Debra L. Beck

TORONTO -- Girls who identified themselves as white were twice as likely as those who identified themselves as black to complete the three-shot vaccination series against the human papillomavirus, according to a retrospective review of medical records.

Dr. Lea Widdice

"This is concerning because, historically, black women have had lower rates of cervical cancer screening and been more at risk from dying of cervical cancer.

With unequal distribution of the vaccine, the racial disparity in cervical cancer may worsen," said Dr. Lea Widdice, an assistant professor of pediatrics at the Cincinnati Children's Hospital Medical Center. Dr. Widdice presented her results in a poster at the annual meeting of the Society for Adolescent Health and Medicine.

Moreover, overall only 14% of girls initiating the HPV vaccine series actually completed the three-shot series within 7 months of the first dose. Clinical recommendations for the vaccine are to get the third shot 6 months after the first.

Dr. Widdice and her colleagues conducted a retrospective review of medical records on 3,297 girls between ages 9-26 years, and who received the first HPV vaccine dose between June 2006 and June 2008 from an urban, academic, pediatric medical center with multiple primary care and specialty clinics.

Overall, 11% of the black girls received all three doses of the vaccine, compared with 22% of the white girls and 15% of those identified as other races.

Patients were predominately from primary care (95%) and 65% used Medicaid. The majority (67%) self-identified as black, 29% said they were white, and 4% were classified as other races.

Interestingly, even after controlling for factors such as type of insurance and the different types of clinics giving the vaccine (primary care pediatrics, adolescent primary care, adolescent specialty clinics, or other specialty clinics), race was still strongly associated with getting all three doses on schedule.

Dr. Widdice said that to maximize the public health benefits of the vaccine, interventions to improve adherence are needed. "School-based clinics, in addition to doctor's clinics may be an effective way to get the vaccine to more people," she said in an interview.

Dr. Widdice said she had no conflicts of interest.

TORONTO -- Girls who identified themselves as white were twice as likely as those who identified themselves as black to complete the three-shot vaccination series against the human papillomavirus, according to a retrospective review of medical records.

Dr. Lea Widdice

"This is concerning because, historically, black women have had lower rates of cervical cancer screening and been more at risk from dying of cervical cancer.

With unequal distribution of the vaccine, the racial disparity in cervical cancer may worsen," said Dr. Lea Widdice, an assistant professor of pediatrics at the Cincinnati Children's Hospital Medical Center. Dr. Widdice presented her results in a poster at the annual meeting of the Society for Adolescent Health and Medicine.

Moreover, overall only 14% of girls initiating the HPV vaccine series actually completed the three-shot series within 7 months of the first dose. Clinical recommendations for the vaccine are to get the third shot 6 months after the first.

Dr. Widdice and her colleagues conducted a retrospective review of medical records on 3,297 girls between ages 9-26 years, and who received the first HPV vaccine dose between June 2006 and June 2008 from an urban, academic, pediatric medical center with multiple primary care and specialty clinics.

Overall, 11% of the black girls received all three doses of the vaccine, compared with 22% of the white girls and 15% of those identified as other races.

Patients were predominately from primary care (95%) and 65% used Medicaid. The majority (67%) self-identified as black, 29% said they were white, and 4% were classified as other races.

Interestingly, even after controlling for factors such as type of insurance and the different types of clinics giving the vaccine (primary care pediatrics, adolescent primary care, adolescent specialty clinics, or other specialty clinics), race was still strongly associated with getting all three doses on schedule.

Dr. Widdice said that to maximize the public health benefits of the vaccine, interventions to improve adherence are needed. "School-based clinics, in addition to doctor's clinics may be an effective way to get the vaccine to more people," she said in an interview.

Dr. Widdice said she had no conflicts of interest.

TORONTO -- Girls who identified themselves as white were twice as likely as those who identified themselves as black to complete the three-shot vaccination series against the human papillomavirus, according to a retrospective review of medical records.

Dr. Lea Widdice

"This is concerning because, historically, black women have had lower rates of cervical cancer screening and been more at risk from dying of cervical cancer.

