High-Risk Cardiac Disease in Pregnancy

Uri Elkayam, Sorel Goland, Petronella Pieper and Candice Silverside.
(UCLA, Jeruselam, Groningen - Netherlands & Toronto)

Good review articles covering most important lesions.

Part I - JACC 2016;68(4): 396-410.
Part II - JACC 2016;68(5): 502-16.

• • Valvular Heart Disease

Heart Valve Prostheses in Pregnancy: Outcomes for Women and Their Infants

1. Claire M. Lawley, et al.
2. 1. JAHA 2014;3:e000953
   2. 1. 
         

1. ¹Clinical Population Perinatal Health Research, Kolling Institute, University of Sydney, Sydney, Australia (C.M.L., C.S.A., J.B.F., C.L.R.)
2. ²Department of Cardiology, Royal North Shore Hospital, St Leonards, Australia (C.M.L., G.A.F.)
3. ³Department of Obstetrics and Gynaecology, Royal North Shore Hospital, St Leonards, Australia (T.A.N.)

1. Correspondence to:
   Claire M. Lawley, BSc(Med)Hons, MBBS(Hons), Clinical Population Perinatal Health Research Group, The Kolling Institute, University of Sydney at Royal North Shore Hospital, Sydney, Australia. E‐mail: claw2317@uni.sydney.edu.au

Abstract

Background As the prognosis of women with prosthetic heart valves improves, an increasing number are contemplating and undertaking pregnancy. Accurate knowledge of perinatal outcomes is essential, assisting counseling and guiding care. The aims of this study were to assess outcomes in a contemporary population of women with heart valve prostheses undertaking pregnancy and to compare outcomes for women with mechanical and bioprosthetic prostheses.

Methods and Results Longitudinally linked population health data sets containing birth and hospital admissions data were obtained for all women giving birth in New South Wales, Australia, 2000–2011. This included information identifying presence of maternal prosthetic heart valve. Cardiovascular and birth outcomes were evaluated. Among 1 144 156 pregnancies, 136 involved women with a heart valve prosthesis (1 per 10 000). No maternal mortality was seen among these women, although the relative risk for an adverse event was higher than the general population, including severe maternal morbidity (139 versus 14 per 1000 births, rate ratio [RR]=9.96, 95% CI 6.32 to 15.7), major maternal cardiovascular event (44 versus 1 per 1000, RR 34.6, 95% CI 14.6 to 81.6), preterm birth (183 versus 66 per 1000, RR=2.77, 95% CI 1.88 to 4.07), and small‐for‐gestational‐age infants (193 versus 95 per 1000, RR=2.03, 95% CI 1.40 to 2.96). There was a trend toward increased maternal and perinatal morbidity in women with a mechanical valve compared with those with a bioprosthetic valve.

Conclusions Pregnancies in women with a prosthetic heart valve demonstrate an increased risk of an adverse outcome, for both mothers and infants, compared with pregnancies in the absence of heart valve prostheses. In this contemporary population, the risk was lower than previously reported.the

Adult CHD: Risk factors for death in pediatric hospitals

Risk Factors for Death After Adult Congenital Heart Surgery in Pediatric Hospitals

1. Yuli Y. Kim, MD,
2. Kimberlee Gauvreau, ScD,
3. Emile A. Bacha, MD,
4. Michael J. Landzberg, MD and
5. Oscar J. Benavidez, MD, MPP

CIRCOUTCOMES.110.958256Published online before print June 21, 2011

1. From the Divisions of Cardiology (Y.Y.K.), Hospital of the University of Pennsylvania and Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, PA; the Department of Cardiology (K.G., M.J.L., O.J.B.), Children's Hospital Boston, Harvard Medical School, Boston, MA; Boston Adult Congenital Heart (BACH) Program (M.J.L.), the Department of Cardiology, Children's Hospital Boston, Boston, MA; the Division of Cardiology (M.J.L.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA; and the Department of Surgery (E.A.B.), Morgan Stanley Children's Hospital of New York, Columbia University College of Physicians and Surgeons, New York, NY.

1. Correspondence to Oscar J. Benavidez, MD, Department of Cardiology, Children's Hospital Boston, 300 Longwood Ave, Boston, MA 02115. E-mailOscar.Benavidez@cardio.chboston.org

Abstract

Background Despite the central role that pediatric hospitals play in the surgical treatment of congenital heart disease, little is known about outcomes of adult congenital cardiac surgical care in pediatric hospitals. Risk factors for inpatient death, including adult congenital heart (ACH) surgery volume, are poorly described.

Methods and Results We obtained inpatient data from 42 free-standing pediatric hospitals using the Pediatric Health Information System data base 2000 to 2008 and selected ACH surgery admissions (ages 18 to 49 years). We examined admission characteristics and hospital surgery volume. Of 97 563 total (pediatric and adult) congenital heart surgery admissions, 3061 (3.1%) were ACH surgery admissions. Median adult age was 22 years and 39% were between ages 25 to 49 years. Most frequent surgical procedures were pulmonary valve replacement, secundum atrial septal defect repair, and aortic valve replacement. Adult mortality rate was 2.2% at discharge. Multivariable analyses identified the following risk factors for death: age 25 to 34 years (adjusted odds ratio [AOR], 2.1; P=0.009), age 35 to 49 years (AOR, 3.2; P=0.001), male sex (AOR, 1.8; P=0.04), government-sponsored insurance (AOR, 1.8; P=0.03), and higher surgical risk categories 4+ (AOR, 21.5; P=0.001). After adjusting for case mix, pediatric hospitals with high ACH surgery volume had reduced odds for death (AOR, 0.4; P=0.003). There was no relationship between total congenital heart surgery volume and ACH inpatient mortality.

