"Comparing the Outcomes of Rheumatic Heart Disease in Pregnancy Complicated with and without Atrial Fibrillation: A Propensity Score Matched Analysis".

BACKGROUND: Atrial fibrillation (AF) may increase the risk of adverse maternal and fetal outcomes among pregnant with rheumatic valvular lesions (RHD). We aimed to assess the rate of occurrence of AF in pregnant with RHD and its impact on cardiac and maternal-fetal outcomes compared to those without it. METHODS: The study group consisted of pregnant women with RHD and AF (cases) and a matched comparison group of pregnant women with RHD but without AF (controls) was derived from the database of pregnant women with RHD receiving care at our center between 2011 and 2021. Incidence of composite adverse outcomes(maternal death, heart failure, or thrombo-embolic events) and pregnancy outcomes were compared between them. RESULTS: Seventy-one (5.1%; 95%CI 4.1%-6.4%) pregnant women with RHD had AF during pregnancy and childbirth, most occurring in the late second or early third trimester. New-onset AF was diagnosed in 34 (47.9%) of them. After matching, the incidence of composite outcome was higher in women with AF (77.5% (95% CI 66.3%-85.7%) compared to women without AF (17.3%(95% CI 13.3% - 22.1%), p<0.001), with seven (9.9%) maternal deaths among cases and two (0.7%) in controls. Heart failure was the most common adverse cardiac event (26.7% vs. 4.2%, p<0.001, cases vs controls). Those with AF had higher odds (adjusted OR 56.6 (14.1 - 226.8)) of adverse cardiac outcomes after adjusting for other risk factors. The frequency of most non-cardiac pregnancy complications was similar in both groups. However, there was a trend towards a higher rate of miscarriage (16.9% vs. 9.9%), small-for-gestational-age babies(16.3 vs. 9.0%), and cesarean rates(31.9% vs. 18.3%) women with AF compared to those who did not experience AF. CONCLUSIONS: Atrial fibrillation in pregnancy among women with RHD was associated with an increased risk of maternal morbidity and mortality, with a trend towards an increase in some non-cardiac pregnancy complications compared to those pregnant women without AF. Our study results provide background data for developing and implementing a pregnancy-specific management strategy tailored to middle-income settings.

Prognostic values of SYNTAX score II in patients with coronary artery disease undergoing percutaneous coronary intervention - Cohort study.

BACKGROUND: The data on prognostic values of SYNTAX score II in patients undergoing percutaneous coronary intervention is limited. We report predictive utility of SYNTAX score II in relation to in hospital and 1 year mortality of the patients undergoing percutaneous coronary intervention. METHODS: This was a cohort study of patients who underwent percutaneous coronary intervention (PCI) at a single centre from January 2018 to December 2019. In hospital and 12-month events and mortality was analysed among 1000 patients. The patients were divided into 3 groups based on tertiles of Syntax II score (<22, 22-27.7 and >27.7). RESULT: The total mortality at 12 months was 60 (6%). Major adverse cardiac events (MACE) occurred in 87 (9%). The patients who died had higher SYNTAX score II score compared to those alive at 12 months 34 (38, 24) vs 24 (28.1, 20.9) P < 0.01. The same trend was seen in patients who had major adverse cardiac events (MACE) 28 (34, 24) vs 24 (28.6, 21) P < 0.01 Among the 3 groups of SYNTAX score II, in hospital mortality, all-cause mortality, cardiovascular death, myocardial infarction, unstable angina, revascularization and major adverse cardiac events (MACE) were higher in the third tertile (>27.7) compared the lower tertiles. CONCLUSION: The patients who had higher SYNTAX score II had more in hospital and 12 month mortality and major adverse cardiac events (MACE). SYNTAX II score is a better predictor of in-hospital, and 12 month cardiovascular and all cause mortality.

Impact of near-miss event during pregnancy and childbirth on maternal health at 12 months.