With unequal distribution of the vaccine, the racial disparity in cervical cancer may worsen," said Dr. Lea Widdice, an assistant professor of pediatrics at the Cincinnati Children's Hospital Medical Center. Dr. Widdice presented her results in a poster at the annual meeting of the Society for Adolescent Health and Medicine.

Moreover, overall only 14% of girls initiating the HPV vaccine series actually completed the three-shot series within 7 months of the first dose. Clinical recommendations for the vaccine are to get the third shot 6 months after the first.

Dr. Widdice and her colleagues conducted a retrospective review of medical records on 3,297 girls between ages 9-26 years, and who received the first HPV vaccine dose between June 2006 and June 2008 from an urban, academic, pediatric medical center with multiple primary care and specialty clinics.

Overall, 11% of the black girls received all three doses of the vaccine, compared with 22% of the white girls and 15% of those identified as other races.

Patients were predominately from primary care (95%) and 65% used Medicaid. The majority (67%) self-identified as black, 29% said they were white, and 4% were classified as other races.

Interestingly, even after controlling for factors such as type of insurance and the different types of clinics giving the vaccine (primary care pediatrics, adolescent primary care, adolescent specialty clinics, or other specialty clinics), race was still strongly associated with getting all three doses on schedule.

Dr. Widdice said that to maximize the public health benefits of the vaccine, interventions to improve adherence are needed. "School-based clinics, in addition to doctor's clinics may be an effective way to get the vaccine to more people," she said in an interview.

Dr. Widdice said she had no conflicts of interest.

TORONTO -- Genital warts and human papillomavirus-related cancers in men are costly and emotionally burdensome conditions that should be prevented with HPV vaccination, according to Susan Rosenthal, Ph.D.

"Vaccinating males also represents a more equitable public health policy in that it recognizes that both genders contribute to the transmission of HPV," Dr. Rosenthal said at the annual meeting of the Society for Adolescent Health and Medicine (SAHM).

The Food and Drug Administration approved the quadrivalent HPV vaccine (Gardasil) for boys aged 9-26 years in October 2009. Since then, the Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices has given a permissive recommendation for vaccination for boys at the discretion of the physician, a recommendation that is supported by a SAHM position paper, said Dr. Rosenthal, whose research has focused on adolescent sexual health and vaccine acceptability.

Although 13 HPV types cause cervical cancer--a well-known bit of information--Dr. Rosenthal pointed out that in a 2006 study, HPV-16 was determined to cause several other cancers, including vulvar, vaginal, anal, penile, and oropharyngeal cancers. There is some evidence also linking HPV-16 to laryngeal and nonmelanoma skin cancer, said Dr. Rosenthal, a pediatric psychologist at Columbia University Medical Center and Morgan Stanley Children's Hospital of New York-Presbyterian.

"So we know that HPV causes cancer in men," said Dr. Rosenthal. Indeed, based on 2008 estimates of the annual number of new cases of HPV-related cancers in U.S. men, of the 38,260 cases involving the oral cavity and oropharynx, larynx, anus, and penis, 10,969 (28.6%) were attributed to HPV infection, according to data from the American Cancer Society and other sources.

In a recent study (New England Journal of Medicine, in press, 2010), the HPV vaccine was found to be 90% effective in preventing external genital lesions, a category that included external genital warts, penile/perianal/perineal intraepithelial neoplasia, and penile/perianal/perineal cancers. Of the 1,397 men and women who received the vaccine, there were only three cases of external genital lesions, all three of which were condyloma.

"It's not fun to have these diseases or the work-up for these diseases. If we use a female-only strategy, we will not protect men who have sex with men, and we don't know at [age] 11 who are the men who have sex with men. And this is a prophylactic vaccine," said Dr. Rosenthal.

In the discussion following Dr. Rosenthal's presentation, some controversy erupted over whether all boys should receive the HPV vaccine or only boys who are likely to have sex with other males should be vaccinated.

"Historically, at least in this country, we're terrible at gender-based vaccination, we don't have high uptake when we try to do risk-based strategies. Vaccinating men will also be the fastest way to achieve protection for women, and vaccinating males is an arguably more equitable public health policy because it recognizes that both genders contribute to the transmission of HPV," argued Dr. Rosenthal.

