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Hodgson NR, Lindor RA, Monas J, Heller K, Kishi P, Thomas A, Petrie C, Querin LB, Urumov A, Majdalany DS. Pregnancy-Related Heart Disease in the Emergency Department. J Pers Med 2025; 15:148. [PMID: 40278327 PMCID: PMC12028907 DOI: 10.3390/jpm15040148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2025] [Revised: 04/01/2025] [Accepted: 04/05/2025] [Indexed: 04/26/2025] Open
Abstract
Pregnancy induces significant physiologic changes that impact the cardiovascular system, potentially exacerbating pre-existing cardiac conditions or precipitating new illnesses. Pregnant patients with cardiac emergencies pose unique challenges, as standard interventions may pose risks to the developing fetus. This article aims to enhance emergency physicians' confidence in managing pregnancy-related cardiac emergencies by providing a structured approach to initial evaluation and stabilization. We review eight common categories of pregnancy-associated cardiac illness: gestational hypertension and pre-eclampsia, cardiomyopathy, arrhythmias, valvular disease, aortopathies, congenital heart disease and pulmonary hypertension, coronary disease, and anticoagulation-related complications. For each condition, we summarize relevant pregnancy-specific pathophysiology and outline evidence-based, personalized emergency management strategies.
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Affiliation(s)
- Nicole R. Hodgson
- Mayo Clinic Department of Emergency Medicine, Phoenix, AZ 85054, USA; (J.M.); (K.H.); (P.K.); (A.T.); (C.P.); (L.B.Q.); (A.U.)
| | - Rachel A. Lindor
- Mayo Clinic Department of Emergency Medicine, Rochester, MN 55905, USA;
| | - Jessica Monas
- Mayo Clinic Department of Emergency Medicine, Phoenix, AZ 85054, USA; (J.M.); (K.H.); (P.K.); (A.T.); (C.P.); (L.B.Q.); (A.U.)
| | - Kimberly Heller
- Mayo Clinic Department of Emergency Medicine, Phoenix, AZ 85054, USA; (J.M.); (K.H.); (P.K.); (A.T.); (C.P.); (L.B.Q.); (A.U.)
| | - Patrick Kishi
- Mayo Clinic Department of Emergency Medicine, Phoenix, AZ 85054, USA; (J.M.); (K.H.); (P.K.); (A.T.); (C.P.); (L.B.Q.); (A.U.)
| | - Aaron Thomas
- Mayo Clinic Department of Emergency Medicine, Phoenix, AZ 85054, USA; (J.M.); (K.H.); (P.K.); (A.T.); (C.P.); (L.B.Q.); (A.U.)
| | - Cody Petrie
- Mayo Clinic Department of Emergency Medicine, Phoenix, AZ 85054, USA; (J.M.); (K.H.); (P.K.); (A.T.); (C.P.); (L.B.Q.); (A.U.)
| | - Lauren B. Querin
- Mayo Clinic Department of Emergency Medicine, Phoenix, AZ 85054, USA; (J.M.); (K.H.); (P.K.); (A.T.); (C.P.); (L.B.Q.); (A.U.)
| | - Andrej Urumov
- Mayo Clinic Department of Emergency Medicine, Phoenix, AZ 85054, USA; (J.M.); (K.H.); (P.K.); (A.T.); (C.P.); (L.B.Q.); (A.U.)
| | - David S. Majdalany
- Mayo Clinic Department of Cardiovascular Diseases, Phoeniz, AZ 85054, USA
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Paul GJ, Princy SA, Anju S, Keepanasseril A. Predicting adverse cardiac events using DEVI and CARPREG-I score in pregnant with valvular heart disease: External validation study from MPAC registry. J Cardiol 2025:S0914-5087(25)00095-4. [PMID: 40139434 DOI: 10.1016/j.jjcc.2025.03.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2024] [Revised: 03/14/2025] [Accepted: 03/19/2025] [Indexed: 03/29/2025]
Abstract
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.
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Affiliation(s)
- Gnanaraj Justin Paul
- Institute of Cardiology, Rajiv Gandhi Government General Hospital, Madras Medical College, Parktown, Chennai, Tamil Nadu, India.
| | - Steaphen Anne Princy
- Department of Cardiology, Tamil Nadu Government Multi Super-Speciality Hospital, Omandurar Government Estate, Anna Salai, Chennai, Tamil Nadu, India
| | - Surendran Anju
- Institute of Cardiology, Rajiv Gandhi Government General Hospital, Madras Medical College, Parktown, Chennai, Tamil Nadu, India
| | - Anish Keepanasseril
- Departments of Obstetrics & Gynaecology, Jawaharlal Institute of Post-graduate Medical Education & Research (JIPMER), Puducherry, India
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Delhomme C, Suc G, Thuillier C, Ducrocq G, Barral T, Brochet E, Himbert D, Bourgeois-Moine A, Iung B, Urena M. Mitral Transcatheter Edge-to-Edge Repair in a Pregnant Woman: Procedure and Pregnancy Outcomes. JACC Case Rep 2025; 30:102995. [PMID: 40054921 PMCID: PMC11911892 DOI: 10.1016/j.jaccas.2024.102995] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2024] [Revised: 10/07/2024] [Accepted: 10/10/2024] [Indexed: 03/20/2025]
Abstract
Secondary mitral regurgitation (MR) associated with left ventricular dysfunction carries a high risk of acute heart failure during pregnancy because of associated hemodynamic changes. Mitral transcatheter edge-to-edge repair (TEER) is currently recommended for symptomatic patients with secondary MR; however, no evidence exists on the use of this therapy in pregnancy. We present a case of secondary MR in a pregnant woman with dilated cardiomyopathy. She was successfully treated with TEER with minimal use of fluoroscopy (35 seconds). This is the first case to our knowledge of mitral TEER during pregnancy described in the literature, suggesting feasibility and safety of this procedure.
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Affiliation(s)
- Clémence Delhomme
- Department of Cardiology, Bichat Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France.
| | - Gaspard Suc
- Department of Cardiology, Bichat Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France; INSERM U 1148, Paris, France; University of Paris Cité, Paris, France
| | - Claire Thuillier
- Department of Gynecology and Obstetrics, Bichat Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France; University of Paris Cité, Paris, France
| | - Grégory Ducrocq
- Department of Cardiology, Bichat Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France; INSERM U 1148, Paris, France; University of Paris Cité, Paris, France
| | - Tiphaine Barral
- Department of Gynecology and Obstetrics, Bichat Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Eric Brochet
- Department of Cardiology, Bichat Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Dominique Himbert
- Department of Cardiology, Bichat Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Agnès Bourgeois-Moine
- Department of Gynecology and Obstetrics, Bichat Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Bernard Iung
- Department of Cardiology, Bichat Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France; INSERM U 1148, Paris, France; University of Paris Cité, Paris, France
| | - Marina Urena
- Department of Cardiology, Bichat Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France; INSERM U 1148, Paris, France; University of Paris Cité, Paris, France
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Ong JYS, Yap JJY, Choolani M, Poh KK, Dashraath P, Low TT. Cardiovascular-obstetric state-of-the-art review: pulmonary hypertension in pregnancy. Singapore Med J 2025; 66:130-140. [PMID: 40116059 PMCID: PMC11991071 DOI: 10.4103/singaporemedj.smj-2024-198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2024] [Accepted: 02/04/2025] [Indexed: 03/23/2025]
Abstract
ABSTRACT Pulmonary hypertension in pregnancy has been associated with negative maternal and fetal outcomes over the past decades. With the emergence of novel treatment modalities, morbidity and mortality of women who have pulmonary hypertension in pregnancy have improved. In this review, we aim to explore the contemporary updates in the management of pre-capillary and post-capillary pulmonary hypertension in pregnancy.
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Affiliation(s)
- Joy Yi Shan Ong
- Department of Cardiology, National University Heart Centre Singapore, Singapore
| | - Jeannie Jing Yi Yap
- Department of Obstetrics and Gynaecology, National University Hospital, Singapore
| | - Mahesh Choolani
- Department of Obstetrics and Gynaecology, National University Hospital, Singapore
- Department of Obstetrics and Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Kian-Keong Poh
- Department of Cardiology, National University Heart Centre Singapore, Singapore
| | - Pradip Dashraath
- Department of Obstetrics and Gynaecology, National University Hospital, Singapore
| | - Ting-Ting Low
- Department of Cardiology, National University Heart Centre Singapore, Singapore
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Jahangiri M, Thilaganathan B. Is Cardiac Surgery Safe During Pregnancy? Ann Thorac Surg 2025; 119:509-512. [PMID: 39216542 DOI: 10.1016/j.athoracsur.2024.08.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2024] [Accepted: 08/10/2024] [Indexed: 09/04/2024]
Affiliation(s)
- Marjan Jahangiri
- Department of Cardiac Surgery, St. George's Hospital, University of London, London, United Kingdom.
| | - Basky Thilaganathan
- Department of Fetal Medicine, St. George's Hospital, University of London, London, United Kingdom
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Sajjadieh Khajouei A, Tavana A, Bahrami P, Movahedi M, Mirshafiee S, Behjati M. Pregnancy outcomes in women with mitral valve stenosis: 10-year experience of a tertiary care center. Arch Gynecol Obstet 2025; 311:229-236. [PMID: 39960518 PMCID: PMC11890220 DOI: 10.1007/s00404-024-07900-9] [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: 08/17/2024] [Accepted: 12/14/2024] [Indexed: 03/09/2025]
Abstract
INTRODUCTION Mitral stenosis (MS) is recognized as one of the most common cardiovascular diseases during pregnancy and can result in adverse outcomes including maternal and fetal mortality if not diagnosed and treated in a timely manner. This study aimed to investigate the pregnancy outcomes of women with MS who were treated at the cardio-obstetric clinic in Alzahra Hospital, Isfahan, from 2011 to 2020. METHODS A total of 81 pregnant women diagnosed with MS were selected for the study. Their demographic and clinical data, along with echocardiography information-including systolic pulmonary artery pressure (SPAP), severity of MS, and NYHA class-were monitored throughout pregnancy. Additionally, the maternal and fetal outcomes were examined. RESULTS Among the participants, 38.3% were diagnosed with progressive MS, 56.8% exhibited severe stenosis, and 4.9% presented with very severe stenosis. Prior to pregnancy, no cases were classified as NYHA class 3 or 4. However, during the first trimester, six patients (7.4%) were classified as NYHA class 3. In the second trimester, 23 patients (28.4%) were in class 3, and 1 patient (1.2%) was classified as class 4. In the third trimester, 24 cases (29.6%) were in class 3, and 14 cases (17.3%) were in class 4. Notably, significant changes in NYHA class were observed throughout pregnancy (P < 0.001). Furthermore, 16% of participants required percutaneous balloon mitral commissurotomy, highlighting the severity of their condition. Additionally, 2.5% experienced decompensated heart failure and another 2.5% developed arrhythmia after delivery. Unfortunately, there was one case (1.2%) of mortality due to complications from MS. The study also documented one stillbirth (1.2%), 11 cases (13.6%) of spontaneous abortion, 17 cases (21%) of induced abortion, six cases (7.4%) of birth anomalies, three cases (3.7%) of prematurity, and four cases (4.9%) of intrauterine growth restriction, underscoring the critical need for careful management. CONCLUSION The results of the study suggest that cardiac function in women diagnosed with MS typically declines during pregnancy. Furthermore, even with optimal treatments, certain complications may still arise.
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Affiliation(s)
- Amirreza Sajjadieh Khajouei
- Department of Internal Medicine, Al Zahra Hospital, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Azar Tavana
- Department of Internal Medicine, Al Zahra Hospital, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Parvin Bahrami
- Department of Internal Medicine, Al Zahra Hospital, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Minoo Movahedi
- Department of Internal Medicine, Al Zahra Hospital, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Shayan Mirshafiee
- Department of Cardiology, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohaddeseh Behjati
- Cardiac Rehabilitation Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran.
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Ambari AM, Qhabibi FR, Desandri DR, Dwiputra B, Baravia PA, Makes IK, Radi B. Unveiling the Group A Streptococcus Vaccine-Based L-Rhamnose from Backbone of Group A Carbohydrate: Current Insight Against Acute Rheumatic Fever to Reduce the Global Burden of Rheumatic Heart Disease. F1000Res 2025; 13:132. [PMID: 39959434 PMCID: PMC11829149 DOI: 10.12688/f1000research.144903.3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/22/2025] [Indexed: 02/18/2025] Open
Abstract
Group A Streptococcus (GAS) is a widely distributed bacterium that is Gram-positive and serves as the primary cause of acute rheumatic fever (ARF) episodes. Rheumatic heart disease (RHD) is a sequela resulting from repeated ARF attacks which are also caused by repeated GAS infections. ARF/RHD morbidity and mortality rates are incredibly high in low- and middle-income countries. This is closely related to poor levels of sanitation which causes the enhanced incidence of GAS infections. Management of carditis in RHD cases is quite challenging, particularly in developing countries, considering that medical treatment is only palliative, while definitive treatment often requires more invasive procedures with high costs. Preventive action through vaccination against GAS infection is one of the most effective steps as a solution in reducing RHD morbidity and mortality due to curative treatments are expensive. Various developments of M-protein-based GAS vaccines have been carried out over the last few decades and have recently begun to enter the clinical stage. Nevertheless, this vaccination generates cross-reactive antibodies that might trigger ARF assaults as a result of the resemblance between the M-protein structure and proteins found in many human tissues. Consequently, the development of a vaccine utilizing L-Rhamnose derived from the poly-rhamnose backbone of Group A Carbohydrate (GAC) commenced. The L-Rhamnose-based vaccine was chosen due to the absence of the Rhamnose biosynthesis pathway in mammalian cells including humans thus this molecule is not found in any body tissue. Recent pre-clinical studies reveal that L-Rhamnose-based vaccines provide a protective effect by increasing IgG antibody titers without causing cross-reactive antibodies in test animal tissue. These findings demonstrate that the L-Rhamnose-based vaccine possesses strong immunogenicity, which effectively protects against GAS infection while maintaining a significantly higher degree of safety.
