Abstracts from the 8th International Congress on Cardiac Problems in Pregnancy by Radcliffe Cardiology

Abstracts from The 8th International Congress on Cardiac Problems in Pregnancy 2023

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ABSTRACTS

8th International Congress on Cardiac Problems in Pregnancy

Abstracts from 8th International Congress on Cardiac Problems in Pregnancy

Citation: Journal of Asian Pacific Society of Cardiology 2023;2(Suppl 2):1–27. DOI: https://doi.org/10.15420/japsc.2023.2.s2 Open Access: This work is open access under the CC-BY-NC 4.0 License which allows users to copy, redistribute and make derivative works for non-commercial purposes, provided the original work is cited correctly.

A1 Peripartum Cardiomyopathy is Associated with Decreased Serum Albumin and Increased High Sensitivity C-reactive Protein: A Systematic Review and Meta-analysis

Background: Cardiomyopathy is a group of disorders in which the heart muscle is structurally and functionally abnormal in the absence of other diseases that can cause myocardial abnormality. The objectives were to evaluate the different types of cardiomyopathies, methods of risk assessment and management of pregnancy and labour outcomes for mothers and babies in the UK.

Yusra Pintaningrum1,2 and Ketut Angga Aditya Putra Pramana1 1. Department of Cardiovascular Medicine, Faculty of Medicine, University of Mataram, Indonesia; 2. Women Cardiology Task Force, Indonesian Heart Association, Indonesia

Methods: All women diagnosed with cardiomyopathy who delivered between January 2019 and June 2023 at a tertiary London hospital were assessed.

Citation: Journal of Asian Pacific Society of Cardiology 2023;2(Suppl 2):A1.

Results: Among 23 pregnancies in 19 women during the study period, peripartum was the most common type of cardiomyopathy, with similar numbers of dilated, hypertrophic and arrhythmogenic. Rarer causes were left ventricular non-compaction and one patient had a history of daunorubicin treatment for osteosarcoma at 7 years of age. This patient was very active, had her first baby at 34 years of age and developed heart failure with an ejection fraction of 35% six days after delivery. One patient with post-COVID myocarditis developed dilated cardiomyopathy with an uneventful pregnancy. There were no mortalities during the study period. Complications such as supraventricular and ventricular arrhythmia and heart failure did occur, but with very good recovery. One patient had hypertrophic obstructive cardiomyopathy and pulmonary artery hypertension with worsening of symptoms postpartum but declined an ICD. Later, the patient had an out-of-hospital ventricular fibrillation arrest and was successfully resuscitated.

Background: Peripartum cardiomyopathy (PPCM) is a potentially lifethreatening dilated cardiomyopathy that can occur in pregnant or postpartum women with no pre-existing heart disease. PPCM diagnosis is often delayed until patients experience major symptoms or adverse events. Several studies have examined biomarkers in PPCM patients, such as serum albumin and high sensitivity C-reactive protein (hs-CRP), but the results are debatable. The aim of this study was to determine the association between maternal serum albumin and hs-CRP concentrations with PPCM. Methods: Searches were performed in PubMed, ScienceDirect and Cochrane databases of the period January 1991 to December 2022 to identify studies that assessed serum albumin and hs-CRP levels in PPCM patients. Outcomes of interest were serum albumin and hs-CRP levels. Meta-analyses were performed on the included studies and MD and 95% CI were estimated using RevMan 5.4.

Conclusion: All patients with known cardiomyopathy had a baseline functional status assessment and early referral to a cardiologist for medical optimisation to better prepare for the difficulties that pregnancy and labour pose to this population.

Results: Six studies were included in the analysis. Patients with PPCM had significantly lower serum albumin levels by 5.03 g/l (MD 5.03; 95% CI [7.38–2.68]; p=0.0001) compared with non-PPCM patients. Patients with PPCM had significantly higher hs-CRP levels by 22.50 mg/l (MD 22.50; 95% CI [19.58–25.43]; p=0.00001) compared with non-PPCM patients.

A3 Comparison of Maternal Cardiovascular Function in Twin Pregnancies Complicated by Pre-eclampsia with those without Pre‑eclampsia: A Cross-sectional Study

Conclusion: Meta-analysis showed that patients with PPCM had significantly lower serum albumin levels and higher hs-CRP levels.

SB Keerti Priya,1 Anish Keepanasseril,1 Akinchan Bhardhwaj,2 J Yavana Suriya 1 and Ajith Ananthakrishna Pillai2

A2 An Observational Study of Cardiomyopathy in Pregnancy

1. Obstetrics and Gynaecology, JIPMER, India; 2. Cardiology, JIPMER, India Citation: Journal of Asian Pacific Society of Cardiology 2023;2(Suppl 2):A3.

Shabana Ashiq, Matthew Cauldwell and Ingrid Watt-Coote

Background: The presence of diastolic dysfunction and cardiac remodelling in women with pre-eclampsia increases the risk of premature cardiovascular morbidity and mortality. Maternal cardiac function

Obstetric Medicine, St Georges University Hospital, NHS Foundation Trust, UK Citation: Journal of Asian Pacific Society of Cardiology 2023;2(Suppl 2):A2.

Abstracts from 8th International Congress on Cardiac Problems in Pregnancy undergoes profound changes in twin compared to singleton gestation, which may be more severe when complicated by pre-eclampsia. The objective was to study the pattern of abnormality in maternal cardiovascular function in twin pregnancy complicated by pre-eclampsia compared to twin pregnancy without pre-eclampsia using the 2016 criteria of the American and European Societies of Echocardiography.

and experiences of women regarding the follow-up they receive during pregnancy. This study aimed to gain an in-depth understanding of experiences of women with cardiovascular disease and describe the barriers to and facilitators of follow-up received throughout pregnancy. Methods: This qualitative phenomenological study included data collection using semi-structured interviews and was performed at a tertiary care centre comprising a cardio-obstetrics outpatient clinic. Purposive sampling was performed. A thematic analysis of the transcribed interviews was done until data saturation was achieved.

Methods: A prospective cross-sectional study was conducted at a tertiary care hospital in southern India of 35 women with twin pregnancy complicated by pre-eclampsia and 55 women with uncomplicated twin pregnancy matched for maternal and gestational ages. Cardiac function and remodelling were assessed using conventional 2D, M-mode and Doppler echocardiography.

Results: Five main themes were identified. Awareness of the disease occurred for many patients when they experienced symptoms or when delivery was premature and their baby was admitted to neonatal care. Facilitators were caregiver skills, such as delivering humane care and providing congruent information, which ensured continuity of care. Barriers were that patients often had to seek help and felt lonely in their journey. Patients felt that they were not listened to when they were symptomatic or felt that something was ‘off’, leading to potentially detrimental but preventable complications. Due to a lack of visibility, the heart pregnancy team was not widely known to care providers in referring hospitals. The entire patient journey had an important impact on patient psyche; unfortunately, the psychological follow-up experience was that it insufficiently addressed their needs.

Results: Among the haemodynamic indices measured, total vascular resistance index and cardiac index were significantly increased in patients with pre-eclampsia. Although there was no significant difference in left ventricular geometry between the groups, women with twin pregnancy and pre-eclampsia had higher left ventricular mass. Evaluation of diastolic function showed the transmitral flow velocity (E/A) to be significantly lower in the twin pregnancy with pre-eclampsia group, whereas the tissue velocity (E/e’) was significantly higher, even though the overall rates of diastolic dysfunction were low. Increased rates of pulmonary oedema were observed among women with pre-eclampsia (four in the preeclamptic versus none in the uncomplicated twin pregnancy group) who had diastolic dysfunction. No significant differences were observed in biventricular systolic function and right ventricular function.

Conclusion: Greater visibility and knowledge about cardiovascular disease in pregnant women, together with implementation of a structured, patient-centred care pathway with special attention to psychological support, will better meet patient needs.

Conclusion: Women with twin pregnancy with pre-eclampsia have altered cardiac function indicative of increased afterload with diastolic dysfunction. These changes may be related to the risk of developing acute complications during pregnancy and might have a lasting impact in later life.

A5 Pregnancy Outcomes among Patients Post Fontan Surgery: A 25-year Single‑centre Retrospective Cohort Study

A4 Experiences and Perceived Barriers and Facilitators of Women with Cardiovascular Disease throughout their Pregnancy: A Qualitative Phenomenological Study

Nili Schamroth Pravda,1 Daniel Yehuda,1 Omri Sudri,1 Eyal Shwartz,1 Leonard Blieden,1 Ilan Richter,1 Alexander Dadashev,1 Shahar Vig,1 Ohad Houri,2 Eran Hadar,2 Ran Kornowski1 and Rafael Hirsh1 1. Cardiology, Rabin Medical Center, Israel; 2. Obstetrics, Rabin Medical Center, Israel

Yael Vanharen,1 Laury Knollenburg,1 An Van Berendoncks,2,3 Dominique Mannaerts4,5 and Eva Goossens1,6,7 1. Department of Nursing Science and Midwifery, Centre for Research and Innovation in Care (CRIC), Faculty of Medicine and Health Sciences, University of Antwerp, Belgium; 2. Department of Cardiology, Antwerp University Hospital/University of Antwerp, Belgium; 3. Department of Genetics, Pharmacology and Physiopathology of Heart, Blood Vessels and Skeleton, Research Group Cardiovascular Diseases, University of Antwerp, Belgium; 4. Anatomy and Research Centre, Antwerp Surgical Training, University of Antwerp, Belgium; 5. Department of Obstetrics and Gynaecology, Antwerp University Hospital, Belgium; 6. Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium; 7. Department of Patient Care, Antwerp University Hospital, Belgium

Citation: Journal of Asian Pacific Society of Cardiology 2023;2(Suppl 2):A5.

Background: Data on the characteristics and outcomes of pregnancy and childbearing in patients with Fontan physiology are limited. This population is at high risk for maternal complications during pregnancy. The objective was to evaluate the immediate and long-term outcomes of such patients followed up at our centre. Methods: Adult patients who had undergone Fontan surgery and were pregnant between 1994 and 2021 were included in the study. Maternal and obstetric outcomes during pregnancy were examined. Results: In a cohort of 109 Fontan patients, 50 were women, 19 (37%) of whom had a pregnancy during the follow-up period. There were 46 pregnancies in total with an average of 2.3 (IQR 1–2.5) pregnancies and 1.1 live births (IQR 1–2). Of these 109 patients, 22 had at least 1 pregnancy with a live birth, 1 patient had ≥1 child via adoption and 2 women had ≥1 child via surrogacy. Intrauterine growth retardation of the foetus was common (11 pregnancies) in 23% of all pregnancies, and 50% among

Citation: Journal of Asian Pacific Society of Cardiology 2023;2(Suppl 2):A4.

Background: Cardiovascular disease is the leading cause of mortality in pregnant women. Most empirical studies and guidelines include assessment of clinical status, prognosis and outcomes of these women, but there is a lack of in-depth understanding of the needs, expectations

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Abstracts from 8th International Congress on Cardiac Problems in Pregnancy those with live births. The main foetal complication was prematurity (20 pregnancies) in 43% of all pregnancies, and 90% among those with a live birth. Maternal complications included pre-eclampsia (1 patient), placental detachment (1 patient), acute heart failure exacerbation (1 patient), arrhythmia (3 atrial arrhythmias) and major peripartum haemorrhage (2 patients). There were no deaths in the peripartum period or in the year following pregnancy. When comparing patients in which the first pregnancy was a live birth (n=13) versus miscarriage (n=6), patients with a live birth were significantly younger (42 ± 5 versus 37 ± 5 years, p=0.075) and had fewer atrial arrhythmias (50% versus 0%, p=0.01).

Background: This study examines the considerations, risks and outcomes of interventional procedures in pregnant women, emphasising the importance of multidisciplinary care and individualised approaches. Methods: A comprehensive literature review was conducted, focusing on studies and case reports related to interventional procedures during pregnancy. PubMed and Google Scholar were searched using keywords such as ‘interventional procedures’, ‘pregnancy’, ‘maternal-foetal medicine’ and ‘outcomes’. Articles reporting on procedure types, associated risks, maternal and foetal outcomes, and multidisciplinary approaches were included.

Conclusion: Maternal and obstetric complications are common among patients following Fontan surgery. Further and expanded long-term data are needed.

Results: Various interventional procedures were identified, including vascular, foetal and urinary tract interventions. Risks encompassed radiation exposure, anaesthesia-related complications, procedural risks and potential foetal effects. Maternal outcomes varied based on intervention type, with complications such as infection, bleeding and embolism. Foetal outcomes were influenced by gestational age, intervention invasiveness and healthcare expertise. Multidisciplinary care involving obstetricians, interventional specialists, foetal medicine experts and anaesthesiologists was consistently emphasised.

A6 Sinus Tachycardia as a Result of Heart Failure in Pregnant Women: A Literature Review David Baghdasaryan

IVF Department, Vitromed Reproductive Health Center, Armenia; Invasive and Interventional Cardiology, Nork Marash Medical Center, Armenia

Conclusion: Interventional procedures during pregnancy necessitate careful consideration and a multidisciplinary approach. Despite inherent risks, studies demonstrate that experienced centres can perform these procedures safely, yielding favourable maternal and foetal outcomes. Key components include shared decision-making, comprehensive evaluations, diligent monitoring and individualised management plans. Continued research and evidence-based guidelines are needed to optimise safety and efficacy.

Citation: Journal of Asian Pacific Society of Cardiology 2023;2(Suppl 2):A6.

Background: Heart failure during pregnancy presents significant risks to both mother and foetus. Sinus tachycardia, an elevated heart rate originating from the sinus node, is commonly observed in pregnant women with heart failure. This literature review explores the relationship between sinus tachycardia and heart failure in pregnant women, including underlying mechanisms, clinical implications and management strategies. Understanding this association is vital for healthcare providers to effectively diagnose, monitor and manage heart failure in pregnant women, ensuring optimal outcomes for both mother and baby.

A8 Pre-eclampsia during Pregnancy: Annual Considerations and Maternal-foetal Outcomes David Baghdasaryan

Methods: A comprehensive literature search was conducted using electronic databases, selecting relevant articles published in the last decade. Studies investigating the relationship between sinus tachycardia and heart failure in pregnant women were included.

IVF Department, Vitromed Reproductive Health Center, Armenia; Invasive and Interventional Cardiology, Nork Marash Medical Center, Armenia Citation: Journal of Asian Pacific Society of Cardiology 2023;2(Suppl 2):A8.

Results: Sinus tachycardia in pregnant women with heart failure may result from increased haemodynamic demands, hormonal changes, and is associated with adverse maternal and foetal outcomes, including preterm labour and pre-eclampsia.

Background: The objective was to investigate the annual considerations, risk factors, management strategies and maternal-foetal outcomes associated with pre-eclampsia during pregnancy.

Conclusion: Sinus tachycardia serves as a valuable clinical marker for assessing cardiac function in pregnant women with heart failure. Comprehensive evaluation and appropriate management strategies, including pharmacological interventions and close monitoring are necessary for optimising outcomes. Further research is needed to better understand the pathophysiology and implications of sinus tachycardia in this population.

Methods: A comprehensive review of the existing literature was conducted, focusing on studies, clinical guidelines and population-based data related to pre-eclampsia. PubMed, Google Scholar and Cochrane Library were searched using keywords such as ‘pre-eclampsia’, ‘gestational hypertension’, ‘maternal-foetal outcomes’, and ‘management strategies’. Articles published within the last 10 years were included in the study. Results: Pre-eclampsia affects 2–8% of pregnancies worldwide and remains a significant cause of maternal and foetal morbidity and mortality. Risk factors include maternal age, obesity, pre-existing hypertension, diabetes, renal disease and previous pre-eclampsia. Pathogenesis involves impaired placental development, endothelial dysfunction, inflammation and oxidative stress. Pre-eclampsia presents with hypertension, proteinuria and organ dysfunction. Annual considerations include awareness campaigns, antenatal screening, risk assessment and

A7 Interventional Procedures during Pregnancy: Considerations, Risks and Outcomes David Baghdasaryan

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Abstracts from 8th International Congress on Cardiac Problems in Pregnancy A10 Mode of Delivery and Perinatal Outcomes in Patients with Low- and Moderate-tohigh-risk Cardiac Disease as Defined by Modified WHO Classification

individualised management strategies. Regular prenatal visits, blood pressure monitoring, urine protein assessment and foetal growth monitoring are crucial. Risk stratification allows for tailored management, including low-dose aspirin, calcium supplementation and antihypertensive therapy. Delivery is the definitive treatment for severe pre-eclampsia. Maternal outcomes include organ damage, eclampsia, stroke and longterm cardiovascular disease. Foetal complications include preterm birth, intrauterine growth restriction, placental abruption, and perinatal mortality. Pre-eclampsia may also increase the risk of adverse outcomes in future pregnancies.

Angela Essa,1 Lara Kovell2 and Gianna Wilkie3

1. Department of Obstetrics and Gynecology, University of Massachusetts Chan Medical School – Baystate Medical Center, US; 2. Department of Medicine, Division of Cardiovascular Medicine, University of Massachusetts Chan Medical School, US; 3. Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, University of Massachusetts Chan Medical School, US

Conclusion: Pre-eclampsia requires annual considerations for early detection, risk assessment and optimal management during pregnancy. Implementing evidence-based guidelines and individualised care can improve maternal and foetal outcomes. Further research is needed to better understand the pathophysiology, risk factors and preventive strategies for pre-eclampsia, aiming to reduce the global burden of this condition and improve pregnancy outcomes.

Citation: Journal of Asian Pacific Society of Cardiology 2023;2(Suppl 2):A10.

Background: Cardiac disease is a leading cause of maternal morbidity and mortality and an increasing number of patients with cardiac disease are reaching childbearing age. Rates of caesarean delivery among patients with cardiovascular disease are higher than those in the general population despite guidelines reserving caesarean delivery for obstetric indications. The objectives were to evaluate mode of delivery and perinatal outcomes among patients with low- and moderate-to-high-risk cardiac disease as defined by the modified WHO (mWHO) classification of maternal cardiovascular risk.

