Pregnancy outcomes in women with significant valve disease: a systematic review and meta-analysis

Predicting adverse cardiac events using DEVI and CARPREG-I score in pregnant with valvular heart disease: External validation study from MPAC registry

BACKGROUND

While numerous risk assessment tools exist for pregnant women with valvular heart disease (VHD), validation studies assessing their performance in diverse settings are few. Such validation is crucial before applying these tools routinely in clinical practice.

OBJECTIVES

To validate and establish the clinical utility of two risk stratification tools - DEVI (VHD-specific tool) and CARPREG-I in predicting adverse cardiac events in pregnant women with VHD.

METHODS

This cohort study involved consecutive pregnancies complicated with VHD enrolled in the prospective Medical College Pregnancy and Cardiac (MPAC) registry from July 2016 to December 2019. Individual risk for adverse composite cardiac events was calculated using DEVI and CARPREG-I models. Performance was assessed through discrimination and calibration characteristics. Clinical utility was evaluated with decision curve analysis.

RESULTS

Of the 1029 pregnancies, 609 had VHD. Mitral regurgitation (67.2 %; 409/609) was most common; 11.5 % (70/609) experienced at least one component of the composite outcome. The area under the receiver operating characteristic curve was 0.747, with 95 % confidence intervals (CI) (0.685-0.809) for DEVI and 0.705 (95%CI 0.646-0.765) for CARPREG-I models. Calibration plots suggested that the DEVI score overestimates risk at higher probabilities, while the CARPREG-I score underestimates risk at most probabilities. Decision curve analysis demonstrated that both models were useful across predicted probability thresholds between 10 % and 60 %.

CONCLUSION

In this external validation study in pregnant women with VHD, both DEVI and CARPREG-I scores showed good discriminative ability and clinical utility across various probabilities. However, both models need recalibration to improve the agreement between the predicted and observed events.

Is Cardiac Surgery Safe During Pregnancy? A 40-Year Single-Institution Experience

BACKGROUND

Limited data exist to characterize maternal and fetal outcomes during pregnancy undergoing cardiac operations using cardiopulmonary bypass.

METHODS

A retrospective review was performed of all pregnant individuals who underwent cardiac surgery using cardiopulmonary bypass at a single center from 1978 to 2023. Descriptive statistical analysis was performed, with a median reported for continuous variables and incidence for dichotomous variables.

RESULTS

Twenty-nine pregnant patients with a median age of 28 years (interquartile range [IQR], 25-32 years) years underwent cardiac surgery using cardiopulmonary bypass at a median gestation of 25 weeks (IQR, 16-29 weeks). Surgery was performed in the first trimester for 3 patients (10%), second trimester for 16 (55%), and third trimester for 10 (35%). Procedures were emergent in 15 (52%) and urgent in 14 (48%). There was 1 (3%) maternal death 2 days after mechanical aortic valve thrombectomy and 5 (17%) fetal losses. Fourteen patients who underwent cardiac surgery using cardiopulmonary bypass with continuing pregnancy experienced a 29% fetal mortality rate, and 7 patients underwent delivery before surgery and experienced 14% fetal mortality. Among cases of fetal loss, surgery was performed at a median of 25 weeks (IQR, 21-26 weeks) compared with a median of 23 weeks (IQR, 20-29 weeks) in cases without fetal loss (P = .55).

CONCLUSIONS

Cardiac surgery during pregnancy was associated with low maternal mortality but significant fetal mortality. This single-institution series supports consideration of cesarean delivery before cardiopulmonary bypass procedures if the fetus is of a viable gestational age to minimize mortality.

Anesthetic Management of a Pregnant Patient With Mixed Aortic Valve Disease Undergoing Cesarean Section

Aortic stenosis is a condition with multiple etiologies that can remain clinically silent for years. The enhanced cardiovascular demands of pregnancy can unmask a previously undetected disease or worsen existing symptoms. Managing anesthesia in pregnant patients with cardiac valvular disease is a complex task that requires a coordinated, multidisciplinary approach. This case report presents a 28-year-old pregnant Hispanic patient with known severe aortic stenosis who was admitted to our hospital at 30 weeks of gestation for multidisciplinary management and delivery planning. Her only symptom was dyspnea, classified as NYHA class II. Upon admission, a transesophageal echocardiogram (TEE) revealed severe subvalvular aortic stenosis caused by a membrane and moderate aortic valve regurgitation with a preserved left ventricular ejection fraction.  Initially, a cesarean section was planned due to breech presentation. The procedure was scheduled for 34 weeks but postponed to 36 weeks of gestational age due to the patient's stable hemodynamic status. The anesthetic approach was a combined spinal-epidural technique that provided better hemodynamic stability and effective pain control and minimized the risk of broncho-aspiration and the maternal-fetal transfer of obstetric drugs associated with general anesthesia. Careful patient selection and continuous hemodynamic monitoring were essential to avoid complications and guarantee a successful outcome. This approach proved to be safe and effective for our patient. This case highlights the importance of a multidisciplinary team approach in managing pregnant patients with cardiac disease. It also demonstrated that combined spinal-epidural anesthesia is a safe and viable option for anesthesiologists caring for these patients.

