimester. One patient underwent balloon valvuloplasty followed by cesarean delivery. However, the other underwent a cesarean delivery followed by double valve replacement. Favorable maternal and fetal outcomes were achieved through peripartum interventions. Good fetomaternal outcomes can be obtained in women with severe valvular heart disease (VHD) presenting late in pregnancy. The decision for the timing of cardiac intervention in relation to cesarean section (CS) can vary from case-to-case basis.
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Case Challenge: Nulliparous Cardiac Challenges: A Diagnostic Case. J Nurse Pract 2021. [DOI: 10.1016/j.nurpra.2021.11.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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