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Canadian Journal of Cardiology

Maternal and Fetal Hemodynamic Adaptations to Pregnancy and Clinical Outcomes in Maternal Cardiac Disease

  • Author Footnotes
    ‡ These authors contributed equally to this work.
    Robin Ducas
    Footnotes
    ‡ These authors contributed equally to this work.
    Affiliations
    Toronto Congenital Cardiac Center for Adults, Peter Munk Cardiac Center, Toronto General Hospital; University of Toronto, Toronto, Ontario, Canada
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  • Author Footnotes
    ‡ These authors contributed equally to this work.
    Brahmdeep S. Saini
    Footnotes
    ‡ These authors contributed equally to this work.
    Affiliations
    Division of Cardiology, Labatt Family Heart Centre, Department of Paediatrics, The Hospital for Sick Children; University of Toronto, Toronto, Ontario, Canada

    Institute of Medical Science, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
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  • Kenichiro Yamamura
    Affiliations
    Toronto Congenital Cardiac Center for Adults, Peter Munk Cardiac Center, Toronto General Hospital; University of Toronto, Toronto, Ontario, Canada
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  • Catriona Bhagra
    Affiliations
    Toronto Congenital Cardiac Center for Adults, Peter Munk Cardiac Center, Toronto General Hospital; University of Toronto, Toronto, Ontario, Canada
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  • Davide Marini
    Affiliations
    Division of Cardiology, Labatt Family Heart Centre, Department of Paediatrics, The Hospital for Sick Children; University of Toronto, Toronto, Ontario, Canada

    Department of Diagnostic Imaging, The Hospital for Sick Children; University of Toronto, Toronto, Ontario, Canada
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  • Candice K. Silversides
    Affiliations
    Toronto Congenital Cardiac Center for Adults, Peter Munk Cardiac Center, Toronto General Hospital; University of Toronto, Toronto, Ontario, Canada

    Department of Obstetrics and Gynaecology, Mount Sinai Hospital; University of Toronto, Toronto, Ontario, Canada
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  • S. Lucy Roche
    Affiliations
    Toronto Congenital Cardiac Center for Adults, Peter Munk Cardiac Center, Toronto General Hospital; University of Toronto, Toronto, Ontario, Canada
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  • Jack M. Colman
    Affiliations
    Toronto Congenital Cardiac Center for Adults, Peter Munk Cardiac Center, Toronto General Hospital; University of Toronto, Toronto, Ontario, Canada

    Department of Obstetrics and Gynaecology, Mount Sinai Hospital; University of Toronto, Toronto, Ontario, Canada
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  • John C. Kingdom
    Affiliations
    Department of Obstetrics and Gynaecology, Mount Sinai Hospital; University of Toronto, Toronto, Ontario, Canada
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  • Mathew Sermer
    Affiliations
    Department of Obstetrics and Gynaecology, Mount Sinai Hospital; University of Toronto, Toronto, Ontario, Canada
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  • Kate Hanneman
    Affiliations
    Toronto Congenital Cardiac Center for Adults, Peter Munk Cardiac Center, Toronto General Hospital; University of Toronto, Toronto, Ontario, Canada

    Joint Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada
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  • Mike Seed
    Affiliations
    Division of Cardiology, Labatt Family Heart Centre, Department of Paediatrics, The Hospital for Sick Children; University of Toronto, Toronto, Ontario, Canada

    Institute of Medical Science, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada

    Department of Diagnostic Imaging, The Hospital for Sick Children; University of Toronto, Toronto, Ontario, Canada
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  • Rachel M. Wald
    Correspondence
    Corresponding author: Dr Rachel M. Wald, 5N 517, 585 University Avenue, Toronto, Ontario M5G 2N2, Canada. Tel.: +1-416-340-5502; fax: +1-416-340-5014.
    Affiliations
    Toronto Congenital Cardiac Center for Adults, Peter Munk Cardiac Center, Toronto General Hospital; University of Toronto, Toronto, Ontario, Canada

    Division of Cardiology, Labatt Family Heart Centre, Department of Paediatrics, The Hospital for Sick Children; University of Toronto, Toronto, Ontario, Canada

    Department of Obstetrics and Gynaecology, Mount Sinai Hospital; University of Toronto, Toronto, Ontario, Canada

    Joint Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada
    Search for articles by this author
  • Author Footnotes
    ‡ These authors contributed equally to this work.

      Abstract

      Background

      Although insufficient maternal cardiac output (CO) has been implicated in poor outcomes in mothers with heart disease (HD), maternal-fetal interactions remain incompletely understood. We sought to quantify maternal-fetal hemodynamics with the use of magnetic resonance imaging (MRI) and explore their relationship with adverse events.

