Heart failure in pregnancy

PD Dr. med Daniel Tobler Leiter angeborene Herzfehler (GUCH)

Universitätsspital Basel !

www.heartdiseaseandpregnancy.com

Heart failure in pregnancy Agenda

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- general considerations - specific lesions

ROPAC Registry Registry Of Pregnancy And Cardiac disease

Update on recruitment (ROPAC)

Speaker

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Cumula1ve#pa1ents#enrolments#

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ROPAC Registry

45 Länder, 112 Zentren

ROPAC Registry

n=1321Roos-Hesselink et al. ROPAC registry, EHJ 2012

Congenital heart disease 66 %Valvular heart disease 25 %Cardiomyopathy 7 %Ischemic heart disease 2 %

ROPAC Registry

n=1321

Roos-Hesselink et al. ROPAC registry, EHJ 2012

•  Hospital admission: 25%

•  Heart failure: 13%

•  Ventricular arrhythmia’s 2.0%

•  Thrombotic complications: 0.4%

•  Endocarditis: 0.3%

Congenital heart disease Heart failure in Pregnancy

CARPREG 2001

Kha

iry 20

06

ZAHARA 2010

Son

g 200

8 Ford

2008

Curt

is 20

09

Stangl

2008

ZAHARA 20

12

0

Other studies Cardiac complications in pregnant women with congenital heart disease

n= 599 90 1302 49 74 131 93 213

5

10

15

20

25

heart failure

Timing of heart failure in pregnancy

Ruys et al. Heart 2013

Hemodynamic changes during pregnancy

Thorne, Heart 2009

Timing of heart failure in pregnancy

Ruys et al. Heart 2013

ROPAC Registry Heart failure specific risk factors

Mul$variate+analyse OR 95%+CI

Signs+of+HF+prior+to+pregnancy 9,6 5,9@15,5

Cardiomyopathy 4,6 2,3@9,1

NYHA+class+>+2 2,3 1,2@4,4

WHO+>+2 2,3 1,5@3,6

Pulmonary+hypertension 1,8 1,0@3,0

Ruys et al. Heart 2013

ROPAC Registry Outcome in women with heart failure

Ruys et al. Heart 2013

! Pa$ents!with!HF!

(n=173) Pa$ents!without!HF!

(n=1148) p!value

Maternal!mortality!(%) 4,8 0,5 <0,001

Cardiac

Atrial!fibrilla$on!(%) 1,2 0,9 0,71

Ventricular!arrhythmias!(%) 2,9 1,8 0,35

ThromboNembolic!events!(%) 1,2 0,3 0,14

Endocardi$s!(%) 1,2 0,1 0,006

Bleeding!complica$ons!during!pregnancy!(%) 2,9 1,4 0,14

Bleeding!complica$ons!post!partum!(%) 4,6 5 0,85

Obstetric

Intra!uterine!growth!retarda$on!(%) 13 4,6 <0,001

Pregnancy!induced!hypertension!(%) 2,9 2,4 0,67

PreNeclampsia!(%) 12 1,9 <0,001

ROPAC Registry Pre-eclampsia and heart failure

Ruys et al. Heart 2013

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• Pre-eclampsia during pregnancy was a predictor for heart failure

• Odds ratio 7:1

• Of all patients with a structural heart disease who developed pre-eclampis, 30% also developed heart failure

• Extra monitoring is indicated in patients with pre-eclampsia

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Fetal&outcome Pa,ents&with&HF&&

(n=173) Pa,ents&without&HF&

(n=1148) p&value

Fetal&death&(%) 4,6 1,2 0,001

Neonatal&death&(%) 0,7 0,6 0,92

Premature&birth&<&37&weeks&(%) 30 13 <0,001

Birthweight&<&2500&gram&(%) 24 13 <0,001

Apgar&score&<&7&(%) 13 9,3 0,10

Adjusted&mean&birthweight&(grams) 3328 3358 0,46

ROPAC Registry Fetal outcome in women with heart failure

Ruys et al. Heart 2013

The role of BNP Prediction of cardiac events in pregnancy

Tanous et al. JACC 2010

The role of BNP Prediction of cardiac events in pregnancy

Tanous et al. JACC 2010

BNP < 100 pg/ml: NPPV 100% Spezifität 70%

The role of BNP Prediction of cardiac events in pregnancy

Kampman et at. EHJ 2013

NPPV NT-proBNP levels <128 pg/mL : 96.9%.

