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Management of acute heart failure during pregnancy: rapid interdisciplinary workup and treatment of mother and foetus (modified from Bauersachs et al. 280 ). AHF = acute heart failure; HF = heart failure.
Context in source publication
Context 1
... 8.3.1 Acute/subacute heart failure and cardiogenic shock during or after pregnancy HF in DCM or PPCM can develop rapidly and Guidelines for the man- agement of acute HF and cardiogenic shock apply. 286,289 For rapid diagnosis and decision-making, a pre-specified management algorithm and expert interdisciplinary team are crucial (Figures 5 and 6). 279,290 8.3.1.1 ...
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Background
The new category of heart failure (HF), Heart Failure with mid range Ejection Fraction (HFmrEF) has recently been proposed with recent publications reporting that HFmrEF represents a transitional phase. The aim of this study was to determine the prevalence and clinical characteristics of patients with HFmrEF and to establish what proport...
Citations
... The European Society of Cardiology advises against pregnancy in patients with vEDS. 6 The American College of Obstetricians and Gynecologists (ACOG) also recommends avoiding pregnancy and discussing abortion if a women with vEDS does become pregnant. 7 Lastly, the American College of Cardiology (ACC) and the American Heart Association (AHA) do not recommend against pregnancy in low-risk populations (i.e. ...
... section can be recommended. 6,8 These considerations might explain the high observed caesarean section rate. In this atrisk population, an emergency caesarean section may be performed in the event of serious life-threatening complications (whether obstetric or not) during pregnancy or labour. ...
... The European Society of Cardiology advises against pregnancy in women with vEDS because of the high risk of arterial rupture. 6 The American College of Cardiology (AAC)/ American Heart Association (AHA) do not advise against pregnancy in a low-risk population (women with specific genetic variants, null mutations and normal vascular imaging). Vaginal delivery could be considered if the aortic diameter is below 4.0 cm and there is no history of chronic aortic dissection. ...
Background
Vascular Ehlers‐Danlos syndrome (vEDS) is a hereditary connective tissue disorder associated with an elevated risk of vascular, uterine and digestive complications. Managing pregnancy in this context can be a challenge.
Objectives
To systematically review the literature data on the complications in pregnancy associated with vEDS.
Search strategy
We searched the Pubmed Medline and Embase databases for articles using the following terms “vascular Ehlers‐Danlos syndrome” or “vEDS” AND “pregnancy”.
Selection criteria
Women with vEDS.
Data collection and analysis
We searched the PubMed® MEDLINE® database for publications evaluating obstetric outcomes in women with vEDS.
Main results
A total of 121 publications were screened, with six (accounting for 412 pregnancies) included in our review. Of the women included in this sample, 30% were infertile. The miscarriage rate was 13.8% (57/412) and 8.8% of the live births were premature. Obstetric anal sphincter injuries occurred in 11.3% (23/203) of the deliveries. The maternal mortality rate per pregnancy was 5.7%.
Conclusions
Women with vEDS present an elevated risk of uterine rupture, vascular events, digestive events and death during pregnancy. Women appear to be most at risk during the peripartum period; to avoid expulsive efforts, a caesarean section should be scheduled at 37 weeks of gestation.
... The biggest difference between the two cases is that our case involved recurrent cardiac surgery. Approximately 20% of fetal losses are caused by CPB [8]. In addition, reoperation is a risk factor for maternal and fetal mortality [9]. ...
Background
Perioperative management and cardiac surgery in pregnant women with anti-phospholipid syndrome combined with heart valve disease have been rarely reported.
Case presentation
We describe a case of transcatheter mitral valve-in-valve replacement in a pregnant woman with bioprosthetic valve failure and anti-phospholipid syndrome at 18 weeks’ gestation. The patient underwent a cesarean section delivery at 34 weeks of gestation, resulting in the birth of a healthy baby.
