Analysis of Cardiovascular Complications during Delivery Admissions Associated with COVID-19

BACKGROUND: Persons with Coronavirus Disease 2019 (COVID-19) infection have an increased risk of pregnancy-related complications. However, data on acute cardiovascular complications during delivery admissions remain limited. OBJECTIVE(S): To determine whether birthing individuals with COVID-19 have an increased risk of acute peripartum cardiovascular complications during their delivery admission. METHOD(S): This population-based retrospective cohort study used the National Inpatient Sample (2020) by utilizing ICD-10 codes to identify delivery admissions with a diagnosis of COVID-19. A multivariable logistic regression model was developed to report an adjusted odds ratio for the association between COVID-19 and acute peripartum cardiovascular complications. RESULT(S): A total of 3,458,691 weighted delivery admissions were identified, of which 1.3% were among persons with COVID-19 (n=46,375). Persons with COVID-19 were younger (median 28 vs. 29 years, p<0.01) and had a higher prevalence of gestational diabetes mellitus (GDM), preterm births and Cesarean delivery (p<0.01). After adjustment for age, race/ethnicity, comorbidities, insurance, and income, COVID-19 remained an independent predictor of peripartum cardiovascular complications including preeclampsia (aOR 1.33 [1.29-1.37]), peripartum cardiomyopathy (aOR 2.09 [1.54-2,84]), acute coronary syndrome (ACS) (aOR 12.94 [8.85-18.90]), and cardiac arrhythmias (aOR 1.55 [1.45-1.67]) compared with no COVID-19. Likewise, the risk of in-hospital mortality, AKI, stroke, pulmonary edema, and VTE was higher with COVID-19. For resource utilization, cost of hospitalization ($5,374 vs. $4,837, p<0.01) was higher for deliveries among persons with COVID-19. CONCLUSION(S): Persons with COVID-19 had a higher risk of preeclampsia, peripartum cardiomyopathy, ACS, arrhythmias, in-hospital mortality, pulmonary edema, AKI, stroke, and VTE during delivery hospitalizations. This was associated with an increased cost of hospitalization. Keywords: COVID-19, Pregnancy, GDM, PCOS, Preeclampsia, CVD, Cardiovascular Disease Abbreviations: COVID-19: Coronavirus disease-2019, GDM: Gestational Diabetes Mellitus, PCOS: Polycystic Ovary Syndrome, National Inpatient Sample: NIS, AHRQ: Agency for Healthcare Research and Quality, HCUP: the Healthcare Cost and Utilization Project Funding and Conflicts of Interest Dr. Michos reports Advisory Board participation for Amgen, AstraZeneca, Amarin, Bayer, Boehringer Ingelheim, Esperion, Novartis, Novo Nordisk, and Pfizer. The remaining authors have nothing to disclose.Copyright © 2023

A Rare Case Of Peripartum Takotsubo Cardiomyopathy

Background: Takotsubo cardiomyopathy is characterized by left ventricular dysfunction with apical ballooning in the absence of significant coronary artery disease. Though rare in pregnancy, this transient cardiac dysfunction may affect women in antepartum, intrapartum, or postpartum period, making it difficult to discern the inciting event or differentiate from spontaneous coronary artery dissection or peripartum cardiomyopathy. Most patients respond well to medical management with spontaneous resolution of cardiac dysfunction within weeks of diagnosis. Case presentation: A 38-year-old female G3P0202 at 36 weeks of gestation with a history of preeclampsia, hypertension, hyperlipidemia, and recent COVID-19 infection presented with severe substernal chest pain. She was hypertensive on arrival with a blood pressure of 220/120 mm Hg. Electrocardiogram showed T-wave inversion in the anterior leads and troponin I level was 2.6 ng/ml. She was treated with aspirin 324 mg, IV hydralazine 20 mg, IV magnesium sulfate infusion for seizure prophylaxis and fetal neuroprotection. A transthoracic echocardiogram revealed left ventricular ejection fraction of 35-40% with apical ballooning. Urgent left heart catheterization did not show signs of epicardial coronary artery disease, prompting the diagnosis of Takotsubo cardiomyopathy. Hospital course included interdisciplinary team-based medical therapy until cesarean section 24 hours after arrival. Following delivery, she was started on guideline directed medical therapy for heart failure and discharged home. At her one month follow-up, she was still experiencing symptoms of heart failure and classified as New York Heart Association Class II. Conclusion(s): Stress-induced cardiomyopathy rarely occurs in gravid females with chest pain;however, it should be considered after ruling out acute myocardial infarction. Distinguishing Takotsubo cardiomyopathy from peripartum cardiomyopathy is important as peripartum cardiomyopathy is considered a contraindication for future pregnancies. Clinical suspicion for Takotsubo cardiomyopathy should be increased in patients with a history of superimposed preeclampsia. Whether COVID-19 infection-associated inflammatory state predisposes high risk pregnant patients to Takotsubo cardiomyopathy is unknown, but this is a possible inciting factor that should be assessed in patient work up. Management should involve an interdisciplinary team approach to ensure the safety of mother and child.Copyright © 2022

