Cardio Obstetrics

New-onset myocardial injury in pregnant patients with coronavirus disease 2019: a case series of 15 patients. Mercedes BR, Serwat A, Naffaa L, Ramirez N, Khalid F, Steward SB, Feliz OGC, Kassab MB, Karout L.Am J Obstet Gynecol. 2020 Oct 22:S0002-9378(20)31206-0. doi: 10.1016/j.ajog.2020.10.031. Online ahead of print.PMID: 33098814 Free PMC article.   Take Home Points - Damien Cullington   Observational study from a single institution from Dominican Republic Study period March 20 2020 - June 30 2020 Total number of symptomatic pregnant patients admitted in study period with COVID-19= 154. Assessment of the clinical, laboratory, radiological and outcomes of 15 pregnant women infected with COVID-19 who developed myocardial injury and ventricular dysfunction – 10% of the larger cohort. Two thirds of patients in the myocardial injury cohort presented with dyspnoea and 16% with palpitations. Patients were admitted circa 10 days (+/- 3 days) after symptoms began. All patients with myocardial injury were admitted to ICU and 87% required ventilation. Mean LV ejection fraction in those with COVID-19 myocardial injury measured 38% (+/- 6.4%) 2 deaths were reported in the myocardial injury group equating to a 13% mortality rate in women with COVID-19 infection and ensuing ventricular dysfunction.   Commentary from Dr. Damien Cullington (Liverpool, UK), chief section editor of Cardio-Obstetrics Journal Watch: COVID-19 has turned the world on its head and as a healthcare community we continue to grapple with understanding whom it may infect and in whom it may have the most profound effects. We certainly have a much wider understanding now as to which individual risk factors convey added risk of significant complications e.g. age, diabetes, BMI, ethnicity.   Throughout the pandemic in the UK, pregnant women have been viewed as being vulnerable to the potential consequences of COVID-19 infection. This is supported by data from the CDC which states that pregnant women are more likely to require hospitalisation than non-pregnant women (31.5% vs 5.8%). Pregnant women are also more likely to be admitted to the ICU requiring mechanical ventilation than non-pregnant patients although local practice may vary.   COVID-19 infection usually results in myocardial injury and ventricular dysfunction in a minority of patients – more-so in patients with severe infection requiring admission to the ICU.   Angiotensin-converting enzyme 2 (ACE-2) receptors are thought to be the entry for COVID-19 into cells. ACE-2 receptor expression increases during pregnancy. COVID-19 infection down-regulates ACE-2 receptors, eliminating cardio-protective effects and this can result in increasing concentrations of TNF-alfa and inflammation.   Results   In the study period March-June 2020, 154 pregnant symptomatic patients presented to this particular hospital, 77 of whom were admitted with ‘moderate’ disease. Thirty four patients had ‘severe’ disease requiring ICU admission and 15 developed myocardial injury (TnI positive) and LV dysfunction (Table 1 & 2).   Maternal and Foetal Outcomes (Table 3) All patients delivered by caesarean section – 60% of whom were pre-term, mostly due to maternal clinical instability. The mean gestational age at delivery was 34.2 +/- 4 weeks. Two patients died post-delivery due to ventricular tachyarrhythmias (VT and TdP). There was one foetal death at 23.3 weeks but this was in the setting of the mother being haemodynamically unstable.           Limitations   Aside from airway and circulatory management, the study cohort predates the use of other guideline based routine therapy used to treat serious COVID-19 infection e.g. dexamethasone – how this and other agents modify outcomes would be of interest. How ethnicity is a risk for COVID-19 infection during pregnancy would certainly be of interest too but cannot be answered by this study. It is not known whether myocardial injury was due to myocarditis or due to Type II myocardial infarction secondary to multi-organ failure. No follow up data is provided regarding myocardial recovery.   Conclusions   This was a single centre observational study reporting outcomes in pregnant women admitted to ICU during the ‘first wave’ of COVID-19 infection in the Dominican Republic. Mortality within this one hospital for pregnant patients admitted with symptomatic COVID-19 infection was 1.3%. Generalisations are difficult to extrapolate to population wide data but provide important insights and highlight important future research questions. Geographic variations in management of COVID-19 together with demographics and risk posed by ethnic status will all be important to understand in time. Treatment for COVID-19 is constantly evolving and inevitably COVID-19 infection and virulence will change too but this study offers a useful snapshot of ‘first wave’ COVID-19 infection in a solely pregnant dataset.      