Conclusions
Transapical mitral valve-in-valve surgery resulted in safe maternal and infant outcomes in a pregnant woman with anti-phospholipid syndrome combined with mitral bioprosthetic valve failure. The success of this procedure underscored the importance of multidisciplinary teamwork.
... Peripartum Cardiomyopathy (PPCM) is a cause of heart failure that occurs in the last months of pregnancy and within ve months after delivery in a previously healthy woman [1]. It is characterized by left ventricular dysfunction and dilatation, however, its cause remains unknown [2]. Its incidence is 1 per 3000 to 1 per 4000 live births [2,3]. ...
... It is characterized by left ventricular dysfunction and dilatation, however, its cause remains unknown [2]. Its incidence is 1 per 3000 to 1 per 4000 live births [2,3]. The incidence of peripartum cardiomyopathy has displayed geographical variability whereby some places like Japan have the lowest of 1 in 20,000 live births, In USA it is 1 in 4000 and the highest in Nigeria 1 in 100 live births with a fatality rate of between 20-50% [3,4]. ...
... The duration of anticoagulation is another ambiguous topic. As per the heart failure guidelines for peripartum cardiomyopathy, anticoagulation therapy should be continued until left ventricular function normalizes [2], that's within 2 to 6 months in 23 to 72% of cases, but it can take longer up to 5 years [20]. In previous cases of biventricular thrombi, 5 patients had clot resolution within 3 weeks [4,11,13,16], except a single patient who had clot resolution after 3 months [15], and other 5 cases lacked data on clot resolution [1,3,12,14,17,18]. ...
Introduction
Peripartum Cardiomyopathy (PPCM) is a rare form of heart failure occurring during late pregnancy or within five months postpartum, its etiology remaining elusive. While typically characterized by left ventricular dysfunction, it may present with intracardiac thrombi, raising the risk of systemic embolization. Here, we report an unusual case of PPCM featuring biventricular intracardiac thrombi, highlighting the importance of a thorough investigation for potential underlying causes.
Case presentation
This is a case of a black African, multiparous woman aged 44 years with an unremarkable past medical history, who presented with symptoms suggestive of acute heart failure five months after her last delivery. A 2D Transthoracic Echocardiography showed multiple biventricular intracardiac thrombi, a rare complication of PPCM without a systemic embolic event. Further, laboratory tests for evidence of a hypercoagulable state came out negative. Treatment involved a combination of acute heart failure, and anticoagulation followed by optimal medical therapy for chronic heart failure, resulting in improved symptoms for heart failure, cardiac function, and significant thrombi resolution after 8 weeks.
Conclusion
Multiple biventricular intracardiac thrombi are uncommon finding in Peripartum Cardiomyopathy (PPCM), emphasizing the need for vigilant diagnosis and management. Despite the absence of identifiable secondary causes, prompt management of acute heart failure and anticoagulation led to significant thrombi resolution and improved cardiac function. This case highlighted the significance of the complex management of PPCM, in an individualized manner.
... Among different intervention options for MS, BMV has been proved to have good immediate and long term results and is, therefore, preferred over open surgery options. 2 BMV, compared to open surgery, during pregnancy has a much lower maternal and foetal mortality (maternal mortality rate of 2 % and foetal mortality rate of 1-8% in BMV as compared to 40 % foetal mortality and 13 % maternal mortality in open surgery). [4][5][6] In current guidelines, for patients with severe MS and favourable valve morphology, BMV has a class I recommendation for non-pregnant patients and a class IIa recommendation for pregnant patients presenting with severe MS. 2,7 Ideally, intervention should be done before pregnancy to avoid high-risk situation. 2 In case of severe MS diagnosed during pregnancy, BMV should, preferably, be done after the 20th gestational week. ...