Heart disease in pregnancy and adverse outcomes: an umbrella review

Background

Heart disease in pregnancy encompasses both congenital heart disease and maternal-acquired heart disease, both of which are associated with an increased risk of various adverse outcomes for mothers and their offspring.

Objective

The objective of the study was to review and summarize the evidence regarding the association between heart disease in pregnancy and adverse outcomes in mothers and their offspring.

Data sources

A comprehensive search was conducted in Embase, PubMed, Web of Science, and the Cochrane Database of Systematic Reviews from inception to March 2024. The protocol for this review was registered in PROSPERO (CRD42024519144).

Study eligibility criteria

This review included systematic reviews and meta-analyses that examined the association between heart disease in pregnancy and adverse outcomes for mothers and their offspring.

Study appraisal and synthesis methods

Data were independently extracted by two reviewers. The quality of the systematic reviews and meta-analyses was assessed using the A Measurement Tool to Assess Systematic Reviews 2 (AMSTAR2), while Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) was used to evaluate the strength of the evidence for each outcome.

Results

A total of 12 meta-analyses and systematic reviews were included, which documented 156 adverse outcomes for mothers and 65 adverse outcomes for offspring. Evidence was found for both primary and secondary adverse outcomes. Adverse outcomes for mothers were death, cardiac events (cardiac arrest, heart failure, surgery, arrhythmia, anesthesia or sedation, endocarditis, mitral regurgitation, myocardial infarction, NYHA III-IV, restenosis, syncope, and others), pulmonary events (respiratory failure, pulmonary edema, and respiratory support), embolism, cerebrovascular events, postpartum hemorrhage, arterial events, delivery mode, and hospital stay. Adverse outcomes for offspring were death, pregnancy loss, growth restriction, low birth weight, preterm birth, recurrence, and uncertainty. No publication bias was detected using Egger's test. The overall AMSTAR 2 confidence rating for the included meta-analyses and systematic reviews was moderate. The majority (55.3%) of the evidence evaluated by GRADE was of low quality, while the remaining outcomes were categorized as having "very low"-quality evidence.

Conclusion

Current evidence links heart disease during pregnancy to adverse maternal outcomes, including death and cardiac, pulmonary, and cerebrovascular events, as well as increased mortality risk for offspring. Many meta-analyses in this field have limitations that raise concerns about their validity, highlighting the need for high-quality prospective studies.

Cardiac Critical Care of the Cardio-Obstetric Patient

Cardiovascular disease (CVD) is the leading cause of pregnancy-related mortality in the United States, with an incidence that has increased from 7.2 to 32.9 fatalities per 100,000 live births in the last 3 decades. This trend underscores the potential for an increase in the volume of admissions to cardiac intensive care units (CICUs) in the peripartum period. While congestive heart failure remains at the forefront of maternal morbidity, other life-threatening conditions include myocardial infarction (MI), hypertensive emergencies, fatal arrhythmias such as ventricular fibrillation, venous thromboembolism, aortopathies, valvular dysfunction, cardiac arrest, and cardiogenic shock. The lack of standardized guidelines to facilitate management of these conditions highlights the significant gap in medical knowledge while caring for acutely ill pregnant women. Through this comprehensive review, we highlight the most common cardiac pathologies encountered in the obstetric population and their diagnosis and contemporary management in the cardiac intensive care unit.

Outcome reporting in cardio-obstetrics studies: A systematic review

BACKGROUND

Although considerable variation in the reporting and definition of outcomes in cardio-obstetrics studies is acknowledged, the extent of this variation has not been documented. The primary objective of this systematic review was to highlight this variation and inform the development of a Core Outcome Set for studies on Cardiac disease in Pregnancy (COSCarP).

METHODS

Medline, Embase, Web of Science and Cochrane Central databases were searched from 1980 to 2018 to identify all English-language publications on pregnancy and heart disease. Title/abstract screening and data extraction which included details on the study, patient population, and all reported outcomes, was performed in duplicate by 2 reviewers. As the aim of the review was to identify variation in outcome reporting, risk-of-bias assessment was not performed. The study protocol was registered on PROSPERO (CRD42016038218).

