Pregnancy in Cardiac Disease

Aug 18, 2023

Pregnancy in Cardiac Disease

Overview:

In this presentation, the speakers will discuss why specialized care in Cardiovascular Obstetrics is needed and how a multidisciplinary Pregnancy Heart Team can help these complex patients. The speakers will also review the hemodynamic changes that occur with pregnancy and present cases which highlight various aspects of management of cardiovascular disease during pregnancy.

Objectives:

· Discuss the importance of specialized care in Cardiovascular Obstetrics and the role of the
Pregnancy Heart Team

· Review hemodynamic changes that occur with pregnancy

· Explore cases which highlight various aspects of management of cardiovascular disease during
pregnancy

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Content

5.819 -> hi good evening and Welcome to our

8.46 -> webinar on pregnancy and cardiac disease

10.38 -> my name is Katie young I'm a

12.3 -> cardiologist here at Mayo Clinic and I'm

14.34 -> joined tonight by two of my colleagues

16.98 -> um we have Dr Carl Rose he's an

18.84 -> associate professor of Obstetrics and

20.4 -> Gynecology and Specialists of maternal

23.039 -> fetal medicine and we also have Dr

25.32 -> Charlie Jane he is also a cardiologist

28.019 -> who specializes in adult congenital

30.48 -> heart disease

32.22 -> um as you all know the breadth of cardio

35.579 -> Obstetrics and cardiac disease and

37.38 -> pregnancy can be very broad can cover

39.6 -> congenital disease acquired heart

41.64 -> disease and we will not have time this

44.04 -> evening to cover all of that but our

46.02 -> goal is to go through some cases and get

48.18 -> get high-yield teaching points from each

50.399 -> of those cases that you can take and use

52.86 -> in your integrate into your clinical

54.48 -> practice

55.399 -> as a reminder there will be a q a at the

58.8 -> end of our presentation please

60.899 -> throughout the presentation you can put

62.76 -> your questions in the Q a and we will go

65.28 -> through as many as we can after our

66.78 -> presentation

69.96 -> so these are our learning objectives so

72.54 -> first we'll review the importance of

74.46 -> Specialized Care in the pregnancy heart

76.14 -> team next we'll briefly highlight the

78.96 -> hemodynamic changes that occur during

80.88 -> pregnancy and then the largest portion

83.759 -> of the presentation will be going

85.14 -> through three cases which highlight

87.06 -> various aspects of management of

88.86 -> cardiovascular disease during pregnancy

92.58 -> the topic of cardio obstetrics is so

95.04 -> important because maternal mortality

96.96 -> remains very high in the U.S and is more

100.259 -> than two-fold higher than other

101.52 -> developed countries

103.86 -> and unfortunately despite our efforts

106.86 -> recent data demonstrates that maternal

109.259 -> mortality rates are continuing to

110.7 -> increase in the U.S in 2021 maternal

114.54 -> mortality rate was 32.9 per 100 000 live

118.02 -> births

119.46 -> and when we look at causes of

121.5 -> pregnancy-related deaths in the United

123.18 -> States and we look at cardiac conditions

126.5 -> cardiomyopathy and hypertensive

128.399 -> disorders of pregnancy and combine them

130.16 -> that makes up the largest portion of

133.28 -> contributors to pregnancy-related deaths

136.44 -> in the U.S

138.84 -> age is an important risk factor more

141.599 -> women are having children in later

144.54 -> childbearing years at which time there's

147.66 -> higher incidence of other cardiovascular

150 -> disease risk factors which likely

152.04 -> contributes to the higher

154.16 -> pregnancy-related death scene in women

156 -> 40 and over

157.98 -> and there are significant racial and

159.84 -> ethnic disparities with material

161.819 -> mortality rates peaking among

163.319 -> non-hispanic black women

166.14 -> well thank you Dr Young

168.3 -> um I would like to introduce the idea of

170.4 -> the pregnancy heart team or the field of

173.28 -> cardio obstetrics and generally in terms

176.519 -> of management strategies uh this will be

179.28 -> comprised of like Cardiology colleagues

181.8 -> uh some from obstetrics my

185.099 -> anesthesiology colleagues in my social

188.34 -> work why labor and delivery colleagues I

191.04 -> am geneticist pharmacist uh sort of on

193.62 -> an as needed basis for each individual

196.14 -> patient to construct a plan for clinical

198.3 -> management

199.58 -> uh this highlights some of the

201.84 -> guidelines that have been uh

204.18 -> um introduced by our major uh

206.94 -> sanctioning organizations uh for

209.34 -> reference

210.659 -> um and just a note on some of the

212.099 -> physiologic changes during pregnancy

214.319 -> and typically we will see cardiac output

216.42 -> increase it during pregnancy usually

218.519 -> even in the first trimester uh typically

221.159 -> this is going to Peak somewhere in the

222.84 -> neighborhood of 28 32 weeks gestation uh

225.959 -> correspondingly we see a drop in the

227.94 -> systemic vascular resistance usually

229.799 -> starting in the first trimester reaches

232.26 -> its nadir somewhere in mid-pregnancy and

235.319 -> slowly comes back at normal by uh the

238.56 -> early postpartum interval and

240.299 -> correspondingly we see blood pressure is

242.04 -> usually Fall Again reaching their lowest

244.56 -> point in the mid second trimester

245.819 -> sometimes speaking a little bit during

247.68 -> the labor process and then returning

249.78 -> back to normal all these physiologic

251.459 -> changes typically result by about six to

254.28 -> eight weeks postpartum now corresponding

256.979 -> changes that one might find on an echo

259.82 -> obtained on a pregnant patient would

262.919 -> include usually an increase in trans

265.56 -> volume gradients across all the valves

267.66 -> we will see a small degree of

269.699 -> regurgitation across all the valves but

272.16 -> importantly the ejection fraction

275 -> ventricular rejection Corrections

276.84 -> essentially remain unchanged

278.759 -> so to shift gears for a moment and go

281.82 -> into some some clinical cases uh here uh

285.54 -> so our first case is a 32 year old

287.94 -> who presents for preconceptional

289.5 -> counseling she has an interesting

290.88 -> history of non-convection cardiomyopathy

292.62 -> and like many of these patients uh she

294.6 -> is experienced uh in arrhythmia uh

298.08 -> ventricular tachycardia in her case for

299.759 -> what she's undergone radio frequency

301.56 -> ablation and a perfect CD placement

304.04 -> unfortunately she also experienced a

306.6 -> right uh embolic MCA stroke and is

309.96 -> currently managed with uh therapeutic

312.84 -> anticoagulation using warfarin so here's

315.84 -> an image of sort of her cardiac function

318.54 -> and of note here I draw detention the

320.58 -> fact that her lbef is 34 and RBF is 30

324.18 -> percent

325.08 -> so current medication regimen consists

327.72 -> of Warfarin in addition to four

328.86 -> milligrams a day Carvedilol spread

330.6 -> alactin and you'll note that

332.419 -> hemodynamically she is stable uh she's

336 -> essentially asymptomatic

338.82 -> um and is able to participate in

340.5 -> activity on a regular basis

343.02 -> so how should we counsel this patient

344.759 -> what would you recommend to her

346.979 -> normal Pregnancy Care

348.979 -> uh more complex Pregnancy Care and

351.6 -> Delivery at a tertiary Center or to

354.539 -> avoid pregnancy altogether because of

356.58 -> the associated risks well in this

359.4 -> situation

360.78 -> we would usually counsel based on the

362.58 -> modified who criteria and looking at her

366.24 -> values for ejection fraction once again

368.039 -> 34 for an ldeo she would fall into

370.86 -> modify who class 3 which would incur as

373.68 -> you see there a relatively substantial

376.199 -> risk of a cardiac event either before

378.78 -> I'm sorry either during or uh following

382.5 -> their pregnancy uh in these situations

385.08 -> the patients would typically be

387.479 -> evaluated on a frequent basis and

389.4 -> delivery should occur in a center that

390.9 -> is able to manage any potential

393 -> intrapartum or postpartum complications

395.819 -> so uh just a note on maternal levels of

398.34 -> care as they are listed in here

401.16 -> um in this situation typically we would

404.039 -> recommend a patient delivering a level

405.419 -> three or level four Center uh once again

408.36 -> in the event than uh

410.88 -> something encouraging the labor or the

413.28 -> delivery process that she could be

415.199 -> managed in that facility and not

416.819 -> necessarily uh transferred elsewhere

419.52 -> so a few words of non-compaction

421.86 -> um this is our experience here here at

423.479 -> Mayo very few patients were actually

425.58 -> diagnosed

426.84 -> um prior to pregnancy about a third of

429.24 -> patients were diagnosed actually during

431.58 -> pregnancy or during the the labor

434.16 -> delivery postpartum process uh and

436.62 -> actually presented with heart failure

438.44 -> and the good news is the majority of

441 -> patients are actually tolerated the

442.319 -> pregnancy well and outcomes were

445.02 -> favorable if you will

448.56 -> um so a few other thoughts in this

450.96 -> particular situation

453 -> then we must address is anticoagulation

455.699 -> management the uh option of prenatal

459.18 -> genetic testing uh for her infant

462.9 -> um and also screening for uh congenital

465.419 -> heart disease uh inner infant now when

468.539 -> when we look at our

471.36 -> options for anticoagulation she is

475.02 -> currently managed with Warfarin now

477 -> Warfarin during pregnancy does cross the

478.8 -> placenta and actually we see an enhanced

480.84 -> Dental coagulation of a baby as a

484.02 -> consequence there's a risk of Warfarin

486.18 -> embryo anytime in the first trimester

488.22 -> mispronounced typically in the uh six to

491.88 -> nine week interval uh it is dose related

494.52 -> when patients are on less than five

496.02 -> milligrams per day the risk seems to be

498.96 -> lower now unfraction in Heparin and

501.36 -> laminate can avoid heparins are

502.8 -> generally tend to be the favorite

504.84 -> anticoagulants during pregnancy with a

507.36 -> not given to a low light to White

508.86 -> Heparin because it's more predictable

510.66 -> response uh unfractioning hepreneurs is

513.659 -> of course also used uh primarily in

516.06 -> situations where anticoagulation needs

518.159 -> to be started or stopped on a relatively

520.02 -> short-term basis

521.7 -> uh any of these can be used during

524.339 -> lactation and also of note on here

527.519 -> um at present we do not recommend oax or

531.3 -> use either during pregnancy or during

533.64 -> the postpartum interval

535.62 -> so in this situation uh we advised her

538.68 -> that she was able to proceed with

540.48 -> pregnancy uh always a concern with

542.64 -> anticoagulation but also unpredictable

544.62 -> is she may be a candidate for neuroxyl

547.2 -> anesthetic human epidural or spinal in

549.06 -> labor depending upon your

551.04 -> anticoagulation status at the time uh

554.339 -> Carvedilol was continued it's been a

555.959 -> long time was discontinued due to

557.339 -> concerns where they've already in antio

559.04 -> anti-androgenic effects and in this

561.66 -> situation after discussion of the

563.459 -> options she was transitioned in advance

565.68 -> of conception to eliminate your weight

568.08 -> heparin

570.36 -> thank you so much Dr Rose and I feel

572.88 -> like I really need to say thank you so

574.98 -> much for all your help with all of our

576.36 -> patients you know what you mentioned the

577.62 -> pregnancy heart team a few slides back

580.14 -> and without a doubt the

581.16 -> multidisciplinary the multidisciplinary

583.86 -> nature of care for these patients is

586.44 -> really really important I think these

588 -> can be really challenging patients and

589.98 -> working side by side with a maternal

591.6 -> penal medicine colleagues I think makes

593.1 -> it for a huge advantage and we're very

595.08 -> grateful to have you and all of your

596.339 -> colleagues so thank you

598.68 -> um we'll go on to another case here now

600.12 -> moving to valvular heart disease in the

602.279 -> setting of pregnancy

603.72 -> and so case two is a 28 year old woman

606.56 -> g1p1 she just had a baby a few months

609.36 -> ago and you're seeing her for a routine

610.98 -> postpartum visit three months later

613.44 -> she has a history of unicuspid aortic

615.899 -> valve stenosis she had a 23 millimeter

618.18 -> Edwards pericardial Magna aortic valve

620.519 -> replacement five years prior to this

622.74 -> pregnancy

624.06 -> now right after that surgery five years

626.16 -> ago her fingerprint mean gradient across

628.14 -> the valve was 12.