Severe Heart Failure After Fetal Loss and COVID-19: A Diagnostically Challenging Case With Complicated Timing.

Coronavirus disease 2019 (COVID-19), initially recognized to cause respiratory system complications, has been found to also affect the cardiovascular system leading to myocardial damage and subsequently causing heart failure. Peripartum cardiomyopathy, though an uncommon condition, may also manifest as heart failure toward the end of pregnancy. This atypical case highlights the potential diagnostic overlap between COVID-19 heart failure and peripartum cardiomyopathy. At this point, there is no recommended algorithm used to distinguish one disease from another.

Obstetric Disorders and Critical Illness.

In this article, we discuss some of the more common obstetric-related conditions that can lead to critical illness and require management in an ICU. These include the hypertensive disorders of pregnancy, postpartum hemorrhage, hemolysis, elevated liver enzymes, and low platelet syndrome, acute fatty liver of pregnancy, amniotic fluid embolism, and peripartum cardiomyopathy. We also discuss pulmonary embolism and Covid-19. Despite not being specific to obstetric patients, pulmonary embolism is a common, life-threatening diagnosis in pregnancy with particular risks and management aspects. Covid-19 does not seem to occur with higher frequency in pregnant women, but it leads to higher rates of ICU admissions and mechanical ventilation in pregnant women than in their nonpregnant peers. Its prevalence during our current global pandemic makes it important to discuss in this article. We provide a basis for critical care physicians to be engaged in informed conversations and management in a multidisciplinary manner with other relevant providers in the care of critically ill pregnant and postpartum women.

A Rare Case of Heart Failure in Third Trimester Pregnancy - Diagnostic and Therapeutic Dilemma

Background Anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) is an extremely rare disorder. Case A 20-year-old, 36-week pregnant female (G1P0) presented with acute shortness of breath, sharp chest pain and fever. She was COVID-19 positive and required BiPAP. Echocardiogram showed 40% EF, dilated LV with global hypokinesis and moderate mitral regurgitation (MR). She was hypotensive and on oxygen despite diuresis, emergent cesarean and COVID-19 treatment. Left heart catheterization showed anomalous takeoff of the left main coronary artery (LCA) from the dilated pulmonary artery (PA) with coronary steal (Figure 1). She had ALCAPA repair with LIMA to LAD bypass grafting. Decision-making Differential diagnoses included peripartum cardiomyopathy, Covid-myocarditis, pulmonary embolism, and spontaneous coronary artery dissection. LHC was performed only when symptoms failed to improve and troponin kept rising. ALCAPA has two major clinical subtypes - Infantile type and adult type. Adult type presents as dyspnea, chest pain, reduced exercise ability, and sudden cardiac death. Despite having good RCA to LCA collaterals, adult patients can still have ongoing ischemia of the LV myocardium, causing ischemic MR, malignant ventricular dysrhythmias. Diagnosis was delayed due to pregnancy and COVID-19 infection. Conclusion ALCAPA is a lethal coronary disorder. Elevated troponin and dilated cardiomyopathy with acute MR should raise suspicion of ALCAPA in young adults. [Formula presented]Copyright © 2023 American College of Cardiology Foundation

Unexpected Course of Left Ventricular Thrombus after COVID-19 Infection in a Woman with Peripartum Cardiomyopathy Single Shield Against Double Shock.

Peripartum cardiomyopathy (PPCMP) is defined as heart failure that develops in the last trimester of pregnancy or in the first few months after delivery without an underlying cause. Altought it is seen rarely, it can lead to thromboembolic events and can be life-threatening. Similarly, COVID-19, which is a viral pneumonia agent, is known to cause thrombogenesis. In this case report, the unexpected course of left ventricular thrombus developing in a patient with peripartum cardiomyopathy accompanied by COVID-19 infection is presented.