OBJECTIVE: To assess the impact of maternal near-miss on late maternal death and the prevalence of hypertension or chronic kidney disease (CKD) and mental health problems at 12 months of follow up. METHODS: This prospective cohort study was conducted in a tertiary hospital in the southeastern region of India from May 2018 to August 2019, enrolling those with maternal near-miss and with follow up for 12 months. The primary outcomes were incidence of late maternal deaths and prevalence of hypertension and CKD during follow up. RESULTS: Incidence of maternal near miss was 6.7 per 1000 live births. Among those who had a near miss, late maternal deaths occurred in 7.2% (95% confidence interval [CI] 3.1%-11.3%); prevalence of CKD was 23.0% (95% CI 16.2%-29.8%), and of hypertension was 56.2% (95% CI 50.5%-66.5%) and only two women had depression on follow up. After adjusting for age, parity, socioeconomic status, gestational age at delivery, hemoglobin levels, and perinatal loss, only serum creatinine was independently associated with late maternal death and CKD on follow up. CONCLUSIONS: Women who survive a life-threatening complication during pregnancy and childbirth are at increased risk of mortality and one or more long-term sequelae contributing to the non-communicable disease burden. A policy shift to increase postpartum follow-up duration, following a high-risk targeted approach after a near-miss event, is needed.

Validation of Risk Stratification for Cardiac Events in Pregnant Women With Valvular Heart Disease.

BACKGROUND: Most risk stratification tools for pregnant patients with heart disease were developed in high-income countries and in populations with predominantly congenital heart disease, and therefore, may not be generalizable to those with valvular heart disease (VHD). OBJECTIVES: The purpose of this study was to validate and establish the clinical utility of 2 risk stratification tools-DEVI (VHD-specific tool) and CARPREG-II-for predicting adverse cardiac events in pregnant patients with VHD. METHODS: We conducted a cohort study involving consecutive pregnancies complicated with VHD admitted to a tertiary center in a middle-income setting from January 2019 to April 2022. Individual risk for adverse composite cardiac events was calculated using DEVI and CARPREG-II models. Performance was assessed through discrimination and calibration characteristics. Clinical utility was evaluated with Decision Curve Analysis. RESULTS: Of 577 eligible pregnancies, 69 (12.1%) experienced a component of the composite outcome. A majority (94.7%) had rheumatic etiology, with mitral regurgitation as the predominant lesion (48.2%). The area under the receiver-operating characteristic curve was 0.884 (95% CI: 0.844-0.923) for the DEVI and 0.808 (95% CI: 0.753-0.863) for the CARPREG-II models. Calibration plots suggested that DEVI score overestimates risk at higher probabilities, whereas CARPREG-II score overestimates risk at both extremes and underestimates risk at middle probabilities. Decision curve analysis demonstrated that both models were useful across predicted probability thresholds between 10% and 50%. CONCLUSIONS: In pregnant patients with VHD, DEVI and CARPREG-II scores showed good discriminative ability and clinical utility across a range of probabilities. The DEVI score showed better agreement between predicted probabilities and observed events.

The genetic polymorphisms and activity of glyoxalase 1 as a risk factor for acute coronary syndrome in South Indians with type 2 diabetes mellitus.

