Dynamic changes in cardiac function before and early postdelivery in women with severe preeclampsia

Mechanisms of myocardial reverse remodelling and its clinical significance: A scientific statement of the ESC Working Group on Myocardial Function

Cardiovascular disease (CVD) is the leading cause of morbimortality in Europe and worldwide. CVD imposes a heterogeneous spectrum of cardiac remodelling, depending on the insult nature, that is, pressure or volume overload, ischaemia, arrhythmias, infection, pathogenic gene variant, or cardiotoxicity. Moreover, the progression of CVD-induced remodelling is influenced by sex, age, genetic background and comorbidities, impacting patients' outcomes and prognosis. Cardiac reverse remodelling (RR) is defined as any normative improvement in cardiac geometry and function, driven by therapeutic interventions and rarely occurring spontaneously. While RR is the outcome desired for most CVD treatments, they often only slow/halt its progression or modify risk factors, calling for novel and more timely RR approaches. Interventions triggering RR depend on the myocardial insult and include drugs (renin-angiotensin-aldosterone system inhibitors, beta-blockers, diuretics and sodium-glucose cotransporter 2 inhibitors), devices (cardiac resynchronization therapy, ventricular assist devices), surgeries (valve replacement, coronary artery bypass graft), or physiological responses (deconditioning, postpartum). Subsequently, cardiac RR is inferred from the degree of normalization of left ventricular mass, ejection fraction and end-diastolic/end-systolic volumes, whose extent often correlates with patients' prognosis. However, strategies aimed at achieving sustained cardiac improvement, predictive models assessing the extent of RR, or even clinical endpoints that allow for distinguishing complete from incomplete RR or adverse remodelling objectively, remain limited and controversial. This scientific statement aims to define RR, clarify its underlying (patho)physiologic mechanisms and address (non)pharmacological options and promising strategies to promote RR, focusing on the left heart. We highlight the predictors of the extent of RR and review the prognostic significance/impact of incomplete RR/adverse remodelling. Lastly, we present an overview of RR animal models and potential future strategies under pre-clinical evaluation.

The impact of echocardiographic indexation to evaluate cardiac reverse remodeling throughout pregnancy and postpartum

INTRODUCTION AND OBJECTIVES

Echocardiography guidelines suggest normalizing left ventricular (LV) volumes and mass (LVM) to body size. During pregnancy, continuous weight variation impacts on body surface area (BSA) calculation, limiting the longitudinal analysis of cardiac remodeling (CR) and reverse remodeling (RR) variables. Our aim was to identify the most common indexing methodologies in the literature on pregnant populations through a systematic review; and, to compare four scaling methods: (i) none (absolute values); (ii) indexing to the BSA before pregnancy; (iii) allomeric indexing; and (iv) indexing to BSA measured at the same day of cardiac assessment, using an illustrative example.

METHODS

We performed a systematic review of CR and RR during pregnancy and post-partum, using two databases. We included studies reporting longitudinal echocardiographic analysis of cardiac chamber volumes in humans. We used a prospective cohort study of healthy pregnant women who underwent four echocardiographic evaluations during pregnancy and postpartum, as an illustrative example.

RESULTS

Twenty-seven studies were included, most studies indexed to BSA measured at each evaluation moment (n=21). Within-subjects design was the most reported to analyse longitudinal data (n=17). Indexation to the pre-pregnancy BSA or application of allometric indexes revealed a higher effect than BSA measured at each evaluation and an equal effect to not indexing using within-subjects design. The within-subjects designs also revealed a higher effect size value than the between-subjects design for longitudinal analysis of LVM adaptations during pregnancy and postpartum.

CONCLUSION(S)

This study concludes that indexation methods do not impact the clinical interpretation of longitudinal echocardiographic assessment but highlights the need to harmonize normalization procedures during pregnancy.

The role of lung and cardiac ultrasound for cardiovascular hemodynamic assessment of women with preeclampsia

Preeclampsia remains the leading cause of maternal morbidity and mortality and is associated with abnormal body fluid homeostasis and cardiovascular dysfunction. Moreover, 2 distinct hemodynamic phenotypes have been described in preeclampsia, which might require different therapeutic approaches. Fluid restriction is mandatory in women at risk of pulmonary edema, whereas additional fluid administration may be required to correct tissue hypoperfusion in women with intravascular volume depletion. As clinical examination alone cannot discriminate among different hemodynamic patterns, optimal management of women with preeclampsia remains challenging. Noninvasive bedside ultrasound has become an important diagnostic and monitoring tool in critically ill patients, and it has been demonstrated that it can also be used in the monitoring of women with preeclampsia. Echocardiography in combination with lung ultrasound provides information on hemodynamic status, cardiac function, lung congestion, and fluid responsiveness and, therefore, could help clinicians identify women at higher risk of life-threatening complications. This review describes the cardiovascular changes in preeclampsia and provides an overview of the ultrasound methodologies that could be efficiently used for better hemodynamic assessment and management of women with preeclampsia.

