heart failure in pregnancy - unispital basel · pdf fileropac registry registry of pregnancy...
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Heart failure in pregnancy
PD Dr. med Daniel Tobler Leiter angeborene Herzfehler (GUCH)
Universitätsspital Basel !
www.heartdiseaseandpregnancy.com
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Heart failure in pregnancy Agenda
!
- general considerations - specific lesions
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ROPAC Registry Registry Of Pregnancy And Cardiac disease
Update on recruitment (ROPAC)
Speaker
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Cumula1ve#pa1ents#enrolments#
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ROPAC Registry
45 Länder, 112 Zentren
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ROPAC Registry
n=1321Roos-Hesselink et al. ROPAC registry, EHJ 2012
Congenital heart disease 66 %Valvular heart disease 25 %Cardiomyopathy 7 %Ischemic heart disease 2 %
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ROPAC Registry
n=1321
Roos-Hesselink et al. ROPAC registry, EHJ 2012
• Hospital admission: 25%
• Heart failure: 13%
• Ventricular arrhythmia’s 2.0%
• Thrombotic complications: 0.4%
• Endocarditis: 0.3%
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Congenital heart disease Heart failure in Pregnancy
CARPREG 2001
Kha
iry 20
06
ZAHARA 2010
Son
g 200
8 Ford
2008
Curt
is 20
09
Stangl
2008
ZAHARA 20
12
0
Other studies Cardiac complications in pregnant women with congenital heart disease
n= 599 90 1302 49 74 131 93 213
5
10
15
20
25
heart failure
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Timing of heart failure in pregnancy
Ruys et al. Heart 2013
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Hemodynamic changes during pregnancy
Thorne, Heart 2009
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Timing of heart failure in pregnancy
Ruys et al. Heart 2013
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ROPAC Registry Heart failure specific risk factors
Mul$variate+analyse OR 95%+CI
Signs+of+HF+prior+to+pregnancy 9,6 5,9@15,5
Cardiomyopathy 4,6 2,3@9,1
NYHA+class+>+2 2,3 1,2@4,4
WHO+>+2 2,3 1,5@3,6
Pulmonary+hypertension 1,8 1,0@3,0
Ruys et al. Heart 2013
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ROPAC Registry Outcome in women with heart failure
Ruys et al. Heart 2013
! Pa$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
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ROPAC Registry Pre-eclampsia and heart failure
Ruys et al. Heart 2013
!
• 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
!
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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
ROPAC Registry Fetal outcome in women with heart failure
Ruys et al. Heart 2013
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The role of BNP Prediction of cardiac events in pregnancy
Tanous et al. JACC 2010
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The role of BNP Prediction of cardiac events in pregnancy
Tanous et al. JACC 2010
BNP < 100 pg/ml: NPPV 100% Spezifität 70%
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The role of BNP Prediction of cardiac events in pregnancy
Kampman et at. EHJ 2013
NPPV NT-proBNP levels <128 pg/mL : 96.9%.
Week 20
n=213
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Frequency of Cardiac disease in Pregnancy
Congenital heart disease 66 %
Valvular heart disease 25 %
Cardiomyopathy 7 %
Ischemic heart disease 2 %
ROPAC registry, EHJ 2012
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Congenital heart disease Improved survival
Khairy et al. JACC 2010
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Congenital heart disease Increased prevalence in adults
Marelli et al , Circulation 2007
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Complex congenital heart disease
Transposition of the Great Arteries Tricuspid atresia Hypoplastic left heart syndrome
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TGA - atrial switch Subaortic right ventricle
Mustard vs Senning procedure
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Fontan palliation Single ventricle physiology
Coutesy of Prof. R. Pretre
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Failing Fontan
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Failing Mustard
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Failing palliation
Greutmann, Tobler et al, in press
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Congenital heart disease Cardiac morbidity in Pregnancy
Drenthen et al. JACC 2007
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Frequency of Cardiac disease in Pregnancy
Congenital heart disease 66 %
Valvular heart disease 25 %
Cardiomyopathy 7 %
Ischemic heart disease 2 %
ROPAC registry, EHJ 2012
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Case 1 24y, G3P2, 24 wks GA
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Case 1 24y, G3P2, 24 wks GA
Unispital B
asel / Kardiologie Tel. ++41 (61)2652525 N
otfallstationNFE
KG
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346472829.09.2013 16:39:230.05-35 Hz
SEMA-200 2.45 /611.04685 (AT-110XP 2.13 1.07.1.00 2.17.8) Seite 1
G eb:Alter:G eschl:Grösse:G ewicht:B D:
Med:B em:
IntervalleRRPP QQ RSQ TQ Tc
H FAchsenPQ RST
Interpretation
Validiert von
14.01.198429 JahreW -.- cm -.- kg- / - mmHg
652 ms----
88 ms332 ms411 ms
19999 °36 °--
92 /min
I
II
III
aVR
aVL
aVF
10.0 mm/mV
V1
V2
V3
V4
V5
V6
25 mm/s
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Valvular heart disease in pregnancy
Roos-Hesselink et al. ROPAC registry, EHJ 2012
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Heart failure in pregnancy due VHD
Ruys et al. ROPAC registry, Heart 2013
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Mitral stenosis in Pregnancy
Silversides et al. Am J Cardiol 2003
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Mitral stenosis in Pregnancy
Silversides et al. Am J Cardiol 2003
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Mitral stenosis in Pregnancy
ESC Guidelines, EHJ 2011
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Aortic stenosis in pregnancy
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Aortic stenosis in Pregnancy
Silversides et al. Am J Cardiol 2003
0
10 8
41
0
10
20
30
40
50
Cardiac ComplicationsDuring Pregancy
Cardiac Surgery DuringFollow-up
Mild or Moderate AS Severe AS
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Mechanical valves and pregnancy
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Mechanical valves and pregnancy
Drenthen et al. EHJ 2010
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Frequency of Cardiac disease in Pregnancy
Congenital heart disease 66 %
Valvular heart disease 25 %
Cardiomyopathy 7 %
Ischemic heart disease 2 %
ROPAC registry, EHJ 2012
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Dilated Cardiomyopathy in pregnancy Risk factors for cardiac events
Grewal et al. JACC 2010
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Outcome in Dilated Cardiomyopathy Pregnancy as risk factor
Grewal et al. JACC 2010
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Maternal risk in DCM
Grewal et al JACC 2000Grewal et al. JACC 2010
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Maternal risk
Beneficial medication for the mother
Effect on the fetus
Risk of stopping meds Effect on the maternal heart
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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
Aldosteron-Antagonists
No data to support safety in pregnancy FDA Class D
Furosemid Can result in uteroplacental hypoperfusion Contraindicated in IUGR / Pre-eclampsia FDA Class C
Digoxin Generally considered safe Useful in treatment in persistent symptoms FDA Class C
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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
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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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