... Las enfermedades cardiovasculares generan morbimortalidad en las mujeres a lo largo de la vida 1 siendo el embarazo una etapa en la que se requiere una alta sospecha dado que son condiciones que pueden comprometer la vida 2 . Los cambios fisiológicos propios de la gestación, como otros aspectos que contribuyen a cambios hemodinámicos significativos como son: las contracciones uterinas, el dolor, la ansiedad, el esfuerzo, el pujo, el sangrado y la involución uterina son retos para el sistema cardiovascular de la mujer, así como la anestesia, la preeclampsia y la sepsis pueden actuar como gatillos precipitantes de estrés hemodinámico y que promueven eventos de novo o la descompensación de enfermedad cardiovascular previa 1 . ...
... Беременность при СЭ противопоказана ввиду высокого риска тяжелых осложнений и смерти матери и плода [3-8, 12-15, 40, 41]. Приводя к физиологическому снижению периферического сосудистого сопротивления, беременность у пациенток с СЭ вызывает нарастание веноартериального сброса и гипоксемии, усугубляет гематологические расстройства и повышает риск парадоксальных эмболий [6,8,40,41]. При этом риск материнской смертности доходит до 30-50%, а перинатальной потери или тяжелой патологии плода -до 30% [40]. ...
... Приводя к физиологическому снижению периферического сосудистого сопротивления, беременность у пациенток с СЭ вызывает нарастание веноартериального сброса и гипоксемии, усугубляет гематологические расстройства и повышает риск парадоксальных эмболий [6,8,40,41]. При этом риск материнской смертности доходит до 30-50%, а перинатальной потери или тяжелой патологии плода -до 30% [40]. Факторами риска для матери служат Ht>60%, SaO 2 <80% и наличие синкопе. ...
Eisenmenger syndrome (ES) is systemic pulmonary hypertension with venoarterial or bidirectional shunting of blood between the ventricles, atria or great arteries due to the progression of pulmonary vascular disease in the natural course of “simple” and “complex” congenital heart defects.Patients with ES require constant attention from a multidisciplinary team of specialists. One of the main tasks is not to destabilize the fragile pathological physiology, which relies on the balance of pulmonary and peripheral vascular resistance. Surgical interventions with anesthesia, if they cannot be avoided, should be performed in specialized centers. Pregnancy is contraindicated in patients with ES. Clinical symptoms of blood hyperviscosity in ES are rare.The anachronistic practice of venesections, which leads to a decrease in the oxygen transport function of the blood, iron deficiency and an increased risk of cerebrovascular complications, should be avoided. Oral and intravenous replenishment of iron deficiency improves exercise tolerance and quality of life. Routine administration of anticoagulants for ES is not indicated. In most cases, endovascular embolization of pathological collateral arteries can eliminate hemoptysis. The use of venous access requires careful prevention of embolism. Therapeutic tactics for ES are discussed in detail in this review
... Considering the increasing incidence of pregnancy in older age, the use of antiplatelets by pregnant women makes an important discussion point for many clinicians [1,2]. These drugs are used for many indications, like angina pectoris, myocardial infarction, ischemic cerebrovascular insult, preeclampsia, prevention of placental thrombosis and miscarriage, intrauterine growth restriction (IUGR) associated with placental insufficiency, antiphospholipid syndrome, thrombophilia and secondary prophylaxis after coronary bypass surgery In addition, they are indicated as an additional therapy for the prevention of mechanical valve thrombosis or as a monotherapy in case of biological heart valves three months after surgery (aspirin only), and in sticky platelets syndrome [1,[3][4][5]. ...
... Considering the increasing incidence of pregnancy in older age, the use of antiplatelets by pregnant women makes an important discussion point for many clinicians [1,2]. These drugs are used for many indications, like angina pectoris, myocardial infarction, ischemic cerebrovascular insult, preeclampsia, prevention of placental thrombosis and miscarriage, intrauterine growth restriction (IUGR) associated with placental insufficiency, antiphospholipid syndrome, thrombophilia and secondary prophylaxis after coronary bypass surgery In addition, they are indicated as an additional therapy for the prevention of mechanical valve thrombosis or as a monotherapy in case of biological heart valves three months after surgery (aspirin only), and in sticky platelets syndrome [1,[3][4][5]. ...