630.06 -> prior to this pregnancy just immediately

632.22 -> before the gradient had increased to 23

634.44 -> so she did have some early prosthetic

636.6 -> valve degeneration

638.64 -> at the peak point of pregnancy and as Dr

640.86 -> Rose described for us a few slides ago

642.779 -> in terms of the hemodynamic changes

644.16 -> usually we start to see the peak of the

646.019 -> hemodynamic loader on 24 to 28 and

648 -> certainly by 32 weeks is a time that

650.04 -> we'll often repeat that assessment with

652.14 -> the transthoracic echo her gradient had

654.48 -> increased to 31 and so remember with the

657.54 -> increased amount of flow and cardiac

659.1 -> output which is appropriate for

660.72 -> pregnancy we will of course see an

662.459 -> increased gradient there's more flow

664.019 -> going through the same size valve now

666.48 -> whether or not from 23 to 31 is more

669.06 -> than we expect can be really really hard

670.74 -> to assess but it doesn't seem

672.899 -> extraordinary here

675.72 -> so now we're seeing her three months

678.24 -> postpartum and by that point we would

680.339 -> expect that those hemodynamic effects of

682.019 -> pregnancy have all resolved she should

683.7 -> be back to her Baseline hemodynamic

685.26 -> status the flows decreased back to her

687.66 -> normal cardiac output and we expect that

689.82 -> the gradient should go back down to 23

691.74 -> or something comparable to their

693.06 -> pre-pregnancy but in this case the

695.82 -> patient's mean grading across the valve

697.38 -> was actually even higher than at the

699 -> peak of pregnancy

700.38 -> therefore this suggests that there is

702.36 -> certainly some wear and tear on this

703.8 -> valve throughout the course of pregnancy

705 -> which we can see we don't necessarily

707.04 -> expect it but we certainly do see this

709.74 -> and there's been a lot of data looking

711 -> at this so for this patient when we

713.22 -> think about what's her modified who

715.1 -> classification at this point if she said

717.18 -> she wanted to get pregnant again she's

719.16 -> falling into that modified who class two

721.62 -> to three or almost into the three

723.18 -> category here and so we told her well

726.36 -> we'll follow up in one year certainly if

728.519 -> you get pregnant in the meanwhile you

729.959 -> need to let us know immediately

732.18 -> so of course she comes back 11 months

735.3 -> later just shy of that one year time

737.339 -> point and at that time she's nine weeks

740.1 -> pregnant and she's not feeling well

741.6 -> she's had some recent Disney on exertion

743.76 -> so even though the hemodynamic changes

745.68 -> of pregnancy are quite minor in the

748.5 -> first trimester they certainly are

750 -> present and for this patient it seemed

751.92 -> to make a difference

753.24 -> on the right you see her trans Echo

755.88 -> paristernal long axis view zoomed in on

758.82 -> aortic prosthesis and you can see that

761.16 -> it's heavily calcified and relatively

763.079 -> immobile leaflets quite concerning here

766.92 -> so now we put a continuous wave Doppler

769.019 -> through the aortic prosthesis and we get

771.06 -> a severely elevated velocity here and

774.06 -> when we look at the mean gradient across

775.86 -> there it was 110 so she has critical

779.22 -> aortic prosthetic stenosis and it's

781.92 -> significantly increased from one year

783.72 -> prior highly concerning so of course she

786.18 -> was admitted to the hospital straight

787.56 -> from the echo lab

789.839 -> she had an urgent trans-esophageal

792 -> echocardiogram performed there is of

794.399 -> course suspicion for thrombos we saw an

796.079 -> acute change in the gradient she's

797.88 -> pregnant a hypercoagulable state

799.32 -> potentially the te did not show any

801.839 -> evidence of thrombus it did show that

803.88 -> there is significant prosthetic aortic

805.98 -> regurgitation and then as you saw on the

808.26 -> 2D on the last slide there's been

810.12 -> significant calcific degeneration in

811.86 -> this valve quite precipitously over the

814.98 -> past year

816.779 -> so what would you recommend at this

818.399 -> point a urgent cardiac surgery B valve

822.42 -> and valve transcatheter aortic valve

824.1 -> intervention or C pregnancy termination

826.279 -> notably there's no option D consult the

828.959 -> pregnancy heart team

830.579 -> so you know I think all these

832.38 -> considerations May potentially be

834.3 -> appropriate for the patient depending on

835.86 -> the setting that you're in and the

837.18 -> expertise available there so let's walk

839.459 -> through these a little bit more

841.44 -> when we think about catheter-based

843.18 -> interventions for the management of a

844.86 -> valvular heart disease during pregnancy

846.66 -> there's a really nice review article

848.76 -> published about a year ago in Jack

850.44 -> advances

851.639 -> some of the important considerations

853.019 -> they mention relate to radiation so for

856.139 -> any transcatheter valve procedure most

858.3 -> of them we like to get a pre-procedural

860.1 -> CTA and so there of course is a

862.92 -> significant radiation if this is in the

864.6 -> first trimester when embryogenesis is

867.3 -> still occurring that's a very

868.5 -> significant risk

870 -> and then of course at the time of the

871.74 -> actual catheterization

873.54 -> there's of course the radiation from the

875.459 -> fluoroscopy the authors of this article

878.399 -> actually recommend that as it's usually

880.56 -> femoral access they recommend using long

882.36 -> sheets to minimize the radiation to the

885 -> uterus during catheter exchanges

888.06 -> so now in terms of data for aortic valve

890.459 -> interventions performed from a

891.839 -> transcatheter fashion while there

894 -> probably have been many more performed

896.04 -> from actual published data at the time

898.32 -> of this review article there's only 14

900.36 -> balloon babyloplasty cases published all

903 -> Native valves

904.459 -> non-prosthetic and then in terms of

906.18 -> trans Catholic aortic valve replacement

907.62 -> there is seven and only one was a native

910.139 -> valve that happened to obey a patient

911.579 -> with bicuspid aortic valve and certainly

913.139 -> had complications

914.519 -> fortunately no fetal complications

916.5 -> published

918.839 -> so back to our patient like we mentioned

921.48 -> she's nine weeks pregnant and she has a

924.24 -> severe prosthetic aortic valve stenosis

926.1 -> with some regurgitation

927.899 -> and she did undergo a pre-procedural CTA

930.6 -> you know we discussed her at our

931.74 -> multidisciplinary conference including

934.079 -> with surgeons as well as our MFM

936.24 -> colleagues and we recommended a Tavern

939.06 -> but then she had the CTA and it showed

940.86 -> the coronaries were too low to allow for

942.899 -> a safe valve and valve procedure so

945.06 -> therefore she was referred for Urgent

946.92 -> cardiac surgery during the first

948.42 -> trimester of pregnancy

950.82 -> so now what do we know about the safety

953.579 -> of cardiopulmonary bypass during

955.26 -> pregnancy well we looked at that here a

957.36 -> little bit over 10 years ago and in a

960 -> little bit over a 30-year time span we

961.74 -> had 21 pregnant patients or underwent

963.72 -> cardiac surgery most of these were for

966 -> aortic and or mitral valve Replacements

968.04 -> and most of these were emergency surgery

970.5 -> so as we know even outside of the

972.54 -> setting of pregnancy emergency surgery

974.279 -> carries a much higher risk for the

975.959 -> patient so there's certainly going to be

977.699 -> elevated maternal mortality but

979.8 -> fortunately in this series maternal

981.3 -> mortality was quite low with only one

983.04 -> early death in the series

985.44 -> now fetal complications are certainly

987.54 -> significant with at least half of the

990.24 -> babies being born preterm and three

992.279 -> pregnancy losses

994.62 -> outside of mayo there was a

996 -> meta-analysis published about a year ago

998.04 -> in ehj and it's a really nice study they

1001.04 -> do show that just like I mentioned with

1003.38 -> any emergency cardiac surgery the risks

1005.48 -> are elevated for the mom ranging from

1007.339 -> four to twelve percent depending on the

1008.959 -> trimester there but I think what's

1011.899 -> really notable about this study is what

1013.699 -> significant fetal mortality risk there

1015.5 -> is certainly it's highest in the first

1017.18 -> trimester as we might expect but it is

1019.579 -> not insignificant you know 29 to 33

1021.92 -> percent even in the second and third

1023.42 -> trimester so really we have to be quite

1026.179 -> thoughtful about this and do not take

1027.919 -> this decision lightly

1030.079 -> so for our patient as the coronators

1032.419 -> were too low for transcatheter

1033.799 -> intervention she did undergo a

1035.66 -> bioprosthetic surgical aortic valve

1037.52 -> replacement with a root enlargement here

1039.5 -> on the right you can see your explanted

1041 -> valve which is heavily calcified as we

