Heart disease in pregnancy

CONSULTANT GUIDE : DR RAJESH KUMARI

SR GUIDE : DR APRAJITA KUMARI
PRESENTER DR VIJAYA BHARATHI KRISHNARAJA
Contents
• Epidemiology
• Morbidity and mortality
• Cardiovascular alterations during pregnancy
• Effects of pregnancy in heart disease
• Effects of heart disease in pregnancy
• Pregnancy and cardiac disease
• Specific cardiac conditions ( congenital/ acquired )
• Conclusion
Epidemiology congenital heart
disease ( 75-82%)

Developed Shunt lesions ( 20-

Why is incidence increasingcountries
? 65 %)
Increasing age at first pregnancy
BetterIncidence
surgical: treatments for Hypertensive
congenital heart (disease
( overall ) 0.1-4% disorders – 5-10 %
worldwide) of all pregnancy

RHD
Developing
predominant : 56-
countries
89 %
Rutherford JD . Heart failure in pregnancy .Curr Heart Fail Rep , 2012 ;9:277-281
➢ Retrospective analysis , 207 pregnant women with cardiac disease who delivered at ≥28
weeks of gestation from June 1994 through December 2000 at AIIMS.
➢ Rheumatic heart disease ( 88%) with isolated mitral stenosis was the predominant
cardiac problem.
➢ Septal defects were the most common form of congenital heart disease
➢ 13.52% women, the diagnosis of cardiac disease was made during pregnancy.
➢ Cardiac complications were noted in 29.95% and fetal complications in 20.28%
pregnancies.
➢ Patients in NYHA class I/II had fewer maternal complications and their babies had a
higher birth weight than those in NYHA class III/IV .
➢ Maternal and fetal outcome was better in patients with prosthetic valves 97.4% of them
remained in NYHA class I/II. Surgical correction of the cardiac lesion prior to
pregnancy was associated with better pregnancy outcome.
➢ None of the newborns of mothers who had received anticoagulants had any congenital
malformation.
Morbidity and mortality
Leading cause of death in women of 25 to 44 years .
ICU admission rates – 6.4 per 1000 deliveries
Farr A ,outcomes and trends of peripartum maternal admissions to the ICU ,2017

Maternal mortality ~ 2.1%

Centre for maternal and child enquiries ,2011
Physiological changes

During During
Post partum
pregnancy labour
Physiological changes during pregnancy
Cardiac output 40-50%
Plasma volume 40-50 %
stroke volume 30-50 %
heart rate 10-20 bpm
heart size upto 30 %

Systemic peripheral resistance

30%
systolic ( 3-5 mm hg )
diastolic pressure ( 5-10 mm
hg )
European Heart Journal (2018 )
Physiological changes in pregnancy

Plasma volume increases 40%

in pregnancy, half of this
increase takes place by 8
weeks and maximum by 24
weeks gestation
Systolic BP (SBP)
In early pregnancy
typically falls early in
increased SV is primary
gestation and diastolic
factor and late
BP (DBP) is usually 10
pregnancy, heart rate is
mmHg below baseline
the major factor for
in the second
increase in cardiac
trimester( active
output
vasodilation by
prostacyclin and
nitrous oxide
European Heart Journal (2011)
Hemodynamic changes during pregnancy
Physical findings in normal pregnancy
Indicators of heart disease in
pregnancy
Inspection
•Hyperventilation
Cyanosis
••Peripheral
Clubbingedema
••Distended neck veins
Systolic murmur with3/6
grade prominent
or morea and v waves and brisk x and y descents
••Capillary
Diastolicpulsation
murmur
• Cardiomegaly
Precordial palpation
• Persistent split S2
•Brisk, diffuse and displaced left ventricular impulse
•• Persistent arrhythmia
Palpable right ventricular impulse
Persistent
••Palpable neck vein
pulmonary
distention
trunk impulse
• Equivocal enlargement of heart (X-
ray).
Auscultation
Presence basilar
••Pulmonary of arrhythmias,
rales
atrial
fibrillation or flutter
•Increased S1 with exaggerated splitting
•Midsystolic ejection type murmurs at lower left sternal edge and over the pulmonary area
•Continuous murmurs (cervical venous hum, mammary soufflé)
Braunwald E et al. Heart Disease. 2001. pg
 Imaging
ECG Changes CXR Changes Echocardiogram

• Left axis deviation (15) • Straightening of left upper • Slightly increased EDV
• Sinus tachycardia cardiac border and ESV
• st segment and t wave • Horizontal positioning of • Slightly improved LV
changes in inferior leads heart function
• Small Q, inverted p or t • Increased lung marking • Enlargements of
wave in lead III • Small pleural effusion at ventricular dimensions
• Inverted t wave in lead V1 early postpartum • Slight enlargement of left
, V2 occasionally V3 atrial size
• Small pericardial effusion
• Increased tricuspid
annulus diameter
• Functional tricuspid
regurgitation

Braunwald E et al. Heart Disease. 2001. pg

Physiological changes during labour

Uterine contractions
Auto transfusion of 300-500 ml blood

Maternal position

Pain , anxiety stress increase cardiac output by 50 – 61 %

Anasthesia , analgesia increase cardiovascular stress

Bleeding , post partum haemorrhage

Cardiac output
Early labour : 15 % increase
Stage 1 : 25 % increase
European Heart Journal (2018)
Stage 2 : 50 % increase
Physiological changes post partum
• Cardiac output – increase by 80 %
reasons :
1)Uterine involution
2)Resorption of leg edema

• Hemorrhage induces additional cardiovascular stress

Effects of pregnancy on heart disease

Congestive
Pulmonary Sudden
heart failure
edema death
Danger period of cardiac decompensation
▪6-8 weeks : peripheral vasodilatation- CO increases by 20%
▪Between 28-32 weeks. pregnancy- induced hypervolemia and cardiac output
reach their maximum
▪Labor and delivery
▪Immediate post partum
▪4-5 days after delivery

European Heart Journal (2011)

Effect of cardiac disease on pregnancy

Preterm delivery

Fetal Growth Restriction

Congenital heart disease (4.5% vs 0.6%)

Fetal Death

European Heart Journal (2011)

 Pre Risk
conceptional assessment Contraindications
counselling in heart to pregnancy Pregnancy
Genetic testing disease

Method of termination
Approach to

Pregnancy and
pregnant
patients wit
heart disease

heart disease Fetal

maternal
assessment Antenatal
Classify
( Assess
and
assessment interventions care NYHA/WH radiation
and follow up O) exposure