A9 In Utero Angiotensin-converting Enzyme Inhibitor Exposure: Data from the ESC-EORP Registry of Pregnancy and Cardiac Disease Johanna van der Zande and Jolien Roos-Hesselink

Cardiology, Erasmus University Medical Center, the Netherlands

Methods: A retrospective cohort study was performed of obstetric patients with cardiac disease as defined by the mWHO cardiovascular classification who underwent perinatal transthoracic echocardiogram at a single academic medical centre between 1 October 2017 and 1 May 2022. Comparisons between patients with low- (mWHO class I) and moderateto-high-risk (mWHO classes II-IV) cardiac disease were made using χ2, Fisher’s exact or Student’s t-tests.

Citation: Journal of Asian Pacific Society of Cardiology 2023;2(Suppl 2):A9.

Background: Angiotensin-converting enzyme (ACE) inhibitors are not recommended during pregnancy due to possible higher risks of neonatal congenital abnormalities. Data regarding these risks, however, are scarce. This study aims to describe patients who used ACE inhibitors during pregnancy and evaluate perinatal outcomes of in utero ACE inhibitor exposure.

Results: In total, 108 subjects were included (n=41 low-risk, n=67 moderate-to-high-risk disease). Subjects had a mean age of 32.1 (±5.5) years at delivery and a mean pre-gravid BMI of 29.9 (±7.8) kg/m2. Rates of vaginal and caesarean delivery were similar between groups (OR 1.5, p=0.43). Patients in the higher-risk group were more likely to be admitted to the intensive care unit (OR 7.8, p=0.05) and experience severe maternal morbidity (SMM) (p=0.01). Mode of delivery was not associated with SMM in the higher-risk group (OR 3.2, p=0.12). Infants of mothers with higherrisk disease were more likely to be admitted to the neonatal intensive care unit (NICU) (OR 3.6, p=0.06) and had longer NICU stays (SD −1.1, p=0.005).

Methods: The Registry of Pregnancy and Cardiac Disease (ROPAC) is a prospective, global registry of pregnancies in women with structural heart disease. Outcomes were compared between women who used ACE inhibitors during pregnancy versus those who did not. Multivariable regression analysis was used for effect of ACE inhibitor use on neonatal congenital abnormalities and small-for-gestational-age. Results: ACE inhibitors were used in 35 (0.6%) of 5,739 ROPAC pregnancies. Compared to women who did not use ACE inhibitors, women who did were more often from a lower-middle-income country (60% versus 40%, p=0.014) and more often had chronic hypertension (23% versus 7%, p=0.001) and left ventricle ejection fraction 40% (34% versus 4%, p=0.001). No therapeutic termination of pregnancy due to foetal abnormality was described. More neonatal congenital anomalies were seen in the infants after in utero ACE inhibitor exposure (11% versus 5%); however, significance was not reached (p=0.097) and not after adjustment for multiple confounders (OR 2.37; 95% CI [0.81–6.92]). ACE inhibitor use was not associated with small-for-gestational-age (OR 0.74, 95% CI [0.25–2.15]).

Conclusion: There was no difference in mode of delivery by mWHO cardiac classification. Mode of delivery was not associated with the risk of SMM. Vaginal delivery appears reasonable for certain patients with wellcompensated cardiac disease. Larger studies are needed to confirm these findings.

A11 Obstetric Predictors of Hypertension: A Crosssectional Study of Women Attending the Postnatal Clinic of Jos University Teaching Hospital

Conclusion: ACE inhibitors are seldom used during pregnancy. Preconception counselling is crucial for careful evaluation of maternal medication use so that the medication can be changed where necessary and possible.

Basil Okeahialam,1 Hadiza Agbo2 and Patrick Daru3

1. Medicine, Jos University Teaching Hospital, Jos, Nigeria; 2. Community Medicine, Jos University Teaching Hospital, Jos, Nigeria; 3. Obstetrics and Gynaecology, Jos University Teaching Hospital, Jos, Nigeria

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Abstracts from 8th International Congress on Cardiac Problems in Pregnancy important points along these women’s life course that should be considered when providing them with treatment. The study findings can be relevant to both the field of women’s medicine, which is becoming more specialised in childbirth in women with high-risk pregnancies, and the field of cardiovascular medicine.

Citation: Journal of Asian Pacific Society of Cardiology 2023;2(Suppl 2):A11.

Background: Hypertensive diseases of pregnancy (HDP) account for high maternal and child morbidity and mortality and can predict future cardiometabolic diseases. This study aimed to identify obstetric predictors of HDP requiring preventive action to reduce consequences when women present to the antenatal clinic (ANC).

A13 Addressing Postpartum Contraception Practices Using a Multidisciplinary Pregnancy Heart Team Approach

Methods: This was a cross-sectional descriptive study using intervieweradministered questionnaire with anthropometric and blood pressure measurement in attendees at the postnatal clinic (PNC) of Jos University teaching hospital and ANC records.

Hayley Miller,1 Samantha Do,1 Giovanna Cruz,1 Danielle Panelli,1 Stephanie Leonard,1 Anna Girsen,1 Christine Lee,1 Abha Khandelwal,3 Kate Shaw2 and Katherine Bianco1

Results: The following indices proved predictive of HDP and subsequent hypertension: weight (p=0.009), hip circumference (p=0.018), parity (p=0.043), waist circumference (p=0.000), abdominal height (p=0.040), waist-to-height ratio (p=0.020), history of hypertension in previous pregnancy (p=0.000), birthweight of baby (p=0.020) and assisted mode of delivery (p=0.05).

1. Maternal Fetal Medicine, Stanford University Hospital, US; 2. Complex Family Planning Services and Research, Division of Gynecology; Stanford University Hospital, US; 3. Division of Cardiology, Department of Medicine, Stanford University Hospital, US Citation: Journal of Asian Pacific Society of Cardiology 2023;2(Suppl 2):A13.

Conclusion: To initiate preventive action on ANC registration to mitigate effects or to outrightly prevent HDP a careful check of anthropometry and history of preterm/operative delivery in a previous pregnancy is necessary.

Background: Cardiovascular disease (CVD) is the leading cause of maternal morbidity and mortality, making planned pregnancy, and thereby reliable contraception among people with CVD, vital. This study aimed to compare postpartum contraceptive practices among people with CVD cared for by a pregnancy heart team to people with other chronic comorbidities (high-risk) and people without comorbidities (low-risk).

A12 The Experience of Young Women who Live with Congenital Heart Disease

Methods: This was a retrospective cohort study comparing postpartum contraceptive practices between a cardiac cohort who received care by a multidisciplinary team between 2012 and 2020, and high-risk and low-risk cohorts delivering at a single academic centre between 2016 and 2019. The presence of a contraceptive plan stratified by the WHO tiered effectiveness model at birthing admission, discharge and postpartum visit, and uptake of reliable contraception by 8 weeks postpartum were investigated.

Albina Rabinovich,1 Albina Rabinovich2 and Hadas Goldblatt1 1. Nursing, Haifa University, Israel; 2. Nursing School, Sheinbron, Israel Citation: Journal of Asian Pacific Society of Cardiology 2023;2(Suppl 2):A12.

Background: The number of people living with congenital heart defects is increasing steadily. Due to developments in science and medicine, approximately 95% of babies born with congenital heart defects will survive into adulthood. One-fifth of children with congenital heart defects will undergo open-heart surgery via opening of the sternum bone. Congenital heart defects affect most areas of life. This study aimed to research the experiences of young women aged 18-43 years who live with congenital heart defects.

Results: The study included 1,464 patients (189 with CVD, 197 with chronic comorbidities and 1,078 low-risk). When compared with the high-risk cohort, the cardiac cohort had similar rates of any contraceptive plan (tiers 1, 2 or 3) at all three timepoints in the study (admission p=0.666; discharge p=.0644; postpartum p=0.397). Compared with the cardiac cohort, by 8 weeks postpartum the high-risk cohort had similar odds of using highly reliable forms of contraception and similar odds of having a plan to use the most reliable forms of contraception at the time of birthing admission, discharge, and postpartum visit. The low-risk cohort had lower odds of using a reliable form of contraception by 8 weeks postpartum and was less likely to have a plan for reliable contraception at the time of birthing admission, discharge, and postpartum visit.

Methods: Research was conducted using the qualitative method. Participants were 16 women with congenital heart disease who underwent open-heart surgery in childhood. Results: Three themes were revealed from the data analysis: (1) You are not like everyone else: The experience of being different from the rest of society; (2) The pitcher and what’s inside: The language of the body. (This theme describes the dissonant feelings between the scarred body that had undergone complex life events, and the feeling of potential and competence, similarly to one’s peer group.); and (3) Not good enough: the need for self- affirmation. (Participants expressed the need to prove themselves.) Implications for further research are that there is little available knowledge about this growing population and scant references to their emotional and social welfare. There is also scant knowledge about coping modes of families of children with such defects.

Conclusion: People with CVD cared for by a pregnancy heart team had higher odds of reliable postpartum contraception planning and uptake compared with a low-risk cohort and similar odds compared with a highrisk cohort.

A14 Placental Appearance and Perinatal Outcome in Fontan Circulation: A Case Series

Elena Jost,1 Philipp Kosian,1 Ulrich Gembruch,1 Waltraut M Merz,1 Andrea Gieselmann,2 Martin Schneider2 and Tiyasha H Ayub1

Conclusion: Findings from this research show that both women and their families would benefit from long-term support. The research raises

1. Department of Obstetrics and Prenatal Medicine, University Hospital

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Abstracts from 8th International Congress on Cardiac Problems in Pregnancy Bonn, Germany; 2. Department of Cardiology, German Pediatric Heart Center, University Hospital Bonn, Germany

was to investigate whether women with CHD have a higher risk of hypertensive pregnancy disorders than women without heart disease.

Citation: Journal of Asian Pacific Society of Cardiology 2023;2(Suppl 2):A14.

Methods: The study identified all childbirths after the 22nd gestational week and diagnoses of hypertensive pregnancy disorders (gestational hypertension, mild pre-eclampsia and severe pre-eclampsia) in the period 1999–2014 from the Medical Birth Registry of Norway. Using the unique personal identification number given to all Norwegian residents, information on maternal CHD diagnoses was collected from four national health registers. Women with heterotaxia, conotruncal defect, atrioventricular septal defect, anomalous pulmonary venous return, left ventricular outflow tract obstruction, right ventricular outflow tract obstruction (except valvular pulmonary stenosis) or other complex heart defects were classified with severe CHD. Risk ratios with 95% CI for hypertensive pregnancy disorders by maternal CHD status were estimated and adjusted for the year of delivery and maternal age.

Background: Advances in the surgical treatment of univentricular circulation allow affected individuals a high quality of life. Consequently, the number of pregnancies in Fontan patients is increasing steadily, along with a rise in maternal and perinatal complication rates. Translating the haemodynamic profile of Fontan circulation to the cardiovascular physiology of pregnancy, the inability to increase cardiac output results in impaired placental perfusion. At the same time, the elevated systemic venous pressure slows down outflow from the placental bed. These changes may contribute to high rates of foetal growth restriction and prematurity in pregnancies with Fontan circulation. The objective was to describe changes in the placental appearance by ultrasonography and correlate these findings to maternal and perinatal data.

Results: A total of 869,062 childbirths in the Medical Birth Registry of Norway were identified. Among these, 2,768 had any maternal CHD and 366 had severe maternal CHD. For women with any CHD, the adjusted risk ratio for gestational hypertension was 1.08 (95% CI [0.83–1.41]), mild pre-eclampsia 1.24 (95% CI [1.01–1.52]) and severe pre-eclampsia 1.32 (95% CI [1.00–1.73]), compared to women without heart disease. For women with severe CHD, the adjusted risk ratio for gestational hypertension was 0.92 (95% CI [0.42–2.02]), mild pre-eclampsia 1,46 (95% CI [0.88–2.45]) and severe pre-eclampsia 1.94 (95% CI [1.05–3.58]), compared to women without heart disease.

Methods: Pregnancies in women with Fontan circulation at our centre between 2018 and 2023 were prospectively observed. Serial ultrasonographic examinations were performed, including biometry, anomaly scan and Doppler studies of the uteroplacental, fetoplacental and foetal circulation. Maternal cardiac, obstetric and perinatal data were collected. Results: Of seven women with Fontan circulation with 17 pregnancies, six pregnancies continued beyond foetal viability (one ongoing pregnancy) and 11 ended in miscarriage. Uteroplacental blood flow indices were within normal range at 20–23 weeks of gestation in all women. During late second trimester the sonomorphological appearance of the placenta was small and globular. Large, congested intervillous blood lakes with sluggish or stagnant blood flow could be detected. Additionally, the placenta appeared inhomogeneous with interspersed calcifications. Preterm birth due to obstetric complications occurred in all cases.

Conclusion: Compared to women without heart disease, a trend of increased risk for hypertensive pregnancy disorders was observed in women with CHD. However, only the risk for severe pre-eclampsia in women with severe CHD reached statistical significance.

A16 Zero Fluoro Interventional Arrhythmology Procedures in Pregnant Women

Conclusion: Causes for poor perinatal outcome in Fontan circulation have not yet been fully elucidated, but placental perfusion may harbour answers. Changes in lymphatic drainage, hepatic function, haemostaseological alterations and rise in intra-abdominal pressure during pregnancy may have additional impact. Further research is urgently required.

Evgenii Kropotkin, Eduard Ivanitsky and Valery Sakovitch Cardiovascular Surgery 2, Federal Center for Cardiovascular Surgery, Russia Citation: Journal of Asian Pacific Society of Cardiology 2023;2(Suppl 2):A16.

A15 Hypertensive Pregnancy Disorders in Women with Congenital Heart Disease in Norway 1999–2014

Background: Neurohumoral changes in pregnancy can cause heart rhythm disorders. Serious adverse events were diagnosed in 20% of patients with sustained or haemodynamically unstable cardiac arrhythmias. Catheter ablation and device implantation are routinely performed under X-ray guidance. Fluoroscopy can have a negative effect on pregnant patients and foetuses. This study presents the experience of zero fluoro procedures in pregnant patients.

Marit Sandberg,1,2 Tatiana Fomina,3 Ferenc Macsali,2,6 Gottfried Greve,1,4 Nina Øyen3,5 and Elisabeth Leirgul4

1. Department of Clinical Science, University of Bergen, Norway; 2. Department of Obstetrics and Gynecology, Haukeland University Hospital, Bergen, Norway; 3. Department of Global Health and Social Medicine, University of Bergen, Norway; 4. Department of Heart Disease, Haukeland University Hospital, Bergen, Norway; 5. Department of Medical Genetics, Haukeland University Hospital, Bergen, Norway; 6. Norwegian Institute of Public Health, Norwegian Institute of Public Health, Norway

Methods: From January 2013 to January 2021, 30 pregnant patients with a mean age of 29.9 + 5.2 (17–43) years underwent interventional procedures due to heart rhythm disorders. Mean pregnancy period at the time of procedure was 20.9 + 8.0 (3–35) gestational weeks. Indications for interventional procedures were made according to the current guidelines. All procedures were performed under local anaesthesia and sedation. Device implantation or replacement was performed in seven patients and catheter ablation in 23. In five out of seven patients, device replacement was performed. One pacemaker and one ICD were implanted under intracardiac echo guidance. Ventricular arrhythmias were ablated

Citation: Journal of Asian Pacific Society of Cardiology 2023;2(Suppl 2):A15.

Background: Altered cardiovascular physiology in women with congenital heart disease (CHD) can affect the course of pregnancy. The objective

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Abstracts from 8th International Congress on Cardiac Problems in Pregnancy in six patients, supraventricular tachycardias due to Wolff–Parkinson– White syndrome in nine, atrioventricular nodal re-entry tachycardia in three and focal atrial tachycardia in three. CARTO 3 (Biosense Webster) or navX (Abbott) navigation systems were used for electroanatomical mapping for catheter ablation.

mWHO risk class. While more research is needed, it is reasonable to offer patients with cardiac disease ASA for prevention of PEC.

A18 Pregnancy Outcomes and Effects on Cardiac Function among Patients with Tetralogy of Fallot: A Single-centre Cohort Study

Results: No major complications were revealed in this cohort of patients. There were no conversions from zero to fluoroscopy guided procedures. One patient refused femoral approach for ventricular tachycardia treatment and in this patient ectopic foci was not eliminated. In one patient ventricular arrhythmia recurrence was revealed 24 hours after ablation but the patient refused repeat of procedure. The other 28 procedures were completed successfully.

Ohad Houri,1,3 Noam Peres,1,3 Eran Hadar,1,3 Ran Kornowski,2,3 Rafael Hirsch2,3 and Nili Schamroth Pravda1,2,3 1. Helen Schneider Hospital for Women, Rabin Medical Center, Israel; 2. Department of Cardiology, Rabin Medical Center, Israel; 3. Faculty of Medicine, Tel Aviv University, Israel Citation: Journal of Asian Pacific Society of Cardiology 2023;2(Suppl 2):A18.

Conclusion: Zero fluoroscopy interventional procedures in pregnant patients for the treatment of cardiac arrhythmias are safe, effective and should be a variant of choice for patients and performed in experienced centres.

Background: Data on the characteristics and outcomes of pregnancy among patients with tetralogy of Fallot (TOF) are limited. Depending on haemodynamic status, the risk of maternal and foetal complications during pregnancy can be considerable. The aim of the study was to evaluate pregnancy outcomes and effects on cardiac function among patients with TOF.

A17 Cardiac Disease and Risk of Hypertensive Disorders of Pregnancy

Methods: Included in the study were adult patients with TOF who were pregnant between the years 1994 and 2022. Maternal and obstetric outcomes during pregnancy were examined. Serial imaging to evaluate the temporal effects of pregnancy on cardiac function was assessed.

Sarah Weingarten, Brittany Roser, Brittany Dodson, Amrin Khander and Inna Landres Obstetrics and Gynecology, Weill Cornell Medicine, US

Citation: Journal of Asian Pacific Society of Cardiology 2023;2(Suppl 2):A17.

