Heart failure in pregnancy

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1 Heart failure in pregnancy PD Dr. med Daniel Tobler Leiter angeborene Herzfehler (GUCH) Universitätsspital Basel!

2 Heart failure in pregnancy Agenda! - general considerations - specific lesions

3 ROPAC Registry Registry Of Pregnancy And Cardiac disease Update on recruitment (ROPAC) 3000# Cumula1ve#pa1ents#enrolments# 2688# 2500# New#enrolled#pa1ents#ROPAC# 2205# 2000# New#enrolled#pa1ents#Preg#I# 1867# 1500# 1345# 1427# 1000# 971# 500# 498# 0# 27# 45# 208# 76# 116# 27# 2008/01# 2008/03# 2008/06# 2008/08# 2008/10# 2008/12# 2009/02# 2009/04# 2009/06# 2009/08# 2009/10# 2009/12# 2010/02# 2010/04# 2010/06# 2010/08# 2010/10# 2010/12# 2011/03# 2011/05# 2011/07# 2011/09# 2011/12# 2012/02# 2012/04# 2012/06# 2012/08# 2012/10# 2012/12# 2013/02# 2013/04# 2013/06# 186# 69# 225#

4 ROPAC Registry 45 Länder, 112 Zentren

5 ROPAC Registry Congenital heart disease 66 % Valvular heart disease 25 % Cardiomyopathy 7 % Ischemic heart disease 2 % n=1321 Roos-Hesselink et al. ROPAC registry, EHJ 2012

6 ROPAC Registry Hospital admission: 25% Heart failure: 13% Ventricular arrhythmia s 2.0% Thrombotic complications: 0.4% Endocarditis: 0.3% n=1321 Roos-Hesselink et al. ROPAC registry, EHJ 2012

7 Congenital heart disease Heart failure in Pregnancy Other studies Cardiac complications in pregnant women with congenital heart disease heart failure n= CARPREG 2001 Khairy 2006 ZAHARA 2010 Song 2008 Ford 2008 Curtis 2009 Stangl 2008 ZAHARA 2012

8 Timing of heart failure in pregnancy Ruys et al. Heart 2013

9 Hemodynamic changes during pregnancy Thorne, Heart 2009

10 Timing of heart failure in pregnancy Ruys et al. Heart 2013

11 ROPAC Registry Heart failure specific risk factors Mul$variate+analyse OR 95%+CI Signs+of+HF+prior+to+pregnancy 9,6 Cardiomyopathy 4,6 NYHA+class+>+2 2,3 WHO+>+2 2,3 Pulmonary+hypertension 1,8 Ruys et al. Heart 2013

12 ROPAC Registry Outcome in women with heart failure! Pa$ents!with!HF! (n=173) Pa$ents!without!HF! (n=1148) p!value Maternal!mortality!(%) 4,8 0,5 <0,001 Cardiac Atrial!fibrilla$on!(%) 1,2 0,9 0,71 Ventricular!arrhythmias!(%) 2,9 1,8 0,35 ThromboNembolic!events!(%) 1,2 0,3 0,14 Endocardi$s!(%) 1,2 0,1 0,006 Bleeding!complica$ons!during!pregnancy!(%) 2,9 1,4 0,14 Bleeding!complica$ons!post!partum!(%) 4,6 5 0,85 Obstetric Intra!uterine!growth!retarda$on!(%) 13 4,6 <0,001 Pregnancy!induced!hypertension!(%) 2,9 2,4 0,67 PreNeclampsia!(%) 12 1,9 <0,001 Ruys et al. Heart 2013

13 ROPAC Registry 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 developed pre-eclampis, 30% also developed heart failure Extra monitoring is indicated in patients with pre-eclampsia! Ruys et al. Heart 2013

14 ROPAC Registry Fetal outcome in women with heart failure Fetal&outcome Pa,ents&with&HF& (n=173) Pa,ents&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&(%) <0,001 Birthweight&<&2500&gram&(%) <0,001 Apgar&score&<&7&(%) 13 9,3 0,10 Adjusted&mean&birthweight&(grams) ,46 Ruys et al. Heart 2013

15 The role of BNP Prediction of cardiac events in pregnancy Tanous et al. JACC 2010

16 The role of BNP Prediction of cardiac events in pregnancy BNP < 100 pg/ml: NPPV 100% Spezifität 70% Tanous et al. JACC 2010

17 The role of BNP Prediction of cardiac events in pregnancy Week 20 n=213 NPPV NT-proBNP levels <128 pg/ml : 96.9%. Kampman et at. EHJ 2013