      Methods

      Pregnant women with moderate or severe HD (n = 22; mean age 32 ± 5 years) were compared with healthy control women (n = 21; 34 ± 3 years). An MRI was performed during the third trimester at peak output (maternal-fetal) and 6 months postpartum with return of maternal hemodynamics to baseline (reference). Phase-contrast MRI was used for flow quantification and was combined with T1/T2 relaxometry for derivation of fetal oxygen delivery/consumption.

      Results

      Third-trimester CO and cardiac index (CI) measurements were similar in HD and control groups (CO 7.2 ± 1.5 vs 7.3 ± 1.6 L/min, P = 0.79; CI 4.0 ± 0.7 vs 4.3 ± 0.7 L/min/m,2 P = 0.28). However, the magnitude of CO/CI increase (Δ, peak pregnancy − reference) in the HD group exceeded that in the control group (CO 46 ± 24% vs 27 ± 16% [P = 0.007]; CI 51 ± 28% vs 28 ± 17% [P = 0.005]). Fetal growth and oxygen delivery/consumption were similar between groups. Adverse cardiovascular outcomes (nonmutually exclusive) in 6 HD women included arrhythmia (n = 4), heart failure (n = 2), and hypertensive disorder of pregnancy (n = 1); premature delivery was observed in 2 of these women. The odds of a maternal cardiovascular event were inversely associated with peak CI (odds ratio 0.10, 95% confidence interval 0.001-0.86; P = 0.04) and Δ,CI (0.02, 0.001-0.71; P = 0.03).

      Conclusions

      Maternal-fetal hemodynamics can be well characterised in pregnancy with the use of MRI. Impaired adaptation to pregnancy in women with HD appears to be associated with development of adverse outcomes of pregnancy.

      Résumé

      Contexte

      Bien qu’un débit cardiaque maternel insuffisant ait été mis en cause dans les issues médiocres apparues chez des mères atteintes d’une cardiopathie, les interactions mère-fœtus à l’origine de ces issues ne sont pas encore bien comprises. Notre objectif était de quantifier les paramètres hémodynamiques mère-fœtus à l’aide de l’imagerie par résonance magnétique (IRM) et d’explorer leur lien avec les événements indésirables.

      Méthodologie

      Des femmes enceintes atteintes d’une cardiopathie modérée ou sévère (n = 22; âge moyen : 32 ± 5 ans) ont été comparées avec des femmes témoins en bonne santé (n = 21; 34 ± 3 ans). Une IRM a été effectuée pendant le troisième trimestre, lorsque le débit cardiaque (mère-fœtus) est maximal, et six mois après la naissance, après la normalisation des paramètres hémodynamiques maternels (valeurs de référence). L’IRM en contraste de phase a été utilisée pour la quantification du flux vasculaire, et a été combinée à la relaxométrie en T1/T2 pour calculer l’approvisionnement en oxygène et la consommation d’oxygène chez le fœtus.

      Résultats

      Les mesures du débit cardiaque et de l’index cardiaque au troisième trimestre étaient similaires dans le groupe atteint d’une cardiopathie et le groupe témoin (débit cardiaque : 7,2 ± 1,5 vs 7,3 ± 1,6 L/min, p = 0,79; index cardiaque : 4,0 ± 0,7 vs 4,3 ± 0,7 L/min/m2; p = 0,28). Toutefois, l’ampleur de l’augmentation du débit/de l’index cardiaque (delta, valeur maximale de référence pendant la grossesse) dans le groupe atteint d’une cardiopathie était supérieure à celle du groupe témoin (débit cardiaque : 46 ± 24 % vs 27 ± 16 % [p = 0,007]; index cardiaque : 51 ± 28 % vs 28 ± 17 % [p = 0,005]). La croissance fœtale et l’approvisionnement en oxygène/la consommation d’oxygène étaient similaires dans les groupes. Les issues cardiovasculaires indésirables (non mutuellement exclusives) survenues chez six femmes atteintes d’une cardiopathie comprenaient l’arythmie (n = 4), l’insuffisance cardiaque (n = 2) et un trouble hypertensif gestationnel (n = 1); l'accouchement prématuré fœtale a été observé chez deux de ces femmes. La probabilité d’une manifestation cardiovasculaire maternelle était inversement associée à l’index cardiaque maximal (rapport d'incidence approché 0,10; intervalle de confiance à 95 % : 0,001-0,86; p = 0,04) et au delta de l’index cardiaque (0,02; 0,001-0,71; p = 0,03).

      Conclusions

      Les paramètres hémodynamiques maternels-fœtaux peuvent être bien caractérisés pendant la grossesse à l’aide de l’IRM. Chez les femmes atteintes d’une cardiopathie, les troubles de l’adaptation hémodynamique à la grossesse semblent être associés à des issues gestationnelles indésirables.
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