Recent research

Am J Cardiol. 2010 Feb 15;105(4):538-41.

Sexuality and reproductive health in women with congenital heart disease

Vigl M, Kaemmerer M, Niggemeyer E, Nagdyman N, Seifert-Klauss V, Trigas V, Bauer U, Schneider KT, Berger F, Hess J, Kaemmerer H.
Contact: Competence Network for Congenital Heart Defects, Deutsches Herzzentrum Berlin, Berlin, Germany

The different biopsychosocial periods in a woman's life are all interactively associated with the cardiovascular system. The present study was designed to address questions related to sexuality and reproductive health in a large cohort of women with congenital heart disease. Overall, 536 women (median age 29 years, range 18 to 75) completed a questionnaire during their visit at 2 tertiary care centers for congenital heart disease. Patients were categorized according to their functional class and according to the degree of severity of the underlying heart defect. The median age at menarche was significantly delayed in patients with functional class III-IV and in women with complex or cyanotic anomalies. More than 1/4 of the women (29%) had at least once sought medical advice for menstrual discomforts, and the proportion was significantly increased for those in the worst functional class (49%, p <0.001) and for patients with a cyanotic heart defect (43%, p = 0.03). Overall, 9% reported increased or altered symptoms related to their heart defect during sexual activity. This proportion increased significantly with worsening functional class (6%, 11%, and 26% in functional class I, II, and III-IV, respectively; p = 0.001), increased severity (5%, 8%, and 17% for simple, moderate, and severe heart defects, respectively; p = 0.005), and in women with cyanosis (8% and 28% in acyanotic and cyanotic patients, respectively; p <0.001). In conclusion, to ensure high-quality care for this demanding and growing patient population, physicians must be aware that issues related to the entire reproductive cycle should be considered when counseling these patients.

Copyright 2010 Elsevier Inc. All rights reserved.

J Korean Med Sci. 2008 Oct;23(5):808-13

Outcomes of pregnancy in women with congenital heart disease: a single center experience in Korea

Song YB, Park SW, Kim JH, Shin DH, Cho SW, Choi JO, Lee SC, Moon JR, Huh J, Kang IS, Lee HJ.
Contact: Department of Medicine, Sungkyunkwan University School of Medicine, Cardiac and Vascular Center, Samsung Medical Center, Seoul, Korea.

Pregnancy outcomes in patients with congenital heart disease have not been fully assessed in Korea. Forty-nine pregnancies that occurred in 34 women with congenital heart disease who registered at our hospital between September 1995 and April 2006 were reviewed. Spontaneous abortions occurred in two pregnancies at 6+1 and 7 weeks, and another two underwent elective pregnancy termination. One maternal death in puerperium occurred in a woman with Eisenmenger syndrome. Maternal cardiac complications were noted in 18.4%, pulmonary edema in 16.3%, symptomatic arrhythmia in 6.1%, deterioration of New York Heart Association (NYHA) functional class by >/=2 in 2.0%, and cardiac death in 2.0%. Independent predictors of adverse maternal cardiac events were an NYHA functional class of >/=3 (odds ratio [OR], 20.3), right ventricular dilation (OR, 21.2), and pulmonary hypertension (OR, 21.8). Neonatal complications occurred in 22.4% of pregnancies and included preterm delivery (16.3%), small for gestational age (12.2%), and neonatal death (2.0%). Independent predictors of adverse neonatal events were pulmonary hypertension (OR, 6.8) and NYHA functional class >/=3 (OR, 23.0). Pregnancy in women with congenital heart disease was found to be significantly associated with maternal cardiac and neonatal complications. Pre-pregnancy counseling and multidisciplinary care involving cardiologists and obstetricians are recommended for women with congenital heart disease contemplating pregnancy.

2008 Sep;3(5):308-16.

Practical assessment of maternal cardiovascular risk in pregnancy

Moghbeli N, Pare E, Webb G.
Contact: Cardiovascular Division, Philadelphia Congenital Heart Center, University of Pennsylvania, Philadelphia, PA, USA.