Audience member Dr. Gary Remafedi of the University of Minnesota Amplatz Children's Hospital, Minneapolis, countered: "There is observational data indicating the benefits of immunizing young men who have sex with men, but we're still awaiting comparable data for the general male population. As we await that data, I believe it would be a disservice not to immunize young men who have sex with men as soon as they are identified as at least being likely to have sex with men. It is absolutely the job of the physician to identify these people."

"I can't predict sexual behavior in the young male.... I think a lot of 11-, and 12-, and 13-year-olds, which is the age at which I think we should immunize, are not clear in their own minds whether they want to have sex with other men," responded Dr. Rosenthal.

Some of the reasons for not vaccinating males, she said, include the questionable cost effectiveness, particularly if high rates of female vaccinations are achieved, and the issues of overall costs.

In separate interviews, Dr. Carol A. Ford and Dr. Marianne E. Felice both felt comfortable with the recommendation to vaccinate both boys and girls against HPV.

"When you look at cost-effectiveness analyses, it is important to figure out whether you are including negative outcomes for men and women, or just for men. STDs affect both partners, so it's an interesting discussion whether you look at the burden of the sexually transmitted disease for both men and women or if you try to isolate it to one partner or the other," said Dr. Ford, director of the adolescent medicine program at the University of North Carolina at Chapel Hill and director of the N.C. Multisite Adolescent Research Consortium for Health.

"There are men that we are vaccinating at our clinics in North Carolina so we are taking seriously the recommendation that this is a vaccination that is appropriate for both men and women. My sense is that we're protecting both men and women in doing this," she said.

Dr. Marianne E. Felice, professor and chair of the department of pediatrics at the University of Massachusetts, Worcester, said in an interview, "Frankly, I think we should just vaccinate all boys. At the division of adolescent medicine at UMass, we are giving the vaccine to boys and most of the parents want their kids to have it. I think if you vaccinate the boys along with the girls, even if they aren't having sex with other boys, this is a way to protect them as well as the girls. They're not going to get warts from someone and then give it to a girl. It's herd immunity."

Disclosures: Dr. Rosenthal disclosed grants from Merck & Co. Dr. Ford, Dr. Felice, and Dr. Remafedi reported no disclosures.

TORONTO -- Genital warts and human papillomavirus-related cancers in men are costly and emotionally burdensome conditions that should be prevented with HPV vaccination, according to Susan Rosenthal, Ph.D.

"Vaccinating males also represents a more equitable public health policy in that it recognizes that both genders contribute to the transmission of HPV," Dr. Rosenthal said at the annual meeting of the Society for Adolescent Health and Medicine (SAHM).

The Food and Drug Administration approved the quadrivalent HPV vaccine (Gardasil) for boys aged 9-26 years in October 2009. Since then, the Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices has given a permissive recommendation for vaccination for boys at the discretion of the physician, a recommendation that is supported by a SAHM position paper, said Dr. Rosenthal, whose research has focused on adolescent sexual health and vaccine acceptability.

Although 13 HPV types cause cervical cancer--a well-known bit of information--Dr. Rosenthal pointed out that in a 2006 study, HPV-16 was determined to cause several other cancers, including vulvar, vaginal, anal, penile, and oropharyngeal cancers. There is some evidence also linking HPV-16 to laryngeal and nonmelanoma skin cancer, said Dr. Rosenthal, a pediatric psychologist at Columbia University Medical Center and Morgan Stanley Children's Hospital of New York-Presbyterian.

"So we know that HPV causes cancer in men," said Dr. Rosenthal. Indeed, based on 2008 estimates of the annual number of new cases of HPV-related cancers in U.S. men, of the 38,260 cases involving the oral cavity and oropharynx, larynx, anus, and penis, 10,969 (28.6%) were attributed to HPV infection, according to data from the American Cancer Society and other sources.

In a recent study (New England Journal of Medicine, in press, 2010), the HPV vaccine was found to be 90% effective in preventing external genital lesions, a category that included external genital warts, penile/perianal/perineal intraepithelial neoplasia, and penile/perianal/perineal cancers. Of the 1,397 men and women who received the vaccine, there were only three cases of external genital lesions, all three of which were condyloma.

