High-Risk Cardiac Disease in Pregnancy: Part I Elkayam, Uri; Goland, Sorel; Pieper, Petronella G ...
Journal of the American College of Cardiology,
07/2016, Volume:
68, Issue:
4
Journal Article
Peer reviewed
The incidence of pregnancy in women with cardiovascular disease is rising, primarily due to the increased number of women with congenital heart disease reaching childbearing age and the changing ...demographics associated with advancing maternal age. Although most cardiac conditions are well tolerated during pregnancy and women can deliver safely with favorable outcomes, there are some cardiac conditions that have significant maternal and fetal morbidity and mortality. The purpose of this paper is to review the available published reports and provide recommendations on the management of women with high-risk cardiovascular conditions during pregnancy.
One-third of women with heart disease use medication for the treatment of cardiovascular disease (CVD) during pregnancy. Increased plasma volume, renal clearance, and liver enzyme activity in ...pregnant women change the pharmacokinetics of these drugs, often resulting in the need for an increased dose. Fetal well-being is a major concern among pregnant women. Fortunately, many drugs used to treat CVD can be used safely during pregnancy, with the exception of high-dose warfarin in the first trimester, angiotensin-converting-enzyme inhibitors, angiotensin-receptor blockers, amiodarone, and spironolactone. A timely and thorough discussion between the cardiologist and the pregnant patient about the potential benefits and adverse effects of medication for CVD is important. Noncompliance with necessary treatment for cardiovascular disorders endangers not only the mother, but also the fetus. This Review is an overview of the pharmacokinetic changes in medications for CVD during pregnancy and the safety of these drugs for the fetus. The implications for maternal treatment are discussed. The Review also includes a short section on the cardiovascular effects of medication used for obstetric indications.
Congenital heart defects are the most common birth defects. Major advances in open-heart surgery have led to rapidly evolving cohorts of adult survivors and the majority of affected women now survive ...to childbearing age. The risk of cardiovascular complications during pregnancy and peripartum depends on the type of the underlying defect, the extent and severity of residual haemodynamic lesions and comorbidities. Careful individualized, multi-disciplinary pre-pregnancy risk assessment and counselling, including assessment of risks in the offspring and estimation on long-term outcomes of the underlying heart defect, will enable informed decision making. Depending on the estimated risks, a careful follow-up plan during pregnancy as well as a detailed plan for delivery and postpartum care can reduce the risks and should be made by the multi-disciplinary team.
In this paper the Working Group on Myocardial and Pericardial Disease proposes a revised definition of dilated cardiomyopathy (DCM) in an attempt to bridge the gap between our recent understanding of ...the disease spectrum and its clinical presentation in relatives, which is key for early diagnosis and the institution of potential preventative measures. We also provide practical hints to identify subsets of the DCM syndrome where aetiology directed management has great clinical relevance.
High-Risk Cardiac Disease in Pregnancy: Part II Elkayam, Uri; Goland, Sorel; Pieper, Petronella G ...
Journal of the American College of Cardiology,
08/2016, Volume:
68, Issue:
5
Journal Article
Peer reviewed
Heart disease continues to be the leading cause of nonobstetric maternal morbidity and mortality. Early diagnosis and appropriate care can lead to prevention of complications and improvement of ...pregnancy outcome. This paper continues the review and provides recommendations for the approach to high-risk cardiovascular conditions during gestation.
Direct oral anticoagulants (DOACs) are increasingly used for anticoagulation or prevention of thromboembolic events in conditions that may co-occur with pregnancy. However, evidence regarding ...efficacy and safety during pregnancy is scarce.
To review the current literature concerning the efficacy, safety and outcome of DOACs during pregnancy in humans.
We systematically searched the MedLine public database for all studies describing the use of DOACs during pregnancy published up to July 4th 2017.
236 cases of DOAC use during pregnancy were reported. Rivaroxaban was the most reported DOAC (n = 178). DOACs were mostly used for prophylaxis or treatment of venous thromboembolism (n = 91). DOACs were discontinued within the first 2 months of pregnancy in 84%, maximum reported duration of use was 26 weeks. Pregnancy outcome data were available for 140 pregnancies. Thirty-nine pregnancies were electively terminated. In the remaining 101 pregnancies total miscarriage rate was 31% (n = 31) and live birth rate was 68% (n = 69, 1 missing). Foetal and neonatal abnormalities were reported in 8 pregnancies, of which at least half were suspected to be related to rivaroxaban use during the 1st trimester of pregnancy. In only 18% of cases (n = 42), the presence or absence of thrombotic and bleeding complications was reported.
The limited available evidence raises concern regarding embryo-foetal safety, with high incidence of miscarriages and a 4% rate of anomalies with the use of rivaroxaban. Not enough data are available to judge safety and efficacy of the use of DOACs during pregnancy.
•The current evidence about the use of DOACs during pregnancy raises concern regarding embryo-foetal safety.•There is a high incidence of miscarriages.•There is a 4% rate of anomalies with the use of rivaroxaban.•Not enough data are available to judge safety and efficacy of the use of DOACs during pregnancy.