CASE REPORT OF SPONTANEOUS CORONARY ARTERY DISSECTION IN A PATIENT POSITIVE FOR COVID-19

SESSION TITLE: Cardiovascular Complications in Patients with COVID-19 SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/19/2022 12:45 pm - 1:45 pm INTRODUCTION: Spontaneous coronary artery dissection (SCAD) is a rare cardiac phenomenon associated with autoimmune and inflammatory conditions seen often in young women with few conventional atherosclerotic risk factors. The presentation is indistinguishable from acute coronary syndrome and can lead to acute myocardial infarction, arrhythmias, and sudden death. We share a thought-provoking case of SCAD in a COVID-19 positive patient. CASE PRESENTATION: 51-year-old physically fit female with BMI of 22.46kg/m2, non-diabetic with recent unremarkable lipid panel and history of anxiety, postpartum cardiomyopathy 15 years prior with recovered ejection fraction presented with complaints of midsternal chest pain at rest, 9/10 intensity, radiating to the right shoulder associated with dyspnea, lasting for 3 hours until relieved by nitroglycerine patch. Initial workup revealed troponin of 3.08 and EKG consistent with acute ischemic changes without STEMI. She was incidentally found positive for SARS-CoV-2. Echocardiogram showed dyskinetic apex with normal ejection fraction. The following day, while she was on aspirin and heparin drip, she developed chest discomfort with EKG revealing dynamic T wave inversions and troponin trending up to 14.79. The patient was taken for an emergent cardiac catheterization which revealed patent coronaries with concern for distal left anterior descending artery dissection. Subsequently, the patient was continued on a heparin drip with an improvement of her symptoms. Troponin declined to 7.97 with no other COVID-19 related concerns. She was deemed medically stable and discharged home after completing her isolation. Furthermore, she underwent a cardiac and coronary artery CT angiogram 2 weeks later, showing patent coronaries and a calcium score of 0 and no findings of coronary artery disease. DISCUSSION: SCAD is an emergent condition closely associated with inflammatory conditions, systemic arteriopathy, emotional stress triggers, fibromuscular dysplasia, and pregnancy. It is not iatrogenic, traumatic or associated with atherosclerosis. The mainstay of detection of SCAD is coronary angiography. In our patient, since it was a distal LAD disease, the echo findings of dyskinetic apex helped established the diagnosis of SCAD. Management is mainly supportive usually carrying a good prognosis. In our case report, the connecting factor to SCAD was the presence of SARS-CoV-2. Our patient was without traditional risk factors for coronary artery disease, which reinforced the likelihood of SCAD instead of acute coronary syndrome. CONCLUSIONS: Thus, as the manifestations, complications, and sequelae of COVID-19 continue to emerge, we believe SCAD needs to remain a top differential in COVID -19 positive patients presenting with symptoms of the acute coronary syndrome. To better elucidate the pathophysiology of SCAD in SARS-CoV-2 patients, we encourage further vigilance of this phenomenon. Reference #1: Hayes, S. N. et al (2018, February 22). Spontaneous coronary artery dissection: Current state of the science: A scientific statement from the American Heart Association. Circulation. Retrieved April 1, 2022, from https://www.ahajournals.org/doi/10.1161/cir.0000000000000564 Reference #2: Ahmed, T., Jeudy, J., & Srivastava, M. C. (2020). Imaging modalities to delineate sequelae of spontaneous coronary artery dissection managed with percutaneous coronary intervention. Cureus. https://doi.org/10.7759/cureus.7591 DISCLOSURES: No relevant relationships by Hareesh Lal No relevant relationships by Jennaire Lewars No relevant relationships by Avani Mohta

Lightning strikes thrice

Introduction: A case of multiple co-existing conditions during pregnancy in a previously fit and well individual. Case Report: A 24-year-old woman presented at 37 weeks during her second pregnancy with a five day history of vomiting and abdominal pain. She had no significant past medical history. Her oxygen saturations were low so she received treatment for aspiration pneumonia. Her initial COVID-19 antigen test was negative however subsequent PCR was positive. The cause of her acute abdomen was unclear, with the differentials being perforated duodenal ulcer, pancreatitis and appendicitis. With input from general surgery, obstetrics and anaesthesia a decision was made to proceed with a diagnostic laparotomy. Classical caesarean section was performed at the beginning of the procedure. A healthy baby was delivered and laparotomy revealed pancreatitis. Due to high intraoperative oxygen requirements, shewas kept intubated and transferred to intensive care post operatively. An echocardiogram revealed biventricular failure and she was commenced on treatment for peripartum cardiomyopathy. Overall, she remained intubated for nine days andwas discharged from hospital 16 days following her surgery. Followup echocardiogram four months after hospital discharge showed her left ventricular ejection fraction remained <35%. Discussion: COVID-19 is increasingly common these days so it is likely to co-exist with other conditions. The incidence of acute pancreatitis during pregnancy is approximately one in 3000 and the incidence of peripartum cardiomyopathy is also approximately one in 3000 in the western world [1,2]. This case serves as a reminder that multiple conditions may be present in one individual and highlights the importance of completing a full set of investigations. This patient had multiple reasons for respiratory failure, however, an echocardiogram was necessary to reveal peripartum cardiomyopathy. Her ejection fraction remains low which puts her at high risk of mortality for future pregnancies. However, this diagnosis has allowed her to receive the appropriate follow up and counselling.

