Pregnancy and Heart Disease. Alexandra A Frogoudaki Adult Congenital Heart Clinic ATTIKON University Hospital

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1 Pregnancy and Heart Disease Alexandra A Frogoudaki Adult Congenital Heart Clinic ATTIKON University Hospital

2 Pregnancy is not a <normal> state

3 Hemodynamic changes During pregnancy Estrogens 1. Renin 2. RAAS Activation 3. Η 2 0 Retention β-hg 1. Erythropoesis 2. Increased prolactin 3. Increased red cells mass 4. Total volume increase (6-8 l) 40% blood volume increase 1 st Trimester

4 Hemodynamic changes during pregnancy Uebing et al Heart 2006

5 Does pregnancy have symptoms? Chest pain Palpitations Shortness of breath

6 Prothrombotic state Increased venous pressure Increased coagulation factors (fibrinogen, F VII, F VIII, F IX, F XII, v WF) Decreased protein S Decreased fibrinolysis Risk of thrombosis 6-fold increase during pregnancy 11-fold increase postpartum

7 Echo in normal pregnancy STRUCTURE Heart changes position (horizontal, IVC compression) Left atrium volume increases 5-10% after 12 th week Pericardial effusion is not uncommon SYSTOLIC FUNCTION LV mass increases 5%, contractility increases (estimated by strain rate) DIASTOLIC FUNCTION Increase in heart rate LV mass increases, LV compliance decreases E/E increases and then stable WHAT IS NOT CLEARLY ABNORMAL MAY BE NORMAL!!!! Head et al Heart 2004

8 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!!!

9 What kind of Heart Disease? Congenital heart disease Cardiomyopathy Valvular heart disease Ischemic heart disease

10 Outcome of pregnancy in women with heart disease CARPEG Investigators 562 patients 599 pregnancies Siu et al Circulation 2001

11 Cardiac risk assessment was improved by including decreased subpulmonary ventricular systolic function and/or severe pulmonary regurgitation Khairy et al Circulation 2006

12 Predictors of maternal cardiovascular events and risk score from the CARPREG study ESC guidelines December 2011

13 Predictors of maternal cardiovascular events identified in congential heart diseases in the ZAHARA and Khairy study ESC guidelines December 2011

14 Modified WHO classification of maternal cardiovascular risk: principles ESC guidelines December 2011

15 ESC guidelines December 2011

16 ESC guidelines December 2011

17 ESC guidelines December 2011

18 Clinical evaluation-ecg Careful clinical evaluation in every visit with focus on 1. Chest and heart auscultation 2. Heart rate-arrhythmia (Holter if necessary) 3. Blood pressure 4. ECG changes 5. Peripheral oedema

19 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)

20 Congenital Heart Disease Can a patient with congenital heart disease deliver a baby? There is no YES or NO What do we need to Know? The maternal risk The fetal risk The obstetrical risk The risk of transmission

21 Preconception Counseling Define the nature and severity of the cardiac condition Clarify/enhance the patient s understanding of her condition Assess and discuss risk of adverse event during pregnancy Maternal life expectancy and ability to care for her child Recurrent risk of congenital heart disease Nature of surveillance

22 Recommendations for the management of cardiomyopathies and heart failure ESC guidelines December 2011

23 Dilated Cardiomyopathy Grewal et al JACC Jan 2010 In pregnant women with DCM the risk of adverse cardiac events is considerable, and pre-pregnancy characteristics can identify women at the highest risk. Pregnancy seems to have a short-term negative impact on the clinical course in women with DCM.

24 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/ 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 Aug

25 Diagnosis Difficult!!! Sliwa et al, Eur J Heart Fail Aug

26 Treatment It depends on the clinical condition Medication (including inotropes if needed) Intra aortic balloon pump Even LVAD may be considered!!! Mode of delivery depends on clinical condition of mam also. Sliwa et al, Eur J Heart Fail Aug

27 Hypetrophic Cardiomyopathy Well tolerated during pregnancy Caution in epidural (SVR drop, obstruction increases) Arrhythmias common B-blockers the drug of choice

28 Valvular Heart Disease Aortic stenosis, mitral stenosis not well tolerated when severe Pulmonary stenosis usually well tolerated unless gradient> 2/3 systemic pressure Endocarditis prophylaxis Anticoagulation is a problem in patients with prosthetic valves

29 Recommendations for the management of valvular heart disease ESC guidelines December 2011

30 ESC guidelines December 2011

31 Anticoagulation ESC valves guidelines 2008

32 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

33 Recommendations for the management of coronary artery disease ESC guidelines December 2011

34 More than 1000 patients enrolled up to September 2010 Target is 2000 patients to 2011

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40 Case 1 37 y old, HOCM, NYHA III, obese, LVOT gradient>100mmhg Underwent septal ablation 7/2007 Pregnant on February 2008, LVOT gradient:30mmhg Atrial fibrillation 7/08 (24 th week), converted to SR with amiodarone, NSVT On anticoagulation (LMWH), b-blockers, amiodarone New AF episode on 36 th week Skipped anticoagulation same morning Caesarian section same evening Healthy baby ICD implantation 2 months later

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42 Case 2 32y old, obese, Ross operation for subvalvular AS 2001, NYHA I-II Mild-moderate AR, PS, good LV function Complains for palpitations Treatment during pregnancy: b-blockers, LMWH Delivery for obstetrical reasons with CS on 37 th week Healthy baby Uncomplicated

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47 Post partum

48 Case 3 30 y old referred because of hemoptysis and shortness of breath, 22 weeks pregnant MS was diagnosed Stabilized on b-blockers and diuretics

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51 Mitral valvuloplasty

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54 She underwent mitral valvuloplasty on week 28 th MVA increased 0.9cm2>1.2cm2 She delivered on 38 th week Healthy girl

55 Case 4 25 y old presented in the 6 th week of pregnancy Situs inversus, dextrocardia, cctga, Tricuspid valve replacement (metallic St Jude) SCARY!!!!!

56 1 st issue: systemic ventricular function

57 2 nd issue: Is valve working?

58 3 rd issue: anticoagulation She was converted to LMWH with anti- Xa measurement every week, up to 12 th week She was put to warfarin up to 35 th week She was brought to the hospital, converted to LMWH for a week, then she had an elective CS She was off LMWH for 24 h LMWH was restarted 6 hours post delivery Subcutaneous hematoma was the only complication!!!

59 4 th issue: pulmonary hypertension?

60 Medication On 20 th week she started carvedilol On 33th week she started furosemide Never had symptoms of heart failure NYHA I Delivered healthy boy weighing 2350gr

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62 Conclusion Pregnancy can be relatively safe in women with complex heart disease Meticulous pre-counseling and follow-up during pregnancy is mandatory Echo plays a major role in follow-up New echo techniques can be very helpful in defining complex anatomy (3D) and function (strain, torsion, diastolic function) in pregnant women with heart disease

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