Results: The study cohort included 52 patients with a known diagnosis of TOF and documented pregnancy. There were 93 pregnancies with 87 live births of which 26 (29%) were delivered by caesarean section (9 women). The mean gestational age at delivery was 38 gestational weeks (GW). Nine deliveries (10.3%) occurred before 37 GW, but only one before 34 GW. Mean birthweight at delivery was 2,759 g (±257). The main foetal complication was small for gestation (n=16, 18.3%). There was one maternal cardiac complication during pregnancy of an atrial arrhythmia that exacerbated heart failure. There were no deaths in the peripartum period or the year following pregnancy. At preconception, 66% had pulmonary regurgitation. The mean pulmonary valve pressure gradient was 18.1 ± 14.6 mmHg and mean early end diastolic pressure was 15.7 ± 8.2 mmHg. The aorta was dilated in 25% and the mean aortic sinus diameter was 32.8 ± 4.06 mm. On echocardiogram at postconception, 80% had pulmonary regurgitation with a mean pulmonary valve pressure gradient of 14.8 ± 7.6 mmHg and mean early end diastolic pressure of 14.5 ± 6.2 mmHg. The aortic diameter remained unchanged with an average mean aortic sinus diameter of 32.9 ± 3.6 mm.

Background: Cardiovascular disease affects 1–4% of pregnancies in the US and is the leading cause of pregnancy-related deaths. There are limited data on hypertensive disorders of pregnancy (HDP) in this population. American College of Obstetricians and Gynecologists (ACOG) and United States Preventive Services Task Force (USPSTF) guidelines for aspirin (ASA) use for reduction of pre-eclampsia (PEC) do not include cardiac disease as a risk factor. The objective was to determine if cardiovascular disease is a risk factor for developing HDP. Methods: This was a retrospective cohort study of pregnancies complicated by maternal cardiac disease at a US academic centre between 2018 and 2022. Patients with cardiac disease (congenital or acquired) who delivered after 20 weeks of gestation were included in the study. Demographics and pregnancy outcomes were recorded. Primary outcome was development of HDP. Secondary outcomes were correlation of HDP with the presence of one high or two moderate risk factors based on ACOG guidelines for ASA use and severity of cardiac disease based on modified WHO (mWHO) risk class.

Conclusion: Maternal and obstetric complications are rare among patients with TOF. Although more patients developed pulmonary regurgitation after conception, this was not correlated to increased pulmonary artery pressure. Further and expanded long-term data is needed.

Results: One hundred and fifteen patients were included in the study. Eighteen patients (15.7%) developed HDP and 71 (61.7%) took ASA. Among 18 patients with HDP 55% developed PEC with severe features and 44% developed PEC postpartum. HDP was associated with multiple gestations (p=0.01), age (p=0.04) and combination of one high or two moderate risk factors for PEC (p=0.03). mWHO class was not associated with development of HDP (p=0.86).

A19 Improving Adverse Pregnancy Outcomes Using Digital Tools: Real World Evidence

Conclusion: It has not been established if cardiac disease in pregnancy is an independent risk factor for developing PEC. The present study reveals high rates of HDP in this cohort (15.7% in the study population compared to the Centers for Disease Control and Prevention [CDC] rate of 4% of pregnancies in the US), even in the setting of ASA use and regardless of

Jane Lombard1,2 and Gayathri Bandrinath2

1. Women’s Heart Center, El Camino Health, US; 2. Devyn, US Citation: Journal of Asian Pacific Society of Cardiology 2023;2(Suppl 2):A19.

Background: Women with adverse pregnancy outcomes (APO), such as

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Abstracts from 8th International Congress on Cardiac Problems in Pregnancy gestational diabetes (GDM), face a markedly higher risk of cardiovascular disease in future life. Despite the wide use of digital technology such as smartphones among women of childbearing age, little implementation of technology has occurred at scale to simplify the management of APO. This study employed a user-centred mobile app to engage women with GDM quickly after diagnosis by simplifying self-monitoring activities and providing access to evidence-based education.

Thirty per cent were in the first and 67% in third trimester at the time of screening. In total, 277 patients (5.6%) had abnormal echo findings. One hundred and ninety-four (3.9%) of the screened population had LV dysfunction (ejection fraction [EF] 46–55%, 51 [1%]; EF 35–45%, 99 [2%]; 35%, 44 [0.9%]). Sixty-six patients (1.3%) had valvular heart disease (73% rheumatic) and 24 had moderate to severe valvular lesions (majority rheumatic mitral stenosis). Seventeen patients (0.3%) had adult congenital heart disease. On logistic regression analysis, pregnancy-induced hypertension, elevated pulse, diabetes, multifoetal pregnancy, and valvular and congenital heart lesions were independent predictors of significant LV dysfunction.

Methods: For the initial deployment, an iOS and Android-compatible mobile app was developed and made accessible in the US through the App Store and Google Play. Users obtained access to the app via referral from a clinician at one of six sites or by completing an access request form directly with the app manufacturer. Individuals without valid access codes were unable to access the app. Users could enter self-reported data for glucose, blood pressure, physical activity, weight and medication intake in the app. Users could also track food intake using text-based descriptions and by adding remote food photography. Data on in app user behaviour were tracked to understand which educational articles or recipes users read most often and to identify opportunities for new features and improvements. User demographics were limited to state of residence, pregnancy due date, type of health insurance provider and whether the episode of GDM was a first or a subsequent occurrence.

Conclusion: A screening echocardiographic protocol found a significant burden of abnormal findings in asymptomatic pregnant women attending routine antenatal visits. 3.9% of the approximately 5,000 women screened had asymptomatic LV dysfunction. This screening initiative provided an opportunity to institute therapy for LV dysfunction and referral to cardioobstetrics programmes for further management.

A21 Burden of Valvular Heart Disease in Pregnancy: An Echocardiography Screening Study in Pakistan Sabha Bhatti,1 Shakeela Naz,1 Sumyia Gurmani,1 Uzma Atif,1 Haleema Yasmin,2 Musa Karim,1 Shazia Ahmad,1 Kiran Zahra,1 Abdul Hakeem1 and Nadeem Qamar1

Results: This study reports preliminary findings in 92 users who registered for the Devyn app between 7 May 2022 and 31 May 2023. Fifty-one per cent of users signed up using a site referral code and 49% signed up directly with Devyn. Most users (84%) reported being diagnosed with GDM for the first time versus having a history of GDM in a previous pregnancy (n=55).

1. Cardiology, National Institute of Cardiovascular Disease, Pakistan; 2. ObGyn, Jinnah Postgraduate Medical Centre, Pakistan Citation: Journal of Asian Pacific Society of Cardiology 2023;2(Suppl 2):A21.

A20 Peripartum Cardiomyopathy Screening Study: Pakistan

Background: Cardiovascular disease (CVD) is the major cause of nonobstetric morbidity and mortality in pregnant women. Pakistan has some of the highest maternal and neonatal mortality rates in the world. The true prevalence of CVD during pregnancy is not known because of a lack of effective screening protocols and masked or overlapping symptoms. In particular, the burden of valvular heart disease in asymptomatic pregnant patients is not known.

Sabha Bhatti,1 Shakeela Naz,1 Sumyia Gurmani,1 Haleema Yasmin,2 Musa Karim,1 Uzma Atif,1 Shazia Ahmad,1 Kiran Zahra,1 Abdul Hakeem1 and Nadeem Qamar1 1. Cardiology, National Institute of Cardiovascular Disease, Pakistan; 2. ObGyn, Jinnah Postgraduate Medical Centre, Pakistan

Methods: Consecutive obstetric patients presenting at antenatal visits are enrolled in this ongoing registry. Patients enrolled between February and May 2023 are presented in this study. A limited 2D transthoracic echocardiogram protocol was followed. Parasternal long, parasternal short, apical 4 and 2 views were obtained. Continuous wave and pulsed wave Doppler across the left ventricular (LV) outlet tract were performed to look for any gradients.

Citation: Journal of Asian Pacific Society of Cardiology 2023;2(Suppl 2):A20.

Background: The true prevalence of cardiovascular disease (CVD) during pregnancy is not known because of a lack of effective screening protocols and masked or overlapping symptoms. This asymptomatic, undiagnosed and consequently untreated left ventricular (LV) dysfunction and other CVD may have adverse maternal and foetal outcomes. Cardiac screening of patients at obstetric appointments provides an opportunity to diagnose, treat and follow up CVD patients to improve outcomes.

Results: A total of 4,984 consecutive pregnant women underwent echocardiographic screening. The mean age of patients was 26.4 ± 5.8 years; 33% were primary para and 12 (0.2%) had multifoetal gestation. Thirty per cent were in the first and 67% in third trimester at the time of screening. 9.1% of patients had a previous abortion. In total, 277 patients (5.6%) had abnormal echo findings. 194 (3.9%) of the screened population had LV dysfunction. Sixty-six patients (1.3%) had valvular heart disease (73% rheumatic) and 24 patients had moderate to severe valvular lesions (majority rheumatic mitral stenosis). Seventeen patients (0.3%) had adult congenital heart disease. Valvular and congenital heart lesions were independent predictors of significant LV dysfunction.

Methods: Consecutive obstetric patients presenting for routine antenatal visits are enrolled in this ongoing registry. Patients enrolled during a 3-month period between February and May 2023 are presented in this study. A limited 2D transthoracic echocardiogram protocol was followed. Parasternal long, parasternal short, and apical 4 and 2 views were obtained. Left ventricular function was calculated by Simpson’s biplane and visually assessed by two independent readers. Results: A total of 4,984 consecutive pregnant women underwent echocardiographic screening. The mean age of patients was 26.4 ± 5.8 years, 33% were primary para and 12 (0.2%) had multifoetal gestation.

Conclusion: A screening echocardiographic protocol revealed a significant burden of abnormal findings in asymptomatic pregnant women

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Abstracts from 8th International Congress on Cardiac Problems in Pregnancy A23 Outcome of Sole Epidural Anaesthesia among Pregnant Women with Severe Mitral Stenosis Presenting for Caesarean Delivery in a Tertiary Care Centre of LMIC

attending routine antenatal visits. This screening initiative provided an opportunity to institute therapy for valvular heart disease (including penicillin G for secondary prophylaxis of rheumatic heart disease) and referral to cardio-obstetrics programmes for further management. Longterm follow-up of this ongoing registry is expected to provide valuable insights into the effectiveness of routine echocardiographic screening during antenatal visits.

Bashu Dev Parajuli, Amit Sharma Bhattrai, Megha Koirala and Pooja Paudyal

Department of Anaesthesiology, Tribhuvan University Teaching Hospital, Nepal

A22 Planning Delivery in a Marfan Patient with Partial Currarino Syndrome: Additional Challenges of a Risky Pregnancy

Citation: Journal of Asian Pacific Society of Cardiology 2023;2(Suppl 2):A23.

Background: Tribhuvan University Teaching Hospital is a tertiary-level referral hospital with a multidisciplinary facility. Pregnancies with cardiac comorbidities are referred to the centre from across the country. In a previous study, we found that anaesthesia (EA) was rarely administered to patients with severe mitral stenosis (MS). Since then, we have developed guidelines regarding sole EA for caesarean delivery (CD) of such patients.

Francesca Bonassin,1 Angela Oxenius,2 Fabienne Noll,3 Franziska Krähenmann,3 Lukas Kandler,4 Vincenzo Cannizzaro,5 Menno Germans6 and Matthias Greutmann1 1. University Heart Center, Cardiology, University Hospital Zurich, Switzerland; 2. Pediatric Cardiology, University Children’s Hospital Zurich, Switzerland; 3. Department of Obstetrics, University Hospital Zurich, Switzerland; 4. Institute of Anaesthesiology, University Hospital Zurich, Switzerland; 5. Department of Neonatology, University Hospital Zurich, Switzerland; 6. Department of Neurosurgery, University Hospital Zurich, Switzerland

Methods: A prospective observational quantitative study was designed to include all pregnant women with severe MS presenting for CD under sole EA. Ethical clearance was approved from the hospital institute review committee. Patients were verbally informed about the study, and they provided consent. Data were collected using a preformed data sheet.

Citation: Journal of Asian Pacific Society of Cardiology 2023;2(Suppl 2):A22.

Background: Pregnancies in patients with Marfan syndrome (MFS) are at high risk (modified WHO [mWHO] risk class III-IV) of aortic dissectionrelated mortality. It is crucial to define a birth plan early with an interdisciplinary team. Extracardiac manifestations, such as dural ectasia, should be considered while planning delivery mode and anaesthesia.

Results: Ten patients, with a mean age of 27.5 years and severe MS were included in the study. Two patients were in their first pregnancy while the rest were in a subsequent pregnancy. Delivery was conducted at 36–38 gestational weeks. Seven patients had normal functional activities while three had limited functional activities. Most of the patients had isolated severe MS while some had concomitant moderate mitral regurgitation and severe tricuspid regurgitation. All patients had undergone planned CD under sole EA. A freshly prepared solution of 2% lidocaine (preservative-free) 18 ml with 100 µg adrenaline and 100 μg fentanyl (2 ml) was titrated slowly with 3–5 ml to a block height of sensory dermatomal level T4. The total solution used was 16–20 ml. Babies born had good APGAR score. Oxytocin, misoprostol and carboprost were titrated on need basis. The epidural catheter was removed 1 hour after injecting 2–2.5 mg morphine. Acetaminophen and diclofenac were sufficient to manage postoperative pain. The postoperative period was uneventful.

Case Description: A 29-year-old woman with genetically confirmed MFS, heterozygous FBN1 mutation c.4224CA, p.(Cys1408*), was diagnosed with a large presacral cyst and sacrum dysgenesis (partial Currarino syndrome). She reported occasional hypoesthesia in the upper left thigh without any other neurological symptoms. A conservative approach was suggested as surgery was expected to be associated with complications and uncertain outcome. The patient underwent neurosurgical and cardiological monitoring. At 34 years of age, the patient had her first pregnancy. Following an abnormal ultrasound screening, amniocentesis was performed and foetal MFS was genetically confirmed. Aortic dimensions remained stable throughout the pregnancy (sinus 3.6 cm, Z score +1.96; ascending aorta 2.8 cm, −0.23). Spine MRI showed minimal increase of cyst dimensions not related to progressive symptoms. The case was reviewed by a multidisciplinary team of cardiologists, neurosurgeons, obstetricians, anaesthetists and neonatologists. After weighing up the risks of cystrelated neurological complications and premature delivery, caesarean section was performed at 34 weeks and 2 days gestation under general anaesthesia with an arterial line and application of low-dose norepinephrine. The postpartum period was uneventful. The preterm baby experienced respiratory distress but recovered quickly and was discharged at 8 days.

Conclusion: The goals of anaesthesia for severe MS are to avoid a sudden fall in systemic vascular resistance, maintain sinus rhythm, avoid tachycardia and maintain preload. Sole EA can achieve these goals.

A24 Management of Infected Cardiac Implantable Electronic Devices by Targeted High-dose Antibiotics to Preserve Early Pregnancy Moris Topaz,1 Ehud Chorin,2 Anna Mazo,2 Michal Dekel,2 Ariel Banai,2 Shira Shifer,3 Mahmoud Suleiman,4 Shmuel Banai,2 Raphael Rosso,2 Avraham Shotan,5 Ofer Havakuk2 and Sami Viskin2

1. Department of Cardiology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; 2. Department of Cardiology, Tel Aviv Sourasky Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel; 3. Internal Medicine, Rabin Medical Center Golda Hasharon Campus, Israel; 4. Department of Cardiology, Rambam Medical Center, Technion – Israel Institute of Technology, Israel; 5. Department of Cardiology, Laniado Medical Center, Israel

Conclusion: Marfan patients planning pregnancy should be screened for the presence of dural abnormalities. Peripartum management of patients with significant dural ectasia is challenging and should be defined early because delivery mode and timing might be affected. Decision-making by an experienced multidisciplinary team at a tertiary centre is mandatory to reduce morbidity and mortality.

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Abstracts from 8th International Congress on Cardiac Problems in Pregnancy ages of 12 and 55 years and at 23 weeks of gestation were included. ICD10 codes were used to identify pre-existing AF and to divide patients into three subgroups: AF without other cardiac disease; AF with left-sided valve disease; and AF with other cardiac disease (congenital heart disease, cardiomyopathy, right-sided valve disease, aortopathy and ischaemic disease). The primary outcome was composite SMM based on 20 complications defined by the CDC as adverse consequences of pregnancy. Secondary outcomes were rates of readmission, bleeding events (composite cerebral, gastrointestinal and obstetric bleeding events), and red blood cell transfusion. χ2 and Fisher’s exact tests were used to compare outcomes. Adjusted ORs were estimated using logistic regression.

Citation: Journal of Asian Pacific Society of Cardiology 2023;2(Suppl 2):A24.

Background: Managing an infected cardiac implantable electronic device during early pregnancy requires careful consideration to balance the need to treat the infection with minimising potential harm to the mother and developing foetus. The current guidelines recommend total removal of generators and leads in combination with adequate antibiotic therapy. This strategy carries surgical risks with additional specific risks related to pregnancy, including irradiation exposure and teratogenicity of the antibiotic treatment. Continuous in situ targeted, ultra-high concentration of antibiotics administration (CITA) directed into the infected pocket of the device is a novel approach that is safe and effective in eradicating infection, reducing the need for device extraction in high-risk pregnant patients.

Results: The cohort included 4,763,360 deliveries of which 1,165 had AF (prevalence 24/100,000). Patients with AF were older, more likely to be black and have obstetric complications compared to patients without AF. The adjusted OR of SMM for AF was 1.81 (CI 1.07–3.07) in the AF only group, 2.16 (CI 0.46–10.18) in the AF with left-sided valve disease group, and 4.85 (CI 2.77–8.51) in the AF with other cardiac disease group. Secondary outcomes occurred more commonly in patients with AF.

Case Description: A 29-year-old patient who was five weeks pregnant had been implanted with an ICD at 20 years of age due to ventricular fibrillation. The patient was considered high risk for extraction and wanted to preserve the pregnancy. She was referred to our centre by her treating cardiologist for CITA and minimally invasive surgery (MIS; Topaz procedure). All efforts were focused on minimising risk to the mother and foetus. The patient underwent MIS, short irradiation by a single exposure of the generator area and short antibiotic treatment with low teratogenicity potential (vancomycin and meropenem) below therapeutic serum drug concentrations for 10 days only. Following uneventful CITA-MIS treatment, the recommendation of the consulting maternal-foetal medicine specialist was to continue preserving the pregnancy.

Conclusion: Patients with AF are at significantly increased risk of SMM during delivery hospitalisation. The risk is highest in patients with other cardiac disease and left-sided valve disease compared to AF without other heart disease.

