Maternal Heart Failure.

Heart failure (HF) remains the most common major cardiovascular complication arising in pregnancy and the postpartum period. Mothers who develop HF have been shown to experience an increased risk of death as well as a variety of adverse cardiac and obstetric outcomes. Recent studies have demonstrated that the risk to neonates is significant, with increased risks in perinatal morbidity and mortality, low Apgar scores, and prolonged neonatal intensive care unit stays. Information on the causal factors of HF can be used to predict risk and understand timing of onset, mortality, and morbidity. A variety of modifiable, nonmodifiable, and obstetric risk factors as well as comorbidities are known to increase a patient's likelihood of developing HF, and there are additional elements that are known to portend a poorer prognosis beyond the HF diagnosis. Multidisciplinary cardio-obstetric teams are becoming more prominent, and their existence will both benefit patients through direct care and increased awareness and educate clinicians and trainees on this patient population. Detection, access to care, insurance barriers to extended postpartum follow-up, and timely patient counseling are all areas where care for these women can be improved. Further data on maternal and fetal outcomes are necessary, with the formation of State Maternal Perinatal Quality Collaboratives paving the way for such advances.

Reduced cardiac function is associated with cardiac injury and mortality risk in hospitalized COVID-19 Patients.

BACKGROUND: Cardiac injury is common in COVID-19 patients and is associated with increased mortality. However, it remains unclear if reduced cardiac function is associated with cardiac injury, and additionally if mortality risk is increased among those with reduced cardiac function in COVID-19 patients. HYPOTHESIS: The aim of this study was to assess cardiac function among COVID-19 patients with and without biomarkers of cardiac injury and to determine the mortality risk associated with reduced cardiac function. METHODS/RESULTS: This retrospective cohort study analyzed 143 consecutive COVID-19 patients who had an echocardiogram during hospitalization between March 1, 2020 and May 5, 2020. The mean age was 67 ± 16 years. Cardiac troponin-I was available in 131 patients and an increased value (>0.03 ng/dL) was found in 59 patients (45%). Reduced cardiac function, which included reduced left or right ventricular systolic function, was found in 40 patients (28%). Reduced cardiac function was found in 18% of patients without troponin-I elevation, 42% with mild troponin increase (0.04-5.00 ng/dL) and 67% with significant troponin increase (>5 ng/dL). Reduced cardiac function was also present in more than half of the patients on mechanical ventilation or those deceased. The in-hospital mortality of this cohort was 28% (N = 40). Using logistic regression analysis, we found that reduced cardiac function was associated with increased mortality with adjusted odds ratio (95% confidence interval) of 2.65 (1.18 to 5.96). CONCLUSIONS: Reduced cardiac function is highly prevalent among hospitalized COVID-19 patients with biomarkers of myocardial injury and is independently associated with mortality.

Risk Factors and Timing of Acute Myocardial Infarction Associated With Pregnancy: Insights From the National Inpatient Sample.

Background Pregnancy increases the risk of acute myocardial infarction (AMI). The purpose of this study was to examine timing and risk factors for AMI in pregnancy and poor outcome. Methods and Results National Inpatient Sample (2003-2015) was screened in pregnancy, labor and delivery, and postpartum. There were 11 297 849 records extracted with 913 instances of AMI (0.008%). One hundred eleven (12.2%) women experienced AMI during labor and delivery, 338 (37.0%) during pregnancy and most during the postpartum period (464; 50.8%). The prevalence of AMI in pregnancy has increased (P=0.0005). Most major adverse cardiovascular and cerebrovascular events occurred in the postpartum period (63.5%). Inpatient mortality was 4.5%. Predictors of AMI include known coronary artery disease (odds ratio [OR], 517.4; 95% CI, 420.8-636.2), heart failure (OR, 8.2; 95% CI, 1.9-35.2), prior valve replacement (OR, 6.4; 95% CI, 2.4-17.1), and atrial fibrillation (OR, 2.7; CI, 1.5-4.7; P<0.001). Risk factors of traditional atherosclerosis including hyperlipidemia, obesity, tobacco history, substance abuse, and thrombophilia were identified (P<0.001). Gestational hypertensive disorders (eclampsia OR, 6.0; 95% CI, 3.3-10.8; preeclampsia OR, 3.2; 95% CI, 2.5-4.2) were significant risk factors in predicting AMI. Risk factors associated with major adverse cardiovascular and cerebrovascular events included prior percutaneous coronary intervention (OR, 6.6; 95% CI, 1.4-31.2) and pre-eclampsia (OR, 2.3; 95% CI, 1.3-3.9). Conclusions AMI is associated with modifiable, nonmodifiable, and obstetric risk factors. These risk factors can lead to devastating adverse outcomes and highlight the need for risk factor modification and public health resource initiatives toward the goal of decreasing AMI in the pregnant population.

