Breastfeeding Practices in Patients with Heart Disease Stratified by Area Deprivation Index.

Objective: We sought to evaluate breastfeeding (BF) practices in patients with maternal cardiac disease (MCD) stratified by area deprivation index (ADI) to identity communities at risk. Study Design: Retrospective cohort of patients managed by the University of Alabama at Birmingham (UAB) Cardio-Obstetrics Program. Patients were included if they had ≥1 prenatal visit with the Cardio-Obstetrics team, delivered at UAB, and had a street address on file. The primary outcome was BF rate at hospital discharge. Secondary outcomes included BF intent on admission and BF at the postpartum (PP) visit. ADI reports socioeconomic disadvantage at the census tract level; 1 = least deprived and 100 = most deprived. Baseline characteristics and BF rates were compared by ADI categories: Low (ADI 1-33), medium (ADI 34-66), and high (ADI 67-100). Results: One hundred and forty-eight patients were included: 14 (10%) low, 42 (28%) medium, and 92 (62%) high ADI. Patients in the high ADI category were younger relative to those in the medium or low ADI (26 versus 28 versus 32 years; p < 0.01) and less likely to be married or living with a partner (30.4% versus 58.5% versus 71.4%; p < 0.01), There was no difference in BF intent between the lowest, medium, and highest ADI categories (85.7% versus 85.4% versus 81.6%; p = 0.38) or BF rates at hospital discharge (100% versus 92.7% versus 85.6%, p = 0.23). However, there was a significant difference in BF rates at the PP visit (90% versus 63.0% versus 38.6%; p < 0.01) even after controlling for differences in baseline characteristics (odds ratio = 0.11 (95% confidence interval [0.01-0.93]), p = 0.043). Conclusions: There was an association between living in a resource-poor community and early cessation of BF in our population of patients with MCD. Community-based interventions targeting mothers with heart disease living in high ADI communities may help these individuals achieve higher BF rates.

Racial Disparities in Breastfeeding Rates in Patients with Heart Disease.

OBJECTIVE: To evaluate racial disparities in breastfeeding rates in patients with heart disease. STUDY DESIGN: Retrospective cohort of pregnant patients with maternal cardiac disease managed by a Cardio-Obstetrics program. Patients self-identifying as Non-Hispanic Black (NHB) and Non-Hispanic White (NHW), who attended ≥ 1 prenatal visit at the Cardio-Obstetrics Program and delivered at the same hospital between March 2015 and June 2019 were included. The primary outcome was breastfeeding rate at discharge from the delivery-associated hospitalization. Secondary outcomes included breastfeeding intent on admission and breastfeeding rates at the postpartum visit among patients who initiated breastfeeding. RESULTS: 138 pregnant patients with cardiac disease were included: 58 (42%) NHB and 80 (58%) NHW patients. Parity, marital status and insurance were statistically different between groups. NHB patients were more likely to have government insurance compared to NHW patients (77.6% vs. 40%; p < 0.001). There was a significant difference in the intent to breastfeed upon admission for the delivery-associated hospitalization (74.2% NHB vs. NHW 91.3%; p = 0.01), but not at hospital discharge (84.5% NHB vs. 93.8% NHW; p = 0.08). However, breastfeeding rates were significantly lower among NHB patients at the postpartum visit among the entire cohort (38.2% in NHB vs. 61.1% in NHW women; p = 0.036) and among those who initiated breastfeeding (35.3% NHB vs. 61.1% NHW, p = 0.018). CONCLUSIONS: Despite similar breastfeeding rates at hospital discharge, NHB patients with maternal cardiac disease were less likely to intend to breastfeed at admission and/or continue breastfeeding by the postpartum visits. Qualitative studies understanding these differences are crucial to improve breastfeeding rates, especially for NHB patients with maternal cardiac disease.

Breastfeeding practices among patients managed by a comprehensive cardio-obstetrics program.