Risk of neonatal complications Cardiac surgery / percutaneous therapy Classify after history ,
examination ,investigations
Labour
and
delivery

Timing and Stage wise,

mode of monitoring Anasthesia and Post Breast feeding
delivery,
method of
and analgesia partum and
induction
management
of labour
considerations period contraception

Pregnancy with anticoagulants Special circumstances

Women on anticoagulants in labour
 Initial assessment Subsequent assessment
Pre conceptional counselling Antepartum management
Risk assessment ( medical , surgical and obstetric
management )
Assessment of pregnant patient
Fetal assessment
Peripartum management
Pre-conceptional counselling
autosomal dominant
disease (e.g. Marfan
Explain anticipated complications during pregnancy , syndrome,
delivery hypertrophic
& their
cardiomyopathy, or long
risks to mother and fetus QT syndrome) have an
inheritance risk of 50%,
regardless of gender of the
affected parent
Advice against pregnancy in certain situations including contraception

Information about congenital heart disease in their offspring

High risk pregnancy : management options , James, steer , 4 edition
th
Contraindications to pregnancy
Pulmonary arterial hypertension of any cause

WHO Severe systemic ventricular dysfunction ( LVEF < 30 % , NYHA III/IV )

Class
Previous peripartum cardiomyopathy with any residual impairment of left ventricular function

Severe mitral stenosis , severe symptomatic aortic stenosis

4 Marfan syndrome with aorta dilated > 45 mm

Aortic dilatation > 50 mm in aortic disease associated with bicuspid aortic valve

Native severe coarctation

Termination of pregnancy and
contraception
First trimester – safest period
Dilatation and evacuation -method of choice
Prostaglandin E1 , E2 can be used
Reduced misoprostol dose – 100 mcg can be used upto 9 weeks
METHODS OF TERMINATION Prostaglandin F ( carboprost ) contraindicated – increase PAP,
decrease coronary perfusion

Both medical and surgical method equally effective

Greater need for unanticipated operative evacuation ( 2.1 vs 0.6
%)
Give antibiotics for endometritis prevention – to be modified
according to endocarditis prophylaxis
Risk assessment: Modified WHO classification of maternal cardiovascular risk
 Risk Assessment

Limitations of risk assessment score :

1) Population dependent
2) Dilated aorta and pulmonary artery hypertension
population under represented

Siu et.al Circulation. 2001;104:515-521 ; Eur Heart J 2010;31:2124–2132. Khairy P et al Circulation 2006;113:517–524.
Approach to pregnant patients with
cardiac disease
Chest x ray ( only in special

Examination
History

Investigations
Dyspnea : NYHA classification ,
Cyanosis circumstances)
onset Clubbing Cardiomegaly,
Prior events : heart failure , Systolic murmur grade 3/6 Pulmonary vascular markings
TIA , stroke or more Enlargement of pulmonary
Associated Symptoms & sign
disease ( anaemia , of Left sided failure:
Diastolic murmur veins
Easy fatigability,
thyrotoxicosis , hypertension ) shortness of breath, Orthopnoea, PND, Pulmonary
Cardiomegaly ECG
congestion,
Drugs : ( kind Cardiac
, compliance ) asthma,Persistent
B/L rales.split S2 Cardiac chamber hypertrophy
Arrythmia Symptoms & sign of RightPersistent sided failure :
arrhythmia Arrhythmia
Weight gain, dependant edema,
Fever with arthalgia
hepatomegaly,
Persistent neck vein JVP (increases) Myocardial ischemia and
Recurrent cyanosis distention infarction
Past history Equivocal enlargement of Conduction abnormalities
heart(X-ray) ECHO
Family history
Presence of arrhythmias ,
atrial fibrillation or flutter
Classify patients - NYHA classification
• Uncomplicated – no limitation of physical activity
Class I

• Slight limitation of physical activity. Comfortable at rest, ordinary activity causes

Class II fatigue, palpitation, dyspnea, or angina

• Marked limitation of physical activity : comfortable at rest , less than ordinary

Class III activity causes fatigue , palpitation, dyspnea, or angina pain

• Severely compromised – inability to perform any physical activity without discomfort

Class IV : Symptoms of cardiac insufficiency or angina may develop even at rest
Predictors of adverse events in pregnant women with heart disease-
The CARPREG II study

Patient history
• Cardiac events prior to pregnancy
• Baseline NYHA functional class
• No cardiac intervention prior to pregnancy

Examination • Cyanosis ( saturation < 90 % at rest )

Specific lesions
• Mechanical valves
• Coronary artery disease
• High risk aortopathy

• Systemic ventricular dysfunction

Imaging • High risk left sided valve lesion / left ventricular outflow tract obstruction
• Pulmonary hypertension

