Heart Disease Among Pregnant Women in the United States: Data, Challenges, and Opportunities for Collaboration

Ways Forward in Preventing Severe Maternal Morbidity and Maternal Health Inequities: Conceptual Frameworks, Definitions, and Data, from a Population Health Perspective.

Heart Disease and Pregnancy: The Need for a Twenty-First Century Approach to Care…

This study was conducted to determine the prevalence of rheumatic heart disease (RHD) and congenital heart disease (CHD) in primary schoolchildren of Menoufia, Egypt and to study the relationship between these two problems and socioeconomic conditions. A total of 8000 children were screened for cardiac disease in their schools. Children with confirmed RHD and CHD in addition to 200 healthy children (controls) were visited at their homes to assess their social environment and other factors according to a designed questionnaire. We found prevalence rates of 3.4/1000 and 2.6/1000 for the RHD and CHD respectively. The most common cardiac defects were double mitral and pulmonary stenosis in the RHD and CHD groups respectively. Nineteen (39.6%) of the patients were diagnosed for the first time during the study. Penicillin prophylaxis was received by only four (14.8%) of the RHD children and none of the CHD children. The number of other affected siblings, increased multiparity, repeated abortion, and intake of contraceptives by mothers were significantly higher in families of the children with CHD. The proportion of illiterate, unskilled, and heavy smoking fathers was higher in the two patient groups. Family income was lowest in the RHD group, while increased crowding index and low whole social environment were significantly related to both RHD and CHD. Effective programs at the community and health service levels are needed in Menoufia to solve the problem of heart disease in schoolchildren in the immediate future.

Adult Congenital Heart Surgery: Adult or Pediatric Facility? Adult or Pediatric Surgeon?

The population of adults with congenital heart disease (ACHD) has increased dramatically over the past few decades, with many people who are now middle-aged and some in the geriatric age range. This improved longevity is leading to increased use of the medical system for both routine and episodic care, and caregivers need to be prepared to diagnose, follow up, and treat the older adult with congenital heart disease (CHD). The predictable natural progression of CHD entities and sequelae of previous interventions must now be treated in the setting of late complications, acquired cardiac disease, multiorgan effects of lifelong processes, and the unrelenting process of aging. Despite the advances in this field, death rates in the population from 20 to >70 years of age may be twice to 7 times higher for the ACHD population than for their peers.1 This American Heart Association (AHA) scientific statement will focus on the older adult (>40 years old) with CHD. It is meant to be complementary to the 2008 American College of Cardiology (ACC)/AHA guidelines for ACHD and orient the reader to the natural history, ramifications of childhood repair, and late initial diagnosis of CHD in the older adult. This population with CHD is unique and distinct from both the pediatric and young adult populations with CHD. Much of the information we provide is from scientific research combined with clinical experience from longitudinal care. We emphasize that this is the beginning of a discussion regarding this rapidly growing population, and continued research aimed at the progression of disease and complications reviewed here is necessary to advance the field of ACHD with the scientific rigor it deserves. ACHD encompass a broad range of presentations. There are people who are diagnosed for the first time in adulthood, as well as those with prior palliative repair …

