EURObservational Research Programme

Titia P.E. Ruys MD1, Jolien W. Roos-Hesselink MD PhD1, Roger Hall MD PhD2, Maria T. Subirana-Domènech3, Jennifer Grando-Ting4, Mette Estensen5, Roberto Crepaz6, Vlasta

Fesslova7, Michelle Gurvitz8, Julie De Backer9, Mark R. Johnson MD PhD10,

Petronella G. Pieper MD PhD11

1. Erasmus Medical Center, Rotterdam, Netherlands, 2. Norfolk & Norwich University NHS Hospital, Norwich, United Kingdom 3. Hospital de Sant Pau, Barcelona, Spain 4. Milton S.

Hershey Medical Center, Hershey, Pennsylvania, USA 5. Oslo University Hospital, Rikshospitalet, Oslo, Norway. 6. Regional Hospital of Bolzano, Bolzano, Italy 7. Policlinico San

Donato IRCCS, Milano, Italy 8. University of Washington, Seattle, Washington, USA 9. Ghent University Hospital, Ghent, Belgium 10. Imperial College London, Chelsea and

Westminster Hospital, London, United Kingdom 11. University Medical Center Groningen, University of Groningen, Netherlands

Heart failure in pregnant women with

cardiac disease:

data from the ROPAC

Nothing to disclose

EURObservational Research Programme

0 n= 599 90 1302 49 74 131 93 213

5

10

15

20

25

heart failure

Introduction Cardiac complications in pregnant women with congenital heart disease

ROPAC

Analysis 2011: 28 countries, 60 centres, 1321 patients

Mean age 30

70 % in NYHA class I

50 % primipara

Admission 26% patients

13% (173 patients) heart failure

872

334

2479

Congenital heart disease

Valvular heart disease

Ischemic heart disease

Cardiomyopathy

872

334

2479

Congenital heart disease

Valvular heart disease

Ischemic heart disease

Cardiomyopathy

Baseline variables Patient with HF

n=173

Patient without HF

n=1148 p value

Mean age in years (SD)* 29 (6.2) 30 (5.6) 0.18

Nulliparity (%) 42 51 0.021

Atrial fibrillation (%) 6.4 1.3 <0.001

Hypertension 8.1 6.5 0.45

Any medication before pregnancy (%) 36 27 0.01

Type of lesion <0.001

Left sided lesions (%) 68 45

Right sided lesions (%) 12 27

Shunt lesions (%) 20 27

Type of heart disease <0.001

Congenital heart disease (%) 41 70

Valvular heart disease (%) 37 24

Cardiomyopathy (%) 21 4.5

Ischemic heart disease (%) 1.2 2

When does heart failure occur? 173 patients (13%) with heart failure

0

2

4

6

8

10

12

14

16

18

20

1-2

(173

)

3-6

(173

)

7-10

(173)

11-1

4 (1

73)

15-1

8 (1

73)

19-2

2 (1

73)

23-2

6 (1

73)

27-3

0 (1

69)

31-3

4 (1

64)

35-3

8 (1

46)

39-4

2 (6

9)

Deliver

y

PP 1-4

PP 5-8

PP 9-1

3

PP 15-1

9

Weeks

Num

ber

of p

atie

nts

with

hea

rt fa

ilure

(%

)

Changes in hemodynamics in pregnancy:

Timing of HF and type of cardiac disease

Type of heart disease Number of patients

Heart failure (%)

Timing of HF IQR *

Complete AVSD 26 15 23 (3-43)

Mitral stenosis 79 31 25 (13-37)

VSD 113 4.4 25 (2-48)

ASD 111 8.1 27 (9-47)

HOCM 11 18 33 (26-40)

Aortic stenosis and regurgitation 19 11 34 (26-42)

Dilated cardiomyopathy 32 34 35 (20-48)

Mitral regurgitation 86 21 37 (24-50)

Mitral stenosis and regurgitation 63 18 38 (19-57)

Peripartum cardiomyopathy/

myocarditis 17 68 40 (37-44)

Non obstructive hypertrophic CMP 16 31 40 (16-66)

Ischemic heart disease* 25 8 42 (41-42)

ROPAC: heart failure specific risks factors

Multivariate analyse OR 95% CI

Signs of HF prior to pregnancy 9,6 5,9-15,5

Cardiomyopathy 4,6 2,3-9,1

NYHA class > 2 2,3 1,2-4,4

WHO > 2 2,3 1,5-3,6

Pulmonary hypertension 1,8 1,0-3,0

Outcome in women with heart failure

Patient with HF

(n=173)

Patient without HF

(n=1148) p value

Maternal mortality (%) 4,8 0,5 <0,001

Cardiaal

Atrial fibrillation (%) 1,2 0,9 0,71

Ventricular arrhythmias (%) 2,9 1,8 0,35

Thrombo-embolic events (%) 1,2 0,3 0,14

Endocarditis (%) 1,2 0,1 0,006

Bleeding complications during pregnancy (%) 2,9 1,4 0,14

Bleeding complications post partum (%) 4,6 5 0,85

Obstetrisch

Intra uterine growth retardation (%) 13 4,6 <0,001

Pregnancy induced hypertension (%) 2,9 2,4 0,67

Pre-eclampsia (%) 12 1,9 <0,001

Pre-eclampsia and heart failure

Pre-eclampsia during pregnancy was a predictor for heart failure

Odds ratio: 7.1

Of all patients with a structural heart disease who develop pre-eclampsia 30% also developed heart failure

Extra monitoring is indicated

Fetal outcome

Fetal outcome Patients with HF

(n=173)

Patient s without

HF (n=1148) p value

Fetal death (%) 4,6 1,2 0,001

Neonatal death (%) 0,7 0,6 0,92

Premature birth < 37 weeks (%) 30 13 <0,001

Birthweight < 2500 gram (%) 24 13 <0,001

Apgar score < 7 (%) 13 9,3 0,10

Adjusted mean birthweight (grams) 3328 3358 0,46

Conclusion

Patient history is not really specific/defining.

Heart failure occured in 13% of the patients with structural heart disease and occurs around the 27th of pregnancy and around the delivery.

Preconception predictors for heart failure:

Complaints of cardiac failure

Cardiomyopathy

WHO > 2 of NYHA > 2

Pulmonary hypertension

Conclusie II

Pre-eclampsia is a predictor for heart failure, addition monitoring is indicated!

Patients with heart failure have an adverse maternal outcome

Patients with heart failure had more adverse fetal outcome

Fetal death

Preterm birth

Low birth weight

EURObservational Research Programme

More data is needed! Please help include pregnant patients!

eorp@escardio.org

Our goal: Happy moms with healthy babies!