Delivery of care • Late first antenatal visit

• Rare and understudied cardiac condition

Other variables •
•
•
Other maternal comorbidities : advanced maternal age , hypertension , obesity
MRI and cardio pulmonary testing
Fertility therapy and patients access to care and therapy
Predictors of maternal cardiovascular events Predictors of neonatal events
• Prior cardiac events ( heart failure , transient ischemic • NYHA class III / IV , cyanosis during baseline prenatal visit
attack , stroke , arrythmia ) • Maternal left heart obstruction
• NYHA class III/IV • Smoking during pregnancy
• Left heart obstruction ( moderate to severe ) • Low maternal oxygen saturation < 90 %
• Reduced systemic ventricular systolic function ( ejection • Multiple gestation
fraction < 40 % ) • Use of anticoagulation throughout pregnancy
• Reduced sub pulmonary ventricular function ( TAPSE <16 • Mechanical valve prosthesis
mm) • Maternal cardiac event during pregnancy
• Systemic atrioventricular valve regurgitation ( moderate to • Maternal decline in cardiac output during pregnancy
severe )
• Pulmonary atrioventricular valve regurgitation ( moderate
to severe )
• Pulmonary artery hypertension
• Cardiac medication before pregnancy
• Cyanosis ( O2 saturation <90 % )
• Smoking history
• Mechanical valve prosthesis
• Repaired / unrepaired cyanotic heart disease
• NT – pro BNP > 128 pg/ml at 20 weeks predictive of event
later in pregnancy
Fetal assessment
• A full fetal echocardiography to evaluate cardiac structure
• NT /NB scan around 12 weeks to r/o and function, arterial and venous flow, and rhythm.
GCA and chromosomal anomalies • Detailed scanning of the fetal anatomy to look for
associated anomalies (particularly the digits and bones).
• NT/NB scan has sensitivity and • Family history to search for familial syndromes.
specificity of 85 [95% confidence • Maternal medical history to identify chronic medical
interval (CI) 78–90%] and 99% (95% CI disorders, viral illnesses, or teratogenic medications.
98–100%), respectively in detecting • Fetal karyotype (with screening for deletion in 22q11.2
CHD when cono-truncal anomalies are present).
• Referral to a maternal–fetal medicine specialist, paediatric
• The incidence of congenital heart cardiologist, geneticist, and/or neonatologist to discuss
disease with normal nuchal fold prognosis, obstetric, and neonatal management, and
thickness is about 1/1000 options
•
• Offer fetal ECHO at 19-22 weeks ,45% of Delivery at an institution that can provide neonatal cardiac
care, if needed
all congenital cardiac malformations
identified Eleftheriades M, Tsapakis E, Sotiriadis A, Manolakos E, Hassiakos D, Botsis D. Detection of congenital heart
defects throughout pregnancy; impact of first trimester ultrasound screening for cardiac abnormalities. J
Matern Fetal Neonatal Med 2012;25:2546–2550.
 Subsequent management :
Antepartum care – medical management
Multidisciplinary team : cardiologist , obstetrician , NYHA class III OR IV
fetal medicine specialist , paediatrician
Hospitalisation for bed rest
Intensive close monitoring
Cardiac intervention , surgery
NYHA CLASS I OR II
• Limit strenuous activities Or
• Adequate rest terminate pregnancy
• Iron and vitamin supplementation to avoid
anaemia
• Salt restriction if ventricular dysfunction
• Regular cardiac and obstetric evaluation
• Stop / change teratogenic drugs used previously
Identify and treat early : • Switchover of anticoagulants at 1st trimester and
Infections , anaemia , hypertension , after 36 weeks
hyperthyroidism , arrhythmias • Endocarditis prophylaxis
Teratogenicity of cardiac drugs

Pregnancy in women with congenital heart disease

BMJ 2018
 Anticoagulants in pregnancy
• Indicated for mechanical valves and not bioprosthetic valves
Maternal mortality : 9 %
Steps Morbidity : 41% ( 16 % thromboembolic complications)
Admit at 6 weeks pog/FCA
documentation from warfarin Risk of valveHeparin ( UFH
thrombosis : /LMWH ) to be started
to heparin Vitamin K antagonist Target
: 0-4aPTT
% – twice normal
ContinueUFH
till 12
in weeks POG / throughout pregnancy : 9-33 %
first trimester
LMWH : 4.4 -8.7 %
> 36 weeks , stop
warfarin start heparin
While using LMWH , it is important to consider and maintain peak and trough Omit heparin after
levels of anti X a
12-36 th week warfarin till labour . Restart after
overlapping with
( INR 2.5-3.5 ) 6 hours of normal and
warfarin once target INR
24 hours of cesarean
is achieved
 Drug Regimens Dosing Monitoring Test Adverse effects

Anticoagulation UFH throughout 18U/kg/hour infusion

pregnancy
aPTT ≥ 2 times or
Anti-Factor Xa level 4-6 hr
after injection
Thrombocytopenia
Osteoporosis

options LMWH
throughout
Begin with 1mg/kg
enoxaparin BD
Antifactor Xa level 4-6 hr after
dose b/w 0.8-1.2 U/ml
Miscarriage rates :12.2
%
Pregnancy Or dalteprin 100U/kg Pre dose level >0.6U/ml,
BD Weekly monitored

Low molecular Unfractioned UFH or LMWH in Heparin infusion Same as above for heparins; Fetal loss rate : 22.7 %
weight heparin heparin 1st trimester and Warfarin daily INR for warfarin
again at 35–36
Dose – 1mg/kg body wk, warfarin
from 14-36 wk
weight
Less Higher incidence of
thrombocytopenia OAC throughout INR of 3.0 (2.5–3.5) embryopathy in 0.6-
thrombocytopenia , pregnancy for warfarin 10%
less frequent dosing monitored weekly < 5 mg- 0.45-0.9 %
due to longer half life 0.7-2%- risk of
, less osteoporosis ACCP guidelines fetopathy in 2nd and 3rd
trimester
advice UFH to be Miscarriage rates : 28.6
administered twice %
daily with aPTT
monitoring six hourly Aspirin added to No longer Maternal bleeding
all above recommended complications
increased

Xu Z, Fan J, Luo X, Zhang WB, Ma J, Lin YB, Ma SH, Chen X, Wang ZP, Ou JS, Zhang X.
Anticoagulation regimens during pregnancy in patients with mechanical heart valves:
ESC guidelines2018:European Heart Journal (2018) A systematic review and meta-analysis. Can J Cardiol 2016;32:1248.e1–1248.e9.
9th ACCP Conference on Antithrombotic and Thrombolytic Therapy Chest 2012;126(suppl):627S– 44S
Women on high dose VKA ( warfarin >5 mg , Women on low dose VKA ( warfarin <5 mg ,
phenprocoumon > 3 mg , acenocoumorol > 2 phenprocoumon < 3 mg , acenocoumorol <2
mg ) mg )

ESC guidelines 2018 :European Heart Journal (2018 )

Prosthetic valves thrombosis (pvt) during pregnancy
Risk of thrombosis
6 fold – pregnancy
11 fold -puerperium
•Greater for older-generation prosthetic valves in mitral position - Bjork- Shiley tilting disc as compared with St. Jude valve
•Mortality rates : 10% - 40%
•Clinical features: dyspnoea and/or an embolic event
•Investigation: Transthoracic echo
Trans oesophageal echo
Fluoroscopy with limited fetal risk
•Treatment
•Right-sided prosthetic valve thrombosis
• In absence of contraindications fibrinolytic therapy preferred over surgical intervention

•Left-sided PVT & large thrombus area(>0.8 cm 2 )

• Early surgery over fibrinolytic therapy
• If contraindications to surgery :fibrinolytic therapy

•Left-sided PVT and small thrombus area ( <0.8 cm 2 )

• Fibrinolytic therapy over surgery
• IV UFH accompanied by serial Doppler echocardiography to document thrombus resolution or improvement