Objective: To evaluate breastfeeding intent, rates at discharge, and continued breastfeeding at follow-up in patients managed in a comprehensive cardio-obstetrics program stratified by severity of maternal cardiac disease.Study Design: Retrospective cohort of patients managed by a comprehensive cardio-obstetrics program at the University of Alabama at Birmingham (UAB). Patients were included if they had ≥1 prenatal visit with the Cardio-Obstetrics team and delivered at UAB. The primary outcome was the breastfeeding rate on discharge from the delivery-associated hospitalization. Secondary outcomes included intent to breastfeed on admission and breastfeeding at the postpartum visit. Baseline characteristics and rates were compared between patients with less severe (mWHO I - II/III) vs. more severe (mWHO III - IV) maternal cardiac disease.Results: 147 patients were included: 85 (57.8%) mWHO class I - II and 62 (42.2%) mWHO class III-IV. Patients with more severe maternal cardiac disease had higher rates of chronic hypertension (22.6% vs. 9.4%; p = 0.027), lower gestational age at delivery (36.4 vs 37.7 weeks; p = 0.008), and higher rates of NICU admission (31.2% vs. 14.1%; p = 0.013). There were no significant differences between mWHO class I-II vs. mWHO class III-IV in intent to breastfeed upon admission to the delivery-associated hospitalization (84.7% vs. 82.3%; p = 0.67), breastfeeding rates upon discharge from the delivery-associated hospitalization (90.6% vs. 87.1%; p = 0.50), or breastfeeding rates at the postpartum visit (54.1% vs. 48.5%; p = 0.60).Conclusions: Despite potential barriers in this high-risk population, over 85% of patients breastfed upon discharge from the delivery-associated hospitalization. However, breastfeeding rates dropped by 40% at the postpartum visit. Strategies to support breastfeeding in the post-partum period in patients with maternal cardiac disease are imperative.

Racial disparities in peripartum cardiomyopathy: eighteen years of observations.

BACKGROUND: Black women have greater than a three-fold risk of pregnancy-associated death compared to White women; cardiomyopathy is a leading cause of maternal mortality. OBJECTIVES: This study examined racial disparities in health outcomes among women with peripartum cardiomyopathy. STUDY DESIGN: Retrospective cohort of women with peripartum cardiomyopathy per the National Heart, Lung, and Blood Institute definition from January 2000 to November 2017 from a single referral center. Selected health outcomes among Black and White women were compared; primary outcome was ejection fraction at diagnosis. Secondary outcomes included cardiovascular outcomes, markers of maternal morbidity, resource utilization, and subsequent pregnancy outcomes. RESULTS: Ninety-five women met inclusion criteria: 48% Black, 52% White. Nearly all peripartum cardiomyopathy diagnoses were postpartum (95.4% Black, 93% White, p=.11). Ejection fraction at diagnosis was not different between Black and White women (26.8 ± 12.5 vs. 28.7 ± 9.9, p=.41). Though non-significant, fewer Black women had myocardial recovery to EF ≥55% (35 vs. 53%, p=.07); however, 11 (24%) of Black women vs. 1 (2%) White woman had an ejection fraction ≤35% at 6-12 months postpartum (p<.01). More Black women underwent implantable cardioverter defibrillator placement: n = 15 (33%) vs. n = 7 (14%), p=.03. Eight women (8.4%) died in the study period, not different by race (p=.48). Black women had higher rates of healthcare utilization. In the subsequent pregnancy, Black women had a lower initial ejection fraction (40 vs. 55%, p=.007) and were less likely to recover postpartum (37.5 vs. 55%, p=.02). CONCLUSIONS: Black and White women have similar mean ejection fraction at diagnosis of peripartum cardiomyopathy, but Black women have more severe left ventricular systolic dysfunction leading to worse outcomes, increased resource use, and lower ejection fraction entering the subsequent pregnancy.

The effects of offering immediate postpartum placement of IUDs and implants to pregnant patients with heart disease.

OBJECTIVE: To evaluate the effects of offering immediate postpartum long-acting reversible contraception to pregnant patients with heart disease. STUDY DESIGN: Retrospective cohort of pregnant patients with cardiac disease managed by a Comprehensive Pregnancy & Heart Program. Patients were divided into 2 cohorts: pre-immediate postpartum LARC Program implementation (March 2015 to January 2017) and post-implementation (February 2017 to June 2019). The primary outcome was LARC (intrauterine device [IUD] or etonogestrel implant) use postpartum, defined as LARC either immediately postpartum or at the postpartum visit. Secondary outcomes included contraception intent at delivery and IUD expulsion rate of IUDs placed immediately postpartum. RESULTS: Of 159 included patients, 96 (60%) delivered during the post-implementation period. LARC use tripled after program implementation, 11% vs 35%, p < 0.01. Specifically, immediate postpartum IUD use increased from 1 (1.6%) to 10 (10.4%), p = 0.05, and use of immediate postpartum implant increased from 0 to 14 (14.6%), p = 0.002. Rates of women without contraception plans at delivery decreased from 32% to 14%, p < 0.01, as did the number of women using medroxyprogesterone acetate: 16% vs 4%, p = 0.01. Tubal ligation rates were not different before and after program implementation: 24% and 29%, p = 0.46. Postpartum visit rates were similar between Pre and Post groups: 70% and 72%, p = 0.78, respectively. One immediate postpartum IUD expulsion occurred. CONCLUSION: LARC use tripled in pregnant patients in an obstetric heart disease program after implementation of an immediate postpartum LARC Program. Access to immediate postpartum IUDs and implants should be a public health priority for women with heart disease to reduce their disproportionate burden of maternal morbidity and mortality. IMPLICATIONS: Access to immediate postpartum IUDs and implants should be a public health priority for women with heart disease - as well as all people with high-risk health conditions - to reduce their disproportionate burden of maternal morbidity and mortality.

