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Atrial septal defect and Pregnancy – Patient Information

What is atrial septal defect (ASD)

Atrial Septal defect is an abnormal communication between the upper two chambers of the heart namely left atrium and right atrium. Normally the left and right atrium are separated by the interatrial septum. So in atrial septal defect (ASD)  a part of the interatrial septum is missing. See the image below

Atrial Septal Defect

(Source : www.wikipedia.org)

In patients with ASD there is mixing of oxygenated blood of left side with venous blood on the right side.

Pregnancy Issues:

Patients with even a large unrepaired secundum atrial septal defect usually tolerate pregnancy without complications. In cases where the ASD has been closed either by surgery or by device, the course of pregnancy is similar to a normal female without heart disease, except when there are preexisting problems with heart rhythm or pulmonary hypertension.

Complications:

The complications include

1- Disorders of heart rhythm – e.g. Atrial fibrillation

2. Pulmonary hypertension – where there is increased pressure in the blood vessels of the lung.

3. Paradoxical embolism – Sometimes blood clots formed in the leg veins (increased chances in pregnant females) can pass through the defect in the heart and get lodged in the brain and can cause stroke .

Precautions:
  1. Elective closure of ASD before contemplating pregnancy is advisable
  2. Meticulous attention should be paid to the maternal leg veins, particularly during peridelivery, because deep venous thrombosis could precipitate a paradoxical embolus and stroke.
  3. In case of any complication like atrial fibrillation, pulmonary hypertension, close follow-up with a cardiologist is recommended.
Keywords: Congenital heart disease, pregnancy and heart disease, Patient information, atrial septal defect.

Coronary artery disease

Coronary artery disease

The heart like any other organ in the body needs constant supply of blood to survive. Blood reaches different parts of the heart through the coronary arteries.  Coronary arteries are of vital importance for the sustenance of life.

The different  normal functions of the coronary arteries include:

1. Carrying blood to different  parts of the heart

2. Regulating  blood supply to the heart in the face of varying blood pressure

3. Increasing blood supply to the heart in the face of increased cardiac demand like during exercise.

The coronary arterial system:  Can be divided into four parts

1. Left main coronary artery (LMCA)

        Which divides into

2. Left anterior descending artery  (LAD) And

3. Left circumflex artery (LCX)

4. Right coronary artery (RCA)

LMCA

Left main coronary artery, left anterior descending and left circumflex coronary artery

RCA

Right coronary artery

What is coronary artery disease (CAD)

Any disease which involves coronary arteries is CAD. Usually the most common form is reduction in the size of the coronary arteries. Many disease conditions can result in coronary artery disease but the most common cause of CAD is atherosclerosis. Other diseases like autoimmune diseases, congenital diseases can result in CAD.

Why CAD occurs?

CAD occurs due to a variety of reasons, which are called risk factors. You can read more about risk factors here.

What are the types of CAD?

CAD is a septum of diseases and it is divided to two categories

1. Chronic stable angina (CSA): In CSA there is a pattern of chest discomfort associated with exertion or emotional excitability. The occurrence of angina is after a predictable amount of work.

2. Acute coronary syndromes ( ACS)

ACS are are again divided into three types

A. Unstable angina: When there is new onset angina, worsening of previous angina, rest angina, it is called unstable angina

B. Non-ST elevation myocardial infarction

C. ST elevation myocardial infarction – the classic heart attack

This classification is important for the point of view of management and the aggressiveness of treatment.

What are the symptoms of coronary artery disease?

 A. Angina : Chest pain or discomfort .

B. Angina equivalents – fatigue , dyspnoea (shortness of breath) , eructations, palpitation

C. Sudden onset acute severe chest pain

D. Cold sweating

Read more about symptoms of heart disease here.

What to do?

First of all see your doctor for evaluation and treatment. Some of the general management modalities are discussed here.

Investigations

For the diagnosis of CAD the following investigations may be needed:

A. ECG – is of central importance in CAD. ECG in many occasions shows changes suggestive of reduced myocardial blood flow

B. Stress test – Different types of stress tests are available like treadmill test, nuclear stress  tests. A stress test can be done by performing exercise on a treadmill or by giving drugs in patients who are unable to do exercise. It is done when the symptoms are not typical and ECG changes are not typical.

C. Echocardiography – is for assessment of structure and function of heart

D. CT coronary angiography – It  is a noninvasive imaging modality for the diagnosis of CAD. It is like any other CT scan. Contrast injections are given to visualize the coronary arteries

E. MRI coronary angiography – Not very widely used for imaging of coronary arteries

F. Coronary angiography – this is the gold standard for the diagnosis of coronary artery disease and any percutaneous treatment for CAD can be done in the same setting

Treatment:

A. Risk factor control – Risk factor control is one of the most effective interventions for reducing the impact of coronary heart disease.  Proper control of blood pressure, diabetes, quitting smoking, treatment of abnormalities of cholesterol are some of the steps that greatly reduce the incidence and prevalence of CAD.

B. Medications- Patients with CAD will on some medications indefinitely (usually life long). For chronic stable angina, the first line of treatment is usually medical management. Even  patients who undergo coronary artery stenting or bypass surgery need to take medicines life long.

