Heart Failure In Pregnancy Research Articles

Obstetric anesthesia management of dilated cardiomyopathies and heart failure: a narrative review

Pregnancy in patients with dilated cardiomyopathy carries a significantly increased risk of maternal mortality or severe morbidity, and pregnancy is typically considered contraindicated for patients with severely reduced ventricular function. Nonetheless, anesthesiologists will still encounter patients with cardiomyopathy requiring delivery or termination care. This review describes how NT-ProBNP testing and echocardiography can help with early recognition of heart failure in pregnancy, and describes a suggested approach to anesthetic management of patients with cardiomyopathies or acute heart failure, including hemodynamic goals, use of vasoactive medications and mechanical support. Vaginal delivery, with effective neuraxial anesthesia is the preferred mode of delivery in most patients with cardiomyopathy, with cesarean delivery reserved for maternal or fetal indications. The Pregnancy Heart Team is vital in coordinating the multidisciplinary care necessary to safely support these patients through pregnancy.

Multidisciplinary care of peripartum heart failure: A scientific statement of the Heart Failure Association of the ESC.

Heart failure is the most common cardiovascular complication during pregnancy and the postpartum period. It is associated with increased risk of maternal morbidity and mortality as well as potentially life-threatening foetal pathology. Management of heart failure in pregnancy requires expert knowledge of cardiovascular disease as well as obstetrics which underscores the importance of multidisciplinary cardio-obstetrics teams in order to optimize diagnosis, treatment and outcome. This includes counselling of women at risk before and during the course of pregnancy in order to strengthen the relationship between medical specialists and patients, as well as to allow patient-centred delivery of care and improve quality of life.

Contemporary Management of Cardiomyopathy and Heart Failure in Pregnancy.

Cardiovascular disease is the primary cause of pregnancy-related mortality and morbidity in the United States, and maternal mortality has increased over the last decade. Pregnancy and the postpartum period are associated with significant vascular, metabolic, and physiologic adaptations that can unmask new heart failure or exacerbate heart failure symptoms in women with known underlying cardiomyopathy. There are unique management considerations for heart failure in women throughout pregnancy, and it is imperative that clinicians caring for pregnant women understand these important principles. Early involvement of multidisciplinary cardio-obstetrics teams is key to optimizing maternal and fetal outcomes. In this review, we discuss the unique challenges and opportunities in the diagnosis of heart failure in pregnancy, management principles along the continuum of pregnancy, and the safety of heart failure therapies during and after pregnancy.

Etiology and predictors of heart failure in pregnancy. Newer Insights from the M-PAC registry

Abstract Background Women with heart disease undergoing pregnancy is on the increase, along with an increasing cardiac contribution to maternal mortality. Aim To identify the proposition of pregnant women with heart disease, who develop heart failure as a complication and to identify the predictors of heart failure in pregnancy Methods The Madras medical college Pregnancy And Cardiac (M-PAC) registry (1) is a single-centre prospective observational registry conducted at a tertiary care public hospital in Tamil Nadu, India from July 2016 to December 2019. Patient with new or worsening heart failure during pregnancy and up to 1 week post-delivery were included in the present analysis. When heart failure was the presenting symptom, it was considered as the primary event and when patient presented with failure symptoms secondary to another inciting event, heart failure was considered as secondary event. This cohort of patient were evaluated for the aetiology, predictors and outcome of heart failure and were placed on extended follow up. The accuracy of mWHO and CARPREG I score to predict heart failure were assessed. Results 1005 women with 1029 pregnancies were enrolled. Heart failure was observed in 127 (%) pregnancies, in 103 as primary event and in 24 as a secondary event. The common aetiologies of heart failure include rheumatic valvar heart diseases (n=45), peripartum cardiomyopathy (n=45) and congenital heart diseases (n=18). The univariable predictors of heart failure include, NYHA class at first visit, mWHO class of disease, first diagnosis of heart disease, during current pregnancy, pulmonary hypertension, left ventricular ejection fraction ≤ 45%, significant mitral stenosis, mechanical prosthetic heart valve and history of prior cardiac events. However, when peripartum cardiomyopathy was excluded from the analysis, current pregnancy diagnosis was no longer a predictor. Multivariable predictors of heart failure are shown in Figure-1. CARPREG-1 score was marginally more effective than modified World Health Organisation (mWHO) score (C-statistic of 0.820 vs 0.802) in predicting heart failure (Figure-2). Maternal death was 15.7% (20/127). Caesarean delivery was more common in patients with heart failure (53/119; 44.5%; vs 318/838; 38%) Patients with heart failure had significantly higher proportion of composite adverse fetal outcome (46.5% vs 31.9%, P<0.001), preterm birth (9.2% vs 4.5%, P=0.029) and low birth weight (41.2% vs 26%, P <0.001) Conclusion Heart failure is the commonest complication of pregnant women with heart disease. Mortality is very high in patients presenting with heart failure. Modified WHO classification and CARPREG 1 score have moderate accuracy to predict heart failure in pregnancy.Fig-1: Predictors of Heart FailueFig-2: Prediction by CARPREG-1 and mWHO