A26 Syncope as an Indicator of Severe Course of Pulmonary Embolism in Pregnant and Postpartum Women

Conclusion: Prompt medical attention from a multidisciplinary team is essential to adequately manage CIED infections during early pregnancy. The appropriate recommendations and individualised care should be based on the specific circumstances to preserve the health of both mother and foetus. MIS and CITA treatment strategy may be as an alternative to extraction in high-risk extraction patients to preserve pregnancy.

Eliza Kozyra-Pydyś, Ewa Szczerba,1,2 Małgorzata Peregud-Pogorzelska,3 Marianna Janion,6,7 Emilia Sawicka,4 Michał Machowski5 and Anna Fijałkowska1 1. Department of Cardiology, Institute of Mother and Child, Poland; 2. First Chair and Department of Cardiology, Medical University of Warsaw, Poland; 3. Department of Cardiology, Pomeranian Medical University in Szczecin, Poland; 4. Department of Cardiology with the Department of Intensive Cardiac Care, Medical University of Bialystok, Poland; 5. Department of Internal Medicine and Cardiology, Medical University of Warsaw, Poland; 6. 2nd Department of Cardiology, Swietokrzyskie Cardiology Center, Poland; 7. Faculty of Medicine and Health Sciences, Jan Kochanowski University, Poland

A25 Pre-existing Atrial Fibrillation and Atrial Flutter in Pregnancy are Associated with Increased Severe Maternal Morbidity: A Retrospective Cohort Study Liliane Ernst,1 Matt Fuller,1 Jerome Federspiel,2 Johanna Quist-Nelson,3 Faisal F Syed,4 Joan Briller,5 Ashraf Habib1 and Marie-Louise Meng1

1. Anesthesiology, Duke University School of Medicine, US; 2. Obstetrics and Gynecology, Duke University School of Medicine, US; 3. Obstetrics and Gynecology, University of North Carolina School of Medicine, US; 4. Cardiology, University of North Carolina School of Medicine, US; 5. Cardiology, University of Illinois College of Medicine, US

Citation: Journal of Asian Pacific Society of Cardiology 2023;2(Suppl 2):A26.

Background: Venous thromboembolism (VTE) and pulmonary embolism (PE) are the leading causes of maternal mortality in developed countries. Diagnosis of PE in pregnancy is particularly challenging because pregnant women often have symptoms, such as shortness of breath, tachycardia or syncope, independent of PE. Evidence to guide clinicians on how to manage women with suspected PE is limited. The objective of this study was to evaluate initial symptoms in prognosis of the course of PE in pregnant and postpartum patients.

Citation: Journal of Asian Pacific Society of Cardiology 2023;2(Suppl 2):A25.

Background: Atrial fibrillation and atrial flutter (AF) are common arrhythmias in pregnancy. There is a lack of data about outcomes in pregnant patients with AF. The objective was to describe characteristics of pregnant patients with AF and rates of severe maternal morbidity (SMM) during delivery hospitalisations. The study hypothesis was that patients with AF have higher rates of SMM.

Methods: ZatPolPreg is a Polish prospective multicentre registry containing data of pregnant and postpartum women with PE. Twenty-six pregnant and postpartum women with a diagnosis of PE were assessed. Symptoms and diagnostic pathways of PE were analysed to identify factors that may predict the composite outcome, defined as hospitalisation in the ICU, need for treatment with pressor amines or death.

Methods: A retrospective cohort study was conducted using the Premier database, representing 25% of deliveries in the US. Delivery hospitalisations from 2016 to 2020 for pregnant patients between the

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Abstracts from 8th International Congress on Cardiac Problems in Pregnancy A28 Miscarriage before First Childbirth in Women with Congenital Heart Disease in Norway 1999–2014

Results: Incidences of syncope were significantly more common in women with PE who had met composite outcome (40% versus 0%; p=0.034). These patients received a higher single dose of low-molecularweight heparin during their hospitalisation (median 80 mg versus 60 mg; p=0.015). Choice of this dosage could be explained by higher mean body weight (88 kg versus 68 kg) of patients, but this difference did not reach statistical significance (p=0.082).

Marit Sandberg,1,2 Tatiana Fomina,3 Ferenc Macsali,2,6 Gottfried Greve,1,4 Nina Øyen3,5 and Elisabeth Leirgul4 1. Department of Clinical Science, University of Bergen, Norway; 2. Department of Obstetrics and Gynecology, Haukeland University Hospital, Bergen, Norway; 3. Department of Global Health and Social Medicine, University of Bergen, Norway; 4. Department of Heart Disease, Haukeland University Hospital, Bergen, Norway; 5. Department of Medical Genetics, Haukeland University Hospital, Bergen, Norway; 6. Norwegian Institute of Public Health, Norwegian Institute of Public Health, Norway

Conclusion: Syncope may be used as a significant factor for predicting severity of a course of pulmonary embolism in pregnant and postpartum women. Patients with this symptom require special attention during hospitalisation. Further studies are required on a larger group of patients to demonstrate other potential prognostic factors.

A27 Cardiac Disorder Contribution to Non‑communicable Disease Burden in Pregnancy: A Prospective Observational Study

Citation: Journal of Asian Pacific Society of Cardiology 2023;2(Suppl 2):A28.

Background: Altered cardiovascular physiology in women with congenital heart disease (CHD) may compromise uteroplacental flow and increase the risk of miscarriage. The objective was to investigate whether women with CHD have a higher risk of miscarriage.

Pooja Sikka,1 Neha Kumari,1 Kathirvel Soundappan,2 Aashima Arora,1 Vanita Jain1 and Vanita Suri1

1. Obsetrics and Gynaecology, Postgraduate Institute of Medical Education and Research, Chandigarh, India; 2. Community Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India

Methods: All first childbirths after the 22nd gestational week to women in Norway in the period 1999–2014 were identified in the Medical Birth Registry of Norway. Using the unique personal identification number given to all Norwegian residents, information on maternal CHD diagnoses was collected from four national health registers, and categorised into four groups: severe CHD, septal defects, valve defects and other/ unspecified defects. Information on previous miscarriages reported by the mother was retrieved from the Medical Birth Registry of Norway. Rates of miscarriages before first childbirth were compared between the groups by Student’s t-test, and risk ratios with 95% CI of experiencing any miscarriage before the first childbirth were calculated by log-binominal regression adjusted for maternal age and smoking.

Citation: Journal of Asian Pacific Society of Cardiology 2023;2(Suppl 2):A27.

Background: Pregnancy outcomes can only be improved if underlying non-communicable diseases (NCDs) are detected and treated early in pregnancy. We have been running a dedicated medico-surgical disorder and cardio-obstetric clinic for approximately five decades. The contribution of cardiac disorders to the overall NCD burden in pregnancy needs to be defined. The objective of this study was to assess the disease spectrum and contribution of cardiac diseases to the overall NCD morbidity and mortality and foetal outcomes during pregnancy in a tertiary care hospital.

Results: A total of 360,434 first childbirths were identified in the Medical Birth Registry of Norway, among which 1,279 of the mothers had CHD. Women with valve defects had a higher rate of previous miscarriages compared to women without heart disease (31 versus 19, per 100 women, p=0.01), and an increased risk of experiencing miscarriage before first birth (RR 1.43; 95% CI [1.10–1.87]). For women within the other CHD subgroups, there was no difference in rates and risks of miscarriage before the first childbirth compared to women without heart disease.

Methods: A hospital-based prospective observational study was conducted over a 12-month period. All pregnant women with specified NCDs who delivered or aborted during the study period were recruited. Maternal and foetal outcomes in patients with cardiac disorders and their contribution to the overall NCD burden were studied. Results: One thousand and three NCDs occurred in 894 women. The most prevalent NCD was chronic hypertension, present in 309 (30.8%) women. Cardiac disorders were present in 159 (15.9%) women and were the second most common NCD. Of these, 80 (50.3%) women had rheumatic heart disease and 56 (35.2%) had congenital heart disease. Overall, among women with NCDs 97.2% pregnancies were uncomplicated compared to 95% in women with heart disease. Maternal near miss occurred in 2.1% of women in the NCD cohort compared to 5% women with heart disease. Three of the six maternal deaths occurred in patients with heart disease. Stillbirth, abortion and low birthweight occurred in 5.7% versus 4.4% (p=0.703), 5.1% versus 7.5% (p=0.255) and 44.7% versus 50.3% (p=0.207) in the overall NCD and cardiac disease cohort, respectively.

Conclusion: This study revealed a higher risk of miscarriage before first childbirth in women with valve defects, but not in women of other CHD subgroups, compared to women without heart disease.

A29 Significant Pregnancy Complications: An Acceptable Risk to Many Fontan Patients Natalie Bottega

Cardio-Obstetrics Clinic, McGill University Health Centre, Montreal, Canada Citation: Journal of Asian Pacific Society of Cardiology 2023;2(Suppl 2):A29.

Conclusion: Cardiac diseases contribute to 15.9% of all NCDs but are responsible for half of all maternal deaths. Ninety-five per cent of pregnant women with heart disease did not have a major complication.

Background: Pregnancy in patients with a Fontan poses significant maternal and foetal risks. Despite this, many Fontan patients willingly pursue pregnancies even after experiencing complications.

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Abstracts from 8th International Congress on Cardiac Problems in Pregnancy Comprehensive preconception counselling of women with a Fontan about the risks of maternal and foetal morbidity and mortality would be a deterrent to pursuing pregnancies.

9.8%) with normal right ventricular (RV) function (mean TAPSE 2.15 ± 0.35). Most of the patients had left ventricular (LV) eccentric hypertrophy (18 [43.9%]) with increased LA volume index (39.15 ± 15.76) and indeterminate diastolic function (18 [43.9%]). Most subjects received standard treatment for HF, including RAAS blockers (39 [95.12%]), β-blockers (29 [70.7%]) and loop diuretics (34 [82.9%]). Thirty (73.17%) patients received bromocriptine and eight (19.5%) also received oral digoxin. Two (4.9%) patients received vitamin K antagonists for intracardiac thrombus. Within 1 year, 14 patients who were still being followed up showed improved EF with an LVEF of 50%, although LV global longitudinal strain still showed mild impairment.

Methods: All women with univentricular Fontan physiology seen in the Cardio-Obstetrics Clinic at the McGill University Health Centre MUHC from 2011 to 2023 were provided with comprehensive preconception counselling by a cardiologist and nurse or high-risk obstetrician. Patients were risk-stratified using the CARPREG score and modified WHO (mWHO) classification. Uncomplicated Fontan patients were mWHO class III and quoted an up to 27% risk of maternal morbidity (arrhythmias, heart failure, thromboembolism and haemorrhage) and mortality and those with any Fontan complication were mWHO class IV and were advised against pregnancy given the prohibitively high risk (40–100%) of maternal morbidity and mortality. Adverse obstetrical and foetal outcomes include high miscarriage rates and premature live births.

Conclusion: Most PPCM patients were younger with a history of gestational hypertension and pre-eclampsia. Optimisation of standard HF therapy with additional bromocriptine therapy is essential for reversibility of remodelling LV and HF improvement.

A31 Pulmonary Hypertension and Maternal Outcomes: A Single-centre Experience

Results: Four pregnant women had Fontan-associated liver disease (FALD). None of the women who deferred pregnancy had FALD but two had arrhythmias. The patient with five pregnancies had four miscarriages, stage 4 cirrhosis and an O2 saturation of 92% from a fenestration. No women or babies died. Most babies had intrauterine growth restriction.

Alexandra Colesnicenco,1 An Vercoutere,2 Sara Derisbourg,2 Laszlo Szegedi1 and Jean Luc Vachiery3 1. Anesthesiology, HUB Erasme, Universite Libre de Bruxelles, Belgium; 2. Gynecology/Obstetrics, Universite Libre de Bruxelles, Belgium; 3. Pulmonary Vascular Diseases Clinic. Department of Cardiology, HUB Erasme, Universite Libre de Bruxelles, Belgium

Conclusion: Despite preconception counselling about adverse maternal, foetal and obstetrical complications in the high-risk Fontan population, many women still pursue recurrent pregnancies even amongst those who have had serious complications. This population poses a burden on the healthcare system and resources, which could be alleviated through easier access to adoption, surrogacy and gestational carriers.

Citation: Journal of Asian Pacific Society of Cardiology 2023;2(Suppl 2):A31.

Background: Pulmonary hypertension (PH) is one of the main contraindications for pregnancy due to increased mortality and risk of maternal death and severe morbidity. Described here is series of cases at a maternity unit with a reference centre for PH. This retrospective study reviews a single-centre experience and describes the outcomes for mother and foetus.

A30 Clinical Characteristics, Risk Factors and Echocardiography Parameters of Peripartum Cardiomyopathy: A Tertiary Single-centre Study from Indonesia

Methods: An analysis of all cases of pregnant patients with PH referred for care to our institution between 2020 and 2022 was performed. All data including demographics, pulmonary arterial hypertension risk profile, medications, mode and timing of delivery, type of anaesthesia, and maternal and foetal outcomes were collected.

Mefri Yanni and Nani Nani

Cardiology and Vascular Medicine, Faculty of Medicine, University of Andalas/Dr. M. Djamil General Hospital, Indonesia Citation: Journal of Asian Pacific Society of Cardiology 2023;2(Suppl 2):A30.

Background: Peripartum cardiomyopathy (PPCM) is defined as an idiopathic cardiomyopathy presenting with heart failure (HF) due to systolic dysfunction with left ventricular ejection fraction (LVEF) 45% towards the end of pregnancy or in the months following delivery, where no other cause of HF is found. Misdiagnosis of PPCM often leads to clinical deterioration and death. Early and definitive diagnosis of PPCM is essential to limit the high risk of morbidity and mortality. The objective of this study was to describe the clinical and echocardiography characteristics of peripartum cardiomyopathy at our centre.

Results: Five pregnant patients with diagnosed pulmonary hypertension were identified, ranging in severity from moderate to severe (class 4–5). Four patients had a pre-pregnancy diagnosis of PH and one was diagnosed in the third trimester of pregnancy. Most patients had poor haemodynamic tolerance due to the increasing demands of pregnancy. Three patients had a caesarean section under combined spinal-epidural anaesthesia and two had early pregnancy medically indicated interruptions (surgical or pharmacological). Two patients required extracorporeal membrane oxygenation and one of them died. In terms of foetal outcomes, severe prematurity was observed in two of three cases of delivery.

Methods and Results: Forty-one patients with PPCM were identified between 2019 and 2022. The mean age of patients was 32.4 ± 5.3 years. Most symptoms of PPCM (48.8%) occurred within weeks before delivery. The average length of in-hospital stay was 7.12 ± 4.74 days. AF, intracardiac thrombus, gestational hypertension, and history of preeclampsia and pneumonia were found in 1 (2.4%), 2 (4.9%), 22 (53.7%), 18 (43.9%) and 14 (34.1%) of the patients, respectively. Echocardiography examination showed a mean reduced ejection fraction (EF) (34.44 ±

Conclusion: As supported by the scientific literature, in this case series it was observed that the presence of PH can severely affect the clinical course of a pregnancy by greatly increasing the risk of morbidity and mortality. A multidisciplinary approach, with individualised patient-centred approach and counselling is essential to improve the chances of a good maternal and foetal outcome.

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Abstracts from 8th International Congress on Cardiac Problems in Pregnancy A32 Large Patent Ductus Arteriosus First Diagnosed during Pregnancy: Haemodynamic Challenges and Dilemma of Timely Interventions

1. Cardiology, Hadassah University Medical Center, Israel; 2. Obstetrics and Gynecology, Hadassah University Medical Center, Israel; 3. Faculty of Health and Life Sciences, Jerusalem College of Technology, Israel Citation: Journal of Asian Pacific Society of Cardiology 2023;2(Suppl 2):A33.

Francesca Bonassin,1 Laura Anna Leo,2 Michèle-Chantal Stahel,3 Verena Bossung,3 Franziska Krähenmann,3 Corinna Von Deschwanden,4 Alexander Gotschy,1 Heiko Schneider,1 Oliver Kretschmar5 and Matthias Greutmann1

Background: Pre-eclampsia (PE) and gestational diabetes (GDM) are associated with increased cardiovascular risk. Most women do not participate in a postpartum programme to prevent cardiovascular disease. New mothers face challenges to participation, including time constraints, financial challenges, childcare issues and fatigue. This qualitative study aimed to explore experiences, views and concerns of women with a history of PE/GDM and of their healthcare providers to design an effective and sustainable intervention.

1. University Heart Center, Cardiology, University Hospital Zurich, Switzerland; 2. Cardiology, Cardiocentro Institute, Cardiology, Ente Ospedaliero Cantonale, Switzerland; 3. Department of Obstetrics, University Hospital Zurich, Switzerland; 4. Institute of Anaesthesiology, University Hospital Zurich, Switzerland; 5. Pediatric Cardiology, University Children’s Hospital Zurich, Switzerland

Methods: In-depth interviews were conducted with women within one year of discharge after a pregnancy complicated by PE/GDM. Focus groups and in-depth interviews were conducted with healthcare providers. Interviews were recorded, transcribed and analysed manually according to the methods of thematic analysis.

Citation: Journal of Asian Pacific Society of Cardiology 2023;2(Suppl 2):A32.

Background: Incidental diagnosis of large patent ductus arteriosus (PDA) is unusual during pregnancy and is more frequently seen in migrant patients. Pregnant women with haemodynamically significant PDA have an increased risk of cardiovascular complications.

Results: Forty women with PE/GDM and 18 healthcare providers participated in the study. Themes identified in the women included: Disease in pregnancy; the meaning of belonging to a high-risk group during pregnancy, awareness of health risks and implications for the future; Coping with the disease and its effects during and after pregnancy; The role of the healthcare system. Themes identified by healthcare providers included: Individualised health promotion-addressing the personal characteristics of the patient; Healthcare providers’ challenges in health promotion of women post-PE/GDM. Specific suggestions related to interventions included: Focus should be placed on psychological and emotional features. Clear instructions for postpartum follow-up and guidelines for patients and providers should be established and integrated, with flexibility that meets the time-challenges of this population. The programme should include both digital and face-to-face components and content should be based on a needs-assessment process. The emphasis should be placed on healthier behaviours rather than weight-loss.

