Strategy of Medical Care for Pregnant Women with Congenital Heart Disease

Grown-up congenital heart (GUCH) is a global challenge nowadays. The strategy of medical care for GUCH women dur-ing pregnancy, childbirth and the postpartum period is a topic of active discussion in the expert community. These patients have significantly increased risk of maternal and perinatal loss. A national obstetric cardiology and cardiac surgery multi-disciplinary team (OCCS) established in academic institutions in 2013 has provided medical support to 896 GUCH pregnant women over the last 7 years. In total, GUCH patients accounted for 36% of the cohort of all the examined pregnant women. Of these, 474 (53%) were primigravid. The mean age of the patients at the time of the first visit was 27.3 ± 5.7 years. Patients with uncorrected CHD accounted for 66.2% (n = 593), and 33.8% (n = 303) of pregnant women had undergone correction, including hemodynamic correction of complex CHD in 5 patients. Risk stratification was performed using several scores (mWHO, ZAHARA, CARPREG) for the comprehensive assessment of cardiovascular risk and prediction of pregnancy, deliv-ery, and postpartum period course. 82 patients were classified as having high cardiovascular risk (CVR) after the stratifica-tion. They needed admission to the cardiac surgery facility to receive different types of medical care. There were 2 (2.4%) cases of maternal loss and 3 (3.8%) cases of adverse perinatal outcomes in this group of patients. The article presents the algorithms for multidisciplinary care strategy choice in GUCH pregnant women with high CVR and their routing principles developed by the OCCS. These algorithms significantly reduced adverse outcomes of pregnancy and childbirth in this group of patients. Long-term results were evaluated in 69 patients (86.3%). The follow-up period ranged from 1 to 91 months, on average 34.4 ± 23.6 months. There were no long-term maternal losses or repeated cardiac surgeries. There was one case of unexplained death of a child 8 months after birth. The strategy of multidisciplinary medical care of a high-class GUCH pregnant woman should be personalized depending on the clinical data and in accordance with the ESC 2018 guidelines.

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Postoperative acute kidney injury in adult non-cardiac surgery: joint consensus report of the Acute Disease Quality Initiative and PeriOperative Quality Initiative

Nature Reviews Nephrology ◽

10.1038/s41581-021-00418-2 ◽

2021 ◽

Author(s):

John R. Prowle ◽

Lui G. Forni ◽

Max Bell ◽

Michelle S. Chew ◽

Mark Edwards ◽

...

Keyword(s):

Chronic Kidney Disease ◽

Acute Kidney Injury ◽

Cardiac Surgery ◽

Kidney Disease ◽

Kidney Injury ◽

Adverse Outcomes ◽

Baseline Risk ◽

Major Surgery ◽

Increased Risk

AbstractPostoperative acute kidney injury (PO-AKI) is a common complication of major surgery that is strongly associated with short-term surgical complications and long-term adverse outcomes, including increased risk of chronic kidney disease, cardiovascular events and death. Risk factors for PO-AKI include older age and comorbid diseases such as chronic kidney disease and diabetes mellitus. PO-AKI is best defined as AKI occurring within 7 days of an operative intervention using the Kidney Disease Improving Global Outcomes (KDIGO) definition of AKI; however, additional prognostic information may be gained from detailed clinical assessment and other diagnostic investigations in the form of a focused kidney health assessment (KHA). Prevention of PO-AKI is largely based on identification of high baseline risk, monitoring and reduction of nephrotoxic insults, whereas treatment involves the application of a bundle of interventions to avoid secondary kidney injury and mitigate the severity of AKI. As PO-AKI is strongly associated with long-term adverse outcomes, some form of follow-up KHA is essential; however, the form and location of this will be dictated by the nature and severity of the AKI. In this Consensus Statement, we provide graded recommendations for AKI after non-cardiac surgery and highlight priorities for future research.

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Assessment of Exercise Intolerance in Patients with Pre-Dialysis CKD with Cardiopulmonary Function Testing: Translation to Everyday Practice

American Journal of Nephrology ◽

10.1159/000515384 ◽

2021 ◽

pp. 1-15

Author(s):

Eva Pella ◽

Afroditi Boutou ◽

Marieta P. Theodorakopoulou ◽

Pantelis Sarafidis

Keyword(s):

