heart disease and pregnancy - livemedia.gr · preconceptional counselling roos hesselink et al...
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Heart Disease and Pregnancy
Alexandra A Frogoudaki
Adult Congenital Heart Clinic
Second Cardiology Department
ATTIKON University Hospital
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Pre Pregnancy
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Heart Disease and Pregnancy
• Can a patient with heart disease deliver a baby?
There is no YES or NO
• What do we need to Know?The maternal riskThe fetal riskThe obstetrical riskThe risk of transmission
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Preconceptional Counselling
Roos Hesselink et al Heart Dec 2017
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Pregnancy
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Hemodynamic changes during pregnancy
Uebing et al Heart 2006
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Cardiac Conditions
• Congenital heart disease
• Cardiomyopathy
• Valvular heart disease
• Ischemic heart disease
• Diseases of the aorta
• Pulmonary hypertension
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Predictors of maternal cardiovascular eventsand risk score from the CARPREG study
ESC guidelines December 2011
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Predictors of maternal cardiovascular eventsidentified in congential heart diseases in the
ZAHARA and Khairy study
ESC guidelines December 2011
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Balci A et al (ZAHARA II). Heart 2014
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Position Paper Organization of Care for Pregnancy in
Congenital Heart Disease
Roos Hesselink et al Heart Dec 2017
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Role of echo in pregnancy and heart disease
• Assess systemic ventricular function
• Assess possible LV obstruction
• Exclude pulmonary hypertension
• Exclude other high-moderate risk conditions
• Follow-up
• As guide to treatment (b-blockers, diuretics)
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What happens during delivery and postpartum?
• Stroke volume and cardiac output increases
• Increase in oxygen needs
• As soon as IVC decompresses, increased venous return
• Blood redistribution to the circulation
• Volume overloaded state followed by vasoconstriction!!!
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Registry Of Pregnancy And Cardiac diseaseROPAC
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ROPAC enrollemnt up to September 2017, 5455 pts!
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Heart failure in pregnancyROPAC 1-1321 pregnancies
Ruys TPE et al. Heart 2014
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Timing of heart failureROPAC 1-1321 pregnancies
Ruys TPE et al. Heart 2014
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Kampman MAM et al. EHJ 2014
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JACC Clinical Electrophysiology August 2015
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Congenital Heart Disease
14/2/2015
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Case
• 35 year old with tricuspid atresia• Just after birth: systemic to pulmonary
shunt• Age 11: Fontan type operation (TCPC
with lateral tunnel)• On aspirin and sotalol because of
supraventicular tachycardia• Got pregnant after several IVFs• Valuable pregnancy!
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• On week 17 SV tachycardia with 170/min• Managed with amiodarone in ICU• Several obstetric complications• SVs continued throughout pregnancy with
controlled heart rate• Delivered a healthy but small baby (1600 gr)
on week 31 with CS• She underwent 2 years later tachycardia
ablation guided by magnetic navigation since post pregnancy she continued to have SupraVT
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Valvular Heart Disease
11/10/2013
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Case
• 28 y old referred because of hemoptysis and shortness of breath, 22 weeks pregnant
• MS was diagnosed
• Stabilized on b-blockers and diuretics
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Mitral valvuloplasty
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• She underwent mitral valvuloplasty on week 28th
• MVA increased 0.9cm2>1.2cm2
• She delivered on 38th week
• Healthy girl
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Van Hagen et al Circulation 2015
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Anticoagulation
ESC guidelines December 2011
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Hypetrophic Cardiomyopathy
• Well tolerated during pregnancy
• Caution in epidural (SVR drop, obstruction increases)
• Arrhythmias common
• B-blockers the drug of choice
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Ischemic Heart Disease
• More common as mean age of pregnant women increases
• Acute MI 1:35000 pregnancies
• Coronary artery dissection is more common in pregnancy
• Kawasaki, LM anomalous origin, drugs
For MI primary PCI or thrombolysis may be considered
B-blockers, aspirin and nitrate may be used
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ESC guidelines December 2011
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Pulmonary Hypertension
• In Eisenmenger’s syndrome maternal mortality up to 20-50%
• Usually planned CS
• Anticoagulation issues
• Increased fetal mortality
ESC guidelines December 2011
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Peripartum Cardiomyopathy
• Definition: Workshop held by the National Heart Lung and Blood Institute and the Office of Rare Diseases,2000 states it is cardiomyopathy that must develop during the last month of pregnancy or within 5 months of delivery.
• Low incidence 1/2500-4000 in USA, up to 1/1000 in South Africa
• Poor prognosis up to 10% and 28% mortality in 6 months and 2 years respectively in USA 14% and 16% in Brazil and Haiti
• Could be a genetic predisposition• Oxidative stress and the generation of a cardiotoxic
subfragment of prolactin may play a role
Sliwa et al, Eur J Heart Fail. 2010 Aug
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Clinical characteristics of patients from the worldwide registry on peripartum
cardiomyopathy (PPCM): EORP in conjunction with the Heart Failure Association of the
European Society of Cardiology Study Group on PPCM
Sliwa K, et al. Eur J Heart Fail 2017
411 PPCM patients (ESC and non ESC)Caucasian (34%) Black African (25.8%)Asian (21.8%) Middle Eastern (16.4%).non-ESC vs. ESC countries continued to have symptomatic heart failure after 1 month (92.3% vs. 81.3%) Venous thrombo-embolic events, arterial embolizations, and cerebrovascular accidents were documented in 28 of 411 patients (6.8%)
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Diagnosis
Difficult!!!
Echo plays major role
Sliwa et al, Eur J Heart Fail. 2010 Aug
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Biomarkers in PPCM
D. Hilfiker-Kleiner et alEur Heart J 2015
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Hilfiker-Kleiner et alEur Heart J 2015
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Issues to be adressed• Mechanical or tissue valves
• Anticoagulation
• Mode of delivery
• Assisted second stage
• Management of the third stage
• Beta-blockers
• Impact of pregnancy on cardiac function
• Impact of Ovarian Hyperstimulation Syndrome in patients with cardiac disease
Johnson, Gatzoulis, Roos-Hessenlink Int J Cardiol 2013
Dayan N et al J Am Coll Cardiol 2014
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Additional Considerations
Managing subfertility in patients with heart disease: What are the choices?
Caudwell et al Am Heart J 2017
• Surrogacy, Is this an option?Roos Hesselink et al Heart 2017
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High Risk Pregnancy ClinicATTIKON Hospital
More than 100 pregnant patients with heart disease
• Dilated Cardiomyopathy
• Hypertrophic Cardiomyopathy
• Congenital Heart Disease
• Mechanical Valves
• Valvular Heart Disease
• Peripartum Cardiomyopathy
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Moving towards CardioObstetrics!
• Pregnancy should be considered as a continuum in women’s life
• Events during pregnancy may reflect the cardiovascular status of the pregnant
• Meticulous follow-up and collaboration between specialties is essential for long life of new mothers, without major cardiovascular events that can be predicted and prevented!
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Conclusion
• Pregnancy can be relatively safe in women with heart disease
• Meticulous pre-counseling and follow-up during pregnancy is mandatory
• A multidisciplinary team (pregnancy team) including cardiologist, obstetrician, anesthesiologist and geneticist is necessary in complex cases for maternal and fetal safety
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11/10/2013