Pregnancy heart team: A lesion-specific approach

To assess the risk of severe maternal morbidity (SMM) and mortality among pregnant patients with cardiovascular disease (CVD). This was a retrospective cohort study of U.S. delivery hospitalizations from 2010 to 2020 using weighted population estimates from the National Inpatient Sample database. The primary objective was to evaluate the risk of SMM and maternal mortality among patients with CVD at delivery hospitalization. International Classification of Diseases, Ninth and Tenth Revision, Clinical Modification codes were used to identify delivery hospitalizations, CVD, and SMM events. Multivariable logistic regression analyses were performed to compare SMM and mortality risk among patients with CVD and those without CVD. Given the substantial racial and ethnic disparities in SMM, mortality, and CVD burden, secondary objectives included evaluating SMM and mortality across racial and ethnic groups and assessing the population attributable fraction within each group. Lastly, subgroup analyses of SMM by underlying CVD diagnoses (eg, congenital heart disease, chronic heart failure) were performed. Variables used in the regression models included socioeconomic and demographic maternal characteristics, maternal comorbidities, and pregnancy-specific complications. Among 38,374,326 individuals with delivery hospitalizations, 203,448 (0.5%) had CVD. Patients with CVD had an increased risk of SMM (11.6 vs 0.7%, adjusted odds ratio [aOR] 12.5, 95% CI, 12.0-13.1) and maternal death (538 vs 5 per 100,000 delivery hospitalizations, aOR 44.1, 95% CI, 35.4-55.0) compared with those without CVD. Patients with chronic heart failure had the highest SMM risk (aOR 354.4, 95% CI, 301.0-417.3) among CVD categories. Black patients with CVD had a higher risk of SMM (aOR 15.9, 95% CI, 14.7-17.1) than those without CVD with an adjusted population attributable fraction of 10.5% (95% CI, 10.0-11.0%). CVD in pregnancy is associated with increased risk of SMM and mortality, with the highest risk of SMM among patients with chronic heart failure. Although CVD affects less than 1% of the pregnant population, it contributes to nearly 1 in 10 SMM events in the United States.

Background: Transthoracic echocardiography (TTE) is an essential noninvasive heart study technique which has changed the practice of cardiology worldwide. The procedure began at the Ekiti State University Teaching Hospital on October 24, 2017, till date. Objective: The objective of the study is to present our early practice with TTE in our location. Materials and Methods: It is a descriptively analyzed retrospective data acquired on demographic parameters, indications for the procedure, echocardiographic parameters, and diagnoses. The procedure was performed using general electric ultrasound machine Logiq C5 premium equipped with 3.5–5.0MHz transducer. Results: Three hundred and three procedures were done between October 24, 2017, and December 17, 2019 (2 years 2 months). There were 158 males and 145 females who were aged 52.8 ± 18.1and 56.6 ± 17.2 respectively. The mean age for all the subjects was 54.6 ± 17.8 years. Hypertension made up 168 (55.4%) and arrhythmia 25 (8.3%) of the indications for the procedure. The various diagnoses made include hypertensive heart disease (HHDx) (47.2%), cardiomyopathy (7.3%), valvular heart disease (rheumatic type) (5.9%), congestive cardiac failure (2.6%), pericardial disease (2.0%), left ventricular failure (1.7%), cor-pulmonale (1.7%), thyrotoxic heart disease (0.7%), ischemic heart disease, incomplete echo due to orthopnea, congenital heart disease (0.3%), and normal echo was recorded in (30%). Conclusion: HHDx was the most common diagnosis in our study. Other diagnoses include dilated cardiomyopathy, valvular heart disease (rheumatic type), cor pulmonale, congestive cardiac failure with varied ejection fractions, and peripartum cardiomyopathies. Congenital heart disease was uncommon.

Background: The advent of echocardiography has tremendously improved the diagnosis of cardiovascular diseases. We present a review of cardiovascular disorders diagnosed using transthoracic echocardiography over 3 years. Materials and Methods: Echocardiographic data of patients from January 2011 to December 2013 were retrieved. All subjects had standard transthoracic echocardiography including Doppler modalities where appropriate. Descriptive statistics was used in assessing the occurrence of the different cardiac disorders. Results: One thousand three hundred and two echocardiograms were considered, out of which 1224 (94%) comprising 591 (48.3%) males and 633 (51.7%) females were analyzed. Ages ranged from 4 days to 105 years with a mode of 60 years and a mean of 39.62 ± 20.58 years. The most common indications were hypertensive heart disease (HHD) (28.2%) and congestive cardiac failure (23.4%). HHD was the most common diagnosis (25.1%) followed by cardiomyopathies (23.9%). Idiopathic dilated (29.3%) and peripartum cardiomyopathy (23.1%) were the most common cardiomyopathies. Valvular heart diseases (VHD) were diagnosed in 14.9%, with rheumatic (60.4%), and degenerative (36.4%) being dominant. Congenital heart disease was diagnosed in 7.2%, with 70.5% of the cases in those ≤14 years. Ischemic heart disease was diagnosed in 6.6%. Pericardial diseases were found in 3.2%, while cor pulmonale was documented in 0.8%. Atrial myxoma dissection of the ascending aorta, athlete's heart, and amniotic fluid embolism were each observed in Conclusion: The most common echocardiographic diagnoses in our center are HHD, cardiomyopathies, and VHD. Congenital and ischemic heart diseases are also prevalent.