Cardiovascular Risk ◽

Risk Stratification ◽

Cardiopulmonary Exercise Testing ◽

Adverse Outcomes ◽

Exercise Intolerance ◽

Exercise Limitation ◽

Integrative Evaluation ◽

Prognostic Utility ◽

Risk Potential

Background: Chronic kidney disease (CKD) is often characterized by increased prevalence of cardiovascular risk factors and increased incidence of cardiovascular events and death. Reduced cardiovascular reserve and exercise intolerance are common in patients with CKD and are associated with adverse outcomes. Summary: The gold standard for identifying exercise limitation is cardiopulmonary exercise testing (CPET). CPET provides an integrative evaluation of cardiovascular, pulmonary, hematopoietic, neuropsychological, and metabolic function during maximal or submaximal exercise. It is useful in clinical setting for differentiation of the causes of exercise intolerance, risk stratification, and assessment of response to relevant treatments. A number of recent studies have used CPET in patients with pre-dialysis CKD, aiming to assess the cardiovascular reserve of these individuals, as well as the effect of interventions such as exercise training programs on their functional capacity. This review provides an in-depth description of CPET methodology and an overview of studies that utilized CPET technology to assess cardiovascular reserve in patients with pre-dialysis CKD. Key Messages: CPET can delineate multisystem changes and offer comprehensive phenotyping of factors determining overall cardiovascular risk. Potential clinical applications of CPET in CKD patients range from objective diagnosis of exercise intolerance to preoperative and long-term risk stratification and providing intermediate endpoints for clinical trials. Future studies should delineate the association of CPET indexes, with cardiovascular and respiratory alterations and hard outcomes in CKD patients, to enhance its diagnostic and prognostic utility in this population.

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Short- and long-term outcomes of preterm spontaneous twin anemia-polycythemia sequence

Journal of Perinatal Medicine ◽

10.1515/jpm-2019-0437 ◽

2020 ◽

Vol 48 (4) ◽

pp. 329-334

Author(s):

Soo Jin Han ◽

Seung Mi Lee ◽

Sohee Oh ◽

Subeen Hong ◽

Jeong Won Oh ◽

...

Keyword(s):

Cord Blood ◽

Neonatal Morbidity ◽

Adverse Outcomes ◽

Control Group ◽

Long Term Outcomes ◽

Neurodevelopmental Outcomes ◽

Monochorionic Twin ◽

Increased Risk ◽

Study Population

AbstractBackgroundIn monochorionic twin pregnancy, placental anastomosis and inter-twin blood transfusion can result in specific complications, such as twin-twin transfusion syndrome (TTTS) and twin anemia-polycythemia sequence (TAPS). It is well established that adverse outcomes are increased in TTTS, but reports on the neonatal and long-term outcomes of TAPS are lacking. The objective of this study was to evaluate the neonatal and neurodevelopmental outcomes in spontaneous TAPS.MethodsThe study population consisted of monochorionic twin pregnancies with preterm birth (24–37 weeks of gestation) between November 2003 and December 2016 and in which cord blood was taken at the time of delivery. According to the result of hemoglobin in cord blood, the study population was divided into two groups: a spontaneous TAPS group and a control group. Neonatal and neurodevelopmental outcomes were compared between the two groups.ResultsDuring the study period, 11 cases were diagnosed as spontaneous TAPS (6.4%). The TAPS group had lower gestational age at delivery and had a higher risk for cesarean delivery. However, neonates with TAPS were not at an increased risk for neonatal mortality and significant neonatal morbidity. In addition, the frequency of severe cerebral lesion during the neonatal period and the risk of cerebral palsy at 2 years of age were not different between the two groups.ConclusionThe spontaneous TAPS diagnosed by postnatal diagnostic criteria was not associated with the increased risk of adverse neonatal and neurodevelopmental outcomes. Further studies are needed to evaluate the morbidity of antenatally diagnosed TAPS.

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684 Cardiac troponins and adverse outcomes in European patients with atrial fibrillation: a report from the ESC-EHRA EORP atrial fibrillation general long-term registry

European Heart Journal Supplements ◽

10.1093/eurheartj/suab127.052 ◽

2021 ◽

Vol 23 (Supplement_G) ◽

Author(s):

Marrco Vitolo ◽

Vincenzo Livio Malavasi ◽

Marco Proietti ◽

Igor Diemberger ◽

Laurent Fauchier ◽

...

Keyword(s):