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Affiliation(s)
- Ade Meidian Ambari
- Cardiovascular Prevention and Rehabilitation Department, National Cardiovascular Center Hospital Harapan Kita, Jakarta, Jakarta, 11420, Indonesia
- Cardiology and Vascular Department, Faculty of Medicine, University of Indonesia, Jakarta, Jakarta, 10430, Indonesia
| | - Faqrizal Ria Qhabibi
- Research Assistant, National Cardiovascular Center Hospital Harapan Kita, Jakarta, Jakarta, 11420, Indonesia
| | - Dwita Rian Desandri
- Cardiovascular Prevention and Rehabilitation Department, National Cardiovascular Center Hospital Harapan Kita, Jakarta, Jakarta, 11420, Indonesia
- Cardiology and Vascular Department, Faculty of Medicine, University of Indonesia, Jakarta, Jakarta, 10430, Indonesia
| | - Bambang Dwiputra
- Cardiovascular Prevention and Rehabilitation Department, National Cardiovascular Center Hospital Harapan Kita, Jakarta, Jakarta, 11420, Indonesia
- Cardiology and Vascular Department, Faculty of Medicine, University of Indonesia, Jakarta, Jakarta, 10430, Indonesia
| | - Pirel Aulia Baravia
- Cardiovascular Prevention and Rehabilitation Department, Dr. Saiful Anwar General Hospital, Malang, East Java, 65122, Indonesia
| | - Indira Kalyana Makes
- Research Assistant, National Cardiovascular Center Hospital Harapan Kita, Jakarta, Jakarta, 11420, Indonesia
| | - Basuni Radi
- Cardiovascular Prevention and Rehabilitation Department, National Cardiovascular Center Hospital Harapan Kita, Jakarta, Jakarta, 11420, Indonesia
- Cardiology and Vascular Department, Faculty of Medicine, University of Indonesia, Jakarta, Jakarta, 10430, Indonesia
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Chen Y, Wang L, Ma D, Cui Z, Liu Y, Pang Q, Jiang Z, Gao Z. Research on rheumatic heart disease from 2013 to early 2024: a bibliometric analysis. J Cardiothorac Surg 2024; 19:659. [PMID: 39702478 DOI: 10.1186/s13019-024-03175-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2024] [Accepted: 12/01/2024] [Indexed: 12/21/2024] Open
Abstract
OBJECTIVES The aim of this bibliometric analysis was to highlight potential future areas for the practical application of research on rheumatic heart disease (RHD), considering past and current research efforts. METHODS A systematic search was conducted in the WoSCC to find articles and reviews focused on RHD published between 2013 and 2024. Microsoft Excel 2019 was used to chart the annual productivity of research relevant to RHD, while ArcGIS (version 10.8) was employed to visualize the global distribution of publications. Analysis tools such as CiteSpace (version 6.1.R6) and VOSviewer (version 1.6.18) were utilized to identify the most prolific countries or regions, authors, journals, and resource-, intellectual-, and knowledge-sharing in RHD research, and to perform co-citation analysis of references and keywords. Additionally, the Bibliometrix R Package was used to analyze topic dynamics. RESULTS From the search, a total of 2,428 publications were retrieved. In terms of countries or regions, the United States was the most productive country (566, 23.31%). As for institutions, most publications have been contributed by the University of Cape Town (149, 6.14%). Regarding authors, Jonathan R. Carapetis produced the most published works, and he received the most co-citations. The most prolific journal was identified as the International Journal of Cardiology (70, 2.88%). The study published in Circulation received the most co-citations. Keywords with ongoing strong citation bursts included "surgical treatment" and "valvular heart disease". CONCLUSION Despite the rapid advancements in the field of RHD research, future efforts should prioritize strengthening collaboration among national institutions to facilitate information dissemination. Current research on RHD mainly focuses on prognosis of patients. While, the emerging research trends in RHD encompass treatment strategies for complications, including atrial fibrillation (AF), heart failure (HF), and infective endocarditis, as well as screening strategies for RHD and surgical interventions for patients with rheumatic mitral valve disease.
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Affiliation(s)
- Yifan Chen
- Department of Cardiology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, 100091, China
| | - Liuding Wang
- Department of Neurology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, 100091, China
| | - Dan Ma
- Department of Cardiology, Suzhou Branch of Xiyuan Hospital, China Academy of Chinese Medical Sciences, Suzhou, 215009, China
| | - Zhijie Cui
- Department of Cardiology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, 100091, China
| | - Yanjiao Liu
- Graduate School, Beijing University of Chinese Medicine, Beijing, 100029, China
| | - Qinghua Pang
- Graduate School, Beijing University of Chinese Medicine, Beijing, 100029, China
| | - Zhonghui Jiang
- Department of Cardiology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, 100091, China.
| | - Zhuye Gao
- Department of Cardiology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, 100091, China.
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Yang JM, Tchakerian N, Silversides CK, Siu SC, Spitzer RF, Kosgei W, Okun N, Lumsden R, D’Souza R, Keepanasseril A. Global Disparities in Outcomes of Pregnant Individuals With Rheumatic Heart Disease: A Scoping Review. JACC. ADVANCES 2024; 3:101368. [PMID: 39817079 PMCID: PMC11734045 DOI: 10.1016/j.jacadv.2024.101368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/09/2024] [Revised: 08/30/2024] [Accepted: 09/04/2024] [Indexed: 01/18/2025]
Abstract
Background Rheumatic heart disease (RHD) remains as 1 of the major contributors to indirect pregnancy-related mortality and morbidity worldwide and disproportionately affects marginalized populations. Objectives In this scoping review, the authors sought to explore the socioeconomic, cultural, and health care access-related causes of global disparities in outcomes of pregnancy among individuals with RHD. Methods We performed a literature search of all studies published between January 1, 1990, and January 1, 2022, that investigated causes for disparate outcomes in pregnant individuals with RHD. Results Of the 3,544 articles identified, 16 were included in the final analysis. The key reasons for disparate outcomes included lack of secondary antibiotic RHD prophylaxis; late and more severe RHD diagnosis, differences in management and antenatal care access; lack of expert and coordinated multidisciplinary care; suboptimal patient health education; inadequate access to RHD medication, intervention and surgery in pregnancy; and limited financial and economic resources. Conclusions These findings illustrated using a life-course approach demonstrate opportunities for clinical and public health interventions to improve outcomes in this population.
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Affiliation(s)
- Jenny M. Yang
- Department of Obstetrics and Gynaecology, University of Toronto, Mount Sinai Hospital, Toronto, Ontario, Canada
- Department of Obstetrics and Gynaecology, Liverpool Hospital, Sydney, New South Wales, Australia
| | | | - Candice K. Silversides
- Division of Cardiology, Miles Nadal Heart Centre, Mount Sinai Hospital and Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Samuel C. Siu
- Division of Cardiology, University of Western Ontario, London, Ontario, Canada
| | - Rachel F. Spitzer
- Department of Obstetrics and Gynaecology, University of Toronto, Mount Sinai Hospital, Toronto, Ontario, Canada
- Section of Gynaecology, Division of Endocrinology, Department of Paediatrics, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Wycliffe Kosgei
- Department of Obstetrics and Gynaecology, Moi Teaching and Referral Hospital, Eldoret, Kenya
| | - Nanette Okun
- Maternal Fetal Medicine, Department of Obstetrics and Gynaecology, Sunnybrook Hospital, Toronto, Ontario, Canada
| | - Rebecca Lumsden
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Rohan D’Souza
- Departments of Obstetrics and Gynaecology and Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
| | - Anish Keepanasseril
- Department of Obstetrics and Gynaecology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
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Dimaano KAM, Shah N, AlQassab O, Al-Sulaitti Z, Nelakuditi B, Dandamudi BJ, Khan S. Risk of Recurrent and Frequent Preterm Birth Among Women With Mitral Valve Prolapse: A Systematic Review and Meta-Analysis. Cureus 2024; 16:e74866. [PMID: 39741597 PMCID: PMC11684995 DOI: 10.7759/cureus.74866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2024] [Accepted: 11/30/2024] [Indexed: 01/03/2025] Open
Abstract
Preterm delivery remains a prominent problem in obstetrics with significant adverse implications for both mothers and the offspring. The incidence of mitral valve prolapse (MVP) in women of childbearing age has raised concerns about pregnancy and pregnancy connotations. The objective of this systematic review and meta-analysis is to help in understanding the plausibility of the association between MVP and preterm birth in women with a history of frequent deliveries. Following the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines, we searched the databases, including PubMed, Embase, Cochrane Library, Web of Science, and Scopus, for studies published in the period 1999 through 2024. Inclusion criteria consisted of studies such as cohort, cross-sectional, and case-control studies related to women diagnosed with MVP out of a total number of 1,029 articles found. Overall, a total of 19 studies were included in this review, with 3 of which were considered for further meta-analysis. It was revealed in the analysis that there was an association between MVP and preterm delivery when the severity of MVP was at Types II and III. The evidence also underscores the importance of both follow-up and preemptive measures among women suffering from MV prolapse for improved maternal and neonatal outcomes. The average Z-value (4.47) and p-value (0.00) for the test for overall effect size indicate the presence of a high correlation between MVP and premature delivery, suggesting satisfactory statistics on the association. The findings do indicate that MVP is a risk factor for preterm delivery (pooled ES = 0.24, 95% CI = 0.14 to 0.35, P <0.001).
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Affiliation(s)
- Kathrina Antheia M Dimaano
- Obstetrics and Gynecology, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Nensi Shah
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Osamah AlQassab
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Zainab Al-Sulaitti
- Obstetrics and Gynecology, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Bhavana Nelakuditi
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Bindu Jyothi Dandamudi
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Safeera Khan
- Neuropsychiatry, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
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11
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Mutarelli A, Pantaleao AN, Nunes MC. Severe Rheumatic Mitral Stenosis During Pregnancy. JACC Case Rep 2024; 29:102634. [PMID: 39534628 PMCID: PMC11551943 DOI: 10.1016/j.jaccas.2024.102634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2024] [Revised: 07/15/2024] [Accepted: 07/22/2024] [Indexed: 11/16/2024]
Abstract
A 28-year-old woman, gravida 2 para 1, with previously unknown severe rheumatic mitral stenosis presented with progressive dyspnea at 26 weeks of gestation. Percutaneous commissurotomy was considered but was deferred after symptom improvement with beta-blockers and diuretics. Pregnancy complications ensued, requiring preterm delivery. Postpartum percutaneous commissurotomy was successful, highlighting the complexities in managing rheumatic heart disease during pregnancy.
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Affiliation(s)
- Antonio Mutarelli
- Department of Internal Medicine, School of Medicine, and Hospital das Clínicas, Belo Horizonte, Brazil
| | | | - Maria C.P. Nunes
- Department of Internal Medicine, School of Medicine, and Hospital das Clínicas, Belo Horizonte, Brazil
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12
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Torosyan N, Ghadiali T, Mehra A, Elkayam U. Management of Woman With Rheumatic Mitral Stenosis During Pregnancy: Importance of Multimodality Evaluation. JACC Case Rep 2024; 29:102628. [PMID: 39534626 PMCID: PMC11551924 DOI: 10.1016/j.jaccas.2024.102628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2024] [Revised: 08/02/2024] [Accepted: 08/12/2024] [Indexed: 11/16/2024]
Abstract
A 29-year-old woman with a history of severe rheumatic mitral stenosis status post mitral valvuloplasty presented with worsening dyspnea on exertion during her second pregnancy. She underwent multimodality evaluation throughout her pregnancy, which helped to guide medical therapy and prevent unnecessary mechanical intervention and premature delivery.
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Affiliation(s)
- Nare Torosyan
- Division of Cardiology, Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Tejal Ghadiali
- Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California USA
| | - Anil Mehra
- Division of Cardiology, Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Uri Elkayam
- Division of Cardiology, Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
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13
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Rizi SS, Wiens E, Hunt J, Ducas R. Cardiac physiology and pathophysiology in pregnancy. Can J Physiol Pharmacol 2024; 102:552-571. [PMID: 38815593 DOI: 10.1139/cjpp-2024-0010] [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] [Indexed: 06/01/2024]
Abstract
Cardiovascular disease is the leading indirect cause of maternal morbidity and mortality, accounting for nearly one third of maternal deaths during pregnancy. The burden of cardiovascular disease in pregnancy is increasing, as are the incidence of maternal morbidity and mortality. Normal physiologic adaptations to pregnancy, including increased cardiac output and plasma volume, may unmask cardiac conditions, exacerbate previously existing conditions, or create de novo complications. It is important for care providers to understand the normal physiologic changes of pregnancy and how they may impact the care of patients with cardiovascular disease. This review outlines the physiologic adaptions during pregnancy and their pathologic implications for some of the more common cardiovascular conditions in pregnancy.
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Affiliation(s)
- Shekoofeh Saboktakin Rizi
- Section of Cardiology, Department of Internal Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Evan Wiens
- Division of Cardiology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Jennifer Hunt
- Department of Obstetrics, Gynecology & Reproductive Science, University of Manitoba, Winnipeg, MB, Canada
| | - Robin Ducas
- Section of Cardiology, Department of Internal Medicine, University of Manitoba, Winnipeg, MB, Canada
- Department of Obstetrics, Gynecology & Reproductive Science, University of Manitoba, Winnipeg, MB, Canada
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14
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Wiens EJ, Kawa K, Kass M, Shah AH. Impact of biological sex on valvular heart disease, interventions, and outcomes. Can J Physiol Pharmacol 2024; 102:585-593. [PMID: 38427984 DOI: 10.1139/cjpp-2023-0390] [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] [Indexed: 03/03/2024]
Abstract
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.