Outcome of subsequent pregnancy after peripartum cardiomyopathy from a low middle income country- a prospective single center study

Abstract Background Heart failure is the most common complication of women wiht heart disease going through pregnancy. Peripartum cardiomyopathy (PPCMP) is the most common cause of heart failure in pregnancy. PPCMP presents towards the end of pregnancy or in the early months following delivery and has devastating medical, mental and socio-cultural consequences. PPCMP patients may land up with a subsequent pregnancy (SSP) due to cultural and social pressures. Early detection and management with multi-disciplinary approach is crucial. Purpose Analysis of clinical course, maternal and fetal outcomes in women with SSP after PPCMP in the index pregnancy (IP). Methods Women diagnosed with PPCMP between 2016 to 2019 in a tertiary referral centre in a low and middle income country, who had at least one SSP were included in this prospective analysis. Patients were followed up throughout the pregnancy and for two years after the SSP. Clinical presentation, medication use, echocardiographic data, breast feeding, contraception use, counselling given, maternal and fetal outcome of pregnancy were analyzed. Results Fifty-two patients were diagnosed to have PPCMP in our institution from 2016 to 2019. Seven patients had eight singleton SSPS. The mean age of these patients was 25.8±4.2 years. Index pregnancy details: Five patients had required inotropic support during the IP with two of them requiring ventilatory support. Other two had mild heart failure. Eight index pregnancies resulted in five live births, one neonatal birth, one still birth and one medical termination of pregnancy (MTP). All five women with live births breast fed their children after the IP. Contraception by IUCD was used in four patients. Two women did not accept any means of contraception. All patients had underwent appropriate multidisciplinary counselling about risks of SSP. All except one patient had recovered LV function with LVEF ≥55% within one year of IP. Three patients had stopped anti failure therapy on their own before SSP. The mean duration of anti-failure therapy was 13±5 months. Subsequent pregnancy details: (Fig. 1) One patient with non-recovered LV function developed HF during the SSP and underwent MTP at 20 weeks. She continues to have LV dysfunction and NYHA III heart failure. Six patients who had recovered LV function, did not suffer any recurrence, one of whom is still in the 34th week of gestation. One of these patients had two SSPs. The first SSP was uneventful without recurrence. She is in the 34th week of her second SSP and is uneventful so far. Neonatal outcome of the SSPs was good with five live births and one MTP in the 6 completed SSPs. Conclusion Baseline LVEF after IP is an important predictor of maternal & fetal outcome outcome. With detailed cardiac evaluation including stress echocardiogram, multidisciplinary counseling and close supervision patients with previous PPCMP patient can be allowed for an SSP with reasonable safety. Funding Acknowledgement Type of funding sources: None. Figure 1. Flowchart of SSP outcome in PPCMP

Anesthetic Management of Women With Heart Failure During Pregnancy: A Retrospective Cohort Study

(Int J Obstet Anesth. 2020;44:40–50) The increases in plasma volume, cardiac output, and heart rate caused by pregnancy may also lead to heart failure in women with underlying cardiac disease. Pregnancy may even reveal first-time symptoms of cardiac disease in tandem with hemodynamic stress, presenting with de novo cardiovascular conditions such as preeclampsia or peripartum cardiomyopathy. Since hypertensive disorders complicate up to 10% of pregnancies, and because known associations exist between heart failure in pregnancy and preeclampsia, this study aimed to examine management (anesthetic, medical, and obstetric) and etiologies of pregnant women with clinical heart failure presenting to a tertiary care center in Canada.