COVID-19 Presenting as Major Thromboembolic Events: Virchow's Triad Revisited and Clinical Considerations of Therapeutic Anticoagulation.

This case series describes clinical course of three COVID-19 patients who presented with major thromboembolic events. Patient 1 is a 57-year-old male with asymptomatic COVID-19 who presented with a large left ventricular thrombus. His hospital course was complicated with a stroke. Patient 2 is a 71-year-old male with mild COVID-19 who presented with an acute stroke. Patient 3 is a 47-year-old male with severe COVID-19 who presented with a large pulmonary embolism. He died of a recurrent massive pulmonary embolism. This case series demonstrates that thromboembolic event can be the presenting feature of COVID-19 and can occur in the patients with asymptomatic or mild COVID-19. Diffuse endothelial injury and hypercoagulability play a pivotal role in recurrent thromboembolic events despite the anticoagulation. Therapeutic anticoagulation may be considered for severe COVID-19 patients and patients with important comorbidities or pre-existing endothelial dysfunction.

TAVR in a 65-Year-Old Man With a Bicuspid Aortic Valve With Extremely Large Annulus and Severe Left Ventricular Dysfunction.

This case illustrates that transfemoral transcatheter aortic valve replacement is safe and feasible in patients with bicuspid aortic stenosis with extremely large annulus and concomitant severe left ventricular dysfunction.

Transcatheter Tricuspid Valve-in-Valve Replacement Via Right Internal Jugular Vein Access in a 39-Year-Old Woman.

Transcatheter tricuspid valve-in-valve replacement via right internal jugular is safe and feasible for failed bioprosthetic valve implantation. Challenging aspects include stiff wire advancement into the pulmonary artery for rail establishment and multiple push-pull manipulations for balloon and valve advancement.

Postpartum Cardiovascular Outcomes Among Women With Heart Disease from A Nationwide Study.

There is limited data on postpartum maternal postpartum major adverse cardiovascular and cerebrovascular events (MACCE) among women with heart disease (HD) in the US. Therefore, we aimed to determine the prevalence and predictors of MACCE in the US. The Nationwide Readmissions Databases (2010 to 2014) were screened for patients with and without HD undergoing delivery. HD subtypes included cardiomyopathy (CDM), congenital heart disease, valvular heart disease, and pulmonary hypertension. Rates and reasons of 42-day readmission were determined using weighted national estimates. Independent predictors of postpartum MACCE were determined using multivariable logistic regression for complex survey data. We found among 15,273,247 patients hospitalized for delivery, 33,827 had HD (CDM 22.78%, congenital heart disease 45.98%, valvular heart disease 24.81%, and pulmonary hypertension 6.41%). Of these, 5.2% of HD patients and 1.4% of No HD were readmitted. MACCE was higher in HD vs No HD (2.68% vs 0.17%, p <0.0001). Median time to MACCE was 5.6 days (interquartile range 3 to 15 days). CDM had >10% readmission at 42 days. Among HD patients, cardiovascular, infectious, hypertensive syndromes, and complications of pregnancy were the most common reasons for 42-day readmission. MACCE predictors in women with HD included HD subtype, age, insurance status, obesity, eclampsia, postpartum hemorrhage, MACCE during delivery, preterm delivery, and thrombotic complications. In conclusion, among a nationwide analysis, postpartum MACCE was more common among patients with HD especially within 1 week of discharge from delivery. Predictors can be easily screened for by clinicians, including presence of any HD, hypertensive syndromes, age, obesity, and obstetrical events during index hospitalization.