Pregnancy Outcomes in Women After Arterial Switch Operation for Transposition of the Great Arteries: Results From ROPAC (Registry of Pregnancy and Cardiac Disease) of the European Society of Cardiology EURObservational Research Programme Tutarel O, Ramlakhan KP, Baris L, Subirana MT, Bouchardy J, Nemes A, Vejlstrup NG, Osipova OA, Johnson MR, Hall R, Roos-Hesselink JW; ROPAC (Registry of Pregnancy and Cardiac Disease) Investigators Group *.J Am Heart Assoc. 2021 Jan 5;10(1):e018176. doi: 10.1161/JAHA.120.018176. Epub 2020 Dec 22.PMID: 33350866 Free article.   Take Home Points: Women with Transposition of the Great Arteries post arterial switch operation can be reassured that pregnancy is safe with a low risk of maternal cardiac complications. Similar to other cardiac pregnancies, premature delivery (17.1%) and low birth weight (14.6%) are the most significant fetal complications. The impact of pregnancy on maternal valvular and ventricular function in the TGA post arterial switch population remains unknown.   Commentary from Dr. Jasmine Grewal (Vancouver, BC, Canada), section editor of Cardio-Obstetrics Journal Watch: This prospective study reports the maternal and fetal outcomes of 41 pregnancies in women with Transposition of the Great Arteries post arterial switch from the ROPAC (Registry of Pregnancy and Cardiac Disease) of the European Society of Cardiology EURObservational Research Program. Data on pregnancy outcomes in this population have been limited and hence no formal risk stratification in the modified WHO classification. Of the 5739 patients included in the ROPAC registry between 2007-2018, 41 were post arterial switch. As compared to the rest of the cohort in which 40% were from an emerging country, 5% in the study group were from an emerging country. The vast majority (97.6%) were NYHA I/II and 24% were on a cardiac medication pre-pregnancy. Maternal outcomes were very good with no maternal mortality during pregnancy and up to 6 months post-partum. A major cardiovascular event occurred in 2 women (5%): one acute heart failure admission thought to be related to reduced systemic ventricular function and one ventricular tachycardia treated with beta-blockers as an outpatient. One fetal loss was reported with no neonatal loss. Other fetal complications of premature birth (17%) and low birth weight (14.6%) were not statistically different than the rest of the ROPAC cohort. The current study is reassuring with favorable maternal and fetal outcomes in this population. However, there is limited data available on the trajectory of valve and ventricular function over the course of pregnancy and into the post-partum period.   

Fatality rates and use of systemic thrombolysis in pregnant women with pulmonary embolism. Hobohm L, Keller K, Valerio L, Ni Ainle F, Klok FA, Münzel T, Kucher N, Lankeit M, Konstantinides SV, Barco S.ESC Heart Fail. 2020 Oct;7(5):2365-2372. doi: 10.1002/ehf2.12775. Epub 2020 Jun 21.PMID: 32567197 Free PMC article.   Take Home Points: Pulmonary embolism has a high mortality rate in pregnant women. Even with thrombolysis once there is haemodynamic compromise there were very high mortality rates. Pulmonary embolism is a common problem pregnancy, complicating 2.2 cases per 10,000 pregnancies and represents 14% of all maternal deaths. Commentary from Dr. Reza Ashrafi (Liverpool, United Kingdom), section editor of Cardio-Obstetrics Journal Watch:   Methods A retrospective analysis of 11 years’ worth of inpatient data from the German national inpatient registry. All pregnant patients were analysed and identified if they had been coded for pulmonary embolism (PE) or obstetric thromboembolism. Administrative data records were then reviewed for management and outcomes from the embolism or thromboembolic event including haemodynamic failure, thrombolysis and maternal death.   Results Over an 11 year period there 8,271,327 livebirths and 1846 hospitalisations with pregnancy associated pulmonary embolism with a median maternal age of 31. Median inpatient stay was 8 days. Overall there was a downward trend in the incidence and mortality of PE during the timeframe of the study (Figure 1).     There was a significant increase in the incidence of PE in the final 4 weeks of pregnancy and in patients who had surgery during their in-hospital stay.   Of 151 women with haemodynamic failure and PE only 51 received thrombolysis with a trend towards use either early in pregnancy or in the final 4 weeks. There was a trend towards an increase in the odds of death in patients receiving thrombolysis (age adjusted odds ratio 3.48).       Discussion Whilst the study is limited by the retrospective nature of the data and the fact it is based on administrative data it does identify the continuing high mortality risk of PE in pregnancy. Once haemodynamic deterioration sets in, thrombolysis is only partially effective as evidenced by the high in-hospital mortality in the thrombolysis group of 43%.   Given the lack of data at a patient level available to the authors it is not possible to suggest thrombolysis is under or overused or that it is clearly associated with worse outcomes only that it requires more research.   More work is needed in identification and prevention for PE before haemodynamic failure occurs.   

