Preconception consultation using treadmill exercise stress echocardiography for pregnant women with the left-sided heart valve stenosis: A preliminary report.

OBJECTIVE: Pregnancy can increase gradients across the heart valves and consequently deteriorates maternal and fetoneonatal conditions. Hence, pregnancy during heart valve diseases can be challenging and we need to risk stratify patients before conception. We tried to assess the role of preconception consultation using treadmill stress echocardiography (TSE) testing for identifying pregnancy outcomes in women with mitral valve stenosis (MS) or aortic valve stenosis (AS). METHODS: Pregnant patients with a diagnosis of MS or AS were evaluated from January 2015 to December 2018. First group included patients undergoing the TSE testing and they were permitted to get pregnant if they met pre-defined criteria. Second group comprised women who did not undergo TSE testing. Maternal and fetoneonatal outcomes were also recorded. RESULTS: A total of 29 and 18 patients with MS and AS, respectively, were recruited. Among MS patients, individuals without TSE had more functional deterioration (11.1% vs. 35%) and more fetoneonatal events (FNE) (22.2% vs. 55%) compared with those undergoing TSE. The rates of maternal events and mitral valvuloplasty during pregnancy were significantly higher in patients without TSE compared with those undergoing TSE (p=0.015 and p=0.042, respectively). Among AS patients, maternal and FNE were higher in patients without TSE compared with those undergoing TSE, but those were comparable. CONCLUSION: Pregnant patients with the left-sided valvular stenosis who received preconception TSE testing had better outcomes compared with those who did not undergo preconception consultation. This underscores the utility of stress echocardiography in the risk stratification of pregnancies.

Percutaneous Transluminal Mitral Commissurotomy in Pregnant Women with Severe Mitral Stenosis.

Background: Mitral stenosis tends to worsen during pregnancy because of the increase in the cardiac output and the heart rate. In nonresponders to medical therapy, percutaneous transluminal mitral commissurotomy (PTMC) may be performed when there is a suitable valvular anatomy. In this study, we aimed to investigate the clinical and fetal outcomes of pregnant women with mitral stenosis who underwent PTMC. Methods: Thirty-one patients undergoing PTMC during pregnancy were enrolled in this study. The mitral valve area (MVA), the transmitral valve mean gradient (MVMG), and the severity of mitral regurgitation were assessed pre- and postprocedurally by transthoracic and transesophageal echocardiography. The radiation time was measured during the procedure. The patients were followed up during pregnancy, and the neonates were monitored for weight, height, the head circumference, the birth Apgar score, and the adverse effects of radiation for at least 12 months. Results: PTMC was successfully performed on 29 (93.5%) patients. No maternal death or pulmonary edema was reported. The mean MVA significantly increased (from 0.73±0.17 cm2 to 1.28±0.24 cm2; P<0.001), and the mean MVMG significantly decreased (from 19.62±5.91 mmHg to 8.90±4.73 mmHg; P<0.001) after the procedure. A significant decrease in the systolic pulmonary artery pressure was also detected. Mitral regurgitation did not increase in severity in 16 (51.6%) patients. There was no significant relationship between the Apgar score, weight, height, and the head circumference at birth and at the radiation time. Conclusion: In our series, PTMC during pregnancy was a safe and effective procedure. Lowering the radiation time with low frame-count techniques confers a significant decrease in radiation-related complications.

COMPARE CPM-RMI Trial: Intramyocardial Transplantation of Autologous Bone Marrow-Derived CD133+ Cells and MNCs during CABG in Patients with Recent MI: A Phase II/III, Multicenter, Placebo-Controlled, Randomized, Double-Blind Clinical Trial.

This article published in Cell J (Yakhteh), Vol 20, No 2, Jul-Sep 2018, on pages 267-277, four affiliations (1, 4, 5, and 10) were changed based on authors request.