Sex-Specific Predictors of Mortality Following Balloon Aortic Valvuloplasty.

BACKGROUND: A differential impact of sex has been observed in balloon aortic valvuloplasty (BAV) outcomes from small observational studies. Accordingly, we sought to compare mortality in men and women undergoing BAV and identify sex-specific predictors of mortality. METHODS: The Nationwide Inpatient Sample was screened for hospitalizations involving adults who underwent BAV between 2006 and 2014. Demographic data and clinical history were recorded. In-hospital mortality and predictors of death after BAV were assessed in men and women. RESULTS: Among an estimated national cohort of 18,415 adults undergoing BAV, 8871 (48.2%) were women and 9543 (51.8%) were men. Compared with male patients, women were older, with a lower prevalence of coronary artery disease, prior myocardial infarction, diabetes mellitus, chronic kidney disease, chronic obstructive lung disease, and peripheral arterial disease but a higher rate of hypertension and obesity. In-hospital mortality rates were 6.7% and 9.4% in women and men respectively (p = 0.004). In multivariable regression analysis, female sex was independently associated with lower mortality [odds ratio (OR) 0.73, 95% confidence interval (CI) 0.57-0.93) following BAV. Sex-specific risk-adjusted predictors of mortality included atrial fibrillation in women and younger age, congestive heart failure, chronic kidney disease, and absence of prior myocardial infarction, hypertension, and peripheral arterial disease in men. CONCLUSIONS: Women undergoing BAV had a different risk profile compared to men. Risk-adjusted in-hospital mortality was lower in women, and disparate predictors of risk-adjusted mortality exist in men and women undergoing BAV. Further studies are warranted to determine whether preventive interventions can improve outcomes in both men and women in this high-risk population.

Peripartum cardiomyopathy-diagnosis, management, and long term implications.

Peripartum cardiomyopathy (PPCM) is a potentially life-threatening pregnancy-associated disease that typically arises in the peripartum period. While the disease is relatively uncommon, its incidence is rising. It is a form of idiopathic dilated cardiomyopathy, defined as pregnancy-related left ventricular dysfunction, diagnosed either towards the end of pregnancy or in the months following delivery, in women without any other identifiable cause. The clinical presentation, diagnostic assessment and treatment usually mirror that of other forms of cardiomyopathy. Timing of delivery and management require a multidisciplinary approach and individualization. Subsequent pregnancies generally carry risk, but individualization is required depending on the pre-pregnancy left ventricular function. Recovery occurs in most women on standard medical therapy for heart failure with reduced ejection fraction, more frequently than in other forms of nonischemic cardiomyopathy. The purpose of this review is to summarize the current state of knowledge with regard to diagnosis, treatment and management, with a focus on long term implications.

Disparities in death rates in women with peripartum cardiomyopathy between advanced and developing countries: A systematic review and meta-analysis.