Atrial Fibrillation ◽

Regression Analysis ◽

Cox Regression ◽

Adverse Outcomes ◽

Cox Regression Analysis ◽

Coronary Syndrome ◽

Increased Risk ◽

History Of ◽

Cardiac Troponins

Abstract Aims Cardiac troponins (cTn) have been reported to be predictors for adverse outcomes in atrial fibrillation (AF), patients, but their actual use is still unclear. To assess the factors associated with cTn testing in routine clinical practice and to evaluate the association of elevated levels of cTn with adverse outcomes in a large contemporary cohort of European AF patients. Methods and results Patients enrolled in the ESC-EHRA EORP-AF General Long-Term Registry were stratified into three groups according to cTn levels as (i) cTn not tested, (ii) cTn in range (≤99th percentile), and (iii) cTn elevated (>99th percentile). The composite outcome of any thromboembolism/any acute coronary syndrome (ACS)/cardiovascular (CV) death, defined as major adverse cardiovascular events (MACE) and all-cause death were the main endpoints. 10 445 (94.1%) AF patients were included in this analysis [median age 71 years, interquartile range (IQR): 63–77; males 59.7%]. cTn were tested in 2834 (27.1%). Overall, cTn was elevated in 904 (8.7%) and in-range in 1930 (18.5%) patients. Patients in whom cTn was tested tended to be younger (P < 0.001) and more frequently presenting with first detected AF and atypical AF-related symptoms (i.e. chest pain, dyspnoea, or syncope) (P < 0.001). On multivariable logistic regression analysis, female sex, in-hospital enrollment, first-detected AF, CV risk factors, history of coronary artery disease (CAD), and atypical AF symptoms were independently associated with cTn testing. After a median follow-up of 730 days (IQR: 692–749), 957 (9.7%) composite endpoints occurred while all-cause death was 9.5%. Kaplan–Meier analysis showed a higher cumulative risk for both outcomes in patients with elevated cTn levels (Figure) (Log Rank tests, P < 0.001). On adjusted Cox regression analysis, elevated levels of cTn were independently associated with a higher risk for MACE [hazard ratio (HR): 1.74, 95% confidence interval (CI): 1.40–2.16] and all-cause death (HR 1.45, 95% CI: 1.21–1.74). Elevated levels of cTn were independently associated with a higher occurrence of MACE, all-cause death, any ACS, CV death and hospital readmission even after the exclusion of patients with history of CAD, diagnosis of ACS at discharge, those who underwent coronary revascularization during the admission and/or who were treated with oral anticoagulants plus antiplatelet therapy. Conclusions Elevated cTn levels were independently associated with an increased risk of all-cause mortality and adverse CV events, even after exclusion of CAD patients. Clinical factors that might enhance the need to rule out CAD were associated with cTn testing.

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Case–control study to estimate odds of death within 28 days of positive test for SARS-CoV-2 prior to vaccination for residents of long-term care facilities in England, 2020–2021

Journal of Epidemiology & Community Health ◽

10.1136/jech-2021-218135 ◽

2021 ◽

pp. jech-2021-218135

Author(s):

Karthik Paranthaman ◽

Hester Allen ◽

Dimple Chudasama ◽

Neville Q Verlander ◽

James Sedgwick

Keyword(s):

Long Term Care ◽

Multivariable Analysis ◽

Adverse Outcomes ◽

Positive Test ◽

Mortality Data ◽

Multivariable Logistic Regression Analysis ◽

Term Care ◽

Increased Risk ◽

Care Facilities

BackgroundPersons living in long-term care facilities (LTCFs) are presumed to be at higher risk of adverse outcomes from SARS-CoV-2 infection due to increasing age and frailty, but the magnitude of increased risk is not well quantified.MethodsAfter linking demographic and mortality data for cases with confirmed SARS-CoV-2 infection between March 2020 and January 2021 in England, a random sample of 6000 persons who died and 36 000 who did not die within 28 days of a positive test was obtained from the dataset of 3 020 800 patients. Based on an address-matching process, the residence type of each case was categorised into one of private home and residential or nursing LTCF. Univariable and multivariable logistic regression analysis was conducted.ResultsMultivariable analysis showed that an interaction effect between age and residence type determined the outcome. Compared with a 60-year-old person not living in LTCF, the adjusted OR (aOR) for same-aged persons living in residential and nursing LTCFs was 1.77 (95% CI 1.21 to 2.6, p=0.0017) and 3.95 (95% CI 2.77 to 5.64, p<0.0001), respectively. At 90 years of age, aORs were 0.87 (95% CI 0.72 to 1.06, p=0.21) and 0.74 (95% CI 0.61 to 0.9, p=0.001), respectively. The model had an overall accuracy of 94.2% (94.2%) when applied to the full dataset of 2 978 800 patients.ConclusionThis study found that residents of LTCFs in England had higher odds of death up to 80 years of age. Beyond 80 years, there was no difference in the odds of death for LTCF residents compared with those in the wider community.

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Pulmonary Edema in Obstetrics: Essential Facts for Critical Care Nurses

AACN Advanced Critical Care ◽

10.4037/aacnacc2018958 ◽

2018 ◽

Vol 29 (3) ◽

pp. 327-335 ◽

Cited By ~ 1

Author(s):

Rebecca L. Cypher

Keyword(s):

Critical Care ◽

Pulmonary Edema ◽

Pregnant Women ◽

Clinical Management ◽

Pulmonary Complications ◽

Pregnancy Complication ◽

Critical Care Nurses ◽

Adverse Outcomes ◽

Increased Risk ◽

Physiologic Changes Of Pregnancy

Pulmonary edema is an acute pregnancy complication that, if uncorrected, can result in increased maternal and fetal morbidity and mortality. Although pulmonary edema is relatively rare in the general obstetrics population, pregnant patients are at increased risk for pulmonary edema because of the physiologic changes of pregnancy. The risk may be exacerbated by certain pregnancy-related diseases, such as preeclampsia. Prompt identification and appropriate clinical management of pulmonary complications is critical to prevent adverse outcomes in pregnant patients. This article reviews the collaborative treatment of pulmonary edema in pregnant women with complex critical illnesses.

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