"It's not fun to have these diseases or the work-up for these diseases. If we use a female-only strategy, we will not protect men who have sex with men, and we don't know at [age] 11 who are the men who have sex with men. And this is a prophylactic vaccine," said Dr. Rosenthal.

In the discussion following Dr. Rosenthal's presentation, some controversy erupted over whether all boys should receive the HPV vaccine or only boys who are likely to have sex with other males should be vaccinated.

"Historically, at least in this country, we're terrible at gender-based vaccination, we don't have high uptake when we try to do risk-based strategies. Vaccinating men will also be the fastest way to achieve protection for women, and vaccinating males is an arguably more equitable public health policy because it recognizes that both genders contribute to the transmission of HPV," argued Dr. Rosenthal.

Audience member Dr. Gary Remafedi of the University of Minnesota Amplatz Children's Hospital, Minneapolis, countered: "There is observational data indicating the benefits of immunizing young men who have sex with men, but we're still awaiting comparable data for the general male population. As we await that data, I believe it would be a disservice not to immunize young men who have sex with men as soon as they are identified as at least being likely to have sex with men. It is absolutely the job of the physician to identify these people."

"I can't predict sexual behavior in the young male.... I think a lot of 11-, and 12-, and 13-year-olds, which is the age at which I think we should immunize, are not clear in their own minds whether they want to have sex with other men," responded Dr. Rosenthal.

Some of the reasons for not vaccinating males, she said, include the questionable cost effectiveness, particularly if high rates of female vaccinations are achieved, and the issues of overall costs.

In separate interviews, Dr. Carol A. Ford and Dr. Marianne E. Felice both felt comfortable with the recommendation to vaccinate both boys and girls against HPV.

"When you look at cost-effectiveness analyses, it is important to figure out whether you are including negative outcomes for men and women, or just for men. STDs affect both partners, so it's an interesting discussion whether you look at the burden of the sexually transmitted disease for both men and women or if you try to isolate it to one partner or the other," said Dr. Ford, director of the adolescent medicine program at the University of North Carolina at Chapel Hill and director of the N.C. Multisite Adolescent Research Consortium for Health.

"There are men that we are vaccinating at our clinics in North Carolina so we are taking seriously the recommendation that this is a vaccination that is appropriate for both men and women. My sense is that we're protecting both men and women in doing this," she said.

Dr. Marianne E. Felice, professor and chair of the department of pediatrics at the University of Massachusetts, Worcester, said in an interview, "Frankly, I think we should just vaccinate all boys. At the division of adolescent medicine at UMass, we are giving the vaccine to boys and most of the parents want their kids to have it. I think if you vaccinate the boys along with the girls, even if they aren't having sex with other boys, this is a way to protect them as well as the girls. They're not going to get warts from someone and then give it to a girl. It's herd immunity."

Disclosures: Dr. Rosenthal disclosed grants from Merck & Co. Dr. Ford, Dr. Felice, and Dr. Remafedi reported no disclosures.

TORONTO -- Genital warts and human papillomavirus-related cancers in men are costly and emotionally burdensome conditions that should be prevented with HPV vaccination, according to Susan Rosenthal, Ph.D.

"Vaccinating males also represents a more equitable public health policy in that it recognizes that both genders contribute to the transmission of HPV," Dr. Rosenthal said at the annual meeting of the Society for Adolescent Health and Medicine (SAHM).

The Food and Drug Administration approved the quadrivalent HPV vaccine (Gardasil) for boys aged 9-26 years in October 2009. Since then, the Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices has given a permissive recommendation for vaccination for boys at the discretion of the physician, a recommendation that is supported by a SAHM position paper, said Dr. Rosenthal, whose research has focused on adolescent sexual health and vaccine acceptability.

