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Dr Fiona Walker
Consultant Cardiologist
Lead for ACHD & maternal cardiology
UCLH NHS Trust
Currently;
• Heart disease complicates ~ 1% pregnancies
• Increased adult survivors with all forms of complex HD
• Increasing complexity of maternal heart disease
• Ascendancy of patient autonomy / demise of medical paternalism
0
20
40
60
80
100
120
140
160
2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
Inherited
Aquired
Congenital
total
Number of completed pregnancies per year in women with heart disease UCLH
Pathology
0
10
20
30
40
50
60
Sepsis PIH PE AFE Bleeding anaesthesia Cardiac Psych
UK Maternal deaths
2000/2
2003/5
2006/8
7
11
10
13
4
2
2
11
2
Cardiac deaths 2006/8
AOD
IHD
SADS
DCM
myocarditis
Valve thrombosis
IE
Myo hypertrophy
CHD
PHT
Most indirect deaths were associated with substandard care
20% of indirect deaths were preventable
Congenital Heart disease (CHD) more common than acquired HD in pregnancy
Incidence CHD 0.8% v’s acquired 0.1%
Deaths in pregnancy in inherited & acquired HD
outnumber those from CHD
Assess patient : ABC
IV access : STAT
HELP : STAT
Maternal health is the PRIORITY
Review by cardiology expert if ........
A sternotomy or thoracotomy scar!
“hole in the heart closed”
FHx of Sudden cardiac death / premature death
Inherited cardiomyopathy -Hypertrophic
Inherited Aortopathies – Marfansyndrome, Loey’s-Dietz,Ehler Danlos IV, Turnersyndrome
Pregnancy in Familial Hypertrophic
Cardiomyopathy (FHC)
Disease of the muscle sarcomere caused by a gene mutation
~ 200 disease causing mutations, 12 genes identified
Annual mortality 1-4% (unselected v tertiary centre population)
Annual mortality risk >1 RF = 3-6%
Prior Cardiac arrest AFSyncope LVOTOFHX SCD Trop T/I MWT > 30mm Myo IschaemiaABPR on Ex LGENSVT Intense Ex
Prevalence 1:3000-5000
Autosomal dominant – 25% cases sporadic
FBN 1 mutations (chromo 15q21.1) - > 500 mutationsTGFβ receptor mutations (chromo 3)
Joint Hypermobility
Loey’s – Dietz syndrome
Autosomal dominant, Phenotypic overlap with MFS
Abnormal TGFβ 1&2 receptors
Elastin disarray - Arterial tortuosity & Aneurysms any
vessels
Joint hypermobility
Bifid uvula/cleft palate
14 patients
2/3 aneurysmal disease extending beyond Asc
Ao
Mean age death 26 yrs
Median survival 37 yrs
Cause of death:
Ao Dissection 67%, Abdo Ao dissection 22%,
Cerebral artery dissection 7%
Autosomal dominant
Deficiency type III collagen
Large eyes, small chin,
lobeless ears, pale
transluscent skin, bruising
Spontaneous Arterial,
visceral GI rupture
Pregnancy – Increased
vascular and uterine
rupture
Maternal mortality ~ 12%
Complete or partial monosomy of X chromosme
1/2000 live births
Short stature (m Ht 4ft 7”), webbed neck Ovarian failure, IQ normal
BAV 20%
Annual incidence AOD (2/3 type A)
(cf rate of 6/100,000 in DK general population)
15/100,000 < 20 yrs
23-78/100,000 20-40 yrs
50/100,000 > 40 yrsRF Dissection ; Age, pregnancy, BAV
7
11
10
13
4
22
1 1
2
Cardiac deaths 2006/8
AOD
IHD
SADS
DCM
myocarditi
s
Valve
thrombosis
IE
Myo
hypertroph
yCHD
7 deaths CMACE
Type A (5), Type B (2)
ED type IV
BAV
FHx AOD
Most deaths post 2 to 3 days delivery
MORTALITY 30%
Chest pain sharp, tearing or burning
Anterior / posterior intra-scapula
Moderate / Severe