Cardiovascular disease in pregnancy is the most common cause of maternal mortality in the developed world and an important cause of heart failure, stroke, and arrhythmia. As more children with congenital heart disease survive into adulthood, there is a more pressing need to understand the risks that pregnancy poses for these women. Pregnancy, labor, and delivery increase the hemodynamic stress on the cardiovascular system and place women with heart disease at increased risk of cardiovascular complications, which include heart failure and death. Systematic assessment of pregnancy risk in these women, ideally before conception, is essential in optimizing maternal and fetal outcomes. This article describes the process of assessing risk of pregnancy-associated cardiovascular complications in women with structural heart disease. We review the current literature on pregnancy risk in women with complex congenital lesions, valvular heart disease, cardiomyopathy, and aortopathy, and suggest an approach to risk stratification. Based on a review of the literature, we report features that pose an increased risk of adverse maternal and fetal outcomes, which include poor maternal functional status; prior history of heart failure, arrhythmia, or cerebral vascular events; cyanosis; poor systemic ventricular function; and severe aortic or mitral stenosis. Pulmonary hypertension and Eisenmenger syndrome place women at exceedingly high risk for cardiovascular complications in pregnancy, including maternal and fetal death.

Int J Cardiol. 2008 Oct 1

Effect of pregnancy on clinical status and ventricular function in women with heart disease

Uebing A, Arvanitis P, Li W, Diller GP, Babu-Narayan SV, Okonko D, Koltsida E, Papadopoulos M, Johnson MR, Lupton MG, Yentis SM, Steer PJ, Gatzoulis MA.
Contact: Adult Congenital Heart Disease Unit, Royal Brompton and Harefield NHS Trust, and the National Heart and Lung Institute at Imperial College, Sydney Street, London SW3 6NP, United Kingdom; Department of Paediatric Cardiology, University Hospital of Schleswig

BACKGROUND: Pregnant women with heart disease (HD) are at an increased risk for maternal and neonatal adverse events. However, the effect of pregnancy on clinical status and ventricular function in women with HD has not been examined in a controlled study. METHODS AND RESULTS: Ninety-three women with HD were studied longitudinally. Of these, fifty-three underwent clinical and echocardiographic evaluation before and 1.5+/-1.1 years after pregnancy (pregnancy group), whereas forty served as controls matched for age (28.6+/-4.6 versus 28.5+/-6.6, p=0.88), diagnosis, and length of follow-up (2.9+/-1.4 versus 2.6+/-1.1, p=0.23). NYHA functional class remained unchanged in both groups during follow-up. End diastolic and end systolic dimensions and shortening fraction of the morphologic left ventricle also remained unchanged. Furthermore, systemic and subpulmonary ventricular function remained unchanged in the pregnancy and control groups on semiquantitative analysis. Pregnancy, however, was associated with a persisting increase in subpulmonary ventricular size in patients with tetralogy of Fallot (ToF) which was not present in tetralogy controls. Furthermore, diagnosis of ToF was the only predictor of an increase in subpulmonary ventricular size after pregnancy on univariate logistic regression analysis (OR 8.8[95% CI 1.9-41.1], p=0.006).
In this longitudinal controlled study amongst women with HD no deleterious midterm effects of pregnancy on clinical status and right and left ventricular function were found. However, pregnancy was associated with a persisting increase in subpulmonary ventricular size, attributable to patients with repaired ToF. This may have prognostic implications and merits further investigation.

G Ital Cardiol (Rome). 2008 Jun;9(6):384-93

How to manage pregnancy in cardiac patients

Melandri G, Semprini F, Nanni S, Vagnarelli F, Calabrese D, Branzi A.
Contact: Terapia Intensiva Cardiologica, U.O. di Cardiologia Policlinico S. Orsola-Malpighi, Via Massarenti, 9, 40138 Bologna.

