Maternal congenital cardiac disease: outcomes of pregnancy in a single tertiary care center.

OBJECTIVE: To evaluate contemporary perinatal and cardiac outcomes of pregnancies in women with major structural congenital heart disease. METHODS: Obstetric, neonatal, and cardiac outcomes were abstracted retrospectively from medical records of all women with congenital cardiac disease delivering at our institution from 2000-2007 and compared by type of structural defect. Predictors of adverse cardiac or obstetric events were identified. RESULTS: Over the 7-year study period, 74 deliveries occurred in 69 women with congenital heart disease, median age 28 years. There were three right-obstructive defects, 14 left-obstructive defects, four right-regurgitant defects, 19 conotruncal defects, 19 shunts, and four miscellaneous lesions. There were 21 adverse cardiac events in 15 pregnancies (20.2%); these were defined as maternal death, congestive heart failure, myocardial infarction, stroke, the need for urgent cardiac intervention, or arrhythmia requiring treatment. There were 44 adverse obstetric events in 34 pregnancies (45.9%), defined as preterm delivery, stillbirth, preeclampsia, small for gestational age, or neonatal intensive care unit admission. Patients with shunt morphology were more likely to experience adverse obstetric and cardiac outcomes. CONCLUSION: Pregnancy in women with underlying major congenital heart defects poses increased risks to both mother and fetus. Nonetheless, favorable maternal and neonatal outcomes occur in the majority of patients.

Cardiac imaging and functional assessment in pregnancy.

There are multiple imaging modalities available for the assessment of pregnant women with known or suspected cardiac disease. Because of its safety and general availability, echocardiography is the preferred study of choice for the evaluation of ventricular function, valvular heart disease, congenital heart disease, evaluation of the aorta, and the estimation of cardiac hemodynamics in a pregnant patient. Cardiac MRI can be performed, especially for diseases of the aorta and complex congenital heart disease. Radiation exposure for the fetus and the mother will be discussed in the use of CT angiography, nuclear imaging, and left-heart catheterization including coronary angiography for specific indications in the pregnant woman. The use of exercise testing during pregnancy for functional assessment will be presented.

Perioperative outcome and long-term mortality for heart failure patients undergoing intermediate- and high-risk noncardiac surgery: impact of left ventricular ejection fraction.

The impact of left ventricular ejection fraction (LVEF) on outcome in patients with heart failure (HF) undergoing noncardiac surgery has not been extensively evaluated. In this study, 174 patients (mean age, 75+/-12 years, 47% male, mean LVEF (47%+/-18%) underwent intermediate- or high-risk noncardiac surgery. Patients were stratified by LVEF, and adverse perioperative complications were identified and compared. Adverse perioperative events occurred in 53 patients (30.5%), including 14 (8.1%) deaths within 30 days, 26 (14.9%) myocardial infarctions, and 44 (25.3%) HF exacerbations. Among the factors associated with adverse perioperative outcomes in the first 30 days were advanced age (>80 years), diabetes, and a severely decreased LVEF (<30%). Long-term mortality was high, and Cox proportional hazards analysis demonstrated that LVEF was an independent risk factor for long-term mortality.

Pulmonary hypertension and long-term mortality in aortic and mitral regurgitation.

BACKGROUND: Outcomes data in patients with aortic regurgitation or mitral regurgitation have been limited to small series with generally <10 years of follow-up. The quantitative impact of pulmonary artery hypertension has not been well described. The purpose of this study was to describe the 15-year mortality of aortic regurgitation and mitral regurgitation. METHODS: Our institution's electronic echocardiography database was queried to identify those patients examined in 1992 and reported to have at least mild aortic regurgitation or mitral regurgitation. Patients were classified by semi-quantitative degree of regurgitation. Pulmonary artery systolic pressure was categorized as normal, borderline, mild, or moderate or greater hypertension (pulmonary artery systolic pressure >40 mm Hg). Age-stratified Cox proportional hazards models compared survival among groups and adjusted for sex, depressed left ventricular ejection fraction, and pulmonary artery systolic pressure. Mortality data were obtained from the 2008 Social Security Death Index. RESULTS: Of 4984 echocardiograms performed in 4050 patients, 1156 patients (28%; aged 72±14 years) had at least mild aortic regurgitation and 1971 patients (49%; aged 69±16 years) had at least mild mitral regurgitation. Overall 15-year mortality in patients with aortic regurgitation was 74% and similar for all grades of aortic regurgitation. Overall 15-year mortality in patients with mitral regurgitation was 71% and got progressively worse with increasing severity grade of mitral regurgitation (63% for mild to 81% for at least moderate-to-severe). For both aortic and mitral regurgitation, moderate or greater pulmonary artery systolic hypertension was associated with increased mortality (in patients with aortic regurgitation, hazard ratio [HR], 1.94; 95% confidence interval [CI], 1.58-2.41, and in mitral regurgitation patients, HR, 1.48; 95% CI, 1.26-1.75). CONCLUSION: Long-term (15-year) survival of patients with aortic regurgitation is poor and is independent of regurgitation severity. In contrast, long-term survival of patients with mitral regurgitation correlates with regurgitation severity. For both groups, moderate or greater pulmonary artery systolic hypertension identified those at highest risk.

Correlation of transthoracic echocardiography and right heart catheterization in pregnancy.

OBJECTIVES: To correlate estimated pulmonary artery pressures (PAP) by echocardiography with right heart catheterization (RHC) measurements and to correlate estimated left ventricular ejection fraction (EF) by echocardiography with cardiac output (CO) measurements by RHC. STUDY DESIGN: All women who had echocardiography at a single institution during a 6-year period and underwent RHC during pregnancy were included. Echocardiography estimates of right ventricular systolic pressure (RVSP) and EF were correlated with measured RHC PAP and CO, respectively. RESULTS: Eighteen patients underwent 21 RHCs, 10 antepartum at the catheterization laboratory and the remaining 11 intrapartum, performed with the use of a pulmonary artery catheter placed prior to the onset or induction of labor. Correlation between RVSP and PAP was good (rho=0.79, P<0.0001); nonetheless, in 30% of cases RHC eliminated the concern for pulmonary hypertension (PHTN). There was minimal correlation between EF and CO. CONCLUSION: Despite good statistical correlation between echocardiography and RHC for determining pulmonary artery pressure, RHC should be considered for major decisions such as pregnancy interruption or preterm delivery given the proportion of cases where concern for PHTN was excluded by RHC. EF provides a poor proxy for CO.