Racial disparities in reliable contraceptive use in women with heart disease.

OBJECTIVE: The aim of the study was to investigate the differences in reliable contraceptive use between black women and white women with maternal cardiac disease. METHODS: The study comprised a retrospective cohort of women with maternal cardiac disease managed by the University of Alabama at Birmingham (UAB) Comprehensive Pregnancy and Heart Program (CPHP). Women were included if they had attended one or more prenatal visits at the UAB CPHP and delivered at the UAB hospital between March 2015 and June 2019. The primary outcome was reliable contraceptive use within 2 months postpartum, defined by receipt of long-acting reversible contraception (i.e., an intrauterine contraceptive device or an etonogestrel implant) or female sterilisation. All outcomes were compared based on self-reported race. RESULTS: One hundred and forty-nine women met the inclusion criteria. Black women (n = 63) were more likely than white women (n = 86) to use reliable contraception (65% vs 43%; p = 0.008). Black women were less likely than white women to be undecided or decline contraception at the time of admission (13% vs 27%; p = 0.037). There was no difference in reliable contraceptive use between black women (n = 20, 63%) and white women (n = 23, 72%) with modified World Health Organisation (WHO) class III/IV lesions (p = 0.42). CONCLUSION: Black women with maternal cardiac disease were more likely than white women to receive reliable contraception. Interventions to prevent unintended pregnancy in women with maternal cardiac disease should focus on improving reliable contraceptive use, especially for women with modified WHO class III/IV lesions.

Heart failure in an elderly man: where is that coronary?

Anomalous coronary arteries from the pulmonary artery are uncommon causes of heart failure in the adult population. This case demonstrates the unusual presentation in a patient with anomalous right coronary artery from the pulmonary artery and discusses the complex pathophysiology of this lesion and the role of guideline-directed medical therapy in the management of these patients.

Management of reproductive health after cardiac transplantation.

Pregnancy after cardiac transplantation poses immense challenges. Maternal risks include hypertensive disorders of pregnancy, rejection, and failure of the cardiac allograft that may lead to death. Fetal risks include potential teratogenic effects of immunosuppression and prematurity. Because of the high-risk nature of pregnancy in a heart transplant patient, management of reproductive health after cardiac transplantation should include preconception counseling to all women in the reproductive age group before and after cardiac transplantation. Reliable contraception is vital as nearly half of the pregnancies in this population are unintended. Despite the associated risks, successful pregnancies after cardiac transplantation have been reported. A multidisciplinary approach proposed in this review is essential for successful outcomes. A checklist for providers to guide management is provided.

Systematic review and meta-analysis of outcomes of anatomic repair in congenitally corrected transposition of great arteries.

BACKGROUND: Treatment of congenitally corrected transposition of great arteries (cc-TGA) with anatomic repair strategy has been considered superior due to restoration of the morphologic left ventricle in the systemic circulation. However, data on long term outcomes are limited to single center reports and include small sample sizes. AIM: To perform a systematic review and meta-analysis for observational studies reporting outcomes on anatomic repair for cc-TGA. METHODS: MEDLINE and Scopus databases were queried using predefined criteria for reports published till December 31, 2017. Studies reporting anatomic repair of minimum 5 cc-TGA patients with at least a 2 year follow up were included. Meta-analysis was performed using Comprehensive meta-analysis v3.0 software. RESULTS: Eight hundred and ninety-five patients underwent anatomic repair with a pooled follow-up of 5457.2 patient-years (PY). Pooled estimate for operative mortality was 8.3% [95% confidence interval (CI): 6.0%-11.4%]. 0.2% (CI: 0.1%-0.4%) patients required mechanical circulatory support postoperatively and 1.7% (CI: 1.1%-2.4%) developed post-operative atrioventricular block requiring a pacemaker. Patients surviving initial surgery had a transplant free survival of 92.5% (CI: 89.5%-95.4%) per 100 PY and a low rate of need for pacemaker (0.3/100 PY; CI: 0.1-0.4). 84.7% patients (CI: 79.6%-89.9%) were found to be in New York Heart Association (NYHA) functional class I or II after 100 PY follow up. Total re-intervention rate was 5.3 per 100 PY (CI: 3.8-6.8). CONCLUSION: Operative mortality with anatomic repair strategy for cc-TGA is high. Despite that, transplant free survival after anatomic repair for cc-TGA patients is highly favorable. Majority of patients maintain NYHA I/II functional class. However, monitoring for burden of re-interventions specific for operation type is very essential.