Aims Data regarding pregnancy outcome in women with congenital heart disease (CHD) are limited. Methods and results In 1802 women with CHD, 1302 completed pregnancies were observed. Independent ...predictors of cardiac, obstetric, and neonatal complications were calculated using logistic regression. The most prevalent cardiac complications during pregnancy were arrhythmias (4.7%) and heart failure (1.6%). Factors independently associated with maternal cardiac complications were the presence of cyanotic heart disease (corrected/uncorrected) (P < 0.0001), the use of cardiac medication before pregnancy (P < 0.0001), and left heart obstruction (P < 0.0001). New characteristics were mechanical valve replacement (P = 0.0014), and systemic (P = 0.04) or pulmonary atrioventricular valve regurgitation related with the underlying (moderately) complex CHD (P = 0.03). A new risk score for cardiac complications is proposed. The most prevalent obstetric complications were hypertensive complications (12.2%). No correlation of maternal characteristics with adverse obstetric outcome was found. The most prevalent neonatal complications were premature birth (12%), small for gestational age (14%), and mortality (4%). Cyanotic heart disease (corrected/uncorrected) (P = 0.0003), mechanical valve replacement (P = 0.03), maternal smoking (P = 0.007), multiple gestation (P = 0.0014), and the use of cardiac medication (P = 0.0009) correlated with adverse neonatal outcome. Conclusion In our tertiary CHD cohort, cardiac, obstetric, and neonatal complications were frequently encountered, and (new) correlations of maternal baseline data with adverse outcome are reported. A new risk score for adverse cardiac complications is proposed, although prospective validation remains necessary.
Abstract Objective Life expectancy of patients with congenital heart disease has improved over the past decades, increasing the need for a durable pulmonary prosthetic valve. Biological valves in ...various forms have become the valve of choice for pulmonary valve replacement (PVR), but structural valve deterioration is unavoidable in the long term. Use of a mechanical valve could be an alternative, but data on long-term outcome is sparse. Methods We retrospectively collected and analyzed data on 364 patients with mechanical valves implanted in the pulmonary position between 1965 and 2014. The data originates from medical centers in Barcelona (Spain), Graz (Austria), Groningen (the Netherlands), Munich (Germany), Rochester (USA), Seoul (Republic of Korea), and Tehran (Iran). Results Median follow-up duration was 4.26 (range 0-27) years, mean age at implantation was 27.16 ± (SD 12.2) years. Tetralogy of Fallot was the most common primary cardiac diagnosis with a subgroup of 69.8%. Freedom from valvar thrombosis was 91% (95%CI 87%-94%) at 5 years and 86% (95% CI 81%-91%) at 10 years post PVR. With a success rate up to 88%, thrombolysis was a successful therapy. Freedom from reoperation was 97% (95% CI 94%-99%) at 5 years post PVR and 91% (95%CI 85%-95%) at 10 years. Conclusion MPVR is associated with a limited risk of valvar thrombosis. Thrombolysis was an effective treatment in the majority.
Heart failure (HF) is one of the most important complications in pregnant women with heart disease, causing maternal and fetal mortality and morbidity.
This is an international observational registry ...of patients with structural heart disease during pregnancy. Sixty hospitals in 28 countries enrolled 1321 women between 2007 and 2011. Pregnant women with valvular heart disease, congenital heart disease, ischaemic heart disease, or cardiomyopathy could be included. Main outcome measures were onset and predictors of HF and maternal and fetal death.
In total, 173 (13.1%) of the 1321 patients developed HF, making HF the most common major cardiovascular complication during pregnancy. Baseline parameters associated with HF were New York Heart Association class ≥ 3, signs of HF, WHO category ≥ 3, cardiomyopathy or pulmonary hypertension. HF occurred at a median time of 31 weeks gestation (IQR 23-40) with the highest incidence at the end of the second trimester (34%) or peripartum (31%). Maternal mortality was higher in patients with HF (4.8% in patients with HF and 0.5% in those without HF p<0.001). Pre-eclampsia was strongly related to HF (OR 7.1, 95% CI 3.9 to 13.2, p<0.001). Fetal death and the incidence of preterm birth were higher in women with HF compared to women without HF (4.6% vs 1.2%, p=0.001; and 30% vs 13%, p=0.001).
HF was the most common complication during pregnancy, and occurred typically at the end of the second trimester, or after birth. It was most common in women with cardiomyopathy or pulmonary hypertension and was strongly associated with pre-eclampsia and an adverse maternal and perinatal outcome.
Mortality in adult congenital heart disease Verheugt, Carianne L.; Uiterwaal, Cuno S.P.M.; van der Velde, Enno T. ...
European heart journal,
05/2010, Volume:
31, Issue:
10
Journal Article
Peer reviewed
Open access
Aims Mortality in adults with congenital heart disease is known to be increased, yet its extent and the major mortality risks are unclear. Methods and results The Dutch CONCOR national registry for ...adult congenital heart disease was linked to the national mortality registry. Cox's regression was used to assess mortality predictors. Of 6933 patients, 197 (2.8%) died during a follow-up of 24 865 patient-years. Compared with the general national population, there was excess mortality, particularly in the young. Median age at death was 48.8 years. Of all deaths, 77% had a cardiovascular origin; 45% were due to chronic heart failure (26%, age 51.0 years) or sudden death (19%, age 39.1 years). Age predicted mortality, as did gender, severity of defect, number of interventions, and number of complications hazard ratio (HR) range 1.1–5.9, P < 0.05. Several complications predicted all-cause mortality beyond the effects of age, gender, and congenital heart disease severity, i.e. endocarditis, supraventricular arrhythmias, ventricular arrhythmias, conduction disturbances, myocardial infarction, and pulmonary hypertension (HR range 1.4–3.1, P < 0.05). These risks were similar in patients above and below 40 years of age. Almost all complications predicted death due to heart failure (HR range 2.0–5.1, P < 0.05); conduction disturbances and pulmonary hypertension predicted sudden death (HR range 2.0–4.7, P < 0.05). Conclusion Mortality is increased in adults with congenital heart disease, particularly in the young. The vast majority die from cardiovascular causes. Mortality risk, particularly by heart failure, is increased by virtually all complications. Complications are equally hazardous in younger as in older patients.
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