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Affiliation(s)
- Evan J Wiens
- Department of Critical Care Medicine, University of Alberta, Edmonton, AB, Canada
| | - Kristal Kawa
- College of Nursing, University of Manitoba, Winnipeg, MB, Canada
| | - Malek Kass
- Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada
- Section of Cardiology, Department of Internal Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Ashish H Shah
- Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada
- Section of Cardiology, Department of Internal Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada
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15
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Sebastian SA, Sethi Y, Mathews AM, Santhosh T, Lorraine Co E, Padda I, Johal G. Cardiovascular complications during pregnancy: Advancing cardio-obstetrics. Dis Mon 2024; 70:101780. [PMID: 38910052 DOI: 10.1016/j.disamonth.2024.101780] [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] [Indexed: 06/25/2024]
Abstract
As the incidence of cardiovascular diseases (CVDs) continues to rise among women of childbearing age, the pregnant population with pre-existing heart conditions presents a complex and heterogeneous profile. These women face varying degrees of risk concerning maternal cardiovascular, obstetric, and fetal complications. Effectively managing adverse cardiovascular events during pregnancy presents substantial clinical challenges. The uncertainties surrounding diagnostic and therapeutic approaches create a dynamic landscape with potential implications for maternal and fetal health. Cardio-obstetrics has become increasingly recognized as a vital multidisciplinary field necessitating a collaborative approach to managing cardiovascular conditions during pregnancy. In this review, we aim to provide a thorough and up-to-date examination of the existing evidence, offering a comprehensive overview of strategies and considerations in the management of cardiovascular complications during pregnancy. Special emphasis is placed on the safety assessment of diagnostic procedures and the exploration of treatment options designed to prioritize the well-being of the mother and fetus. We also explore the significance of a multidisciplinary cardio-obstetrics team in providing comprehensive care for women of childbearing age with or at risk for CVD.
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Affiliation(s)
- Sneha Annie Sebastian
- Department of Internal Medicine, Azeezia Medical College, Kollam, Kerala, India; Research Nexus, Philadelphia, United States.
| | - Yashendra Sethi
- Department of Internal Medicine, Government Doon Medical College, HNB Uttarakhand Medical Education University, Dehradun, India
| | | | - Tony Santhosh
- Department of Internal Medicine, Dr. Somervell Memorial CSI Medical College, KUHS, Kerala, India
| | - Edzel Lorraine Co
- Research Nexus, Philadelphia, United States; Department of Internal Medicine, University of Santo Tomas Faculty of Medicine and Surgery, Manila, Philippines
| | - Inderbir Padda
- Department of Internal Medicine, Richmond University Medical Center/Mount Sinai, Staten Island, NY, USA
| | - Gurpreet Johal
- Department of Cardiology, University of Washington, Valley Medical Center, Seattle, USA
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16
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Marangou J, Ferguson D, Unger HW, Kaethner A, Ilton M, Remenyi B, Ralph AP. Assessing the Role of Echocardiography in Pregnancy in First Nations Australian Women: Is it an Underutilised Resource? Heart Lung Circ 2024; 33:1307-1313. [PMID: 38918121 DOI: 10.1016/j.hlc.2024.04.301] [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: 01/29/2024] [Revised: 04/10/2024] [Accepted: 04/16/2024] [Indexed: 06/27/2024]
Abstract
BACKGROUND Rheumatic heart disease (RHD) remains prevalent within First Nations Australian communities. RHD is more common in females and peak prevalence corresponds with childbearing age. Significant valvular disease can complicate pregnancy. Current practice in Northern Australia is to refer pregnant women for echocardiography if there are signs or symptoms of possible cardiac pathology or a history of acute rheumatic fever (ARF) or RHD. It is not currently routine practice to offer echocardiographic screening for all pregnant women at high risk of RHD. AIM This study aimed to assess the current referral practices for echocardiography and disease patterns in pregnant women in the Northern Territory, Australia-a region with a known high prevalence of RHD in the First Nations population. METHOD A retrospective analysis of all echocardiography referrals of pregnant women over a 4-year period was performed. Data included indication for echocardiography, clinical history, echocardiographic findings, and location of delivery. Comparisons were made using Fisher's exact and Mann-Whitney U tests. RESULTS A total of 322 women underwent echocardiography during pregnancy: 195 First Nations and 127 non-Indigenous women (median age, 25 vs 30 years, respectively; p<0.01). Indications for echocardiography differed by ethnicity, with history of ARF or RHD being the most common indication in First Nations women, and incidental murmur the most common in non-Indigenous women. First Nations women were more likely to have abnormal echocardiograms (35.9% vs 11.0% in non-Indigenous women; p<0.01) or a history of ARF or RHD (39.5% vs 0.8%; p<0.01), but less likely to have documented cardiac symptoms as an indication for echocardiography (8.2% vs 20.5%; p<0.01). New cardiac diagnoses were made during pregnancy in 11 (5.6%) First Nations and two (1.6%) non-Indigenous women (p=0.02). Moderate or severe valve lesions were detected in 26 (13.3%) First Nations women (all previously diagnosed), and 11 (5.6%) had previous cardiac surgery. No severe valve lesions were identified in the non-Indigenous group. Interstate transfer to a tertiary centre with valve intervention services was required during pregnancy or the puerperium for 12 (6.2%) First Nations women and no non-Indigenous women. CONCLUSIONS Amongst pregnant women in the Northern Territory who had an indication for echocardiography, First Nations women were more likely to have abnormal echocardiograms. This was mainly due to valvular disease secondary to RHD. Cardiac symptoms were infrequently recorded as an indication for echocardiography in First Nations women, suggesting possible underappreciation of symptoms. Having a low threshold for echocardiographic investigation, including consideration of universal screening during pregnancy, is important in a high RHD-burden setting such as ours. A better understanding of the true prevalence and spectrum of disease severity in this population would enable health services to invest in appropriate resources.
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Affiliation(s)
- James Marangou
- Global and Tropical Health, Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia.
| | - Dominic Ferguson
- Departments of Medicine, Paediatrics and Obstetrics, Royal Darwin Hospital, Darwin, NT, Australia
| | - Holger W Unger
- Global and Tropical Health, Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia; Departments of Medicine, Paediatrics and Obstetrics, Royal Darwin Hospital, Darwin, NT, Australia; Liverpool School of Tropical Medicine, Liverpool, UK
| | - Alex Kaethner
- Global and Tropical Health, Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia
| | - Marcus Ilton
- Departments of Medicine, Paediatrics and Obstetrics, Royal Darwin Hospital, Darwin, NT, Australia
| | - Bo Remenyi
- Global and Tropical Health, Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia; Departments of Medicine, Paediatrics and Obstetrics, Royal Darwin Hospital, Darwin, NT, Australia
| | - Anna P Ralph
- Global and Tropical Health, Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia; Departments of Medicine, Paediatrics and Obstetrics, Royal Darwin Hospital, Darwin, NT, Australia
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17
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Shari SS, Kazemi T, Bidokhti A, Riahi SM. Comparison of maternal and fetal outcomes in mothers with non-congenital mitral valve stenosis and healthy control. Eur J Obstet Gynecol Reprod Biol X 2024; 22:100290. [PMID: 39011058 PMCID: PMC11247151 DOI: 10.1016/j.eurox.2024.100290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 02/03/2024] [Accepted: 02/09/2024] [Indexed: 07/17/2024] Open
Abstract
Background Physiological changes during pregnancy cause complications in mothers with mitral stenosis and their infants. This study was designed to assess maternal and fetal pregnancy outcomes in women with rheumatic mitral valve stenosis and compare them with the control group. Materials and methods This study is a case-control study on 153 pregnant women, including 51 with mitral stenosis (MS) and 102 without MS as the control group, between 2007-2022. For each studied patient, two control participants were selected and matched in residence, age, and year of pregnancy. SPSS version 22 was used for data analysis. Results The mean age was 31.7 ± 4.6 years in cases and 31.6 ± 4.7 in the healthy controls. Demographic variables were not significantly different between the case and control groups. The rate of stillbirth (5.9% vs. 0.0%), %), NICU admission (13.7% vs. 2.0%), and IUGR (5.9% vs. 0.0%) were higher in the fetal case group compared with the control group. On the other hand, maternal outcomes, including pulmonary edema (13.7% vs. 0.0%), ICU admission (23.5% vs. 0.0%), limb edema (15.7% vs. 0.0%), dyspnea (37.3% vs. 0.0%), pulmonary hypertension (9.8% vs. 0.0%), palpitations (21.1% vs. 0.0%) and hospital admission during pregnancy (37.2% vs. 4.9%) were statistically more common in the case groups. Conclusions Pregnancy is associated with significant fetomaternal morbidities in women with mitral valve heart disease. So they need a multidisciplinary approach in preconception and antenatal care.
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Affiliation(s)
- Sima sobhani Shari
- Student Research Committee, Birjand University of Medical Sciences, Birjand, Iran
| | - Tooba Kazemi
- Cardiovascular Diseases Research Center, Birjand University of Medical Sciences, Birjand, Iran
| | - Ali Bidokhti
- Cardiovascular Diseases Research Center, Birjand University of Medical Sciences, Birjand, Iran
| | - Seyed Mohammad Riahi
- Department of Community Medicine, School of Medicine, Cardiovascular Diseases Research Center, Birjand University of Medical Sciences, Birjand, Iran
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18
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Li S, Girgla S, Sherman A, Alpay-Savasan Z, Mehta N. Atrial fibrillation considerations in the fourth trimester (postpartum period). J Interv Card Electrophysiol 2024; 67:901-914. [PMID: 38363430 DOI: 10.1007/s10840-023-01611-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Accepted: 07/18/2023] [Indexed: 02/17/2024]
Abstract
Postpartum atrial fibrillation is an uncommon but increasingly prevalent tachyarrhythmia that merits special management considerations with regards to the safety and efficacy of anticoagulation, rate and rhythm control as well as drug exposure to infants throughout breastfeeding. In this state-of-the-art review, we examine the demographics of postpartum atrial fibrillation with its associated risk factors, describe the safety of commonly used atrial fibrillation therapies, and discuss important considerations for women considering subsequent pregnancies.
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Affiliation(s)
- Shuo Li
- Internal Medicine Residency, Beaumont Hospital Royal Oak, Royal Oak, MI, USA
| | - Saavia Girgla
- Department of Cardiovascular Medicine, Beaumont Hospital Royal Oak, Royal Oak, MI, USA
| | - Andrew Sherman
- Internal Medicine Residency, Beaumont Hospital Royal Oak, Royal Oak, MI, USA
| | - Zeynep Alpay-Savasan
- Division of Maternal and Fetal Medicine, Beaumont Hospital Royal Oak, Royal Oak, MI, USA
| | - Nishaki Mehta
- Department of Cardiovascular Medicine, Beaumont Hospital Royal Oak, Royal Oak, MI, USA.
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19
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Seitler S, Ahmad M, Ahuja SAC, Ahmed MT, Stevenson A, Schreiber TR, Sodhi PS, Diyasena HK, Ogbeide O, Arularooran S, Shokraneh F, Cassandra M, Marijon E, Celermajer DS, Khanji MY, Providencia R. Routine Antenatal Echocardiography in High-Prevalence Areas of Rheumatic Heart Disease: A WHO-Guideline Systematic Review. Glob Heart 2024; 19:39. [PMID: 38681969 PMCID: PMC11049603 DOI: 10.5334/gh.1318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 03/20/2024] [Indexed: 05/01/2024] Open
Abstract
Background Rheumatic Heart Disease (RHD) is the most common cause of valvular heart disease worldwide. Undiagnosed or untreated RHD can complicate pregnancy and lead to poor maternal and fetal outcomes and is a significant factor in non-obstetric morbidity. Echocardiography has an emerging role in screening for RHD. We aimed to critically analyse the evidence on the use of echocardiography for screening pregnant women for RHD in high-prevalence areas. Methods We searched MEDLINE and Embase to identify the relevant reports. Two independent reviewers assessed the reports against the eligibility criteria in a double-blind process. Results The searches (date: 4 April 2023) identified 432 records for screening. Ten non-controlled observational studies were identified, five using portable or handheld echocardiography, comprising data from 23,166 women. Prevalence of RHD varied across the studies, ranging from 0.4 to 6.6% (I2, heterogeneity >90%). Other cardiac abnormalities (e.g., congenital heart disease and left ventricular systolic dysfunction) were also detected <1% to 2% of cases. Certainty of evidence was very low. Conclusion Echocardiography as part of antenatal care in high-prevalence areas may detect RHD or other cardiac abnormalities in asymptomatic pregnant women, potentially reducing the rates of disease progression and adverse labor-associated outcomes. However, this evidence is affected by the low certainty of evidence, and lack of studies comparing echocardiography versus standard antenatal care. Prospective Registration PROSPERO 2022 July 4; CRD42022344081 Available from: https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=344081. Research question 'In areas with a high prevalence of rheumatic heart disease, should handheld echocardiography be added to routine antenatal care?'