Cardiovascular Complications of Pregnancy-Associated COVID-19 Infections.

Cardiovascular complications are frequently present in coronavirus-2019 (COVID-19) infection. These include microvascular and macrovascular thrombotic complications such as arterial and venous thromboembolism, myocardial injury or inflammation resulting in infarction, heart failure, and arrhythmias. Data suggest increased risk of adverse outcomes in pregnant compared with nonpregnant women of reproductive age with COVID-19 infection, including need for intensive care unit admission, mechanical ventilation, and extracorporeal membrane oxygenation utilization. Current statements addressing COVID-19-associated cardiac complications do not include pregnancy complications that may mimic COVID-19 complications such as peripartum cardiomyopathy, spontaneous coronary artery dissection, and preeclampsia. Unique to pregnancy, COVID-19 complications can result in preterm delivery and modify management of the pregnancy. Moreover, pregnancy has often been an exclusion criterion for enrollment in research studies. In this review, we summarize what is known about pregnancy-associated COVID-19 cardiovascular complications.

BLOOD PRESSURE MEASUREMENT AMONG PATIENTS WITH PERIPARTUM CARDIOMYOPATHY;CONTROL AND BARRIERS DURING FOLLOW UP

Objective: To identify the frequency of blood pressure (BP) control among patients with peripartum cardiomyopathy (PPCM), barriers for follow up, and causes for elevation of BP. Design and method: Data about BP values, control, follow up, and treatment were prospectively documented for patients with PPCM who were presented to the cardio-maternal unit between 2015 - 2020. Baseline BP values were compared with the second readings between six months to one year postpartum. Adherence to medication and identifying the causes of elevated BP were reported. Results: Among 64 patients with PPCM presented to the unit, loss of follow up reported in 59.4% of patients;60.5% for unknown cause, 21.1% due to COVID-19 pandemic, and 18.4 due to death. For 26 (40.6%) patients who adhered to follow up, the mean age was (32.5 ± 7), 61.5% patients had normal BP at baseline and during follow up, while 38.5% of them had elevated BP at baseline or during follow up (cutoff 140/90);30% showed reduced BP to normal values comparing to their baseline measurements, and 70% developed increased in BP values during follow up (Table 1). All patients with increased BP measurements during follow up had hypertension associated with pregnancy, however, only 28.6% of them had known history of hypertension before pregnancy. Most common anti-hypertensive drug used post delivery was angiotensin-converting enzyme inhibitors 77%. Causes for increased BP measurements during follow up were obesity 57.1%, stress 28.6%, and use of oral contraceptive pills 14.3%. Conclusions: Among patients with PPCM with elevated BP at baseline, control of BP was reported in less than one-third of the patients. However, data for more than half of the patients was missing due to loss of follow up which is related to COVID-19 pandemic or mortality, but for the majority of patients the cause was unknown. Factors associated with elevated BP were obesity, stress, and use of oral contraceptive pills. Therefore, future enhancement in patient education regarding the importance of follow up and life style modifications is essential for better BP control among patients with PPCM. (Figure Presented).