OBJECTIVE: The individuals' genetic traits predispose them to a higher or lower risk of Type 2 diabetes mellitus (T2DM) and its complications, for example, acute coronary syndrome (ACS). As carbonyl stress is responsible for the pathogenesis and complications of T2DM, and glyoxalase 1 (GLO1) is the most crucial determinant of carbonyl stress, the study aimed to explore the association between GLO1 gene polymorphism, GLO1 activity in red blood cell (RBC), plasma methylglyoxal (MG) levels, and ACS risk in South Indian T2DM patients. METHODS: A total of 150 T2DM patients with ACS as cases and 150 T2DM patients without ACS as controls were recruited in a case-control study. The rs4746, rs1049346 and rs1130534 of the GLO1 gene were analysed using TaqMan allele discrimination assay. The RBC GLO1 activity and plasma MG levels were measured. RESULTS: Significantly lower RBC GLO1 activity and higher plasma MG levels were found in cases compared to controls (p < 0.001 and p = 0.008, respectively). The genotype and allele frequencies of rs1049346 significantly differed between cases and controls (p < 0.001). For rs1130534 and rs1049346, no significant difference was found. For rs1049346, the TT and CC genotypes were associated with higher (p = 0.002) and lower (p = 0.001) ACS risk, respectively, in various genetic models. The TT genotype of rs1049346 was associated with lower RBC GLO1 activity (p = 0.004) and higher MG level (p = 0.010). In haplotype analysis, higher ACS susceptibility with the TAT haplotype (p < 0.001) and lower ACS susceptibility with the TAC haplotype (p < 0.001) were observed. Also, lower RBC GLO1 activity was associated with the TAT haplotype (p = 0.002). CONCLUSIONS: The rs1049346 of the GLO1 gene may be associated with ACS risk in South Indian T2DM patients, and the T and C allele might be essential precipitating and protective factors, respectively.

Altered expression of a disintegrin and metalloproteinase 10 in peripheral blood mononuclear cells in type 2 diabetes mellitus patients with the acute coronary syndrome: a pilot study.

PURPOSE: Advanced glycation end products (AGEs) are responsible for the complications in type 2 diabetes mellitus (T2DM) patients by acting via its receptor (RAGE). The soluble form of RAGE (sRAGE) prevents the harmful effects of AGE-RAGE signalling. The sRAGE is produced either by alternate splicing (esRAGE) or proteolytic RAGE cleavage by a disintegrin and metalloproteinase 10 (ADAM10). Hence, the study aimed to compare the expression of ADAM10 in peripheral blood mononuclear cell (PBMC), serum sRAGE and esRAGE levels in T2DM patients with and without acute coronary syndrome (ACS). METHODS: Forty-five T2DM patients with ACS and 45 age, gender and duration of DM-matched T2DM patients without ACS were recruited. Serum sRAGE and esRAGE levels were measured by enzyme-linked immunosorbent assay. The expression of ADAM10 in PBMC was determined by quantitative reverse transcription-polymerase chain reaction. RESULTS: The expression of ADAM10 in PBMC and serum sRAGE levels were significantly lower in T2DM patients with ACS than in T2DM patients without ACS (p < 0.001). Serum sRAGE levels and expression of ADAM10 in PBMC were positively correlated with each other and negatively correlated with markers of cardiac injury and glycaemic status (p < 0.05). Simple logistic regression showed that the models containing the expression of ADAM10 and serum sRAGE level could predict the ACS risk among T2DM patients. ROC analysis showed that both might be used for ACS diagnosis in T2DM patients. CONCLUSION: Reduced expression of ADAM10 in PBMC might be responsible for lower serum sRAGE levels, predisposing T2DM patients to high ACS risk.

Short term outcomes with dual chamber versus single chamber pacing for atrioventricular block - A crossover trial.

A total of 42 patients were studied for primary outcomes of quality of life and 6MWD between VVIR and DDD modes. At end of 2 months after device implantation, randomization was done and the device was programmed to VVIR or DDD modes. At the end of 2 months in this mode QOL and functional was assessed and the patient was switched to other mode. The same protocol was followed at the end of 2 months. We found no difference in functional capacity and quality of life between the two pacing modes. None of the patients developed pacemaker syndrome and there was no preference for any of the modes.

Serum biomarkers of maternal morbidity and adverse outcome in severe pre-eclampsia.