An increasing number of women with cardiac disease come up with the idea of becoming pregnant. Immigrants are frequently affected by valvular heart disease. Recently, arrhythmias, high blood pressure and ischemic heart disease affect many less-young pregnant women. Finally, grown-up patients with congenital heart disease have now entered their fertility period (particularly following the Fontan operation). Pregnancy is legitimate and frequently cannot be restrained; it calls for a careful evaluation of all its treatment aspects by a multidisciplinary team and the cardiologist role is of the utmost importance. A few conditions make pregnancy a hazard to both mother and fetus: pulmonary hypertension, left ventricular failure, left-heart obstruction, Marfan syndrome with aortic dilatation, and cyanosis. Most remaining cases are compatible with an (almost) normal course whereby mothers can be reassured. However, all items covered by guidelines should be met, according to the quality imperative.

J Pak Med Assoc. 2008 Apr;58(4):175-8

Foetomaternal outcome of pregnancy with cardiac disease

Wasim T, Amer W, A, Siddiq S.Majrroh
Contact: Department of Obstetrics and Gynaecology, Services Institute of Medical Sciences, Lahore.

INTRODUCTION: To study the prevalence of cardiac disease in pregnancy and to assess the foetomaternal outcomes.
METHODS: It was a 5 year descriptive study. All pregnant females with a known or newly diagnosed congenital or acquired cardiac lesion on echo cardiography were included in the study.
RESULTS: There were 17,056 births during the study period, of whom 160 were cardiac patients giving a prevalence of 1%. Out of these 36% patients were diagnosed to have cardiac disease during current pregnancy. Acquired valvular heart lesions were found in 132 (82%) patients with mitral stenosis being the commonest (55%), others were congenital. Of the group, 43% patients were in class III & IV according to NYHA. Majority delivered vaginally and only 29% had c/section, 9% had therapeutic termination of pregnancy and 45% babies were low birth weight. Ten babies expired. Maternal mortality was low (3.8%), while 55(35%) had obstetric complications. Poor functional class (III & IV) was the key determinant of adverse footomaternal outcome (p<0.0001).
CONCLUSION: The good results of this study can be attrihuted to the team efforts of between obstetricians, cardiologists and patients. Adverse foetomaternal outcome was related to poor functional class III and IV of NYHA.

Cardiol Young. 2008 Aug;18(4):423-9. Epub 2008 Jun 18

Outcomes of pregnancy in women with tetralogy of Fallot

Pedersen LM, Pedersen TA, Ravn HB, Hjortdal VE.
Contact: Department of Cardiothoracic Surgery, Skejby Hospital, Aarhus University Hospital, Aarhus, Denmark.

BACKGROUND: Surgical results after repair of tetralogy of Fallot have remained excellent for the last decades, with current long-term rates of survival over 95%. Since functional capacity, quality of life, and social interactions are basically normal in this large group of patients, pregnancy obviously becomes a relevant issue for the female subgroup. In consequence, adequate obstetrical and cardiological management of pregnancy is particularly important.
OBJECTIVE: To describe the outcomes of pregnancy, and fertility, in a series of women who underwent surgery for tetralogy of Fallot in a single centre.
METHODS AND RESULTS: We obtained data from hospital records, national registries, and questionnaires on 78 women who underwent surgical correction of tetralogy of Fallot between 1972 and 1992. Of 58 women who reached an age of at least 18 years, with 45 of this cohort currently surviving, 13 having died as adults, there were 54 pregnancies in 25 women. The recorded rate of spontaneous abortion was 15%, and infertility rate was 3.4%. There have been 41 life births, with a median weight at birth of 3.2 kg. Only 1 newborn was small for gestational age, and no one was born before the 36th week. The recurrence rate of congenital heart disease was high, at 9.8%. Cardiac complications during or after pregnancy were not observed, and only one woman had pre-eclampsia.
CONCLUSIONS: Pregnancy is well tolerated in women with tetralogy of Fallot, and an excellent neonatal outcome is expected. The recurrence risk of congenital cardiac disease, most often tetralogy of Fallot, is high.