ECG and symptoms of AMI (1-2%)
Aortic regurgitation murmur (50%)
JVP elevation - pericardial effusion
Weak or Unequal limb pulses / BP
ABC
Opiate analgesia
Control BP – Labetolol, SNP, Hydrallazine, CCB
Urgent Expert help – Cardiologist / Cardiothoracic surgeon
ECG / TTE / TOE / MRI / CT
Transfer CTITU
FHx premature IHD / RF CAD
Immigrant + SOB Rheumatic or congenital HD
PHx chemotherapy : Dilated cardiomyopathy
Other indications for cardiology review
7
11
10
13
4
2 2
1 1
2
Cardiac deaths 2006/8
AOD
IHD
SADS
DCM
myocarditis
Valve
thrombosis
IE
Myo
hypertrophy
CHD
PHT
Incidence 0.7 per 100,000 maternities
4 fold increase since 2002
10% women with AMI are < 35 yrs old
All women who died had RF for IHD
Atheroma 43%
Dissection 16%
Normal coronaries 29%
Thrombosis 21%6
Mortality 7 – 21%
Pain / tightness
Central chest, epigastrium, shoulders, back, arms
Exacerbated by physical activity
SOB, Sweaty, N&V
Relieved by opiate analgesia
ABC / IV access / HELP
12 lead ECG
Troponin x 3, 3 hrs apart
(onset 2-12 hrs, peak 18-24 hrs)
Opiate analgesia
Minutes means myocardium
Normal ST segments (CCU) concave curved, upsloping
ST elevation MI : STEMI
Non ST elevation MI : non STEMI
Patient with suspected cardiac chest pain
ECG
ST elevation
STEMI Pathway
Ongoing / recurrent chest pain with ST depression, T wave
inversion, dynamic T waves or Trop>0.014
Check Troponin immediately
Other cardiac sounding chest pain
Troponin <0.014 and chest pain <6 hours at
admissionRepeat Troponin at 3
hoursTroponin <0.014 and
chest pain >6 hours at admission
Discharge and arrange follow up
Admit for cardiology review
Risk>1.5% at 6 months
Troponin <0.014 Troponin >0.014
Troponin >0.014 (without chest pain or
new ECG change)
Recurrent chest pain in hospital is a high risk situation, regardless of troponin levels and should lead to1) Re-evaluation for STEMI / NSTEACS pathways2) Admission for cardiology review
Admit patient and repeat Troponin at 3 hrs to see trend
Simon Woldman 26/06/13
Aspirin 300mg stat
Clopidogrel safe
Beta blockers safe
IV Nitrates safe
LMWH safe
Transfer for PCI
Thrombolysis only if no access to PCI (does not cross the placenta but risk of haemorrhage ~ 8%)
PCI within 120 minutes from onset of symptoms
• Safe and reduces maternal mortality ~ 5-10%
• Radial approach preferred• Non-drug eluting stents• Mean radiation dose 0.02 mSv
(c.f AXR 1.4)
Effect of radiation on fetus9/7-8/40 Organ deformity > 1000mSv8-15/40 Mental retardation 500-1000mSv>15/40 Childhood cancer 500mSv
► Cardiac Output (CO) increases by 40-50%
► Further increases peripartum
► Stroke Volume and Heart Rate increase
► Peripheral vasodilation and decrease SVR
► PCWP and CVP unaltered
► Colloid osmotic pressure reduced
► Cardiac Output (CO) increases by 40-50%
► Further increases peripartum
► Stroke Volume and Heart Rate increase
► Peripheral vasodilation and decrease SVR
► PCWP and CVP unaltered
► Colloid osmotic pressure reduced
Threshold for developing pulmonary oedema
is reduced
Fatigue
Dry cough –
especially on lying flat
Progressive SOB
and decreased
exercise tolerance
SOB lying down
(even lying on side
• Tachycardia HR > 100 bpm• Subjective SOB – not overt• +/- Elevated JVP• +/- Sacral oedema• Vitals normal• Chest - clear or crackles!