ACCP2012 Guidelines.Chest 2012;141;7S-47S

Surgical management

Cardiac surgery with

Percutaneous therapy
Cardiopulmonary bypass :
cardiopulmonary bypass
Monitor 1) fetal heart rate
• Best time : 4 month POG
2) uterine tone
• Best period of surgery ( 13-28
• Heparin – 40-70
To maintain u/kg
adequate target aPTT
uteroplacental flow weeks POG )
200 s flow 2.5 L/min/m2
1) Pump • Consider surgery after delivery if
2) Perfusion pressure : 70 mm hg POG > 26 weeks POG ( survival > 80
3) Haematocrit ( maternal ) : 28 %
4) Monitor pH
% with 20 % risk of neurological
5) Normothermic perfusion impairment
6) Minimise procedure time

Chandrasekhar S, Cook CR, Collard CD. Cardiac surgery in the parturient. Anesth
Analg 2009;108:777–785.
Obstetrical management
Frequency of visits

USG

Hospital admission

Time and mode of delivery

Labour
Frequency of visits : two weekly
During visits :
•Routinely question and examine about signs and symptoms of cardiac
failure
•Monitor vital signs and weight gain
•Obtain anaesthesia consultation prior to delivery
•Discuss contraception

USG :
If there is increased risk of IUGR :
Monitor by USG – 2 to 4 weekly
Fetal surveillance -32-34 weeks
General medical objectives of treatment
• Shunts : avoid favoring R to L shunting, lower PA pressure ,avoid
hypoxemia , avoid prolonged valsalva
• Obstructive lesions: Beta blockers, avoid volume depletion maintain
preload
• CHF – diuretics (only with pulmonary edema), reduce afterload(NTG ,
Hydralazine)
• Arrhythmias : Rate and rhythm control , anticoagulation as necessary,
higher dose digoxin
• Marfan’s , Aortic dissection: Beta blockers
Admission criteria
ELECTIVE

Class I , II : Atleast two weeks prior to expected date of delivery

Class III and IV : As soon as pregnancy is diagnosed. The patient should be kept in the hospital throughout
pregnancy

EMERGENCY

On deterioration of the functional grading

Appearance of dyspnea or nocturnal cough or basal crepitation's or tachy arrythymias

Appearance of any pregnancy complication like anemia , pre-eclampsia , pulmonary hypertension

Heparin switch over : In case of mechanical valve on oral anticoagulant

▪in 1st trimester 6-12 wk
▪At 36 wk
Timing of delivery

• Spontaneous labour preferred

• It is individualized according to the severity of maternal disease and
any associated fetal compromise
• In cyanotic HD significant IUGR may warrant premature termination
• Women with mild unrepaired congenital heart disease and with
successful cardiac surgical repair – treated same as normal pregnancy

European society of cardiology guidelines for management of cardiovascular diseases during pregnancy , 2018
recommends elective induction at 40 weeks POG
Reduces risk of caesarean by 12 %
Mishanina E ,Use of labour induction and risk of cesarean delivery: A systematic review and
Stillbirth risk : reduced by 50 % meta-analysis, CMAJ ,2014
 Indications for elective LSCS:
❑ Any obstetric indications
Should be considered in
➢ Aortic dissection, acute or chronic ,
Mode of delivery ➢ on oral anticoagulants (OACs) in pre-
term labour ( decrease risk of
intracranial hemorrhage in baby)
• Vaginal delivery is safer except certain situation
➢ acute & unless
intractable there
heart failure.
➢ Severe forms of pulmonary
is an obstetric indication of CS hypertension ( includes Eisenmenger’s
• Induction done for obstetric reasons syndrome)
➢ Marfan syndrome with dilated aortic
root (>4.5cm)
➢ Taken warfarin within 2 weeks of labor
Method of induction
➢ Aortic aneurysm
➢ Endocarditis needing- emergency valve
Bishop favourable Oxytocin and artificial rupture of
membrane replacement at or near term
➢ Severe AS
Both misoprostol and dinoprostone can be ➢ History of recent MI
used safely
May be considered
Active CVD ➢ Marfan patients with an aortic
Dinoprostone contraindicated
Cyanosis ( drop in SVR detrimental ) Foley catheter preferreddiameter 40–45mm.
➢ In patients with high risk of valve
ESC guidelines2018 :European Heart Journal (2018 ) thrombosis
Labour in cardiac disease

General considerations during labour

Delivery in anticoagulated women with

prosthetic valve

Infective endocarditis prophylaxis

 General considerations during labour
Reducing the effects of tachycardia & increased Pain relief ( reduces tachycardia, myocardial work, CO)
cardiac output in labor
Restriction of IV fluid 75ml/hour
Ensuring effective analgesia
O2 inhalation & pulse oximetry

Anticoagulation where needed Antibiotic prophylaxis where needed , endocarditis prophylaxis

Shorten second stage of labour Fetal heart monitoring

Management of PPH Prevention of postpartum pulmonary edema

Avoid IV methergin or bolus oxytocin but control PPH

Avoid difficult instrumental delivery

Position and cardiac return

• Consider lateral decubitus, position

Supine with obstructive lesions
• Consider supine position with CHF
Versus (reduce VR and so Cardiac
Lateral workload)

Decubitus
During labour, the mother with significant heart disease
Position should be kept in a semi recumbent position with lateral tilt
Place of epidural analgesia
Systemic vasodilation
Decrease CO 25-45% even in normal patients
Well tolerated (often beneficial):
• AR ,MR, L to R Shunts
Poorly tolerated:
• Limited ability to increase SV
• R to L shunts
• AS, MS
• Hypertrophic CM
• Pulmonary hypertension without ASD
First stage
Should be confined to bed with lateral recumbent position to minimize aorta – caval compression

O2 by mask

Analgesia , majority by epidural

Fluid infusion should not be more than 75ml/hr to prevent pulmonary edema , concentrated syntocinon
augmentation

Careful watch of pulse & resp. rate every 15 mins frequent chest auscultations every 30 mins

Cardiac monitoring and pulse oximetry can detect arrhythmias & hypoxia ( indicative pulmonary edema )

Increases in Pulse rate much above 100bpm or respiratory rate above 24 per min, particularly when associated with dyspnea,
may suggest impending ventricular failure
Second stage

Delay in 2nd stage of labour to be curtailed by forceps/ventouse application under pudendal and
/ or perineal block

Ventouse preferred as it can be applied in lateral recumbent position

Prolonged valsalva increase PA pressures, increases R to L Shunting

Pulse or respiratory rate to be checked 10 mins

Third stage
Conventional management to be followed.