Heart failure in pregnancy: what is the long-term impact of pregnancy on cardiac function? A tertiary care centre experience and systematic review

BackgroundWomen with cardiomyopathy (CM) are often advised against pregnancy due to risk for major adverse cardiovascular events (MACE). However, the impact of CM subtype on maternal MACE is not understood,...

Obesity-associated cardiovascular risk in women: hypertension and heart failure.

The pathogenesis of obesity-associated cardiovascular diseases begins long prior to the presentation of a cardiovascular event. In both men and women, cardiovascular events, and their associated hospitalizations and mortality, are often clinically predisposed by the presentation of a chronic cardiovascular risk factor. Obesity increases the risk of cardiovascular diseases in both sexes, however, the clinical prevalence of obesity, as well as its contribution to crucial cardiovascular risk factors is dependent on sex. The mechanisms via which obesity leads to cardiovascular risk is also discrepant in women between their premenopausal, pregnancy and postmenopausal phases of life. Emerging data indicate that at all reproductive statuses and ages, the presentation of a cardiovascular event in obese women is strongly associated with hypertension and its subsequent chronic risk factor, heart failure with preserved ejection fraction (HFpEF). In addition, emerging evidence indicates that obesity increases the risk of both hypertension and heart failure in pregnancy. This review will summarize clinical and experimental data on the female-specific prevalence and mechanisms of hypertension and heart failure in women across reproductive stages and highlight the particular risks in pregnancy as well as emerging data in a high-risk ethnicity in women of African ancestry (AA).

Intersection of Heart Failure and Pregnancy: Beyond Peripartum Cardiomyopathy.

Heart failure (HF) is a leading cause of morbidity and mortality in pregnant women in the United States. Although peripartum cardiomyopathy is the most common diagnosis for pregnant women with HF, women with preexisting cardiomyopathies and systolic dysfunction are also at risk as the hemodynamic demands of pregnancy can lead to decompensation, arrhythmia, and rarely death. The differential diagnosis of HF in pregnancy is broad and includes Takotsubo or stress cardiomyopathy, exacerbation of a preexisting cardiomyopathy, such as familial cardiomyopathy, hypertrophic cardiomyopathy, arrhythmogenic right ventricular cardiomyopathy, or left ventricular noncompaction. This review will explore the implications of pregnancy in women with preexisting cardiomyopathies and de novo HF, risk assessment and preconception planning, decisions about contraception, the safety of HF medications and implantable cardioverter-defibrillators during pregnancy, pregnancy in women with left ventricular assist devices and following heart transplantation.

Reproductive Health Crisis During Waves One and Two of the COVID-19 Pandemic in India: Incidence and Deaths From Severe Maternal Complications in More than 202000 Hospital Births