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Affiliation(s)
- Samuel Seitler
- Royal Free Hampstead NHS Trust, Royal Free London NHS Foundation Trust, Pond St, London NW3 2QG, UK
| | - Mahmood Ahmad
- Royal Free Hampstead NHS Trust, Royal Free London NHS Foundation Trust, Pond St, London NW3 2QG, UK
| | | | | | - Alexander Stevenson
- Department of Cardiology, High Wycombe Hospital, Queen Alexandra Rd, High Wycombe HP11 2TT, UK
| | - Tamar Rachel Schreiber
- Royal Free Hampstead NHS Trust, Royal Free London NHS Foundation Trust, Pond St, London NW3 2QG, UK
| | - Prem Singh Sodhi
- Royal Free Hampstead NHS Trust, Royal Free London NHS Foundation Trust, Pond St, London NW3 2QG, UK
| | - Hiruna Kojitha Diyasena
- Royal Free Hampstead NHS Trust, Royal Free London NHS Foundation Trust, Pond St, London NW3 2QG, UK
| | - Osarumwense Ogbeide
- Royal Free Hampstead NHS Trust, Royal Free London NHS Foundation Trust, Pond St, London NW3 2QG, UK
| | - Sankavi Arularooran
- Royal Free Hampstead NHS Trust, Royal Free London NHS Foundation Trust, Pond St, London NW3 2QG, UK
| | - Farhad Shokraneh
- GENEs health and social care evidence SYnthesiS unit, Institute of Health Informatics, University College London, UK
- Evidence Synthesis, Systematic Review Consultants LTD, Nottingham, UK
| | | | - Eloi Marijon
- Paris Cardiovascular Research Centre, INSERM U970, European Georges Pompidou Hospital, Paris, FR
- Department of Cardiology, European Georges Pompidou Hospital, Paris, FR
| | - David S. Celermajer
- The University of Sydney, Sydney, AU
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, AU
| | - Mohammed Y. Khanji
- Cardiology Department, Barts Heart Centre, Barts Health NHS Trust, London, UK
- Newham University Hospital, Barts Health NHS Trust, Glen Road, Plaistow, London E13 8SL, UK
- NIHR Barts Biomedical Research Centre, William Harvey Research Institute, Queen Mary University, London EC1A 7BE, UK
| | - Rui Providencia
- GENEs health and social care evidence SYnthesiS unit, Institute of Health Informatics, University College London, UK
- Cardiology Department, Barts Heart Centre, Barts Health NHS Trust, London, UK
- Newham University Hospital, Barts Health NHS Trust, Glen Road, Plaistow, London E13 8SL, UK
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20
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Batra J, Mourad M, Collado FK, Takeda K, Greenwald A, Ring L, Chen X, Haythe J. Case report of pregnancy complicated by severe pulmonary hypertension from mitral stenosis and placenta accreta spectrum disorder: management of two life-threatening conditions. Eur Heart J Case Rep 2024; 8:ytae055. [PMID: 38425728 PMCID: PMC10903160 DOI: 10.1093/ehjcr/ytae055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 01/20/2024] [Accepted: 01/24/2024] [Indexed: 03/02/2024]
Abstract
Background Antenatal cardiovascular disease is a major cause of maternal morbidity and mortality. Severe rheumatic mitral stenosis is especially poorly tolerated during pregnancy. Case Summary We present a young woman with severe pulmonary hypertension secondary to rheumatic mitral stenosis. She presented at 25 weeks 4 days gestation for evaluation of a pregnancy complicated by placenta accreta spectrum disorder. Invasive hemodynamic testing was carried out to delineate her hemodynamics, and a multidisciplinary cardio-obstetrics team collaborated closely with the patient and her partner to create a management plan. Ultimately, the patient was initiated on veno-arterial extracorporeal membrane oxygenation and underwent caesarean section delivery followed by hysterectomy and subsequent valve replacement surgery. Discussion This case describes the treatment options considered to balance the risk of decompensation in the setting of severe pulmonary hypertension with hemorrhage associated with placenta accreta spectrum disorder. It highlights the importance of a multidisciplinary, team-based approach to the management of high-risk cardiac conditions throughout pregnancy.
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Affiliation(s)
- Jaya Batra
- Division of Cardiology, Department of Medicine, Columbia University Vagelos College of Physicians and Surgeons, 630 W 168th St, PH 12 STEM, New York, NY 10032, USA
| | - Mirella Mourad
- Department of Obstetrics and Gynecology, Columbia University Vagelos College of Physicians and Surgeons, 630 W 168th St, New York, NY 10032, USA
| | - Fady Khoury Collado
- Department of Obstetrics and Gynecology, Columbia University Vagelos College of Physicians and Surgeons, 630 W 168th St, New York, NY 10032, USA
| | - Koji Takeda
- Division of Cardiac, Thoracic, and Vascular Surgery, Department of Surgery, Columbia University Vagelos College of Physicians and Surgeons, 630 W 168th St, New York, NY 10032, USA
| | - Andrew Greenwald
- Department of Anesthesiology, Columbia University Vagelos College of Physicians and Surgeons, 630 W 168th St, New York, NY 10032, USA
| | - Laurence Ring
- Department of Anesthesiology, Columbia University Vagelos College of Physicians and Surgeons, 630 W 168th St, New York, NY 10032, USA
| | - Xuxin Chen
- Department of Pediatrics, Columbia University Vagelos College of Physicians and Surgeons, 630 W 168th St, New York, NY 10032, USA
| | - Jennifer Haythe
- Division of Cardiology, Department of Medicine, Columbia University Vagelos College of Physicians and Surgeons, 630 W 168th St, PH 12 STEM, New York, NY 10032, USA
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21
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Fraccaro C, Karam N, Möllmann H, Bleiziffer S, Bonaros N, Teles RC, Carrilho Ferreira P, Chieffo A, Czerny M, Donal E, Dudek D, Dumonteil N, Esposito G, Fournier S, Hassager C, Kim WK, Krychtiuk KA, Mehilli J, Pręgowski J, Stefanini GG, Ternacle J, Thiele H, Thielmann M, Vincent F, von Bardeleben RS, Tarantini G. Transcatheter interventions for left-sided valvular heart disease complicated by cardiogenic shock: a consensus statement from the European Association of Percutaneous Cardiovascular Interventions (EAPCI) in collaboration with the Association for Acute Cardiovascular Care (ACVC) and the ESC Working Group on Cardiovascular Surgery. EUROINTERVENTION 2023; 19:634-651. [PMID: 37624587 PMCID: PMC10587846 DOI: 10.4244/eij-d-23-00473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 08/07/2023] [Indexed: 08/26/2023]
Abstract
Valvular heart disease (VHD) is one of the most frequent causes of heart failure (HF) and is associated with poor prognosis, particularly among patients with conservative management. The development and improvement of catheter-based VHD interventions have broadened the indications for transcatheter valve interventions from inoperable/high-risk patients to younger/lower-risk patients. Cardiogenic shock (CS) associated with severe VHD is a clinical condition with a very high risk of mortality for which surgical treatment is often deemed a prohibitive risk. Transcatheter valve interventions might be a promising alternative in this setting given that they are less invasive. However, supportive scientific evidence is scarce and often limited to small case series. Current guidelines on VHD do not contain specific recommendations on how to manage patients with both VHD and CS. The purpose of this clinical consensus statement, developed by a group of international experts invited by the European Association of Percutaneous Cardiovascular Interventions (EAPCI) Scientific Documents and Initiatives Committee, is to perform a review of the available scientific evidence on the management of CS associated with left-sided VHD and to provide a rationale and practical approach for the application of transcatheter valve interventions in this specific clinical setting.
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Affiliation(s)
- Chiara Fraccaro
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Nicole Karam
- Heart Valves Unit, Georges Pompidou European Hospital, Université Paris Cité, INSERM, Paris, France
| | - Helge Möllmann
- Department of Cardiology, St. Johannes Hospital, Dortmund, Germany
| | | | - Nikolaos Bonaros
- Cardiac Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Rui Campante Teles
- Hospital de Santa Cruz, Centro Hospitalar de Lisboa Ocidental (HSC), Carnaxide, Portugal and Comprehensive Health Research Center (CHRC), Nova Medical School, Lisbon, Portugal
| | - Pedro Carrilho Ferreira
- Cardiology Department, Santa Maria University Hospital, CHULN, CAML, CCUL, Faculty of Medicine, University of Lisbon, Lisbon, Portugal
| | - Alaide Chieffo
- Interventional Cardiology Unit, San Raffaele Scientific Institute, Milan, Italy
| | - Martin Czerny
- Department of Cardiovascular Surgery, University Heart Centre, Freiburg University, Freiburg, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Erwan Donal
- Service de Cardiologie, CCP CHU de Rennes, University of Rennes, INSERM, LTSI-UMR 1099, Rennes, France
| | - Dariusz Dudek
- Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland
| | | | - Giovanni Esposito
- Divisions of Cardiology and Cardiothoracic Surgery, Department of Advanced Biomedical Sciences, Federico II University, Naples, Italy
| | - Stephane Fournier
- Service of Cardiology, Lausanne University Hospital, Lausanne, Switzerland and University of Lausanne, Lausanne, Switzerland
| | - Christian Hassager
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Denmark
| | - Won-Keun Kim
- Department of Cardiology, St. Johannes Hospital, Dortmund, Germany
| | - Konstantin A Krychtiuk
- Duke Clinical Research Institute, Durham, NC, USA
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Julinda Mehilli
- Department of Cardiology, German Centre for Cardiovascular Research (DZHK), Ludwig Maximilian University of Munich, Partner Site Munich Heart Alliance, Munich, Germany
- Medizinische Klinik I, Landshut-Achdorf Hospital, Landshut, Germany
| | - Jerzy Pręgowski
- Department of Interventional Cardiology and Angiology, National Institute of Cardiology, Warszawa, Poland
| | - Giulio G Stefanini
- Department of Biomedical Sciences Humanitas University, Pieve Emanuele, Italy
- Humanitas Research Hospital IRCCS Rozzano, Milan, Italy
| | - Julien Ternacle
- Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec, QC, Canada and Université Laval, Quebec, QC, Canada
- Haut-Leveque Cardiology Hospital, Bordeaux University, Pessac, France
| | - Holger Thiele
- Department of Internal Medicine/Cardiology, Heart Center Leipzig, Leipzig, Germany and University of Leipzig, Leipzig, Germany
| | - Matthias Thielmann
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center, University Hospital Essen, Essen, Germany
| | - Flavien Vincent
- Service de Cardiologie, Centre Hospitalier Universitaire de Lille, Lille, France
| | | | - Giuseppe Tarantini
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
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22
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Zhao Y, Zhao C, Ye Q, Li F, Liu K, Zhao S, Wang J. Childbearing Performances and Outcomes of Female Patients with Rheumatic Mitral Valve Diseases after Different Mitral Interventions. Ann Thorac Cardiovasc Surg 2023; 29:223-232. [PMID: 36878609 PMCID: PMC10587480 DOI: 10.5761/atcs.oa.22-00213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Accepted: 02/01/2023] [Indexed: 03/06/2023] Open
Abstract
PURPOSE This study aimed to illustrate how percutaneous balloon mitral valvuloplasty (PBMV) and mitral valve (MV) surgeries influence women of childbearing age with rheumatic mitral valve diseases (RMVDs) from two aspects, including clinical outcomes and their postoperative childbearing performances. METHODS Female patients with RMVD who were of childbearing age and underwent MV interventions between 2007 and 2019 at Beijing Anzhen Hospital were identified. Outcomes included all-cause deaths, repeated MV interventions, and atrial fibrillation. A survey about childbearing attempts and complications during pregnancy was also performed during follow-up. RESULTS A total of 379 patients were involved in this study, consisting of 226 cases of mitral valve replacements, 107 cases of mitral valve repairs (MVrs), and 46 cases of PBMVs. PBMV was associated with higher possibilities of repeated MV interventions (P <0.05). Postoperative childbearing attempts were more frequently observed among bioprosthesis, MVr, and PBMV (P <0.05). However, PBMV and MVr showed a higher incidence of cardiac complications during pregnancy as compared to prosthesis replacement (P <0.05). CONCLUSIONS MVr and PBMV are not recommended to young female patients for higher incidences of postoperative complications. Safe pregnancy is more likely to be present among patients with biological prosthesis.
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Affiliation(s)
- Yichen Zhao
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Cheng Zhao
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Qing Ye
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Fei Li
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Kemin Liu
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Shihua Zhao
- Department of Magnetic Resonance Imaging, Fuwai Hospital and National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Jiangang Wang
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
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23
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Pande SN, Yavana Suriya J, Ganapathy S, Pillai AA, Satheesh S, Mondal N, Harichandra Kumar KT, Silversides C, Siu SC, D'Souza R, Keepanasseril A. Validation of Risk Stratification for Cardiac Events in Pregnant Women With Valvular Heart Disease. J Am Coll Cardiol 2023; 82:1395-1406. [PMID: 37758434 DOI: 10.1016/j.jacc.2023.07.023] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 07/13/2023] [Accepted: 07/21/2023] [Indexed: 10/03/2023]
Abstract
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.
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Affiliation(s)
- Swaraj Nandini Pande
- Department of Obstetrics and Gynaecology, Jawaharlal Institute of Post-graduate Medical Education and Research (JIPMER), Puducherry, India
| | - J Yavana Suriya
- Department of Obstetrics and Gynaecology, Jawaharlal Institute of Post-graduate Medical Education and Research (JIPMER), Puducherry, India
| | - Sachit Ganapathy
- Department of Biostatistics, Jawaharlal Institute of Post-graduate Medical Education and Research (JIPMER), Puducherry, India
| | - Ajith Ananthakrishna Pillai
- Department of Cardiology, Jawaharlal Institute of Post-graduate Medical Education and Research (JIPMER), Puducherry, India
| | - Santhosh Satheesh
- Department of Cardiology, Jawaharlal Institute of Post-graduate Medical Education and Research (JIPMER), Puducherry, India
| | - Nivedita Mondal
- Department of Neonatology, Jawaharlal Institute of Post-graduate Medical Education and Research (JIPMER), Puducherry, India
| | - K T Harichandra Kumar
- Department of Biostatistics, Jawaharlal Institute of Post-graduate Medical Education and Research (JIPMER), Puducherry, India
| | - Candice Silversides
- Division of Cardiology, University of Toronto Pregnancy and Heart Disease Program, Mount Sinai and Toronto General Hospitals, University of Toronto, Toronto, Ontario, Canada
| | - Samuel C Siu
- Division of Cardiology, University of Toronto Pregnancy and Heart Disease Program, Mount Sinai and Toronto General Hospitals, University of Toronto, Toronto, Ontario, Canada; Division of Cardiology, University of Western Ontario, London, Ontario, Canada
| | - Rohan D'Souza
- Department of Obstetrics and Gynaecology and Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Anish Keepanasseril
- Department of Obstetrics and Gynaecology, Jawaharlal Institute of Post-graduate Medical Education and Research (JIPMER), Puducherry, India.
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24
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Joglar JA, Kapa S, Saarel EV, Dubin AM, Gorenek B, Hameed AB, Lara de Melo S, Leal MA, Mondésert B, Pacheco LD, Robinson MR, Sarkozy A, Silversides CK, Spears D, Srinivas SK, Strasburger JF, Tedrow UB, Wright JM, Zelop CM, Zentner D. 2023 HRS expert consensus statement on the management of arrhythmias during pregnancy. Heart Rhythm 2023; 20:e175-e264. [PMID: 37211147 DOI: 10.1016/j.hrthm.2023.05.017] [Citation(s) in RCA: 47] [Impact Index Per Article: 23.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 05/12/2023] [Indexed: 05/23/2023]
Abstract
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.