... Besides understanding the pathology for treating any of these diseases, clinicians should always be aware of the common pharmacokinetic changes affecting this special population of patients. A rise in the activity of liver enzymes, an increased degree of glomerular filtration and plasma volume, changes in protein binding and reduction in serum albumin levels should always be accounted for in pregnant women [1]. In addition, various risk factors such as smoking, hypertension, diabetes, dyslipidemia, acquired thrombophilic conditions (antiphospholipid antibody syndrome and hyperhomocysteinemia), thrombophilia (acquired or inherited), infections, etc., that may cause cardiovascular pathologies in pregnant women should also be assessed on an individual patient basis [1]. ...
When clinicians opt for antithrombotic therapy to manage or prevent thrombotic complications during pregnancy, it is imperative to consider the unique physiological state of the pregnant woman’s body, which can influence the pharmacokinetics of the drug, its ability to traverse the placental barrier, and its potential teratogenic effects on the fetus. While the efficacy and safety of aspirin during pregnancy have been relatively well-established through numerous clinical studies, understanding the effects of newer, more potent antiplatelet agents has primarily stemmed from individual clinical case reports necessitating immediate administration of potent antiplatelet therapy during pregnancy. This review consolidates the collective experiences of clinicians confronting novel thrombotic complications during pregnancy, often requiring the use of dual antiplatelet therapy. The utilization of potent antiplatelet therapy carries inherent risks of bleeding, posing threats to both the pregnant woman and the fetus, as well as the potential for teratogenic effects on the fetus. In the absence of official guidelines regarding the use of potent antiplatelet drugs in pregnancy, a plethora of cases have demonstrated the feasibility of preventing recurrent thrombotic complications, mitigating bleeding risks, and successfully managing pregnancies, frequently culminating in cesarean deliveries, through meticulous selection and dosing of antiplatelet medications.
... Epidural analgesia can substantially reduce these factors and could help to explain a protective effect in some groups of women, such as those with underlying cardiac or respiratory disease in whom the role of epidural analgesia has been established. 6 Another potential explanation for the protective effect could relate to the increased medical care and attention individuals with epidurals in place receive, thereby enabling more timely detection and response to incipient morbidity. An epidural in situ allows for swift conversion from analgesia to anaesthesia for emergency caesarean birth, reducing the need for general anaesthesia with its increased risks of morbidity and mortality. ...
... Arrhythmias in pregnancy represent a complex problem to manage, both because they involve the risk of maternal and fetal complications and because their pharmacological and interventional management must consider the possible teratogenic effects and adverse events that the fetus may encounter. Drug therapy with antiarrhythmic drugs can be partially effective in some types of arrhythmias, and, for this reason, recent guidelines indicate the possibility of performing catheter ablation procedures in selected cases and in expert centers [1]. ...
... Many cornerstone drugs for the treatment of arrhythmias cannot be used (such as unselective beta-blockers, like atenolol, associated with higher rates of fetal growth retardation, or diltiazem, which is definitely teratogenic in animals) or must be carefully monitored in this clinical context. Adenosine, a beta-1-selective blocker, ibutilide, or flecainide seem usable, based on different levels of evidence, in the acute management of supraventricular arrhythmias, as long as they are accompanied by a medium/high surveillance level [1]. Electrical cardioversion should be considered in the case of hemodynamic instability or failure of pharmacological heart rate control. ...
... However, the assumption that medical radiation doses must be kept "as low as is reasonable", which is valid for all patients, is even more important at any stage of pregnancy. "Zero-fluoroscopic" or minimal fluoroscopic ablation (fetal radiation exposure of <1 mGy, with abdominal shielding), with the help of three-dimensional electroanatomical mapping systems and intracardiac echocardiography, should be considered in case of arrhythmias that are poorly tolerated and refractory to pharmacological therapy (Class IIA-C according to ESC guidelines) [1]. Although zero-fluoroscopy ablations are increasing, this procedure in pregnant women continues to be very challenging due to the risks, including the unknown risks that the mother and fetus may encounter during ablation. ...