Background: The SARS-CoV-2 pandemic in India has adversely affected many aspects of population health. We need detailed evidence of the impact on reproductive health in India so that lessons can be learnt. Methods: Hospital-based repeated monthly survey of nine severe maternal complications and death in 15 hospitals across five states in India covering a total of 202,986 hospital births, December-2018 through to May-2021. We calculated incidence rates (with 95% Confidence Intervals (CIs)) per 1000 hospital births, case-fatality and rate ratios (RR) with 95% CIs. Linear regression was used to examine the association between the Government Response Stringency Index (GRSI) for India and changes in hospital births, incidence and case-fatality. Results: There was a significant decrease in hospital births per month during the pandemic period with a 4.8% decrease per 10% increase in the GRSI scores (p<0.001). The overall incidence of severe complications in the pandemic period was not significantly different from the pre-pandemic period, but hospital admissions from septic abortion was 56% higher (RR=1.56; 95% CI=1.22–1.99; p<0.001). The overall case-fatality of complications increased by 23% (RR=1.23; 95% CI=1.03–1.46; p=0.022) and remained high across the different phases of the pandemic with a notable significant increase in deaths from heart failure in pregnancy. Conclusion: Our study supports the legitimacy of the calls made to maintain sexual and reproductive health services as essential services during the pandemic. Lessons learnt should be used to avert the ongoing reproductive health crisis while India plans to manage a third wave of the pandemic. Funding Information: The MaatHRI platform and this study was funded by a Medical Research Council Career Development Award to MN (Ref:MR/P022030/1). Declaration of Interests: The authors declare that they have no competing interests. Ethics Approval Statement: The MaatHRI platform and the repeated monthly survey have been approved by the institutional review boards (IRB) of each coordinating Indian institution, namely: Srimanta Sankaradeva University of Health Sciences, Guwahati, Assam (No.MC/190/2007/Pt-1/126); Nazareth hospital, Shillong, Meghalaya (Ref No. NH/CMO/IEC/COMMUNICATIONS/18-01); Emmanuel Hospital Association, New Delhi (Ref. Protocol No.167); Mahatma Gandhi Institute of Medical Sciences, Sevagram, Maharashtra (Ref No. MGIMS/IEC/OBGY/118/2017); and the Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh (No.Dean/2018/EC/290). The project has also been approved by the Government of India’s Health Ministry’s Screening Committee, the Indian Council of Medical Research, New Delhi (ID number 2018-0152) and by the Oxford Tropical Research Ethics Committee (OxTREC), University of Oxford, UK (OxTREC Ref: 7-18).

Patient characteristics and in-hospital outcomes of Takotsubo Cardiomyopathy in pregnancy: a retrospective analysis

Abstract Introduction Takotsubo Cardiomyopathy (TCM) is characterized by reversible left ventricular dysfunction and predominantly affects post-menopausal women. However, it is rarely identified as a cause of acute heart failure in pregnancy. Objective We aimed to determine patient characteristics and in-hospital outcomes of TCM occurring in pregnancy. Methods We retrospectively analyzed the United States - National Inpatient Sample (NIS) Database from 2010–2014 to assess TCM in pregnant women ≥18 years using international classification of diseases 9th revision clinical modification (ICD-9-CM) codes. We compared patient demographics, co-morbidities and in-hospital outcomes between pregnant and non-pregnant women with TCM aged 18–49 years. Patients with a diagnosis of peripartum cardiomyopathy were excluded. Chi-square test and Student-t test or Mann- Whitney U test were used for categorical and continuous variables with normal and skewed distribution, respectively. Results TCM occurred at a younger age in pregnant women compared to non-pregnant women (Age [Mean ±SD]: 31.2±7.2 years vs. 41.8±7.1 years; p&amp;lt;0.001). Rates of TCM were higher during pregnancy in African American (19% vs. 11.5%; p=0.008), Hispanic (27.3% vs. 9.6%; p&amp;lt;0.001) and Asian women (11.3% vs. 2.6%; p&amp;lt;0.001) compared to non-pregnant women of similar race. However, among Caucasian women rates of TCM were higher in non-pregnant women (42.4% vs. 72.7%; p&amp;lt;0.001). There were no in-hospital deaths among pregnant women with TCM (0% vs. 5.2%; p=0.005), however they had higher rates of cardiogenic shock (13.8% vs. 5.8; p&amp;lt;0.001) and respiratory failure requiring mechanical ventilation (51.7% vs. 20.9%; p&amp;lt;0.001). The average length of hospitalization was also longer among pregnant women with TCM (Days [Mean±SD]: 5.8±4 vs. 5.5±7.5; p&amp;lt;0.001). Pregnant women had lower rates of diagnostic angiography (24.1% vs. 55.6%; p&amp;lt;0.001). Pregnant women with TCM had higher rates of ventricular fibrillation (6.9% vs. 2.9%; p=0.02), but had no atrial fibrillation (0% vs. 2.6%; p=0.05), atrial flutter (0% vs. 0.4%; p=0.43), paroxysmal supraventricular tachycardia (0% vs. 0.5%; p=0.4) and ventricular tachycardia (0% vs. 4.8%; p=0.07). Pregnant women with TCM had lower rates of psychiatric and certain medical co-morbidities: anxiety (6.9% vs. 20.4%; p&amp;lt;0.001), depression (0% vs. 2.6%; p=0.05), bipolar disorder (0% vs. 0.8%; p=0.3), hypertension (27.6% vs. 40.3%; p=0.002), hyperlipidemia (3.4% vs. 25.7%; p&amp;lt;0.001) and smoking (6.9% vs. 40.2%; p&amp;lt;0.001). The rates of diabetes (13.8% vs. 15.9%; p=0.5) and obesity (10.3% vs. 8.2%; p=0.37) were similar between the two groups. Conclusion There was no in-hospital mortality observed in pregnant women who developed TCM, however, they had increased rates of cardiogenic shock, mechanical ventilation, ventricular fibrillation and had longer hospitalizations. Funding Acknowledgement Type of funding source: None