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Affiliation(s)
- José A Joglar
- The University of Texas Southwestern Medical Center, Dallas, Texas
| | | | - Elizabeth V Saarel
- St. Luke's Health System, Boise, Idaho, and Cleveland Clinic Lerner College of Medicine at Case Western Reserve University, Cleveland, Ohio
| | | | | | | | | | | | | | - Luis D Pacheco
- The University of Texas Medical Branch at Galveston, Galveston, Texas
| | | | - Andrea Sarkozy
- University Hospital of Antwerp, University of Antwerp, Antwerp, Belgium
| | | | - Danna Spears
- University Health Network, Toronto, Ontario, Canada
| | - Sindhu K Srinivas
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | | | | | | | - Carolyn M Zelop
- The Valley Health System, Ridgewood, New Jersey; New York University Grossman School of Medicine, New York, New York
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25
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Heitkamp A, Sandberg E, Moodley A, Burke J, van Roosmalen J, Gebhardt S, Vollmer L, de Vries JI, van den Akker T, Theron G. Pulmonary oedema in the course of severe maternal outcome in South Africa: A cohort study combined with clinical audit. Trop Med Int Health 2023; 28:677-687. [PMID: 37340987 DOI: 10.1111/tmi.13905] [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] [Indexed: 06/22/2023]
Abstract
OBJECTIVES To describe the incidence and outcomes of pulmonary oedema in women with severe maternal outcome during childbirth and identify possible modifiable factors through audit. METHODS All women with severe maternal outcome (maternal deaths or near misses) who were referred to Tygerberg referral hospital from health facilities in Metro East district, South Africa, during 2014-2015 were included. Women with severe maternal outcome and pulmonary oedema during pregnancy or childbirth were evaluated using three types of critical incident audit: criterion-based case review by one consultant gynaecologist, monodisciplinary critical incident audit by a team of gynaecologists, multidisciplinary audit with expert review from anaesthesiologists and cardiologists. RESULTS Of 32,161 pregnant women who gave birth in the study period, 399 (1.2%) women had severe maternal outcome and 72/399 (18.1%) had pulmonary oedema with a case fatality rate of 5.6% (4/72). Critical incident audit demonstrated that pre-eclampsia/HELLP-syndrome and chronic hypertension were the main conditions underlying pulmonary oedema (44/72, 61.1%). Administration of volumes of intravenous fluids in already sick women, undiagnosed underlying cardiac illness, administration of magnesium sulphate as part of pre-eclampsia management and oxytocin for augmentation of labour were identified as possible contributors to the pathophysiology of pulmonary oedema. Women-related factors (improved antenatal care attendance) and health care-related factors (earlier diagnosis and management) would potentially have improved maternal outcome. CONCLUSIONS Although pulmonary oedema in pregnancy is rare, among women with severe maternal outcome a considerable proportion had pulmonary oedema (18.1%). Audit identified options for prevention of pulmonary oedema and improved outcome. These included early detection and management of preeclampsia with close monitoring of fluid intake and cardiac evaluation in case of suspected pulmonary oedema. Therefore, a multidisciplinary clinical approach is recommended.
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Affiliation(s)
- Anke Heitkamp
- Department of Obstetrics and Gynaecology, Stellenbosch University and Tygerberg Academic Hospital, Cape Town, South Africa
- Department of Obstetrics and Gynaecology, Amsterdam UMC, Vrije Universiteit Amsterdam and Research Institute Amsterdam Reproduction & Development, Amsterdam, The Netherlands
| | - Evelien Sandberg
- Department of Obstetrics and Gynaecology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Ashley Moodley
- Department of Obstetrics and Gynaecology, Stellenbosch University and Tygerberg Academic Hospital, Cape Town, South Africa
| | - Jonathan Burke
- Department of Anaesthesiology and Critical Care, Stellenbosch University and Tygerberg Academic Hospital, Cape Town, South Africa
| | - Jos van Roosmalen
- Department of Obstetrics and Gynaecology, Leiden University Medical Centre, Leiden, The Netherlands
- Athena Institute, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Stefan Gebhardt
- Department of Obstetrics and Gynaecology, Stellenbosch University and Tygerberg Academic Hospital, Cape Town, South Africa
| | - Linda Vollmer
- Department of Obstetrics and Gynaecology, Stellenbosch University and Tygerberg Academic Hospital, Cape Town, South Africa
| | - Johanna I de Vries
- Department of Obstetrics and Gynaecology, Amsterdam UMC, Vrije Universiteit Amsterdam and Research Institute Amsterdam Reproduction & Development, Amsterdam, The Netherlands
| | - Thomas van den Akker
- Department of Obstetrics and Gynaecology, Leiden University Medical Centre, Leiden, The Netherlands
- Athena Institute, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Gerhard Theron
- Department of Obstetrics and Gynaecology, Stellenbosch University and Tygerberg Academic Hospital, Cape Town, South Africa
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26
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Parks T, Narube L, Perman ML, Sakumeni K, Fong JJ, Engelman D, Colquhoun SM, Steer AC, Kado J. Population-based assessment of cardiovascular complications of rheumatic heart disease in Fiji: a record-linkage analysis. BMJ Open 2023; 13:e070629. [PMID: 37094887 PMCID: PMC10152053 DOI: 10.1136/bmjopen-2022-070629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Accepted: 03/23/2023] [Indexed: 04/26/2023] Open
Abstract
OBJECTIVE To determine population-based rates of non-fatal complications of rheumatic heart disease (RHD). DESIGN Retrospective cohort study based on multiple sources of routine clinical and administrative data amalgamated by probabilistic record-linkage. SETTING Fiji, an upper-middle-income country, where most of the population has access to government-funded healthcare services. PARTICIPANTS National cohort of 2116 patients with clinically apparent RHD aged 5-69 years during 2008 and 2012. PRIMARY AND SECONDARY OUTCOME MEASURES The primary outcome was hospitalisation for any of heart failure, atrial fibrillation, ischaemic stroke and infective endocarditis. Secondary outcomes were first hospitalisation for each of the complications individually in the national cohort as well as in hospital (n=1300) and maternity (n=210) subsets. Information on outcomes was obtained from discharge diagnoses coded in the hospital patient information system. Population-based rates were obtained using relative survival methods with census data as the denominator. RESULTS Among 2116 patients in the national cohort (median age, 23.3 years; 57.7% women), 546 (25.8%) were hospitalised for an RHD complication, a substantial proportion of all cardiovascular admissions in the country during this period in those aged 0-40 years (heart failure, 210/454, 46.3%; ischaemic stroke 31/134, 23.1%). Absolute numbers of RHD complications peaked during the third decade of life with higher population-based rates in women compared with men (incidence rate ratio 1.4, 95% CI 1.3 to 1.6, p<0.001). Hospitalisation for any RHD complication was associated with substantially increased risk of death (HR 5.4, 95% CI 3.4 to 8.8, p<0.001), especially after the onset of heart failure (HR 6.6, 95% CI 4.8 to 9.1, p<0.001). CONCLUSIONS Our study defines the burden of RHD-attributable morbidity in the general population of Fiji, potentially reflecting the situation in low-income and middle-income countries worldwide. Hospitalisation for an RHD complication is associated with markedly increased risk of death, re-emphasising the importance of effective early prevention.
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Affiliation(s)
- Tom Parks
- Department of Infectious Disease, Imperial College London, London, UK
- Wellcome Centre for Human Genetics, University of Oxford, Oxford, UK
| | - Litia Narube
- Department of Obstetrics and Gynaecology, Fiji National University College of Medicine Nursing and Health Sciences, Suva, Rewa, Fiji
| | - Mai Ling Perman
- Department of Internal Medicine, Fiji National University College of Medicine Nursing and Health Sciences, Suva, Rewa, Fiji
| | - Kelera Sakumeni
- Fiji Ministry of Health and Medical Services, Suva, Rewa, Fiji
| | - James J Fong
- Fiji Ministry of Health and Medical Services, Suva, Rewa, Fiji
| | - Daniel Engelman
- Tropical Diseases, Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Samantha M Colquhoun
- National Centre for Epidemiology and Population Health, Australian National University, Canberra, Australian Capital Territory, Australia
| | - Andrew C Steer
- Tropical Diseases, Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Joseph Kado
- Fiji Ministry of Health and Medical Services, Suva, Rewa, Fiji
- Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, Perth, Western Australia, Australia
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27
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Curtis SL, Belham M, Bennett S, James R, Harkness A, Gamlin W, Thilaganathan B, Giorgione V, Douglas H, Carroll A, Kitt J, Colebourn C, Ribeiro I, Fairbairn S, Augustine DX, Robinson S, Thorne SA. 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. Echo Res Pract 2023; 10:7. [PMID: 37076874 PMCID: PMC10116662 DOI: 10.1186/s44156-023-00019-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Accepted: 03/30/2023] [Indexed: 04/21/2023] Open
Abstract
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.
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Affiliation(s)
- Stephanie L Curtis
- University Hospitals Bristol and Weston NHS Trust, Bristol Heart Institute, Marlborough Street, Bristol, BS2 8HW, UK.
| | - Mark Belham
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Sadie Bennett
- University Hospitals of North Midlands, Stoke-On-Trent, UK
| | - Rachael James
- University Hospitals Sussex NHS FT, Brighton, UK
- United Kingdom's Maternal Cardiology Society, London, UK
| | - Allan Harkness
- East Suffolk and North Essex NHS Foundation Trust, Essex, UK
| | - Wendy Gamlin
- North West Heart Centre, Wythenshawe Hospital, Manchester, UK
| | | | | | | | | | - Jamie Kitt
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | | | - Isabel Ribeiro
- University Hospitals Bristol and Weston NHS Trust, Bristol Heart Institute, Marlborough Street, Bristol, BS2 8HW, UK
| | - Sarah Fairbairn
- University Hospitals Bristol and Weston NHS Trust, Bristol Heart Institute, Marlborough Street, Bristol, BS2 8HW, UK
| | - Daniel X Augustine
- Royal United Hospitals Bath NHS Foundation Trust, Bath, UK
- Department for Health, University of Bath, Bath, UK
| | | | - Sara A Thorne
- University Health Network Toronto, Toronto General Hospital & Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
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28
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Elazrag A, Altahir A, Abbas A, Hasabo EA, Ahmed H, Ali H, Abdelrazig I, Ahmed M, Almahal M, Siddig M, Asmally R, Alrawa S, Mohamedelrasheed S, Elnaiem W, Ali S. Handheld echocardiographic screening for rheumatic heart disease by non-experts in rural South Kordofan, Sudan: Supporting task shifting for control of a serious disease. Int J Cardiol 2023; 377:99-103. [PMID: 36681245 DOI: 10.1016/j.ijcard.2023.01.024] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 01/05/2023] [Accepted: 01/16/2023] [Indexed: 01/20/2023]
Abstract
BACKGROUND Rheumatic heart disease (RHD) is a major and preventable cause of cardiac morbidity in Sudan. It can be detected early with a handheld echocardiography (HHE) machine. Our study aimed to screen for RHD in rural South Kordofan and to investigate the ability of non-experts to obtain good quality HHE records. METHODS A cross-sectional study was conducted in South Kordofan, Sudan. A team of non-experts was trained for two weeks on handheld echocardiographic screening for RHD using a simplified protocol. Cases were recorded and reviewed by a pediatric cardiologist. Demographic and clinical features of screened subjects were studied. Descriptive statistics were presented as "number (%)" or "mean ± SD". RHD frequency was expressed as cases per 1000, and the Chi-Square test/Fisher's Exact test was used to compare RHD findings between different groups. RESULTS A total of 467 subjects were screened. Echocardiographic quality was acceptable in 93% of recorded studies, hence 452 cases were included in the analysis. The disease frequency was found to be 50 per 1000. Out of 452 screened subjects (age 10-25 years), 23 were found to have RHD. The disease was mild in 70% and moderate or involving two valves in 30% of patients. Risk factors for the disease included the father's occupation and the village of residence. CONCLUSION Shortly trained non-expert medicals can assist in RHD surveillance in remote areas using HHE for early detection and management. South Kordofan state is highly endemic to RHD and a control program needs to be implemented.
