Comparing the outcomes of rheumatic heart disease in pregnancy complicated with and without atrial fibrillation: A propensity score matched analysis

BACKGROUND

Atrial fibrillation (AF) may increase the risk of adverse maternal and fetal outcomes among pregnant with rheumatic valvular lesions (RHD). We aimed to assess the rate of occurrence of AF in pregnant with RHD and its impact on cardiac and maternal-fetal outcomes compared to those without it.

METHODS

The study group consisted of pregnant women with RHD and AF (cases) and a matched comparison group of pregnant women with RHD but without AF (controls) was derived from the database of pregnant women with RHD receiving care at our center between 2011 and 2021. Incidence of composite adverse outcomes(maternal death, heart failure, or thrombo-embolic events) and pregnancy outcomes were compared between them.

RESULTS

Seventy-one (5.1%; 95%CI 4.1%-6.4%) pregnant women with RHD had AF during pregnancy and childbirth, most occurring in the late second or early third trimester. New-onset AF was diagnosed in 34 (47.9%) of them. After matching, the incidence of composite outcome was higher in women with AF (77.5% (95%CI 66.3%-85.7%) compared to women without AF (17.3%(95%CI 13.3%-22.1%), P < .001), with seven (9.9%) maternal deaths among cases and two (0.7%) in controls. Heart failure was the most common adverse cardiac event (26.7% vs. 4.2%, P < .001, cases vs controls). Those with AF had higher odds (adjusted OR 56.6 (14.1-226.8)) of adverse cardiac outcomes after adjusting for other risk factors. The frequency of most non-cardiac pregnancy complications was similar in both groups. However, there was a trend towards a higher rate of miscarriage (16.9% vs. 9.9%), small-for-gestational-age babies(16.3 vs. 9.0%), and cesarean rates(31.9% vs. 18.3%) women with AF compared to those who did not experience AF.

CONCLUSIONS

Atrial fibrillation in pregnancy among women with RHD was associated with an increased risk of maternal morbidity and mortality, with a trend towards an increase in some non-cardiac pregnancy complications compared to those pregnant women without AF. Our study results provide background data for developing and implementing a pregnancy-specific management strategy tailored to middle-income settings.

Concurrent valve replacement and caesarean section for rheumatic mitral valve disease with refractory heart failure in late pregnancy

Objective

To assess clinical characteristics and outcomes of women who underwent concurrent valve replacement with caesarean section for severe rheumatic mitral valve disease with refractory heart failure.

Methods

All women admitted to a single centre from 2011 to 2020 with severe rheumatic mitral valve disease, having recurrent episodes of pulmonary edema on optimal medical therapy and contraindication to percutaneous balloon mitral valvotomy, who underwent concurrent valve replacement (for native valve disease) along with caesarean section, were included.

Results

Among 1300 pregnancies with rheumatic heart disease, six underwent the concurrent procedure. All had replacement of mitral valve except one who had both aortic and mitral valve replacements, between 33 and 39 weeks of gestation. There were no maternal deaths, and there was one neonatal loss from late-onset sepsis.

Conclusion

Pregnant women with severe rheumatic mitral valve disease with refractory heart failure, unsuitable for minimal access interventions, can be considered for a concurrent valve replacement with caesarean section.

A validated and optimized method for separation and quantification of total fatty acids by gas chromatography-ion trap mass spectrometry in human plasma

Fatty acids (FAs) are associated with many physiological functions of tissues, and their alteration has been linked with tissue-specific or systemic diseases. The current situation warrants us to have a sensitive and specific method for analysis of total FAs simultaneously from the biological fluid so that the risk prediction, diagnosis or prognosis of the disease can be made effectively. Because of greater sensitivity and resolution, a method of gas chromatography-ion trap mass spectrometry (GC-IT/MS) has been optimized and validated to quantify simultaneously 19 total FAs levels in plasma and compared with GC-triple quadrupole mass spectrometry. FAs have been transesterified by methanolic acetyl chloride to fatty acid methyl esters (FAMEs). A 65 min GC method separated all 19 FAMEs. The calibration curve had good linearity up to 313-922 μM with a correlation coefficient between 0.9882 and 0.9998. The LODs and LOQs of FAMEs were in the range of 0.63 to 9.55 and 2.12 to 31.8 μM, respectively. The method has recovery up to 144 %, stability at 4 °C for 48 h and one freeze-thaw cycle, and good intra-day and inter-day precision. The optimized method has been used to quantify plasma total FAs in type 2 diabetes mellitus patients with and without acute coronary syndrome. Though a significant difference has been found between IT/MS and triple quadrupole mass spectrometry, the GC-IT/MS can help to quantify total FAs in the clinical setting.