Cardiovascular risk factors during pregnancy impact the postpartum cardiac and vascular reverse remodeling

Pregnant women with cardiovascular risk (CVR) factors are highly prone to develop cardiovascular disease later in life. Thus, recent guidelines suggest extending the follow-up period to 1 yr after delivery. We aimed to evaluate cardiovascular remodeling during pregnancy and determine which CVR factors and potential biomarkers predict postpartum cardiac and vascular reverse remodeling (RR). Our study included a prospective cohort of 76 healthy and 54 obese and/or hypertensive and/or with gestational diabetes pregnant women who underwent transthoracic echocardiography, pulse-wave velocity (PWV), and blood collection at the 1st trimester (1T) and 3rd trimester (3T) of pregnancy as well as at the 1st/6th/12th mo after delivery. Generalized linear mixed-effects models was used to evaluate the extent of RR and its potential predictors. Pregnant women develop cardiac hypertrophy, as confirmed by a significant increase in left ventricular mass (LVM). Moreover, ventricular filling pressure (E/e') and atrial volume increased significantly during gestation. Significant regression of left ventricular (LV) volume, LVM, and filling pressures was observed as soon as 1 mo postpartum. The LV global longitudinal strain worsened slightly and recovered at 6 mo postpartum. PWV decreased significantly from 1T to 3T and normalized at 1 mo postpartum. We found that arterial hypertension, smoking habits, and obesity were independent predictors of increased LVM during pregnancy and postpartum. High C-reactive protein (CRP) and low ST2/IL33-receptor levels are potential circulatory biomarkers of worse LVM regression. Arterial hypertension, age, and gestational diabetes positively correlated with PWV. Altogether, our findings pinpoint arterial hypertension as a critical risk factor for worse RR and CRP, and ST2/IL33 receptors as potential biomarkers of postpartum hypertrophy reversal.NEW & NOTEWORTHY This study describes the impact of cardiovascular risk factors (CVR) in pregnancy-induced remodeling and postpartum reverse remodeling (up to 1 yr) by applying advanced statistic methods (multivariate generalized linear mixed-effects models) to a prospective cohort of pregnant women. Aiming to extrapolate to pathological conditions, this invaluable "human model" allowed us to demonstrate that arterial hypertension is a critical CVR for worse RR and that ST2/IL33-receptors and CRP are potential biomarkers of postpartum hypertrophy reversal.

Focused cardiac ultrasound in pregnancy

Cardiac disease in pregnancy is an important cause of maternal morbidity and mortality. In many high-income countries, acquired cardiac disease is now the largest cause of maternal mortality. Given its prevalence in low- and middle-income countries (LMICs), rheumatic heart disease is the most common cause of cardiac disease in pregnancy worldwide and is associated with poor maternal outcome. The diagnosis of cardiac disease in pregnancy is often delayed resulting in excess maternal morbidity and mortality. Maternal mortality review committees have suggested that prompt recognition and treatment of heart disease in pregnancy may improve maternal outcome. Given the similarities between symptoms of normal pregnancy and those of cardiac disease, the clinical diagnosis of heart disease in pregnancy is challenging with echocardiography being the primary diagnostic modality. Focused cardiac ultrasound (FOCUS) at the point of care provides supplemental data to the history and physical examination and has been demonstrated to permit early diagnosis and improvement in the management of cardiac disease in emergency medicine, intensive care, and anesthesia. It has also been demonstrated to be useful in surveillance for rheumatic heart disease in LMICs. The use of FOCUS may allow earlier and more accurate diagnosis of cardiac disease in pregnancy with the potential to decrease morbidity and mortality in both developed and developing countries.

Peripartum echocardiographic changes in women with hypertensive disorders of pregnancy

OBJECTIVE

Hypertensive disorders of pregnancy (HDP) are associated with significant myocardial dysfunction on echocardiography. The impact of hemodynamic changes related to volume redistribution following delivery on myocardial function in women with HDP has not been evaluated systematically. The aim of this study was to compare echocardiographic findings immediately before and after delivery in women with HDP.

METHODS

This was a prospective longitudinal study including 30 women with a diagnosis of HDP who underwent two consecutive transthoracic echocardiographic (TTE) examinations, before delivery and in the early postpartum period. Paired comparisons of the findings from the two assessments were performed.

