Who, what, where – Management of pregnancy in women post congenital cardiac surgery - the cardiologist’s view Dr. Aisling Carroll Consultant Cardiologist Adult Congenital Heart Disease Clinical Lead ACHD & Obstetric Cardiology Obstetric Anaesthetic Association Scientific Meeting 2013 , Bournemouth
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Who, what, where Management of pregnancy in women post ... May 091… · women post congenital cardiac surgery-the cardiologist’s view Dr. Aisling Carroll Consultant Cardiologist
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Who, what, where – Management of pregnancy in women post congenital cardiac surgery
- the cardiologist’s view
Dr. Aisling Carroll
Consultant Cardiologist
Adult Congenital Heart Disease
Clinical Lead ACHD & Obstetric Cardiology
Obstetric Anaesthetic Association
Scientific Meeting 2013, Bournemouth
No Disclosures
Overview
• Who?
• What?
• Where?
• How?
Leading Causes of Maternal Death
CMACE report 2011
Congenital Heart Disease and Maternal Death
2000-2002
• 1 Eisenmenger ASD (previously undiagnosed)
• 2 Repaired septal defects with progression of modest PHT
• 1 coarctation (previously undiagnosed)
• 1 Fontan
• 1 Pulmonary stenosis, Noonan
• 3 Valve/other
2006-2008
• 1 Thrombosed aortic valve
• 2 pulmonary hypertension
Scope of the Problem
• Congenital heart disease in 1% live births
• Survival to adulthood over 90%
• ACHD population increase ~1600pa, approx 159,000
• Many will develop ventricular dysfunction evolving into symptomatic heart failure
Verheugt et al, Int J Cardiol 08
Proportion of Patients in Contact with the
Healthcare System
Marelli et al, Circ 09
Median age at loss to follow-up from cardiology care: 15 yrs
Prevention of Maternal Mortality and Morbidity
• Accurate pre-conception counselling
• Many can have a successful pregnancy
• Unacceptable risk in others
• Risk assessment to make an informed decision
• Appropriate contraceptive advice
Approximate mortality risks in pregnancy
• Entirely healthy woman 1 in 20,000
• Population average 1 in 10,000
• Corrected Fallot 1 in 1,000
• Severe aortic stenosis 1 in 100
• Pulmonary hypertension 1 in 3
• Eisenmenger’s complex 1 in 2
Pre-pregnancy Counseling
• Risk assessment
• Cardiac investigations
• Full and frank discussion
• Appropriate contraception
• Medication adjustment
• When to contact Team if pregnant
Risk Assessment
• Define underlying cardiac lesion
• Maternal functional status
Distribution of Peak VO2 in Asymptomatic CHD Pts
– NYHA Class I
Risk Assessment
• Define underlying cardiac lesion
• Maternal functional status
• Need for further palliative or corrective surgery
• Additional associated risk factors
• Issues of maternal health and life expectancy
• Genetics
Predictors of Cardiac Events
1) Prior CHF, stroke or arrhythmia
2) Baseline NYHA class >II or cyanosis
3) Left heart obstruction
MVA <2cm2, AVA <1.5cm2
LVOT gradient >30mmHg by echo
4) ↓ systemic vent function (EF<40%)
Risk index predicts CV event rate
Siu et al: Circulation 2001
Actual vs Predicted Primary Cardiac Event Rates with Varying Numbers of Predictors
Siu, S. C. et al. Circulation 2001;104:515-521
23 yo
• VSD – repaired at 18months
Subsequent TR
Normal ventricular function
• Asymptomatic
AF in past – none for 2 years
• Considering pregnancy
What is the primary CV concern during pregnancy?
• 1) Heart failure
• 2) Arrhythmia
• 3) Paradoxical embolism
Predicted CV event rate 20%
due to arrhythmia history
What cardiac conditions are low risk?
Lesion Specific Maternal Risk
Mortality < 2%
Unoperated small septal
defects/PDA
Mild valvar stenosis
Most repaired septal
defects
Good coarctation repair
Most regurgitant lesions
Repaired Fallot
Mortality 2-10%
Expert advice & Mgt
Mechanical valve
Systemic R ventricle
Cyanotic, no PHT
Fontan circulation
Mortality 10-50%
Expert advice &
Mgt
Pulmonary
hypertension
↓ Ventricular
function
Aortic aneurysm
Severe L-sided
obstruction
Low risk Significant risk Contraindicated
24 yo PE teacher
Bicuspid Aortic Valve with Stenosis
Careful monitoring throughout pregnancy
C section in view of twins
Twins!
Marfan Syndrome
• Main maternal risk is Type A aortic dissection – 1%
• High risk:
• poor family history
• cardiac involvement
• aortic root > 4cm or rapidly expanding
• Appropriate counselling
• B blockers and elective section Elkayam et al. Ann Intern Med 1995;123:117-
22
Marfan SyndromeContraindications to pregnancy
Aorta >40mm
Decreased ventricular fn, EF<40%Class III-IV
Aortic Coarctation
MRA/CTA
• Delineate location, extent,
and severity of coarct
• Collaterals – flow direction
• Associated lesions
• Postop eval – aneurysm,
dissection, recoarctation
Compliments echo
Coarctation in Pregnancy
•50 pts had118 pregnancies resulting in 106 births
•11 miscarriages (9%), 4 premature (3%), 1 neonatal death