Impact of nurse-led cardiac rehabilitation on patient's behavioral and physiological parameters after a coronary intervention: A pilot randomized controlled trial

BACKGROUND

Coronary artery disease, one of the leading causes of mortality and morbidity globally, is a major burden on healthcare resources. Cardiovascular rehabilitation is highly recommended for the early recovery of patients with Ischemic heart disease by improving the functional capacity and decreasing disease progression. A randomized controlled trial was conducted to assess the effect of nurse-led cardiac rehabilitation (CR) on behavioural parameters.

MATERIALS AND METHODS

Sixty-two adult patients who underwent percutaneous coronary intervention (PCI) were randomised to two groups to assess the effect of nurse-led cardiac rehabilitation (CR) on behavioural parameters, including adherence to drugs, cardiac diet, lifestyle changes, and selected physiological parameters. The intervention group had nurse-led individualized discharge counseling and clinical follow-up by telephone, whereas the control group received usual care. The comparisons between the control and intervention groups were made using independent Student's t-test or Mann-Whitney U test as appropriate. Pre-test and post-test scores were compared using paired t-test; all tests performed at 5% significance level.

RESULTS

Participants in the intervention group presented with moderate to good smoking cessation, improved adherence to drugs (P < 0.0001), physically active lifestyle in 90.3 versus 45.2% (P < 0.0001), adherence to dietary changes, and improved healthcare satisfaction (P < 0.0001). There was also a significant reduction in triglycerides level in the intervention group at 62.51 versus 20.12 mg/dl in the control arm with (P < 0.05), and better controlled physiological indices, including a reduction in systolic blood pressure of 1.54 vs-7.12 mmHg (P = 0.003), bodyweight reduction of 2.48 kg versus-0.09 kg (P < 0.0001) and body mass index of 0.9 versus-0.05 (P < 0.0001).

CONCLUSION

Personalised, nurse-led CR significantly improved the participants adherence to healthy lifestyle behaviors and decreased the cardiac risk factors in patients with coronary artery disease.

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

INTRODUCTION

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Influence of maternal and perinatal characteristics on risk of postpartum chronic hypertension after pre-eclampsia

OBJECTIVE

To assess the prevalence of new-onset postpartum chronic hypertension (PPCH) after pre-eclampsia and to determine the factors are associated with it.

METHODS

This study was conducted in a tertiary center in south India, between June 2018 and February 2019, consisting of pre-eclamptic women who were recruited as part of an ongoing cohort and had completed at least 3 months of postpartum follow-up. Demographic, medical, and laboratory details were collected. Primary outcome was a diagnosis of new-onset PPCH at 3 months.

RESULTS

PPCH at 3 months was noted in 32 (18.1%) women. During postnatal follow-up, 2 (1.1%) women experienced hemiplegia from stroke and 19 (10.7%) had elevated serum creatinine levels (>1.1 mg/dL). On multivariate analysis, advancing maternal age (adjusted odds ratio [aOR] 1.10, 95% confidence interval [CI] 1.01-1.21), multiparity (aOR 2.79, 95% CI 1.07-7.24), and eclampsia (aOR 3.07, 95% CI 1.03-9.13) increased the risk of PPCH at 3 months postpartum.

CONCLUSION

One in five women present with a diagnosis of new-onset PPCH within 3 months postpartum in a cohort of predominantly preterm and/or severe pre-eclampsia. A significant but weak association of PPCH with peripartum clinical characteristics was noted. The role of biochemical, hemodynamic, and echocardiographic biomarkers should be evaluated for prediction of PPCH after pre-eclampsia in future studies.

Outcome of pregnancies in women with pulmonary hypertension: a single-centre experience from South India

OBJECTIVE

To study maternal complications and pregnancy outcome in women with pulmonary hypertension, attending a tertiary centre in south India.

STUDY DESIGN

Retrospective observational study.

SETTING

Tertiary centre in south India.

POPULATION

Pregnant women with pulmonary hypertension.

METHOD

Data regarding demographics, clinical course, medication received, and echocardiographic diagnosis regarding pulmonary hypertension and antenatal care received were collected from the records. Details of labour and delivery, and postpartum follow up were retrieved. We compared the outcome based on the presence or absence of cyanosis and right ventricular systolic pressure levels.

MAIN OUTCOME MEASURES

Maternal mortality, occurrence of complications such as heart failure, fetal growth restriction.