1042.679 -> saw in the Echo significant penis

1044.6 -> formation no obvious thrombus

1047.78 -> now usually for a new tissue aortic

1049.82 -> valve replacement we would place them on

1051.28 -> Warfarin for at least three months

1053.419 -> because she was still in the first

1055.28 -> trimester and as Dr Rose mentioned the

1057.08 -> war for embryopathy we avoided Warfarin

1059.66 -> initially for her just to use aspirin

1061.46 -> and then a couple weeks later as she

1063.2 -> entered the second trimester war from it

1065.059 -> started for three months

1067.039 -> she was later induced at 38 weeks

1069.38 -> unfortunately I had a healthy baby she

1070.76 -> had no further cardiac complications and

1072.44 -> in terms of her Echo at the time of

1074.539 -> dismissal from herortic valve surgery

1076.22 -> her immigraine was 26 and at the peak of

1078.38 -> pregnancy a few months later it was went

1081.2 -> up to 28 so it didn't increase

1082.52 -> significantly and the postpartum looked

1084.98 -> very good as well so

1086.96 -> thank you

1088.88 -> very good thank you so much so I'm going

1091.52 -> to be moving us on to our final Case

1093.62 -> Case three and again just a reminder any

1096.799 -> questions feel free to put post them in

1098.96 -> the Q a and we will start addressing

1101.24 -> them after we finish our cases

1104.179 -> so case three is a 34 year old female so

1107.72 -> she is presenting five days after a

1110.66 -> repeat C-section with symptoms of

1113.419 -> dyspnea and headache and her notable

1115.7 -> history includes gestational

1117.32 -> hypertension with a prior pregnancy as

1120.32 -> well as gestational diabetes with her

1122.48 -> most recent pregnancy and other

1124.46 -> comorbidities including ra obesity and

1127.58 -> sleep apnea

1130.52 -> at her presentation she was markedly

1132.98 -> hypertensive chest x-ray demonstrated

1136.22 -> mild pulmonary edema her biomarkers her

1139.82 -> troponins were elevated but flat and her

1142.52 -> NT probe and P was elevated her renal

1145.4 -> function was normal though a UA did

1147.44 -> demonstrate proteinuria

1150.559 -> and so I when you're seeing this patient

1153.38 -> and thinking about it kind of thinking

1155.059 -> of our buckets of hypertensive disorders

1156.919 -> of pregnancy

1158.36 -> um thinking about which one this patient

1160.1 -> would fit under

1161.6 -> and here on the next slide are the

1164.2 -> definitions of those and what's

1166.94 -> important to highlight is that our

1169.039 -> patient was presenting with features

1171.74 -> consistent with preeclampsia and thus

1174.74 -> can occur severe hypertension and

1176.48 -> preeclampsia can occur in the postpartum

1178.52 -> period and

1180.559 -> um you know her presentation as I

1182.48 -> mentioned was most consistent with

1183.799 -> preeclampsia with severe features

1187.46 -> and a few notes on that and and the

1189.74 -> importance of preeclampsia in in women

1193.16 -> and noting that in their history as many

1196.039 -> papers have shown there's increased risk

1198.62 -> of these women later in life increase

1200.179 -> more cardiovascular mortality increased

1202.88 -> risk of coronary disease increased risk

1204.919 -> of heart failure

1206.12 -> and so for any woman you're seeing your

1207.86 -> cardiology practice obtaining that

1209.96 -> obstetric history and history of

1212.78 -> hypertensive disorders of pregnancy

1214.1 -> gestational diabetes pre-term deliveries

1216.74 -> these are important things that should

1218.539 -> be incorporated into your hmp for all

1220.4 -> your patients

1223.059 -> and Dr Oz could you comment on aspirin

1226.64 -> prophylaxis yeah so just a few words on

1228.98 -> aspirin um since late 2015 uh the uspstf

1233.24 -> recommendations have suggested that

1235.039 -> Lotus aspirin uh uh 81 milligrams per

1238.28 -> day is the current in the United States

1239.72 -> does uh seems to reduce the risk of

1243.38 -> preeclampsia in patients from previous

1244.94 -> early onset preeclampsia by about

1246.679 -> roughly 20

1248.9 -> um and we have extrapolated that to

1250.78 -> multiple other indications uh at this

1254 -> time including interested in history

1255.799 -> preeclampsia or in particular a patient

1259.28 -> with chronic hypertension who is going

1261.08 -> to be at substantial risk for

1262.94 -> development of preeclampsia so to draw

1265.28 -> your attention this trial was published

1266.6 -> last year chaps trial uh essentially

1269.299 -> looking at patients with chronic

1272.059 -> hypertension prior to pregnancy uh in

1275.24 -> him we'd always treated previously down

1277.64 -> to

1279.08 -> um a level of less than 160 over 110 uh

1282.98 -> suggesting that the incidence of supreme

1285.2 -> preclassy requiring uh late preterm

1287.96 -> delivery prior to 34 hour recording

1290 -> delivery prior to 35 weeks was lower in

1292.34 -> patients if we targeted lower numbers uh

1295.7 -> and keeping their blood pressures in the

1297.38 -> range of less than 140 over 90. so

1299.419 -> essentially a lower threshold to start

1301.7 -> medications than historically we had

1303.74 -> used

1305.539 -> perfect thank you and when we think

1307.82 -> about what medications to use for

1310.039 -> hypertension and pregnancy for your

1312.08 -> reference here is a table outlining

1314.659 -> which medications are safe both in

1316.52 -> pregnancy and in lactation and notably

1318.919 -> labetalol nifedipine in pregnancy are

1321.86 -> certainly kind of our first line

1323.36 -> treatments for women with hypertension

1325.76 -> and pregnancy and remember that ACE

1328.22 -> inhibitors and ARB should be avoided in

1330.74 -> pregnancy

1332.72 -> so back to our case so given her

1335.059 -> presentation

1336.86 -> um looking for cardiogenic causes is you

1339.2 -> know additional creation and

1340.28 -> contributors to her symptoms a

1342.799 -> transthoracic echocardiogram was

1344.299 -> obtained and as you can see in these

1346.52 -> images sure LV was markedly and severely

1349.82 -> dilated in her lvf was reduced at 37

1354.26 -> percent and we had no prior history or

1358.34 -> transthoracic Echo Imaging for this

1360.38 -> patient so presumably a new reduction in

1364.1 -> her lvf and I remember she's in that

1366.26 -> five-day postpartum period

1368.96 -> so certainly her timing of presentation

1371.14 -> is concerning and would be consistent

1373.88 -> with peripartum chromyopathy and

1376.28 -> remember the definition of such is a new

1378.62 -> cardiomyopathy which is defined as an

1380.78 -> lvf less than 45 without another

1384.559 -> etiology so certainly is a diagnosis of

1386.9 -> exclusion you still want to think about

1388.88 -> other causes of cardiomyopathy in women

1392.48 -> um but again given the time course is

1395.6 -> this patient's case is seemingly

1397.76 -> consistent with peripharma chromopathy

1399.62 -> and there is a coexistence and overlap

1401.84 -> with the hypertensive disorders of

1403.52 -> pregnancy and about 40 percent

1405.679 -> we know that women that present with

1407.96 -> more with lower EFS more dilated left

1411.559 -> ventricles and RV involvement have worse

1414.38 -> outcomes and worse recovery and prior

1417.559 -> Studies have also shown us that many

1419.96 -> women tend to recover within six months

1422.6 -> and that major cardiovascular events so

1425.48 -> needing a transplant lvad or mortality

1428.78 -> and death almost exclusively occurred in

1431.179 -> women with EFS less than 30 percent

1435.559 -> on data from here at Mayo from a

1439.1 -> community cohort showed incidents of

1441.74 -> Perry primary mapathy of about 20 cases

1444.08 -> per 100 000 live births and of the 48

1447.44 -> confirmed cases 43 of those did recover

1450.5 -> there was one death in the group and

1453.44 -> there were six women that

1456.38 -> um six of 23 women that had subsequent

1458.539 -> pregnancies did Relapse but all of them

1461.179 -> recovered LV function

1464.539 -> another publication similar similar

1467.72 -> patient Community patient cohort again

1470.6 -> demonstrating that the rate of Perry

1473.24 -> primary map they relapse so again here

1475.7 -> we're looking at subsequent pregnancies

1477.26 -> in women with a history of period

1479.179 -> primary math but the the rate of relapse

1481.46 -> was about 20 21 with the EF at that time

1485.659 -> going to be about 43 but again all of

1489.26 -> these women with relapse did recover

1491.539 -> their LV function

1494.84 -> so what about management of

1496.34 -> cardiomyopathy and heart failure and

1498.08 -> pregnancy so again we medications are

1501.98 -> important but there are certain

1503.539 -> medicines that we can and cannot use

1505.94 -> during pregnancy preconception as well

1508.28 -> as in the postpartum period

1510.32 -> for our patient she was breastfeeding

1513.559 -> she was postpartum so we did initiate

1516.44 -> her on medical therapy with beta blocker

1518.539 -> ACE inhibitor

1520.88 -> um she was also starting spironolactone

1522.5 -> and did need some diuretics as well

