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Abraham MS, Andrews LM, Deo H, Paul J, Angappan S, Samuel A, Abraham AS. Pregnancy with a Left Ventricular Assist Device: A Narrative Review. Ann Card Anaesth 2025; 28:10-16. [PMID: 39851146 PMCID: PMC11902364 DOI: 10.4103/aca.aca_136_24] [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: 06/25/2024] [Revised: 09/04/2024] [Accepted: 09/22/2024] [Indexed: 01/26/2025] Open
Abstract
ABSTRACT This narrative review discusses the various challenges associated with the presence of a left ventricular assist device (LVAD) during pregnancy. Given the hemodynamic and coagulation changes associated with pregnancy, the presence of an LVAD adds a layer of complexity with respect to optimal management. This review will discuss the anesthetic considerations when dealing with this subset of patients who may have other comorbidities alongside their advanced heart failure. Additionally, this paper aims to review successful pregnancies with an LVAD placement focusing on the mode of delivery and hemodynamic management risk.
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Affiliation(s)
| | - Lijo M. Andrews
- Midwestern University Chicago College of Osteopathic Medicine, Downers Grove, IL 60515, USA
| | - Harsha Deo
- School of Medicine, University of Leeds, Leeds LS2 9JT, UK
| | - John Paul
- School of Medicine, University of Leeds, Leeds LS2 9JT, UK
| | - Santhalakshmi Angappan
- Department of Intensive Care and Resuscitation, Cleveland Clinic Foundation, Cleveland, OH 44195, USA
| | - Abraham Samuel
- Department of Cardiothoracic Anesthesiology, Freeman Hospital, Newcastle Upon Tyne, NE7 7DN, UK
| | - Abey S. Abraham
- Department of Cardiothoracic Anesthesiology, Cleveland Clinic Foundation, Cleveland, OH 44195, USA
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Oren D, Moeller CM, Haythe JH, Rubinstein G, Fernandez Valledor A, Lotan D, Rosenblum H, Colombo PC, Yuzefpolskaya M, Topkara VK, Clerkin KJ, Raikhelkar JK, Fried JA, Naka Y, Takeda K, Latif F, Sayer G, Uriel N. Pumping for Two: Pregnancy in Patients Supported With a Left Ventricular Assist Device. ASAIO J 2024; 70:461-468. [PMID: 37934714 DOI: 10.1097/mat.0000000000002082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2023] Open
Abstract
This review discusses the challenges and outcomes associated with pregnancy during left ventricular assist device (LVAD) support. Women account for a third of the heart failure population in the United States. Left ventricular assist devices have emerged as a safe and effective treatment option for patients with advanced heart failure. Pregnancy during LVAD support can occur, and it presents significant risks to both mother and fetus, including hemodynamic stress, thrombotic events, medication-associated teratogenicity, and uterine impingement. This literature review identified 10 cases of confirmed pregnancy during LVAD support, of which eight resulted in successful births. Maternal and fetal mortality occurred in one case, and there was a spontaneous abortion in one case. The review highlights the importance of a multidisciplinary approach, promotion of shared decision-making, thoughtful anticoagulation, adjustment of LVAD speed, and medication optimization to maintain hemodynamic support during pregnancy. Hemodynamic changes during pregnancy include increased cardiac output, heart rate, and plasma volume, as well as decreased systemic vascular resistance, which can impact LVAD support. Despite reduced pulsatility in LVAD-supported patients, ovulation and reproductive capacity might be preserved, and viable pregnancies may be achieved with appropriate management. The review provides insights into the risks and considerations for a viable pregnancy during LVAD support, including the need for ongoing research to inform joined decision-making.