There is limited information about differences in maternal deaths from peripartum cardiomyopathy (PPCM) between advanced and developing countries. To review the literature to define the global prevalence of death from PPCM, and to determine the differences in PPCM mortality rates and risk factors between advanced and developing countries. Studies in the English language reporting mortality data on patients with PPCM were included from searches of MEDLINE, Embase, CINAHL, the Cochrane Library, the Web of Science Core Collection and Scopus from 01 January 2000 to 11 May 2016. Of the 4294 articles identified, 1.07% were included. The primary outcome was death; rates of heart transplant, acute myocardial infarction, heart failure, arrhythmia, cerebrovascular events, embolism and cardiac arrest were recorded. Studies were categorized as having been conducted in advanced or developing countries. Data from 46 studies, 4925 patients and 13 countries were included. There were 22 studies from advanced countries (n=3417) and 24 from developing countries (n=1508); mean follow-up was 2.6 (range 0-8.6) years. Overall mortality prevalence was 9% (95% confidence interval [CI] 6-11%). The mortality rate in developing countries (14%, 95% CI 10-18%) was significantly higher than that in advanced countries (4%, 95% CI 2-7%). There was no difference in the prevalence of risk factors (chronic hypertension, African descent, multiple gestation and multiparity) between advanced and developing countries. Studies with a higher prevalence of women of African descent had higher death rates (correlation coefficient 0.29, 95% CI 0.13-0.52). The risk of death in women with PPCM was higher in developing countries than in advanced countries. Women of African descent had an increased risk of death.

Neonatal and Maternal Outcomes in Pregnant Women With Cardiac Disease.

Background Pregnant women with underlying heart disease ( HD ) are at increased risk for adverse maternal, obstetric, and neonatal outcomes. Methods and Results Inpatient maternal delivery admissions and linked neonatal stays for women with cardiomyopathy, adult congenital HD, pulmonary hypertension ( PH ), and valvular HD were explored utilizing the Statewide Planning and Research Cooperative System (New York), January 1, 2000, through December 31, 2014, with the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM). Maternal major adverse cardiac events, neonatal adverse clinical events ( NACE ), and obstetric complications were recorded. Outcomes were compared using multiple logistic regression modeling. Among 2 284 044 delivery admissions, 3871 women had HD ; 676 (17%) had cardiomyopathy, 1528 (40%) had valvular HD, 1367 (35%) had adult congenital HD, and 300 (8%) had PH . Major adverse cardiac events occurred in 16.1% of women with HD , with most in the cardiomyopathy (45.9%) and PH (25%) groups. NACE was more common in offspring of women with HD (18.4% versus 7.1%), with most in the cardiomyopathy (30.0%) and PH (25.0%) groups. Increased risk of NACE was noted for women with HD (odds ratio [ OR ]: 2.8; 95% confidence interval [ CI ], 2.5-3.0), with the highest risk for those with cardiomyopathy ( OR : 5.9; 95% CI , 5.0-7.0) and PH ( OR : 4.5; 95% CI , 3.4-5.9). Preeclampsia ( OR : 5.1; 95% CI , 3.0-8.6), major adverse cardiac events ( OR : 2.3; 95% CI , 1.8-2.9), preexisting diabetes mellitus ( OR : 4.3; 95% CI , 1.5-12.3), and obstetric complications ( OR : 2.9; 95% CI , 1.7-5.2) were independently associated with higher NACE risk. Conclusions Neonatal complications were higher in offspring of pregnant women with HD , particularly cardiomyopathy and PH . Preeclampsia, major adverse cardiac events, obstetric complications, and preexisting diabetes mellitus were independently associated with a higher risk of NACE .

Pulmonary Hypertension and Pregnancy Outcomes: Insights From the National Inpatient Sample.