Case Description: A left parasternal thrill and 5/6 continuous murmur was detected in a 27-year-old pregnant (G1P0) woman who had recently migrated from southeast Asia to Switzerland. The patient was referred to our tertiary centre at 18/0 gestational weeks (GW). She was asymptomatic (New York Heart A class 1) and there were neither clinical signs of heart failure nor Eisenmenger physiology (e.g. no differential cyanosis). NTproBNP was normal (65 ng/l). Transthoracic echocardiography (TTE) and non-contrast MRI confirmed a large, haemodynamically significant PDA (6 × 8 mm, Qp:Qs 2.6:1) with severe left ventricular (LV) dilation and moderate secondary mitral valve regurgitation. According to CW Doppler across the PDA, severe pulmonary hypertension was unlikely. Her case was reviewed by a multidisciplinary team, and it was decided to see her every four weeks and to plan elective caesarean section in the cardiovascular operation room at 37+0 GW. Percutaneous PDA closure and/or earlier delivery were kept as bailout strategy. She remained asymptomatic with stable serial echocardiographic findings but was admitted at 35/3 GW for progressive cholestasis and skin rash. The patient underwent caesarean section at 37/0 GW with epidural anaesthesia and phenylephrine/ephedrine application. The postpartum period was uneventful. The patient was discharged at 5 days with her baby (birthweight 3,110 g, length 46 cm). Elective, percutaneous PDA closure was successfully performed after 3 months with a 14/12-mm LifeTech PDA occluder. Postprocedural TTE showed decreased LV size and mitral regurgitation.

Conclusion: Given the increased risk after PE/GDM or pre-eclampsia, it is crucial to provide lifestyle interventions to these women. The study findings highlight the need for distinctive approaches to health promotion interventions for PE/GDM women.

A34 Pregnancy and Valvular Heart Disease – Validation of Two Risk Stratification Tools: DEVI and CARPREG II

Conclusion: Management of pregnancy in women with haemodynamically significant PDA is challenging and requires a multidisciplinary approach at a tertiary centre with expertise in congenital heart disease to reduce foeto-maternal morbidity and mortality.

Malini Sukayogula,1 Tarakeswari Surapaneni1 and Anish Keepanasseril2

1. Obstetric Medicine, Fernandez Hospital, India; 2. Obstetrics and Gynaecology, Jawaharlal Institute of Postgraduate Medical Education & Research, Puducherry (JIPMER), India

A33 Health Promotion to Reduce Cardiovascular Risk after Pre-eclampsia and Gestational Diabetes: Patient and Provider Perspectives

Citation: Journal of Asian Pacific Society of Cardiology 2023;2(Suppl 2):A34.

Background: Rheumatic heart disease (RHD) remains the most common cause of valvular disease in lower-middle-income countries (LMICs) where nearly one-third of cases are diagnosed for the first time in pregnancy. Most of the existing risk tools/scoring systems predict outcomes among

Deborah Barasche-Berdah,1 Adi Finkelstein,3 Shayma Abu-Sneinah,1 Joshua Rosenbloom,2 Doron Kabiri,2 Simcha Yagel2 and Donna Zwas1

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Abstracts from 8th International Congress on Cardiac Problems in Pregnancy pregnant women with heterogeneous cardiac lesions and may not be generalisable to valvular heart disease (VHD). The objective of the study was to validate and establish the clinical utility of two risk stratification tools: DEVI (VHD-specific tool) and CARPREG-II for predicting adverse cardiac events in pregnant patients with VHD.

Results: A total of 16 studies with 1,503 patients were included in the study. Meta-analysis revealed NOP modification significantly decreased PE development in high-risk PE populations (RR 0.54; 95% CI [0.31–0.95]; p=0.03; I2 63%]. All types of NOP modification significantly decreased umbilical artery pulsatile index [MD −0.39; 95% CI −0.62–(−0.17); p=0.0007; I2 75%], systolic blood pressure [MD −5.49; 95% CI −9.83– (−1.15); p=0.01; I2 97%] and diastolic blood pressure [MD −4.39; 95% CI −7.13–(−2.72); p=0.0001; I2 93%] compared with standard treatment. NOP modification also significantly reduced infant adverse events [RR 0.61; 95% CI [0.42–0.88]; p=0.03; I2 48%], especially in the L-arginine subgroup [RR 0.41; 95% CI [0.23–0.72]; p=0.002; I2 0%] and NO medication [RR 0.48; 95% CI [0.34–0.69]; p=0.0001; I2 0%]. Preterm birth was significantly reduced in the L-arginine supplementation subgroup [RR 0.54; 95% CI [0.37–0.77]; p=0.0007; I2 0%].

Methods: This was a retrospective cohort study involving consecutive pregnancies complicated with VHD admitted to a tertiary perinatal centre from January 2011 to June 2023. Individual risk for adverse composite cardiac events was calculated using DEVI and CARPREG-II models. Performance was assessed through discrimination and calibration characteristics. Clinical utility was evaluated with decision curve analysis. Results: Of 205 eligible pregnancies, 19 (9.3%) experienced a component of the composite outcome. A majority (92.7%) had rheumatic aetiology, with mitral regurgitation as the predominant lesion (62.9%). The AUC for DEVI (0.846, 95% CI [0.7650–0.9274]) was better than CARPREG-II (0.762, 95% CI [0.652–0.872]; p=0.029). Calibration plots suggested that DEVI score overestimates risk at higher probabilities, whereas CARPREG-II score overestimates risk at both extremes. Decision curve analysis demonstrated that both models were useful across predicted probability thresholds between 10% and 35%.

Conclusion: NOP modification potentially showed better maternal and infant outcomes in GH, high-risk PE and PE populations and therefore may serve as an important therapeutic target in these patients.

A36 Real-world Engagement Outside of Healthcare Settings in Women with Adverse Pregnancy Outcomes Jane Lombard and Gayathri Bandrinath

Conclusion: In pregnant patients with VHD, lesion-specific DEVI score had better discriminative ability and better agreement between predicted probabilities and observed events than CARPREG-II (general risk assessment tool).

Devyn, US Citation: Journal of Asian Pacific Society of Cardiology 2023;2(Suppl 2):A36.

Background: Women with adverse pregnancy outcomes (APO), such as gestational diabetes (GDM), face a markedly higher risk of future cardiovascular disease. Smartphone apps provide a highly scalable method of engaging women with APO during and after pregnancy, but limited data exist on the use of apps for this purpose in real-world settings. The objective was to evaluate the use of an iOS and Android-compatible mobile app developed by Devyn to engage women with GDM to simplify self-monitoring and provide evidence-based education.

A35 Nitric Oxide Pathway Modification as a Novel Therapeutic Approach in Patients with Gestational Hypertension, High‑risk Pre-eclampsia and Pre‑eclampsia: Systematic Review and Meta-analysis AA Ayu Dwi Adelia Yasmin1 and Gusti Ngurah Prana Jagannatha2

Citation: Journal of Asian Pacific Society of Cardiology 2023;2(Suppl 2):A35.

Methods: Registered users could enter self-reported data for food, glucose, blood pressure, physical activity, weight and medication intake in the app. Users had access to automated schedules to assist with logging, reminders to check glucose, remote food photography and a logbook report. Users could also access educational articles on GDM, pre-eclampsia, heart health and diabetes.

Background: Gestational hypertension (GH) and pre-eclampsia (PE) are serious multisystem disorders that lead to adverse events in infants and mothers. Endothelial dysfunction and reduced nitric oxide (NO) bioavailability are presumed to play an important role in this maternal condition and foetal pathophysiology. The objective was to assess maternal and infant outcomes of NO pathway (NOP) modification in hypertension in pregnancy, which comprises of GH, high risk of PE and PE.

Results: Reported here are preliminary findings of 79 users who registered between May 2022 and June 2023. These users logged 16,770 clinical observations using the Devyn app. Fifty-six per cent of observations were glucose values and 42% were food intake. Users who used the app for more than one day logged an average of five observations per day (n=65 users). Fifty-eight per cent of users logged clinical observations across more than 30 days. The average duration between first and last observation logged was 42 days.

Methods: Systematic review and meta-analysis were conducted according to the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) statement. Studies that compared the outcome of NOP modification treatment (NO, phosphodiesterase-5 [PDE-5] inhibitors and L-arginine medication) against standard treatment in GH, high-risk PE, and PE were searched in multiple databases. All outcomes were subgroup analysed based on the type of NOP modification.

Conclusion: Real-world analysis of app usage data can help inform how to support patients outside of healthcare settings. Use of the Devyn app was associated with high engagement rates as evidenced by the average number of observations logged per day and user persistence beyond 30 days. Future research is needed to evaluate whether this app can be used to increase knowledge on the role of adverse pregnancy outcomes as well as facilitate transition of care after pregnancy.

1. Department of Cardiology and Vascular Medicine, Faculty of Medicine, Udayana University/Prof. Dr. I.G.N.G. Ngoerah General Hospital, Indonesia; 2. Faculty of Medicine, Udayana University/Prof. Dr. I.G.N.G. Ngoerah General Hospital, Indonesia

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Abstracts from 8th International Congress on Cardiac Problems in Pregnancy A37 Management of Pregnancy after Cancer Treatment: The Viewpoint of Onco-cardio-obstetrics

type and most cases improve with administration of antiarrhythmic drugs or electrical cardioversion. Reported here is a case of supraventricular arrhythmia during pregnancy with concomitant heart failure requiring multidisciplinary tactics.

Yumiko Doi, Hiromi Ga, Satoshi Nitta, Chikako Hikosaka, Shinya Imada, Haruko Iwase, Takahiro Kasamatsu, Koji Kugu and Hironobu Hyodo

Case: The patient was a 35-year-old woman (G2P1). Her pregnancy had been progressing uneventfully, but she had palpitation that did not improve, even at rest, from around the 30th week of pregnancy. She visited her doctor at 30+5 weeks of gestation and was transferred to our hospital where atrial tachycardia and raised heart rate of 214 bpm were found. Blood pressure was maintained but tachycardia was poorly controlled even with several applications of electrical cardioversion or administration of verapamil. The next day the patient developed acute heart failure. A multidisciplinary conference was held immediately and catheter ablation was conducted. After induction of anaesthesia, foetal heart rate pattern showed prolonged deceleration with decrease of maternal blood pressure but improved with left uterine displacement and administration of vasopressors. Based on mapping, the localised origin was on the ventral ceiling side of the left atrium and was determined to be atrial tachycardia due to ectopic automaticity. The rhythm changed to sinus after the ablation. Furosemide was required for two days because of persistent pulmonary congestion, as was noradrenaline for maintenance of blood pressure. The patient was extubated on the next day and no recurrence of arrhythmia occurred thereafter. The patient was discharged with no medication on postoperative day 7. She had vaginal delivery under epidural anaesthesia at 38 weeks with no tachycardia and no recurrence of arrhythmia.

Department of Obstetrics and Gynecology, Tokyo Metropolitan Bokutoh Hospital, Japan Citation: Journal of Asian Pacific Society of Cardiology 2023;2(Suppl 2):A37.

Advances in cancer treatment have improved the life expectancy of cancer patients while taking into consideration the impact of cardiovascular damage caused by cancer treatment on the subsequent life of patients. Cancer survivors are therefore more likely to have the ability to become pregnant after treatment. Pregnancy is a dynamic process in which cardiovascular dynamics change dramatically within a short period of time and women with cardiac disease need care based on the characteristic changes that occur in pregnancy. Onco-cardiology focuses on the link between cancer and the cardiovascular system, and the field of cardioobstetrics focuses on the link between the cardiovascular system and pregnancy. Here we discuss the significance of the combined views of onco-cardiology and cardio-obstetrics on these on two cases. Case 1 was a 41-year-old woman (G1P0) who had developed cervical cancer at 36 years of age. The patient had received chemotherapy with no observed cardiovascular event. She conceived two years after treatment. The pregnancy course was uneventful on follow-up of cardiac function.

Conclusion: Even when supraventricular tachycardia with heart failure is treatment-resistant, multidisciplinary preparation and treatment are helpful to improve the prognosis of the mother and foetus.

Case 2 was a 36-year-old woman (G1P0), who had developed a blast-like plasmacytoid dendritic cell tumour at 26 years of age. The patient had received chemotherapy, total-body irradiation and peripheral blood stem cell transplantation, including treatment for relapse three years later. After one observed instance of reduced cardiac function, there was no recurrence for five years and cardiac function was maintained. The patient subsequently conceived with a previously frozen embryo. The pregnancy course has been uneventful on follow-up for cardiac function.

A39 Clinical Profile, Time of Presentation and Delivery Modality in Pregnant Patients Presenting to a Tertiary Cardiac Care Centre in North India Shibba Takkar Chhabra, Anshuman Gupta, Akash Batta, Gautam Singal, Rohit Tandon, Abhishek Goyal, Naved Aslam, Bishav Mohan and Gurpreet Singh Wander

Cardiology, Dayanand Medical College & Hospital Unit, Hero DMC Heart Institute, India

Cardiac dysfunction after chemotherapy is discussed from the viewpoint of onco-cardiology. Follow-up plans for cardiac function during pregnancy are discussed from the viewpoint of cardio-obstetrics. In pregnancies of cancer survivors after chemotherapy, cardiac function should be checked from the early stages of pregnancy and the follow-up for perinatal changes may play an important role in the management of pregnancy. Such multidisciplinary collaboration will improve medical care of women who survive cancer.

Citation: Journal of Asian Pacific Society of Cardiology 2023;2(Suppl 2):A39.

Background: India is undergoing obstetric transition with greater maternal mortality linked to cardiovascular causes. Data pertaining to cardiovascular ailments and their management in pregnant patients could highlight the required changes and consequently improve maternofoetal outcomes. The objective was to study the clinical profile, time of presentation, delivery modality and outcomes in pregnant patients presenting to a tertiary cardiac centre .

A38 Treatment-resistant Atrial Tachycardia Requiring Catheter Ablation at 30 Weeks of Pregnancy

Citation: Journal of Asian Pacific Society of Cardiology 2023;2(Suppl 2):A38.

Methods: A retrospective, observational single-centre study was conducted for the period May 2017 to July 2023. All pregnant patients consecutively hospitalised in the cardiac care centre were included in the study. Data collection comprised of clinical diagnosis, timing of presentation, management strategy needs of ventilation, renal replacement therapy and any cardiac procedures.

Background: Arrhythmia requiring hospitalisation during pregnancy is seen in 0.17% of cases. Supraventricular arrhythmia is the most common

Results: A total of 119 pregnant patients presented with cardiovascular ailments. One hundred and seven patients presented to cardiac

Satoshi Nitta, Mako Inoue, Gosuke Yoshida, Risa Kumazawa, Fusako Sue, Shinya Imada and Hyodo Hironobu

Department of Obstetrics and Gynecology, Tokyo Metropolitan Bokutoh Hospital, Japan

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Abstracts from 8th International Congress on Cardiac Problems in Pregnancy A41 Electronic Platform Reveals Eclampsia as the Commonest Cause of Maternal Mortality in Nigerian Tertiary Hospitals

emergency post lower uterine segment caesarean section (LSCS) versus only 12 pre-LSCS (p=0.001). None of the patients underwent vaginal delivery. The presenting diagnosis was inclusive of peripartum cardiomyopathy (n=63, 75%), congenital heart disease (n=5, 6%), valvular heart disease (n=13, 15% [rheumatic heart disease n=8, bicuspid aortic stenosis n=2, severe mitral stenosis n=5]), prosthetic valve in situ n=4, 5% (with stuck valve in two patients), deep vein thrombosis (n=8, 9%), pulmonary embolism (n=6, 7%), sepsis (n=14,16%), tropical fever (n=4, 5%) and infective endocarditis (n=1, 1%). Eleven (13%) patients presented with hypertension (pre-eclampsia n=5 and eclampsia n=4). Gestational diabetes and dyslipidaemia were noted in three patients each. Nine (11%) patients presented with arrhythmias with ventricular tachycardia (n=1), atrial flutter (n=1) and supraventricular tachycardia (n=7), respectively. Balloon mitral valvotomy (n=1), direct current cardioversion (n=1), radiofrequency ablation (n=1) and uterine artery embolisation (n=2) were performed as indicated. Ventilation (n=23, 27%) and renal replacement therapy (n=3,4%) were required.

Jamilu Tukur,1 Aisha Abdurrahman,2 Aliyu Labaran Dayyabu3 and Hashim Ibrahim4

1. Department of Obstetrics and Gynaecology, Umaru Musa Yaradua University/Federal Teaching Hospital, Katsina, Nigeria; 2. Department of Obstetrics and Gynaecology, Federal Teaching Hospital, Katsina, Nigeria; 3. Department of Obstetrics and Gynaecology, Bayero University/Aminu Kano Teaching Hospital, Nigeria; 4. MPD4QED Data Analysis Unit, Aminu Kano Teaching Hospital, Nigeria Citation: Journal of Asian Pacific Society of Cardiology 2023;2(Suppl 2):A41.

Background: Nigeria has one of the highest burdens of maternal deaths in the world. Provision of accurate data establishes causes of maternal deaths so that quality improvement initiatives can be established. The Maternal Perinatal Database for Quality Equity and Dignity Programme established an electronic platform for the collection of accurate maternal and perinatal data in 54 tertiary hospitals in Nigeria.

Conclusion: Pregnant patients with cardiovascular ailments were referred late, usually after LSCS, with one-third needing ventilatory support. A timely referral to a cardio-obstetric team could help mitigate adverse maternofoetal outcomes and encourage a favourable protocol-based approach for these patients.

Methods: The electronic platform was developed by customising the DHIS2 to facilitate collection of routine data from women who presented for delivery, such as biodemographic information, antenatal and delivery history, and outcome of pregnancy. Medical record officers were trained to use internet-enabled tablets and upload the collected data. A central team analysed the data at national, regional and facility levels, and provided feedback to participating facilities.

A40 Managing Type 1 Diabetic Pregnancy with Prior Coronary Artery Disease and Myocardial Infarction Shabana Ashiq and Matthew Cauldwell

Obstetric Medicine, St George’s Hospital NHS Foundation Trust, UK

Results: In the first year of the programme, data were obtained from 76,563 women who delivered in the health facilities. There were 69,055 live births, 4,498 stillbirths and 1,090 early neonatal deaths. 44,614 women (58.3%) had at least one pregnancy complication, of which 940 women (1.2%) died. Leading causes of maternal death were eclampsia (n=187, 20.6%), postpartum haemorrhage (n=103, 11.4%) and sepsis (n=99, 10.8%). Antepartum hypoxia (n=1,455, 31.1%) and acute intrapartum events (n=913, 19.6%) were the leading causes of perinatal mortality.

