Heart failure in pregnancy PD Dr. med Daniel Tobler Leiter angeborene Herzfehler (GUCH) Universitätsspital Basel! www.heartdiseaseandpregnancy.com
Heart failure in pregnancy Agenda! - general considerations - specific lesions
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#
ROPAC Registry 45 Länder, 112 Zentren
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
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
Congenital heart disease Heart failure in Pregnancy Other studies Cardiac complications in pregnant women with congenital heart disease 25 20 heart failure 15 10 5 0 n= 599 90 1302 49 74 131 93 213 CARPREG 2001 Khairy 2006 ZAHARA 2010 Song 2008 Ford 2008 Curtis 2009 Stangl 2008 ZAHARA 2012
Timing of heart failure in pregnancy Ruys et al. Heart 2013
Hemodynamic changes during pregnancy Thorne, Heart 2009
Timing of heart failure in pregnancy Ruys et al. Heart 2013
ROPAC Registry Heart failure specific risk factors Mul$variate+analyse OR 95%+CI Signs+of+HF+prior+to+pregnancy 9,6 5,9@15,5 Cardiomyopathy 4,6 2,3@9,1 NYHA+class+>+2 2,3 1,2@4,4 WHO+>+2 2,3 1,5@3,6 Pulmonary+hypertension 1,8 1,0@3,0 Ruys et al. Heart 2013
ROPAC Registry Outcome in women with heart failure! Pa$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
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
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&(%) 30 13 <0,001 Birthweight&<&2500&gram&(%) 24 13 <0,001 Apgar&score&<&7&(%) 13 9,3 0,10 Adjusted&mean&birthweight&(grams) 3328 3358 0,46 Ruys et al. Heart 2013
The role of BNP Prediction of cardiac events in pregnancy Tanous et al. JACC 2010
The role of BNP Prediction of cardiac events in pregnancy BNP < 100 pg/ml: NPPV 100% Spezifität 70% Tanous et al. JACC 2010
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
Frequency of Cardiac disease in Pregnancy Congenital heart disease 66 % Valvular heart disease 25 % Cardiomyopathy 7 % Ischemic heart disease 2 % ROPAC registry, EHJ 2012
Congenital heart disease Improved survival Khairy et al. JACC 2010
Congenital heart disease Increased prevalence in adults Marelli et al, Circulation 2007
Complex congenital heart disease Transposition of the Great Arteries Tricuspid atresia Hypoplastic left heart syndrome
TGA - atrial switch Subaortic right ventricle Mustard vs Senning procedure
Fontan palliation Single ventricle physiology Coutesy of Prof. R. Pretre
Failing Fontan
Failing Mustard
Failing palliation Greutmann, Tobler et al, in press
Congenital heart disease Cardiac morbidity in Pregnancy Drenthen et al. JACC 2007
Frequency of Cardiac disease in Pregnancy Congenital heart disease 66 % Valvular heart disease 25 % Cardiomyopathy 7 % Ischemic heart disease 2 % ROPAC registry, EHJ 2012
Case 1 24y, G3P2, 24 wks GA
Case 1 24y, G3P2, 24 wks GA G eb: Alter: G eschl: Grösse: G ewicht: B D: Med: B em: 14.01.1984 29 Jahre W -.- cm -.- kg - / - mmhg H F 92 /min Achsen P 19999 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 0.05-35 Hz SEMA-200 2.45 /611.04685 (AT-110XP 2.13 1.07.1.00 2.17.8) Seite 1
Valvular heart disease in pregnancy Roos-Hesselink et al. ROPAC registry, EHJ 2012
Heart failure in pregnancy due VHD Ruys et al. ROPAC registry, Heart 2013
Mitral stenosis in Pregnancy Silversides et al. Am J Cardiol 2003
Mitral stenosis in Pregnancy Silversides et al. Am J Cardiol 2003
Mitral stenosis in Pregnancy ESC Guidelines, EHJ 2011
Aortic stenosis in pregnancy
Aortic stenosis in Pregnancy Mild or Moderate AS Severe AS 50 40 41 30 20 10 0 0 10 Cardiac Complications During Pregancy 8 Cardiac Surgery During Follow-up Silversides et al. Am J Cardiol 2003
Mechanical valves and pregnancy
Mechanical valves and pregnancy Drenthen et al. EHJ 2010
Frequency of Cardiac disease in Pregnancy Congenital heart disease 66 % Valvular heart disease 25 % Cardiomyopathy 7 % Ischemic heart disease 2 % ROPAC registry, EHJ 2012
Dilated Cardiomyopathy in pregnancy Risk factors for cardiac events Grewal et al. JACC 2010
Outcome in Dilated Cardiomyopathy Pregnancy as risk factor Grewal et al. JACC 2010
Maternal risk in DCM Grewal et al JACC 2000 Grewal et al. JACC 2010
Maternal risk Beneficial medication for the mother Effect on the fetus Risk of stopping meds Effect on the maternal heart
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
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
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