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# 2688# Cumula1ve#pa1ents#enrolments# 2500# New#enrolled#pa1ents#ROPAC# 2205# New#enrolled#pa1ents#Preg#I# 2000# 1867# 1500# 1345# 971# 1000# 498# 500# 208# 27# 45# 76# 116# 186# 27# 69# 225# 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# 0# 1427# ROPAC Registry 45 Länder, 112 Zentren ROPAC Registry Congenital heart disease Valvular heart disease Cardiomyopathy Ischemic heart disease n=1321 Roos-Hesselink et al. ROPAC registry, EHJ 2012 66 % 25 % 7% 2% 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 heart failure 20 15 10 5 20 08 AR A 20 ZA H s rti Cu gl 20 08 213 12 93 09 131 20 d Fo r 20 ng 20 A AR 74 St an 49 10 06 ZA H Kh ai ry 20 20 G RE RP CA 1302 08 90 So n= 599 01 0 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$ents!without!HF! (n=1148) p!value 4,8 0,5 <0,001 Atrial!fibrilla$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$ons!post!partum!(%) 4,6 5 0,85 Intra!uterine!growth!retarda$on!(%) 13 4,6 <0,001 Pregnancy!induced!hypertension!(%) 2,9 2,4 0,67 PreNeclampsia!(%) 12 1,9 <0,001 ! Maternal!mortality!(%) Cardiac Obstetric 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 3328 3358 0,46 Adjusted&mean&birthweight&(grams) 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 Achsen 92 /min P 19999 ° 36 ° QRS -T Intervalle RR P PQ QRS QT QTc Interpretatio n 652 ms --88 ms 332 ms 411 ms V1 II V2 III V3 aVR V4 aVL V5 aVF V6 25 mm/s 10.0 mm/mV SEMA-200 2.45 /611.04685 29.09.2013 16:39:23 I Me h a b u b A m etula 3464728 V alidiert vo n 0.05-35 Hz (AT-110XP 2.13 1.07.1.00 2.17.8) Unispital Basel / Kardiologie Tel. ++41 (61)2652525 NotfallstationNFEKG1 Me d: B e m: HF Pat-Name: 14.01.1984 29 Jahre W -.- cm -.- kg - / - mmHg Pat-Nr: G e b: Alter: G e s c hl: G rö s s e: G e wic ht: B D: 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 41 40 30 20 10 10 0 8 0 Cardiac Complications During Pregancy 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 et 2010 al JACC 2000 Grewal etGrewal al. JACC 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 Generally safe and effective Can cause IUGR FDA Class C ACE-I / ARB Contraindicated ➔ teratogenic effects Consider Hydralzine or Amlodipine FDA Class D for 2nd and 3rd trimester AldosteronAntagonists Furosemid Digoxin 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 27th 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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