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In this episode, CardioNerds (Amit Goyal), Cardio-OB series co-chair and UT Southwestern cardiology fellow, Dr. Sonia Shah, and episode lead fellow, Dr. Laurie Femnou (UT Southwestern) are joined by Dr. Michael Luna (UT Southwestern) to discuss cardiovascular interventions during pregnancy. We discuss practical considerations for performing coronary angiography and valvular interventions in the pregnant patient, the timing and indication of procedures, and ways to minimize radiation exposure to both mom and baby. Audio editing by CardioNerds Academy Intern, Hirsh Elhence.

Pearls • Notes • References • Guest Profiles • Production Team

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Pearls- Cardiac Interventions during Pregnancy

1. Attempt should be made to manage pregnant patients with valvular disease with medical therapy, and cardiac interventions during pregnancy should be considered a last resort.
2. Ideally, procedures in the gravid patient should be performed after 20 weeks gestation to minimize fetal risk. 
3. Specific ways to minimize radiation to the pregnant patient and fetus in the catheterization lab include: using an abdominal shield, radial access for coronary procedures, proper positioning of the C-arm to avoid extreme angulation, using collimation, and minimizing fluoroscopic time, frame rate, and use of cine-acquisition. When appropriate, intracoronary imaging modalities (ie. IVUS or OCT) should also be considered.
4. Fetal monitoring should be performed during any cardiac intervention in the pregnant patient
5. Multidisciplinary involvement and contingency planning are critical for the success of any high-risk cardiac intervention in the pregnant patient.

Quatables – Cardiac Interventions during Pregnancy

“Meetings including all providers— our cardiac surgical colleagues, cardiac anesthesiologists, and our obstetrics team—in the care of [pregnant] patients has to be had well ahead of a cardiac procedure to plan every detail.”

Show notes – Cardiac Interventions during Pregnancy

1. What are special considerations for performing a balloon valvuloplasty in a pregnant patient with mitral stenosis?

•  In pregnant patients with severe mitral stenosis who cannot be adequately managed with medical therapy, percutaneous balloon mitral valvuloplasty (PMBV) is the treatment of choice given the high risk of morbidity and fetal loss with cardiac surgery.
• Ideally, procedures in the gravid patient should be performed after 20 weeks gestation to minimize risk to the fetus. 
• Assessment of valve anatomy and consideration of the Wilkin’s score are especially important in pregnant patients to minimize the risk of peri-procedural complications.
• PBMV should performed at experienced centers with cardiac surgery and MFM available.
• Complications of PBMV are rare but include atrial perforation, cardiac tamponade, arrhythmias, emboli, mitral regurgitation, hypotension and maternal death. Mechanical support should be readily available and a delivery strategy in place in case there is sudden maternal or fetal deterioration.

2. What are ways to minimize radiation exposure in the catheterization lab to the pregnant patient and fetus?

• The general principle for imaging during pregnancy is similar to imaging for the general population, with the goal of radiation exposure being as low as reasonably achievable (ALARA). The mean radiation exposure to the unshielded abdomen is 1.5 mGy, and <20% of this reaches the fetus. 
• Specific ways to minimize radiation to the pregnant patient and fetus in the catheterization lab include the following: using an abdominal shield, radial access for coronary procedures, proper positioning of the C-arm to avoid extreme angulation, using collimation, and minimizing fluoroscopic time, frame rate, and use of cine-acquisition. When appropriate, intracoronary imaging modalities (ie IVUS or OCT) should also be considered.

3. What should we know about coronary angiography and revascularization in the pregnant woman?

• According to a large US-based study of 859 patients presenting with acute myocardial infarction during pregnancy and the postpartum period, less than half of patients undergo cardiac catheterization. In stable, low-risk NSTEMI, a non-invasive approach should be considered per ESC guidelines. In pregnant patients who present with STEMI, PCI is the preferred revascularization strategy.
• Radial access should be used if possible, as femoral artery access involves direct pelvic radiation.
• In pregnancy-associated SCAD, enhanced vascular vulnerability should be considered when performing angiography, from obtaining access to engaging the coronary ostia.
• Fetal monitoring should be performed during any cardiac intervention in the pregnant patient

4. What is the role of mechanical support in the management of peripartum patients with cardiogenic shock?

• Urgent intervention with mechanical assist support, including intra-aortic balloon pump, impella, and VA-ECMO, may be necessary in rare circumstances. Prompt assessment of hemodynamics can be helpful to determine the level of support needed. Axillary access may be considered in patients with favorable anatomy.

References

Patel C, Akhtar H, Gupta S, Harky A. Pregnancy and cardiac interventions: What are the optimal management options? Journal of Cardiac Surgery, 2020. 35(7): 1589-1596.

Regitz-Zagrosek V, Lundqvist CB,  Borghi C, et al. ESC Guidelines on the management of cardiovascular diseases during pregnancy The Task Force on the Management of Cardiovascular Diseases during Pregnancy of the European Society of Cardiology (ESC). European Heart Journal, 2011. 32, 3147–3197 doi:10.1093/eurheartj/ehr218

Guest Profiles

CardioNerds Cardioobstetrics Production Team