Week 20

n=213

Frequency of Cardiac disease in Pregnancy

Congenital heart disease 66 %

Valvular heart disease 25 %

Cardiomyopathy 7 %

Ischemic heart disease 2 %

ROPAC registry, EHJ 2012

Congenital heart disease Improved survival

Khairy et al. JACC 2010

Congenital heart disease Increased prevalence in adults

Marelli et al , Circulation 2007

Complex congenital heart disease

Transposition of the Great Arteries Tricuspid atresia Hypoplastic left heart syndrome

TGA - atrial switch Subaortic right ventricle

Mustard vs Senning procedure

Fontan palliation Single ventricle physiology

Coutesy of Prof. R. Pretre

Failing Fontan

Failing Mustard

Failing palliation

Greutmann, Tobler et al, in press

Congenital heart disease Cardiac morbidity in Pregnancy

Drenthen et al. JACC 2007

Frequency of Cardiac disease in Pregnancy

Congenital heart disease 66 %

Valvular heart disease 25 %

Cardiomyopathy 7 %

Ischemic heart disease 2 %

ROPAC registry, EHJ 2012

Case 1 24y, G3P2, 24 wks GA

Case 1 24y, G3P2, 24 wks GA

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Valvular heart disease in pregnancy

Roos-Hesselink et al. ROPAC registry, EHJ 2012

Heart failure in pregnancy due VHD

Ruys et al. ROPAC registry, Heart 2013

Mitral stenosis in Pregnancy

Silversides et al. Am J Cardiol 2003

Mitral stenosis in Pregnancy

Silversides et al. Am J Cardiol 2003

Mitral stenosis in Pregnancy

ESC Guidelines, EHJ 2011

Aortic stenosis in pregnancy

Aortic stenosis in Pregnancy

Silversides et al. Am J Cardiol 2003

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41

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20

30

40

50

Cardiac ComplicationsDuring Pregancy

Cardiac Surgery DuringFollow-up

Mild or Moderate AS Severe AS

Mechanical valves and pregnancy

Mechanical valves and pregnancy

Drenthen et al. EHJ 2010

Frequency of Cardiac disease in Pregnancy

Congenital heart disease 66 %

Valvular heart disease 25 %

Cardiomyopathy 7 %

Ischemic heart disease 2 %

ROPAC registry, EHJ 2012

Dilated Cardiomyopathy in pregnancy Risk factors for cardiac events

Grewal et al. JACC 2010

Outcome in Dilated Cardiomyopathy Pregnancy as risk factor

Grewal et al. JACC 2010

Maternal risk in DCM

Grewal et al JACC 2000Grewal et al. JACC 2010

Maternal risk

Beneficial medication for the mother

Effect on the fetus

Risk of stopping meds Effect on the maternal heart

Medical Management of Chronic Heart Failure in Pregnancy

Betablockers Generally safe and effective Can cause IUGR FDA Class C

ACE-I / ARB Contraindicated ➔ teratogenic effects Consider Hydralzine or Amlodipine FDA Class D for 2nd and 3rd trimester

Aldosteron-Antagonists

No data to support safety in pregnancy FDA Class D

Furosemid Can result in uteroplacental hypoperfusion Contraindicated in IUGR / Pre-eclampsia FDA Class C

Digoxin Generally considered safe Useful in treatment in persistent symptoms FDA Class C

Management of acute decompensation in pregnancy

✓In adherence to guidelines in nonpregnant women

✓ Intravenous diuretics / intravenous nitrates

✓ Hydralazine in hypertensive status

✓ Bed rest / oxygen / consider delivery

Take home messages

• Heart failure occurs in 13% of the patients with structural heart disease • Heart failure shows a peak around the 27th weeks of pregnancy and

around delivery • Preconception predictors for heart failure:

– Complaints of cardiac failure – Cardiomyopathy – WHO > 2 and NYHA > 2 – Pulmonary hypertension

• Pre-eclampsia is a predictor for heart failure • Women with heart failure had more adverse fetal events

– Fetal death, preterm birth, low birth weight

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