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Affiliation(s)
- Amna Elazrag
- University of Khartoum, Faculty of Medicine, Al-Qasr Avenue, Box 11111, Khartoum, Sudan
| | - Anfal Altahir
- University of Khartoum, Faculty of Medicine, Al-Qasr Avenue, Box 11111, Khartoum, Sudan
| | - Azza Abbas
- University of Khartoum, Faculty of Medicine, Al-Qasr Avenue, Box 11111, Khartoum, Sudan
| | - Elfatih A Hasabo
- University of Khartoum, Faculty of Medicine, Al-Qasr Avenue, Box 11111, Khartoum, Sudan
| | - Hayat Ahmed
- University of Khartoum, Faculty of Medicine, Al-Qasr Avenue, Box 11111, Khartoum, Sudan
| | - Hiba Ali
- University of Khartoum, Faculty of Medicine, Al-Qasr Avenue, Box 11111, Khartoum, Sudan
| | - Ibrahim Abdelrazig
- University of Khartoum, Faculty of Medicine, Al-Qasr Avenue, Box 11111, Khartoum, Sudan
| | - Mohamed Ahmed
- University of Khartoum, Faculty of Medicine, Al-Qasr Avenue, Box 11111, Khartoum, Sudan
| | - Mohamed Almahal
- University of Khartoum, Faculty of Medicine, Al-Qasr Avenue, Box 11111, Khartoum, Sudan
| | - Musab Siddig
- University of Khartoum, Faculty of Medicine, Al-Qasr Avenue, Box 11111, Khartoum, Sudan
| | - Rofida Asmally
- University of Khartoum, Faculty of Medicine, Al-Qasr Avenue, Box 11111, Khartoum, Sudan.
| | - Salma Alrawa
- University of Khartoum, Faculty of Medicine, Al-Qasr Avenue, Box 11111, Khartoum, Sudan
| | | | - Walaa Elnaiem
- University of Khartoum, Faculty of Medicine, Al-Qasr Avenue, Box 11111, Khartoum, Sudan
| | - Sulafa Ali
- University of Khartoum, Faculty of Medicine, Al-Qasr Avenue, Box 11111, Khartoum, Sudan
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29
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Ismail S, Urooj S. Anaesthetic Management and Peripartum Outcomes for Parturients With Valvular Heart Disease in a Tertiary Care Hospital of Pakistan. Cureus 2023; 15:e37666. [PMID: 37206518 PMCID: PMC10189299 DOI: 10.7759/cureus.37666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/16/2023] [Indexed: 05/21/2023] Open
Abstract
Introduction Parturients with valvular heart disease are at increased risk of maternal cardiac and neonatal complications. We aim to observe maternal cardiac complications in relation to the type of anaesthesia and mode of delivery as our primary objective and neonatal complications as the secondary outcomes. Methods We retrospectively reviewed all parturients with valvular heart disease undergoing delivery over a five-year period at the Aga Khan University Hospital, Karachi, Pakistan. to identify maternal cardiac and neonatal complications occurring during the peripartum period. Results Of 83 patients with valvular heart disease, 79.5% had rheumatic heart disease. Caesarian section (CS) was performed in 79.5% of patients and regional anaesthesia (RA) was given to 62.1%. Patients with cardiac risk index > 2 were delivered by CS and 64.5% received RA. One maternal and three neonatal deaths were reported with a complication event rate of 9.64% in parturients and 40.9% in neonates. Incidence of maternal cardiac events was one in 17 (5.8%) for vaginal deliveries versus seven in 66 (10.6 %) for CS. Maternal events for CS under RA was 5/66 (7.5 %) vs 2/66 (3%) under general anaesthesia. The incidence of peripartum maternal cardiac events when stratified by severity of cardiac disease was similar to a previously derived cardiac risk index for pregnant women with cardiac disease with no statistical difference in the adverse events rate from the estimated rates (p-value= 0.42). Conclusion Elective CS with RA was a common approach for high-risk parturients; however, the benefits cannot be ascertained. Despite low maternal and neonatal mortality, significant maternal cardiac and neonatal complications were observed.
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Affiliation(s)
- Samina Ismail
- Department of Anaesthesiology, Aga Khan University Hospital, Karachi, PAK
| | - Sana Urooj
- Department of Anaesthesiology/Pain Management/Surgical ICU, Dr. Ruth K. M. Pfau Civil Hospital Karachi, Dow University of Health Sciences, Karachi, PAK
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30
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Chillo P, Mutagaywa R, Nkya D, Njelekela M, Kwesigabo G, Kahabuka F, Kerry V, Kamuhabwa A. Sub-clinical rheumatic heart disease (RHD) detected by hand-held echocardiogram in children participating in a school-based RHD prevention program in Tanzania. BMC Cardiovasc Disord 2023; 23:155. [PMID: 36966309 PMCID: PMC10040127 DOI: 10.1186/s12872-023-03186-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Accepted: 03/15/2023] [Indexed: 03/27/2023] Open
Abstract
BACKGROUND Rheumatic Heart Disease (RHD) continues to cause suffering and premature deaths in many sub-Saharan Africa (SSA) countries, where the disease is still endemic. RHD is largely preventable and determining its community burden is an important critical step in any RHD prevention program. METHODS We conducted a cross-sectional study of 5-16 years old pupils from 11 primary schools participating in an RHD prevention program in 4 districts in Tanzania, between 2018 and 2019. At the school, all children were invited to participate after receiving consent from their parents/guardians. Participating children filled a questionnaire and were auscultated for cardiac murmurs. Echocardiographic screening was done by two experienced cardiologists, using a hand-held machine (V-Scan, GE®). All positive screening tests were stored for further examination by the same two cardiologists to reach to a consensus of definite, borderline or no RHD, using a modified World Heart Federation (WHF) criterion. RESULTS Of the 6895 children invited, 4738 (68.7%) were screened and 4436 (64.3%) had complete data. The mean (SD) age was 10.04 (2.43) years, and 2422 (54.6%) were girls. Fifty three (1.2%) children were found to have a murmur. The proportion of children with trace or mild valvular regurgitation, sub-valvular/chordal thickening and valvular thickening/deformity were 8.3%, 1.3%, and 1.0%, respectively. Sub-clinical RHD was found in 95 children (59 definite and 36 borderline), giving a prevalence of 2.1%, [95% CI 1.7% - 2.6%]. Sub-clinical RHD was independently associated with female sex (aOR 1.83, 95% CI 1.18-2.85, p = 0.007), older age groups (aOR 1.73, 95% CI 1.10-2.72, p = 0.018 for age group 11-14 years; and aOR 3.02 95% CI 1.01-9.05, p = 0.048 for age group 15-16 years), as well as presence of a cardiac murmur, aOR 5.63 95% CI 2.31-13.69, p < 0.0001. None of the studied socio- or economic factors was associated with the presence of sub-clinical RHD in this study. CONCLUSION The prevalence of sub-clinical RHD among primary school children in Tanzania is 2.1%, similar to previous reports in SSA. Efforts to prevent and control RHD in our communities are highly warranted.
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Affiliation(s)
- Pilly Chillo
- Department of Internal Medicine, Section of Cardiology, School of Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania.
| | - Reuben Mutagaywa
- Department of Internal Medicine, Section of Cardiology, School of Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Deogratias Nkya
- Department of Paediatric and Child Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Marina Njelekela
- Department of Physiology, Muhimbili University of Health and Allied Sciences and Deloitte Consulting Limited, Dar es Salaam, Tanzania
| | - Gideon Kwesigabo
- Department of Epidemiology and Community Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Febronia Kahabuka
- Department of Orthodontics Paedodontics & Community Dentistry, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Vanessa Kerry
- Department of Global Health and Social Medicine, Seed Global Health Partnerships, Boston, USA
- Harvard Medical School, Center for Global Health, Mass General Hospital, Boston, MA, USA
| | - Appolinary Kamuhabwa
- Department of Clinical Pharmacy and Pharmacology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
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Meng ML, Arendt KW, Banayan JM, Bradley EA, Vaught AJ, Hameed AB, Harris J, Bryner B, Mehta LS. Anesthetic Care of the Pregnant Patient With Cardiovascular Disease: A Scientific Statement From the American Heart Association. Circulation 2023; 147:e657-e673. [PMID: 36780370 DOI: 10.1161/cir.0000000000001121] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/15/2023]
Abstract
The pregnancy-related mortality rate in the United States is excessively high. The American Heart Association is dedicated to fighting heart disease and recognizes that cardiovascular disease, preexisting or acquired during pregnancy, is the leading cause of maternal mortality in the United States. Comprehensive scientific statements from cardiology and obstetrics experts guide the treatment of cardio-obstetric patients before, during, and after pregnancy. This scientific statement aims to highlight the role of specialized cardio-obstetric anesthesiology care, presenting a systematic approach to the care of these patients from the anesthesiology perspective. The anesthesiologist is a critical part of the pregnancy heart team as the perioperative physician who is trained to prevent or promptly recognize and treat patients with peripartum cardiovascular decompensation. Maternal morbidity is attenuated with expert anesthesiology peripartum care, which includes the management of neuraxial anesthesia, inotrope and vasopressor support, transthoracic echocardiography, optimization of delivery location, and consideration of advanced critical care and mechanical support when needed. Standardizing the anesthesiology approach to patients with high peripartum cardiovascular risk and ensuring that cardio-obstetrics patients have access to the appropriate care team, facilities, and advanced cardiovascular therapies will contribute to improving peripartum morbidity and mortality.
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Thakkar A, Hameed AB, Makshood M, Gudenkauf B, Creanga AA, Malhamé I, Grandi SM, Thorne SA, D'Souza R, Sharma G. Assessment and Prediction of Cardiovascular Contributions to Severe Maternal Morbidity. JACC. ADVANCES 2023; 2:100275. [PMID: 37560021 PMCID: PMC10410605 DOI: 10.1016/j.jacadv.2023.100275] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 01/30/2023] [Accepted: 02/03/2023] [Indexed: 08/11/2023]
Abstract
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.
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Affiliation(s)
- Aarti Thakkar
- Division of Cardiology, Department of Medicine, Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Afshan B. Hameed
- Department of Obstetrics & Gynecology, Department of Medicine, University of California-Irvine, Irvine, California, USA
| | - Minhal Makshood
- Division of Cardiology, Department of Medicine, Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Brent Gudenkauf
- Division of Cardiology, Department of Medicine, Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Andreea A. Creanga
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Department of Gynecology and Obstetrics, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Isabelle Malhamé
- Division of General Internal Medicine, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
- Center for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Sonia M. Grandi
- Child Health Evaluative Sciences Program, The Hospital for Sick Children, Toronto, Ontario, Canada
- Division of Epidemiology, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Sara A. Thorne
- Division of Cardiology, Pregnancy & Heart Disease Program, Mount Sinai Hospital & University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Rohan D'Souza
- Departments of Obstetrics & Gynaecology and Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Garima Sharma
- Division of Cardiology, Department of Medicine, Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Turi ZG. The 40th Anniversary of Percutaneous Balloon Valvuloplasty for Mitral Stenosis: Current Status. STRUCTURAL HEART : THE JOURNAL OF THE HEART TEAM 2022; 6:100087. [PMID: 37288059 PMCID: PMC10242581 DOI: 10.1016/j.shj.2022.100087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 08/04/2022] [Accepted: 08/08/2022] [Indexed: 06/09/2023]
Abstract
Percutaneous balloon mitral valvuloplasty (PBMV), once the most complex of percutaneous cardiac procedures and essentially the first adult structural heart intervention, set the stage for a host of new technologies. Randomized studies comparing PBMV to surgery were the first to provide a high-level evidence base in structural heart. The devices used have changed little in 40 years, but the advent of improved imaging and the expertise gained in interventional cardiology has provided some additional procedural safety. However, with the decline in rheumatic heart disease, PBMV is being performed in fewer patients in industrialized nations; in turn, these patients have more comorbidities, less favorable anatomy, and thus a higher rate of procedure-related complications. There remain relatively few experienced operators, and the procedure is distinct enough from the rest of the structural heart intervention world that it has its own steep learning curve. This article reviews the use of PBMV in a variety of clinical settings, the influence of anatomic and physiologic factors on outcomes, the changes in the guidelines, and alternative approaches. PBMV remains the procedure of choice in patients with mitral stenosis with ideal anatomy and a useful tool in patients with less than ideal anatomy who are poor surgical candidates. In the 40 years since its first performance, PBMV has revolutionized the care of mitral stenosis patients in developing countries and remains an important option for suitable patients in industrialized nations.
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Affiliation(s)
- Zoltan G. Turi
- Address correspondence to: Zoltan G. Turi, MD, Structural and Congenital Heart Center, Hackensack University Medical Center, Hackensack Meridian School of Medicine, Hackensack, NJ 07601.
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Galusko V, Ionescu A, Edwards A, Sekar B, Wong K, Patel K, Lloyd G, Ricci F, Khanji MY. Management of mitral stenosis: a systematic review of clinical practice guidelines and recommendations. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2022; 8:602-618. [PMID: 34878131 DOI: 10.1093/ehjqcco/qcab083] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 11/08/2021] [Indexed: 11/13/2022]
Abstract
A number of guidelines exist with recommendations for diagnosis and management of mitral stenosis (MS). We systematically reviewed existing guidelines for diagnosis and management of MS, highlighting their similarities and differences, in order to guide clinical decision-making. We searched national and international guidelines in MEDLINE and EMBASE (5/4/2011-5/9/2021), the Guidelines International Network, Guideline Library, National Guideline Clearinghouse, National Library for Health Guidelines Finder, Canadian Medical Association Clinical Practice Guidelines Infobase, and websites of relevant organizations. Two independent reviewers screened titles and abstracts, and the full text of potentially relevant articles where needed. Selected guidelines were assessed for rigor of development; only guidelines with Appraisal of Guidelines for Research and Evaluation II instrument score >50% were included in the final analysis. Four guidelines were retained for analysis. There was consensus for percutaneous mitral balloon commissurotomy as first-line treatment of symptomatic severe rheumatic MS with suitable anatomy. In patients with unfavourable anatomy, surgical intervention should be considered. Exercise testing is indicated if discrepancy exists between symptoms and echocardiographic measurements. There was no clear divide between rheumatic MS and degenerative MS for their respective diagnoses and management. Pregnancy in severe MS is discouraged and the stenosis should be treated before conception. Long-term antibiotic prophylaxis is recommended for patients with rheumatic MS. Recommendations for the management of patients with mixed valvular diseases are lacking.