Although 13 HPV types cause cervical cancer--a well-known bit of information--Dr. Rosenthal pointed out that in a 2006 study, HPV-16 was determined to cause several other cancers, including vulvar, vaginal, anal, penile, and oropharyngeal cancers. There is some evidence also linking HPV-16 to laryngeal and nonmelanoma skin cancer, said Dr. Rosenthal, a pediatric psychologist at Columbia University Medical Center and Morgan Stanley Children's Hospital of New York-Presbyterian.

"So we know that HPV causes cancer in men," said Dr. Rosenthal. Indeed, based on 2008 estimates of the annual number of new cases of HPV-related cancers in U.S. men, of the 38,260 cases involving the oral cavity and oropharynx, larynx, anus, and penis, 10,969 (28.6%) were attributed to HPV infection, according to data from the American Cancer Society and other sources.

In a recent study (New England Journal of Medicine, in press, 2010), the HPV vaccine was found to be 90% effective in preventing external genital lesions, a category that included external genital warts, penile/perianal/perineal intraepithelial neoplasia, and penile/perianal/perineal cancers. Of the 1,397 men and women who received the vaccine, there were only three cases of external genital lesions, all three of which were condyloma.

"It's not fun to have these diseases or the work-up for these diseases. If we use a female-only strategy, we will not protect men who have sex with men, and we don't know at [age] 11 who are the men who have sex with men. And this is a prophylactic vaccine," said Dr. Rosenthal.

In the discussion following Dr. Rosenthal's presentation, some controversy erupted over whether all boys should receive the HPV vaccine or only boys who are likely to have sex with other males should be vaccinated.

"Historically, at least in this country, we're terrible at gender-based vaccination, we don't have high uptake when we try to do risk-based strategies. Vaccinating men will also be the fastest way to achieve protection for women, and vaccinating males is an arguably more equitable public health policy because it recognizes that both genders contribute to the transmission of HPV," argued Dr. Rosenthal.

Audience member Dr. Gary Remafedi of the University of Minnesota Amplatz Children's Hospital, Minneapolis, countered: "There is observational data indicating the benefits of immunizing young men who have sex with men, but we're still awaiting comparable data for the general male population. As we await that data, I believe it would be a disservice not to immunize young men who have sex with men as soon as they are identified as at least being likely to have sex with men. It is absolutely the job of the physician to identify these people."

"I can't predict sexual behavior in the young male.... I think a lot of 11-, and 12-, and 13-year-olds, which is the age at which I think we should immunize, are not clear in their own minds whether they want to have sex with other men," responded Dr. Rosenthal.

Some of the reasons for not vaccinating males, she said, include the questionable cost effectiveness, particularly if high rates of female vaccinations are achieved, and the issues of overall costs.

In separate interviews, Dr. Carol A. Ford and Dr. Marianne E. Felice both felt comfortable with the recommendation to vaccinate both boys and girls against HPV.

"When you look at cost-effectiveness analyses, it is important to figure out whether you are including negative outcomes for men and women, or just for men. STDs affect both partners, so it's an interesting discussion whether you look at the burden of the sexually transmitted disease for both men and women or if you try to isolate it to one partner or the other," said Dr. Ford, director of the adolescent medicine program at the University of North Carolina at Chapel Hill and director of the N.C. Multisite Adolescent Research Consortium for Health.

"There are men that we are vaccinating at our clinics in North Carolina so we are taking seriously the recommendation that this is a vaccination that is appropriate for both men and women. My sense is that we're protecting both men and women in doing this," she said.

Dr. Marianne E. Felice, professor and chair of the department of pediatrics at the University of Massachusetts, Worcester, said in an interview, "Frankly, I think we should just vaccinate all boys. At the division of adolescent medicine at UMass, we are giving the vaccine to boys and most of the parents want their kids to have it. I think if you vaccinate the boys along with the girls, even if they aren't having sex with other boys, this is a way to protect them as well as the girls. They're not going to get warts from someone and then give it to a girl. It's herd immunity."

Disclosures: Dr. Rosenthal disclosed grants from Merck & Co. Dr. Ford, Dr. Felice, and Dr. Remafedi reported no disclosures.

TORONTO — Genital warts and human papillomavirus-related cancers in men are costly and emotionally burdensome conditions that should be prevented with HPV vaccination, according to Susan Rosenthal, Ph.D.