It is preferable to administer oxytocin in an i.v drip to all cases who are not in failure and simultaneously furosemide
20 mg i.v. to relieve volumetric load

Slight blood loss is beneficial and if in excess Oxytocin infusion may be continued.

Episiotomy wound repaired early. Pt kept in propped up position , O2 supply throughout.

If resp. distress develops secondary to pulm, congestion, should be treated aggressively as pulm edema in I.C.U
PPH control and postpartum
A slow i.v. infusion of oxytocin (2 U/min), which avoids systemic hypotension, is administered after placental delivery to prevent maternal
haemorrhage.

Prostaglandin F analogues are useful to treat post-partum haemorrhage, unless an increase in pulmonary artery pressure (PAP) is undesirable.

Methylergonovine is contraindicated because of the risk (10%) of vasoconstriction and hypertension. de Labriolle A, Genee O, Heggs LM, Fauchier L.
Acute myocardial infarction following oral methyl-ergometrine intake. Cardiovasc Toxicol 2009;9:46–48

Meticulous leg care, elastic support stockings, and early ambulation are important to reduce the risk of thrombo-embolism.

Delivery is associated with important haemodynamic changes and fluid shifts, particularly in the first 12–24 h, which may precipitate heart
failure in women with structural heart disease.

Haemodynamic monitoring should therefore be continued for at least 24 h after delivery.

Puerperium management

Signs of pulmonary congestion & edema to be looked for

Any infection however during puerperium should be seriously viewed

Not too many visitors

Breast feeding is not contraindicated unless there is failure

Pts. on warfarin should be allowed to breast feed as secretion through breast milk is extremely small

Jakes AD, Coad F, Nelson-Piercy C. A review of contraceptive methods for women with cardiac
disease. The Obstetrician & Gynaecologist.
2018;20:21–9.
Urgent delivery during full anticoagulation

• Warfarin reversed with FFP & vit –K ( 5-10 mg i.v ) and UFH with
protamine sulfate
• In case of LMWH : repeated dose of protamine sulfate required ( due
to longer half life of LMWH and slow subcutaneous absorption
• If a fully anticoagulated patient required CS, GA should be
administered &wound drains and interrupted skin sutures to be
considered
• Four factor prothrombin concentrate gives better reversal than FFP
and should be given prior to delivery to achieve INR </- 1.5
Infective endocarditis prophylaxis
• Overall annual incidence of I.E.:
1 per 1000 patients with congenital heart disease
3-12 per 1000 in patients with prosthetic valves
• Incidence higher in drug addicts
• Efficacy to prevent IE questionable
• Administer intra-partum to at risk patients only in
presence of suspected bacteraemia or active
infection
• Prophylactic antibiotic therapy during vaginal or
caesarean delivery is not recommended.( level of
evidence C, class 3 recommendation)

❖ESC guidelines 2018 :European Heart Journal (2018 ) 32

Habib G ,ESC guidelines for the management of infective endocarditis. Eur Heart J 2015
 Indications Of Infective Endocarditis
Prophylaxis
Anticipated vaginal or ceasarean delivery associated with infection AND

ACOG: Use of prophylactic antibiotics in labor and delivery. Practice Bulletin No. 120, June 2011a
Prevention of Infective Endocarditis: Guidelines From the AHA:, Circulation. 2007;116:1736-1754
Regimen for I.E. Prophylaxis
Situation Agent Single dose 30 to 60 min Before
Procedure

Oral Amoxicillin 2g

Unable to take oral medication Ampicillin,OR 2 g IM or IV

Cefazolin or ceftriaxone 1 g IM or IV

Allergic to penicillins oral Cephalexin,OR 500 mg PO

Clindamycin,OR 600 mg PO
Azithromycin or clarithromycin 500 mg PO

Allergic to penicillins & unable to take Cefazolin or ceftriaxone 1 g IM or IV

oral medication OR 600 mg IM or IV
Clindamycin

Anaphylaxis to penicillins Clindamycin 600 mg oral/IM/IV

If enterococcus infection concern Vancomycin 1gm I.V.
ACOG: Use of prophylactic antibiotics in labor and delivery. Practice Bulletin No. 120, June 2011a
Prevention of Infective Endocarditis: Guidelines From the AHA:, Circulation. 2007;116:1736-1754
Classification of heart disease

Others
Congenital
Acquired arrhythmia infective
Cyanotic ( r to l ) ( tetrology of endocarditis
Rheumatic heart disease Obstructive (mitral stenosis ,
fallot , tricuspid atresia , ebsteins
aortic stenosis , pulmonary marfan’s syndrome
Ischaemic heart disease anamoly ,tga , tapvc )
stenosis , coarctation of aorta ) mitral valve prolapse
Cardiomyopathies Acyanotic ( l to r)
( ASD,VSD,PDA) pulmonary hypertension
eisenmenger syndrome
 Mitral stenosis
Pre pregnancy Maternal risk Obstetric and
•Assess cardiac function , optimise medical therapy offspring risk
•Consider surgical correction
•Decide on Comissurotomy vs replacement

Prenatal • Decompensation proportional to severity • Prematurity :

•Monitor weight gain , prevent and treat • Heart failure commonly occurs in moderate and 20-30 %
tachycardia severe MS • IUGR : 5-20 %
•Prevent arrythmias • Risk of AF < 10% ( precipitates heart failure and • Still birth 1-3
•Therapeutic anticoagulation in case of h/o thromboembolic events ) %
embolism , left atrial thrombus , or permanent or • Mortality 0-3 % , higher in low income
paroxysmal atrial fibrillation countries
•Serial ECHO ( monthly / bimonthly ) in mild MS
evaluate in every trimester
•If severe : perform commissurotomy( PTMC) ( if
PAP > 50 mm Hg despite optimal treatment )

Labour , delivery and post natal

•Icu setting
•Consider epidural analgesia , shorten second stage
•Antibiotic prophylaxis

ESC guidelines 2018 :European Heart Journal (2018 )

High risk pregnancy : management options , James, steer , 4 th edition
 Mitral regurgitation

Pre pregnancy Maternal risk obstetric and offspring risk

•Evaluate cardiac function with ECHO ,
valve replacement if required

Prenatal • Severity depends on regurgitation • No increased risk of obstetric

•Restrict activity , surgery for symptomatic severity complications
severe disease • Complication risk increases in
symptomatic regurgitation
• IUGR occurs in 5-10 % cases