BACKGROUND: Pregnant women with pulmonary hypertension (PH) are at risk for adverse cardiac outcomes, particularly at the time of labor and delivery. The purpose of this study is to define the impact of PH on pregnancy outcomes and the risk of major adverse cardiac events (MACE). METHODS AND RESULTS: The National Inpatient Sample was screened for hospital admissions of women delivering during the years 2003 to 2012. The primary outcome was MACE, a composite of death, cardiac arrest, cardiogenic shock, myocardial infarction, respiratory failure, arrhythmia, stroke, and embolic event. Data on 1519 patients with PH and 6 757 582 without heart disease or PH were available. There were 59.6% with isolated PH; 10.7% with PH and congenital heart disease; 18.1% with PH and valvular heart disease; 3% with PH and valvular heart disease and congenital heart disease; 6.6% PH and cardiomyopathy; and 1.9% with PH and cardiomyopathy and valvular heart disease. Compared with women without heart disease or PH, women with PH experienced significantly higher MACE (24.8 versus 0.4%, P<0.0001). Among the subsets of women with PH, the highest MACE was noted in women with the combination of PH and cardiomyopathy and valvular heart disease, and PH and cardiomyopathy, primarily because of heart failure and arrhythmia. Women with PH were significantly more likely to experience eclampsia syndromes, preterm delivery, and intrauterine fetal demise (P<0.0001 for all). PH subtype was significantly associated with MACE in multivariable analysis (P<0.001). CONCLUSIONS: In a contemporary data set of pregnant women in the United States, PH was associated with an increase in MACE during the hospitalization for delivery, with an exceptionally elevated risk among women with associated cardiomyopathy.

National Trends and In-Hospital Outcomes in Pregnant Women With Heart Disease in the United States.

Investigation of trends and outcomes in heart disease (HD) and pregnancy has been limited. We chose to identify the prevalence, trends, and outcomes of pregnant women with different forms of HD in the United States. Healthcare Cost and Utilization Project's National Inpatient Sample was screened for hospital admissions for delivery in pregnant women with HD from 2003 to 2012. Maternal clinical characteristics and outcomes were identified in women with and without HD, and in HD subtypes: congenital (CHD), valvular HD, cardiomyopathy, and pulmonary hypertension (PH). Primary outcomes of interest were prevalence, trends, and major adverse cardiac events (MACEs), a composite of in-hospital death, acute myocardial infarction, heart failure, arrhythmia, cerebrovascular event, embolic events, or cardiac complications of anesthesia. We studied 81,295 patients with HD and 39,894,032 without. CHD was the most frequent type (41.8%, 33,982 of 81,295 patients), followed by valvular HD (30.9%, 25,138 of 81,295 patients), cardiomyopathy (20.8%, 16,926 of 81,295 patients), and PH (6.5%, 5,250 of 81,295 patients). MACE was highest among women with cardiomyopathy and lowest among women with CHD (44.0%, 7,449 of 16,926 vs 6.2%, 2,102 of 33,982; p <0.0001). PH patients had the highest in-hospital death, followed by cardiomyopathy patients (1.0%, 51 of 5,250 and 0.7%, 124 of 16,926, respectively). Pregnant women with HD significantly increased by 24.7%, related to increases in cardiomyopathy, CHD, and PH from 2003 to 2012. MACE significantly increased by 18.8%. In conclusion, pregnancy in women with HD is increasing, particularly for high risk conditions such as cardiomyopathy and PH. There is a significant and gradual increase in MACE for women with HD.

Quality of Life in Survivors of Peripartum Cardiomyopathy.

Little data exist with regard to the effect of peripartum cardiomyopathy (PPCM) on quality of life. The aim of this study was to determine the impact of PPCM on quality of life and emotional well-being. We sought to determine the feasibility of using social media to perform quality of life research. We conducted a study using a survey distributed to established members of "Peripartum Cardiomyopathy Survivors" support group on the social networking site Facebook. A total of 116 women completed the survey (age 36 ± 6.4 years; 91% white, 75% married, 46% college educated), with 4.9 ± 0.5 years (range 0.02 to 24 years) since the initial diagnosis. Most women (41%) never returned to their baseline level of activity, and 28% discontinued their job because of the diagnosis. Most respondents (56%) were not limited or only slightly limited by heart failure symptoms over the past 2 months. Most respondents (56%) never returned to their baseline emotionally after the diagnosis of PPCM, and most patients (73%) were dissatisfied with their current level of heart failure symptoms. Most patients (67%) felt discouraged frequently (more than several times per month) because of heart failure. Only 26% of women were satisfied with the counseling they received from their providers. The emotional and physical burden of PPCM on young mothers with PPCM years after the diagnosis is striking. Identifying strategies that promote better emotional health and potential treatment strategies may be required.