Peripartum Cardiomyopathy: A Case Report

Peripartum cardiomyopathy is one of the potentially life-threatening complications of pregnancy. It is characterized by symptoms of heart failure in the last months of gestation or within five months after birth. The objective of this case report was to report a case of peripartum cardiomyopathy. A 20-years-old (G1P0) pregnant woman was referred for further evaluation of heart failure in pregnancy. The patient’s family and medical histories were both unremarkable. She had a 36 weeks and 2 days dichorionic diamniotic twin pregnancy. Emergency cesarean section was performed under spinal anesthesia. During the early postoperative period, the patient complaint of respiratory distress and the diagnosis of peripartum cardiomyopathy was confirmed with physical examination, laboratory and echocardiography findings. She was transferred to the cardiac intensive care unit and received supplemental oxygen, noninvasive ventilation and intravenous infusion of lidocaine. She well tailored the medical therapy and she and her babies were discharged uneventfully after 10 days of delivery.The clinicians should keep in mind the diagnosis of peripartum cardiomyopathy in young woman with twin pregnancy in third trimester who presents with symptoms of heart failure even after delivery. Emergent cardiologic evaluation and intervention must be done for this rare and potentially morbid and mortal condition.Keywords: Ejection fraction, Peripartum cardiomyopathy, Pregnancy

Anesthetic management of women with heart failure during pregnancy: a retrospective cohort study

BackgroundThe incidence of heart failure among pregnant women with pre-existing cardiac disease is quoted as 13%, with 10% requiring hospitalization. There is limited literature on heart failure in the pregnant population. The study objective was to describe the etiology and management of women hospitalized in our institution for heart failure during pregnancy. MethodsA retrospective cohort study investigated women who presented with heart failure in pregnancy between 2004 and 2017. Hospital records were interrogated using International Classification of Diseases v10 codes for heart failure. Patient characteristics, investigations, treatment, obstetric and anesthetic management, and maternal-fetal outcome data were collected and summarized using descriptive statistics. ResultsOne-hundred-and-twenty cases (in 93 122 deliveries) were identified across the 13-year period (antepartum heart failure 51%, postpartum heart failure 49%).The most common etiologies were pre-eclampsia (28%), cardiomyopathy (22%), and valvular heart disease (18%). Cesarean delivery occurred in 76% of cases (13% because of the maternal cardiac condition). Neuraxial techniques were used for most deliveries (cesarean 83%; vaginal 90%). For cesarean delivery, titrated epidural or general anesthesia was employed in 48% and 16%, respectively. Cardiac arrest occurred in two cases (1.7%) and 44% required coronary or intensive care unit admission. ConclusionsThe incidence of heart failure was 0.13% (1:776 deliveries). Pre-eclampsia was the leading cause but may have been historically under-acknowledged. Anesthetic and obstetrical decisions were tailored by means of multidisciplinary input, with cesarean delivery and regional anesthesia used in the majority. The postpartum period warrants heightened attention for these patients.

Correlation Between Risk or Severity of Heart Failure and Outcome of Pregnancy.