Background:
Arrhythmias in pregnancy are complex to manage due to the teratogenic effects of many antiarrhythmic drugs and the common use of ionizing radiation during catheter ablation procedures. Furthermore, pregnant women are extremely vulnerable and difficult to treat because of the progressive physical and hormonal changes that occur during the nine months of pregnancy.
Case presentation:
In this case report, we describe a complex clinical case of a 34-year-old pregnant woman who was affected by an incessant right atrial tachycardia, with signs and symptoms of initial hemodynamic instability. This tachycardia was refractory to antiarrhythmic drugs, so a zero-fluoroscopy ablation was performed. The first procedure was complicated by cardiac tamponade, quickly resolved without further complications for the mother or the fetus. In the following days, a deep venous thrombosis occurred at the femoral venous access. After a few days, the patient underwent a second procedure that was successful and resulted in the restoration of a sinus rhythm.
Conclusions:
The management of this clinical case was complex both from a procedural and a clinical (cardiological and gynecological) point of view. Finally, the integration of the various skills led to an excellent result.
... Pregnancy poses unique challenges for women with mechanical heart valves (MHVs). Indeed, gestation in these patients is associated with a very high risk of complications, namely risk class III according to the Modified World Health Organization (mWHO) classification of maternal cardiovascular risk (risk classes I-IV), 1 with an estimated rate of an event-free pregnancy with a live birth of 58%, compared with 79% for women with bioprostheses, and 78% for those with heart disease but no prosthetic valves. 2 The delicate balance between maintaining maternal hemostasis and ensuring fetal well-being becomes a critical concern in managing these high-risk pregnancies, hence requiring a thoughtful and multidisciplinary approach. ...
... Particularly, optimal anti-Xa levels, evaluation of peak versus trough levels, and the time interval for anti-Xa monitoring are still matter of debate. 1 In addition, maternal bleeding has been associated with all anticoagulant regimens, but a lower incidence has been described with VKA than with UFH/LMWH. 1 The aim of this Position Paper is to provide guidance for clinicians involved in the management of pregnant women with MHVs, in order to optimize maternal and fetal outcomes while ...
... Particularly, optimal anti-Xa levels, evaluation of peak versus trough levels, and the time interval for anti-Xa monitoring are still matter of debate. 1 In addition, maternal bleeding has been associated with all anticoagulant regimens, but a lower incidence has been described with VKA than with UFH/LMWH. 1 The aim of this Position Paper is to provide guidance for clinicians involved in the management of pregnant women with MHVs, in order to optimize maternal and fetal outcomes while ...
The management of anticoagulant therapy in pregnant women with mechanical heart valves (MHVs) is difficult and often challenging even for clinicians experienced in the field. These pregnancies, indeed, are burdened with higher rates of complications for both the mother and the fetus, compared to those in women without MHVs. The maternal need for an optimal anticoagulation as provided by vitamin K antagonists (VKAs) is counterbalanced by their teratogen effect on the product of conception. On the other hand, several concerns have been raised about the efficacy of heparins in pregnant women with MHVs, considering the high risk of thrombotic complications in these patients. Therefore, numerous clinical issues about the management of pregnant women with MHVs remain unanswered such as the selection of the best anticoagulant agent, the optimal anticoagulation levels to be achieved and maintained, and the evaluation of long-term effects for both the mother and the fetus. Based on a comprehensive review of the current literature, the Italian Federation of the Centers for the Diagnosis and the Surveillance of the Antithrombotic Therapies (FCSA) proposes experienced-based suggestions and expert opinions. Particularly, this consensus document aims at providing practical guidance for clinicians dealing with pregnant women with MHVs, to optimize maternal and fetal outcomes while guaranteeing adequate anticoagulation. Finally, FCSA highlights the need for the creation of multidisciplinary teams experienced in the management of pregnant women with MHVs during pregnancy, delivery, and post-partum, in order to better deal with such complex clinical issues and provide a comprehensive counseling to these patients.