COMPARE CPM-RMI Trial: Intramyocardial Transplantation of Autologous Bone Marrow-Derived CD133+ Cells and MNCs during CABG in Patients with Recent MI: A Phase II/III, Multicenter, Placebo-Controlled, Randomized, Double-Blind Clinical Trial.

OBJECTIVES: The regenerative potential of bone marrow-derived mononuclear cells (MNCs) and CD133+ stem cells in the heart varies in terms of their pro-angiogenic effects. This phase II/III, multicenter and double-blind trial is designed to compare the functional effects of intramyocardial autologous transplantation of both cell types and placebo in patients with recent myocardial infarction (RMI) post-coronary artery bypass graft. MATERIALS AND METHODS: This was a phase II/III, randomized, double-blind, placebo-controlled trial COMPARE CPM-RMI (CD133, Placebo, MNCs - recent myocardial infarction) conducted in accordance with the Declaration of Helsinki that assessed the safety and efficacy of CD133 and MNCs compared to placebo in patients with RMI. We randomly assigned 77 eligible RMI patients selected from 5 hospitals to receive CD133+ cells, MNC, or a placebo. Patients underwent gated single photon emission computed tomography assessments at 6 and 18 months post-intramyocardial transplantation. We tested the normally distributed efficacy outcomes with a mixed analysis of variance model that used the entire data set of baseline and between-group comparisons as well as within subject (time) and group×time interaction terms. RESULTS: There were no related serious adverse events reported. The intramyocardial transplantation of both cell types increased left ventricular ejection fraction by 9% [95% confidence intervals (CI): 2.14% to 15.78%, P=0.01] and improved decreased systolic wall thickening by -3.7 (95% CI: -7.07 to -0.42, P=0.03). The CD133 group showed significantly decreased non-viable segments by 75% (P=0.001) compared to the placebo and 60% (P=0.01) compared to the MNC group. We observed this improvement at both the 6- and 18-month time points. CONCLUSIONS: Intramyocardial injections of CD133+ cells or MNCs appeared to be safe and efficient with superiority of CD133+ cells for patients with RMI. Although the sample size precluded a definitive statement about clinical outcomes, these results have provided the basis for larger studies to confirm definitive evidence about the efficacy of these cell types (Registration Number: NCT01167751).

Echocardiographic Evaluation of Hemodynamic Changes in Left-Sided Heart Valves in Pregnant Women With Valvular Heart Disease.

Physiologic changes during pregnancy can deteriorate or improve patients' hemodynamic status in the setting of valvular heart disease. There are sparse data regarding the effect of pregnancy on valve hemodynamics in normal pregnant women with known valvular heart disease. In a prospective study from July 2014 to January 2016, a total of 52 normal pregnant women who had mitral stenosis, aortic stenosis, or a history of mitral valve or aortic valve replacements were assessed. All patients underwent echocardiographic examinations and hemodynamic parameters were measured for both the mitral valve and aortic valve at first, second, and third trimesters. The parameters included mean gradient, peak gradient, mean gradient/heart rate, peak gradient/heart rate, pressure halftime, dimensionless velocity index, and valve area. Although most hemodynamic parameters (i.e., mean gradient, peak gradient, mean gradient/heart rate, and peak gradient/heart rate) increased approximately 50% from first to second trimester and first to third trimester (p <0.05) but those remained stable at third compared with second trimester (p >0.05). The ratio of changes between trimesters for valve area and dimensionless velocity index were comparable. No clinical decompensations were observed except for 3 and 7 cases of deterioration to functional class II at second and third trimesters, respectively. In conclusion, during a full-term and uncomplicated pregnancy, mitral and aortic valve gradients increase without significant changes in valve area that are more marked between the second and first trimester than between the third and second trimester.

An Intracardiac Mass in a Pregnant Woman Presenting With Ventricular Tachycardia.

A pregnant patient presented with symptomatic ventricular tachycardia. Echocardiography revealed a large intramyocardial mass. Surgical resection was attempted in conjunction with cryoablation of the surrounding myocardial tissue. Histologic examination of the resected mass revealed cardiac neurofibroma. To the best of our knowledge, this is the first report of cardiac neurofibroma in a pregnant patient in the absence of any neurocutaneous syndromes such as neurofibromatosis.