Why is heart failure in children important? If we just consider the number of individuals affected, adult heart failure is clearly a more compelling public health problem. However, the relatively small numbers belie the overall economic and social impact of pediatric heart failure. When a child is admitted to the hospital for heart failure, the costs are considerably higher for children than adults because of the frequent need for surgical or catheter-based intervention. The demands of medical care can fray the family structure and adversely affect parental economic productivity. When a child dies of heart failure, the economic impact is magnified enormously because of the number of potentially productive years lost per death. For these and other reasons, heart failure in children is a serious public health concern. In addition, growing numbers of children with heart failure are reaching adulthood because of the successful application of medical and surgical heart failure therapies and the improved outcomes of congenital heart surgery. A greater understanding of the pathophysiology of heart failure in childhood may help inform therapeutic strategies once these children become adults. Furthermore, given the recent explosion of research in the impact of cardiac development and cardiogenetics on pediatric cardiovascular disease, it is not outside the realm of possibility for a pediatric discovery to be made that will also benefit adults with heart failure. We may not yet be able to agree on a definition of heart failure, but the cardinal symptoms, dyspnea, anasarca (“dropsy”), and cachexia, were well recognized in antiquity.1 These symptoms were not specific for cardiac pathology, and it was not until the 17th century, when William Harvey definitively identified the heart as an organ that pumped blood rather than generating heat, that the heart could begin to be understood as a source of dyspnea, edema, and …

ACC/AHA 2008 Guideline Update on Valvular Heart Disease: Focused Update on Infective Endocarditis

ObjectivesThe purpose of this study to determine the clinical pattern and prevalence of heart disease in pregnancy at the first established cardio-maternal unit in Iraq over the last 4 years; since January 2015 till May 2019. Data are presented as number and percentage.ResultsA total of 252 pregnant women presented to cardio-maternal unit included in this study. According to the collected data, among the main diagnosis of heart disease during pregnancy was valvular heart disease 34.1%, followed by congenital heart disease 30.5%, cardiomyopathy 29.8%, pulmonary hypertension 4%, and ischemic heart disease 1.6%. Among subtypes of the main heart diseases in pregnant women, the most clinical pattern was: the prosthetic heart valve (26.7%) in valvular heart disease, both atrial septal defect and ventricular septal defect (35%) in congenital heart disease, and peripartum cardiomyopathy (76%) among cardiomyopathies.

Pregnancy of women with heart disease is still a challenging condition because it is associated with elevated maternal and fetal morbidity and mortality. In the clinical setting, an accurate individual risk assessment is of fundamental importance. The current study was carried out in the Department of Cardiology, & the Department of Obstetrics, El-Minia University during the period from January 2009 to December 2009. We surveyed 150 pregnant ladies with structural heart disease as a part of the Euro Heart Survey on pregnancy & heart disease; they were followed up till 6 weeks postpartum. The follow-up of 121 cases during pregnancy and postpartum period was completed; there were 23 cases still pregnant while the follow-up of 6 cases was missed. So we included the 121 cases in our statistical analysis regarding maternal and fetal events during pregnancy, delivery & postpartum. Inclusion criteria: All patients with structural heart disease, valvular heart disease, congenital heart disease, ischemic heart disease, cardiomyopathy, pulmonary hypertension presenting with pregnancy, independent of age, any concomitant diseases and type of heart disease had been enrolled. Structural heart disease was diagnosed through full history taking, clinical examination and investigations such as ECG & echocardiography. Exclusion criteria: Non-structural heart disease even arrhythmias occurring in the context of a normal heart. A follow-up of all patients had been performed for at least 6 weeks after delivery using telephone contact or in our outpatient clinic (for heart disease with pregnancy) in the El-Minia University Hospital. 78% cases were with valvular heart disease, 7.3% with congenital heart disease, 10.7% with cardiomyopathy, 2% with ischemic heart disease while 0.6% cases with Lutembacher syndrome and 1.3% cases with pulmonary hypertension. Maternal cardiovascular complications during pregnancy were heart failure 6.6%, thrombotic complications: 0.8%, arrhythmia 1.6%, and hemorrhagic complications 2.5%. Maternal mortality was 3.3%, 30.4% of the high-risk group suffered from maternal complications in comparison to only 9.5% of the women at low-risk. Accordingly, the high-risk group 30.4% had a 3.1-fold greater severe maternal event rate; maternal mortality was 8.2% of the women in high-risk group versus 0% in the low-risk group. Also fetal complications occurred in 14.3% of the high-risk group versus 0% in low-risk group. APGAR score and birth weight were much lower in the high-risk group ( p value 0.001). RHD is the commonest cardiac lesion among pregnant women. Peripartum cardiomyopathy was the 1st etiology of heart failure in our study but fortunately it had a good prognosis.

