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ABSTRACT: Objectives: Recommendations for the peripartum obstetric management of women with heart disease have included early induction of labour, shortening the second stage of labour during vaginal delivery, and low threshold for elective Caesarean section, although such techniques may result in complications. The objective of this study was to determine whether a less aggressive approach without routine preterm induction, shortening of the second stage, or Caesarean section adversely affects the mother or neonate. Methods: We examined peripartum obstetric management and its relationship with adverse maternal and neonatal outcomes in 1677 pregnancies: 559 in women with heart disease and 1118 in women without heart disease (control subjects). Logistic regression with propensity matching was used to compare outcomes in women with and without heart disease. Results: Women with heart disease were more likely than control subjects to undergo induction of labour (P < 0.001). Induction of labour tended to be at term and for logistical reasons, not for the indication of maternal heart disease. Assisted vaginal deliveries were more common in women with heart disease (29% vs. 11%, P < 0.001) than in those without, and the second stage of labour was also more prolonged in women with heart disease. Rates of Caesarean section were similar in both groups (P = 0.66). A significant proportion of women with heart disease had unassisted vaginal deliveries. Invasive cardiac monitoring was rarely used. Adverse maternal cardiac events at delivery were rare (2% of pregnancies) and were not associated with mode of delivery. In multivariate analysis, maternal heart disease was not predictive of adverse neonatal events or third- or fourth- degree lacerations. Maternal heart disease was associated with postpartum hemorrhage, but this was not related to assisted delivery or prolonged second stage of labour. Conclusion: This large study has shown that in women with heart disease, avoidance of early induction of labour, rare use of Caesarean section for cardiac indications, and selective use of invasive monitoring produces safe obstetric outcomes.
Journal of obstetrics and gynaecology Canada: JOGC = Journal d'obstetrique et gynecologie du Canada: JOGC 09/2012; 34(9):812-9.
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ABSTRACT: Cardiovascular magnetic resonance (CMR) imaging is the reference standard for measurement of right ventricular (RV) volumes and function. To date, no study has compared methods of data acquisition and analysis by CMR for adults with a systemic RV. Our objective was to evaluate RV size and function using axial and short axis views in adults post atrial switch (Mustard) surgery. A total of 34 adults (20 male, mean age at CMR 32 ± 6 years) were identified at our centre. Volumes, RV end-diastolic (EDV) and end-systolic (ESV) were measured in short axis and axial orientations by two independent experienced readers, blinded to clinical and CMR data. Intra and interobserver measurements in each view were compared using Bland-Altman plots and intraclass correlation coefficients (ICC). Although mean volumes were larger in the axial as compared with the short axis view [RVEDV 247 ± 67 vs. 233 ± 54 ml (p = 0.002) and RVESV 148 ± 54 vs. 136 ± 50 ml (p = 0.001)], mean RV ejection fractions (EF) were similar [41 ± 9 % vs. 43 ± 12 % (p = 0.13)]. Bland-Altman plots demonstrated better agreement for axial measures of RVEDV and right ventricular ejection fraction (RVEF) within and between observers. Similarly, ICC values were stronger for axial as compared with short axis volumes and function-intraobserver RVEDV 0.99 (0.98-0.99) versus 0.96 (0.92-0.98) and RVEF 0.96 (0.93-0.98) versus 0.90 (0.82-0.95); interobserver RVEDV 0.97 (0.94-0.98) versus 0.90 (0.73-0.95) and RVEF 0.85 (0.53-0.94) versus 0.82 (0.67-0.90). Axially derived measurements of RV volumes and function have better agreement and reproducibility as compared with short axis values; whereas axial volumes tend to be larger, RVEF is not significantly different between the two methods.