1526.7 -> as far as counseling for future

1528.32 -> pregnancies this is also really

1530.059 -> important

1531.799 -> um thing not to forget so when you see a

1533.84 -> woman that has a history of brown

1535.46 -> chromopathy or you're seeing them with

1537.98 -> this new diagnosis we should always be

1540.08 -> thinking about and counseling regarding

1542 -> future pregnancies what are their

1543.86 -> pregnancy wishes are they planning

1545.84 -> another pregnancy so we can even start

1548.12 -> that process early very early on and

1551.659 -> it's important to note that women that

1553.46 -> do not recover their LV function which

1555.44 -> is defined as an lvef of 50 so women

1559.46 -> that do not recover and their EF remains

1562.279 -> less than 50 percent are modified who

1565.7 -> um class four and are advised against

1568.1 -> pregnancy because they are at a higher

1570.44 -> risk of relapse with more morbidity and

1572.779 -> mortality

1575.96 -> as far as future directions and

1577.58 -> peripartum chromopathy

1579.62 -> um it can be very challenging women can

1581.96 -> present with symptoms that overlap with

1583.7 -> heart failure

1585.32 -> um that are normal in pregnancy as well

1587.299 -> so the need for an easily applied

1590.299 -> screening tool to help catch these women

1592.52 -> earlier is certainly needed and here

1595.539 -> there has been promising work looking at

1598.76 -> using AI ECG algorithms and detecting a

1602.36 -> low EF in women that are pregnant and

1604.46 -> postpartum and certainly be watching

1607.279 -> soon for additional data coming from

1609.08 -> prospective studies looking at the use

1612.38 -> of these algorithms in pregnant and

1614.36 -> postpartum women

1617.6 -> so for resolution kind of going back to

1620 -> our case so she remain in the hospital

1622.279 -> for about a week she was Diaries

1624.4 -> initiated medical therapy she did have a

1628.22 -> coronary CT coordinary angiogram which

1630.679 -> showed normal coronary arteries in the

1633.2 -> outpatient setting we did do a cardiac

1635.24 -> MRI which was fairly Bland showed no

1637.94 -> delayed enhancement her genetic testing

1640.1 -> was also negative

1641.72 -> and in follow-up for about four months

1644.539 -> later after her initial presentation we

1646.94 -> were seeing some beginning to see some

1648.98 -> improvement her LV was smaller and her

1651.44 -> EF had improved to about 47 percent

1656.48 -> so in summary

1658.34 -> um that kind of wraps up our cases here

1660.679 -> the as I mentioned starting this you

1663.74 -> know care of the pregnant woman with

1665.059 -> cardiovascular disease covers a wide

1667.279 -> clinical Spectrum so it's important to

1670.22 -> have

1671.299 -> um you know colleagues in metronomial

1673.76 -> medicine and even within all aspects of

1675.559 -> Cardiology to help guide

1678.4 -> these decision making for these patients

1681.38 -> and the multidisciplinary care and the

1684.26 -> pregnancy heart team is is really

1685.7 -> essential in helping care for these

1687.5 -> women

1690.44 -> and with that we thank you and we'll

1693.02 -> open it up to questions

1695.36 -> and I'm gonna just switch over here to

1698.179 -> this so I can read through some

1699.5 -> questions here

1700.76 -> we have plenty of time here so please uh

1703.1 -> we encourage you to answer your

1704.299 -> questions into the Q a and hopefully we

1706.88 -> can address all of them

1709.76 -> so first question here um when is

1712.34 -> pregnancy a complete contraindication

1716.419 -> um so we should go back we're gonna go

1719.659 -> back yep let's go back sorry I thought

1721.82 -> there'd be a way to

1723.279 -> modified who class four

1726.559 -> um and uh generally speaking this is

1729.98 -> most likely in patients uh who have

1732.98 -> pulmonary hypertension uh patients who

1736.4 -> have uh severe mitral stenosis severe

1740.9 -> aortic diseases or have an injection

1743.24 -> fraction less than 30 percent

1746.179 -> that prior peripheral who's all prior

1749.6 -> prayer

1751.84 -> for that as well

1755.179 -> and then another question is

1757.7 -> spironolactone safe in breastfeeding

1762.38 -> so we do tend to use it clinically here

1764.659 -> for women that are that are

1766.46 -> breastfeeding

1768.14 -> um Dr Oz I know if you have any others

1770.12 -> uh no the use of spray so a little bit

1774.2 -> of editorial there we generally avoid

1776.12 -> spread a lot too and during pregnancy

1777.559 -> because there are concerns theoretical

1779.659 -> for antigen androgenic effects however

1782 -> there's really no human data that

1783.38 -> actually supports that uh and it always

1785.899 -> does seemed sort of paradoxical to me

1787.94 -> that there's some medications that we

1789.26 -> use during pregnancy

1790.88 -> but we don't use during lactation which

1794.24 -> doesn't always kind of seem to be

1797.179 -> synonymous if you will and in terms of

1800.659 -> safety I think we would uh look at each

1803.299 -> individual patient and ask risk benefit

1805.039 -> approach in this and in those cases

1808.94 -> and next question is for the last

1811.88 -> patient we presented to the Perry

1813.399 -> primaryopathy patient her EF did not

1816.2 -> recover she should be counseled on no

1818.539 -> more pregnancies that is correct so she

1821.779 -> um the caveat to that being I mean she

1823.1 -> was

1823.82 -> um this was kind of her first initial

1826.039 -> check she was kind of just four this was

1828.08 -> come four months after her so um you

1830.84 -> know she's having still actually coming

1832.58 -> back to clinic and we're still following

1834.32 -> her but if her EF remains

1838.46 -> um reduced I'll be quite dilated as it

1840.919 -> is that is correct she should be

1842.419 -> counseled on no additional pregnancies

1844.58 -> and right now we've counseled her that

1846.98 -> we would not want her to be pregnant and

1848.779 -> you know we make sure she has a

1851 -> contraception plan in place and just as

1853.52 -> an editorial there since we do rarely uh

1856.46 -> assume others whom we counsel against

1857.96 -> pregnancy I try to emphasize to them

1861.02 -> that uh future pregnancies for

1864.559 -> themselves are contraindicated however

1867.2 -> biologically uh they could potentially

1869.419 -> have a child through use of a surrogate

1871.399 -> so it doesn't preclude future children

1873.559 -> it just means from a maternal risk

1875.899 -> perspective uh it would be unwise

1883.1 -> very good and bad girls this might come

1885.559 -> to you again but um how does your team

1887.36 -> decide vaginal versus C-section great

1890.899 -> question

1892.399 -> um so I will preface this by saying that

1895.22 -> the Rope hack group has a wonderful

1897.08 -> publication uh where they looked at all

1899.6 -> the different permutations of delivery

1901.58 -> either planned vaginal delivery with

1903.799 -> emergent cesarean section plans is there

1905.779 -> in section with vaginal delivery sort of

1907.94 -> all the different manifestations that

1909.62 -> one could anticipate and they could find

1910.82 -> any difference in outcomes

1912.74 -> um we will typically make that decision

1915.52 -> uh primarily contingent upon the

1918.08 -> resources that they've required for each

1919.82 -> individual patient uh in as a practical

1923.659 -> matter there's not a single answer to

1926.419 -> that question if we have a patient for

1928.7 -> instance

1929.659 -> um a scenario if we have a pulmonary

1931.22 -> hypertensive mom who we need to have

1933.86 -> Nitro College side available for uh and

1936.74 -> we really need sort of from a resource

1938.96 -> allocation and Personnel availability to

1941.48 -> have that deliver your current and plan

1942.86 -> based in those situations we would

1945.2 -> suggest this area in moms who have a

1947.899 -> mechanical heart valve in him sort of

1950.419 -> the timing or the wind of time that

1952.58 -> their authentic valuation May

1954.32 -> substantially increase their risk for

1955.82 -> clotting the bowel in those cases uh

1958.58 -> similarly we would advise the Syrian

1960.38 -> sanction mostly from a logistics

1962.659 -> perspective in those cases

1965 -> um but I would say each each case is

1967.039 -> individual

1968.48 -> yeah good question no no really simple

1971.299 -> answer to that yeah

1973.76 -> and then if I may just in terms of that

1976.399 -> um in terms of other potential

1977.419 -> indications maybe Katie would you want

1979.279 -> to discuss a little bit about your topic

1980.779 -> in pregnancy

1981.98 -> yeah and we can certainly yeah because

1984.26 -> that would be one other potential reason

1986.779 -> why we may prefer a C-section

1990.62 -> um would be women who have had

1994.58 -> um progression of their aorticilitation

1996.5 -> during pregnancy or you know at a

1998.179 -> significant rate or who's a you know are

2000.64 -> coming in pregnant in their aortas are

2003.039 -> you know quite dilated and again that is

2005.14 -> a little dependent on

2007.12 -> the etiology of the aortopathy so if we