RESULTS

The final analysis included 422 cardio-obstetric studies. Maternal mortality or survival were reported in 232/422 studies, with inconsistency in terms of cause of death (all-cause [n = 65], cardiac [n = 55] or obstetric [n = 10]) or timeframe (ranging from in-hospital mortality [n = 11] to mortality 5 years following pregnancy). In 95/232 (41%) studies, the cause and timeframe were not specified. Similar inconsistencies in reporting and definitions were noted for outcomes such as heart failure (n = 298), perinatal loss (n = 296), fetal growth (n = 221), bleeding (n = 205), arrhythmias (n = 202), preterm birth (n = 191), thromboembolism (n = 153) and hypertensive disorders (n = 122). Functioning / life-impact and adverse effects of treatment were sparingly reported in published cardio-obstetric studies.

CONCLUSIONS

This systematic review hopes to create awareness among cardio-obstetrics teams about the inconsistencies in reporting and defining outcomes which makes it difficult to compare studies and perform meta-analyses. COSCarP which is being developed through international consensus between patients and care-providers will provide cardio-obstetrics teams with a minimal set of outcomes to be reported in future cardio-obstetrics studies.

Cardiac physiology and pathophysiology in pregnancy

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.

Impact of biological sex on valvular heart disease, interventions, and outcomes

Valvular heart disease (VHD) is common, affecting >14% of individuals aged >75, and is associated with morbidity, including heart failure and arrhythmia, and risk of early mortality. Increasingly, important sex differences are being found between males and females with VHD. These sex differences can involve the epidemiology, pathophysiology, presentation, diagnosis, and outcomes of the disease. Females are often disadvantaged, and female sex has been shown to be associated with delayed diagnosis and inferior outcomes in various forms of VHD. In addition, the unique pathophysiologic state of pregnancy is associated with increased risk for maternal and fetal morbidity and mortality in many forms of VHD. Therefore, understanding and recognizing these sex differences, and familiarity with the attendant risks of pregnancy and management of pregnant females with VHD, is of great importance for any primary care or cardiovascular medicine practitioner caring for the female patient. This review will outline sex differences in aortic, mitral, pulmonic, and tricuspid VHD, with particular focus on differences in pathophysiology, clinical presentation, and outcomes. In addition, the pathophysiology and management implications of pregnancy will be discussed.

Pregnancy-related maternal deaths due to cardiovascular diseases in Japan from 2010 to 2019: an analysis of maternal death exploratory committee data

OBJECTIVE

Cardiovascular disease (CVD) is the leading cause of maternal deaths in high-income countries. This study aimed to assess the characteristics of maternal deaths due to CVDs and the quality of care provided to patients, and to identify elements to improve maternal care in Japan.

METHODS

This descriptive study used the maternal death registration data of the Maternal Deaths Exploratory Committee of Japan between 2010 and 2019.

RESULTS

Of 445 eligible pregnancy-related maternal deaths, 44 (9.9%) were attributed to CVD. The most frequent cause was aortic dissection (18 patients, 40.9%), followed by peripartum cardiomyopathy (8 patients, 18.2%), and pulmonary hypertension (5 patients, 11.4%). In 31.8% of cases, cardiopulmonary arrest occurred within 30 min after initial symptoms. Frequent symptoms included pain (27.3%) and respiratory symptoms (27.3%), with 61.4% having initial symptoms during the prenatal period. 63.6% of the patients had known risk factors, with age ≥35 years (38.6％), hypertensive disorder (15.9%), and obesity (15.9%) being the most common. Quality of care was assessed as suboptimal in 16 (36.4%) patients. Cardiac risk assessment was insufficient in three patients with preexisting cardiac disease, while 13 patients had symptoms and risk factors warranting intensive monitoring and evaluation.

CONCLUSION

Aortic dissection was the leading cause of maternal death due to CVDs. Obstetrics care providers need to be familiar with cardiac risk factors and clinical warning signs that may lead to impending fatal cardiac events. Timely risk assessment, patient awareness, and a multidisciplinary team approach are key to improving maternal care in Japan.

Validation of Risk Stratification for Cardiac Events in Pregnant Women With Valvular Heart Disease

BACKGROUND

Most risk stratification tools for pregnant patients with heart disease were developed in high-income countries and in populations with predominantly congenital heart disease, and therefore, may not be generalizable to those with valvular heart disease (VHD).

OBJECTIVES

The purpose of this study was to validate and establish the clinical utility of 2 risk stratification tools-DEVI (VHD-specific tool) and CARPREG-II-for predicting adverse cardiac events in pregnant patients with VHD.

METHODS

We conducted a cohort study involving consecutive pregnancies complicated with VHD admitted to a tertiary center in a middle-income setting from January 2019 to April 2022. Individual risk for adverse composite cardiac events was calculated using DEVI and CARPREG-II models. Performance was assessed through discrimination and calibration characteristics. Clinical utility was evaluated with Decision Curve Analysis.