Clinical characteristics and outcomes in pregnant women with Ebstein anomaly at the time of delivery in the USA: 2003-2012.

BACKGROUND: Ebstein anomaly is an uncommon congenital cardiac lesion that may be associated with cyanosis, arrhythmias and right heart dysfunction. Investigation into patient characteristics and outcomes in pregnant women with Ebstein anomaly has been limited. AIMS: To characterize patient characteristics and clinical events for pregnant women with Ebstein anomaly during hospitalization for delivery in the USA; also, to determine the effect of Ebstein anomaly on maternal clinical outcomes and individual predictors of poor outcome at time of delivery. METHODS: We screened the Healthcare Cost and Utilization Project's National Inpatient Sample for hospital admissions of pregnant women for delivery (vaginal or caesarean section) in the USA from 2003-2012, and identified a cohort of 7,850,381. Clinical characteristics and maternal outcomes were identified in those with and without Ebstein anomaly. The primary outcome of interest was major adverse cardiac events (MACE), a composite of in-hospital death, acute myocardial infarction, cerebrovascular events, embolic events, cardiac complications of labour and delivery heart failure or arrhythmia. RESULTS: Our study population consisted of 82 hospitalizations of pregnant women with Ebstein anomaly and 7,850,299 without. The Ebstein cohort more frequently had ostium secundum-type atrial septal defect and/or patent foramen ovale and anomalous atrioventricular excitation (P<0.001 for both). The MACE rate was significantly higher among Ebstein patients (P<0.001). Preterm delivery, postpartum haemorrhage and caesarean delivery occurred more frequently among the Ebstein cohort (19.5% vs 7.2%, 8.5% vs 2.8% and 47.6% vs 31.1%, respectively; P≤0.001). In a multivariable analysis, anomalous atrioventricular excitation (odds ratio [OR] 21.75, 95% confidence interval [CI] 1.03-457.91) and preterm delivery (OR 11.71, 95% CI 1.39-98.89) were associated with MACE among those with Ebstein anomaly. CONCLUSIONS: Pregnant women with Ebstein anomaly are at higher risk of MACE during pregnancy and delivery. Preterm delivery occurred more frequently in women with Ebstein anomaly.

Pregnant women with heart disease: Placental characteristics and their association with fetal adverse events.

BACKGROUND: Pregnant women with heart disease (HD) have higher rates of adverse fetal outcomes. We describe placental pathologic characteristics and their association with fetal events. METHODS: In pregnant women, known HD were categorized into: (1) cardiomyopathy (CM) or (2) other HD (congenital, coronary, arrhythmia, or valvular). Outcomes were maternal major adverse cardiac events (MACE), fetal adverse clinical events (FACE), a composite of infant death, prematurity, underweight status, intracranial hemorrhage, and respiratory distress. Only pathologically reported placental analyses were included. RESULTS: We studied 86 pregnancies in women with CM and HD, with pathologic analyses on 35 CM and 52 HD placentas. CM placentas, compared with those with HD, were more likely to have ischemic changes (65.7% vs. 37%, p 0.008), demonstrate immaturity (62.90% vs. 10%, p < 0.001), and have a lower weight (p < 0.001), despite similar gestational age. CM was independently associated with increased risk for MACE (OR 7.38, 95%CI 2.20-24.76). Ischemic placental changes were associated with increased odds of FACE (OR 24.78, 95%CI 2.37-259.03). CONCLUSIONS: Women with CM were more likely to have ischemic placentas, with lower placental and fetal weights, and evidence of immaturity compared with those with other forms of HD, and an increased odds of MACE.