The international journal of cardiovascular imaging 07/2012; · 2.15 Impact Factor
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Journal of Cardiovascular Magnetic Resonance 02/2012; 14 Suppl 1:P141. · 3.72 Impact Factor
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Laura Jimenez Juan,
Eric Krieger,
Anne Marie Valente,
Julia Ley-Zaporozhan,
Hadas Moshonov,
Bernd J Wintersperger,
Candice Silversides,
Sam Siu,
Andrew M Crean,
Sebastian Ley,
Jack M Colman,
Elsie T Nguyen,
Narinder S Paul,
Mathew Sermer, Rachel M Wald
Journal of Cardiovascular Magnetic Resonance 02/2012; 14 Suppl 1:O68. · 3.72 Impact Factor
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ABSTRACT: BACKGROUND: The utility of cardiac magnetic resonance imaging (CMR) for assessment of adults with Ebstein anomaly is not well-defined. We sought to evaluate CMR characteristics in this population and to relate these to exercise parameters. METHODS: We analyzed CMR studies in adults with unrepaired Ebstein anomaly for measures of severity of Ebstein disease, including atrialized, functional and total right ventricular (RV) volumes, ejection fraction (EF) and severity index (area of atrialized RV+right atrium/functional RV+left ventricle+left atrium). We related these CMR values to cardiopulmonary exercise test measurements. RESULTS: Twenty-seven adults (mean age 41±14years, 70% female) were included. Functional RV end-diastolic volume (EDV) was 150±68mL/m(2) and atrialized RVEDV was 25±24mL/m(2). In 17 patients (63%), the functional RVEDV was enlarged (>114mL/m(2)). Percent predicted peak VO(2) for the population was 65±20%. On univariable analysis, peak VO(2) was inversely related to atrialized RVEDV (p=0.011), total RVEDV (p=0.041), functional RVEDV/left ventricular EDV ratio (p=0.015) and magnitude of tricuspid valve displacement (p=0.031). In the multivariate model, the only CMR factor to relate to peak VO(2) was atrialized RVEDV (p=0.011, β=-0.48). No significant correlations were found between CMR measures and heart rate response or ventilatory response to exercise. CONCLUSION: In adults with unrepaired Ebstein anomaly, atrialized RV volume was independently related to aerobic capacity. The volume of the atrialized RV is a novel CMR measure which may express severity of disease. Further research is needed to evaluate the prognostic relevance of this exploratory work.
International journal of cardiology 08/2011; · 7.08 Impact Factor
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Daniel Tobler,
Andrew M Crean,
Andrew N Redington,
Glen S Van Arsdell,
Christopher A Caldarone,
Kumar Nanthakumar,
Dominik Stambach,
Laura Dos,
Bernd J Wintersperger,
Erwin N Oechslin,
Candice K Silversides, Rachel M Wald
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ABSTRACT: Adverse ventricular-ventricular interactions have been recognized in those with repaired tetralogy of Fallot (TOF) and severe pulmonary regurgitation.
We aimed to examine the impact of pulmonary valve replacement (PVR) on the left heart late after TOF repair.
Left ventricular (LV) volumes and ejection fractions (EF) were analyzed in adults with severe pulmonary regurgitation after TOF repair with cardiac magnetic resonance imaging (CMR) before and after PVR. Thirty-nine patients (median age 33[20-65] years) were reviewed. Post-PVR, LVEF improved significantly in the entire cohort (50±9%→54±7%, p<0.001) and in those with moderately impaired (defined as LVEF ≤45%) preoperative LVEF (38±5%→47±6%, p<0.0001), but was not statistically different in those with relatively preserved (defined as LVEF >45%) preoperative LVEF. By multivariate linear regression analysis to evaluate independent CMR predictors of improved LVEF post-PVR for the entire cohort, the only CMR variable to emerge was preoperative LVEF (p=0.012, regression coefficient -0.54, SE 0.13). Whereas PVR resulted in increased LV filling in patients with relatively preserved preoperative LVEF reflected by an increase in LV end-diastolic volumes (77±10→82±16mL/m(2), p=0.05), LV end-systolic volumes decreased after PVR in patients with impaired preoperative LVEF (65±12→54±10mL/m(2), p=0.001) but LV end-diastolic volumes were not significantly changed.
When LVEF is decreased after TOF repair, PVR appears to have a salutary effect on postoperative LVEF, thereby supporting the concept of recovery of adverse right-left heart interactions. Mechanisms of left heart improvement post-PVR differ depending on degree of preoperative LV systolic dysfunction.
International journal of cardiology 05/2011; 160(3):165-70. · 7.08 Impact Factor
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ABSTRACT: Young women with heart disease are increasingly being seen in obstetrical referral centres owing, in large part, to the dramatic improvements in survival of young adults with congenital heart disease in recent years. Although pregnancies in most women with heart disease result in favourable outcomes, there are important exceptions that must be recognized. These exceptions pose a significant mortality risk to the mother and/or the fetus. The present article provides a general framework for the classification of congenital heart lesions in pregnant women as well as a detailed lesion-specific review.