Brisandy Ruiz Mercedes, MD; Ayna Serwat, MBBS; Lena Naffaa, MD; Nairovi Ramirez, MD; Fatima Khalid, MBBS; Sofia B. Steward, MD; Omar Gabriel Caro Feliz, MD; Mohamad Bassam Kassab, MD; Lina Karout, MD   Take Home Points - Damien Cullington Observational study from a single institution from Dominican Republic Study period March 20 2020 - June 30 2020 Total number of symptomatic pregnant patients admitted in study period with COVID-19= 154. Assessment of the clinical, laboratory, radiological and outcomes of 15 pregnant women infected with COVID-19 who developed myocardial injury and ventricular dysfunction – 10% of the larger cohort. Two thirds of patients in the myocardial injury cohort presented with dyspnoea and 16% with palpitations. Patients were admitted circa 10 days (+/- 3 days) after symptoms began. All patients with myocardial injury were admitted to ICU and 87% required ventilation Mean LV ejection fraction in those with COVID-19 myocardial injury measured 38% (+/- 6.4%) 2 deaths were reported in the myocardial injury group equating to a 13% mortality rate in women with COVID-19 infection and ensuing ventricular dysfunction. Dr. Reza Ashrafi Adult Congenital Heart Disease and Electrophysiology Liverpool, UK   Reza Ashrafi BSc MBBS MD MCRP is a consultant adult congenital cardiologist who works at Liverpool Heart and Chest Hospital. He qualified in 2006 from St. Bartholomew’s and The Royal medical school. He was awarded a doctorate in medicine (MD) in 2017 from the University of Liverpool for work on cardiac genetic expression changes in diabetes. He was appointed a consultant in 2018 in Liverpool. His clinical and research interests include complex mapping and ablation in congenital heart disease and novel techniques in complex pacing in congenital heart disease.   COVID-19 has turned the world on its head and as a healthcare community we continue to grapple with understanding whom it may infect and in whom it may have the most profound effects. We certainly have a much wider understanding now as to which individual risk factors convey added risk of significant complications e.g. age, diabetes, BMI, ethnicity. Throughout the pandemic in the UK, pregnant women have been viewed as being vulnerable to the potential consequences of COVID-19 infection. This is supported by data from the CDC which states that pregnant women are more likely to require hospitalisation than non-pregnant women (31.5% vs 5.8%). Pregnant women are also more likely to be admitted to the ICU requiring mechanical ventilation than non-pregnant patients although local practice may vary. COVID-19 infection usually results in myocardial injury and ventricular dysfunction in a minority of patients – more-so in patients with severe infection requiring admission to the ICU. Angiotensin-converting enzyme 2 (ACE-2) receptors are thought to be the entry for COVID-19 into cells. ACE-2 receptor expression increases during pregnancy. COVID-19 infection down-regulates ACE-2 receptors, eliminating cardio-protective effects and this can result in increasing concentrations of TNF-alfa and inflammation.   Results In the study period March-June 2020, 154 pregnant symptomatic patients presented to this particular hospital, 77 of whom were admitted with ‘moderate’ disease. Thirty four patients had ‘severe’ disease requiring ICU admission and 15 developed myocardial injury (TnI positive) and LV dysfunction (Table 1 & 2).     Maternal and Foetal Outcomes (Table 3) All patients delivered by caesarean section – 60% of whom were pre-term, mostly due to maternal clinical instability. The mean gestational age at delivery was 34.2 +/- 4 weeks. Two patients died post delivery due to ventricular tachyarrhythmias (VT and TdP). There was one foetal death at 23.3 weeks but this was in the setting of the mother being haemodynamically unstable.     Limitations Aside from airway and circulatory management, the study cohort predates the use of other guideline based routine therapy used to treat serious COVID-19 infection e.g. dexamethasone – how this and other agents modify outcomes would be of interest. How ethnicity is a risk for COVID-19 infection during pregnancy would certainly be of interest too but cannot be answered by this study. It is not known whether myocardial injury was due to myocarditis or due to Type II myocardial infarction secondary to multi-organ failure. No follow up data is provided regarding myocardial recovery.   Conclusions This was a single centre observational study reporting outcomes in pregnant women admitted to ICU during the ‘first wave’ of COVID-19 infection in the Dominican Republic. Mortality within this one hospital for pregnant patients admitted with symptomatic COVID-19 infection was 1.3%. Generalisations are difficult to extrapolate to population wide data but provide important insights and highlight important future research questions. Geographic variations in management of COVID-19 together with demographics and risk posed by ethnic status will all be important to understand in time. Treatment for COVID-19 is constantly evolving and inevitably COVID-19 infection and virulence will change too but this study offers a useful snapshot of ‘first wave’ COVID-19 infection in a solely pregnant dataset.