Feto-maternal outcomes of urgent open-heart surgery during pregnancy.

BACKGROUND AND AIM OF THE STUDY: Cardiac surgery during pregnancy is rarely required and potentially increases feto-maternal mortality. The study aim was to evaluate pregnancy outcomes in females who underwent open-heart surgery with cardiopulmonary bypass (CPB) during pregnancy. METHODS: Between 1999 and 2014, a total of 16 pregnant women (mean age 27 ± 7 years; mean gestational age 13 ± 7.7 weeks) underwent urgent cardiac surgery using CPB. The preoperative diagnosis included prosthetic valve dysfunction in 12 women (five aortic, seven mitral), native valve endocarditis and critical aortic stenosis each in one woman, and intracardiac masses in two women. Eleven patients were in the first trimester, three in the second trimester, and two in the third trimester. A retrospective analysis was conducted that included maternal variables of age, gestational age, cardiac diagnosis, prior operations, surgical details, maternal morbidity and mortality and type of delivery, while fetal variables included incidence of low birth weight, prematurity, and fetal malformation. Patients were allocated to two groups: Group A (n = 9) included pregnant women with living neonates, while group B (n = 7) included pregnant women with an aborted fetus or dead neonate. All data were compared between the groups. RESULTS: There was no in-hospital maternal mortality. There were no significant differences between the two groups regarding age, gestational age, previous cardiac operation, type of surgery, duration of operation, perfusion pressure and core temperature during CPB. The CPB time was longer in group B (110.3 ± 57.1 min) than in group A (62 ± 15.7 min) (p = 0.028), as was the aortic cross-clamp time (54.3 ± 27.2 min and 38.7 ± 9.3 min in groups A and B, respectively) (p = 0.014). Group B patients received higher doses of inotropes perioperatively. No congenital abnormalities were identified in any of the living neonates. CONCLUSION: The durations of CPB and aortic cross-clamping may not affect maternal outcome, but shorter CPB and aortic cross-clamp times led to better fetal outcomes. Increasing the perioperative dosage of inotropes may lead to a reduced fetal survival.

Risk factors associated with endometriosis among infertile Iranian women.

INTRODUCTION: Endometriosis is defined as overgrowth of endometrial tissue outside the uterine cavity. Endometriosis may be asymptomatic or associated with dysmenorrheal symptoms, dyspareunia, pelvic pain, abnormal uterine bleeding and infertility. The aim of this study was to explore the risk factors related to endometriosis among infertile Iranian women. MATERIAL AND METHODS: In this case control study, infertile women referred for laparoscopy and infertility workup to two referral infertility clinics in Tehran, Iran were studied. According to the laparoscopy findings, women were divided into case (women who had pelvic endometriosis) and control (women with normal pelvis) groups. The case group was divided into two subgroups: stage I and II of endometriosis were considered as mild while stage III and IV were categorized as severe endometriosis. A questionnaire was completed for each patient. RESULTS: Logistic regression showed that age, duration of infertility, body mass index (BMI), duration of menstrual cycle, abortion history, dyspareunia, pelvic pain and family history of endometriosis are independent predictive factors for any type of endometriosis. In addition, it was shown that education, duration of infertility, BMI, amount and duration of menstrual bleeding, menstrual pattern, dyspareunia, pelvic pain and family history of endometriosis are independent predictive factors of severe endometriosis. The AUCs for these models were 0.781 (0.735-0.827) and 0.855 (0.810-0.901) for any type of endometriosis and severe endometriosis, respectively. CONCLUSIONS: It seems that any type of endometriosis and severe ones could be predicted according to demographic, menstrual and reproductive characteristics of infertile women.

Pregnancy outcome after mechanical mitral valve replacement: a prospective study.