Outpatient oral corticosteroid strategy for non-fulminant myocarditis associated with COVID-19

Case presentation A 36-year-old with recent vaginal delivery cocaine abuse, and COVID-19 infection was admitted for new acute systolic heart failure. Etiology of heart failure was suspected as peripartum cardiomyopathy, cocaine-induced, or COVID myocarditis. EKG had no ischemic changes and echocardiography revealed an ejection fraction (EF) of 10-15% with severe global hypokinesis. Additional diagnostics showed a BNP of 3600 and a stable high-sensitivity troponin with a negative delta of 60-65. No arrhythmia on telemetry noted as well. Cardiac MRI was suggestive of myocarditis and no evidence of ischemia on stress MRI (figure 1). The patient received diuresis until euvolemia and tolerated lisinopril and carvedilol. With a diagnosis of clinically suspected non-fulminant COVID myocarditis, she was discharged on a tapered oral dexamethasone for two weeks. On a follow-up telemedicine encounter, the patient denied any chest pain, shortness of breath, and was otherwise asymptomatic Discussion Currently, there remain no guidelines of treatment for COVID-19 myocarditis. Many published management strategies are focused on use of IV corticosteroids and other immunosuppression for cases of fulminant myocarditis. However there is limited data on outpatient management of nonfulminant myocarditis associated with COVID-19. In our case report, we demonstarte successfully managing a patient with non-fulimant myocarditis in the setting of severely reduced EF with an outpatient steroid regimen. Of note, her systolic dysfunction was not exclusively from myocarditis as the patient also had a history of cocaine abuse and possible peripartum cardiomyopathy. At the time of hospital discharge, she was clinically stable, euvolemic, tolerated guideline-directed medical therapy, and her troponins suggested no on-going myocardial injury.

Severe peripartum cardiomyopathy complicated by COVID-19 infection and small intestinal obstruction.

COVID-19 infection can be a possible trigger for peripartum cardiomyopathy. Multidisciplinary teamwork was crucial for the favorable outcome in our patient. Small bowel strangulation is a rare complication post-cesarean section.

Diagnostic dilemma: COVID-19 related cardiomyopathy or peripartum cardiomyopathy?

Peripartum cardiomyopathy is a relatively rare condition, that usually presents with features of heart failure in the peripartum period. The ongoing pandemic caused by coronavirus disease 2019 (COVID-19) has been reported to be associated with myocarditis, with progression to dilated cardiomyopathy and heart failure. Dilated cardiomyopathy in a peripartum patient with COVID-19 infection may present a diagnostic dilemma. We report a case of dilated cardiomyopathy in a peripartum patient with COVID-19 infection. She presented with shortness of breath in the peripartum period. Chest X-ray showed a grossly enlarged heart with bilateral pulmonary infiltrates consistent with congestive heart failure or viral pneumonia. Echocardiography revealed dilated chambers with 22% left ventricular ejection fraction (LVEF) and global hypokinesis. Despite completing 5 days of remdesivir and dexamethasone, she had worsening dyspnea on postpartum day 10, a repeat echocardiogram showed further reduction in LVEF to 10-15% and was discharged with a life-vest after acute management. She had multiple hospital admissions for decompensated heart failure. Myocardial core biopsy showed marked acute inflammation and necrosis. She had an intra-aortic balloon pump, left ventricular and right ventricular assist devices placed on account of persistent hemodynamic instability, and is now scheduled to have a cardiac transplant. .

Being responsible for someone else: a shared duty for parents and heart failure specialists during the COVID-19 pandemic.

A pandemic by a novel coronavirus disease (COVID-19) has been declared by the World Health Organization. Lombardy, the region of our tertiary referral centre for heart diseases in Northern Italy, has been particularly hit by the pandemic. According to the government's prescriptions, all elective activities and procedures in the last months were suspended in order to concentrate our efforts on COVID-19 patients' care. Entire departments have been turned into 'COVID-19 units', where healthcare professionals are daily involved in supporting critically ill patients. On a personal level, this was a period of special feelings and peculiar unexpected events. People close to healthcare workers have been affected, and our lives have been turned upside down. Furthermore, right in this period, few colleagues (and friends) are facing entirely new events in their lives, such as fatherhood with its load of joy and concern. Through the case of a young woman recently admitted to our department with a severe heart failure due to a peripartum cardiomyopathy, described in narrative form, this manuscript would help all those involved in the front line in the fight against the pandemic in these difficult times.

Peripartum cardiomyopathy mimicking COVID-19 infection.

A pregnant patient presented with fever and desaturation, without breathlessness. She was suspected to have COVID-19 but SARS-CoV-2 was negative. She developed fetal distress and underwent an uneventful Cesarean section. Postoperatively, she developed respiratory distress and needed mechanical ventilation support. The clinical features suggested COVID-19 infection and antiviral treatment were empirically initiated. Repeat SARS-CoV-2 was negative. Echocardiography, computed tomography scans, and biochemical investigations supported a diagnosis of peripartum cardiomyopathy. She was successfully managed with decongestive therapy and could be discharged home on the fifth day.