RESULTS

There were 81 pregnancies in 73 women with pulmonary hypertension. The majority of them had pulmonary hypertension secondary to congenital heart disease (80.8%); 17.8% had Eisenmenger syndrome. An advanced pulmonary artery hypertension (PAH) medication, sildenafil, was administered in 25 (31.3%) pregnancies. There were four maternal deaths, of which three had Eisenmenger syndrome. Heart failure complicated 6.3% and fetal growth restriction 26.3% of pregnancies. Morbidity was significantly increased in women with pulmonary hypertension associated with a cyanotic cardiac lesion or with right ventricular systolic pressure >70 mmHg.

CONCLUSION

Despite advances in care, mortality in pregnant women with pulmonary hypertension is a matter of concern, especially in those with Eisenmenger syndrome. Multidisciplinary team management in tertiary centres and the use of advanced PAH medications even in low- to middle-income countries with limited resources, could lead to a reduction in morbidity and mortality related to pulmonary hypertension.

TWEETABLE ABSTRACT

Multidisciplinary care and use of new medication may improve outcomes in pregnant women with pulmonary hypertension.

Coronary Angiography Findings and Its Determinants in Patients Presenting With Acute Coronary Syndrome: A Descriptive Analysis from Asian Population

The aim was to study the angiographic profile in patients presented as acute coronary syndrome and its relation with risk factors and comparison between genders. This prospective observational study was performed on total 352 patients of acute coronary syndrome were analyzed for various risk factors, angiographic pattern in Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, South India from January 2015 to July 2016. Mean age of presentation was 52.62±11.63 years. Male were 271(77.0%) and female were 81(23.0%). Majority of patients were STEMI (67.6%) followed by UA (24.4%) and NSTEMI (8%). Smoker was 117(33.3%) patients. Hypertensive were 124(35.2%) of patients and 149(42.3%) were diabetics. Family history of CAD was positive in 45(12.8%). On angiographic evaluation left main reference diameter was lower in females (4.02±0.72) than males (4.07±0.82). LAD was most commonly involved followed by RCA and LCX among all three group of acute coronary syndrome. Left main was least involved (8.3%). In STEMI SVD (40.3%) was most common presentation, after that DVD was seen in 22.3%, TVD in 10.5%, non-obstructive coronary was seen in 16% of patients and normal coronary was seen in 11% of patients. In UA 28%, 22.8%, 13.2%, 15.8%, 20.2% was seen in SVD, DVD, TVD, non-obstructive and normal coronary respectively. Long length coronary lesions (>20mm) were seen in majority in all type of acute coronary syndrome. Coronary lesion length was not associated with presentation acute coronary syndrome and genders. Male were most commonly presented as acute coronary syndrome. STEMI was most common presentation. Diabetic was most prevalent risk factor. SVD was most common angiographic pattern and LAD was most common involved arteries.

Treatment of HCV infection in liver transplant recipients with ledipasvir and sofosbuvir without ribavirin

BACKGROUND

Ledipasvir and sofosbuvir is a well-tolerated regimen with high sustained virological response (SVR) rates in pre-liver transplant patients infected with chronic hepatitis C virus (HCV), but data in liver transplant recipients outside of clinical trials is limited.

AIM

To address this knowledge gap and assess SVR rates without the use of ribavirin in liver transplant recipients METHODS: This is a retrospective study examining the treatment of 75 post-liver transplant recipients with ledipasvir and sofosbuvir without ribavirin. Differences between SVR cohorts and predictors of SVR were analysed in an intention-to-treat (ITT) fashion.

RESULTS

A total of 408 genotype 1, HCV patients were treated with ledipasvir/sofosbuvir from October 2014 to August 2015 at our centre. Seventy-three patients were post-liver transplant and were treated with a median of 2.9 years from transplant. Ledipasvir/sofosbuvir achieved an SVR12 of 95.9%. African Americans made up 28.8% of the cohort. Sixty-three per cent of patients were treated previously, including 13.7% of patients previously treated with direct-acting antivirals. Only 2.7% had recurrent allograft cirrhosis, and the majority (90.4%) was on calcineurin inhibitor based immunosuppressive therapy. Approximately 82% of patients had chronic kidney disease (CKD) stage 2 or 3. In univariate logistic regression, only detectable week 8 viral load was predictive of failure to achieve SVR.

CONCLUSION

Our data confirm excellent SVR outcomes and favourable safety and tolerability profiles with ledipasvir/sofosbuvir without ribavirin in post-liver transplant recipients infected with HCV, despite treatment guidelines to use ribavirin.