2010.6 -> kind of can go down sorry it's two

2013.179 -> slides here I wasn't sure if there's a

2014.919 -> way to skip

2016.059 -> we'll go down and show but for instance

2019.12 -> um you know bike if it's a bicuspid

2021.059 -> aortic valve related aerotopathy we

2023.86 -> generally look at the cutoff of around

2025 -> 50 50 millimeters above that which

2029.5 -> um

2030.22 -> and then certainly for those for the the

2034.24 -> cutoffs are lower for women with marvan

2036.58 -> always Deeds Turner

2038.44 -> um Etc kind of as we have outlined here

2040.36 -> and I guess from a Maternal Fetal

2042.46 -> Medicine perspective any particular

2044.98 -> cut off and a rate of change too right

2048.639 -> that probably would would influence this

2050.679 -> as well uh again exactly as you've

2053.44 -> highlighted uh lower threshold in

2055.359 -> patients with uh underlying genetic

2057.7 -> conditions particularly sometimes if

2060.159 -> there is a family history of dissection

2062.26 -> as well yes that can influence yeah

2070.48 -> so here's another question a patient

2073 -> with history of periperm chromopathy

2075.099 -> with lvef recovered to more than 50

2077.98 -> percent is pregnancy contraindicated or

2080.919 -> would you consider Case by case

2083.04 -> uh I would say in in that situation I'm

2086.56 -> just going to flip a couple slides back

2088.599 -> um by one of our wonderful former

2090.58 -> fellows looked at that data from uh our

2094.96 -> institution and essentially of the

2097.48 -> patients who had recovered uh as you see

2100.599 -> there are 21 had a relapse and

2102.76 -> interestingly enough that relapse did

2104.02 -> not always occur in the subsequent

2106.359 -> pregnancy after the index pregnancy in

2108.28 -> other words some patients an episode of

2109.839 -> Fairborn chronomyopathy a

2111.16 -> non-complicated subsequent pregnancy and

2112.48 -> then had a relapse in the in the third

2114.04 -> pregnancy if you will

2116.079 -> um but all of those patients improved

2118.119 -> and they got better afterwards so that

2121.24 -> has changed our Counseling in this

2124.119 -> situation uh we we generally quote you

2127 -> know our numbers there are within the

2128.56 -> range of which usually published in the

2129.88 -> literature 25 percent plus minus five

2132.7 -> um and so we don't counsel against

2134.859 -> future pregnancy

2136.44 -> if it truly is recovered oh yes

2140.98 -> yeah and a couple other things to

2142.72 -> consider there so totally agree I mean

2145.48 -> it's a it's a shared decision making but

2148.18 -> again I would not be going in like you

2150.94 -> said thinking we would have to counsel

2152.859 -> against pregnancy

2154.78 -> um we'd also need to look at their

2156.16 -> medications because certainly that's

2157.66 -> another thing you know what have they

2158.8 -> been on for medical therapy because many

2160.839 -> of those may need to be discontinued

2162.579 -> prior to conception so that takes a lot

2165.94 -> of you know some planning as well and

2168.28 -> sometimes even after stopping some of

2169.839 -> that therapy and allowing some time to

2172.119 -> pass and rechecking that LV function

2173.859 -> before they become pregnant it's helpful

2175.96 -> also

2179.74 -> um so we have another patient here or

2181.599 -> another question in young patients who

2184.119 -> have severe as may be congenital but in

2186.579 -> their early 20s they need a valve

2188.56 -> replacement how do you counsel them

2190.78 -> regarding bile prosthetic versus

2192.339 -> mechanical and how do you decide

2196.24 -> who wants to feel that yeah that's a

2199.24 -> very good question okay very good

2201.339 -> question I think it's really

2203.02 -> controversial if you want to go first

2204.42 -> you should both yeah I don't know if I

2207.16 -> shouldn't but I guess I will so

2209.98 -> um really controversial and I think it

2211.72 -> really comes down to patient-centered

2213.64 -> decision making

2214.66 -> um shared decision making with the

2215.8 -> patient and it also depends on your

2217.42 -> surgical expertise

2219.4 -> um nearby so I think if we're talking

2221.859 -> about patients with significant aortic

2223.839 -> stenosis who require valve replacement

2225.76 -> before considering a pregnancy

2228.22 -> as we learned or as we discussed you

2230.859 -> know anticoagulation the setting of

2232.42 -> pregnancy if it can be avoided I think

2235.119 -> it really should both for the mom and

2237.04 -> baby's sake and so and patients who are

2241.24 -> um Resolute that they certainly want to

2243.579 -> have

2244.78 -> um their own child and not through

2246.16 -> surrogate or adoption on the Resolute

2248.5 -> that they want to have their own baby I

2250.599 -> mean you have a thoughtful discussion

2251.859 -> with them discussing the risks and then

2255.28 -> um in terms of that situation generally

2257.579 -> and again a case-by-case basis but we

2260.14 -> would recommend against a mechanical

2261.64 -> valve and so then the options being a

2264.4 -> tissue prosthesis or alternative

2266.44 -> procedures such as the Ross procedure

2268.72 -> again then that gets back to your

2270.579 -> surgical expertise nearby and patient

2273.28 -> decision making and what they think

2274.54 -> about pluses and minuses of each

2276.099 -> approach no approach is perfect for Mom

2278.98 -> or baby but oftentimes here at least in

2282.099 -> our experiences I think we would

2284.32 -> recommend against a mechanical valve but

2287.56 -> I think you know this kind of highlights

2288.82 -> this whole point of in patients with

2290.32 -> known cardiac disease women in their

2292.06 -> child bearing years

2293.32 -> even in a pre and a visit we're just

2295.66 -> routine follow-up and you're not talking

2297.16 -> about pregnancy it's not on their mind I

2299.92 -> think it's really really essential that

2301.96 -> we mention it they're on childbearing

2303.88 -> age and if pregnancy is not on their

2305.68 -> mind then are they on contraception if

2307.359 -> they have a high risk cardiac condition

2309.579 -> um I think it's important and

2310.96 -> appropriate to discuss it and if the

2312.7 -> patient doesn't want to discuss it

2313.72 -> that's a different story but I think

2316 -> that's our job it's really important

2317.619 -> because when this comes up then they're

2319.24 -> modified who class three or sometimes

2321.82 -> four and they are pregnant and it's

2323.56 -> never been discussed it's a really

2325.18 -> really challenging to backtrack

2327.78 -> yeah preconception counseling definitely

2330.82 -> important for women with heart disease

2333.64 -> congenital acquired absolutely

2339 -> next question is any guidance on

2341.619 -> patients that may require Telemetry as

2343.72 -> an inpatient during admission for

2345.339 -> delivery we did that

2348.22 -> um I I'll feel that when we do that in

2350.44 -> our labor and delivery

2352.599 -> um it's typically patients who have

2353.859 -> frequent arrhythmias

2355.359 -> um late in the third trimester uh It

2358.119 -> generally tends not to be I I guess that

2360.28 -> sort of Hearts back to uh delivery in

2362.56 -> those patients at level three level four

2364.119 -> uh maternal Care Center uh are

2367.48 -> um difficult Arrangement here is a

2369.76 -> patient will be on Telemetry or ICU is

2371.8 -> 74 is up so the ECG is monitored in the

2375.52 -> ICU during labor and if someone has an

2378.579 -> arrhythmia uh they will usually the ICU

2381.76 -> will send send one down manage it there

2383.98 -> very rarely actually won't be

2385.9 -> transferred up to neighboring deliver or

2387.52 -> up to the ICU uh but it actually works

2390.579 -> incredibly well

2392.32 -> um and uh it's sort of a

2394.42 -> um I think we'll synchronous care

2397.3 -> and we do have a small sub patients then

2399.76 -> that we kind of transition briefly to

2402.52 -> the ICU postpartum and that come 24 36

2406.599 -> hours after delivery and continue that

2408.76 -> monitoring right we expect a lot of

2410.5 -> hemodynamic changes in those situations

2412.48 -> all the intravascular vascular volume

2414.64 -> shifting uh as the uterus contracts it

2417.88 -> sort of gives an immediate Auto

2419.2 -> transfusion and probably about a unit

2421.96 -> and a half

2423.4 -> um and just to sort of be in this and

2426.76 -> being as a

2429.82 -> um an area might be the best way to put

2431.38 -> it that can manage acutely any type of

2433.9 -> cardiac decompensation

2438.339 -> and

2439.72 -> engine is for those moms with reduced EF

2443.2 -> how does the team decide on invasive

2445.599 -> monitoring

2448.3 -> it's pretty rare here that someone

2450.579 -> requires invasive monitoring

2453.099 -> um my anesthesiology colleagues

2455.74 -> um generally will go based on

2458.14 -> non-invasive monitoring uh the only time

2460.3 -> I've seen that be an issue is in

2463.119 -> permanent hypertension

2465.099 -> um and uh in those situations of right

2468.339 -> uh you know a swan floated but otherwise

2471.7 -> uh I guess I say our institutional