RESULTS

Of 577 eligible pregnancies, 69 (12.1%) experienced a component of the composite outcome. A majority (94.7%) had rheumatic etiology, with mitral regurgitation as the predominant lesion (48.2%). The area under the receiver-operating characteristic curve was 0.884 (95% CI: 0.844-0.923) for the DEVI and 0.808 (95% CI: 0.753-0.863) for the CARPREG-II models. Calibration plots suggested that DEVI score overestimates risk at higher probabilities, whereas CARPREG-II score overestimates risk at both extremes and underestimates risk at middle probabilities. Decision curve analysis demonstrated that both models were useful across predicted probability thresholds between 10% and 50%.

CONCLUSIONS

In pregnant patients with VHD, DEVI and CARPREG-II scores showed good discriminative ability and clinical utility across a range of probabilities. The DEVI score showed better agreement between predicted probabilities and observed events.

2023 HRS expert consensus statement on the management of arrhythmias during pregnancy

This international multidisciplinary expert consensus statement is intended to provide comprehensive guidance that can be referenced at the point of care to cardiac electrophysiologists, cardiologists, and other health care professionals, on the management of cardiac arrhythmias in pregnant patients and in fetuses. This document covers general concepts related to arrhythmias, including both brady- and tachyarrhythmias, in both the patient and the fetus during pregnancy. Recommendations are provided for optimal approaches to diagnosis and evaluation of arrhythmias; selection of invasive and noninvasive options for treatment of arrhythmias; and disease- and patient-specific considerations when risk stratifying, diagnosing, and treating arrhythmias in pregnant patients and fetuses. Gaps in knowledge and new directions for future research are also identified.

Reproductive Health in Congenital Heart Disease: Preconception, Pregnancy, and Postpartum

The prevalence of congenital heart disease (CHD) in pregnancy is rising due to the improved survival of patients with CHD into childbearing age. The profound physiological changes that occur during pregnancy may worsen or unmask CHD, affecting both mother and fetus. Successful management of CHD during pregnancy requires knowledge of both the physiological changes of pregnancy and the potential complications of congenital heart lesions. Care of the CHD patient should be based on a multidisciplinary team approach beginning with preconception counseling and continuing into conception, pregnancy, and postpartum periods. This review summarizes the published data, available guidelines and recommendations for the care of CHD during pregnancy.

Transthoracic Echocardiographic Assessment of the Heart in Pregnancy-a position statement on behalf of the British Society of Echocardiography and the United Kingdom Maternal Cardiology Society

Pregnancy is a dynamic process associated with profound hormonally mediated haemodynamic changes which result in structural and functional adaptations in the cardiovascular system. An understanding of the myocardial adaptations is important for echocardiographers and clinicians undertaking or interpreting echocardiograms on pregnant and post-partum women. This guideline, on behalf of the British Society of Echocardiography and United Kingdom Maternal Cardiology Society, reviews the expected echocardiographic findings in normal pregnancy and in different cardiac disease states, as well as echocardiographic signs of decompensation. It aims to lay out a structure for echocardiographic scanning and surveillance during and after pregnancy as well as suggesting practical advice on scanning pregnant women.

Does Delayed Fertility Explain the Rise in Comorbidities Among the Birthing Population?

Background: The increasing prevalence of preexisting health conditions among pregnant people is often attributed to the concurrent rise in maternal age. However, the link between advanced maternal age (AMA) and increases in chronic conditions among the birthing population has not been systematically documented at the population level. Materials and Methods: This retrospective population-based cohort study was based on linked hospitalization discharge and birth certificate data for live birth deliveries in California from 1991 to 2012. Decomposition techniques evaluated whether changes in the prevalence of selected preexisting health conditions during delivery (autoimmune conditions, chronic hypertension, cardiac disease, diabetes, and renal disease) were explained by population-level increases in maternal age. Analyses further adjusted for maternal education, plurality, insurance status, and availability of paternal information on the birth certificate. Results: Between 1991 and 2012, there were more than 11.5 million live birth deliveries in California. AMA (≥35 years) increased nearly 70% over this period. The prevalence of autoimmune conditions, chronic hypertension, diabetes, and renal disease rose among the birthing population, while cardiac disease declined. The prevalence of all conditions was higher for AMA, but changes in maternal age accounted for only 5.3%, 8.4%, 13.9%, and 0.4%, of the increase in autoimmune conditions, chronic hypertension, diabetes, and renal disease, respectively. Conclusion: While AMA was associated with higher rates of preexisting health conditions, it contributed little to the increase in autoimmune conditions, chronic hypertension, and diabetes and nothing to the rise in renal disease during childbirth.

