congenital heart disease and pregnancy
TRANSCRIPT
Matthias Greutmann, MDAdult Congenital Heart Disease Program
University Hospital Zurich, Switzerland
Congenital Heart Disease and
Pregnancy
Case: 25 year old
Normal ccTGA
Case: 25 year old
ccTGA Age 9: Mechanical tricuspid
valve replacement
Postop AV-block
Pacemaker
Case: 25 year old
Age 25: Planned pregnancy
• Warfarin LMWH
Dalteparin fixed dose
200U/kg = 10,000 U s.c. OD
12 weeks gestation:
Mean p across valve:
10 16 mmHg
ch
an
ge
in
%
0
10
20
30
40
50
60
-10
20
30
40
5 8 12 16 20 24 28 32 36 38
week of gestation
PVR
Hb
HR
SV
CO
Hemodynamic changes
Case: 25 year old
Mean p: 15 mmHg
Case: 25-year old
What went wrong
Risk stratification
Counselling
Pregnancy management
Early detection of complications
Objectives
Scope of the problem
Risk stratification
Counselling
Management & Care
Objectives
Scope of the problem
Risk stratification
Counselling
Management & Care
Deaths / 100,000 maternities2006-2008
0,00
0,50
1,00
1,50
2,00
2,50
Cardiac deaths1985 - 2008
0
10
20
30
40
50
60
Cardiac deaths1985 - 2008
0
10
20
30
40
50
60
Other acquired
Ischemic HD
CHD
CHD
Improved Survival- complex congenital heart disease -
1940 1950 1960 1970 1980 1990 2000 20100
20
40
60
80
100
%
20 2540
5570
80 85 90
BT-ShuntFallot-repair
Atrial switch
Fontan-operation
Arterial switch
Norwood
children
adults
Marelli, Circ 2007
0
500
1000
1500
2000
2500
1985 1990 1995 2000
Num
ber
of pa
tients
Complex CHD
Objectives
Scope of the problem
Risk stratification
Counselling
Management & Care
Risk stratification - global
0
2
4
6
8
10
12
14
16
CARPREG*… ZAHARA**… ROPAC*…
Heart failureOther non-fatal cardiovascular complicationsDeath
%
*CHD and acquired
** CHD only
Risks – lesion specific%
0
5
10
15
20
25
30
35
Arrhythmia
Heart Failure
Stroke / death
Drenthen, JACC 2007
Risks – lesion specific%
0
5
10
15
20
25
30
35
Arrhythmia
Heart Failure
Stroke / death
Drenthen, JACC 2007
Risk stratification
Modified WHO classification
Thorne, Heart 2006
WHO I WHO II WHO III WHO IV
No Risk Small Risk Signifcant Risk Contraindicat.
Risk stratification
Modified WHO classification
Thorne, Heart 2006
WHO I WHO II WHO III WHO IV
No Risk Small Risk Signifcant Risk Contraindicat.
• Mild PS
• Small VSD
• …
Risk stratification
Modified WHO classification
Thorne, Heart 2006
WHO I WHO II WHO III WHO IV
No Risk Small Risk Signifcant Risk
• Mild PS
• Small VSD
• …
• Severe AS, MS
• PHT
• Marfan – root > 45
• LVEF < 30
• NYHA III or IV
• S/p PpCMP &
LVEF < 55%
Risk stratification
Modified WHO classification
Thorne, Heart 2006
WHO I WHO II WHO III WHO IV
No Risk Small Risk Signifcant Risk
• Mild PS
• Small VSD
• …
• ASD
• Mild LVEF
• …
• Mechanical valve
• Fontan
• Systemic RV
• …
• Severe AS, MS
• PHT
• Marfan – root > 45
• LVEF < 30
• NYHA III or IV
• S/p PpCMP &
LVEF < 55%
Individual risk
stratification!
Individual risk stratification
Pre-Pregnancy!
Type of CHDSeverity
Associated lesions
Individual risk stratification
Type of CHDSeverity
Associated lesions
Cardiac function
Individual risk stratification
Type of CHDSeverity
Associated lesions
Cardiac function
Hemodynamicsi.e. pulmonary HTN
Residual shunts
Individual risk stratification
Exercise capacity
Comorbidities
Previous complications
Risk for twin pregnancy(IVF!)
Risk for preeclampsia
…
Individual risk stratification
Fetal risk: Risk factors
NYHA class >II or cyanosis
Left heart obstruction
Smoking during pregnancy
Multiple gestation
Oral anticoagulants
Mechanical valve prosthesis
Siu, Circ 2001
Khairy, Circ 2006
Drenthen, EHJ 2010
ACE-inhibitors, ARB
Statins
…
Fetal risk: Medication
Case: 34 years
Case: 34 years
Most dangerous – unknown HD!
Objectives
Scope of the problem
Risk stratification
Counselling
Management & Care
Kovacs AK, JACC 2008
Counselling
Contraindication to
pregnancy
No Yes
Patient being told
to avoid pregnancy
No
Yes
Kovacs AK, JACC 2008
Counselling
Contraindication to
pregnancy
No Yes
Patient being told
to avoid pregnancy
No 69%
Yes 8%
Kovacs AK, JACC 2008
Counselling
Contraindication to
pregnancy
No Yes
Patient being told
to avoid pregnancy
No 69% 8%
Yes 16% 8%
Maternal riskDuring pregnancyLong-term risk
Fetal risksRecurrence riskPreterm delivery
Type of complications
Managable
Avoidable
Fatal / irreversible
Counselling
Objectives
Scope of the problem
Risk stratification
Counselling
Management & Care
Management & Care: Team!
Pregnantwoman
Hematologist, ICU-specialists, …
Obstetrician
Cardiologist Anesthetist
0
5
10
15
20
25
30
1st Trimester 3rd Trimester
BNP > 100 pg/ml (%)
Tanous, JACC 2010
Controls: 0% BNP > 100
BNP < 100: 100% neg. predictive
for cardiovascularcomplications
Management & Care: Serial BNP
Patient education!
Management plan
Available!
Clear & detailed enough!
Drugs that need to be available
Management & Care
Complex anatomy: Drawing!
www.heartdiseaseandpregnancy.com
Ressources
Matthias Greutmann, MDAdult Congenital Heart Disease Program
University Hospital Zurich, Switzerland
Thank you