Cardiac Function and Sudden Cardiac Death in Heart Failure With Preserved Ejection Fraction (from the TOPCAT Trial).

Patients with heart failure with preserved ejection fraction (HFpEF) have a significantly elevated risk of sudden cardiac death (SCD). However, few imaging data have been correlated to this risk. We evaluated the value of multiple echocardiographic markers of left ventricular (LV) function to predict SCD in HFpEF patients. The Treatment of Heart Failure with Preserved Ejection Fraction with Aldosterone Trial (TOPCAT)-Americas cohort was used to evaluate the echocardiographic predictors of SCD and/or aborted cardiac arrest (SCD/ACA). A retrospective cohort design was used. Cox proportional hazards and Poisson regression models were used to determine the associations between the risk of SCD/ACA and echocardiographic parameters: diastolic dysfunction grade, left ventricle ejection fraction, and LV global longitudinal strain (GLS) during follow-up. Impaired left ventricle ejection fraction and GLS were associated with SCD/ACA in univariate models (p = 0.007 and 0.002, respectively), but not diastolic function grade. After multivariate adjustment, only GLS remained a significant predictor of the incidence rate of SCD/ACA (p = 0.006). There was a 58% increase in the hazard of incident SCD/ACA for every 1 unit increase in GLS (1.58, 95%CI: 1.12 to 2.22, p = 0.009). These findings remained robust in the competing risk analyses. In conclusion, amongst the multiple echocardiographic parameters of LV function, GLS may help prognosticate the risk of SCD/ACA in HFpEF patients.

Anemia, Mortality, and Hospitalizations in Heart Failure With a Preserved Ejection Fraction (from the TOPCAT Trial).

In this post-hoc analysis of the TOPCAT trial, we evaluated the prognostic role of anemia in adverse cardiovascular (CV) outcomes in heart failure with a preserved ejection fraction (HFpEF). Anemia was defined as hemoglobin of <12 g/dl in females and <13 g/dl in males. The primary outcome was a composite of CV mortality, aborted cardiac arrest (ACA), and heart failure (HF) hospitalization. Secondary outcomes were components of the primary outcome, all-cause, CV and non-CV mortality, cause-specific CV and non-CV mortality, all-cause and HF hospitalization, myocardial infarction, and stroke. Among 1,748 patients from TOPCAT-Americas, patients with anemia had a 52% higher risk of the primary outcome (hazard ratio [HR] 1.52, 95% confidence interval 1.27, 1.83, p<0.05) during a median follow up of 2.4 years. These patients were also at higher risk of all-cause and CV mortality with no difference in non-CV mortality. Among CV causes, patients with anemia had higher risk of sudden cardiac death (SCD)/ACA and presumed CV death with no difference in death due to pump failure. Among non-CV causes, patients with anemia had higher risk of death due to malignancy (HR 2.61, p<0.05). Patients with anemia had higher risk of all-cause and HF hospitalizations (HR 1.26 and 1.56, respectively, p<0.05 for both). There was no difference in the risk of myocardial infarction or stroke. In conclusion, patients with HFpEF and anemia are at higher risk of mortality and hospitalization. Anemia is a significant risk factor for SCD/ACA, death due to presumed CV causes and malignancy in HFpEF.

Comparison of Transcatheter Pulmonic Valve Implantation With Surgical Pulmonic Valve Replacement in Adults (from the National Inpatient Survey Dataset).