OBJECTIVE: To evaluate the association of maternal serum biomarkers of myocardial damage, oxidative stress and angiogenic imbalance with maternal adverse outcomes in women with severe pre-eclampsia. METHODS: This was a prospective cohort study, where maternal serum biomarkers were evaluated in women admitted with severe pre-eclampsia to a tertiary care centre between March 2019 and February 2020. Serum markers included brain naturetic peptide (BNP), cardiac troponin-T (cTnT), cystatin-C (cys-C), soluble fms-like tyrosine kinase-1 (sFlt-1), placental growth factor (PlGF), Total Anti-Oxidant status (TAO) and malondialdehyde (MAO). Main outcome measures were adverse maternal outcomes defined as eclampsia, pulmonary oedema, acute kidney injury, placental abruption and HELLP syndrome. RESULTS: Adverse maternal outcomes occurred in 93(37.2%, 95% CI: 31.2%-43.6%) of the 250 women with severe pre-eclampsia included in the study, including 21 with pulmonary oedema, 25 with acute kidney injury and 36 with eclampsia. BNP levels were higher among women who developed pulmonary oedema (55.4 pg/mL vs 42.0 pg/mL, p = 0.008). TAO levels were higher in women who developed eclampsia (4.6 mM, IQR 3.1-5.7, p < 0.001) and acute kidney injury (4.1 mM, IQR 3.2-6.3, p = 0.002) compared to those who did not develop any complications (2.93 mM, IQR 2.3-4.1). CONCLUSIONS: Even though the endothelial dysfunction and oxidative stress biomarkers were associated with development of preeclampsia, it may have limited utility in identifying women who might develop adverse outcomes.

Association between serum netrin-1, netrin-4 and risk of the acute coronary syndrome in patients with type 2 diabetes mellitus-A pilot study.

The present study was done to assess the diagnostic utility of serum netrin-1 and netrin-4 for recognising the acute coronary syndrome (ACS) in type 2 diabetes mellitus (T2DM) patients. Forty-two T2DM patients with ACS (Cases) and forty-two T2DM patients without ACS (Controls) were compared. Cases had lower serum netrin-1 and netrin-4 levels than controls and were negatively associated with creatinine kinase-total, creatinine kinase-MB, troponin-T and H-FABP. ROC analysis showed that netrin-1 and netrin-4 had good sensitivity and specificity for ACS prediction in T2DM patients. Serum netrin-1 and netrin-4 levels might be considered complementary markers for ACS diagnosis in T2DM patients.

Maternal and perinatal outcomes of pregnant women with tetralogy of Fallot: a tertiary center experience from south-India.

BACKGROUND: Women with tetralogy of Fallot especially uncorrected are at increased risk of adverse maternal and perinatal outcomes. METHOD: We reviewed the maternal complications and pregnancy outcomes of women with tetralogy of Fallot (ToF), having corrected or uncorrected lesion during the period from 2011 to 2019 attending a south-Indian tertiary care center. Data regarding demographics, clinical course, and medications received and echocardiographic diagnosis regarding ToF, labor and delivery details, and postpartum follow-up was collected from the records. For each case, four women matched for age (±2 years), without a diagnosis of heart disease, were included as controls. We compared the outcomes in pregnant women with ToF and controls as well between those who have undergone repair with those without repair and also with the controls. RESULTS: There were 27 pregnancies in 19 patients with ToF, including eight pregnancies in seven women with uncorrected lesions. There was no maternal death or occurrence of infective endocarditis. Women with uncorrected lesion had significantly higher rates of fetal growth restriction (37.5% vs 6.7%), preterm birth (50% vs. 13.3%) resulting in lower birth weight (1907.5 g vs. 2607.3 g)) compared to those with a corrected lesion. Women with corrected lesion had similar outcomes to the controls (p > .5). CONCLUSION: Women with uncorrected ToF are at increased risk of perinatal complications compared to those with corrected lesion and require care under a multidisciplinary team, with an individualized plan for delivery to optimize the outcomes.

Ebstein's anomaly during pregnancy: experience from a tertiary care centre - a case series and review of literature.