Assessment and Prediction of Cardiovascular Contributions to Severe Maternal Morbidity

Severe maternal morbidity (SMM) refers to any unexpected outcome directly related to pregnancy and childbirth that results in both short-term delivery complications and long-term consequences to a women's health. This affects about 60,000 women annually in the United States. Cardiovascular contributions to SMM including cardiac arrest, arrhythmia, and acute myocardial infarction are on the rise, probably driven by changing demographics of the pregnant population including more women of extreme maternal age and an increased prevalence of cardiometabolic and structural heart disease. The utilization of SMM prediction tools and risk scores specific to cardiovascular disease in pregnancy has helped with risk stratification. Furthermore, health system data monitoring and reporting to identify and assess etiologies of cardiovascular complications has led to improvement in outcomes and greater standardization of care for mothers with cardiovascular disease. Improving cardiovascular disease-related SMM relies on a multipronged approach comprised of patient-level identification of risk factors, individualized review of SMM cases, and validation of risk stratification tools and system-wide improvements in quality of care. In this article, we review the epidemiology and cardiac causes of SMM, we provide a framework of risk prediction clinical tools, and we highlight need for organization of care to improve outcomes.

COVID-19 Pregnancies with Heart Disease: Challenges of Delivery

This case series of four cases of pregnancy with rheumatic heart disease with COVD-19 disease reports on the management of delivery and complications of heart disease with COVID-19, high-lighting the presentation, severity, delivery concerns, and clinical management with the maternal and fetal outcomes. Of the four full-term deliveries, one delivered normally, one instrumental delivery and two by cesarean section. All four required oxygen support post-delivery, 2/4 (50%) were transferred for intensive care unit (ICU) care, 1/4 (25%) required mechanical ventilation, 1/4 (25%) had postpartum hemorrhage, 1/4 (25%) had COVID related sepsis and received convalescent plasma therapy, and 2/4 (50%) received antiviral remdesivir. The most severe disease (COVID sepsis and ICU stay) was seen in patient of heart disease with COVID with preclampsia. All neonates tested SARS-CoV-2 negative, with one early neonatal death. All four mothers were discharged in stable condition of COVID and heart status. COVID-19 in cardiac disease pregnancies has increased rates of complications, oxygen, and ICU requirements than other pregnancies with COVID, requiring multidisciplinary team for intensive monitoring of intrapartum and postpartum period.

Role of MicroRNAs in Cardiac Disease with Stroke in Pregnancy

Pregnancy-related cardiovascular disease with stroke remains a considerable source of higher maternal morbidity and mortality occurs in periods of pregnancy, delivery, and postpartum. It is essential to counsel the mother before pregnancy by an expert cardiologist and obstetric team to discuss any event related to preexistent cardiac or past preeclampsia for estimation of maternal and fetal risks. In pregnancy, the cardiac state includes hypertensive disorders, ischemic heart disease, valvular disease, and postpartum stroke. The incidence of stroke is increasing in pregnancy, particularly in postpartum, and its strong relationship with hypertensive disorders of pregnancy (preeclampsia). The combined cardiologist and obstetrics team requires during pregnancy mainly due to the approach to the management of a cardiac disease that subsequently prevents stroke postpartum. Therefore, a general perception of cardiac disease during pregnancy, delivery, and postpartum should be a core knowledge extent for all cardiovascular and clinicians. Many studies provided linked that deregulation of microRNAs (miRNAs) in maternal circulation and placenta tissue may development of pregnancy complications including preeclampsia considered a diagnostic marker. The desire of this review provides a detailed outline of current knowledge and dealing in this field with strength on the physiological changes during pregnancy.

Managing Rheumatic Heart Disease in Pregnancy: A Practical Evidence-Based Multidisciplinary Approach

Rheumatic heart disease (RHD) remains a leading cause of mortality and morbidity in pregnant patients in low- to middle-income countries. Apart from the clinical challenges, these areas face poor infrastructure and resources to allow for early detection, with many women presenting to medical services for the first time when they deteriorate clinically during the pregnancy. The opportunity for preconception counselling and planning may thus be lost. It is ideal for all women to be seen before conception and risk-stratified according to their clinical state and pathology. The role of the cardio-obstetrics team has emerged over the past decade with the aim of a seamless transition to and from the appropriate levels of care during pregnancy. Severe symptomatic mitral and aortic valve stenoses portend the greatest risk to both mother and fetus. In mitral stenosis, beta-blockers are the cornerstone of therapy and only a small number of patients require balloon valvuloplasty. Regurgitant lesions mostly require diuretics alone for the treatment of heart failure. The mode of delivery is usually vaginal; caesarean section is performed in those with obstetrical indications or in cases with severe stenosis and a poor clinical state. The postpartum period presents a second high-risk period for maternal adverse events, with heart failure and arrhythmias being the most frequent. This review aims to provide a practical evidence-based multi-disciplinary approach to the management of women with RHD in pregnancy.