Citation: Journal of Asian Pacific Society of Cardiology 2023;2(Suppl 2):A40.

Background: Coronary artery disease is exceedingly rare during pregnancy, complicating about 0.01% of all pregnancies. The overall incidence of cardiovascular disease in pregnant women is around 0.4– 4.1%. Reported here is the successful outcome of a type 1 diabetic pregnancy with a history of MI. Case Description: A 40-year-old woman para 0+1 (earlier miscarriage at 7 weeks) presented at 8 weeks. She had a known case of type 1 diabetes since the age of 9, which was well controlled on Tresiba and NovoRapid. Her pre-pregnancy HbA1c was 61 and was maintained at around 54–58 during pregnancy. The patient was a chronic hypertensive on ramipril and bisoprolol, ezetimibe for hypertriglyceridaemia, and levothyroxine 125 mcg for hypothyroidism. She had stopped ramipril and ezetimibe on the advice of her doctor. Eight years prior, she had a massive ST-elevation MI and underwent percutaneous coronary intervention (PCI) to the left circumflex. Two months later she had a staged PCI and stenting to the mid and right coronary artery. Her most recent stress ECHO was two years earlier, which showed a structurally and functionally normal heart, with no evidence of inducible ischaemia and no ECG changes during exercise. She had an ECHO at 12 weeks, which was normal, with an ejection fraction (EF) of 57%. The patient was a chronic smoker and continued to smoke between one and five cigarettes during pregnancy. She had normal renal functions at booking and urine PCR of 100 (in the background of diabetic nephropathy). Her scan at 22 weeks showed symmetrical growth restriction.

Conclusion: Eclampsia is the most common cause of maternal mortality in Nigerian tertiary hospitals. Quality improvement strategies targeting eclampsia will help reduce maternal mortality in Nigeria. Electronic data collection is feasible in developing countries and leads to the collection of accurate data.

A42 Early Results of PPCM-R: A Patient-directed Peripartum Cardiomyopathy Registry Jennifer Lewey,2 Sara Matloub,1 Madeline Smith,2 Zoltan Arany2 and Sarah Thordsen1

1. Department of Medicine, Medical College of Wisconsin, US; 2. Department of Medicine, University of Pennsylvania, Perelman School of Medicine, US Citation: Journal of Asian Pacific Society of Cardiology 2023;2(Suppl 2):A42.

Background: Research on peripartum cardiomyopathy (PPCM) has been limited by the rarity of the disease and difficulty in recruiting cohorts for study. Patient-directed registries have been successful in other uncommon disease processes to increase enrolment. PPCM-R, a patient-directed

Conclusion: Pregnancy in patients with angioplasty and normal EF appears possible and safe as corroborated in the case reported here.

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Abstracts from 8th International Congress on Cardiac Problems in Pregnancy peripartum cardiomyopathy (PPCM) registry, was opened to enrolment in January 2023. The objective is to describe baseline characteristics of the first participant cohort.

was performed to better characterise the anatomy. The possibility of a pannus was excluded, and the stenosis was considered secondary to a mismatch. In November 2022 the patient underwent a further surgery to replace the metallic pulmonary valve with an Inspiris Resilia 25 biologic pulmonary valve, with a favourable clinical course.

Methods: Participants with self-reported PPCM were invited to enrol in PPCM-R via social media and PPCM support group outreach. Participants were asked to complete several assessments regarding their PPCMrelated health history, social history and quality of life.

Conclusion: The desire for a pregnancy helped this asymptomatic patient obtain a routine cardiovascular consultation, which led to an additional necessary surgical intervention because the moderate stenosis in the right ventricular outflow tract due to the patient-prosthesis mismatch required intervention. This also helped assure a safer status for the patient to begin a pregnancy.

Results: After four months of enrolment, 103 participants had registered and 63 (75.9%) had completed basic demographic assessments. Of these, the mean (SD) age was 32.3 (4.7) years at the time of PPCM diagnosis. None of the respondents had a family history of PPCM; however, 20 (41.7%) had a family history of heart failure and 9 (18.6%) had a family history of sudden cardiac death. Most participants, 61 (96.8%), were diagnosed with PPCM postpartum and the median time to diagnosis was 6 days postpartum (IQR 3 [33 days]). At diagnosis, 49 (77.8%) had left ventricular ejection fraction (LVEF) ≤35% and 31 (57.4%) required intensive care unit-level care. At the time of survey completion, 48 (78.7%) had recovered LVEF to ≥50%.

A44 Severe Preterm Pre-eclampsia Presenting as a Case of Acute Pulmonary Oedema

Shabana Ashiq, Ingrid Watt-Coote and Matthew Cauldwell Obstetric Medicine, St George’s Hospital NHS Foundation Trust, UK Citation: Journal of Asian Pacific Society of Cardiology 2023;2(Suppl 2):A44.

Conclusion: This early sample of PPCM patients enrolled in PPCM-R reports similar rates of recovery and comorbid conditions as reported in other PPCM cohorts. PPCM-R provides proof of concept for the success of patient-directed enrolment in a PPCM registry. Efforts are ongoing to expand recruitment and to incorporate electronic health records. PPCM-R is already the largest active North American PPCM registry, with plans to increase enrolment several-fold.

Background: Acute pulmonary oedema in pregnancy is a rare but lifethreatening condition with variable incidence in pregnancy ranging from 0.08% to 1.5%. Case Description: Presented here is a case of acute pulmonary oedema in a 47-year-old woman with IVF pregnancy, history of hypothyroidism and ulcerative colitis on treatment. At 18 weeks, the patient was diagnosed with hypertension and managed with nifedipine. Her hypertension worsened and from 21 weeks she required admission and stabilisation twice. On one occasion, she was inadvertently given a dose of nifedipine 60 mg. This caused profound maternal hypotension, requiring administration of IV fluids. The patient then developed acute pulmonary oedema and was referred to our hospital for further management. The severity of pulmonary oedema, protracted response to IV furosemide, advanced maternal age and raised markers such as BNP and tyrosine kinase suggested an underlying cardiac disease. A few days later, she developed generalised oedema, severe albuminemia with proteinuria, and raised creatinine with hyponatremia necessitating delivery at 26+6 weeks of gestation.

A43 When the Desire for a Pregnancy Turns into a Blessing for a 27-year-old Woman with Tetralogy of Fallot Ana Maria Radulescu,1 Roxana Enache,1 Monica Buta1 and Eugen Sandica2

1. Cardiology, C.C. Iliescu Emergency Institute for Cardiovascular Diseases, Romania; 2. Department of Pediatric Heart Surgery and Surgery for Congenital Heart Defects, Heart and Diabetes Center, Germany Citation: Journal of Asian Pacific Society of Cardiology 2023;2(Suppl 2):A43.

Discussion: Although the patient was managed as having possible cardiogenic pulmonary oedema, it later became evident that she was very early onset preterm pre-eclampsia. Postnatal recovery with a complete return to normal pre-pregnant state and a normal ECHO eventually ruled out cardiac aetiology. Echocardiogram was crucial in differential diagnosis to exclude other causes of acute pulmonary oedema and evaluate cardiac function (systolic dysfunction and reduced ejection fraction in peripartum cardiomyopathy versus diastolic dysfunction and preserved ejection fraction in pre-eclampsia).

Background: Presented here is the case of a 27-year-old woman with a complex medical history consisting of tetralogy of Fallot diagnosed at the age of two and surgically corrected at the age of eight, together with a series of additional complications. One year after the surgery, at the age of 9, the patient had complete atrioventricular block for which a dualchamber pacemaker was placed. At the age of 14 she developed severe pulmonary regurgitation, for which an additional surgery was performed in which the native pulmonary valve was replaced with an ATS-21 metallic bi-leaflet prosthesis. At the age of 21 she received an ICD after an episode of syncope due to a documented ventricular tachycardia. The patient underwent a cardiac check-up in June 2022, being completely asymptomatic, but with the intention of planning a pregnancy. The objectives were to assess the overall cardiovascular status of the patient and the risks associated with a potential pregnancy at that time and to evaluate whether further cardiovascular interventions would be needed.

Conclusion: Acute pulmonary oedema is a leading cause of death in women with pre-eclampsia. It is a rare entity needing prompt investigation and appropriate treatment. Ultimate management relies on antihypertensive treatment and on delivery, which may be a challenging decision in extreme prematurity.

A45 Genetics and a Double Chance at Life

Methods and Results: Transthoracic echocardiography revealed a moderate stenosis of the pulmonary metallic prosthesis (transvalvular V max 3.9 m/s), probably due to a patient-prosthesis mismatch. A CT scan

Ana Maria Radulescu, Gabriela Neculae, Andreaa Marcu and Ruxandra Jurcut

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Abstracts from 8th International Congress on Cardiac Problems in Pregnancy was the mitral (68.8%), 20.8% of patients had mild mitral regurgitation and 35.4% were anticoagulated. ECG showed AF in 10.4% of patients, admission due to heart failure in three (severe MS in two and infective endocarditis in one), all patients had EF 50%, vegetation was detected in two cases (one on the aortic valve and on the mitral), big thrombus in one patient with mitral valve replacement, 25% of patients were anaemic, 56.3% delivered by caesarean, 35.4% delivered vaginally, and in one case pregnancy was terminated. The death rate was 6.3%; three patients died aged 31, 33 and 43 years, all of whom presented with dyspnoea, one had been diagnosed with severe MS and PHT, one with prosthetic mitral valve thrombosis and one with infective aortic endocarditis, respectively.

Cardiology, C.C. Iliescu Emergency Institute for Cardiovascular Diseases, Romania Citation: Journal of Asian Pacific Society of Cardiology 2023;2(Suppl 2):A45.

Background: We present the case of a 31-year-old woman with no previous medical history who presented to our clinic for cardiac evaluation before planning a pregnancy. The patient was a first-degree relative of a proband previously diagnosed in 2007 at our clinic with non-obstructive hypertrophic cardiomyopathy with heterozygote pathogenic mutation of MYH7 gene. The patient was asymptomatic. Our main goal was to make a complete cardiac evaluation and perform cascade genetic testing to assess the overall cardiovascular risk and decide whether pregnancy was a safe option. We also wanted to assure the best possible evolution of pregnancy and minimise any risks.

Conclusion: Mitral RHD was the most common VHD in this study. Caesarean section is the preferable method of delivery in patients with VHD.

A47 Influence of Maternal Aerobic Exercise on Foetal Cardiac Function and Health: A Systematic Review

Methods and Results: A transthoracic echocardiography was performed which revealed non-obstructive hypertrophic cardiomyopathy. The genetic test came back positive. On 48-hour ECG monitoring, multiple sequences of non-sustained ventricular tachycardia were revealed and after assessing the risk of sudden cardiac death, an ICD was placed for primary prevention. The patient was in OMS cardiovascular risk class III and monitored accordingly from a cardiac standpoint during the pregnancy obtained through IVF, making possible the effective treatment of cardiac decompensation at around 28 weeks followed by a successful birth and healthy baby.

Ameer FA1 and Hashim Talib Hashim2

1. Medicine, Al-Qadisiyah University/College of Medicine, Iraq; 2. Medicine, Baghdad University/College of Medicine, Iraq Citation: Journal of Asian Pacific Society of Cardiology 2023;2(Suppl 2):A47.

Background: Maternal health has a substantial impact on foetal development throughout pregnancy. A variety of factors, such as nutrition, lifestyle choices and physical exercise, all contribute to the health of the mother and the unborn child. There has been a recent surge in studies of the effects of maternal activity during pregnancy, particularly on foetal heart health. The goal of this systematic review is to uncover potential links between mother exercise routines and foetal heart health. The findings of this study have the potential to improve healthcare procedures, resulting in better outcomes for expectant mothers and their unborn children.

Conclusion: Cascade genetic testing in the context of first-degree relation to a positive proband was an essential tool for diagnosing a previously asymptomatic patient, making it possible to elaborate an adequate monitorisation and treatment plan from a cardiovascular standpoint during pregnancy, at birth and afterwards.

A46 Pregnancy Outcome of Libyan Women with Valvular Heart Disease at Tripoli University Hospital, Libya 2022–2023

Methods: A meticulous review was conducted, encompassing 12 relevant studies, of which nine were randomised controlled trials (RCTs), and three were non-RCTs. Risk of bias assessment revealed that five studies had high risk, two had moderate risk and the remaining had low risk.

Elham Elgdhafi1,3 and Laila Sabei2

1. Cardiac, Tripoli University Hospital, Libya; 2. Community and family Medicine, University of Tripoli, Libya; 3. Medicine, University of Tripoli, Libya

Results: Almost all the included studies showed that physical activity during pregnancy is safe and does not affect the mother and the child’s heart activity. One study showed that regular exercise during pregnancy may be associated with faster maternal and foetal recovery after maternal exertion, and a lower increase in foetus heart rate. One study concluded that physical exercise during pregnancy is associated with increased foetal DA-PI at 20 weeks and EF at 36 weeks, which could reflect adaptive mechanisms. Analysis revealed a statistically significant difference (p=0.03; 95% CI).

Citation: Journal of Asian Pacific Society of Cardiology 2023;2(Suppl 2):A46.

Background: Cardiac disease in pregnant patients presents challenges in maternal-foetal management and is the leading cause of maternal mortality. The aim of this study was to characterise valvular pathologies and define maternal outcomes. Methods: A search was conducted of the medical records archive at the obstetric department of Tripoli University Hospital from January 2022 to May 2023. Mothers with valvular heart disease (VHD) were included in this retrospective study. A predesigned case sheet was used to collect valvular pathology and obstetric outcome data from the records. SPSS 22 was used for statistical analysis.

Conclusion: This review highlights the value of mother wellness and physical activity in promoting optimum foetal health. The findings encourage continuing physical activity throughout pregnancy, highlighting its potential advantages for promoting the health of mothers and fetuses.

A48 Mode of Delivery among Women with Maternal Cardiac Disease: Tripoli University Hospital Experience 2022–2023

Results: In 48 Libyan women with VHD, the maternal age range was 23– 45 (median 34) years, 31.3% lived outside the capital (Tripoli), 37.5% presented with dyspnoea, 66.7% had known cases of rheumatic heart disease and 25% had prostatic valves. The most commonly affected valve

Elham Elgdhafi1,2 and Laila Sabei3

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Abstracts from 8th International Congress on Cardiac Problems in Pregnancy Case Description: A 21-year-old women was referred to the cardiology department at 17 weeks of pregnancy for management of arterial hypertension and unexplained systolic murmur. The year before presentation an elevated blood pressure was noticed but was left unexplored. Clinical exam revealed a loud systolic murmur extending to the subclavicular and scapular regions. Pulses were very weak in the lower extremities and blood pressure was mildly elevated with a significant gradient between upper and lower extremities. Echocardiography showed absence of pulsatile flow in the abdominal aorta and narrowing just distal from the subclavian artery with typical diastolic tail pattern. Cardiac MRI confirmed the presence of a severe coarctation allocating this patient to the category of extremely high-risk pregnancy with up to 40–100% risk of maternal cardiac event.

1. Cardiac, Tripoli University Hospital, Libya; 2. Medicine, University of Tripoli, Libya; 3. Community and Family Medicine, University of Tripoli, Libya Citation: Journal of Asian Pacific Society of Cardiology 2023;2(Suppl 2):A48.

Background: Patients with cardiac disease are reaching childbearing age with increasing rates of caesarean delivery among them than the general population regardless of the severity of cardiac diseases. The objective was to evaluate the mode of delivery and perinatal outcomes among patients with low-risk and moderate-to-high-risk cardiac disease as defined by the modified WHO (mWHO) classification of maternal cardiovascular risk Methods: A search was conducted of medical records from January 2022 to May 2023 in the archive of the obstetric department at Tripoli University Hospital, Libya. All mothers with heart disease were included in this retrospective study. Demographics, clinical characteristics, mode of delivery and perinatal outcomes were collected. A predesigned case sheet was used to collect information regarding type of cardiac disease and obstetric outcomes. SPSS 22 was used for statistical analysis.

An extensive multidisciplinary team meeting that included a cardiologist, obstetrician, anaesthesiologist, thoracic surgeon, neonatologist and genetic specialist was convened. After initial medical optimisation, increased claudication and signs of placental hypoperfusion necessitated an endovascular procedure at 23 weeks of pregnancy. A Bentley BeGraft Plus stent (16 × 38 mm) was successfully placed. Postoperative ultrasound showed improved placenta perfusion and normalisation of blood pressure. At 36 weeks of pregnancy the patient gave birth to a healthy baby.

Results: In 64 women with cardiac disease, the maternal age ranged between 23 and 45 (median 34) years, 60.9% lived in Tripoli, 48% had rheumatic heart disease and 17% had mechanical valves. According to the mWHO classification of maternal cardiovascular risk, 60.9% of the patients were low risk, 17% were moderate risk, and 14% were high risk. Caesarean section (C/S) was the mode of delivery in 56.25% of the total number of patients (all patients in the moderate-to-high-risk groups and 29% in the low-risk group delivered by C/S). The death rate after C/S was 5.5% (two patients); one patient had mitral valve thrombosis, the other patient had post-viral myocarditis with low ejection fraction and mural thrombus. There were no post-delivery complications such as infection, heart failure, arrhythmias or thromboembolism.

Conclusion: CoA should be considered in every young patient presenting with arterial hypertension. Altered maternal haemodynamics resulted in severe symptomatic CoA and reduced placental flow necessitating percutaneous intervention during pregnancy. A multidisciplinary pregnancy heart team is essential for optimal management in these highrisk patients.

A50 Evaluation of the Diagnosis of Peripartum Cardiomyopathy and its Management in a Single-centre Health System

Conclusion: Even in the absence of guideline-indicated C/S delivery, C/S was the most common mode of delivery for pregnant cardiac patients.