Pregnancy complicated with uncorrected Ebstein's anomaly is uncommon and may pose a serious threat to maternal and foetal life in the clinical setting of altered hemodynamics of pregnancy. Data of eight pregnancies in four women with Ebstein's anomaly who delivered in a tertiary care institute was analysed. Among the four women, one had associated atrial septal defect, one had pulmonary hypertension and three had right bundle branch block. There were two miscarriages and six successful pregnancies resulting in live births. Three of the pregnancies were delivered by caesarean section. There was one pregnancy complicated by severe preeclampsia, no preterm births or maternal cardiac complications. There was one neonate with congenital ostium secundum atrial septal defect. All patients were managed by a multidisciplinary team involving Obstetrician, Cardiologist, Anaesthesiologist and Neonatologist.IMPACT STATEMENTWhat is already known on this subject? Ebstein's anomaly is a rare congenital anomaly with apical displacement of the septal tricuspid leaflet in association with leaflet dysplasia. It may cause varied presentation in pregnancy depending on the severity of the lesion.What do the results of this study add? Ebstein's anomaly may become symptomatic for the first-time during pregnancy. Patients with NYHA class II symptoms and no cyanosis generally tolerate pregnancy well. Miscarriages and intrauterine growth restriction may occur in the presence of this condition. Vaginal delivery is advised and caesarean is done only for obstetric indications.What are the implications of these findings for clinical practise and/or future research? The management of pregnancy with uncorrected Ebstein's anomaly is highly challenging especially in a low resource setting and requires tertiary centre care. Multidisciplinary team involvement can help to improve the outcomes in such pregnancies.

Maternal cardiovascular dysfunction in women with early onset preeclampsia: a cross-sectional study.

BACKGROUND: Cardiac remodeling and diastolic dysfunction may occur, in women with early-onset preeclampsia, following raised total vascular resistance in response to the impaired placentation. These changes can increase the risk of premature cardiac morbidity and mortality later in life. According to updated guidelines by the American and European Societies of Echocardiography (ASE/ESE) to diagnose diastolic dysfunction, using a simpler criterion is not yet used in pregnant women. OBJECTIVE: To compare the maternal cardiovascular changes and the variation in the diastolic dysfunction using the 2009 and 2016 criteria by ASE/ESE among women with early onset preeclampsia and gestational age-matched normotensive controls. METHODS: A prospective matched cross-sectional study conducted in a tertiary hospital in South India, involving 40 women with early and 40 women with gestational age-matched normotensive controls. Cardiac function and remodeling were assessed by conventional 2D, M-mode, and Doppler echocardiography. RESULTS: Compared to the controls, women with early-onset preeclampsia had significantly higher. Total vascular resistance index (2867.6 vs. 2277.2 dynes/s/cm5/m2, p = .035) and median end-systolic stress index (5.2 vs. 9.2 dyne/cm2/m2), suggesting a higher afterload. Cases had a significant rate of left ventricular diastolic dysfunction using the 2009 criteria (grade II/III: 21 (52%) vs. 0 (0%), p<.001) whereas the rates were much lower when the updated 2016 guidelines were used (grade II/III: 9 (22.5%) vs. 1 (2.5%), p<.001). CONCLUSIONS: In women with early-onset preeclampsia, cardiovascular adaption occurs to minimize wall stress and myocardial oxygenation. The prevalence of diastolic dysfunction was observed to be lower with the 2016 criteria. Further studies involving pregnant women are required to assess the impact of newer guidelines on association with short- and long-term cardiovascular outcomes in high-risk women.

Alternatives to Low Molecular Weight Heparin for Anticoagulation in Pregnant Women with Mechanical Heart Valves in Middle-Income Countries: A Cohort Study.

