Congenital heart disease in pregnancy

Adult Congenital Heart Disease with Pregnancy

The number of women with congenital heart disease (CHD) at risk of pregnancy is growing because over 90% of them are grown-up into adulthood. The outcome of pregnancy and delivery is favorable in most of them provided that functional class and systemic ventricular function are good. Women with CHD such as pulmonary hypertension (Eisenmenger syndrome), severe left ventricular outflow stenosis, cyanotic CHD, aortopathy, Fontan procedure and systemic right ventricle (complete transposition of the great arteries [TGA] after atrial switch, congenitally corrected TGA) carry a high-risk. Most frequent complications during pregnancy and delivery are heart failure, arrhythmias, bleeding or thrombosis, and rarely maternal death. Complications of fetus are prematurity, low birth weight, abortion, and stillbirth. Risk stratification of pregnancy and delivery relates to functional status of the patient and is lesion specific. Medication during pregnancy and post-delivery (breast feeding) is a big concern. Especially prescribing medication with teratogenicity should be avoidable. Adequate care during pregnancy, delivery, and the postpartum period requires a multidisciplinary team approach with cardiologists, obstetricians, anesthesiologists, neonatologists, nurses and other related disciplines. Caring for a baby is an important issue due to temporarily pregnancy-induced cardiac dysfunction, and therefore familial support is mandatory especially during peripartum and after delivery. Timely pre-pregnancy counseling should be offered to all women with CHD to prevent avoidable pregnancy-related risks. Successful pregnancy is feasible for most women with CHD at relatively low risk when appropriate counseling and optimal care are provided.

Risk Assessment and Management of the Mother with Cardiovascular Disease

Chronic medical conditions account for most nonobstetrical pregnancy-related maternal complications. Preconception counseling of women with cardiovascular disease can be aided by an understanding of cardiovascular physiology in pregnancy and risk scores to guide management.

Comparison of long-term clinical outcomes between sirolimus-eluting stents and paclitaxel-eluting stents following rotational atherectomy

Rotational atherectomy (RA) can facilitate smooth stent delivery and stent expansion through lesion modification for a calcified coronary lesion. Several studies reported that sirolimus-eluting stent (SES) implantation following RA showed a lower rate of revascularization compared with bare-metal stents (BMS). However, there are limited data that compared the clinical outcomes between SES and paclitaxel-eluting stents (PES) after RA. We compared the long-term clinical outcomes of SES and PES following RA. Two hundred and thirty-three consecutive patients (SES n = 179, PES n = 54) who were treated with SES or PES following RA between 10^th September 2004 and 13^th April 2010 were investigated. Follow-up data for clinical outcomes were obtained in 91.4% of all subjects. The median follow-up period was 630 days (interquartile range, 300 to 1170 days) in the SES group, and 625 days (interquartile range, 285 to 900 days) in the PES group. Clinical outcomes including target lesion revascularization (TLR) (SES 4.9% versus PES 9.8%, P = 0.31), target vessel revascularization (TVR) (SES 6.8% versus PES 11.8%, P = 0.25), and major adverse cardiac events (MACE) (SES 14.8% versus PES 13.7%, P = 0.8) were not statistically different between the groups. The unadjusted cumulative event rates estimated by the Kaplan-Meier method and the log-rank test showed no significant differences between the two groups for time to event for TLR, cardiovascular death, all-cause death, or MACE. In conclusion, there was no significant difference in the long-term clinical outcomes between SES and PES following RA.

Anesthetic management for cesarean delivery in a patient with severe aortic stenosis and severe obesity

Valvular heart disease has significant effect on the maternal and fetal outcome of pregnancy. The severity and extent of aortic stenosis is of great value for risk assessment and for the design of a therapeutic plan. The therapeutic plan for such patients is further complicated by severe obesity. We report a case describing the anesthetic management of an extremely obese patient for cesarean delivery with severe aortic valve stenosis and regurgitation. The case was made complex due to the patient's deteriorating condition and not offering consent to emergency surgical procedures. The 34-year-old parturient underwent cesarean delivery at 32 weeks gestation under general anesthesia in the presence of a cardiothoracic surgical team. This case report demonstrates the importance of multidisciplinary preoperative assessment in such patients and careful anesthetic planning to avoid the deterioration of perioperative cardiac performance in parturients with complex valvular disease.