Conclusions Older adults, male sex, government-sponsored insurance, and greater surgical case complexity have the highest likelihood of in-hospital death when adult congenital surgery is performed in free-standing pediatric hospitals. After risk-adjustment, pediatric hospitals with high ACH surgery volume have the lowest inpatient mortality.

Radiation Exposure during Radial Access (Right vs. Left)

CIRCINTERVENTIONS.111.961185

Published online before print May 17, 2011

Referenced here, more to highlight the methodology of the adult study and for actual reports of measurement dose, etc. This adult study compares right and left radial access. Radiation exposures were similar between right and left radial approached. Slightly increased exposure to the wrist in right radial approach compared to left radial approach.

Operator Radiation Exposure During Percutaneous Coronary Procedures Through the Left or Right Radial Approach

The TALENT Dosimetric Substudy

1. Alessandro Sciahbasi, MD at al.


Background—Transradial percutaneous coronary procedures may be effectively performed through the right radial approach (RRA) or the left radial approach (LRA), but data on radiation dose absorbed by operators comparing the two approaches are lacking. The aim of the present study was to evaluate radiation dose absorbed by operators during coronary procedures through the RRA and LRA.

Methods and Results—Three operators were equipped with 5 different dosimeters (left wrist, shoulder, thorax outside the lead apron, thorax under the lead apron, and thyroid) during RRA or LRA for coronary procedures. Each month, the dosimeters were analyzed to determine the radiation dose absorbed. From February to December 2009, 390 patients were randomly assigned to the RRA (185 patients; age, 66±11 years) or the LRA (185 patients; age, 66±11 years). There were no significant differences in fluoroscopy time (for RRA, 369 seconds; interquartile range, 134 to 857 seconds; for LRA, 362 seconds; interquartile range, 142 to 885 seconds; P=0.58) between the 2 groups. There were no significant differences in monthly radiation dose at the thorax (0.85±0.46 mSv for RRA and 1.12±0.78 mSv for LRA, P=0.33), at the thyroid (0.36±0.2 mSv for RRA and 0.34±0.3 mSv for LRA, P=0.87), and at the shoulder (0.73±0.44 mSv for RRA and 0.94±0.42 mSv for LRA, P=0.27). The dose at the wrist was significantly higher for the RRA (2.44±1.12 mSv) compared with the LRA (1±0.8 mSv, P=0.002). In both radial approaches, the thoracic radiation dose under the lead apron was undetectable.

Conclusions—Compared with RRA, LRA for coronary procedures is associated with similar radiation dose for operators at the body, shoulder, or thyroid level, with a possible significant advantage at the wrist. The cumulative radiation dose for both approaches is well under to the annual dose-equivalent limit.

Clinical Trial Registration—URL: http://www.clinicaltrials.gov/. Unique identifier: NCT00282646.

Adult: Echo evaluation of hemodynamics in heart failure

CIRCIMAGING.111.963496Published online before print March 11, 2011

Echocardiographic Evaluation of Hemodynamics in Patients with Decompensated Systolic Heart Failure

1. Sherif Nagueh1*,
2. Rajat Bhatt1,
3. Ray P. Vivo1,
4. Selim R. Krim1,
5. Sebastian Imre Sarvari2,
6. Kristoffer Russell2,
7. Thor Edvardsen2,
8. Otto A. Smiseth2 and
9. Jerry D. Estep

Abstract

Background—Doppler echocardiography is currently applied for the assessment of left ventricular (LV) and right ventricular (RV) hemodynamics in patients with cardiovascular disease. However, there are conflicting reports about its accuracy in patients with unstable decompensated heart failure. The objective of this study was to evaluate the accuracy of the technique in patients with unstable heart failure.

Methods and Results—Consecutive patients with decompensated heart failure had simultaneous assessment of LV and RV hemodynamics invasively and by Doppler echocardiography. In 79 patients, the non-invasive measurements of stroke volume (r=0.83, p<0.001), r="0.83," r="0.51," p="0.009)," r="0.85,">15 mmHg (AUC from 0.86 to 0.92). The recent ASE/EAE guidelines were highly accurate (sensitivity : 98%, specificity : 91%) in identifying patients with increased wedge pressure. In 12 repeat studies, Doppler echocardiography readily detected the changes in mean wedge pressure (r=0.75, p=0.005) as well as changes in pulmonary artery systolic pressure and mean right atrial pressure.

Conclusions—Doppler echocardiography provides reliable assessment of LV hemodynamics in patients with decompensated heart failure.

Copyright © 2011, American Heart Association, Inc. All rights reserved. Unauthorized use prohibited