The session comprised of multiple topics that discussed various cardiac interventions including hemodynamic support, transcatheter aortic valve replacement (TAVI), COVID-19, spontaneous coronary artery dissection (SCAD) and imaging in pregnancy.
Hemodynamic Support in Pregnancy: Role of the Expanded Heart Team
A case of a 32-year pregnant woman at 26 weeks gestation was presented with cardiogenic shock and known pre-existing cardiomyopathy to understand the advantages of advanced hemodynamic support in peripartum period. Additionally, an emphasis on risks/benefits and potential complications of mechanical advanced support were presented. Peripartum cardiogenic shock in 60% of cases are caused by peripartum cardiomyopathy, of which 33% receive advanced support with survival in 84% of cases. Mechanical circulatory support initiated within 6 days improves mortality. In the US, the mortality due to cardiogenic shock in pregnant patients decreased with increased use of mechanical circulatory support. This support includes intra-aortic balloon pump (IABP), left ventricular assist device (LVAD), extracorporeal membrane oxygenation (ECMO) and impala. The Literature on percutaneous circulatory support devices in patients (n=15) with impala showed 88% survival, 53% recovery and 40% bridging to LVAD. ECMO in pregnancy has limited data but has reported effectiveness with postpartum outcomes.
There is a need for more data in the field of hemodynamic support. Referring back to the case of 32-year pregnant woman in cardiogenic shock. She was initially stabilized with inotropic support, later placed on ECMO eventually and then bridged to LVAD followed by stabilization. She had a caesarean delivery followed by heart transplant. This implied that early initiation of mechanical hemodynamic support may improve outcomes. However, the risks include bleeding, limb ischemia and neurologic complications. For better outcomes and decisions, it is important to involve everyone with inclusion of various teams comprising of intensivists, cardio-obstetrics expert, other specialists etc.
I Have Access but Who Has Baby? TAVI in Pregnancy: When and How?
To understand TAVI in pregnancy, a case of 37-year-old G1P0000 presented for symptomatic decompensated heart failure and currently gestational 17 week was discussed. The echocardiogram findings showed critical case of aortic stenosis. The treatment options included pregnancy termination (refused by patient) and balloon aortic valvuloplasty (BAV) procedure with high risk. C-section prior to BAV surgery was not a feasible option due to the gestational age. To consider TAVI, four factors played an important role including valve sizing, radiation considerations, procedural considerations and post-procedure pharmacology. In this case, for valve sizing, CT scan was applied with a low dose radiation directing only to the chest. The radiation considerations during catheter-based diagnostic and interventional studies included various measures to reduce radiological exposure to foetus. Procedural considerations include use of ultrasound for access and no to minimal fluoroscopy for abdomen/pelvis area. It was concluded that TAVI is feasible during pregnancy, CT angiography of chest is to be performed with low dose radiation and low dose contrast, transoesophageal echocardiogram (TEE) and cardiovascular magnetic resonance (CMR) are good alternatives for valve sizing, post procedural antithrombotic can be simplified to single antiplatelet if anticoagulation is not indicated for other indications. Antiplatelet agents can be held for delivery.
COVID-19 In Pregnant Women with Heart Disease
COVID-19 in pregnant women with heart disease stands on crossroad of 3 morbidity and mortality risks and current literature lacks adequate knowledge on all the three conditions together. In pregnant women, multiple factors that increase the risk of COVID include downregulation of maternal immune system, increased oxygen consumption and decreased lung functional residual capacity, increased heart rate and stroke volume, decreased systemic vascular resistance, and increased thromboembolic risk. Data gathered from ‘surveillance in emerging threats to mothers and babies network’ reported a very small percentage (1.8%) of women with cardiovascular disease. There were a number of risk factors in pregnant women for more severe COVID infection including health care occupation, obesity, chronic lung disease, hypertension, pregestational diabetes and age. Of these a number of risk factors overlap with that for cardiovascular disease. Higher the number of conditions increased was the risk. Of ~35,000 women included, infection in the third trimester was associated with increased preterm birth and there were no differences in still birth and birth defects. Among the term infants, when women were in third trimester, a higher percentage to babies were admitted to NICU.
A different series reported 9.7% of pregnant women (n=15/154) with COVID had myocardial injury with mean age of 30 years and ejection fraction of ~38%. On this series, as the symptoms of shortness of breath and palpitations overlap between COVID and pregnancy, it is not easy to judge the actual cause of these symptoms. Of the 15 women 13 (86%) were intubated and 2 died because of arrythmia and 1 foetal demise was observed. All infants were delivered by caesarean section. Another case series focused on congenital heart disease and COVID that included 2% pregnant women. Owing to the sample size pregnancy was not found as a risk for any untoward event. Coronary artery disease and heart failure has not shown any association with COVID. To summarize, COVID is most dangerous to the foetus in third trimester with preterm birth and NICU admission. The symptomatic pregnant women with COVID along with myocardial injury show a very high mortality (13%). Prevention of COVID in pregnant woman is important and can be achieved with vaccination and masking.
Inside Out Ischemia: SCAD and Pregnancy
To understand the cardiac intervention with SCAD in pregnancy a case of 35-year-old female who had pregnancy associated multi-vessel SCAD (P-SCAD) was presented. P-SCAD is the most common cause of pregnancy associated myocardial infarction with various predisposing factors including hormonal imbalance and the patients suffer with outcomes that worsen with time. For acute management, timely diagnosis and address of etiology using various approaches is of utmost important. Acute management in terms of percutaneous intervention have well reported adverse outcomes as coronary arteries are very friable vessels. Algorithm for management states that over 80% of patients can be managed conservatively. In case of catheterization, to minimize the risk, various factors were discussed including minimizing the radiation and various delivery conditions. Medical therapy in SCAD management during pregnancy and associated practice scenarios were presented with safe use of beta blockers in pregnancy and lactation both. Whereas, the ACE inhibitors can only be used during lactation. However, there is no clear evidence on statins. To summarize, P-SCAD is bad as it has a potential for significant adverse outcomes and timely diagnosis is of utmost importance.
Global Perspective Imaging: Screening to Intervention
In general, diagnostic testing strategies to evaluate cardiovascular disease in pregnancy are similar to those used in nonpregnant women. It is important to understand the appropriateness of indication for imaging and its alteration for clinical management. Ultrasonography should be used prudently and only when its use is expected to answer a relevant clinical question or otherwise if it provides a medical benefit to the patient. Positioning of a pregnant patient and changes to the image quality are to be balanced. The American college of obstetricians and gynaecologists (ACOG) recommendations and 2018 ESC guidelines for echocardiography were also presented. The use of agitated saline contrast should be avoided until the postpartum period. Alternatively, other imaging modalities such as cardiac MRI without gadolinium-based contrast agents can also be considered.
Due to lack of emerging safety data ultrasonic enhancing agents use is not recommended in pregnancy. With cardiac MRI, Evidence regarding gadolinium-based contrast in pregnancy is controversial and its use should be avoided in the first trimester. The techniques that use ionizing radiation should be avoided due to elevated risk of childhood cancer.
The extent of radiation is to be reduced. However, the reductions in radiation exposure must be balanced to avoid reduced image quality whereby there is insufficient information for the diagnosis in question. As per ACOG committee opinion, ultrasonography and MRI are not associated with risk and are the imaging techniques of choice for pregnant patients. Elective procedures involving exposure to ionizing radiation should be deferred.
American College of Cardiology (ACC) International Congress 2023, 4th March - 6th March 2023, New Orleans