There are no large reports of comparative outcomes of transcatheter pulmonic valve implantation (TPVI) and surgical pulmonic valve replacement (SPVR). Prospective studies are unlikely to be feasible in the future also. Thus, we utilized a large adult inpatient database to compare the two with respect to temporal trends, in hospital outcomes and costs. Data from the National Inpatient Sample database from 2003 to 2014 was analyzed to extract patients who underwent TPVI and SPVR using unique ICD 9-CM codes. In-hospital outcomes and charges were then analyzed. All charges were converted to 2018 dollars and a loss of wages analysis was performed using the Bureau of Labor Statistics published median weekly wages. A total of 8,449 and 555 SPVR and TPVI discharges were identified. 5.8% SPVR procedures were done in rural setting versus 1.8% of TPVI. Complications including in-hospital mortality (2.3 vs 0.9%; p = 0.02) were higher in SPVR group. Length of stay was significantly shorter for the TPVI group (1 vs 5 days; p <0.001), which also contributed to lower loss of wages ($1028.57 vs $6042.86; p <0.001) with similar hospital charges. In conclusion, volumes of both TPVI and SPVR are increasing across adult hospitals in the United States, reflecting an overall increase in the adult congenital heart disease population. TPVI offers improved short-term outcomes and decreased loss of wages through shorter recovery time in this real-world database analysis.

Trans-septal approach for percutaneous closure of infra-diaphragmatic veno-venous collateral in a patient after Fontan palliation.

In this article, we present a case of a desaturated Fontan patient with an infra-diaphragmatic venous collateral to the pulmonary vein, which was too tortuous to attempt closure at the source. A trans-septal approach was successfully used to close the collateral in a retrograde manner.

Transcatheter Pulmonary Valve Implantation: A Comprehensive Systematic Review and Meta-Analyses of Observational Studies.

BACKGROUND: Transcatheter pulmonary valve implantation is approved for the treatment of dysfunctional right ventricle to pulmonary artery conduits. However, the literature is limited because of a small patient population, and it does not reflect changing procedural practice patterns over the last decade. METHODS AND RESULTS: A comprehensive search of Medline and Scopus databases from inception through August 31, 2016 was conducted using predefined criteria. We included studies reporting transcatheter pulmonary valve implantation in at least 5 patients with a follow-up duration of 6 months or more. In 19 eligible studies, 1044 patients underwent transcatheter pulmonary valve implantation with a pooled follow-up of 2271 person-years. Procedural success rate was 96.2% (95% confidence intervals [CI], 94.6-97.4) with a conduit rupture rate of 4.1% (95% CI, 2.5-6.8) and coronary complication rate of 1.3% (95% CI, 0.7-2.3). Incidence of reintervention was 4.4 per 100 person-years overall (95% CI, 3.0-5.9) with a marked reduction in studies reporting ≥75% prestenting (2.9 per 100 person-years [95% CI, 1.5-4.3] versus 6.5/100 person-years [95% CI, 4.6-8.5]; P<0.01). Pooled endocarditis rate was 1.4 per 100 person-years (95% CI, 0.9-2.0). CONCLUSIONS: Our study provides favorable updated estimates of procedural and follow-up outcomes after transcatheter pulmonary valve implantation. Widespread adoption of prestenting has improved longer-term outcomes in these patients.

Current attitudes and clinical practice towards the care of pregnant women with underlying CHD: a paediatric cardiology perspective.

OBJECTIVES: The growing number of women with CHD presents unique challenges, including those related to pregnancy, which can lead to significant morbidity and mortality. We sought to evaluate the perception of paediatric cardiologists towards the reproductive health of women with CHD. METHODS: Paediatric cardiologists in the United States of America were invited to participate in a cross-sectional, anonymous survey. Information solicited included knowledge of contraceptive methods, experience caring for pregnant women with CHD, and referral patterns including the utilisation of high-risk obstetric and adult CHD specialists. RESULTS: A total of 110 cardiologists responded - 90% with an academic affiliation and 70% with ⩾10 years' clinical experience. Although 95% reported an understanding of available contraceptive options, 32% did not feel comfortable recommending birth control. Pregnant women with CHD were seen by 83% of responders, and 37% of the responders reported a low level of comfort in doing so. Among all respondents, 73% indicated that they would refer a pregnant CHD patient to a high-risk obstetrician and 60% to an adult CHD specialist - almost all respondents would not transfer care to a non-adult CHD cardiologist. Among paediatric cardiologists, 81% indicated that they would resume their patient's care following delivery. CONCLUSION: Our results illustrate a gap in what physicians feel should be done and the care that they feel comfortable providing pregnant women with CHD. As this population continues to grow, training adult CHD cardiologists with specific skills in reproductive health in women with CHD is the first step to closing the care gap that exists in the management of such patients.