Labour , delivery , postnatal

•Avoid fluid overload and hypertension ,
provide maternal cardiac monitoring
•Endocarditis prophylaxis
 Prosthetic valves
Pre pregnancy Maternal risk Obstetric and offspring risk
• Counsel about risk associated with
warfarin and risks of thrombosis
• Provide counselling about
• valve function

Prenatal • Risk of valve thrombosis : • Use of anticoagulants :

• When patient on bioprosthetic valve – • Vitamin K antagonist : 0-4 % • Increased risk of miscarriage
counsel about deterioration • UFH in first trimester / throughout • Retroplacental bleeding -> premature
• When on mechanical valve counsel pregnancy : 9-33 % birth and fetal death
about anticoagulation • LMWH : 4.4 -8.7 % • Warfarin embropathy
• Vigilance for thrombocytopenia when • LMWH more efficacious as compared • embryopathy in 0.6-10%
using heparin to UFH • < 5 mg- 0.45-0.9 %

Labour , delivery , post partum

• Adjust anticoagulation
• Endocarditis prophylaxis
• Vaginal delivery is contraindicated in
mother while on oral anticoagulants
• Due to increased risk of intracranial
bleeding
 Bioprosthetic valve Mechanical valve

• Less thrombogenic , associated with high risk of structural • Durable , but more thrombogenic
valve deterioration ~ 50 % women < 30 years 10 years post • Requires anticoagulation
implantation
• Valve deterioration more in aortic and mitral than in
pulmonary or tricuspid
 Aortic regurgitation

Pre pregnancy Maternal risk Obstetric and offspring risk

•Optimize medical control ( digoxin )
•Evaluate : regurgitation severity , LV
dimension and function . Measure
ascending aortic diameter in case of
bicuspid valves
•Valve replacement if indicated

Pre natal • Symptoms depends on regurgitation • No increased obstetric complications

•Surveillance for cardiac failure , surgery severity , symptoms and LV function
for failed medical therapy
• Rarely acute AR can occur in patients
with APLA
Labour , delivery ,post partum
•Avoid fluid overload , invasive
monitoring unnecessary , epidural
beneficial
 Aortic stenosis
Pre pregnancy Maternal risk Obstetric and offspring risk
•Can be asymptomatic even with
severe AS
•In patients with bicuspid aortic
valve , measure aortic diameters
before and during pregnancy
•High risk of aortic dilatation and
dissection

Pre natal • Increase in cardiac output • Obstetric complications

•Limit physical activity -> increase in gradient include – hypertension
•Fetal echo , fetal surveillance • Heart failure ~ 10 % of severe related disorders ~ 13 %
AS
• Arrythmias – 3- 25 % • Pre term birth , IUGR , low
• Mortality is rare if careful birth weight 20-25 % in
management is provided patients with severe AS
Labour , delivery , post partum
•Avoid fluid overload ,invasive
monitoring unnecessary ,
epidural beneficial
 Aortic syndromes
Leading causes of maternal death ( 2003-2005 ) Centre for Maternal and Child Enquiries; 2008

Pre pregnancy Maternal risk Obstetric risk and offspring risk

•counsel all women with genetically
proven Marfans syndrome or any other
familial aortic pathology
•Complete aortic imaging with CT / MRI

Prenatal • Maternal heamodynamic and hormonal • Fetal growth to be monitored when

•Monitor ECHO every 4- 12 weeks and 6 changes -> increased risk of dissection mother takes beta blocker
months postpartum • Incidence : last trimester :50 %
•Use beta blockers to decrease BP in early post partum 33%
Marfans syndrome and celiprolol in
Ehlers Danlos type 4 • Parity is associated with increased aortic
diameter ( Gutin LS . Parity and aortic dimensions in
healthy women . Int J Cardiol 2013 )

Labour , delivery , postpartum

•Ceaserean section if aortic root
diameter > 45 mm
•< 40 mm , vaginal delivery preferred
•40-45 mm – vaginal delivery , with
labour epidural
Marfans Ehlers danlos syndrome Turner syndrome Bicuspid aortic valve

Normal aortic root diameter – 1 % • High risk of uterine rupture • Prevalence of cardio vascular • ~ 50 % of patients with bicuspid
risk of dissection • So is a contraindication for malformation – 25-50 % aortic valve and aortic stenosis
4 cm a/w increase d risk of pregnancy have aortic root dilatation
dissection • Turner syndrome alone with • Perform pre pregnancy MRI /
> 45 mm , discourage pregnancy • Prophylactic surgery : not pregnancy does not increase CT to look for distal aortic
40 – 45 mm , risk factors for useful complication dilatation not visible
dissection ( rapid growth , family adequately in ECHO
history ) • Higher risk if associated with • If aortic root >50 mm, consider
Following replacement – risk of bicuspid aortic valve , pre pregnancy surgery
disease in residual aorta coarctation of aorta ,
hypertension
• Thoracic aortic diameters
should be evaluated in terms of
body surface area , as they
have short stature
• Aortic diameter index > 27
mm/m2
• a/w high risk of dissection ,
prophylactic surgery considered
Congenital heart disease
Maternal high risk conditions ( WHO III- Maternal low and moderate risk
IV ) conditions ( WHO class I , II, III )
• Atrial septal defect
• Pulmonary hypertension • Ventricular septal defect
• Patients with eisenmengers • Atrioventricular septal defect
syndrome • Coarctation of aorta
• Pulmonary valve stenosis and regurgitation
• Severe left ventricular outflow • Aortic stenosis
tract obstruction • Tetrology of fallot
• Ebstein anomaly
• Transposition of great arteries -
• Corrected TGA
• Fontan circulation
 Pulmonary hypertension

Pre pregnancy Maternal risk Obstetric or offspring risk

Counsel against pregnancy

Pre natal / antenatal visits • High maternal mortality risk • Neonatal risk : 87-89 %
•Counsel against pregnancy • 16-30 % in patients Bedard E , 2009
•Sterilization if required ( Mandalenakis Z ,2017 ) • Increased fetal and neonatal mortality : 0-
•Thromboembolism prophylaxis , hospital 30%
admission and monitor spo2 • Death occurs in last trimester of pregnancy
•Treat pulmonary hypertension – prostacyclin or first few months after delivery
analogues , bosentan , PDE inhibitors sildenafil ,
inhaled nitric oxide • Risk factors for maternal death :
• Late hospitalisations
• Severity of pulmonary hypertension
• General anaesthesia