Anesthetic management of parturients with congenitally corrected transposition of the great arteries: three cases and a review of the literature

Women with congenitally corrected transposition of the great arteries (CCTGA) have a propensity for congestive heart failure and cardiac dysrhythmias during pregnancy, labor, and delivery. We report the successful obstetric and anesthetic management of three women with CCTGA, review the pertinent medical literature, and discuss important issues surrounding the anesthetic management of parturients with CCTGA.

Pregnancy: Maternal and Fetal Heart Disease

Cardiac disorders complicate less than 1% of all pregnancies. Physiologic changes in pregnancy may mimic heart disease. In order to differentiate these adaptations from pathologic conditions, an in-depth knowledge of cardiovascular physiology is mandatory. A comprehensive history, physical examination, electrocardiogram, chest radiograph, and echocardiogram are sufficient in most cases to confirm the diagnosis. Care of women with cardiac disease begins with preconception counseling. Severe lesions should be taken care of prior to contemplating pregnancy. Management principles for pregnant women are similar to those for the non-pregnant state. A team approach comprised of a maternal fetal medicine specialist, cardiologist, neonatologist, and anesthesiologist is essential to assure optimal outcome for both the mother and the fetus. Although fetal heart disease complicates only a small percentage of pregnancies, congenital heart disease causes more neonatal morbidity and mortality than any other congenital malformation. Unfortunately, screening approaches for fetal heart disease continue to miss a large percentage of cases. This weakness in fetal screening has important clinical implications, because the prenatal detection and diagnosis of congenital heart disease may improve the outcome for many of these fetal patients. In fact, simply the detection of major heart disease prenatally can improve neonatal outcome by avoiding discharge to home of neonates with ductal-dependent congenital heart disease. Fortunately, recent advances in screening techniques, an increased ability to change the prenatal natural history of many forms of fetal heart disease, and an increasing recognition of the importance of a multidisciplinary, team approach to the management of pregnancies complicated with fetal heart disease, together promise to improve the outcome of the fetus with congenital heart disease.

Pregnancy in women with congenital heart disease

Congenital heart disease is the most common form of structural heart disease affecting women of childbearing age in developed countries. Pregnancy in these patients is associated with an increased risk to both mother and fetus. Appropriate prepregnancy evaluation and counseling is recommended to assess the pregnancy-related maternal and fetal risk and to identify patients who should avoid pregnancy. Once pregnancy occurs, cardiovascular reevaluation is generally recommended; the frequency is individualized. Monitoring during delivery may be necessary and the postpartum period is a concern in select individuals. Data regarding the outcome of pregnancy in patients with operated congenital cardiac defects are available. Individualized care is mandatory.

Anaesthetic management of a parturient with pulmonary stenosis and aortic incompetence for Caesarean section

Anaesthetic management of Caesarean section in a parturient with severe pulmonary stenosis and aortic regurgitation is described. The valvular sequelae resulted from previous unsuccessful surgical correction (Ross procedure) of congenital aortic stenosis. This case demonstrates the importance of multi-disciplinary assessment and careful anaesthetic planning, to avoid deterioration in perioperative cardiac performance in parturients with complex valvular disease.

Cardiac disease in pregnancy

Congenital heart disease in pregnancy is increasingly common because of the advances in surgery and medical therapy which have taken place over the last 30 years, which means that more affected women are surviving into the reproductive age. Antenatal counselling needs to be tailored to the specific lesion, with pulmonary hypertension and cyanotic disease presenting a risk of maternal mortality of up to 50%. The use of anticoagulants in women with artificial valves presents a particular challenge, heparin being safer for the baby and warfarin for the mother. Peripartum cardiomyopathy and Marfan's syndrome may be less dangerous than once thought. The risk of congenital heart disease in the fetus is increased, from twice to 20-fold, depending on the nature of the mother's lesion. Care throughout pregnancy and in the puerperium should be multidisciplinary and include cardiologists, obstetricians and midwives with experience of such cases, preferably in a tertiary centre.