Cardiovascular and Obstetric Delivery Complications in Pregnant Women With Valvular Heart Disease

Women with valvular heart disease may be more likely to have adverse obstetric and cardiovascular complications during pregnancy. Most current recommendations focus on stenotic lesions with less guidance regarding regurgitant lesions. We aimed to compare adverse events at delivery for women with various stenotic and regurgitant valvular diseases. We used the 2016 to 2018 National Inpatient Sample data to compare demographics, comorbidities, and obstetric and cardiovascular complications during delivery hospitalizations. After adjusting for clinical and socioeconomic factors, logistic regression was performed to investigate associations between valvular disease and outcomes. Among >11.2 million deliveries, 20,349 were in women with valvular disease. Women with valvular disease were older, had longer length of stays, and higher costs associated with delivery. They had higher prevalence of underlying cardiovascular comorbidities compared with women without valvular disease (hypertension: 5.1 vs 0.25%; pulmonary hypertension: 7.0 vs <0.1%). At delivery, they had higher adjusted odds of obstetric events including preeclampsia and/or eclampsia (aOR 1.9 [1.8 to 2.2]) and intrapartum/postpartum hemorrhage (aOR 1.4 [1.2 to 1.6]), and cardiovascular events including peripartum cardiomyopathy (aOR 65 [53 to 78]), pulmonary edema (aOR 17 [13 to 22]), acute ischemic heart disease (aOR 19 [12 to 30]) and arrhythmias (aOR 22 [19 to 27]). There were valve lesion-specific differences in the magnitude of risk but both stenotic and regurgitant lesions were associated with elevated risk of cardiovascular complications. In conclusion, pregnant women with stenotic and regurgitant valvular disease have a greater burden of cardiovascular comorbidities and increased odds of obstetric and cardiovascular events at delivery. These women may benefit from specialized care from a Cardio-Obstetrics team.

Cardiac Complications in Pregnant Women With Isolated Mitral Stenosis and Their Association With Echocardiographic Changes During Pregnancy

In women with mitral stenosis (MS), mitral valve gradients and right ventricular systolic pressure (RVSP) can increase in response to the physiologic stress of pregnancy. The prognostic significance of these echocardiographic changes has not been well studied. Pregnancy outcomes and serial echocardiograms were collected in women with MS prospectively recruited as part of a larger study on pregnancy outcomes. Third trimester echocardiograms were compared with baseline echocardiograms. Changes in mitral valve area (MVA), transmitral mean gradient (MG), and RVSP during pregnancy and their relationship to adverse cardiac events (CE) were examined. Fifty-six pregnancies in 47 women with MS were included. The MVA did not change during pregnancy (1.6 ± 0.6 cm² at baseline vs 1.7 ± 0.6 cm² in the third trimester, p = 0.46). There was an increase in the MG (8 ± 3 vs 11 ± 6 mm Hg, p <0.001) and the RVSP (39 ± 14 vs 47 ± 20 mm Hg, p <0.001) during the third trimester. Adverse CE occurred in 45% (25/56) of pregnancies. CE were associated with baseline MG>10 mm Hg, baseline RVSP >40 mm Hg, third-trimester MG>10 mm Hg, and RVSP >40 mm Hg. Women with mitral valve MG ≤10 mm Hg who had a normal RVSP at baseline and in the third trimester were at lowest risk for CE (11%) with a negative predictive value of 89%. In conclusion, baseline echocardiographic assessment of MS severity as well as changing echocardiographic parameters during pregnancy can help identify women at risk for cardiac complications during pregnancy.

Long-term survival in patients with isolated pulmonary valve stenosis: a not so benign disease?

Background and objectives

During the last decades, the survival rates in patients with congenital heart disease have increased dramatically, particularly in patients with complex heart malformations. However, the survival in patients with simple defects is still unknown. We aimed to determine the characteristics and the risk of mortality in patients with isolated pulmonary valve stenosis (PS).

Methods

Swedish inpatient, outpatient and cause of death registries were used to identify patients born between 1970 and 2017 with a diagnosis of PS, without any other concomitant congenital heart lesion. For each patient with PS, 10 control individuals without congenital heart disease were matched by birth year and sex from the total population registry. We used median-unbiased method and Kaplan-Meier survival analysis to examine the risk of mortality.