Right ventricular (RV) function may be impaired in pulmonary hypertension (PH), congenital heart disease (CHD), and coronary artery disease and in patients with left-sided heart failure (HF) or valvular heart disease. In recent years, many studies have demonstrated the prognostic value of RV function in cardiovascular disease. In the past, however, the importance of RV function has been underestimated. This perception originated from studies on open-pericardium dog models and from the observation that patients may survive without a functional subpulmonary RV (Fontan procedure). In the 1940s, studies using open-pericardium dog models showed that cauterization of the RV lateral wall did not result in a decrease in cardiac output or an increase in systemic venous pressure.1–3 As was later demonstrated, the open-pericardium model did not take into account the complex nature of ventricular interaction. In 1982, Goldstein and colleagues2 showed that RV myocardial infarction (RVMI) in a closed-chest dog model led to significant hemodynamic compromise. These findings were further supported by clinical studies demonstrating an increased risk of death, arrhythmia, and shock in patients with RVMI.4 The study of the RV is a relatively young field. In 2006, the National Heart, Lung, and Blood Institute identified RV physiology as a priority in cardiovascular research.5 The goal of this review is to present a clinical perspective on RV physiology and pathobiology. In the first article of the series, the anatomy, physiology, embryology, and assessment of the RV were discussed. In this second part, we discuss the pathophysiology, clinical importance, and management of RV failure. RV failure is a complex clinical syndrome that can result from any structural or functional cardiovascular disorder that impairs the ability of the RV to fill or to eject blood. The cardinal clinical manifestations of RV failure are (1) fluid retention, which may lead …

Heart transplantation has emerged as the definitive therapy for patients with end-stage cardiomyopathy. The two most common forms of cardiac disease that lead to transplantation are ischemic cardiomyopathy and dilated cardiomyopathy, which together comprise approximately 90% of cases. The other less common forms of heart disease include viral cardiomyopathy, infiltrative cardiomyopathy, postpartum cardiomyopathy, valvular heart disease and congenital heart disease. KEYWORDS: Anesthetic management; Cardiomyopathy; Cardiopulmonary bypass; Heart failure; Heart transplantation; Pulmonary artery hypertension; INTRODUCTION: Heart transplantation has emerged as the definitive therapy for patients with end- stage cardiomyopathy. The two most common forms of cardiac disease that lead to transplantation are ischemic cardiomyopathy and dilated cardiomyopathy, which together comprise approximately 90% of cases. The other less common forms of heart disease include viral cardiomyopathy, infiltrative cardiomyopathy, postpartum cardiomyopathy, valvular heart disease and congenital heart disease. The introduction of cyclosporine in 1981 and monoclonal antibody okT3 in 1983 for heart transplant patients greatly accelerated the progress of organ transplantation.1 The peak period of heart transplantation was mid-1980s.The pace slowed down due to the limitations in the availability of donor organs. We have performed five heart transplant surgeries at Rajiv Gandhi Government General Hospital, Chennai, India during 2009 to 2011. The corresponding author was a member of the team during three cardiac transplant surgeries while the co-author was a member during all the five transplant surgeries. This article is intended to share our experiences and anesthetic challenges during cardiac transplantations.