Objective: To compare cardiac complications and pregnancy outcomes in women with mechanical heart valves (MHVs) on two different anticoagulation regimens in a middle-income country. Methods: We conducted a retrospective cohort study comparing outcomes in pregnant women with MHVs that received vitamin K antagonists (VKAs) throughout pregnancy versus sequential anticoagulation (heparins in the first trimester and peripartum period and VKAs for the remainder of pregnancy), at a tertiary centre in South India, from January 2011 to August 2020. Results: We identified 138 pregnancies in 121 women, of whom 32 received VKAs while 106 were on sequential anticoagulation. There were no differences between groups with regard to maternal deaths [0 vs. 6 (5.7%), p = 0.34], thromboembolic events [2 (6.3%) vs. 15 (14.2%), p = 0.36], haemorrhagic complications [4 (12.5%) vs. 12 (11.3%), p = 0.85], cardiac events [1 (3.1% vs. 17 (16%), p = 0.07], spontaneous miscarriages [5 (15.6%) vs. 13 (12.3%), p = 0.62], stillbirths [0 vs. 5 (5.4%), p = 0.581] or neonatal deaths [2 (8.7%) vs. 1 (1.1%), p = 0.11]. Both cases of warfarin embryopathy received >5 mg warfarin in the first trimester. Thromboembolic events were associated with subtherapeutic doses of heparin in the first and third trimesters and the early postpartum period. Fetal growth restriction and preterm birth complicated 34 (29.3%) and 26 (22.4%) pregnancies respectively. Conclusion: Pregnancy complications associated with MHVs in middle-income countries may be reduced by multidisciplinary surveillance, avoiding first-trimester warfarin if daily doses >5 mg and ensuring therapeutic levels of heparin during bridging in the first and third trimesters and peripartum period. Administration of low-dose aspirin should be considered as this may prevent placentally-mediated complications of pregnancy. Highlights: Pregnancy complications associated with MHVs in LMICs may be reduced by multidisciplinary surveillance, avoiding first-trimester warfarin if the daily dose is >5 mg, ensuring therapeutic levels of heparin in the first trimester and peripartum period.Placentally-mediated complications of pregnancy can be prevented by administering low-dose aspirin.Vitamin K antagonists or sequential regimen can be used as suitable alternatives to LMWH for anticoagulation in pregnant women with MHVs.

Sudden death and its predictors in myocardial infarction survivors in an Indian population.

OBJECTIVE: This study was conducted to assess the incidence of sudden cardiac death (SCD) in post myocardial infarction patients and to determine the predictive value of various risk markers in identifying cardiac mortality and SCD. METHODS: Left ventricular function, arrhythmias on Holter and microvolt T wave alternans (MTWA) were assessed in patients with prior myocardial infarction and ejection fraction ≤ 40%. The primary outcome was a composite of cardiac death and resuscitated cardiac arrest during follow up. Secondary outcomes included total mortality and SCD. RESULTS: Fifty-eight patients were included in the study. Eight patients (15.5%) died during a mean follow-up of 22.3 ± 6.6 months. Seven of them (12.1%) had SCD. Among the various risk markers studied, left ventricular ejection fraction (LVEF) ≤ 30% (Hazard ratio 5.6, 95% CI 1.39 to 23) and non-sustained ventricular tachycardia (NSVT) in holter (5.7, 95% CI 1.14 to 29) were significantly associated with the primary outcome in multivariate analysis. Other measures, including QRS width, heart rate variability, heart rate turbulence and MTWA showed no association. CONCLUSIONS: Among patients with prior myocardial infarction and reduced left ventricular function, the rate of cardiac death was substantial, with most of these being sudden cardiac death. Both LVEF ≤30% and NSVT were associated with cardiac death whereas only LVEF predicted SCD. Other parameters did not appear useful for prediction of events in these patients. These findings have implications for decision making for the use of implantable cardioverter defibrillators for primary prevention in these patients.

Catheter ablation of scar based ventricular tachycardia - Procedural characteristics and outcomes.