Results

We included 3910 patients with PS and 38 770 matched controls. The median age of diagnosis of PS was 0.7 years (IQR 0.3–7.0). During a median follow-up of 13.5 years (IQR 6.5–23.5), 88 patients with PS and 192 controls died; 500 patients with PS (12%) underwent at least one transcatheter or surgical valve intervention. The overall mortality rate was significantly higher in patients with PS compared with matched controls (HR 4.67, 95% CI 3.61 to 5.99, p=0.001). Patients with an early diagnosis of PS (0–1 year) had the highest risk of mortality (HR 10.99, 95% CI 7.84 to 15.45).

Conclusions

In this nationwide, register-based cohort study, we found that the risk of mortality in patients with PS is almost five times higher compared with matched controls. Patients with an early diagnosis of PS appears to be the most vulnerable group and the regular follow-up in tertiary congenital heart units may be the key to prevention.

Canadian Cardiovascular Society: Clinical Practice Update on Cardiovascular Management of the Pregnant Patient

The number of women of childbearing age with cardiovascular disease (CVD) is growing due to increased survival of children with congenital heart disease (CHD). More women are also becoming pregnant at an older age, which is associated with increased co-morbidities including hypertension, diabetes and acquired CVD. Over the last decade the field of cardio-obstetrics has significantly advanced with the development of multidisciplinary cardio-obstetric programs (COPs) to address the increasing burden of CVD in pregnancy. With the introduction of formal COPs, pregnancy outcomes in women with heart disease have improved. COPs provide preconception counseling, antenatal and postpartum cardiac surveillance, labor and delivery planning. Pre-pregnancy counseling by a COP should be offered to women with suspected CVD who are of child bearing age. In those women who present while pregnant, counseling should be performed by a COP as early as possible in pregnancy. The purpose of counseling is to reduce the risk of pregnancy to the mother and fetus whenever possible. This is done through accurate maternal and fetal risk stratification, optimizing cardiac lesions, reviewing safety of medications in pregnancy, and making a detailed plan for the pregnancy, labor and delivery. This Clinical Practice Update highlights the COP approach to pre-pregnancy counseling, risk stratification, and management of commonly encountered cardiac conditions through pregnancy. We highlight "red flags" that should trigger a more timely assessment by a COP. We also describe the approach to some of the cardiac emergencies that the care provider may encounter in a pregnant woman.

Peripartum considerations for women with cardiac disease

PURPOSE OF REVIEW

The aim of this review of cardiac disease in pregnancy is to delineate current best practices and highlight emerging themes in the literature.

RECENT FINDINGS

Cardiovascular disease is the leading cause of death among pregnant women in the United States. Many clinicians and institutions have developed care pathways to approach care in these high-risk patients including highly coordinated multidisciplinary teams. The diagnosis of pulmonary hypertension is the greatest risk factor for an adverse event in pregnant women. Vaginal delivery, with good neuraxial anesthesia, is usually the preferred mode of delivery in women with cardiac disease, although the rate of cesarean delivery is higher among women with heart disease.

SUMMARY

The leading cause of morbidity and mortality in pregnant women is cardiac disease. Preconception counseling is useful for optimizing patients for pregnancy and setting appropriate expectations about care and outcomes. Ensuring that women are cared for in centers with appropriate multidisciplinary resources is key for improving outcomes for cardio-obstetric patients.

Risk Associated With Valvular Regurgitation During Pregnancy

BACKGROUND

Pregnancies in women with regurgitant valve lesions are generally considered low risk, but this has not been well studied.

OBJECTIVES

This study determined the frequency of adverse cardiac events (CEs) in pregnant women with moderate or severe regurgitant valve lesions.

METHODS

Maternal and fetal outcomes in women with moderate or severe chronic valve regurgitation enrolled in a prospective multicenter study on pregnancy outcomes were examined. Adverse CEs included heart failure, sustained arrhythmias, cardiac arrest, or death. A multivariate logistic regression model was used to identify determinants of CEs in women at the highest risk.

RESULTS

Outcomes of 430 pregnancies in women with moderate or severe regurgitant lesions were examined: 145 with mitral regurgitation (MR), 101 with pulmonary regurgitation (PR), 71 with multivalve disease, 73 with tricuspid regurgitation (TR), and 40 with aortic regurgitation (AR). Most women had associated congenital or acquired heart disease. Adverse CEs occurred in 13% of pregnancies: 27% of pregnancies with multivalve disease; 15% with MR; 15% with TR; 5% with AR; and 3% with PR. Maternal mortality was rare. In women with MR, TR, or multivalve disease (n = 289), left ventricular systolic dysfunction (p = 0.001), pulmonary hypertension (p = 0.005), and cardiac events before pregnancy (p < 0.001) were important determinants of CEs during pregnancy.