RESULTS

Left-ventricular (LV) concentric remodeling or hypertrophy was detected in 21 (70%) patients. There was no significant difference in cardiac morphology indices such as LV mass index (78.9 ± 16.3 g/m² vs 77.9 ± 15.4 g/m² ; P = 0.611) or relative wall thickness (0.45 ± 0.1 vs 0.44 ± 0.1; P = 0.453) before vs after delivery. LV diastolic function did not demonstrate any peripartum variation, with similar left-atrial volume (52.4 ± 15.3 mL vs 51.0 ± 15.6 mL; P = 0.433), lateral E' (0.12 ± 0.03 m/s vs 0.12 ± 0.03 m/s; P = 0.307) and E/E' ratio (7.9 ± 2.2 vs 7.9 ± 1.7; P = 0.934) before vs after delivery. Systolic function indices, such as LV ejection fraction (57.5 ± 3.4% vs 56.4 ± 2.1%; P = 0.295) and global longitudinal strain (-15.3 ± 2.6% vs -15.1 ± 3.1%; P = 0.582), also remained unchanged between before vs after delivery.

CONCLUSIONS

Maternal hemodynamic changes associated with delivery did not influence significantly peripartum TTE indices in women with HDP. Suboptimal maternal echocardiographic findings in HDP are likely to be the consequence of chronic pregnancy cardiovascular load changes or pre-existing maternal cardiovascular impairment. Severity and persistence of myocardial dysfunction in the postpartum period may be related to the long-term maternal cardiovascular disease legacy of HDP. © 2021 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Myocardial Mechanics in Hypertensive Disorders of Pregnancy: a Systematic Review and Meta-Analysis

Global longitudinal strain (GLS) is becoming routinely used to direct the medical management of various cardiac diseases, but its application in pregnancy is unclear. Our objective was to perform a meta-analysis and pool multiple study data to consolidate the evidence base for the role of GLS in the assessment of women with hypertensive disorders of pregnancy (HDP). Electronic database searches were performed in PubMed/Medline and EMBASE for research articles reporting GLS in pregnancies complicated by HDP and normotensive pregnancies that have been published up to September 2021. The meta-analysis included 17 studies with a pooled sample size of 1723 participants, which included 951 women with HDP, of which 680 were preeclamptic, and 772 controls. The primary random-effects pooled analysis demonstrated a statistically significant weighted mean difference in GLS between the HDP and control group (mean difference: 3.08% [CI, 2.33-3.82], P<0.001). When analyzed including only preeclamptic studies, there was also a statistically significant mean difference (mean difference: 2.98% [95% CI, 1.97-3.99], P<0.001). This meta-analysis demonstrates that HDP is associated with greater cardiac maladaptation, evidenced by a significantly reduced GLS compared with normal pregnancy. Echocardiography should be considered as a screening tool in women with HDP to enable early cardiovascular risk prevention through national initiatives.

Value of Ultrasonic Image Features in Diagnosis of Perinatal Outcomes of Severe Preeclampsia on account of Deep Learning Algorithm

This study is aimed at discussing the value of ultrasonic image features in diagnosis of perinatal outcomes of severe preeclampsia on account of deep learning algorithm. 140 pregnant women singleton with severe preeclampsia were selected as the observation group. At the same time, 140 normal singleton pregnant women were selected as the control group. The hemodynamic indexes were detected by color Doppler ultrasound. The CNN algorithm was used to classify ultrasound images of two groups of pregnant women. The differential scanning calorimetry (DSC), mean pixel accuracy (MPA), and mean intersection of union (MIOU) values of CNN algorithm were 0.9410, 0.9228, and 0.8968, respectively. Accuracy, precision, recall, and F1-score were 93.44%, 95.13%, 95.09%, and 94.87%, respectively. The differences were statistically significant (P < 0.05). Compared with the normal control group, the umbilical artery (UA), uterine artery-systolic/diastolic (UTA-S/D), uterine artery (UTA), and digital video (DV) of pregnant women in the observation group were remarkably increased; the minimum alveolar effective concentration (MCA) of the observation group was obviously lower than the MCA of the control group, and the differences between groups were statistically valid (P < 0.05). Logistic regression analysis showed that UA-S/D, UA-resistance index (UA-RI), UTA-S/D, UTA-pulsatility index (UTA-PI), DV-peak velocity index for veins (DV-PVIV), and MCA-S/D were independent risk factors for the outcome of perinatal children with severe preeclampsia. In the perinatal management of severe epilepsy, the combination of the above blood flow indexes to select the appropriate delivery time had positive significance to improve the pregnancy outcome and reduce the perinatal mortality.