BackgroundThe incidence of heart failure in pregnancy increases by 1–4% every year and causes 9% of maternal mortality worldwide. Determinant factors, characteristics, and risk factors influence the incidence of heart disease in pregnancy, so the early detection of determinant factors can reduce the incidence of heart disease in pregnancy. This study aimed to find the relationship between determinant factors of maternal and fetal outcomes with the severity of heart disease in pregnancy.MethodsThis was an observational cross-sectional analytical study. We used 342 cases of heart disease in pregnancy that were recorded in medical records at Dr. Hasan Sadikin Hospital, Bandung, Indonesia, from January 2014 to December 2018. The data were grouped based on the severity of heart disease according to the New York Heart Association (NYHA) classification. The relationship of maternal determinant factors with the severity of heart disease was analyzed based on the NYHA classification.ResultsMaternal occupation was significantly associated with a higher risk of NYHA class III–IV heart disease. Most of the patients with NYHA class III-IV were housewives. The severity of heart disease was also influenced by severe preeclampsia (p<0.05) as a risk factor. Maternal outcome with heart disease of severity NYHA class III–IV was worse than with NYHA class I–II. The risk of maternal death was higher, and the mother’s length of stay in hospital and her need for monitoring were also increased. There were no significant differences in the outcome of the fetus, but the incidence of fetal mortality increased in patients with heart disease severity III–IV.ConclusionMaternal determinant factors did not correlate with the severity of heart disease in pregnancy. Maternal outcomes were worse with increasing severity of heart disease. Fetal mortality was correlated with severity of heart disease but other outcomes were not affected.

The role of oxytocin and vasopressin in the pathophysiology of heart failure in pregnancy and in fetal and neonatal life.

Pregnancy and early life create specific psychosomatic challenges for the mother and child, such as changes in hemodynamics, resetting of the water-electrolyte balance, hypoxia, pain, and stress, that all play an important role in the regulation of the release of oxytocin and vasopressin. Both of these hormones regulate the water-electrolyte balance and cardiovascular functions, maturation of the cardiovascular system, and cardiovascular responses to stress. These aspects may be of particular importance in a state of emergency, such as hypertension in the mother or severe heart failure in the child. In this review, we draw attention to a broad spectrum of actions exerted by oxytocin and vasopressin in the pregnant mother and the offspring during early life. To this end, we discuss the following topics: 1) regulation of the secretion of oxytocin and vasopressin and expression of their receptors in the pregnant mother and child, 2) direct and indirect effects of oxytocin and vasopressin on the cardiovascular system in the healthy mother and fetus, and 3) positive and negative consequences of altered secretion of oxytocin and vasopressin in the mother with cardiovascular pathology and in the progeny with heart failure. The present survey provides evidence that moderate stimulation of the oxytocin and vasopressin receptors plays a beneficial role in the healthy pregnant mother and fetus; however, under pathophysiological conditions the inappropriate action of these hormones exerts several negative effects on the cardiovascular system of the mother and progeny and may potentially contribute to the pathophysiology of heart failure in early life.

Precipitating factors and maternal and neonatal outcomes of heart failure in pregnancy: a retrospective analysis in a large tertiary hospital in China, 2012-2017.

To investigate the precipitating factors of heart failure (HF) and to investigate the maternal and neonatal outcomes in pregnant women with HF. We reviewed the medical records of pregnant women with HF who were treated at West China Second University Hospital between September 2012 and September 2017. We recorded baseline characteristics, onset and treatment of HF, comorbidities, modes of delivery, and maternal and fetal mortality and morbidity. Chi-square tests or Fisher's exact tests were used to explore the comorbidities in different subgroups. Seventy pregnant women with HF were identified. The most common pregnancy-specific conditions were severe preeclampsia (36/70, 51.43%) and multiple pregnancies (16/70, 22.86%). The most common nonpregnancy-specific conditions were lung infections (34/70, 48.57%) and cardiac problems (25/70, 35.71%). Sixty patients (85.71%) developed HF during pregnancy. Sixty-seven pregnancies (95.71%) ended in cesarean section. Three maternal deaths (4.29%) from HF were recorded. Of the 87 fetuses, three fetuses (3.45%) ended in miscarriages and stillbirth occurred in 5.75% of fetuses. The mean birth weight of a neonate was 2174.49 ± 609.57 (817-3430) g. There were eight neonatal deaths (8/79, 10.13%). The incidence of lung infection (P = 0.031) or cardiac problems (P = 0.044) differs between patients with NYHA classes II and patients with NYHA classes III/IV. The incidence of lung infection (P = 0.006) was also different in patients with prenatal HF and patients with postpartum HF. Peripartum HF is associated with high maternal and neonatal morbidity and mortality. Hypertensive disorders in pregnancy, lung infections, and cardiac problems are most common precipitating factors of HF in pregnancy.