CONCLUSIONS

Women with AR and PR are at low risk for cardiac complications during pregnancy. While many women with MR, TR, and multivalve regurgitation do well during pregnancy, additional clinical variables help stratify those at highest risk. This new information will enhance the quality and precision of preconception counseling and pregnancy planning.

2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

This executive summary of the valvular heart disease guideline provides recommendations for clinicians to diagnose and manage valvular heart disease as well as supporting documentation to encourage their use.

METHODS

A comprehensive literature search was conducted from January 1, 2010, to March 1, 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, Cochrane, Agency for Healthcare Research and Quality Reports, and other selected database relevant to this guideline. Structure: Many recommendations from the earlier valvular heart disease guidelines have been updated with new evidence and provides newer options for diagnosis and treatment of valvular heart disease. This summary includes only the recommendations from the full guideline which focus on diagnostic work-up, the timing and choice of surgical and catheter interventions, and recommendations for medical therapy. The reader is referred to the full guideline for graphical flow charts, text, and tables with additional details about the rationale for and implementation of each recommendation, and the evidence tables detailing the data considered in developing these guidelines.

Schwangerschaftsverlauf bei maternalen Herzklappenerkrankungen

Dank des medizinischen Fortschritts erreichen immer mehr Frauen mit angeborenen Herzklappenfehlern das fortpflanzungsfähige Alter. Angesichts der erheblichen hämodynamischen Veränderungen während einer Schwangerschaft stellt sich die Frage, welche Risiken eine Gravidität für die betroffenen Frauen sowie die Feten darstellt. Kanadische Wissenschaftler beschäftigten sich mit dieser Thematik im Rahmen einer Metaanalyse.

Percutaneous balloon mitral valvotomy during pregnancy: A systematic review and meta-analysis

INTRODUCTION

The objective of this study was to systematically review the maternal and fetal outcomes in pregnant women who underwent percutaneous balloon mitral valvuloplasty (PBMV) during pregnancy.

MATERIAL AND METHODS

A search was conducted on MEDLINE and Embase databases to identify studies published between 2000 and 2018 that reported on maternal and fetal outcomes following PBMV performed in pregnancy. Randomized controlled trials, cohort studies, case-control studies, cross-sectional studies and case series with four or more pregnancies in which PBMV was performed during pregnancy were included. Reference lists from relevant articles were also hand-searched for relevant citations. A successful procedure was defined as one where there was a reported improvement in the valve area or reduction in the mitral valve gradient. A random effects model was used to derive pooled estimates of various outcomes and the final estimates were reported as percentages with a 95% confidence interval (95% CI).

RESULTS

Twenty-one observational studies reporting 745 pregnancies were included in the review, all of them having reported outcomes without a comparison group. Most of the studies fell into the low-risk category as determined using the Joanna Briggs Institute (JBI) critical appraisal checklist for case series. Most of the studies (86%) were reported from low- to middle-income countries and PBMV was mostly performed during the second trimester of pregnancy. Forty-three procedures (5.7%) were unsuccessful, nearly half (n = 19) of them reported among women with the severe subvalve disease (Wilkins subvalve score 3 or more). There were 11 maternal deaths among those with suboptimal valve anatomy (severe subvalve disease or Wilkin score >8). Mitral regurgitation was the most common cardiac complication (12.7%; 95% CI 7.3%-19.1%), followed by restenosis (2.4%; 95% CI 0.02%-7.2%). Pooled incidence of cesarean section was 12.1% (95% CI 3.6%-23.8%), preterm delivery 3.9% (95% CI 0.6%-9.0%), stillbirth 0.9% (95%CI 0.2%-2.2%) and low birthweight 5.4% (95% CI 0.2%-14.7%).

CONCLUSIONS

PBMV may be an effective and safe procedure for optimizing outcomes in pregnant women with mitral stenosis in the absence of severe subvalve disease.

Vaginal delivery in a patient with severe aortic stenosis under epidural analgesia, a case report

BACKGROUND

A history of previous cardiac disease increases the maternal mortality risk by as much as 100%. There is no consensus on the absolute contraindications to vaginal delivery in valvular heart disease, but central regional anesthesia is traditionally considered contraindicated in patients with severe aortic stenosis.

CASE PRESENTATION

A 29-year-old primigravid woman with severe aortic stenosis was admitted to the obstetrics department for programmed labor induction. With epidural anesthesia and mini-invasive hemodynamic monitoring labor and operative vaginal delivery were well tolerated, and hemodynamic stability was always maintained.

CONCLUSIONS

Epidural analgesia and oxytocin induction are possible for the labor management of parturients with severe aortic stenosis given that continuous non-invasive followed by invasive hemodynamic monitoring can be provided and given the absence of any obstetric or cardiologic contraindications and the strong will of the patient.