Retu Saxena,1,2 Retu Saxena,1 Sarah Schwager,1 Gretchen Benson,1 Delaine Thomas,1 Ellen Cravero1 and Peter Eckman1,2

A49 First Diagnosis of Severe Aortic Coarctation Necessitating Percutaneous Intervention during Pregnancy

1. Minneapolis Heart Institute Foundation, Allina Health, US; 2. Minneapolis Heart Institute, Allina Health, US Citation: Journal of Asian Pacific Society of Cardiology 2023;2(Suppl 2):A50.

An Van Berendoncks,1,5 Dominique Mannaerts,2,6 Lawek Berzenji,4,6 Ine Adriaensens,3 Anouck Wittock,3 Yves Jacquemyn2,6 and Jeroen Hendriks4,6

Background: Peripartum cardiomyopathy (PPCM) is heart failure that typically develops within the last month of pregnancy or up to five months postpartum. PPCM is a diagnosis of exclusion with no other identifiable causes of heart disease and with diminished left ventricular systolic dysfunction (LVEF) ≤45%. Although rare (1/1,000 pregnancies), PPCM has important implications for future cardiovascular health. The objectives were to estimate the number of patients with a PPCM-related visit within the last 3 years, adjudicate and characterise patients with a true diagnosis, and assess guideline-directed medical therapy (GDMT) in patients with true PPCM.

1. Cardiology, Antwerp University Hospital, Belgium; 2. Obstetrics and Gynaecology, Antwerp University Hospital, Belgium; 3. Anaesthesiology, Antwerp University Hospital, Belgium; 4. Thoracic and Vascular Surgery, Antwerp University Hospital, Belgium; 5. Cardiovascular Diseases, GENCOR, University of Antwerp, Belgium; 6. Antwerp Surgical Training, Anatomy and Research Centre (ASTARC), University of Antwerp, Belgium Citation: Journal of Asian Pacific Society of Cardiology 2023;2(Suppl 2):A49.

Methods: This was a retrospective analysis of 92 patients aged 18 years or older with a diagnosis of PPCM who received care within the Allina Health system between 1 January 2018 and 31 December 2021. Diagnosis of true PPCM was evaluated as LVEF ≤45%, with symptoms occurring within the diagnosis window and excluding all other occurrences of heart disease. All cases were adjudicated independently by two cardiologists.

Background: Coarctation of the aorta (CoA) is a common congenital heart defect. Despite clear signs on clinical examination, diagnosis is sometimes not made until adulthood. During pregnancy, un unrepaired or severe CoA is considered modified WHO class IV, implying a very high risk of maternal mortality and morbidity.

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Abstracts from 8th International Congress on Cardiac Problems in Pregnancy Results: Fifty-two patients received follow-up care at Allina Health and 24 (46%) met criteria for a true PPCM diagnosis. Seventy-nine per cent of patients with PPCM received GDMT (n=19), 100% received β-blockers, 95% ACE/ARB/ARNI and 47% MRA. Diagnosis of PPCM for most patients occurred in the first 30 days of postpartum (n=18, 75%). For patients with ‘other heart failure’ (n=28), pre-eclampsia was the most frequent complication during pregnancy and postpartum (n=5 [19%]; n=4 [14%]).

1. Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Lehigh Valley Health Network, US; 2. Division of Cardiology, Cardio Obstetrics Program, Lehigh Valley Health Network, US; 3. Division of Maternal Fetal Medicine, Cardio Obstetrics Program, Lehigh Valley Health Network, US

Conclusion: Adherence to PPCM guidelines for identification and management of the condition is essential. GDMT management is suggested for all PPCM patients. In this large urban health centre, PPCM was often diagnosed when patients had other causes for heart failure. Identifying the aetiology of heart failure in these patients has implications not only for future pregnancies but also for lifelong cardiovascular health.

Background: Fontan circulation increases the risk of both thromboembolic and haemorrhagic complications during pregnancy. Controversy remains regarding recommending antepartum and postpartum anticoagulation for women with Fontan circulation. Reported here are the cases of two women with Fontan circulation, seen in our Cardio Obstetrics programme, who experienced significant postpartum bleeding complications.

Citation: Journal of Asian Pacific Society of Cardiology 2023;2(Suppl 2):A52.

Case Descriptions: Case 1 was a 28-year-old nulliparous woman who presented for preconception consultation with history of congenital tricuspid atresia s/p extracardiac conduit Fontan procedure, Blalock– Taussig shunt and bidirectional Glenn shunt. Case 2 was a 27-year-old nulliparous woman who presented at 10 weeks of gestation with chronic hypertension and history of double outlet right ventricle s/p coarctation repair, Damus–Kaye–Stansel procedure, right bidirectional Glenn shunt and fenestrated lateral tunnel Fontan procedure.

A51 Maternal Blood Pressure Variations during Different Stages of Labour Bindu Valiyakkil Balakrishnan, Reham Abdelhalem and Nageena Mahmood

Obstetrics and Gynecology, Corniche Hospital, United Arab Emirates Citation: Journal of Asian Pacific Society of Cardiology 2023;2(Suppl 2):A51.

Background: There are limited data on normal physiological blood pressure variations during labour and the immediate postpartum period. In the few reported studies no thresholds have been defined. The primary objective was to assess blood pressure (BP) variations during the three stages of labour. Incidence of intrapartum hypertension in previously normotensive women was noted.

Case 1 was managed with low-dose aspirin (LDA) and plans for prophylactic anticoagulation with low molecular weight heparin (pLMWH) after delivery. The patient delivered via caesarean at 33 weeks and 6 days gestation after preterm prelabour rupture of membranes. She received pLMWH as planned and presented on postoperative day 9 with a wound separation. After serial debridement and packing, the wound healed by secondary intention.

Methods: Electronic medical records were reviewed retrospectively for all women who delivered at Corniche Hospital from 1 May to 31 May 2023. Exclusion criteria were twin pregnancy, caesarean delivery, pregnancyrelated hypertensive disorders, pre-existing hypertension and inadequate data. BP in the different stages of labour and postnatal BP were compared and time taken for normalisation to prelabour values.

During pregnancy Case 2 was managed with LDA with no plans for postpartum pLMWH. Due to early onset foetal growth restriction, labour was induced at 37 weeks. Course was complicated by pre-eclampsia with severe features and 2-l blood-loss due to uterine atony and retained tissue. After transfusion of two units of packed red blood cells, she was discharged on LDA on postpartum day 3.

Results: Among the 123 deliveries studied, greater variations in BP were found between prelabour (114/72) and first stage of labour (122/74) versus first and second stages of labour (119/73). Thirty-two per cent of women had intrapartum hypertension, 55% had an epidural in labour, and the average time to return to baseline BP was 24 hours. None of the women had postpartum hypertension. No difference was found in time to normalisation between the normotensive and intrapartum hypertension groups.

Conclusion: Recommending anticoagulation to all women with Fontan circulation remains controversial. Although expert opinion recommends the use of LDA plus pLMWH for patients with low-risk Fontan circulation during pregnancy and after delivery, careful shared decision-making is recommended for these patients due to the risk of significant postpartum bleeding as illustrated in the above cases.

A53 Management of Paroxysmal Supraventricular Tachycardia in Pregnant Woman with Wolff–Parkinson–White Syndrome

Conclusion: This study revealed no significant variation in BP during labour among normotensive women compared to previously reported studies. This could be due to the use of epidural analgesia in 55% of the present study cohort. A prospective study with long-term follow-up is proposed to establish the significance of intrapartum hypertension and future risk of chronic hypertension in these women.

Mary Gray1,2

1. Department of Medicine, Division of Cardiology, University of California, San Francisco, US; 2. Division of Cardiology, San Francisco General Hospital, US

A52 Anticoagulation Considerations in Pregnant Women with Fontan Circulation

Citation: Journal of Asian Pacific Society of Cardiology 2023;2(Suppl 2):A53.

Current Clinical Scenario: A 26-year-old woman (G2P1; live birth via lowtransverse caesarean section) presented to labour triage at 27 weeks and 4 days gestational age (GA) with severe palpitations and a heart rate of

Shekinah Dosunmu,1 Matthew Romagano,1 Amy Ahnert2 and Joanne N Quinones3

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Abstracts from 8th International Congress on Cardiac Problems in Pregnancy 240 BPM. No telemetry record on arrival is available. Tachycardia and symptoms resolved following standard vagal manoeuvres.

black (93.6%), single (63.2%) and from the capital city (58.2%). The most prevalent cardiac diseases were native valve diseases (33%), most of rheumatic origin (52.5%), followed by arrythmias (13.8%), congenital diseases (7.4%) and heart failure with reduced ejection fraction (4.5%); other cardiopathies totalled 3.5% of cases and disfunction of prosthetic valves (3.1%). Hypertensive disorder of pregnancy (HDP) was present in 26.3% of patients. The combined outcome of death, preterm delivery, ICU stay or mechanical ventilation occurred in 59.8% of patients, having as predictors the presence of native valvular disease and the occurrence of HDP (p=0.001).

Prior Cardiac Evaluation: The patient was diagnosed with Wolff– Parkinson–White (WPW) syndrome 4 years earlier based on palpitations associated with short PR interval and delta wave on ECG. Ambulatory monitoring confirmed predominant sinus rhythm with WPW conduction. Rare atrial and ventricular premature complexes were present. Exercise treadmill test confirmed ability to walk 11 minutes on Bruce protocol to 91% maximum predicted heart rate. Pre-excitation was present on baseline ECG, but no delta wave was observed at peak heart rate. Essentially normal resting cardiac ultrasound was obtained.

Conclusion: There is high morbidity in pregnant women with cardiac diseases, with a high proportion of rheumatic aetiology in this population, comprised mostly of black women who were assisted at a referral centre of a low-income country. These data endorse the prominent need of public health policies to improve the prognosis of this population.

Clinical Decision-making: A young woman with known WPW syndrome but otherwise healthy presented with presumed atrioventricular re-entry tachycardia at 27 weeks and 4 days GA with plan for induction of labour at 39 weeks. She was advised to start vagal manoeuvres if supraventricular tachycardia (SVT) recurred and seek prompt medical attention. Adenosine administration might be required if tachycardia did not respond to nonpharmacologic strategy. DC cardioversion may be performed with deep sedation during pregnancy but with significant aspiration risk. We advised against β-blocker therapy because of mild risk to foetal growth and concern for more severe tachycardia if AF developed with conduction down the accessory pathway. SVT ablation can be performed without fluoroscopy in pregnant patients with incessant tachycardia. Ablation is not advised after an isolated SVT episode and left-sided pathway.

A55 Pulmonary Arterial Hypertension‑related Maternal Death in Japan

Shinji Katsuragi,1 Chizuko Kamiya,2 Hiroaki Tanaka,3 Junichi Hasegawa,4 Masamitsu Nakamura,5 Tatsuta Aragaki,6 Masafumi Nii,3 Eijiro Hayata,7 Naohiko Kanayama,8 Masahiko Nakata,7 Takeshi Murakoshi,9 Jun Yoshimatsu,2 Kazuhiro Osato,3 Kayo Tanaka,3 Yoshiki Maeda,3 Akihiko Sekizawa,6 Isamu Ishiwata10 and Tomoaki Ikeda11 1. Obstetrics and Gynecology, Miyazaki University, Japan; 2. Obstetrics and Gynecology, National Cerebral Cardiovascular Center, Japan; 3. Obstetrics and Gynecology, Mie University, Japan; 4. Obstetrics and Gynecology, Saint Marianna University, Japan; 5. Obstetrics and Gynecology, Fujita Health University, Japan; 6. Obstetrics and Gynecology, Showa University, Japan; 7. Obstetrics and Gynecology, Toho University, Japan; 8. Obstetrics and Gynecology, Hamamatsu University, Japan; 9. Obstetrics and Gynecology, Seireihamamatsu Hospital, Japan; 10. Obstetrics and Gynecology, Ishiwata Clinic, Japan; 11. On behalf of the Maternal Death Exploratory Committee in Japan, and Japan Association of Obstetricians and Gynecologists, Japan

Clinical Outcome Update: The patient delivered a healthy baby girl at 38 weeks GA after presenting with premature rupture of membranes. The baby had normal Apgar scores and birthweight.

A54 Clinical and Obstetric Prognosis of Pregnant and Postpartum Women with Cardiac Diseases Assisted in a Referral Centre in Bahia, Brazil Larissa Novais,1,2 Rachel Peixoto,1,2 Flávia Valladares,1,2 Jamile Regis,1,2 Leonardo Dourado,1,2 Vanessa Corral,1,2 Itana Ferreira,1,2 Sabrina Freitas,2 Mario Rocha1,2 and Ng Kin Key1,2

1. Medical Sciences, Escola Bahiana de Medicina e Saúde Pública, Brazil; 2. Cardiac Diseases in Pregnancy, Maternidade de Referência Professor José Maria de Magãlhaes Netto, Brazil

Citation: Journal of Asian Pacific Society of Cardiology 2023;2(Suppl 2):A55.

Background: The aim was to clarify the clinical characteristics and risk factors in cases of maternal death due to pulmonary arterial hypertension (PAH) in Japan.

Citation: Journal of Asian Pacific Society of Cardiology 2023;2(Suppl 2):A54.

Background: In recent decades there has been a worldwide increase in maternal age at first and subsequent pregnancies, making these women more susceptible to become pregnant with comorbidities such as hypertension, obesity and diabetes. Despite some decrease in maternal mortality, it is still above what is preconised by WHO. The objective was to describe the clinical and obstetric prognoses of pregnant women assisted from 2018 to 2022 at a referral centre for high-risk pregnancies in Salvador, Brazil.

Methods: Cases of maternal death due to PAH between 2010 to 2022 were extracted from 550 cases discussed at the Committee for Evaluation of Cases of Maternal Death. Onset of gestational weeks, clinical type of PAH, period from onset to death and drugs for PAH were examined. Results: There were seven cases of PAH-related maternal death in the observed period. Two occurred at 16 weeks of gestation, two at 28 weeks, and one each at 28, 36 and 40 weeks. Two cases were diagnosed by catheter test and five cases by cardiac ultrasonography. The period from onset to death was 2–7 (medium 3) weeks, while clinical type was idiopathic PAH in six cases and the rest were SLE-related PH. In six cases, two to four types of anti-PAH drugs were used. Two cases were diagnosed after emergency caesarean section due to hypertensive disorder of pregnancy, the other two showed sudden cardiac arrest just after caesarean section, five cases showed thrombocytopenia, and three cases exhibited 5–8 weeks of short of breath or fatigue before diagnosis.

Methods: This was a retrospective study of 513 pregnant and postpartum women assisted at the Cardiopathy in Pregnancy Clinic of the Referral Centre in Salvador, Brazil between 2018 and 2022. Continuous variables were described as averages ±SD and dichotomous variables were developed as contingents. The association between prognostic factor and outcome was determined using logistic regression analysis. Results: The mean age of participants was 31.3 years. Most patients were

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Abstracts from 8th International Congress on Cardiac Problems in Pregnancy Conclusion: Most of the seven cases might have had PAH before congestion and became symptomatic during pregnancy. It is important to think of PAH as shortness of breath and low SpO2. Progression of disease was rapid, and preventability was thought to be impossible in each of the cases discussed at the committee. Hypertensive disorder of pregnancy was regarded as the aggravating factor. Thrombocytopenia made the diagnosis of PAH difficult, and this is the characteristic point shown five fatal cases of PAH during pregnancy.

women who received perinatal care at the hospital between 2011 and 2023. Results: Seven pregnant women with PAH were included in the study: three idiopathic or heritable PAH, three congenital heart disease (CHD)PAH, and one connective tissue disease (CTD)-PAH. Six women were nulliparous. Maternal age ranged from 23 to 40 years. One mortality was noted: a woman with large patent ductus arteriosus was diagnosed with Eisenmenger syndrome in childhood, but had received no medical care for the condition for several years. At 21 weeks of gestation she had haemoptysis and cardiogenic shock and died 3 days later. In the other six cases, the median systolic pulmonary arterial pressure (sPAP) before pregnancy or at early pregnancy was 60.5 (33–105) mmHg. Four women received PH-specific therapy before and during pregnancy. The median gestational week at delivery was 32 (29–34). All women had caesarean deliveries. The median birthweight was 1,582 (1,298–1,877) g including one small-for-gestational-age baby. Only one woman with CTD-PAH had >10 mmHg increase in sPAP (33–55 mmHg) during pregnancy, but with no deterioration. One woman with idiopathic PAH had been treated with epoprostenol infusion therapy during and after delivery.

A56 Signatures and Clinical Significance of Amino Acids as Potential Biomarkers for Pre-eclampsia: A Systematic Review and Meta-analysis Iclal Sena Gezer1 and Nuray Yazihan1,2

1. Interdisciplinary Food, Metabolism and Clinical Nutrition Department, Institute of Health Sciences, Ankara University, Turkey; 2. Department of Pathophysiology, Internal Medicine Division, Faculty of Medicine, Ankara University, Turkey Citation: Journal of Asian Pacific Society of Cardiology 2023;2(Suppl 2):A56.

Background: Dysregulation of amino acids is closely linked to the initiation and progression of pre-eclampsia. Summarised here are recent advancements in studies of amino acid profiles and the clinical significance of amino acid flux in pre-eclampsia. The present systematic review and meta-analysis aims to establish the possible value of serum/plasma levels of amino acids as markers of pre-eclampsia.

Conclusion: There were no maternal deaths in women who received perinatal management from the early stage of pregnancy. In contrast, one case without medical care resulted in maternal death. Preconception counselling is very important for women with PAH at the time of diagnosis.

A58 Inappropriate Sinus Tachycardia in Pregnancy

Methods: This is a review of three databases (PubMed, Web of Science Core Collection, Scopus) to capture all studies examining metabolomics that include mean and SD values of serum/plasma blood amino acid levels in pre-eclampsia up to July 2023. Meta-analysis of eligible studies was performed using RevMan software following PRISMA guidelines.

Nageena Mahmood

Obstetric Medicine, Corniche Hospital, United Arab Emirates Citation: Journal of Asian Pacific Society of Cardiology 2023;2(Suppl 2):A58.

Results: The study findings suggest the value of serum/plasma levels of several amino acids in the discrimination of pre-eclampsia patients from healthy subjects.