Paediatrics & child health 05/2011; 16(5):e33-7. · 0.78 Impact Factor
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ABSTRACT: Young women with heart disease are increasingly being seen in obstetrical referral centres owing, in large part, to the dramatic improvements in survival of young adults with congenital heart disease in recent years. Although pregnancies in most women with heart disease result in favourable outcomes, there are important exceptions that must be recognized. These exceptions pose significant mortality risk to the mother and/or the fetus. The present article outlines cardiovascular adaptations to pregnancy, general outcomes and management considerations for practitioners caring for pregnant young women with congenital heart disease. A lesion-specific review is published in a complementary article.
Paediatrics & child health 04/2011; 16(4):e25-9. · 0.78 Impact Factor
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Circulation 03/2011; 123(10):e373. · 14.74 Impact Factor
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ABSTRACT: No published studies have evaluated the role of cardiac magnetic resonance (CMR) imaging for the assessment of Ebstein anomaly. Our objective was to evaluate the right heart characteristics in adults with unrepaired Ebstein anomaly using contemporary CMR imaging techniques. Consecutive patients with unrepaired Ebstein anomaly and complete CMR studies from 2004 to 2009 were identified (n = 32). Volumetric measurements were obtained from the short-axis and axial views, including assessment of the functional right ventricular (RV) end-diastolic volume (EDV) and end-systolic volume. The volume of the atrialized portion of the right ventricle in end-diastole was calculated as the difference between the total RVEDV and the functional RVEDV. The reproducibility of the measurements in the axial and short-axis views was determined within and between observers. The median value derived from the short-axis and axial views was 136 ml/m(2) (range 59 to 347) and 136 ml/m(2) (range 63 to 342) for the functional RVEDV, 153 ml/m(2) (range 64 to 441) and 154 ml/m(2) (range 67 to 436) for the total RVEDV, 49% (range 32% to 46%) and 50% (range 40% to 64%) for the functional RV ejection fraction, respectively. The axial measurements demonstrated lower intraobserver and interobserver variability than the short-axis approach for all values, with the exception of the intraobserver functional RVEDV and interobserver total RVEDV for which the limits of agreement and variance were not significantly different between the 2 views. In conclusion, measurements of right heart size and systolic function in patients with Ebstein anomaly can be reliably achieved using CMR imaging. Axial imaging appeared to provide more reproducible data than that obtained from the short-axis views.
The American journal of cardiology 03/2011; 107(5):767-73. · 3.58 Impact Factor
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ABSTRACT: There is a growing population of young adults with tetralogy of Fallot. Although surgical approaches have evolved, many adults with repaired tetralogy of Fallot have been left with residual pulmonary regurgitation. Pulmonary regurgitation is an important contributor to a number of late complications including exercise limitations, right heart failure, arrhythmia, and sudden death. Because bioprosthetic valves are used in this population, clinicians must weigh the beneficial effects of pulmonary valve replacement against the associated risks, including subsequent re-operation. In this review, we will appraise the evidence supporting pulmonary valve replacement in the adult with repaired tetralogy of Fallot, as well as the optimal timing and mode of intervention.
Pediatric Cardiac Surgery Annual of the Seminars in Thoracic and Cardiovascular Surgery 01/2011; 14(1):92-7.
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ABSTRACT: Up to one third of the population will die as a direct result of cancer. Accurate and timely diagnosis of disease often requires multiple different approaches including the use of modern imaging techniques. Prompt recognition of adverse consequences of some anti-cancer therapies also requires a knowledge of the optimum imaging strategy for the problem at hand. The purpose of this article is to review not only some of the commoner cardiovascular manifestations of malignancy but also to discuss the strengths, weaknesses and appropriate use of cardiovascular imaging modalities.
Cardiology research and practice. 01/2011; 2011:378041.
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Cardiology in the Young 12/2010; 20(6):699-700. · 0.76 Impact Factor
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ABSTRACT: The right ventricular (RV) systolic function is important for decision making in adults with repaired tetralogy of Fallot (rTOF). Our aim was to assess regional RV systolic function and its impact on global RV systolic function by echocardiography.
In 101 adults with rTOF, regional RV systolic function on echocardiography was compared to 50 individuals with structurally normal hearts. In patients with rTOF, the impact of echocardiographic measures of regional RV systolic function on global RV-ejection fraction as measured by cardiac magnetic resonance imaging (CMR-RVEF) was determined.