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Affiliation(s)
- Daniel Oren
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Cathrine M Moeller
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Jennifer H Haythe
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Gal Rubinstein
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Andrea Fernandez Valledor
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Dor Lotan
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Hannah Rosenblum
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Paolo C Colombo
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Melana Yuzefpolskaya
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Veli K Topkara
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Kevin J Clerkin
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Jayant K Raikhelkar
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Justin A Fried
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Yoshifumi Naka
- Department of Cardiothoracic Surgery, Columbia University Irving Medical Center, New York, NY
| | - Koji Takeda
- Department of Cardiothoracic Surgery, Columbia University Irving Medical Center, New York, NY
| | - Farhana Latif
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Gabriel Sayer
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Nir Uriel
- From the Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
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DeFilippis EM, Bhagra C, Casale J, Ging P, Macera F, Punnoose L, Rasmusson K, Sharma G, Sliwa K, Thorne S, Walsh MN, Kittleson MM. Cardio-Obstetrics and Heart Failure: JACC: Heart Failure State-of-the-Art Review. JACC. HEART FAILURE 2023; 11:1165-1180. [PMID: 37678960 DOI: 10.1016/j.jchf.2023.07.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 05/26/2023] [Accepted: 07/05/2023] [Indexed: 09/09/2023]
Abstract
Heart failure and cardiomyopathy are significant contributors to pregnancy-related deaths, as maternal morbidity and mortality have been increasing over time. In this setting, the role of the multidisciplinary cardio-obstetrics team is crucial to optimizing maternal, obstetrical and fetal outcomes. Although peripartum cardiomyopathy is the most common cardiomyopathy experienced by pregnant individuals, the hemodynamic changes of pregnancy may unmask a pre-existing cardiomyopathy leading to clinical decompensation. Additionally, there are unique management considerations for women with pre-existing cardiomyopathy as well as for those women with advanced heart failure who may be on left ventricular assist device support or have undergone heart transplantation. The purpose of this review is to discuss: 1) preconception counseling; 2) risk stratification and management strategies for pregnant women extending to the postpartum "fourth trimester" with pre-existing heart failure or "pre-heart failure;" 3) the safety of heart failure medications during pregnancy and lactation; and 4) management of pregnancy for women on left ventricular assist device support or after heart transplantation.
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Affiliation(s)
- Ersilia M DeFilippis
- Division of Cardiology, NewYork-Presbyterian Columbia University Irving Medical Center, New York, New York, USA
| | - Catriona Bhagra
- Department of Cardiology, Cambridge University and Royal Papworth NHS Foundation Trusts, Cambridge, United Kingdom
| | - Jillian Casale
- Department of Pharmacy Services, Cooperman Barnabas Medical Center, Livingston, New Jersey, USA
| | - Patricia Ging
- Department of Pharmacy, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Francesca Macera
- De Gasperis Cardio Center and Transplant Center, Niguarda Hospital, Milan, Italy; Department of Cardiology, Cliniques Universitaires de Bruxelles - Hôpital Erasme, Brussels, Belgium
| | - Lynn Punnoose
- Vanderbilt Heart and Vascular Institute, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Kismet Rasmusson
- Intermountain Heart Institute, Intermountain Medical Center, Salt Lake City, Utah, USA
| | - Garima Sharma
- Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Karen Sliwa
- Cape Heart Institute, Department of Medicine, Division of Cardiology, Faculty of Health Sciences, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Sara Thorne
- Division of Cardiology, Pregnancy & Heart Disease Program, Mount Sinai Hospital & University Health Network, University of Toronto, Toronto, Ontario, Canada
| | | | - Michelle M Kittleson
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA.
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Management of pregnancy in left ventricular assist device and heart transplant recipients: a concise review. Curr Opin Cardiol 2023; 38:257-265. [PMID: 36927986 DOI: 10.1097/hco.0000000000001036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/18/2023]
Abstract
PURPOSE OF REVIEW Women of reproductive age are increasingly undergoing heart transplantation (HT) or left ventricular assist device (LVAD) implantation for advanced heart failure. This review is intended to give an overview of the current state of the art management of pregnancy in patients with LVAD or HT recipients. RECENT FINDINGS Heart transplant recipients are at increased risk for graft rejection, renal dysfunction, preeclampsia and worsening of comorbidities (hypertension and diabetes). Patients with LVAD are at higher risk of thromboembolic events, infections, right ventricular failure and require close surveillance during pregnancy. Preconception counseling must be offered to all women of reproductive age group with HT or LVAD to avoid unplanned pregnancies. SUMMARY A multidisciplinary approach with close antepartum and postpartum surveillance is recommended.
