Interventional Cardiac Procedures and Pregnancy

Abstract

As the average maternal age advances with increasing concurrent cardiovascular disease risk factors, more women are entering pregnancy with or at risk for various cardiovascular conditions. Although rare, pregnant patients may require various cardiac interventions in the catheterization laboratory. An understanding of indications for intervention in pregnant patients with conditions such as myocardial infarction, severe valvular disease, and cardiogenic shock is critical to optimizing both fetal and maternal outcomes. This document highlights the most common cardiovascular conditions that may be encountered during pregnancy that may require intervention and highlights indications for intervention and periprocedural considerations to facilitate favorable maternal and fetal outcomes.

Keywords: cardiogenic shock; maternal-fetal medicine; myocardial infarction; percutaneous coronary intervention; peripartum cardiomyopathy; pregnancy-associated spontaneous coronary artery dissection.

Graphical abstract

Figure 1

Maternal changes in pregnancy and risk of CV conditions. Significant changes during pregnancy can increase the risk of various cardiovascular conditions. AS, aortic stenosis; CV, cardiovascular; MS, mitral stenosis; PE, pulmonary embolism; PPCM, peripartum cardiomyopathy; SCAD, spontaneous coronary artery dissection.

Central Illustration

Components of an interventional cardio-obstetrics team. Interdisciplinary team care across various levels of clinical care and expertise is critical in treating pregnant patients with cardiovascular disease. HF, heart failure; L&D, labor and delivery; OB, obstetrics.

Figure 2

Measures to reduce maternal and fetal risk during coronary angiography and percutaneous coronary intervention. Procedural considerations to reduce maternal and fetal risk during cardiac catheterization and intervention are noted here.

Figure 3

Management of MI in pregnancy. Suggested algorithm to guide assessment and management of MI in pregnancy. ECG, electrocardiography; GRACE, Global Registry of Acute Coronary Events; MI, myocardial infarction; NSTEMI, non–ST-elevation myocardial infarction; SCAD, spontaneous coronary artery dissection; STEMI, ST-elevation myocardial infarction.

Figure 4

Management of suspected P-SCAD. Pregnant patients with suspected P-SCAD should be carefully managed with close attention to procedural techniques for diagnostic angiography and intervention with either PCI or surgery, as noted here. CABG, coronary artery bypass graft surgery; LM, left main; PCI, percutaneous coronary intervention; P-SCAD, pregnancy-associated spontaneous coronary artery dissection; TIMI, thrombolysis in myocardial infarction.

Figure 5

Evaluation and management of CS in pregnancy. Management of cardiogenic shock in pregnancy should involve the interdisciplinary cardio-obstetrics team with an indication for hemodynamic support based on patient-specific characteristics and institutional expertise. CS, cardiogenic shock; HF, heart failure; LVEF, left ventricular ejection fraction; PPCM, peripartum cardiomyopathy; RHC, right heart catheterization; SVR, systemic vascular resistance.

Figure 6

Management of PE in pregnancy and considerations for intervention. Suggested algorithm to guide the management of PE and indications for potential intervention. ECMO, extracorporeal membrane oxygenation; LV, left ventricle; PE, pulmonary embolism; PERT, pulmonary embolism response team; RV, right ventricle; SBP, systolic blood pressure; sPESI, simplified Pulmonary Embolism Severity Index.