2473.8 -> preference to generally to avoid if

2475.48 -> possible uh with the exception I should

2478.06 -> say invasive monitoring art lines art

2480.52 -> lines for patients who has to Nordic

2482.079 -> balance particularly as in whom cardiac

2484.599 -> output monitoring and accurate blood

2486.46 -> pressure assessment is important I think

2488.68 -> of an invasive monitoring as Central

2490.3 -> works

2491.32 -> and perhaps if it's okay slight aside

2493.78 -> but in terms of as you mentioned

2495.099 -> catheterizations and pregnancy I think

2497.2 -> for women as we describe you know

2499.48 -> there's increased flow throughout

2500.68 -> pregnancy which is appropriate so even

2502.48 -> values such as the right ventricular

2503.859 -> systolic pressure and echocardial

2506.04 -> echocardiography it's appropriate should

2508.119 -> increase some but sometimes there's one

2510.22 -> where it increases more than expected

2511.96 -> and there's this question of do they

2513.16 -> have pulmonary hypertension that wasn't

2514.48 -> previously diagnosed and I think you

2516.76 -> know in those situations and there's

2518.2 -> again patient-centered discussion about

2520.06 -> whether or not you should receive a

2521.56 -> diagnostic catheterization during

2523 -> pregnancy I think you know

2525.46 -> in many ways that can be achieved at

2527.68 -> very low risk to the mom and baby and

2529.42 -> maybe most appropriate if we're talking

2530.98 -> about well the more of the potential

2532.06 -> risks of proceeding with the pregnancy

2534.04 -> in a patient with pulmonary hypertension

2535.9 -> trying to associate and actually

2537.46 -> calculate what's the pulmonary vascular

2539.14 -> resistance not just appropriate

2540.46 -> increases in flow so I think you know in

2543.16 -> those situations it can be considered

2544.96 -> and can be done safely but of course we

2546.7 -> reserve it for when we really need it

2551.32 -> okay very good and what is um your

2554.98 -> approach our approach to symptomatic

2556.78 -> resting

2557.94 -> symptomatic rusting sinus tachycardia in

2561.16 -> patient with a mild anemia of pregnancy

2563.859 -> but with a structurally normal heart

2567.04 -> so symptomatic

2569.02 -> tachycardia

2570.78 -> mild anemia structurally Normal Heart

2573.28 -> metabriel

2575.5 -> yeah yeah no and we do use metoprolol so

2578.68 -> beta blockers in pregnancy yep so

2581.68 -> um we do use metoprol certainly I would

2584.14 -> make sure that some you know obviously

2585.579 -> excluding all other you know science

2587.44 -> tachycardia excluding all other

2589.06 -> contributors

2591.04 -> um that could be driving that but if the

2593.68 -> if the patient or the she's really

2595.839 -> symptomatic metoprolol certainly yes

2598.599 -> could be yeah I mean you may be

2600.339 -> considering a 24-hour halter just to

2603.04 -> make sure we're not missing any time but

2605.619 -> uh yes I mean any beta blockers in

2609.04 -> pregnancy have been Associated and we

2610.9 -> use that term relationally with fetal

2612.64 -> growth restriction but in these

2614.8 -> situations if there's a substantial

2616.24 -> maternal benefit then we would typically

2618.22 -> do so and perhaps look at growth

2621.04 -> ultrasounds in the third trimester

2625.42 -> okay next question

2627.28 -> um looks like I have a patient related

2629.319 -> scenario so patient with congenital

2631.18 -> critical critical as

2633.579 -> stasis so neonatal treatment and

2636.76 -> subsequent

2637.96 -> four so four additional surgeries so

2641.26 -> they had a Ross they had an aortic root

2643.18 -> pseudo aneurysm repair bioprosthetic ABR

2645.599 -> septomyectomy RV to PA homographed

2649 -> current functional 21 millimeter Onyx

2651.88 -> AVR

2653.14 -> normal LV function

2656.56 -> um what how does five prior

2659.26 -> cardiothoracic surgeries affect your

2661 -> recommendations for pregnancy

2664.3 -> really good question really complicated

2666.579 -> patient and unfortunately we see this

2668.8 -> commonly and I think you know one of the

2671.26 -> current limitations of the data that we

2673.24 -> have or the guidelines that we have you

2675.04 -> know the modified who and chiropractor

2677.98 -> risk cores are fantastic but one thing

2680.98 -> that is missing in my opinion is

2682.9 -> incorporation of functional status and

2685.72 -> so you know you can have a patient with

2687.819 -> such as this patient or patient with you

2690.099 -> know asymptomatic significant valve

2691.96 -> disease

2692.94 -> but what their functional status is

2696.54 -> impacts your management significantly if

2698.74 -> we take this outside of the context of

2700.18 -> pregnancy and you just think well how is

2702.16 -> this patient doing and how do you think

2703.359 -> they would do with you know non-cardiac

2704.98 -> surgery or something else again it gets

2706.599 -> back to what's their functional status

2707.8 -> if they're feeling short of breath going

2709.72 -> up the stairs you're going to be more

2710.98 -> concerned about them than if they

2712.359 -> exercise every day and so I mean I think

2714.76 -> that's a really crucial piece to a

2716.98 -> decision making there

2718.839 -> um in the with the assumption that that

2720.76 -> patient's functional status is good

2722.02 -> they're asymptomatic valves working well

2723.819 -> as you may mention the left ventricular

2725.56 -> functions okay we're also assuming the

2727.54 -> RV to PA conduit is without significant

2729.4 -> disease the right ventricle is doing

2730.78 -> well certainly they would be at

2732.7 -> increased risk but if their functional

2734.8 -> status is okay then you know you would

2736.839 -> think that well their overall risk for

2738.4 -> maternal complications is not as high

2740.38 -> now the major thing just comes in about

2742 -> the anticoagulation and then that

2744.339 -> approaches semi-dynamic other patient

2746.14 -> with anticoagulation and it's not

2748.18 -> insignificant I think there's this

2749.92 -> question out there of you know what the

2751.359 -> Onyx valves maybe there's the slower

2752.92 -> thrombosis risk

2754.9 -> could we manage them a little bit more

2756.46 -> Loosely or conservatively but I don't

2758.5 -> think we have any data to support that

2759.88 -> yet so the risk that we would think

2761.5 -> about with anticoagulation any woman in

2764.8 -> pregnancy would be comparable for this

2766.3 -> patient there's a nice Jack review

2768.099 -> article from a couple of years ago which

2769.599 -> has a nice pictorial to help guide

2771.94 -> decision making in those situations and

2774.16 -> I think you just have to have a really

2775.599 -> thoughtful conversation with the patient

2776.92 -> make sure they recognize the significant

2778.54 -> risk to them as well as to the baby and

2781 -> then as we've mentioned consider

2782.8 -> alternative options surrogacy and or

2784.66 -> adoption

2787.06 -> and

2792.16 -> so in a patient with Prairie Prime

2793.96 -> primopathy they're EF normalized with

2796.06 -> therapy when do you consider stopping

2798.46 -> the ace inhibitor and or beta blocker

2801.28 -> so that's a really good question and

2803.98 -> um I'll kind of take for first go out

2806.56 -> that one the um

2808.66 -> generally at least you know therapy for

2810.7 -> at least a year has come generally

2812.2 -> because you know postpartum

2814.54 -> um but I think I I discuss a lot with my

2817 -> patients too if if they're not playing

2818.98 -> like such as a patient not planning

2820.66 -> additional pregnancies if they're

2822.52 -> tolerating the medications well they're

2824.319 -> not particularly symptomatic or they're

2826 -> not bothersome to them

2827.56 -> I do consider at least keeping some sort

2829.839 -> of medical therapy ongoing

2832.72 -> um and there's not a lot of per se data

2835.96 -> for that but there's one study of the

2838.78 -> trade HF study which did show that when

2841.3 -> medical therapy was taken away or

2843.7 -> stopped and there was a very few number

2846.64 -> of periprime chromatopathy patients in

2848.44 -> that

2849.339 -> um patients did these dilated

2851.14 -> cardiopathies did tend to

2853.359 -> read it you know things got worse or

2855.22 -> I'll be red dilated their EF could go

2856.96 -> down again and clinically I have seen

2859.06 -> that as well where a woman therapy keep

2862.18 -> following her and then the next Echo the

2864.4 -> LV was a little more dilated the EF is

2866.5 -> now down like 49.50 so I um if they're

2871.359 -> tolerating it

2872.859 -> um I kind of treat them like a dilated

2875.02 -> creamyopathy and would encourage them to

2877.119 -> stay on the medical therapy if it's not

2879.4 -> particularly bothered some or at least

2881.92 -> one of them you know maybe the

2883.18 -> metoprolol if they want to stop face and

2885.94 -> you know it's a it's a discussion it's a

2888.579 -> discussion and each patient's a little

2890.02 -> different

2890.859 -> they certainly wouldn't want them to

2892.9 -> stop anything for at least a year

2895.3 -> postpartum

2900.56 -> [Music]