Compared to normals, patients with rTOF had impaired systolic function of the RV outflow tract. Patients with rTOF and normal CMR-RVEF compensate this loss of RV outflow tract function with increased contractions of the RV-body, measured as fractional area change on short axis (30±12% versus 19±7%, p<0.0001) and on 4-chamber views (42±7% versus 38±8%, p=0.06). In contrast, patients with rTOF and abnormal global CMR-RVEF showed significantly lower systolic function of the RV-body compared to normal controls (fractional area change on 4-chamber view: 31±6% versus 38±8%, p<0.0001). A simple regression model, incorporating fractional shortening of RV outflow tract and fractional area change on 4-chamber view allows accurate echocardiographic estimation of the CMR-derived RVEF.
Patients with repaired tetralogy of Fallot have markedly different regional systolic RV-function compared to normals, even when the global RV systolic function is preserved. The systolic function of the RV outflow tract and of the RV body are both important determinants of global systolic RV function in these patients. Their prognostic significance needs to be determined.
International journal of cardiology 12/2010; 157(1):53-8. · 7.08 Impact Factor
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ABSTRACT: The objectives of this study were to examine: 1) B-type natriuretic peptide (BNP) response to pregnancy in women with heart disease; and 2) the relationship between BNP levels and adverse maternal cardiac events during pregnancy.
Pregnancy imposes a hemodynamic stress on the heart. BNP might be a useful biomarker to assess the ability of the heart to adapt to the hemodynamic load of pregnancy.
This was a prospective study of women with structural heart disease seen at our center. Serial clinical data and plasma BNP measurements were obtained during the first trimester, third trimester, and after delivery (>6 weeks).
Seventy-eight pregnant women were studied; 66 women with heart disease (age 31 ± 5 years), and 12 healthy women (age 33 ± 5 years). During pregnancy, the median peak BNP level was higher in women with heart disease compared with control subjects (median 79, interquartile range 51 to 152 pg/ml vs. median 35, interquartile range 21 to 43 pg/ml, p < 0.001). In women with heart disease, those with subaortic ventricular dysfunction had higher BNP levels (p = 0.03). A BNP >100 pg/ml was measured in all women with events during pregnancy (n = 8). Sixteen women had increased BNP levels during pregnancy but did not have clinical events. None of the women with BNP ≤100 pg/ml had events. BNP ≤100 pg/ml had a negative predictive value of 100% for identifying events during pregnancy.
Many pregnant women with heart disease have increased BNP levels during pregnancy. Incorporating serial BNP levels in into clinical practice can be helpful, specifically in adjudicating suspected adverse cardiac events during pregnancy.
Journal of the American College of Cardiology 10/2010; 56(15):1247-53. · 14.16 Impact Factor
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ABSTRACT: There is a growing population of young women of child-bearing age with complete transposition of the great arteries (TGA) who have had an arterial switch operation (ASO). Pregnancy imposes a hemodynamic stress on the heart and, therefore, adverse cardiac events can occur during this period; however, pregnancy outcomes in this population have not been well studied. We sought to describe cardiac outcomes during pregnancy in women with TGA who had undergone an ASO in childhood. Women were identified from 2 large tertiary care hospitals. A retrospective chart review was performed to determine the prevalence of adverse maternal cardiac events during pregnancy. Overall, 74 women of child-bearing age were identified, 9 of whom had 17 pregnancies. There were 4 miscarriages. Six women (67%) had clinically important valve (n = 5) and ventricular (n = 1) lesions before the index pregnancy. Two women developed cardiac complications during pregnancy; 1 woman with impaired left ventricular systolic function had nonsustained ventricular tachycardia and 1 woman with a mechanical systemic atrioventricular valve developed postpartum valve thrombosis. There were no maternal deaths. In conclusion, young women with TGA from this early cohort repaired with ASO are reaching child-bearing age. A significant proportion have residua and/or sequelae that can confer risk for adverse cardiac events in pregnancy. Co-ordinated care between a congenital heart disease specialist and a high-risk obstetrician should be implemented.