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Affiliation(s)
- Victor Galusko
- Department of Cardiology, King's College Hospital, London SE5 9RS, UK
| | - Adrian Ionescu
- Morriston, UK Cardiac Regional Centre, Swansea Bay Health Board, Swansea SA6 6NL, UK
| | - Amy Edwards
- Department of Cardiology, Newham University Hospital, Barts Health NHS Trust, Glen Road, London E13 8SL, UK
| | - Baskar Sekar
- Morriston, UK Cardiac Regional Centre, Swansea Bay Health Board, Swansea SA6 6NL, UK
| | - Kit Wong
- Barts Heart Centre, Barts Health NHS Trust, West Smithfield, London EC1A 7BE, UK
| | - Ketna Patel
- Barts Heart Centre, Barts Health NHS Trust, West Smithfield, London EC1A 7BE, UK
| | - Guy Lloyd
- Department of Cardiology, Newham University Hospital, Barts Health NHS Trust, Glen Road, London E13 8SL, UK
- Barts Heart Centre, Barts Health NHS Trust, West Smithfield, London EC1A 7BE, UK
| | - Fabrizio Ricci
- Department of Neuroscience, Imaging and Clinical Sciences, Institute of Advanced Biomedical Technologies, G.d'Annunzio University, 66100 Chieti, Italy
- Department of Clinical Sciences, Lund University, Jan Waldenströms gata 35-205 02, Malmö, SE-221 00, Sweden
- Department of Cardiology, Casa di Cura Villa Serena, 65013 Città Sant'Angelo, Pescara, Italy
| | - Mohammed Y Khanji
- Department of Cardiology, Newham University Hospital, Barts Health NHS Trust, Glen Road, London E13 8SL, UK
- Barts Heart Centre, Barts Health NHS Trust, West Smithfield, London EC1A 7BE, UK
- NIHR Barts Biomedical Research Centre, William Harvey Research Institute, Queen Mary University of London, London EC1A 7BE, UK
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Park K, Bortnick AE, Lindley KJ, Sintek M, Sethi S, Choi C, Davis MB, Walsh MN, Voeltz M, Bello NA, Saw J, Ahmed MM, Smilowitz NR, Vidovich MI, American College of Cardiology Cardiovascular Disease in Women Committee and the Cardio-Obstetrics Work Group. Interventional Cardiac Procedures and Pregnancy. JOURNAL OF THE SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY & INTERVENTIONS 2022; 1:100427. [PMID: 39131483 PMCID: PMC11307807 DOI: 10.1016/j.jscai.2022.100427] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 07/05/2022] [Accepted: 07/11/2022] [Indexed: 08/13/2024]
Abstract
As the average maternal age advances with increasing concurrent cardiovascular disease risk factors, more women are entering pregnancy with or at risk for various cardiovascular conditions. Although rare, pregnant patients may require various cardiac interventions in the catheterization laboratory. An understanding of indications for intervention in pregnant patients with conditions such as myocardial infarction, severe valvular disease, and cardiogenic shock is critical to optimizing both fetal and maternal outcomes. This document highlights the most common cardiovascular conditions that may be encountered during pregnancy that may require intervention and highlights indications for intervention and periprocedural considerations to facilitate favorable maternal and fetal outcomes.
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Affiliation(s)
- Ki Park
- North Florida/South Georgia Veterans Health System, Malcom Randall VA Medical Center, Gainesville, Florida
- Division of Cardiovascular Medicine, University of Florida College of Medicine, Gainesville, Florida
| | - Anna E. Bortnick
- Department of Medicine, Division of Cardiology, Maternal and Fetal Medicine-Cardiology Joint Program and Department of Medicine, Division of Geriatrics, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York
| | - Kathryn J. Lindley
- Cardiovascular Division, Department of Medicine, Washington University in St. Louis, St. Louis, Missouri
| | - Marc Sintek
- Cardiovascular Division, Department of Medicine, Washington University in St. Louis, St. Louis, Missouri
| | - Sanjum Sethi
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Calvin Choi
- North Florida/South Georgia Veterans Health System, Malcom Randall VA Medical Center, Gainesville, Florida
- Division of Cardiovascular Medicine, University of Florida College of Medicine, Gainesville, Florida
| | - Melinda B. Davis
- Division of Cardiology, VA Ann Arbor Healthcare System and University of Michigan, Ann Arbor, Michigan
| | | | - Michele Voeltz
- Northside Hospital Cardiovascular Institute, Atlanta, Georgia
| | - Natalie A. Bello
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Jacqueline Saw
- Division of Cardiology, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - Mustafa M. Ahmed
- Division of Cardiovascular Medicine, University of Florida College of Medicine, Gainesville, Florida
| | - Nathaniel R. Smilowitz
- Department of Medicine, Leon H. Charney Division of Cardiology, New York University School of Medicine, New York, New York
| | - Mladen I. Vidovich
- Department of Medicine, Division of Cardiology, University of Illinois, Chicago, Illinois
| | - American College of Cardiology Cardiovascular Disease in Women Committee and the Cardio-Obstetrics Work Group
- North Florida/South Georgia Veterans Health System, Malcom Randall VA Medical Center, Gainesville, Florida
- Division of Cardiovascular Medicine, University of Florida College of Medicine, Gainesville, Florida
- Department of Medicine, Division of Cardiology, Maternal and Fetal Medicine-Cardiology Joint Program and Department of Medicine, Division of Geriatrics, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York
- Cardiovascular Division, Department of Medicine, Washington University in St. Louis, St. Louis, Missouri
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
- Division of Cardiology, VA Ann Arbor Healthcare System and University of Michigan, Ann Arbor, Michigan
- St. Vincent Heart Center, Indianapolis, Indiana
- Northside Hospital Cardiovascular Institute, Atlanta, Georgia
- Division of Cardiology, Vancouver General Hospital, Vancouver, British Columbia, Canada
- Department of Medicine, Leon H. Charney Division of Cardiology, New York University School of Medicine, New York, New York
- Department of Medicine, Division of Cardiology, University of Illinois, Chicago, Illinois
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Jones GL, Mitchell CA, Hirst JE, Anumba DOC. Understanding the relationship between social determinants of health and maternal mortality: Scientific Impact Paper No. 67. BJOG 2022; 129:1211-1228. [PMID: 35139580 DOI: 10.1111/1471-0528.17044] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Within this document we use the terms pregnant woman and women's health. However, it is important to acknowledge that it is not only people who identify as women for whom it is necessary to access care. Obstetric and gynaecology services and delivery of care must therefore be appropriate, inclusive and sensitive to the needs of those individuals whose gender identity does not align with the sex they were assigned at birth.
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Affiliation(s)
| | | | - Jane E Hirst
- Royal College of Obstetricians and Gynaecologists, London, UK
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Elkayam U, Bansal P, Mehra A. Catheter-Based Interventions for the Management of Valvular Heart Disease During Pregnancy. JACC. ADVANCES 2022; 1:100022. [PMID: 38939308 PMCID: PMC11198064 DOI: 10.1016/j.jacadv.2022.100022] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 03/01/2022] [Accepted: 03/09/2022] [Indexed: 06/29/2024]
Abstract
Pregnancy is associated with a significant increase in hemodynamic burden. These changes can lead to maternal morbidity and mortality as well as unfavorable fetal outcomes in patients with valvular heart disease and limited cardiac reserve. Mechanical interventions may be needed for the management of severe hemodynamic deterioration not responding to medical therapy. Catheter-based percutaneous interventions can provide an alternative therapy to surgery during pregnancy. The purpose of this article is to review indications, potential advantages, and limitations of catheter-based interventions for the management of women with valvular heart disease in pregnancy.
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Affiliation(s)
- Uri Elkayam
- Division of Cardiology, Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
- Department of Obstetrics and Gynecology, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Priya Bansal
- Division of Cardiology, Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Anil Mehra
- Division of Cardiology, Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
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Rivera FB, Magalong JV, Tantengco OA, Mangubat GF, Villafuerte MG, Volgman AS. Maternal and neonatal outcomes among pregnant women with cardiovascular disease in the Philippines: a retrospective cross-sectional study from 2015-2019. J Matern Fetal Neonatal Med 2022; 35:9922-9933. [PMID: 35634711 DOI: 10.1080/14767058.2022.2076590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
PURPOSE Several studies link maternal cardiovascular disease (CVD) to maternal and fetal morbidity and mortality. This study describes the profile of maternal, obstetric, and neonatal outcomes among pregnant women with CVD in a tertiary hospital in the Philippines. It identifies the clinical and sociodemographic variables associated with these outcomes. MATERIALS AND METHODS A single-center, retrospective analysis of pregnant women admitted for delivery at the Philippine General Hospital from 2015 to 2019 was performed. Of these patients, pregnant women with CVD were identified as the cohort for this study. Data on clinical and sociodemographic factors, maternal major adverse cardiovascular events, neonatal adverse clinical events, and obstetric complications were collected. Logistic regression analysis was performed to determine the odds ratio for the risk factors for small-for-gestational-age (SGA) babies and preterm birth. RESULTS Among 30,053 delivery admissions in the Philippine General Hospital from 2015 to 2019, 293 (0.98%) pregnant women had CVD. Of the CVDs present in this cohort, congenital heart diseases (n = 119, 40.6%) were the most common, followed by rheumatic heart disease (n = 109, 37.2%). Maternal adverse events were rarely observed. Four women experienced symptomatic arrhythmias, two presented with worsening heart failure, three experienced thromboembolic events, and one had cerebrovascular infarction. There was no reported maternal death, cardiac arrest, shock, or acute renal failure. The majority (69.3%) of the women included in the study were delivered by spontaneous vaginal delivery and assisted vaginal delivery by vacuum or forceps; however, a significant portion of these women had undergone cesarean section. Almost all the study cohort delivered live births, with most neonates being delivered at 37-38 weeks gestational age (83.6%) and only 16.0% born preterm. However, a significant portion, a third of the neonates, were classified as having low birth weight. Around 17.4% of neonates born from gravidocardiac mothers were admitted neonatal intensive care unit. Conditions associated with preterm birth were low educational attainment, previous history of early neonatal death, maternal low ejection fraction, and abnormal maternal left ventricular geometry. The conditions associated with SGA babies were high gravidity and parity, a history of abortion/stillbirth, a history of previous cesarean section delivery, low ejection fraction, a history of multiple gestations, and higher BMI. CONCLUSION In this cohort study, adverse maternal outcomes were rarely observed. CVD in pregnancy is associated with an increased risk of preterm birth and SGA babies. We identified certain maternal conditions and sociodemographic factors associated with these outcomes. Despite having CVD, our study cohort had no mortality from the pregnancy.
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Affiliation(s)
- Frederick Berro Rivera
- Department of Medicine, University of the Philippines-Philippine General Hospital, Manila, Philippines
| | - John Vincent Magalong
- Department of Medicine, University of the Philippines-Philippine General Hospital, Manila, Philippines
| | | | | | - Mary Grace Villafuerte
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of the Philippines - Philippine General Hospital, Manila, Philippines
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Liaw J, Gorton S, Heal C, White A. Adherence to secondary prevention of rheumatic fever and rheumatic heart disease in young people: an 11-year retrospective study. Aust N Z J Public Health 2022; 46:758-763. [PMID: 35616403 DOI: 10.1111/1753-6405.13250] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Revised: 02/01/2022] [Accepted: 03/01/2022] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVES To evaluate the secondary prevention of acute rheumatic fever (ARF) and rheumatic heart disease (RHD) in the Townsville region, Australia. METHODS Adherence to benzathine benzylpenicillin G (BPG) was determined for 196 children and young adults aged under 22 years between January 2009 and December 2019, and factors associated with BPG adherence were analysed. Secondary outcomes included attendance at specialist reviews and echocardiograms. RESULTS Adequate adherence (80%) to regular BPG injections was met by 51.1% of the cohort. Adequate BPG adherence more likely occurred for those that attended the Paediatric Outreach Clinic (OR4.15, 95%CI:2.13-8.05) or a school delivery program (OR1.87, 95%CI:1.11-3.45). People with moderate/severe RHD had greater BPG adherence (OR1.76,95%CI:1.00-3.10). People in rural/remote areas were less likely to have adequate BPG adherence compared to urban counterparts (OR0.31, 95%CI:0.15-0.65). Adherence to echocardiography was 66% and specialist review attendance was 12.5-50%. CONCLUSION Half of the cohort in the Townsville region received adequate BPG prophylaxis to prevent ARF/RHD. Although rates were relatively higher than those reported in other Australian regions, health delivery goals should be close to 100%. Low attendance at specialist services was reported. Implication for public health: Delivery models with dedicated services, case management and family support could improve BPG adherence in individuals with ARF/RHD. Further resources in rural and remote areas are needed.
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Affiliation(s)
- Joshua Liaw
- College of Medicine and Dentistry, James Cook University, Queensland
| | - Susan Gorton
- College of Medicine and Dentistry, James Cook University, Queensland
| | - Clare Heal
- College of Medicine and Dentistry, James Cook University, Queensland
| | - Andrew White
- College of Medicine and Dentistry, James Cook University, Queensland.,Department of Paediatrics, Townsville University Hospital, Queensland
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40
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Cardiac disease in pregnancy. Best Pract Res Clin Anaesthesiol 2022; 36:191-208. [PMID: 35659955 DOI: 10.1016/j.bpa.2022.02.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 02/16/2022] [Indexed: 11/22/2022]
Abstract
In the developed world, cardiovascular disease has become the most frequent cause of death during pregnancy and postpartum, outnumbering by far obstetric causes of death such as bleeding or thromboembolism. Many factors contribute to this phenomenon, including an increasing age of pregnant women, co-morbidities, and an unhealthy lifestyle. The cardiovascular system is not only significantly challenged by physiological alterations in pregnancy but also by obstetric medication. Depending upon the severity of the underlying condition, pregnant women with cardiovascular disease should be managed by a multidisciplinary heart team in which anaesthesiologists play an important role. Profound knowledge of the cardiac pathophysiology is a prerequisite for the successful anaesthesiologic management of pregnant patients with cardiovascular disease. As there is no difference in general and regional anaesthesia regarding maternal outcomes, neuraxial anaesthesia using incremental techniques should be preferred for labour and (caesarean) delivery if not contraindicated by non-cardiac issues.
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41
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Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Rafael Sádaba J, Tribouilloy C, Wojakowski W. Guía ESC/EACTS 2021 sobre el diagnóstico y tratamiento de las valvulopatías. Rev Esp Cardiol 2022. [DOI: 10.1016/j.recesp.2021.11.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Rajan M, Sachan S, Abhinay A, Verma B. Maternal and fetal outcomes of COVID-19 infection in pregnant women with chronic rheumatic heart disease in a South Asian population: A case series. J Obstet Gynaecol Res 2022; 48:1480-1483. [PMID: 35354225 PMCID: PMC9115210 DOI: 10.1111/jog.15248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2022] [Revised: 03/12/2022] [Accepted: 03/21/2022] [Indexed: 11/27/2022]
Abstract
Rheumatic heart disease (RHD) is associated with an increased risk of adverse maternal, fetal, and neonatal outcomes, particularly in developing countries. The current COVID-19 pandemic has also affected pregnant women, probably increasing the adverse effects. It is speculated that COVID-19 infection in pregnant women would further increase the risk of complications. However, factual data is still lacking, especially from resource-constrained countries. We conducted a case series of 20 pregnant women with RHD and COVID-19 infection and compared their outcomes with 40 with RHD but without COVDI-19. We observed a high risk of adverse cardiac and pregnancy effects across the whole cohort of 60 patients. However, the comparative study between the two groups failed to show any incremental risk of complications due to COVID-19 infection. Although the sample size was limited; the results are encouraging, particularly for developing countries.