Heart Failure signs
Haemodynamic tolerance in young people is high
Signs of HF and radiological pulmonary oedema is a peri-arrest situation
Pre-eclampsia Acute MI – any cause Peri-partum cardiomyopathy Un-diagnosed HCM/DCM Un-diagnosed Obstructive valve disease
– AS/MS Aortic dissection Massive PE Mechanical valve thrombosis Tachyarrhythmias
Acute HF in pregnancy
ABC/ IV access/ HELP
Supplemental Oxygen
IV Furosemide 20mg stat
Transfer to HDU / ITU
CXR / Transthoracic echo
Caution : LV function should be Hyper-dynamic, if reportedly
low-normal EF% and clinical picture suggests HF,
it probably is HF!
CVC & arterial line
If pregnant consider interrupting the pregnancy
Inotropic support
Consider transfer to VAD centre
Palpitations
SADS ~ 500 cases per yr in UK
10 deaths CMACE
Presumed arrhythmia
All other causes sudden collapse excluded
Drug screens negative
Obesity common
Undiagnosed channelopathy?
7
11
10
13
4
22
1 1
2
Cardiac deaths 2006/8
AOD
IHD
SADS
DCM
myocarditis
Valve
thrombosis
IE
Myo
hypertrophy
CHD
PHT
Symptoms:
Palpitations
SOB
Pre syncope or syncope
Chest pain / tightness
Sustained
Paroxysmal
Narrow complex
Broad complex
Most atrial tachyarrhythmias are well tolerated in the absence of structural heart disease
AV nodal tachycardia (AVMT)
AV nodal re entrant tachycardia
(AVNRT)
Ectopic atrial tachycardia (EAT)
Atrial flutter (AFL)
Atrial fibrillation (AFL)
SVT with BBB
WPW / pre-excitation
VT
Antidromic conduction causes a broad complex SVT
Pre-excited AF
ABC / IV access / HELP
High flow oxygen and left tilt
Cardiac monitoring
12 lead ECG
Assess haemodynamic status & look for adverse features
Cool and clammy
Sweaty
Dyspnoea
Hypotension SBP<90mmHg
Pre Syncope
Chest pain
Amiodarone 300mg IV over 10 to 20 minutesAnd further 900 mg IV over 24 hours
Narrow complex SVT : QRS < 120 ms
No adverse features
Vagal stimulation
Adenosine mg, 12mg, 18mg, 24 mg
Beta blockers
Flecanide
Regular: AVRT, AFL Irregular: Afib
Try to terminate arrhythmia or rate control
Beta blockers
Diltiazem
Digoxin
Amiodarone
Broad complex : QRS > 120 ms
VT : Amiodarone
AFL BBB : Adenosineor Flecanide
Regular :
VTAFL with BBB
Irregular:AFib BBBAfib with pre-excitation
Polymorphic VT
Try to terminate!
Afib BBB : as per SVT
Afib Pre-excitation: Amiodarone
Polymorphic VT : Mg
The anaesthetist is Labour ward front-line medic
CT surgery/CCU
Haematologist
Obstetric
Anaesthesia
Expert cardiologist Obstetricians
FMU / neonatologist
Level 3 adult &
neonatal ITUIntervnetionalist
Cardiac anaesthesia
Manpower for the maternal cardiology service
ME! Cathy Head, Nathalie Chung GSTT LondonLorna Swan, Brompton, LondonMichael Gatzoulis, Brompton, LondonLeisa Freeman, NorwichRachel James, BrightonAshling Carroll, SouthamptonStephanie Curtis & Graham Stuart, BristolAidan Bolger, LeicesterHelen Wallis, CardiffSara Thorne & Lucy Hudsmith, BirminghamDawn Adamson, CoventryBernard Clarke, ManchesterKate English, LeedsHamish Walker, Glasgow