The American journal of cardiology 08/2010; 106(3):417-20. · 3.58 Impact Factor
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ABSTRACT: Congenitally corrected transposition of the great arteries (CCTGA) in the absence of major cardiac anomalies is thought to have a good outcome, although this has not been well documented. The objective of the present study was to compare the characteristics and outcomes of patients with a prenatal diagnosis of CCTGA to the characteristics and outcomes of those diagnosed postnatally. The optimal outcome was defined as intervention-free survival. All patients with CCTGA diagnosed prenatally and postnatally from 1999 to 2006 at 2 tertiary care institutions were reviewed. Patients with a single ventricle, heterotaxy, or valvar atresia were excluded. The differences between groups were assessed using the t test and chi-square test. A total of 54 patients (16 prenatal with 14 live born and 39 postnatal) were included. The patients diagnosed prenatally were diagnosed at a median gestational age of 20 weeks (range 16 to 37). Two deaths in each group were due to heart failure. The intervention-free survival rate for the prenatal and postnatal groups at 1, 6, and 36 months was 79%, 45%, and 30% and 85%, 61%, and 23%, respectively (p = NS). Of 37 patients, 14 (38%) underwent an arterial switch plus atrial baffling so that the morphologic left ventricle supported the systemic circulation, and 6 (16%) underwent repair of associated lesions so the morphologic right ventricle supported the systemic circulation; 4 (11%) of the 37 patients had pacemaker only. Prenatal patients with >1 fetal echocardiogram (12 of 14) did not have progression before birth. In conclusion, CCTGA has a >70% risk of intervention in the first 3 years after birth. The outlook is guarded and has an important effect on prenatal counseling.
The American journal of cardiology 11/2009; 104(9):1276-9. · 3.58 Impact Factor
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ABSTRACT: Individuals with repaired tetralogy of Fallot (TOF) comprise a substantial proportion of the current adult congenital heart disease population. Pulmonary regurgitation (PR) is one of the most prevalent postoperative sequelae, but timing of pulmonary valve replacement (PVR) in the asymptomatic TOF patient remains controversial.
We sought to explore thresholds for PVR referral among adult congenital physicians.
Physicians attending an international adult congenital cardiac disease conference were given a survey focusing on PVR referral patterns for the asymptomatic individual with repaired TOF. Survey questions related to an asymptomatic adult with repaired TOF, at least moderate PR, and varying degrees of right ventricular (RV) dilation and RV dysfunction.
A total of 128 surveys were completed. Nine percent did not feel that PVR was indicated in the asymptomatic patient. Of those practitioners who felt that PVR was indicated, many [(69%, [74/107]) relied on RV end-diastolic volumes (RVEDV) to guide decision making. Fewer relied on RVEDV for surgical referral as RV ejection fraction (EF) decreased. RVEDV thresholds for PVR referral varied depending on the RV function: with normal RVEF, 180 cc/m(2) was the most commonly used cutoff; if RV dysfunction was significant, 150 cc/m(2) was the threshold most often cited. Physicians who utilized RV volumes to guide decision making tended to work in a tertiary care setting (P= 0.008).
PVR referral patterns for an asymptomatic TOF patient with significant PR and important RV dilation are variable among adult congenital cardiologists. Uncertainty regarding thresholds for PVR referral underscores the need for further study of this important issue.
Congenital Heart Disease 08/2009; 4(4):231-8. · 0.90 Impact Factor
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04/2009: pages 237 - 259; , ISBN: 9781444311846
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ABSTRACT: The underlying mechanisms that contribute to global right ventricular (RV) dysfunction in patients with repaired tetralogy of Fallot are incompletely understood. We therefore sought to quantify regional RV abnormalities and to determine the relationship of these to global RV function and exercise capacity.
Clinical and cardiac magnetic resonance data from 62 consecutive patients with repaired tetralogy of Fallot were analyzed (median age at follow-up 23 years [limits 9 to 67 years]). Using cardiac magnetic resonance data, 3D RV endocardial surface models were reconstructed from segmented contours, and a correspondence between end diastole and end systole was computed with a novel algorithm. Regional RV abnormalities were quantified and expressed as segmental ejection fraction, spatial extent of dyskinetic area, displacement of dyskinetic area, and score of extent of late gadolinium enhancement. Regional abnormalities of function and hyperenhancement were greatest in the RV outflow tract (RVOT). These regional RVOT abnormalities correlated with global RV ejection fraction: RVOT ejection fraction r=0.64, P<0.0001; RVOT dyskinetic area r=-0.51, P<0.0001; RVOT displacement of dyskinetic area r=-0.49, P<0.0001; and RVOT late gadolinium enhancement score r=-0.33, P=0.01. Peak oxygen consumption during exercise correlated best with RVOT ejection fraction (r=0.56, P=0.0002) compared with the remainder of the RV (r=0.35, P=0.03). The only cardiac magnetic resonance variable independently predictive of aerobic capacity was RVOT ejection fraction (P=0.02).
A greater extent of regional abnormalities in the RVOT adversely affects global RV function and exercise capacity after tetralogy of Fallot repair. These regional measures may have important implications for patient management, including RVOT reconstruction, at the time of pulmonary valve replacement.
Circulation 04/2009; 119(10):1370-7. · 14.74 Impact Factor