BACKGROUND: Ventricular tachycardia (VT) is a major cause of morbidity in patients with cardiomyopathy. Radiofrequency ablation has emerged as the mainstay of the management of recurrent sustained VT in these patients. We describe the clinical characteristics, procedural and medium term outcomes of patients undergoing ablation of scar VT in a tertiary care center in India. METHODS: This was a single-center descriptive cohort study. All patients who underwent ablation for scar related VT were included. Endpoints were immediate procedural success, procedural complications and recurrence during follow up. RESULTS: A total of 72 patients with scar VT underwent ablation with electroanatomic mapping. Previous myocardial infarction (MI) was the commonest etiology (69.4%) with arrhythmogenic right ventricular cardiomyopathy (ARVC) being the next common (19.4%). Acute procedural success was achieved in 69.4% patients, partial success in 9.7% and failure in 1 patient (1.4%). Outcome was labeled indeterminate in 19.4% who did not undergo post ablation VT induction. Procedural complications were seen in 4%. Follow up data was available in 95% of the patients with a mean follow up of 28.9 ± 22.8 months. At one year, freedom from VT was 83.8% and mortality was 13.2%. Overall mortality during follow up was 22.1% while VT recurrence was seen in 35.3%. Recurrence rate was higher in ARVC as compared to previous MI. CONCLUSIONS: Ablation of scar VT has high acute success rates. Ablation is safe with low risk of major complications. Rates of recurrence are higher in patients with ARVC as compared to post MI VT.

Pregnancy outcome in women with an uncorrected single ventricle: A single-centre experience from South India.

BACKGROUND: Women with an uncorrected single ventricle heart are at increased risk of adverse maternal and perinatal outcomes. METHODS: We report our experience of managing pregnant women with uncorrected single ventricles, during the time period 2011 to 2017, in a low-resource setting and compare pregnancy outcome with healthy concurrent controls. Outcomes assessed include the mode of delivery, maternal complications, neonatal death and birth weight. RESULTS: There were six pregnant women with uncorrected single ventricles who had a total of 14 pregnancies. There was one maternal death in a woman with atrioventricular-septal defect and Eisenmenger syndrome. Caesarean section rates and preterm delivery were similar, whereas perinatal loss and low-birth weight rates were higher among women with a single ventricle compared to healthy controls. CONCLUSION: Unplanned pregnancies without prenatal counselling/care pose a challenge to physicians especially in low to middle income countries and with the high risk of morbidity/mortality, pregnancy should be discouraged.

Prediction of adverse cardiac events in pregnant women with valvular rheumatic heart disease.

OBJECTIVE: To assess the incidence of adverse cardiac events in pregnant women with rheumatic valvular heart disease (RHD) and to derive a clinical risk scoring for predicting it. METHODS: This is an observational study involving pregnant women with RHD, attending a tertiary centre in south India. Data regarding obstetric history, medical history, maternal complications and perinatal outcome till discharge were collected. Eight-hundred and twenty pregnancies among 681 women were included in the analysis. Primary outcome was composite adverse cardiac event defined as occurrence of one or more of complications such as death, cardiac arrest, heart failure, cerebrovascular accident from thromboembolism and new-onset arrhythmias. RESULTS: Of the 681 women with RHD, 180 (26.3%) were diagnosed during pregnancy. Composite adverse cardiac outcome during pregnancy/post partum occurred in 122 (14.9%) pregnancies, with 12 of them succumbed to the disease. In multivariate analysis, prior adverse cardiac events (OR=8.35, 95% CI 3.54 to 19.71), cardiac medications at booking (OR=0.53, 95% CI 0.32 to 0.86), mitral stenosis (mild OR=2.48, 95% CI 1.08 to 5.69; moderate OR=2.23, 95% CI 1.19 to 4.18; severe OR=7.72,95% 4.05 to 12.89), valve replacement (OR=2.53, 95% CI 1.28 to 5.02) and pulmonary hypertension (OR=6.90, 3.81 to 12.46) were predictive of composite adverse cardiac events with a good discrimination (area under the curve=0.803) and acceptable calibration. A predictive score combining these factors is proposed for clinical utility. CONCLUSION: Heart failure remains the most common adverse cardiac event during pregnancy or puerperium. Combining the lesion-specific characteristics and clinical information into a predictive score, which is simple and effective, could be used in routine clinical practice.