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Kittleson MM, DeFilippis EM, Bhagra CJ, Casale JP, Cauldwell M, Coscia LA, D'Souza R, Gaffney N, Gerovasili V, Ging P, Horsley K, Macera F, Mastrobattista JM, Paraskeva MA, Punnoose LR, Rasmusson KD, Reynaud Q, Ross HJ, Thakrar MV, Walsh MN. Reproductive health after thoracic transplantation: An ISHLT expert consensus statement. J Heart Lung Transplant 2023; 42:e1-e42. [PMID: 36528467 DOI: 10.1016/j.healun.2022.10.009] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Accepted: 10/10/2022] [Indexed: 11/16/2022] Open
Abstract
Pregnancy after thoracic organ transplantation is feasible for select individuals but requires multidisciplinary subspecialty care. Key components for a successful pregnancy after lung or heart transplantation include preconception and contraceptive planning, thorough risk stratification, optimization of maternal comorbidities and fetal health through careful monitoring, and open communication with shared decision-making. The goal of this consensus statement is to summarize the current evidence and provide guidance surrounding preconception counseling, patient risk assessment, medical management, maternal and fetal outcomes, obstetric management, and pharmacologic considerations.
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Affiliation(s)
- Michelle M Kittleson
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California.
| | - Ersilia M DeFilippis
- Division of Cardiology, New York Presbyterian-Columbia University Irving Medical Center, New York, New York
| | - Catriona J Bhagra
- Department of Cardiology, Cambridge University and Royal Papworth NHS Foundation Trusts, Cambridge, UK
| | - Jillian P Casale
- Department of Pharmacy Services, University of Maryland Medical Center, Baltimore, Maryland
| | - Matthew Cauldwell
- Department of Obstetrics, Maternal Medicine Service, St George's Hospital, London, UK
| | - Lisa A Coscia
- Transplant Pregnancy Registry International, Gift of Life Institute, Philadelphia, Pennsylvania
| | - Rohan D'Souza
- Division of Maternal and Fetal Medicine, Department of Obstetrics and Gynecology, McMaster University, Hamilton, Ontario, Canada
| | - Nicole Gaffney
- Lung Transplant Service, Alfred Hospital, Melbourne, Australia; Department of Medicine, Central Clinical School, Monash University, Melbourne, Australia
| | | | - Patricia Ging
- Department of Pharmacy, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Kristin Horsley
- Department of Obstetrics and Gynecology, McMaster University, Hamilton, Ontario, Canada
| | - Francesca Macera
- De Gasperis Cardio Center and Transplant Center, Niguarda Hospital, Milan, Italy; Dept of Cardiology, Cliniques Universitaires de Bruxelles - Hôpital Erasme, Brussels, Belgium
| | - Joan M Mastrobattista
- Department of Obstetrics & Gynecology, Division of Maternal-Fetal Medicine, Baylor College of Medicine Houston, Texas
| | - Miranda A Paraskeva
- Lung Transplant Service, Alfred Hospital, Melbourne, Australia; Department of Medicine, Central Clinical School, Monash University, Melbourne, Australia
| | - Lynn R Punnoose
- Vanderbilt Heart and Vascular Institute, Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - Quitterie Reynaud
- Cystic Fibrosis Adult Referral Care Centre, Department of Internal Medicine, Hospices civils de Lyon, Pierre Bénite, France
| | - Heather J Ross
- Peter Munk Cardiac Centre of the University Health Network, Toronto, Ontario, Canada; Ted Rogers Centre for Heart Research, Toronto, Ontario, Canada; University of Toronto, Toronto, Ontario, Canada
| | - Mitesh V Thakrar
- Department of Medicine, Division of Respirology, University of Calgary, Calgary, Alberta, Canada
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Yadalam AK, Yoo BW, Horton JP, Krishna I, Vega JD, Bhatt KN, Gupta D, Abdou MH. Left Ventricular Assist Devices and Pregnancy: Systematic Review of Existing Literature and Case Report. Curr Probl Cardiol 2023; 48:101469. [PMID: 36272549 DOI: 10.1016/j.cpcardiol.2022.101469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 10/13/2022] [Indexed: 01/04/2023]
Abstract
Although pregnancy is generally contraindicated in advanced heart failure (AHF), successful pregnancies have been observed in patients with left ventricular assist devices (LVADs). The number of pregnancies in patients with LVADs is increasing, yet optimal management strategies remain undefined. Additionally, no successful pregnancies have been reported with the HeartMate 3 (HM3) (Abbott) LVAD. A systematic review of pregnancy in patients with LVADs was prepared utilizing 3 major scientific databases. We also present the first reported case of successful pregnancy and delivery in a patient supported by an HM3 LVAD. The systematic search yielded 95 results. After filtering to include only relevant citations, eight unique cases were identified. Cases were compared on the basis of several clinical factors. Although pregnancies supported by LVADs are medically complex, several cases of successful deliveries have been observed. Clinical management between cases, however, did vary significantly. Several areas requiring further study were identified.
