Cardio-Obstetrics and Heart Failure JACC: Heart Failure State-of-the-Art Review (JACC Heart Failure September 2023)-Article: Cardio-Obstetrics and Heart Failure JACC: Heart Failure State-of-the-Art Review (JACC Heart Failure September 2023)

Article: Cardio-Obstetrics and Heart Failure JACC: Heart Failure State-of-the-Art Review (JACC Heart Failure September 2023)

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A "State-of-the-Art Review" in JACC: Heart Failure addresses the rising maternal mortality rates in the US and emphasizes the critical role of multidisciplinary cardio-obstetric teams in managing heart failure (HF) in pregnant women. It highlights the necessity of comprehensive preconception risk assessment and effective management strategies extending through postpartum care.<br /><br />The review recognizes heart failure and cardiomyopathy as significant contributors to pregnancy-related deaths, noting peripartum cardiomyopathy (PPCM) as the most common cardiomyopathy during pregnancy. Pregnancy's hemodynamic changes may reveal pre-existing cardiomyopathies, leading to clinical decompensation. Women with advanced HF, those on left ventricular assist device (LVAD) support, or who have undergone heart transplantation (HT) face unique management challenges.<br /><br />Key focus areas include:<br />1. **Preconception Counseling**: Cardiovascular and obstetrical risk assessments are vital for women with pre-existing HF or high risk factors for HF. Recommended evaluations include history, physical examination, and various cardiovascular tests.<br />2. **Pregnancy Management**: Monitoring and adjustments are crucial for pregnant women with HF, including those on LVAD support or post-HT. Safe and optimal medication regimens during pregnancy and lactation must be determined.<br />3. **Labor and Delivery**: Vaginal delivery is generally preferred to minimize fluid shifts and risks associated with cesarean deliveries. Specialized anesthesia and close hemodynamic monitoring are essential.<br />4. **Fourth Trimester Care**: Postpartum monitoring is critical for recognizing and managing HF symptoms, transitioning to appropriate medications, and addressing contraception and mental health.<br /><br />Medications commonly used in HF need careful evaluation for safety during pregnancy and breastfeeding. For example, renin-angiotensin system inhibitors are contraindicated due to known risks to fetal development.<br /><br />Cardiac implantable electronic devices, like pacemakers and defibrillators, generally present low risk during pregnancy, though careful monitoring and potential adjustments are necessary.<br /><br />Challenges and strategies in managing pregnancies in women on LVAD support or following HT are also discussed. Despite contraindications due to complications and medication risks, successful pregnancies have been reported under stringent multidisciplinary care.<br /><br />In summary, a proactive approach involving patient education, preconception counseling, and constant interdisciplinary care is pivotal in managing pregnant women with HF to improve outcomes for both mothers and babies.

Keywords

maternal mortality

cardio-obstetric teams

heart failure

preconception risk assessment

peripartum cardiomyopathy

LVAD support

heart transplantation

pregnancy management

postpartum care

multidisciplinary care