Background: Inappropriate sinus tachycardia is a symptomatic tachycardia, unexplained by physiological demands. It is usually associated with pregnancy, but the exact incidence is unknown. The objective was to determine the incidence of inappropriate sinus tachycardia in the pregnant population of a major maternity hospital in the United Arab Emirates.

Conclusion: Serum amino acid levels must be evaluated carefully.

A57 Pregnant Women with Pulmonary Hypertension: A Case Series

Methods: Retrospective electronic medical record review of pregnant women with heart rate ≥115 BPM recorded at a single hospital encounter from 1 to 30 June 2023 was conducted. Subsequent heart rates were recorded to determine if this was a transient or permanent phenomenon. The aetiology of the tachycardia in each woman was identified.

1. Department of Obstetrics and Gynecology, National Cerebral and Cardiovascular Center, Japan; 2. Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center, Japan

Results: During the study period a total of 3,915 pregnant women attended Corniche Hospital. One hundred (3%) women had a heart rate ≥115 BPM. The maximum heart rate recorded was 146 BPM. The average age of this cohort was 31 (range 19–46) years. Gestation age ranged from 6 to 39 weeks, with an average of 27 weeks. Causative factors were identified in all except four women. These four women were diagnosed with persistent inappropriate sinus tachycardia after relevant investigations were performed.

Nao Konagai,1 Chizuko Kamiya,1 Shuhei Ebisu,1 Masami Sawada,1 Toru Iwasa,2 Tae Konishi,1 Atsushi Nakanishi,1 Aiko Kakigano,1 Naoko Iwanaga,1 Takeshi Kanagawa1 and Jun Yoshimatsu1

Citation: Journal of Asian Pacific Society of Cardiology 2023;2(Suppl 2):A57.

Background: Pregnancy in women with pulmonary arterial hypertension (PAH) is contraindicated due to high mortality for mothers and foetuses. Some recent reports have described better prognosis in pregnant women with PAH managed with appropriate medication. The objective of this study was to investigate the clinical outcome of pregnant women with PAH in recent years.

Conclusion: Tachycardia in pregnancy must be taken seriously as it may be a red flag for serious underlying pathology, but it is important to avoid both under- and over-investigation. Inappropriate sinus tachycardia is a diagnosis of exclusion. The incidence in the present study cohort was 4%.

Methods: A retrospective observational study was conducted of pregnant

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Abstracts from 8th International Congress on Cardiac Problems in Pregnancy A59 Maternal Deaths from Cardiovascular Pathologies in a Tertiary Centre in Rural India: Pointing the Need of FoCUS Training of Obstetricians

cardiac care is systematic and easily available to all, pregnancy represents a unique challenge in women with prosthetic heart valves. Pregnancy unmasks underlying cardiac diseases due to its large haemodynamic changes.

Swaraj Nandini Pande,1 Anish Keepanasseril,3 Benudhar Pande,1 Nayan Patel2 and Ojaswini Patel1

Methods and Results: A retrospective cohort study was undertaken at a tertiary care institute in North India of 683 women aged between 19 and 35 years who received mechanical prosthetic valves at a single unit. Ninety-two of 587 surviving pregnancies were followed to study pregnancy outcomes. All women received only oral nicoumalone as anticoagulant as standard care before pregnancy. The pregnant women were managed jointly by the departments of Maternal and Reproductive Health and Cardiovascular and Thoracic Surgery. When indicated, antepartum foetal wellbeing was monitored, serial ultrasonic measurements and antepartum non-stress cardiotocography. The mean age of women was 32.45 years and mean weight was 45.78 kg. Most women had mitral valve repair (71.91%), 20.21% had DVR, and 7.87% had AVR. Forty-six (66.7%) women had successful deliveries and the rest 23 (33.3%) had single or multiple pregnancy failure. 41.30% of women had LSCS and 54.34% had normal vaginal delivery. Foetal morbidity was 37.68% and none of the pregnant women had valve thrombosis. The majority had successful outcome except for 13.04% of babies who developed anticoagulation-related congenital defects. This was mainly seen in cases where women presented late in pregnancy. Various highrisk factors were correlated with maternal and neonatal outcomes and will be presented in the study.

1. Obstetrics and Gynaecology, VIMSAR Burla, India; 2. Cardiology, VIMSAR Burla, India; 3. Obstetrics and Gynaecology, JIPMER Puducherry, India Citation: Journal of Asian Pacific Society of Cardiology 2023;2(Suppl 2):A59.

Background: The UN Sustainable Development Goals (SDGs) aim for a reduction in maternal mortality ratio (MMR) to below 70 per 100,000 live births by 2030. The rate of maternal death in lower-middle-income countries (LMICs) is higher (479 per 100,00 live births) compared to highincome countries (41) and the contributions from cardiovascular pathologies are increasing. Availability of specialist care for aiding management is limited in LMICs, especially in rural settings. The objective was to ascertain the causes of maternal death and contribution of cardiovascular pathologies to these deaths in a tertiary centre in rural setting in Odisha, India. Methods: This is a retrospective observational study conducted in a tertiary care hospital located in the western (tribal majority) area of Odisha, a state in India. The annual delivery rate is 7,500, with two specialists available to provide round-the-clock cardiology services. All pregnant women who died between January 2021 and December 2022 at the hospital were evaluated and their cases analysed to ascertain cause of and contribution to maternal mortality.

Conclusion: Decision regarding anticoagulation in pregnancy requires intense counselling at multiple sittings in terms of complete prospective follow-up to predict the efficacy and safety of any regime in pregnancy.

Results: During the study period, the maternal mortality rate was 812 per 100,000 live births. The most common cause of death was pulmonary oedema (51.2%). All the women were admitted with breathlessness and New York Heart Association class IV. One-third were diagnosed with preeclampsia among those with pulmonary oedema. The exact cause of pulmonary oedema could not be ascertained as echocardiography was performed in only 1.5% of cases because of limited availability of these services.

A61 Association of IL1R1 Gene (SNP rs2071374) with the Risk of Pre-eclampsia

Nagarjuna Sivaraj,1 Rachel K Vijaya1 and Tarun Kumar Suvvari2 1. Department of Biochemistry and Bioinformatics, GITAM University, India; 2. Medical Intern, Rangaraya Medical College, India Citation: Journal of Asian Pacific Society of Cardiology 2023;2(Suppl 2):A61.

Conclusion: Pulmonary oedema is the major cause of maternal mortality in this setting. Training obstetricians in limited point-of-care focused cardiovascular ultrasonography will help identify and initiate intensive therapy in a limited resource setting to reduce maternal morbidity and mortality.

Background: Several studies have examined SNPs in inflammatory mediator genes and their association with pre-eclampsia; however, findings have not been conclusive to better explain the possible role of SNPs in the risk of pre-eclampsia in inflammatory mediator genes. IL1R1 gene SNP rs2071374 is examined here to figure out the association of inflammatory mediator genes in pre-eclampsia.

A60 Correlation of Risk Factors with Pregnancy Outcome in Pregnant Women with Valvular Heart Disease

Methods: A case-control study was conducted of 304 pregnant women with pre-eclampsia (n=152) and normotensive pregnancies (n=152). SNP rs2071374 was genotyped by PCR-RFLP. Sample size was determined using the sample size calculator Clinical web tool considering 95% CI and 70% power. Statistical analysis was performed using OpenEpi online. Parametric variables were prepared by mean ± SD, percentage and its level of significance calculated using Student’s t-test. Fisher’s exact analysis was used to test genotype and allele distribution between the two groups by comparing with the p-value.

Amrit Gupta,1 Varuna Verma,2 Indrani Ghosh3 and Nirmal Kumar Gupta2

1. Maternal and Reproductive Health, Sanjay Gandhi Post Graduate Institute of Medical Sciences, India; 2. CVTS, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India; 3. Maternal and Reproductive Health, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India Citation: Journal of Asian Pacific Society of Cardiology 2023;2(Suppl 2):A60.

Results: Seventy per cent of pre-eclampsia pregnancies were primigravida and 30% were multigravida. The presence of IL1R1 rs2071374G allele was

Background: Even in developed nations where standard maternal and

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Abstracts from 8th International Congress on Cardiac Problems in Pregnancy associated with increased risk of pre-eclampsia p=0.01741, OR 0.7006 (95% CI [0.5023–0.9759]). In cases (CG: 58.6%, GG: 27%) the CG and GG genotypes were more common than in controls (CG: 44.8%, GG: 25%). The disparity in the genotype profile of the two groups is statistically significant (p=0.00335). Association of recessive GG model with mild preeclampsia OR 0.3751 (95% CI [0.1689–0.7803]) was stronger than severe pre-eclampsia OR 0.398 (95% CI [0.1668–0.876]) and was seen only in recessive models.

considered when the diagnosis is uncertain. Cardiac catheterisation was deferred given the preserved LVEF, normal wall motion and clinical stability of the patient.

Conclusion: Study results indicate that there is an association in IL1R1 rs2071374SNP with pre-eclampsia compared to non-pre-eclampsia women. It is the first study to evaluate that IL1R1 polymorphism is correlated with pre-eclampsia pathogenesis in the population in India and the association differed by risk of pre-eclampsia subgroups.

1. Cardiology, Lehigh Valley Health Network, US; 2. Maternal Fetal Medicine, Lehigh Valley Health Network, US; 3. Department of Medicine Residency, Lehigh Valley Health Network, US

A63 Aortopathy of Unknown Cause: Preconception Counselling is a Window of Opportunity Amy Ahnert,1 Joanne Quinones,2 Cheri Silverstein Fadlon1 and Catherine Nguyen3

Citation: Journal of Asian Pacific Society of Cardiology 2023;2(Suppl 2):A63.

A62 Myocardial Injury following Eclampsia

Background: Thoracic aortic aneurysms (TAAs) in young patients are uncommon. Possible aetiologies include infectious aortitis, inflammatory conditions, syndromic connective tissue (CT) disorders (Marfan, Ehlers– Danlos [EDS], Loeys–Dietz [LDS] and Turner syndromes], bicuspid aortic valves and familial TAAs. Familial TAAs are increasingly being recognised. Presented here is the case of a woman with an incidentally identified TAA subsequently diagnosed with a pathological genetic mutation.

Jennifer Heibig,1 Catherine Nguyen,3 Louisa Appiah,1 Joanne N Quiñones,2 Amy Ahnert4 and William E Scorza2 1. Obstetrics and Gynecology, Lehigh Valley Health Network, US; 2. Maternal Fetal Medicine, Lehigh Valley Health Network, US; 3. Internal Medicine, Lehigh Valley Health Network, US; 4. Cardiology, Lehigh Valley Health Network, US

Methods: A 34-year-old healthy woman (G0) presented to the cardioobstetrics programme for preconception counselling. Evaluation for palpitations incidentally noted aortic dilation on echocardiogram and a 4.0 × 4.3-cm aneurysm on CT. Medical history was negative for hypertension and trauma. Family history was negative for aneurysms. Aortic valve was tri-leaflet. She had no clinical features of syndromic CT disorders.

Citation: Journal of Asian Pacific Society of Cardiology 2023;2(Suppl 2):A62.

Background: Peripartum chest pain (CP) has a broad differential and requires immediate evaluation to exclude life-threatening conditions. Presented here is a case of postpartum myocardial injury (MI), evaluation and management. Methods: A 21-year-old woman (G1P0) underwent induction of labour for foetal growth restriction at 38 weeks of gestation. The intrapartum course of the patient was complicated by gestational hypertension and eclampsia. She received IV magnesium sulphate and delivered vaginally. On postpartum day 1, the patient reported moderate to severe substernal CP. Serial high sensitivity (HS) troponin was obtained (3,550 ng/L and 2,826 ng/l; 99th percentile upper reference limit for females 12 ng/l). Urgent electrocardiogram (ECG) showed no acute ST/T wave changes with poor R wave progression. Cardiology was consulted and urgent echocardiogram revealed left ventricular ejection fraction (LVEF) 50–55%, small circumferential pericardial effusion and normal regional wall motion.

Results: Repeat echocardiogram and cardiac MRI showed stable aortic dimensions. Genetic testing was deferred due to stable measurements. After conception, serial measurements remained stable. The patient delivered vaginally at term; the pregnancy was complicated by gestational hypertension. Postpartum, she was referred to rheumatology and cardiogenetics due to multiple constitutional symptoms. Evaluation raised concern for hypermobility-type EDS (hypermobility, enlarged aorta and musculoskeletal pain). Initial genetic panel was non-diagnostic for pathogenic mutations, but whole genome sequencing identified a deletion of 230kb in chromosomal region 15q23, part of the THSD4 gene. This mutation is pathogenic for familial TAA/dissections and follows autosomal dominant inheritance.

Results: The patient was transferred to cardiac ICU. On postpartum day 2, CP resolved and there was no haemodynamic or rhythm instability. CT was negative for pulmonary embolus (PE). Repeat echocardiogram with contrast demonstrated normal LVEF and wall motion. The patient was managed conservatively due to symptom resolution and echocardiographic findings. She was discharged on aspirin and metoprolol. Two weeks postpartum, she was seen by cardiology and remained asymptomatic.

Conclusion: Pregnancy is a window of opportunity to diagnose previously undetected cardiac conditions. The science of familial aortopathies is increasing exponentially. The maternal risk of TAA is related to the underlying aetiology, which in turn affects treatment and management. It is imperative to extensively evaluate TAAs to assist with pregnancy, labour and delivery planning. Findings can have significant impact on first degree relatives if a genetic syndrome is discovered. Collaboration with specialists and geneticists is paramount to making this important diagnosis.

Conclusion: This case highlights the importance of urgent cardiology consultation, ECG, HS troponin and echocardiographic imaging. Initial diagnoses considered were non-ST-elevation MI, spontaneous coronary artery dissection, stress cardiomyopathy, peripartum cardiomyopathy and PE. Urgent ECG and echocardiogram are critical to help differentiate these conditions. Troponin elevation was deemed type II MI due to seizures and hypertension. The patient’s preserved LVEF and wall motion helped exclude other aetiologies. Multimodality imaging, such as cardiac MRI and cardiac CT angiography are complementary tests that can be

A64 Does Pregnancy Accelerate Bioprosthetic Valve Degeneration? Highlights of a Compelling Case

Amy Ahnert,1 Joanne Quinones2 and Cheri Silverstein Fadlon1 1. Cardiology, Lehigh Valley Health Network, US; 2. Maternal Fetal Medicine, Lehigh Valley Health Network, US

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Abstracts from 8th International Congress on Cardiac Problems in Pregnancy SA was born with double inlet left ventricle, rudimentary right ventricle (RV), ventricular-arterial discordance and pulmonary stenosis. A total cavo-pulmonary connection (TCPC) was established at age 11. She became pregnant at 23 years of age and delivered a preterm infant (1,700 g) at 33 weeks via forceps. The postpartum period was complicated by circulatory collapse attributed to pulmonary embolism and the patient was thrombolysed systemically with low molecular weight heparin (LMWH). This resulted in significant vaginal bleeding from which the patient recovered.

Citation: Journal of Asian Pacific Society of Cardiology 2023;2(Suppl 2):A64.

Background: The literature debates whether pregnancy accelerates bioprosthetic valve deterioration. Described here is a case of relatively rapid valve dysfunction during pregnancy. Case Presentation: In 2012, a 26-year-old woman with no prior cardiac history presented with a febrile illness and was found to have aortic valve endocarditis complicated by severe aortic regurgitation and an aortic root abscess. She underwent aortic valve replacement (AVR) with a 21-mm Carpentier-Edwards Magna-Ease, aortic root debridement, and reconstruction of the left ventricular outflow tract and aortic annulus with a bovine pericardial patch. In 2015 the patient had an uncomplicated pregnancy with NSVD at 40 weeks of gestation and a 22-week foetal loss in 2017. AVR was normally functioning on echo Doppler. During her third pregnancy in 2018, the patient was noted to have relatively rapid AVR dysfunction. One year after delivery, she required redo of AVR, only 7 years after the initial surgery. During her third pregnancy, the patient developed severe bioprosthetic aortic stenosis. The surgeon described a severely stenotic and calcified prosthetic aortic valve with significant pannus and pathology demonstrated myxoid and nodular calcific degeneration.

The patient had a second pregnancy at 26 years of age, which was complicated by intrauterine growth restriction (IUGR) needing emergency caesarean section at 29 weeks to deliver a female infant (634 g). There were no maternal complications and the infant has no long-term morbidities. The patient had medical termination of pregnancy at 28 years of age and was counselled against further pregnancies. She remained stable with no signs of Fontan failure. Her echocardiogram demonstrated unobstructed TCPC connections with dilated single ventricle and preserved systolic function. At 36 years of age, the patient became pregnant and presented at 22 weeks for antenatal care. She was taking aspirin, enoxaparin 40 mg daily, clopidogrel (stopped), furosemide 20 mg daily and lansoprazole. During pregnancy, she became progressively breathless and developed ankle oedema, for which diuretic was increased to 40 mg daily. At 26 weeks she was diagnosed with gestational diabetes requiring insulin. She also developed obstetric cholestasis (bilirubin 20 μmol/l, ALT 210 units/l). At 30+6 weeks she presented with haemoptysis and shortness of breath, but CT pulmonary angiography excluded pulmonary embolism.

Conclusion: The present case highlights the importance of preconception counselling for women with prosthetic valves regarding possible valve degeneration, as well as the importance of frequent clinical and echocardiographic monitoring of valve function during pregnancy. Although a single case cannot prove causality, it highlights the importance of further investigating the incidence of pregnancy-related valve dysfunction.

A65 Pregnancy in a Patient with Fontan Circulation

At 32 weeks, the growth scan showed severe IUGR with abnormal Doppler necessitating urgent delivery. She delivered a male foetus (1st centile). Post-delivery, her echocardiogram showed a visually more dilated SV compared to pre-pregnancy and a persistent reduced/low-normal systolic function. She was maintained on furosemide 60 mg daily, spironolactone 25 mg daily and apixaban 5 mg twice-daily post-delivery.

Gurleen Wander,1 Roshni Patel,1 Isma Rafiq,2 Claudia Montanaro2 and Mark Johnson1

1. Department of Metabolism, Digestion and Reproduction, Imperial College, UK; 2. Cardiology, Royal Brompton Hospital, UK Citation: Journal of Asian Pacific Society of Cardiology 2023;2(Suppl 2):A65.

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