BACKGROUND: Pregnant patients with mechanical heart valves require anticoagulation. The risk of bleeding and embryopathy associated with oral anticoagulants must be weighed against the risk of valve thrombosis. METHODS: In this prospective study, undertaken between 1999 and 2009, 53 pregnancies (47 women with mechanical mitral valves; 29.8 ± 4.8 years old) were studied. Patients were divided into two groups: group I (n = 43) received Warfarin throughout the pregnancy, while group II (n = 10) received Heparin in the first trimester and then Warfarin until the 36(th) week. RESULTS: Thirty-two (60.4%) pregnancies resulted in live births, whereas 18 (34%) abortions, 2 (3.8%) stillbirths, and one (1.9%) maternal death occurred. In group I, there were 26 (60.5%) live births, one (2.3%) stillbirth, and 15 (34.9%) abortions. In group II, there were 6 (60%) live births, one (10%) stillbirth, and 3 (30%) abortions. There were no significant differences between the two groups in terms of fetal outcome. Thirty-nine (90.7%) of the pregnancies in group I and 50% of those in group II (p value = 0.001) were without complications. There were no congenital malformations in the two groups. CONCLUSION: Fetal outcome was almost the same between the Warfarin and Heparin regimens. In maternal outcome, the Warfarin regimen is safer than Heparin.

Anti-coagulation during pregnancy in women with mechanical heart valves: a prospective study.

BACKGROUND: Pregnancy is associated with a hypercoagulable state, therefore the optimal anticoagulants for potential use in pregnant women with prosthetic heart valves are controversial. The aim of this study is to investigate the effect of anticoagulants on pregnancy outcomes and their potential risks in pregnant women with mechanical heart valves. MATERIALS AND METHODS: In this prospective cohort study, we followed 44 women with 49 pregnancies who had mechanical heart valves from September 2002 to September 2007. A total of 38 patients took warfarin throughout their pregnancies (group A). In 11 patients, warfarin was changed to heparin during the first trimester and then again to warfarin during 12thto 36thweeks of gestational age (group B). All women took warfarin from 36thweeks of gestational age until delivery. RESULTS: In group A, there were 22 live births (57.9%), 15 abortions (39.5%) and 1 maternal death (2.6%). In group B, there were seven live births (63.6%), three spontaneous abortions (27.3%) and one intra-uterine fetal death (9.1%). There was no significant difference in live birth rate between the two groups (p=0.24). Thirty-three pregnancies (86.8%) in group A and five pregnancies (45.4%) in group B had no maternal complications (p=0.004). The difference in pregnancy complications between both groups was significant (p<0.001). CONCLUSION: The present study shows that low dose warfarin (5 mg/day or less) may be safe during the first trimester of pregnancy. Maternal adverse events are low when pregnant women with mechanical heart valves remain on a warfarin regimen. The risk of embryopathy does not necessarily increase.

Anticoagulation for prosthetic heart valves in pregnancy. Is there an answer?

The aim of this retrospective study was to compare the different anticoagulation regimens used in pregnant women with prosthetic heart valves. We reviewed 196 pregnancies in 110 women from 1974 to 2000. The patients were divided into two groups: group 1 (142 pregnancies) had warfarin throughout pregnancy; and in group 2 (54 pregnancies), warfarin was replaced by subcutaneous heparin during the first trimester and last two weeks of pregnancy. There were no maternal complications in 129 pregnancies in group 1 and 44 in group 2. There were significantly fewer normal births in group 1 (56; 39.4%) compared to group 2 (39; 72.2%). Group 1 had a significantly higher rate of spontaneous abortion (46.5% vs 14.8%), but group 2 had a higher rate of valve thrombosis. In group 1, women with a warfarin requirement < 5 mg had a lower rate of spontaneous abortion. Warfarin is an effective anticoagulant in pregnant women with mechanical valves but it results in significant fetal loss when the dose is > 5 mg. Heparin is a less effective anticoagulant resulting in more maternal complications, but it is more protective of the fetus.