18 Frequency of Cardiac disease in Pregnancy Congenital heart disease 66 % Valvular heart disease 25 % Cardiomyopathy 7 % Ischemic heart disease 2 % ROPAC registry, EHJ 2012

19 Congenital heart disease Improved survival Khairy et al. JACC 2010

20 Congenital heart disease Increased prevalence in adults Marelli et al, Circulation 2007

21 Complex congenital heart disease Transposition of the Great Arteries Tricuspid atresia Hypoplastic left heart syndrome

22 TGA - atrial switch Subaortic right ventricle Mustard vs Senning procedure

23 Fontan palliation Single ventricle physiology Coutesy of Prof. R. Pretre

24 Failing Fontan

25 Failing Mustard

26 Failing palliation Greutmann, Tobler et al, in press

27 Congenital heart disease Cardiac morbidity in Pregnancy Drenthen et al. JACC 2007

28 Frequency of Cardiac disease in Pregnancy Congenital heart disease 66 % Valvular heart disease 25 % Cardiomyopathy 7 % Ischemic heart disease 2 % ROPAC registry, EHJ 2012

29 Case 1 24y, G3P2, 24 wks GA

30 Case 1 24y, G3P2, 24 wks GA G eb: Alter: G eschl: Grösse: G ewicht: B D: Med: B em: Jahre W -.- cm -.- kg - / - mmhg H F 92 /min Achsen P Q RS 36 T -- Intervalle RR 652 ms P -- P Q -- Q RS 88 ms Q T 332 ms Q Tc 411 ms Interpretation Validiert von I V1 II V2 III V3 avr V4 avl V5 avf V6 25 mm/s 10.0 mm/mv Hz SEMA / (AT-110XP ) Seite 1

31 Valvular heart disease in pregnancy Roos-Hesselink et al. ROPAC registry, EHJ 2012

32 Heart failure in pregnancy due VHD Ruys et al. ROPAC registry, Heart 2013

33 Mitral stenosis in Pregnancy Silversides et al. Am J Cardiol 2003

34 Mitral stenosis in Pregnancy Silversides et al. Am J Cardiol 2003

35 Mitral stenosis in Pregnancy ESC Guidelines, EHJ 2011

36 Aortic stenosis in pregnancy

37 Aortic stenosis in Pregnancy Mild or Moderate AS Severe AS Cardiac Complications During Pregancy 8 Cardiac Surgery During Follow-up Silversides et al. Am J Cardiol 2003

38 Mechanical valves and pregnancy

39 Mechanical valves and pregnancy Drenthen et al. EHJ 2010

40 Frequency of Cardiac disease in Pregnancy Congenital heart disease 66 % Valvular heart disease 25 % Cardiomyopathy 7 % Ischemic heart disease 2 % ROPAC registry, EHJ 2012

41 Dilated Cardiomyopathy in pregnancy Risk factors for cardiac events Grewal et al. JACC 2010

42 Outcome in Dilated Cardiomyopathy Pregnancy as risk factor Grewal et al. JACC 2010

43 Maternal risk in DCM Grewal et al JACC 2000 Grewal et al. JACC 2010

44 Maternal risk Beneficial medication for the mother Effect on the fetus Risk of stopping meds Effect on the maternal heart

45 Medical Management of Chronic Heart Failure in Pregnancy Betablockers ACE-I / ARB Aldosteron- Antagonists Furosemid Digoxin Generally safe and effective Can cause IUGR FDA Class C Contraindicated teratogenic effects Consider Hydralzine or Amlodipine FDA Class D for 2nd and 3rd trimester No data to support safety in pregnancy FDA Class D Can result in uteroplacental hypoperfusion Contraindicated in IUGR / Pre-eclampsia FDA Class C Generally considered safe Useful in treatment in persistent symptoms FDA Class C

46 Management of acute decompensation in pregnancy In adherence to guidelines in nonpregnant women Intravenous diuretics / intravenous nitrates Hydralazine in hypertensive status Bed rest / oxygen / consider delivery

47 Take home messages Heart failure occurs in 13% of the patients with structural heart disease Heart failure shows a peak around the 27 th weeks of pregnancy and around delivery Preconception predictors for heart failure: Complaints of cardiac failure Cardiomyopathy WHO > 2 and NYHA > 2 Pulmonary hypertension Pre-eclampsia is a predictor for heart failure Women with heart failure had more adverse fetal events!! Fetal death, preterm birth, low birth weight

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