Left Atrial Strain and Compliance Correlate with Diastolic Dysfunction Grades and Complications during Pre-eclampsia: A Speckle-Tracking Echocardiography Study

This study aimed to investigate left atrium (LA) strain components in the assessment of cardiac function and its clinical correlates in pre-eclampsia (PE). With the use of speckle tracking echocardiography, phasic LA strain and (LASr)/(E/e'), the surrogate of LA compliance, were compared between healthy pregnant women (n = 70) and those with PE (n = 146) and among different diastolic dysfunction (DD) grades in PE. Receiver operating characteristic curves and logistic regression analysis were used to identify the role of strain components in distinguishing DD grades and predicting cardiac complications. LA reservoir strain, conduit strain and LA compliance reduced significantly in PE (p < 0.01). LASr/(E/e') gradually decreased with worsening DD and LASr/(E/e') <3.40 was the independent risk factor for cardiac events in PE (p < 0.01). This study observed significantly decreased LA strain and compliance in PE. Notably, LA compliance decreased progressively with the severity of DD, and LASr/(E/e') <3.40 is the independent risk factor for cardiac complications during PE pregnancy.

Evolution of cardiac geometry and function in women with severe preeclampsia from immediately post-delivery to 1 year postpartum

Preeclampsia is associated with left ventricular (LV) geometrical and functional changes, which could be related to cardiovascular risk later in life. The purpose of our study was to evaluate evolution of LV dimensions and function in severe preeclamptic women from immediately post-delivery to 1 year postpartum. Twenty-five women with severe preeclampsia and 15 healthy term controls underwent standard and speckle-tracking echocardiography 1 day after delivery and 1 year postpartum. On day 1 post-delivery preeclamptic women were exposed to higher preload (p = 0.003) and afterload (p < 0.001) compared to controls. Parameter of longitudinal LV systolic function s' was significantly lower in preeclamptic compared to control group (p = 0.017) 1 day post-delivery. Additionally, diastolic function parameters were significantly more impaired in preeclamptic compared to control group (lower e' (p = 0.02) and higher E/e' ratio (p = 0.003) in preeclamptic group). Larger LV mass (p = 0.03) and a trend of higher proportion of altered cardiac geometry (p = 0.061) were observed in preeclampsia 1 day post-delivery. One year after delivery both groups had comparable geometric and functional parameters with similar afterload and preload (p > 0.05, for all). In preeclamptic group systolic and diastolic functional parameters improved significantly during follow-up (p < 0.05), while no such evolution was noted in controls (> 0.05). In women with severe preeclampsia subtle cardiac functional impairment immediately post-delivery completely resolved 1 year postpartum. Observed cardiac alterations suggest intrinsic myocardial dysfunction in preeclampsia, which became unmasked or exacerbated by higher load imposed on the LV immediately post-delivery that disappeared in mid-term follow-up.

Cardiovascular function during triplet pregnancy

Pregnancy is recognized as a natural physiological stressor to the maternal cardiovascular system. Cardiovascular adaptation is markedly greater in twin pregnancy compared with singleton pregnancy; however, these changes are sparsely documented in triplet pregnancy. The aim of this case series was to compare maternal cardiac function, cardioautonomic regulation, and blood pressure reactivity in healthy singleton, twin, and triplet pregnancies. Resting cardiac structure and function (echocardiography), beat-by-beat blood pressure variability (BPV; photoplethysmography), and heart rate variability (HRV; electrocardiogram) were measured in two triplet, three twin, and three singleton pregnancies (matched for maternal age, prepregnancy body mass index, and gestational age). Hemodynamic responses to a 3-min cold pressor test were also recorded to assess blood pressure reactivity. Due to the small sample size of this case series, statistical comparisons were not made between groups. Compared with singleton and twin pregnancies, individuals pregnant with triplets had greater resting cardiac output but lower cardiac deformation (longitudinal strain, basal circumferential strain, and torsion), sympathetic dominance in cardioautonomic regulation (lower HRV and higher BPV), and elevated blood pressure reactivity in response to the cold pressor test. Taken together, these observations suggest that females with triplet pregnancies may have reduced cardiovascular function, which may contribute to the heightened risk of complications in multifetal pregnancies.NEW & NOTEWORTHY Individuals with healthy triplet pregnancies had greater resting cardiac output but lower left ventricular mechanics when compared with singleton and twin pregnancies matched for gestational age. In addition, triplet pregnancies had greater blood pressure variability and lower overall heart rate variability compared with singleton pregnancies, as well as greater blood pressure reactivity to the cold pressor test. Healthy triplet pregnancies may have reduced cardiovascular function as well as a greater sympathetic contribution to cardiac control.

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.