C. Coronary angiography and percutaneous coronary interventions are usually advised for patients who have more serious symptoms or for whom symptoms are not easily controlled with medicines. In presence of certain high risk factors patients should undergo early angiography and intervention or surgery

D. Coronary artery bypass grafting (CABG)

Drugs used in treatment of CAD:

1. Anti- platelets e.g. Aspirin, Clopidogrel, Prasugrel, ticagrelor, etc

2. Statins e.g. rosuvastatin, atorvastatin etc

C. Beta blockers (metoprolol, bisoprolol etc)

D. Ace inhibitors or angiotensin receptor blockers

E. Anticoagulants (heparin)

F. Nitrates

G. Nikorandil

H. Ranolazine

I. Trimetazadine

H. Therapies for refractory angina

Details about each class of drug I will post each week( Monday )

So please follow up

Cardiac interventions for CAD:

Known as percutaneous coronary intervention(PCI). In this procedure coronary angiography is done and then stenting is done as required.

Coronary artery bypass grafting:

CABG may be needed where PCI is not feasible or doesn’t give optimum results.

Finally there are a spectrum of patients who have drug refractory angina who are not suitable for PCI or CABG. They have refractory angina and the treatment options are limited in such patients.

Conclusion: Coronary artery disease is the leading cause of death and suffering in the world. The most common symptoms include chest pain, shortness of breath. It is diagnosed by ECG, stress tests, coronary angiography etc. The treatment include risk factor reduction, medical management and PCI or bypass surgery as needed.

Key words: Patient information, Coronary artery disease, heart disease, coronary angiography, ECG, Angina, CAD, PCI, CABG

Fetal echocardiography

Congenital anomalies are the leading cause of infant death and congenital heart diseases accounts for 30 to 50 percent of these deaths. As the major cause of the largest single category of mortality, the identification and management of fetal cardiac abnormalities is of paramount importance. Population screening studies have shown that congenital heart disease occurs in 5/1000 to 8/1000 newborns, with about one-half causing major disease and one-half causing minor disease. Fetal echocardiography is a reasonably accurate investigation for the detection of such anomalies. The prospective parents, obstetricians and cardiologists should have some basic concepts about this extremely useful tool.

Indications for fetal echocardiography:

The common indications are divided into three categories: 1. familial 2.maternal 3.fetal. Each is elaborated below

1. Familial risk factors

●First or second degree relatives with congenital heart disease (eg, the fetus’ siblings, parents, and grandparents)

●Syndromes including congenital heart disease (eg, Noonan, tuberous sclerosis, Holt-Oram, velocardiofacial [DiGeorge] syndrome)

2. Maternal risk factors

●Maternal congenital heart disease

●Cardiac teratogen medications (e.g., lithium, methotrexate, thalidomide, drugs for seizure, isotretinoin, paroxetine, warfarin)

●Maternal medical illness (e.g., diabetes, phenylketonuria, anti Ro/SSA or anti La/SSB antibodies)

●Exposure to prostaglandin synthetase inhibitors (can cause premature closure of the ductus arteriosus in the third trimester)

●Rubella infection in the first trimester

●In vitro fertilization

3. Fetal risk factors

●Suspected cardiac anomaly during basic sonogram

●Extracardiac anomaly

●Aneuploidy

●Nonimmune hydrops

●Arrhythmia

●Abnormal fetal situs

●Increased nuchal translucency at 11 to 14 weeks of gestation

●Chromosomal abnormality

●Monochorionic twins, with or without twin-twin transfusion syndrome

What is the timing of fetal echocardiogram?

Usually between 18 to 22 weeks

How accurate is fetal echocardiography for detection of cardiac anomalies?

Studies suggest widely variable sensitivity of fetal echo ranging from 0 to 80%. A reasonable figure would be an accuracy of 40%.

How fetal echocardiography changes the outcome?

Any cardiac anomaly should be properly explained to the parents. Though parents are less interested to know the exact anatomical details of the cardiac problem. What is more important for them is the short-, mid- and long-term prognosis of the child. Also information about place of child birth, and method to be used like- normal labour, LSCS etc. Though fetal cardiac interventions have been tried , they are far from being of routine use in near future.

For doctors it is important to explain the prognosis in clear terms. One study showed that cardiac anomalies which were amenable to biventricular repair had better outcome than single ventricle physiology (Ultrasound Obstet Gynecol. 1997 Oct;10(4):237-41. PMID 9383873)

.

Referral to a maternal-fetal medicine specialist, pediatric cardiologist, geneticist, and/or neonatologist to discuss prognosis, obstetrical and neonatal management, and options is recommended.

Conclusion:

The following interventions are recommended when a fetal cardiac anomaly is suspected:

•Full fetal echocardiography to evaluate cardiac structure and function, arterial and venous flow, and rhythm.

•Detailed scanning of the fetal anatomy to look for associated anomalies, particularly involving the digits and bones.

•Thorough family history to evaluate for familial abnormalities or syndromes.

•Thorough maternal medical history to identify chronic medical disorders, viral illnesses, or medications which are potential teratogens.

•Fetal karyotype, with screening for deletion in 22q11.2 when conotruncal anomalies are present

•Referral to a maternal-fetal medicine specialist, pediatric cardiologist, geneticist, and/or neonatologist to discuss prognosis, obstetrical and neonatal management, and options.

•Delivery at an institution that can provide neonatal cardiac care, if needed.

Dr. Anupam Jena
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