“Vaccinating males also represents a more equitable public health policy in that it recognizes that both genders contribute to the transmission of HPV,” Dr. Rosenthal said at the annual meeting of the Society for Adolescent Health and Medicine (SAHM).

The Food and Drug Administration approved the quadrivalent HPV vaccine (Gardasil) for boys aged 9–26 years in October 2009. Since then, the Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices has given a permissive recommendation for vaccination for boys at the discretion of the physician, a recommendation that is supported by a SAHM position paper, said Dr. Rosenthal, whose research has focused on adolescent sexual health and vaccine acceptability.

Although 13 HPV types cause cervical cancer—a well-known bit of information—Dr. Rosenthal pointed out that in a 2006 study, HPV-16 was determined to cause several other cancers, including vulvar, vaginal, anal, penile, and oropharyngeal cancers. There is some evidence also linking HPV-16 to laryngeal and nonmelanoma skin cancer, said Dr. Rosenthal, a pediatric psychologist at Columbia University Medical Center and Morgan Stanley Children's Hospital of New York-Presbyterian.

“So we know that HPV causes cancer in men,” said Dr. Rosenthal. Indeed, based on 2008 estimates of the annual number of new cases of HPV-related cancers in U.S. men, of the 38,260 cases involving the oral cavity and oropharynx, larynx, anus, and penis, 10,969 (28.6%) were attributed to HPV infection, according to data from the American Cancer Society and other sources.

In a recent study (New England Journal of Medicine, in press, 2010), the HPV vaccine was found to be 90% effective in preventing external genital lesions, a category that included external genital warts, penile/perianal/perineal intraepithelial neoplasia, and penile/perianal/perineal cancers. Of the 1,397 men and women who received the vaccine, there were only three cases of external genital lesions, all three of which were condyloma.

“It's not fun to have these diseases or the work-up for these diseases. If we use a female-only strategy, we will not protect men who have sex with men, and we don't know at [age] 11 who are the men who have sex with men. And this is a prophylactic vaccine,” said Dr. Rosenthal.

In the discussion following Dr. Rosenthal's presentation, some controversy erupted over whether all boys should receive the HPV vaccine or only boys who are likely to have sex with other males should be vaccinated.

“Historically, at least in this country, we're terrible at gender-based vaccination, we don't have high uptake when we try to do risk-based strategies. Vaccinating men will also be the fastest way to achieve protection for women, and vaccinating males is an arguably more equitable public health policy because it recognizes that both genders contribute to the transmission of HPV,” argued Dr. Rosenthal.

Audience member Dr. Gary Remafedi of the University of Minnesota Amplatz Children's Hospital, Minneapolis, countered: “There is observational data indicating the benefits of immunizing young men who have sex with men, but we're still awaiting comparable data for the general male population. As we await that data, I believe it would be a disservice not to immunize young men who have sex with men as soon as they are identified as at least being likely to have sex with men. It is absolutely the job of the physician to identify these people.”

“I can't predict sexual behavior in the young male. … I think a lot of 11-, and 12-, and 13-year-olds, which is the age at which I think we should immunize, are not clear in their own minds whether they want to have sex with other men,” responded Dr. Rosenthal.

Some of the reasons for not vaccinating males, she said, include the questionable cost effectiveness, particularly if high rates of female vaccinations are achieved, and the issues of overall costs.

In separate interviews, Dr. Carol A. Ford and Dr. Marianne E. Felice both felt comfortable with the recommendation to vaccinate both boys and girls against HPV.

“When you look at cost-effectiveness analyses, it is important to figure out whether you are including negative outcomes for men and women, or just for men. STDs affect both partners, so it's an interesting discussion whether you look at the burden of the sexually transmitted disease for both men and women or if you try to isolate it to one partner or the other,” said Dr. Ford, director of the adolescent medicine program at the University of North Carolina at Chapel Hill and director of the N.C. Multisite Adolescent Research Consortium for Health.

“There are men that we are vaccinating at our clinics in North Carolina so we are taking seriously the recommendation that this is a vaccination that is appropriate for both men and women. My sense is that we're protecting both men and women in doing this,” she said.