2901.96 -> okay so in patients with more fans with

2905.2 -> normal aortic size versus those with a

2908.38 -> dilated aorta how often during pregnancy

2910.96 -> and when postcardum do you assess for

2913.3 -> aortic size

2916.48 -> I can probably feel that one and I will

2918.339 -> tell you that our institutional

2919.48 -> preference here has been to Echo our

2921.76 -> patients with more fans on a monthly

2923.5 -> basis all the way through the pregnancy

2927.099 -> um and we didn't see very frequently a

2931.359 -> moment with more fins and a dilated

2933.16 -> aortic root I think in those situations

2935.2 -> we might have to have a trained

2936.579 -> discussion about the advisability of

2938.079 -> pregnancy

2940 -> um but in those cases I would anticipate

2942.76 -> we would AKA moms once again probably on

2945.52 -> a monthly basis and then postpartum

2947.98 -> actually prior to on discharge

2957.48 -> so kind of prior to dismissal and then

2960.16 -> having that follow-up before they leave

2961.66 -> the hospital as well I'm gonna rip it

2963.819 -> after that

2964.9 -> I guess I may just kind of bring up the

2967.359 -> question of in terms of method of

2969.64 -> evaluating if you want to talk about

2970.859 -> multimodality Imaging and pregnancy

2973.72 -> um in terms of MRIs how often will you

2975.579 -> tend to use those yeah so I guess I

2978.28 -> would say so MRIs

2980.619 -> um and you know they can do mras without

2982.42 -> contrast

2984.4 -> um and I would think clinically myself

2986.56 -> about doing that so echo's great

2988.78 -> obviously there's no radiation there's

2990.76 -> no

2992.02 -> um it's easy it's ultrasound

2995.319 -> um but if there was concern that there's

2996.88 -> been a change so if you're seeing a

2998.92 -> change or

3000.48 -> um you know clinically something is

3002.88 -> different than I would that's when I

3004.859 -> would probably trigger to do the Mrs

3007.619 -> um or if things are stable and again

3009.839 -> even postpartum again you watch them in

3012.48 -> that close time frame again kind of

3014.339 -> reimaging after the pregnancy but

3016.74 -> um certainly if there's a clinical

3018.119 -> change or you're concerned or

3019.98 -> something's rapidly changing on Echo or

3022.2 -> you can't see it very well certainly

3024.18 -> then you'd want to they're looking at

3025.74 -> cross-sectional Imaging absolutely

3030.599 -> the next one says pre-pregnancy

3033.54 -> counseling

3034.74 -> so certainly important

3038.28 -> um I don't know if it's maybe how we do

3040.74 -> that here or

3042.66 -> um

3044.52 -> um we you know because I think for

3046.5 -> someone a woman with cardiac disease

3048.359 -> certainly having them meet with Maternal

3050.7 -> Fetal Medicine as well as Cardiology and

3053.28 -> having a similar message to the patient

3055.44 -> as well I think is really important

3058.2 -> um

3058.92 -> and then oftentimes that pregnancy

3061.68 -> assessment may include exercise testing

3064.319 -> basic lab evaluation EKG Echo most

3068.46 -> typically

3069.74 -> one of the things I would say when we do

3072.119 -> in the rare instances we recommend

3074.099 -> against pregnancy I

3076.5 -> always offer once again the option of a

3079.68 -> gestational carrier or a surrogate but I

3082.559 -> also emphasize that if they

3085.079 -> wish to conceive then they go in uh

3088.14 -> preferably knowing the risk we will do

3090.059 -> our utmost to take care of them that we

3091.619 -> possibly can but we do not know where

3093 -> the outcomes can go and in particular in

3095.76 -> these situations if we're talking about

3097.319 -> a mom who's deteriorating you know when

3100.2 -> she's 24 weeks in gestations she's an

3102.42 -> ICU in those cases not only are we

3105.42 -> looking at a mom who's critically ill

3106.92 -> but we're also not uncommonly looking at

3109.859 -> a preterm baby who may incur long-term

3112.02 -> morbidity as consequence of that preterm

3113.88 -> delivery as well uh but but I do

3116.46 -> emphasize to those moms that we will be

3118.5 -> there for them whatever decision that

3119.76 -> they would make

3123.42 -> next question is what is the max

3125.76 -> pulmonary pressure that would preclude

3127.68 -> pregnancy

3131.579 -> that's a good question yes yeah

3137.64 -> I think it'd probably depend on RV

3139.319 -> function wouldn't it more than anything

3140.46 -> else I think kind of all of it together

3142.619 -> yeah I think

3144.839 -> I think yeah you know when we think

3146.52 -> about the right particular systemic

3147.96 -> pressure there's multiple determinants

3149.339 -> of it you know the left atrial pressure

3150.66 -> being one of the major drivers for the

3152.22 -> pulsidial pressure but the amount of

3154.079 -> flow as we talked about of course

3155.76 -> pulmonary vascular resistance but right

3157.68 -> ventricular functions really really

3159.18 -> important so you know you may have a

3161.22 -> patient with significantly reduced right

3162.48 -> ventricular cystolic functions severe pH

3164.4 -> and an rvsp that's not significantly

3166.8 -> elevated but they're pbrs through the

3168.599 -> roof and so I think looking at just that

3171.059 -> one number unfortunately can potentially

3173.7 -> mislead us and so we have to look at the

3175.92 -> patient in whole look at their Echo and

3177.54 -> hole and if they have invasive data look

3179.339 -> at that all in context and then kind of

3181.74 -> getting in terms of trying to actually

3183.3 -> answer that question not just punt

3185.46 -> um I will just say that you know there's

3187.2 -> been some interesting data in the recent

3188.94 -> past couple years looking at either

3190.619 -> patient with eisenmangers or significant

3192.839 -> pH and showing that you know some of

3194.7 -> them can actually do okay with pregnancy

3196.44 -> not zero risk but not as high as we

3198.839 -> previously thought I think that some is

3200.52 -> due to earlier recognition advances in

3202.859 -> treatment but I think you know it it

3206.16 -> certainly is a formidable undertaking to

3208.2 -> carry a patient um or guide them through

3210.119 -> pregnancy with significant pulmonary

3212.28 -> retention but it can potentially be done

3214.28 -> and in terms of a Max I think that's an

3217.2 -> interesting question in that we don't

3218.46 -> know patients with a moderate degree of

3220.859 -> pulmonary hypertension is their risk is

3223.2 -> it a linear risk you know in terms of

3224.94 -> moderate versus severe or is there some

3227.46 -> exponential risk once you get to a

3228.96 -> certain PVR or RV dysfunction or PA

3231.66 -> pressure it's an interesting question