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Affiliation(s)
- Adithya K Yadalam
- Department of Medicine, Emory University School of Medicine, Atlanta, GA..
| | - Bianca W Yoo
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA
| | - John P Horton
- Department of Obstetrics and Gynecology, Emory University School of Medicine, Atlanta, GA
| | - Iris Krishna
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Emory University School of Medicine, Atlanta, GA
| | - John D Vega
- Department of Surgery, Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, GA
| | - Kunal N Bhatt
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA
| | - Divya Gupta
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA
| | - Mahmoud H Abdou
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA
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Rubinstein G, Lotan D, Moeller CM, DeFilippis EM, Slomovich S, Oren D, Yuzefpolskaya M, Sayer G, Uriel N. Sex differences in patients undergoing heart transplantation and LVAD therapy. Expert Rev Cardiovasc Ther 2022; 20:881-894. [PMID: 36409479 DOI: 10.1080/14779072.2022.2149493] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Left ventricular assist device (LVAD) and heart transplantation (HT) are the two life-sustaining therapies that have revolutionized the management of end-stage heart failure (HF). Yet, significant sex differences exist with respect to their use and effects. AREAS COVERED This review summarizes sex differences in the utilization, outcomes, and complications of LVAD and HT. Particular emphasis is placed on leading clinical trials in the field, historical and recent large registries-based analyses, as well as contemporary technological and policy changes affecting these differences. EXPERT OPINION Women with advanced HF remain under-treated with guideline-directed medical therapy and are less likely to be referred for consideration for LVAD and HT. This remains true despite newer LVAD technology and the new heart transplant allocation system. Community outreach, education, as well as increased representation of women in clinical research may reduce inequities.
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Affiliation(s)
- Gal Rubinstein
- Division of Cardiology, Center of Advance Cardiac Care, Columbia University Irving Medical Center/New York-Presbyterian Hospital New York, New York, NY, USA
| | - Dor Lotan
- Division of Cardiology, Center of Advance Cardiac Care, Columbia University Irving Medical Center/New York-Presbyterian Hospital New York, New York, NY, USA
| | - Cathrine M Moeller
- Division of Cardiology, Center of Advance Cardiac Care, Columbia University Irving Medical Center/New York-Presbyterian Hospital New York, New York, NY, USA
| | - Ersilia M DeFilippis
- Division of Cardiology, Center of Advance Cardiac Care, Columbia University Irving Medical Center/New York-Presbyterian Hospital New York, New York, NY, USA
| | - Sharon Slomovich
- Division of Cardiology, Center of Advance Cardiac Care, Columbia University Irving Medical Center/New York-Presbyterian Hospital New York, New York, NY, USA
| | - Daniel Oren
- Division of Cardiology, Center of Advance Cardiac Care, Columbia University Irving Medical Center/New York-Presbyterian Hospital New York, New York, NY, USA
| | - Melana Yuzefpolskaya
- Division of Cardiology, Center of Advance Cardiac Care, Columbia University Irving Medical Center/New York-Presbyterian Hospital New York, New York, NY, USA
| | - Gabriel Sayer
- Division of Cardiology, Center of Advance Cardiac Care, Columbia University Irving Medical Center/New York-Presbyterian Hospital New York, New York, NY, USA
| | - Nir Uriel
- Division of Cardiology, Center of Advance Cardiac Care, Columbia University Irving Medical Center/New York-Presbyterian Hospital New York, New York, NY, USA