Combined cesarean section and mitral valve replacement in severe symptomatic mitral valve disease with unfavorable valve anatomy: Experience at a tertiary referral center of North India

Objective: To discuss the management in a subset of patients with severe mitral valve disease having calcified, nonpliable valves not suitable for percutaneous balloon mitral valvuloplasty during pregnancy, presenting with Stage III–IV of the clinical classification of New York Heart Association. Methods: Patients with nonpliable valves presenting with heart failure in pregnancy at advanced gestation were planned for simultaneous cesarean section followed by mitral valve replacement. Results: All patients underwent successful surgery with good maternal and neonatal outcome. Conclusion: Patients with severe mitral valvular disease in failure in pregnancy, who are at high risk of mortality in pregnancy or during and following delivery, benefit from combined surgery.

Heart failure in pregnancy: A review of clinical status and meta-analysis of diagnosis and medication safety

Heart failure in pregnancy: A review of clinical status and meta-analysis of diagnosis and medication safety

The challenge of cardiomyopathies and heart failure in pregnancy.

To discuss the risk preexisting or new onset cardiomyopathy/heart failure (CMP/heart failure) in pregnant woman, and recent insights regarding their management and therapy. Recent data from the European Registry on Pregnancy and Heart disease of the European Society of Cardiology (ROPAC) suggest that, after an adequate prepregnancy evaluation in specialized centres, the vast majority of pregnancies are safe for both mother and foetus. A tailored approach is required according to cardiac phenotype (i.e. type of cardiomyopathy), clinical and functional status, and new potential treatments (i.e. bromocriptine in patients with peripartum cardiomyopathy). In clinical practice, prepregnancy cardiac evaluation is mandatory, including evaluation of the clinical status, standard ECG (and 24-48 h monitoring, whenever required), and imaging, to define the individual risk profile. In presence of severe symptoms (advanced New York Heart Association class), cardiac dysfunction (moderate-severe reduced ejection fraction), haemodynamic load (left ventricular outflow tract obstruction, pulmonary hypertension), pregnancy is contraindicated. A tailored monitoring is warranted in other cases (mild-moderate risk pregnancies). Likewise, in women who develop PPCM, a risk stratification and tailored monitoring and therapy should be achieved by an expert, multidisciplinary team, including cardiologists, gynaecologists, obstetricians, genetic counsellor, and psychologists.

Heart Failure in Pregnancy

AbstractCardiovascular mortality remains an important cause of maternal mortality other than the obstetric direct causes. Most cardiovascular deaths occur due to heart failure. Rheumatic heart diseases (RHD) account for more than two-thirds of heart diseases in pregnancy in low–middle income countries. Among RHD patients, 49% of patients with severe mitral stenosis, 31% with moderate mitral stenosis, and 23% with moderate to severe mitral regurgitation present with heart failure during pregnancy. In the U.K. registry, 25% of patients had heart failure due to cardiomyopathy. Congenital heart diseases such as atrial septal defect with severe pulmonary hypertension, significant atrioventricular valve regurgitation, peripartum, or dilated cardiomyopathy are less common causes of heart failure in pregnancy. Coronary artery diseases usually present as acute coronary syndromes during pregnancy, and heart failure as presentation is a rare occurrence. Preeclampsia and chronic hypertension can lead to increased vascular resistance, diastolic dysfunction, acute pulmonary edema, and acute heart failure. Two-thirds of heart diseases are diagnosed during the antepartum period itself. Preconception counseling, optimal medical therapy and avoidance of teratogens, and planning interventional or surgical therapies in patients with severe or moderate valvular diseases and congenital heart diseases will enable patients to enter the pregnancy well compensated. During pregnancy and postpartum, close surveillance and a multidisciplinary approach involving the obstetrician, cardiologist, physician, and anesthetist will lead to better maternal and fetal outcomes.