Labour , delivery , postnatal

•Elective cesearean
•Oxytocin or E series prostaglandins are safe
monitor BP , maintain fluid balance
Postnatal :
•O2 therapy , thromboembolism prophylaxis ,
•Maintain vigilance for fluid retention and
consequences consider sterilization
 Eisenmengers syndrome

Pre pregnancy Maternal risk Obstetric and offspring risk

•Same as primary pulmonary hypertension

Pre natal • 20 – 50 % mortality rate • Live birth unlikely ( < 12% ) if saturation
•Same as above • Occuring in peripartum and post < 85 %
partum period Presbitero P, 2014
• Fetal and neonatal risks increased and
relate to maternal cardiac output and
Labour , delivery , post partum degree of cyanosis
•Monitor volume status , look for signs
and symptoms of right heart failure
 Cyanotic heart disease without pulmonary hypertension

Pre pregnancy Maternal risk Obstetric and offspring risk

•If spO2 is < 85 % , advice against
pregnancy

Pre natal Complications : • If spO2 90 % , good fetal outcome

•Restrict physical activity •Advise against pregnancy • If < 85 % , chances of live birth is ~
•High risk of paradoxical embolism, •If saturation , 85% - substantial risk 12 % , pregnancy discouraged as
prevent venous stasis . of maternal and fetal mortality live birth rate is only 12 %
•If prolonged bed rest , consider •Heart failure , pulmonary or systemic
anticoagulants thrombosis , supraventricular
•Hematology review should be done arrythmias , infective endocarditis

Labour , delivery , postpartum

•Vaginal delivery advised
•Early caesarean to be planned
 Severe left ventricular outflow tract obstruction

Pre pregnancy Maternal risk Obstetric and offspring risk

• Advise against pregnancy
• Treat condition before pregnancy

Pre natal • Same as aortic severe stenosis -

• Management same as aortic stenosis

Labour , delivery , postpartum

• Same as aortic stenosis
• Pregnancy however contraindicated
 Atrial septal defect
Pre pregnancy Maternal risk Obstetric and offspring risk
• Screen for arrhythmia , pulmonary
hypertension

Pre natal • pregnancy is well tolerated • Prematurity , SGA babies occur more
• Same as routine management , unless • Closure of hemodynamically significant frequently
patient has complications like ASD , to be performed before
arrythmia , pulmonary hypertension pregnancy
• Screen fetus for congenital heart defect • 5 % risk of thromboembolic
complication

Labour , delivery , post partum

• Avoid fluid overload, monitor blood
pressure , screen for arrythmias
• Epidural beneficial
• Postnatal :
• Early mobilisation
• Screen new born for CHD
• Contraceptive of choice : depo provera
 Ventricular septal defect

Pre pregnancy Maternal risk Obstetric and offspring risk

•Screen for pulmonary hypertension,
presence of residual defect , cardiac
dimensions , estimation of pulmonary
pressures
•Repair of uncorrected lesions

Pre natal • Morbidity related to size of VSD and • No evidence of increased obstetric risk
•Screen fetus for CHD pulmonary hypertension
• High risk of complications in large VSD
• Small perimembranous VSD ( without
Labour , delivery , post partum left heart dilatation ) –low risk of
•Antibiotics prophylaxis ( unless patient complications during pregnancy
has uncomplicated vaginal delivery ,
defect is repaired ) prior to ceserean
•Spontaneous vaginal delivery is
appropriate
•Postnatal : early ambulation careful fluid
balance , screen for CHD
 Fallots tetralogy

Pre pregnancy Maternal risk Obstetric and offspring risk

• Surgical correction abd evaluate cardiac
status post surgery

Pre natal • Repair indicated before pregnancy • Increased risk of offspring complication
• Uncorrected lesions – consider • Repaired TOF ( Class II ) • Maternal screening for 22q11 deletions
termination • 12% patents have cardiac complications pre pregnancy recommended
• Rest and oxygen supplementation
• Fetal ECHO
• fetal surveillance

Labour , delivery , post partum

• Fluid management
• Monitor BP , spo2 , ECG ,
• Shorten second stage ,
• Maintain blood pressure ,
• Avoid fluid overload
• Postnatal : maternal monitoring
• Contraception
 Pulmonary stenosis

Pre pregnancy Maternal risk Obstetric and offspring risk

• ECHO to determine degree of stenosis
• Balloon valvuloplasty to be performed
to relieve severe stenosis ( peak
doppler gradient > 64 mm hg

Pre natal • Well tolerated in pregnancy • Offspring complications higher than

• Balloon valvotomy as clinically • Incidence of hypertension – related general population Drenthen W,2006
indicated disorders increased with pregnancy
• Mild and moderate PS ( class I , II ) ;
follow up once in every trimester
• Severe lesions : monthly and bimonthly
visits

Labour , delivery , post partum

• Monitor volume and signs of right
heart failure
• Vaginal delivery ( mild / mod PS , NYHA
I/II )
• Ceaserean
 Pulmonary regurgitation

Pre pregnancy Maternal risk Obstetric and offspring risk

• Consider pulmonary valve replacement
in symptomatic women and women
with ventricular dysfunction

Pre natal • Severe pulmonary regurgitation is • No additional offspring risk

• Routine ANC visits considered as an independent
predictor of maternal complications in
women with impaired ventricular
function

Labour , delivery , post partum

• Normal delivery is preferred
Coronary artery disease and acute coronary syndrome

Pre pregnancy Maternal risk Obstetric and offspring risk

•Assess cardiac function ( ECHO , stress testing )
•Optimise medical therapy
•Consider pregnancy in women with coronary artery
disease in absence of residual ischemia and clinical
signs of LV dysfunction