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Wolfe DS, Liu C, Alboucai J, Karten A, Mushi J, Yellin S, Berkowitz JL, Vega S, Felix N, Liaqat W, Kankaria R, Vorawandthanachai T, Bortnick AE. Maternal Outcomes in Women with Peripartum Cardiomyopathy versus Age and Race-Matched Peers in an Urban US Community. J Cardiovasc Dev Dis 2022; 9:250. [PMID: 36005414 PMCID: PMC9410188 DOI: 10.3390/jcdd9080250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 08/01/2022] [Accepted: 08/03/2022] [Indexed: 11/16/2022] Open
Abstract
Peripartum cardiomyopathy (PPCM) is idiopathic systolic congestive heart failure around pregnancy. Comparisons with matched controls are lacking. We investigated maternal characteristics and outcomes up to 12 months in a cohort admitted to Montefiore Health System in Bronx, New York 1999−2015 (n = 53 cases and n = 92 age and race-matched controls, >80% Black or Hispanic/Latina). Compared to peers, women with PPCM had more chronic hypertension (24.5% vs. 8.8%, p = 0.001), prior gestational hypertension (20.8% vs. 5.4%, p = 0.001), prior preeclampsia (17.0% vs. 3.3%, p = 0.001), familial dilated cardiomyopathy (5.7% vs. 0.0%, p = 0.04), smoking (15.1% vs. 2.2%, p = 0.001), lower summary socioeconomic scores (−4.12 (IQR −6.81, −2.13) vs. −1.62 (IQR −4.20, −0.74), p < 0.001), public insurance (67.9% vs. 29.3% p = 0.001), and frequent depressive symptoms. Women with PPCM were often admitted antepartum (34.0% vs. 18.5%, p = 0.001) and underwent Cesarean section (65.4% vs. 30.4%, p = 0.001), but had less preterm labor (27.3% vs. 51.1%, p = 0.001). Women were rarely treated with bromocriptine (3.8%), frequently underwent left ventricular assist device placement (9.4% and n = 2 with menorrhagia requiring transfusion and progesterone) or heart transplantation (3.8%), but there were no in-hospital deaths. In sum, women with PPCM had worse socioeconomic disadvantage and baseline health than matched peers. Programs addressing social determinants of health may be important for women at high risk of PPCM.
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Affiliation(s)
- Diana S. Wolfe
- Department of Obstetrics and Gynecology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY 10461, USA
- Maternal Fetal Medicine-Cardiology Joint Program, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY 10461, USA
| | - Christina Liu
- Department of Emergency Medicine, Woodhull Medical and Mental Health Center, Brooklyn, NY 11206, USA
| | - Jack Alboucai
- Department of Medicine, North Shore University Hospital, Manhasset, NY 11030, USA
| | - Ariel Karten
- Department of Medicine, Division of Cardiology, New York University Long Island School of Medicine, Mineola, NY 11501, USA
| | - Juliet Mushi
- Department of Obstetrics, Gynecology & Reproductive Sciences, Yale University Maternal Fetal Medicine, Greenwich Hospital, Greenwich, CT 06830, USA
| | - Shira Yellin
- Department of Medicine, Mount Sinai Health System, New York, NY 10029, USA
| | - Julia L. Berkowitz
- Department of Medicine, Brown University Warren Alpert Medical School, Providence, RI 02903, USA
| | - Shayna Vega
- Department of Obstetrics and Gynecology, Kaiser Permanente Oakland Medical Center, Oakland, CA 94611, USA
| | - Nicole Felix
- Department of Psychiatry and Human Behavior, Brown University Warren Alpert Medical School, Providence, RI 02903, USA
| | - Wasla Liaqat
- Department of Medicine, New York Health and Hospitals Jacobi Medical Center, Bronx, NY 10461, USA
| | - Rohan Kankaria
- Department of Medicine, Division of Cardiology, Albert Einstein College of Medicine, Bronx, NY 10461, USA
| | | | - Anna E. Bortnick
- Maternal Fetal Medicine-Cardiology Joint Program, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY 10461, USA
- Department of Medicine, Division of Cardiology, Albert Einstein College of Medicine, Bronx, NY 10461, USA
- Department of Medicine, Division of Geriatrics, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY 10461, USA
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