Heart Disease and Pregnancy

Alexandra A Frogoudaki

Adult Congenital Heart Clinic

Second Cardiology Department

ATTIKON University Hospital

Pre Pregnancy

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

Preconceptional Counselling

Roos Hesselink et al Heart Dec 2017

Pregnancy

Hemodynamic changes during pregnancy

Uebing et al Heart 2006

Cardiac Conditions

• Congenital heart disease

• Cardiomyopathy

• Valvular heart disease

• Ischemic heart disease

• Diseases of the aorta

• Pulmonary hypertension

Predictors of maternal cardiovascular eventsand risk score from the CARPREG study

ESC guidelines December 2011

Predictors of maternal cardiovascular eventsidentified in congential heart diseases in the

ZAHARA and Khairy study

ESC guidelines December 2011

Balci A et al (ZAHARA II). Heart 2014

Position Paper Organization of Care for Pregnancy in

Congenital Heart Disease

Roos Hesselink et al Heart Dec 2017

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)

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!!!

Registry Of Pregnancy And Cardiac diseaseROPAC

ROPAC enrollemnt up to September 2017, 5455 pts!

Heart failure in pregnancyROPAC 1-1321 pregnancies

Ruys TPE et al. Heart 2014

Timing of heart failureROPAC 1-1321 pregnancies

Ruys TPE et al. Heart 2014

Kampman MAM et al. EHJ 2014

JACC Clinical Electrophysiology August 2015

Congenital Heart Disease

14/2/2015

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!

• 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

Valvular Heart Disease

11/10/2013

Case

• 28 y old referred because of hemoptysis and shortness of breath, 22 weeks pregnant

• MS was diagnosed

• Stabilized on b-blockers and diuretics

Mitral valvuloplasty

• She underwent mitral valvuloplasty on week 28th

• MVA increased 0.9cm2>1.2cm2

• She delivered on 38th week

• Healthy girl

Van Hagen et al Circulation 2015

Anticoagulation

ESC guidelines December 2011

Hypetrophic Cardiomyopathy

• Well tolerated during pregnancy

• Caution in epidural (SVR drop, obstruction increases)

• Arrhythmias common

• B-blockers the drug of choice

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

ESC guidelines December 2011

Pulmonary Hypertension

• In Eisenmenger’s syndrome maternal mortality up to 20-50%

• Usually planned CS

• Anticoagulation issues

• Increased fetal mortality

ESC guidelines December 2011

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

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%)

Diagnosis

Difficult!!!

Echo plays major role

Sliwa et al, Eur J Heart Fail. 2010 Aug

Biomarkers in PPCM

D. Hilfiker-Kleiner et alEur Heart J 2015

Hilfiker-Kleiner et alEur Heart J 2015

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

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

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

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!

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

11/10/2013