Prenatal • Increasing age of pregnant women leads to • Thrombi and dissections occur more frequently in
•Avoid strenuous exercise , surveillance for failure and increase pregnancy related ACS peripartum period than before delivery
arrythmia , management is as for non pregnant • Mortality after ACS – 5-10 % , highest in
•Percutaneous coronary artery intervention can be • ACS is rare during pregnancy , estimated 1.7-6.2 / peripartum period
used 100000 deliveries ( O ‘ Connor DJ ,2011 ) • Survival has improved with primary percutaneous
•Thrombolytic therapy as indicated coronary intervention
Predisposing factors : • Before delivery , ACS results in fetal mortality and
• Pre eclampsia , thrombophilia , post partum prematurity , risk related to severity of maternal
infections , severe post partum haemorrhage heart disease
Aetiology : non atherosclerotic mechanisms
• Pregnancy related spontaneous pulmonary artery
Labour , delivery , postnatal dissection ( 43%)
•Monitor ECG , supplement oxygen , epidural • Angiographically normal coronary arteries ( 18%)
beneficial • Coronary thrombosis ( 17%)
•Consider caesarean if labour occurs within 4 days of
acute myocardial infarction
•Delivery should be postponed for atleast 2 weeks post
MI to facilitate maternal management
•Postnatal : avoid fluid overload , discuss contraception
Cardiomyopathies and heart failure
Peripartum cardiomyopathy
First attributed by Gouley and colleagues in 1937

Incidence: vary by geographic location 1:3000 pregnancies(US)

1:100 (a small region of sub-Saharan Africa)
Mortality : nil to 19% majority within few months of delivery

Cardiac transplantation eventually necessary in 10%

Findings at initial presentation predicting persistent dysfunction
Fractional shortening <20%,
Left end-diastolic dimension > 6 cm
Left end-systolic dimension >5.5 cm
EF< 27%, and
LV thrombus
Recurrence: Depends on LV function at start of pregnancy
EF RECURRENCE
<45% 66.7%
<55% 46.2%
>55% 17%
Mayosi B.Heart 2007;93:1176–83
Offer termination who have persistent echo abnormalities Amos AM. Am Heart J 2006;152:509–13
Fett JD et al.Int J Obstet Gynecol 104:125, 2009.
 The deletion of STAT3 (cardiomyocyte-specific protein involved in
cellPPCM Risk
growth and Factors
Apoptosis)  increases expression of cardiac
cathepsin D, promoting the formation of a 16-kD form of prolactin
(antiangiogenic, pro apoptotic ) Hilfiker-Kleiner D., et al.Cell 2007;128:589–600
High
parity/
Prolonged Gravidity Multifetal
Tocolysis gestation

Genetics PPCM Smoking

Cocaine

Extremes of
Malnutrition reproductive
Ethical
Diabetes age
Socio-
economic
Management of peripartum cardiomyopathy
Pre pregnancy
With normal cardiac function, pregnancy less contraindicated
Inform potential for worsening cardiac function in pregnancy

Antepartum
Echo to document ventricular size and function, mural thrombi
Non pharmaceutical therapies
Low sodium diet ( 2g/day)
Fluid restriction 2L/day
Light daily activity
Pharmacologic treatment
Beta blockers – carvedilol, extended release metoprolol ( avoid in decompensated heart
failure)
Digoxin
Thiazide diuretic (hydrochlorothiazide)
May consider loop diuretic with caution
Low molecular weight heparin if ejection fraction <35%
Vasodilators like hydralazine

Postpartum
ACE inhibitors and Angiotensin receptor blockers ( preterm neonates : cause hypotension)
Loop diuretics
Beta blocker American Journal of Critical Care2012;21: 89-98
Warfarin if ejection fraction <35%
Endomyocardial biopsy :exclude treatable causes of cardiomyopathy
Bromocriptine and peripartum
cardiomyopathy

Prolactin acts as a scavenger of thrombin , its elimination by bromocriptine may

however increase risk of thromboembolism and hence concomitant heparin
anticoagulation has been advised
Braunwald’s Heart disease ,11 th edition
 Hypertrophic cardiomyopathy

Pre pregnancy Maternal risk Obstetric and offspring risk

•ECHO used to diagnose condition
•Implantable defrillator can be used as
indicated

Pre natal • Tolerate pregnancy well • Consider beta blockers – in women

•Limit activity , give beta bockers for • High risk in women symptomatic before with mild LVOTO , and maximal wall
symptomatic patients pregnancy and with high outflow tract thickness > 15 mm to prevent sudden
gradient pulmonary congestion during exertion
or emotional stress . Used to control
Labour , delivery , post partum rate in AF .
•Avoid dehydration or hypotension
•Give beta blockers for tachycardia • If paroxysmal / persistant AF present –
•Low risk cases can have vaginal delivery therapeutic anticoagulation to be used
•Use epidural anaesthesia with caution • Patient with past and family history of
•Avoid volume overload sudden death need close surveillance
•Syntocinon to be given as slow iv infusion
 Dilated cardiomyopathy ( heart failure + LV dilatation + LV systolic dysfunction )

Pre pregnancy Maternal risk Obstetric and offspring risk

•Important to differentiate DCMP and
peripartum cardiomyopathy
•Counsel against pregnancy if there is
residual cardiac dysfunction

Pre natal • Counsel about risk of deterioration • Anticoagulation with LMWH or vitamin
•Multi-displinary team care during pregnancy and postpartum K antagonists should be considered for
• If LVEF < 40 % close monitoring in those with atrial arrhythmias .
tertiary centre advised
• If LVEF < 20 % maternal mortality is
Labour , delivery , post partum very high and termination advised
•Monitor heart failure
•Avoid fluid overload
•Vigilance for arrythmias
•Adequate analgesia
•Postnatal : avoid fluid overload , discuss
contraception
Management of heart failure during pregnancy

2018 ESC Guidelines for the management of cardiovascular diseases during pregnancy
Eur Heart J. 2018;39(34):3165-3241. doi:10.1093/eurheartj/ehy340
Management of heart failure in pregnancy

2018 ESC Guidelines for the management of cardiovascular diseases during pregnancy
Eur Heart J. 2018;39(34):3165-3241. doi:10.1093/eurheartj/ehy340
CARDIAC ARRHYTHMIAS
• Common in pregnancy
• Most are benign: sinus bradycardia & tachycardia, atrial and ventricular premature contractions
• Pregnancy may exacerbate pre-existing arrhythmias because of increased catecholamines and
adrenergic receptor sensitivity
• Healthy, asymptomatic patients without underlying pathology: reassurance, observation, and rest
• Supraventricular tachycardia often seen in pregnancy: vagal manoeuvres or, if fails, i.v. adenosine
• AF: usually associated with underlying cardiac disease
• Any arrhythmias: cardiac decomposition can occur
• Recurrence
• Atrial arrhythmias 50%,
• Ventricular arrhythmias 25% Silversides CK. Am J Cardiol 97:1206, 2006
Thank you