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Affiliation(s)
- Mamta Rajan
- Department of Obstetrics and Gynecology, Institute of Medical Sciences, BHU, Varanasi, India
| | - Shikha Sachan
- Department of Obstetrics and Gynecology, Institute of Medical Sciences, BHU, Varanasi, India
| | - Abhishek Abhinay
- Department of Pediatrics, Institute of Medical Sciences, BHU, Varanasi, India
| | - Bhupendra Verma
- Department of Cardiology, Institute of Medical Sciences, BHU, Varanasi, India
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Wu FM, Quade BJ, Carreon CK, Schefter ZJ, Moses A, Lachtrupp CL, Markley JC, Gauvreau K, Valente AM, Economy KE. Placental Findings in Pregnancies Complicated by Maternal Cardiovascular Disease. JACC. ADVANCES 2022; 1:100008. [PMID: 38939083 PMCID: PMC11198399 DOI: 10.1016/j.jacadv.2022.100008] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 01/31/2022] [Accepted: 02/07/2022] [Indexed: 06/29/2024]
Abstract
Background The incidence of pregnancy in women with cardiovascular disease (CVD) has increased, yet little is known about placental pathology in these women. Objectives The objectives of this study were to describe placental pathology in pregnancies complicated by maternal CVD and to compare findings among categories of maternal CVD. Methods A retrospective, single-center study was conducted. Pathology reports for 264 placentas from pregnancies complicated by maternal CVD were reviewed for prespecified pathologic findings which were then compared against maternal characteristics. Results Placentas were from pregnancies associated with maternal congenital heart disease (n = 171), arrhythmia (n = 43), cardiomyopathy (n = 20), connective tissue disease (n = 20), and valvular heart disease (n = 10). Median maternal age at delivery was 32 years (range: 19-49). Median gestational age at delivery was 39 weeks (range: 25-41). Placental pathology was identified in 75% (199/264) of placentas. Anatomic pathology, primarily small placenta by weight, was present in 45% (119/264) of placentas. Vascular pathology, primarily maternal vascular malperfusion or fetal vascular malperfusion, was seen in 41% (107/264) of placentas. Acute chorioamnionitis and villitis of unknown etiology (VUE) were seen in 23% (61/264) and 11% (28/264) of placentas, respectively. Prevalence of VUE differed across CVD categories (P = 0.008) and was most common in maternal congenital heart disease; there were no differences in anatomic, infectious, and vascular pathologies across CVD categories. Conclusions Pregnancies among women with CVD commonly demonstrate abnormal placental findings, especially anatomic and vascular pathology. Prevalence of VUE differed across CVD categories. Otherwise, the incidence of specific pathology findings did not differ based on maternal characteristics.
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Affiliation(s)
- Fred M. Wu
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Bradley J. Quade
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Pathology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Chrystalle Katte Carreon
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Pathology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Zoë J. Schefter
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts
| | - Abigail Moses
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts
| | - Cara L. Lachtrupp
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts, USA
| | - John C. Markley
- Department of Anesthesia and Perioperative Care, Zuckerberg San Francisco General Hospital and Trauma Center, University of California-San Francisco, San Francisco, California, USA
| | - Kimberlee Gauvreau
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Anne Marie Valente
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Katherine E. Economy
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Brigham and Women’s Hospital, Boston, Massachusetts, USA
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Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W. 2021 ESC/EACTS Guidelines for the management of valvular heart disease. EUROINTERVENTION 2022; 17:e1126-e1196. [PMID: 34931612 PMCID: PMC9725093 DOI: 10.4244/eij-e-21-00009] [Citation(s) in RCA: 200] [Impact Index Per Article: 66.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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45
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Gupta R, Alcantara R, Mahajan S, Malik AH, Mehta SS, Frishman WH, Aronow WS. Interventional Cardiology and Catheter-Based Interventions in Pregnancy. Cardiol Rev 2022; 30:24-30. [PMID: 33027066 DOI: 10.1097/crd.0000000000000361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Cardiovascular disease is the leading cause of maternal mortality worldwide and has been increasing in prevalence over the last several decades. Pregnancy is associated with significant hemodynamic changes that can overwhelm the maternal cardiovascular reserve, and may exacerbate previously asymptomatic cardiovascular disease. Complications associated with these may cause substantial harm to both the mother and the fetus, and the management of these conditions is often challenging. Numerous novel treatments and interventions have demonstrated the safety and efficacy of managing these conditions outside of pregnancy. However, there are little data regarding their use in the pregnant population. In this review, we describe the common cardiovascular diseases encountered during pregnancy and discuss their management strategies, with a particular focus on the role of percutaneous, catheter-based therapeutic interventions.
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Affiliation(s)
- Rahul Gupta
- From the Lehigh Valley Heart Institute, Lehigh Valley Health Network, Allentown, PA
| | | | - Sugandhi Mahajan
- Department of Internal Medicine, Carle Foundation Hospital, Urbana, IL
| | - Aaqib H Malik
- Department of Medicine, Division of Cardiology, Westchester Medical Center and New York Medical College, Valhalla, NY
| | - Sanjay S Mehta
- Department of Cardiology, Carle Foundation Hospital, Urbana, IL
| | - William H Frishman
- Department of Medicine, Division of Cardiology, Westchester Medical Center and New York Medical College, Valhalla, NY
| | - Wilbert S Aronow
- Department of Medicine, Division of Cardiology, Westchester Medical Center and New York Medical College, Valhalla, NY
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46
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Büber İ. A response to percutaneous mitral commissurotomy in women with asymptomatic severe mitral stenosis before pregnancy. Acta Cardiol 2021; 77:666. [PMID: 34886741 DOI: 10.1080/00015385.2021.2014109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- İpek Büber
- Faculty of Medicine, Department of Cardiology, Pamukkale University, Denizli, Turkey
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47
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Hammami R, Ibn Hadj MA, Mejdoub Y, Bahloul A, Charfeddine S, Abid L, Kammoun S, Dammak A, Chaabene K. Predictors of maternal and neonatal complications in women with severe valvular heart disease during pregnancy in Tunisia: a retrospective cohort study. BMC Pregnancy Childbirth 2021; 21:813. [PMID: 34876044 PMCID: PMC8653539 DOI: 10.1186/s12884-021-04259-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2020] [Accepted: 11/09/2021] [Indexed: 11/10/2022] Open
Abstract
Background Severe valvular heart disease, especially stenosis, is a contraindication for conception according to the World Health Organization. This is still encountered in countries with a high rheumatic fever prevalence. The objective of this study was to determine predictors of maternal cardiac, obstetric and neonatal complications in pregnant women with severe valve disease. Methods This is an observational retrospective cohort study of all pregnant women with severe heart valvulopathy who gave birth between 2010 and 2017. Results We included 60 pregnancies in 54 women. Cardiac complications occurred during 37 pregnancies (61%). In multivariate analysis, parity (aOR =2.41, 95% CI[1.12–5.16]), revelation of valvulopathy during pregnancy (aOR = 6.34; 95% CI[1.26–31.77]), severe mitral stenosis (aOR = 6.98, 95% CI[1.14–41.05],) and systolic pulmonary arterial pressure (aOR =1.08, 95% CI[1.01–1.14]) were associated with cardiac complications. Obstetrical complications were noted during 19 pregnancies (31.8%). These complications were associated with nulliparity (aOR = 5.22; 95% CI[1.15–23.6]), multiple valve disease (aOR = 5.26, 95% CI[1.19–23.2]), systolic pulmonary arterial pressure (aOR =1.04, 95% CI[1.002–1.09]), and treatment with vitamin K antagonists (aOR = 8.71, 95% CI[1.98–38.2]). Neonatal complications were noted in 39.3% of newborns (n = 61) and these were associated with occurrence of obstetric complications (aOR = 16.47, 95% CI[3.2–84.3]) and revelation of valvulopathy during pregnancy (aOR = 7.33, 95% CI[1.4–36.1]). Conclusions Revelation of valvular heart disease during pregnancy is a predictor of not only cardiac but also neonatal complications. Valvular heart disease screening during pre-conceptional counseling is thus crucial. Supplementary Information The online version contains supplementary material available at 10.1186/s12884-021-04259-6.
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Affiliation(s)
- Rania Hammami
- Department of Cardiology, Hedi Chaker Hospital, 3029, Sfax, Tunisia. .,Research Unit UR 17ES37, Faculty of Medicine, University of SFAX, Sfax, Tunisia.
| | | | - Yosra Mejdoub
- Department of Epidemiology, Hedi Chaker Hospital, Sfax, Tunisia
| | - Amine Bahloul
- Department of Cardiology, Hedi Chaker Hospital, 3029, Sfax, Tunisia.,Research Unit UR 17ES37, Faculty of Medicine, University of SFAX, Sfax, Tunisia
| | - Selma Charfeddine
- Department of Cardiology, Hedi Chaker Hospital, 3029, Sfax, Tunisia.,Research Unit UR 17ES37, Faculty of Medicine, University of SFAX, Sfax, Tunisia
| | - Leila Abid
- Department of Cardiology, Hedi Chaker Hospital, 3029, Sfax, Tunisia.,Research Unit UR 17ES37, Faculty of Medicine, University of SFAX, Sfax, Tunisia
| | - Samir Kammoun
- Department of Cardiology, Hedi Chaker Hospital, 3029, Sfax, Tunisia.,Research Unit UR 17ES37, Faculty of Medicine, University of SFAX, Sfax, Tunisia
| | - Abdallah Dammak
- Department of Obstetrics & Gynecology, Hedi Chaker Hospital, Sfax, Tunisia
| | - Kais Chaabene
- Department of Obstetrics & Gynecology, Hedi Chaker Hospital, Sfax, Tunisia
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48
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Cupido B, Zühlke L, Osman A, van Dyk D, Sliwa K. Managing Rheumatic Heart Disease in Pregnancy: A Practical Evidence-Based Multidisciplinary Approach. Can J Cardiol 2021; 37:2045-2055. [PMID: 34571164 DOI: 10.1016/j.cjca.2021.09.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 09/17/2021] [Accepted: 09/18/2021] [Indexed: 10/20/2022] Open
Abstract
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.
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Affiliation(s)
- Blanche Cupido
- Division of Cardiology, Department of Medicine, Groote Schuur Hospital, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.
| | - Liesl Zühlke
- Division of Cardiology, Department of Medicine, Groote Schuur Hospital, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa; Division of Paediatric Cardiology, Department of Paediatrics and Child Health, Red Cross Children's Hospital, Cape Town, South Africa; Cape Heart Institute, Department of Medicine, University of Cape Town, Cape Town, South Africa; The Deanery, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Ayesha Osman
- Department of Obstetrics and Gynaecology: Maternal Fetal Medicine Unit, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Dominique van Dyk
- Department of Anaesthesia and Perioperative Medicine, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa
| | - Karen Sliwa
- Division of Cardiology, Department of Medicine, Groote Schuur Hospital, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa; Cape Heart Institute, Department of Medicine, University of Cape Town, Cape Town, South Africa
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49
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The Spectrum, Severity and Outcomes of Rheumatic Mitral Valve Disease in Pregnant Women in Australia and New Zealand. Heart Lung Circ 2021; 31:480-490. [PMID: 34840063 DOI: 10.1016/j.hlc.2021.10.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 08/16/2021] [Accepted: 10/21/2021] [Indexed: 11/23/2022]
Abstract
BACKGROUND Rheumatic heart disease (RHD) poses significant perinatal risks. We aimed to describe the spectrum, severity and outcomes of rheumatic mitral valve disease in pregnancy in Australia and New Zealand. METHODS A prospective, population-based cohort study of pregnant women with RHD recruited 2013-14 through the hospital-based Australasian Maternity Outcomes Surveillance System. Outcome measures included maternal and perinatal morbidity and mortality. Univariable and multivariable logistic regression analyses were undertaken to test for predictors of adverse maternal and perinatal outcomes. RESULTS Of 274 pregnant women identified with RHD, 124 (45.3%) had mitral stenosis (MS) and 150 (54.7%) had isolated mitral regurgitation (MR). One woman with mild MS/moderate MR died. There were six (2.2%) stillbirths and two (0.7%) neonatal deaths. Babies born to women with MS were twice as likely to be small-for-gestational-age (22.7% vs 11.4%, p=0.013). In women with MS, use of cardiac medication (AOR 7.42) and having severe stenosis (AOR 16.35) were independently associated with adverse cardiac outcomes, while NYHA class >1 (AOR 3.94) was an independent predictor of adverse perinatal events. In women with isolated MR, use of cardiac medications (AOR 7.03) and use of anticoagulants (AOR 6.05) were independently associated with adverse cardiac outcomes. CONCLUSIONS Careful monitoring and specialist care for women with RHD in pregnancy is required, particularly for women with severe MS, those on cardiac medication, and those on anticoagulation, as these are associated with increased risk of adverse maternal cardiac outcomes. In the context of pregnancy, contraception and preconception planning are important for young women diagnosed with RHD.
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50
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Minhas AS, Rahman F, Gavin N, Cedars A, Vaught AJ, Zakaria S, Resar J, Schena S, Schulman S, Zhao D, Hays AG, Michos ED. Cardiovascular and Obstetric Delivery Complications in Pregnant Women With Valvular Heart Disease. Am J Cardiol 2021; 158:90-97. [PMID: 34452683 PMCID: PMC8765669 DOI: 10.1016/j.amjcard.2021.07.038] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Revised: 07/10/2021] [Accepted: 07/16/2021] [Indexed: 10/20/2022]
Abstract
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.
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Affiliation(s)
- Anum S Minhas
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland.
| | - Faisal Rahman
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Nicole Gavin
- Department of Maternal Fetal Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Ari Cedars
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Arthur Jason Vaught
- Department of Maternal Fetal Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Sammy Zakaria
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jon Resar
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Stefano Schena
- Division of Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Steven Schulman
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Di Zhao
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Allison G Hays
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Erin D Michos
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland; The Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland
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