3232.98 -> and I'm not aware of data that really

3235.02 -> outlines that

3236.76 -> no

3237.839 -> no no

3240.359 -> um this kind of question kind of was

3241.8 -> along with it

3243.359 -> with a pregnancy

3245.22 -> hypertension

3246.72 -> and then how often do you recommend

3248.7 -> pregnancy termination and if they refuse

3251.52 -> that do you follow the you know how

3253.8 -> often do you follow the patient I think

3255.059 -> we you're kind of addressing that you

3256.859 -> know you Counsel on risks yeah the

3258.72 -> technical answer to that is if you look

3260.4 -> at the modified W show criteria any

3262.079 -> degree of permanent hypertension is

3263.76 -> considered a quality indicator in

3264.96 -> pregnancy contraindication to pregnancy

3266.22 -> and obviously if there's probably a

3267.42 -> spectrum there usually quite about a 16

3269.16 -> mortality risk um is the most recent

3271.74 -> data that I've seen and what we do

3274.319 -> during pregnancy is typically we will

3277.38 -> Echo those moms

3279.14 -> at least every trimester if not more

3282.42 -> frequently than that we will uh from 20

3285.18 -> weeks onward follow serial sonography we

3287.52 -> will generally

3289.319 -> um have our anesthesiology colleagues

3291.42 -> involved early have a plan for the

3294.3 -> delivery aspect both on a scheduled or

3297.059 -> an unscheduled basis in case the

3298.38 -> paintwork patient were to deteriorating

3299.819 -> the interim and in general we have tried

3303 -> to achieve 34 weeks in those pregnancies

3305.52 -> I haven't always been successful uh but

3308.16 -> have tried and a lot of that is based

3310.079 -> upon either onset of worsened clinical

3312.9 -> symptomatology or uh sort of achieving a

3316.859 -> gestational age where we really

3318.059 -> anticipate a very good outcome on behalf

3320.64 -> of the neonate and having all the

3322.5 -> resources available We're Alone to

3324.18 -> auditory

3326.339 -> excellent yeah

3328.859 -> just add a quick congenital spin to that

3331.38 -> the other question is you know even the

3332.819 -> absence of pulmonary hypertension but

3334.2 -> right ventricular hypertension if they

3335.7 -> have an obstructed conduit or a

3337.5 -> pulmonary homograph whatever it may be

3339.119 -> we don't know if the risk is comparable

3341.46 -> to an rvsp of ADA if the PA pressure is

3343.8 -> an 80. you know so there's a lot of

3345.48 -> unknown questions here I think in terms

3347.16 -> of what is really the driver of those

3348.66 -> high-risk situations

3353.22 -> um next question is do you routinely

3354.48 -> hold any medications such as

3356.54 -> antihypertensives or antiarrhythmics

3358.559 -> during delivery in case hypotension or

3361.98 -> blood loss occurs or just treat if it

3364.079 -> does occur

3365.16 -> I would say during the labor and the

3368.22 -> delivery process

3370.98 -> um

3371.64 -> we don't generally hold medications

3373.859 -> um and usually my anesthesiologist

3375.839 -> particularly if they're putting in

3376.92 -> anorexial and the word that a patient

3378.72 -> will become hypertensive will have a

3380.16 -> phenylephrine infusion running so that

3382.5 -> that way they can titrate it to maternal

3384.78 -> blood pressure and in particular in a

3386.22 -> patient with say severe Mass they will

3388.98 -> usually have an hard line and

3390.48 -> simultaneously uh and but I don't think

3394.02 -> we necessarily hold any medications in

3396.599 -> particular I mean off some of my head

3398.46 -> I'm thinking maybe anticoagulation

3400.859 -> um but uh otherwise as far as

3403.28 -> antiarrhythmics or

3405.9 -> um you know an intravitational one thing

3408.66 -> I would say is you know getting back to

3410.7 -> an earlier question about safety of

3412.2 -> certain medications in pregnancy but not

3413.88 -> in lactation certain antiarrhythmics do

3416.76 -> fall into that category and so if the

3419.04 -> mother knows that they'd like to

3420 -> breastfeed immediately postpartum then

3423.54 -> sometimes it will hold you know for that

3425.7 -> medication to wash out so that'd be

3427.92 -> other the only other thing I might think

3429.72 -> about there

3432.78 -> and then this may be kind of one of our

3434.46 -> last questions here just given the time

3437.52 -> um but that says are there situations

3439.079 -> when obtaining genetic testing during

3441.18 -> pregnancy or new diagnosis conditions

3444.839 -> such as connective tissue disorders

3446.46 -> would guide or change your management

3451.68 -> I think I'd like an undiagnosed Louie's

3453.48 -> needs or modern fan yeah yeah like a new

3456.96 -> diagnosis of morphine ehlers-danlos

3460.14 -> um certainly if it would

3463.14 -> um change your monitoring how you'd

3465.42 -> monitor the patient how closely you

3466.8 -> would monitor the patient

3468.66 -> um like from an aorta perspective that

3470.819 -> could be important and I think even if

3473.099 -> we're seeing someone for preconception

3475.44 -> counseling or if they're already

3476.64 -> pregnant we do like to involve genetics

3479.099 -> as soon you know certainly whenever

3481.98 -> um as soon as we can for the for the

3483.9 -> women so I think that if that resource

3486.54 -> is available even if they're already

3487.98 -> pregnant I mean I I guess I would not

3489.78 -> hesitate to really pursue that because

3492.119 -> it potentially could add to your

3495.9 -> um help you in terms of monitoring and

3499.859 -> kind of how you know your risk

3501.24 -> stratification for that patient

3502.559 -> potentially and delivery decision making

3504.359 -> as well yeah yep and then for the

3506.4 -> congenital heart disease population you

3508.079 -> know certain diseases common like

3509.339 -> tetralogy of the low well may only carry

3511.8 -> a four percent fetal um transmission

3513.66 -> rate but if the mom has genetic

3515.4 -> abnormality associated with astrology of

3517.14 -> flow autosomal dominant now it's a 50 so

3519.9 -> from a fetal screening standpoint has

3521.94 -> significant implications yeah very good

3528.18 -> um well I think that I mean with the we

3530.52 -> have one minute left

3532.559 -> um I think we're going to take um just

3536.04 -> to wrap up and again say thank you to

3538.079 -> everyone for joining us this evening

3539.88 -> thank you for the wonderful questions

3543.119 -> um we hope you had some good takeaways

3544.5 -> from our discussion here tonight and

3546.839 -> again we really thank you for joining us

3548.7 -> and

3550.319 -> um hope you have a good rest of your

3551.64 -> evening so thank you

3553.619 -> thank you

Source: https://www.youtube.com/watch?v=5babpnLMIfw