Dr. Marianne E. Felice, professor and chair of the department of pediatrics at the University of Massachusetts, Worcester, said in an interview, “Frankly, I think we should just vaccinate all boys. At the division of adolescent medicine at UMass, we are giving the vaccine to boys and most of the parents want their kids to have it. I think if you vaccinate the boys along with the girls, even if they aren't having sex with other boys, this is a way to protect them as well as the girls. They're not going to get warts from someone and then give it to a girl. It's herd immunity.”

Disclosures: Dr. Rosenthal disclosed grants from Merck & Co. Dr. Ford, Dr. Felice, and Dr. Remafedi reported no disclosures.

TORONTO — Genital warts and human papillomavirus-related cancers in men are costly and emotionally burdensome conditions that should be prevented with HPV vaccination, according to Susan Rosenthal, Ph.D.

“Vaccinating males also represents a more equitable public health policy in that it recognizes that both genders contribute to the transmission of HPV,” Dr. Rosenthal said at the annual meeting of the Society for Adolescent Health and Medicine (SAHM).

The Food and Drug Administration approved the quadrivalent HPV vaccine (Gardasil) for boys aged 9–26 years in October 2009. Since then, the Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices has given a permissive recommendation for vaccination for boys at the discretion of the physician, a recommendation that is supported by a SAHM position paper, said Dr. Rosenthal, whose research has focused on adolescent sexual health and vaccine acceptability.

Although 13 HPV types cause cervical cancer—a well-known bit of information—Dr. Rosenthal pointed out that in a 2006 study, HPV-16 was determined to cause several other cancers, including vulvar, vaginal, anal, penile, and oropharyngeal cancers. There is some evidence also linking HPV-16 to laryngeal and nonmelanoma skin cancer, said Dr. Rosenthal, a pediatric psychologist at Columbia University Medical Center and Morgan Stanley Children's Hospital of New York-Presbyterian.

“So we know that HPV causes cancer in men,” said Dr. Rosenthal. Indeed, based on 2008 estimates of the annual number of new cases of HPV-related cancers in U.S. men, of the 38,260 cases involving the oral cavity and oropharynx, larynx, anus, and penis, 10,969 (28.6%) were attributed to HPV infection, according to data from the American Cancer Society and other sources.

In a recent study (New England Journal of Medicine, in press, 2010), the HPV vaccine was found to be 90% effective in preventing external genital lesions, a category that included external genital warts, penile/perianal/perineal intraepithelial neoplasia, and penile/perianal/perineal cancers. Of the 1,397 men and women who received the vaccine, there were only three cases of external genital lesions, all three of which were condyloma.

“It's not fun to have these diseases or the work-up for these diseases. If we use a female-only strategy, we will not protect men who have sex with men, and we don't know at [age] 11 who are the men who have sex with men. And this is a prophylactic vaccine,” said Dr. Rosenthal.

In the discussion following Dr. Rosenthal's presentation, some controversy erupted over whether all boys should receive the HPV vaccine or only boys who are likely to have sex with other males should be vaccinated.

“Historically, at least in this country, we're terrible at gender-based vaccination, we don't have high uptake when we try to do risk-based strategies. Vaccinating men will also be the fastest way to achieve protection for women, and vaccinating males is an arguably more equitable public health policy because it recognizes that both genders contribute to the transmission of HPV,” argued Dr. Rosenthal.

Audience member Dr. Gary Remafedi of the University of Minnesota Amplatz Children's Hospital, Minneapolis, countered: “There is observational data indicating the benefits of immunizing young men who have sex with men, but we're still awaiting comparable data for the general male population. As we await that data, I believe it would be a disservice not to immunize young men who have sex with men as soon as they are identified as at least being likely to have sex with men. It is absolutely the job of the physician to identify these people.”

“I can't predict sexual behavior in the young male. … I think a lot of 11-, and 12-, and 13-year-olds, which is the age at which I think we should immunize, are not clear in their own minds whether they want to have sex with other men,” responded Dr. Rosenthal.

Some of the reasons for not vaccinating males, she said, include the questionable cost effectiveness, particularly if high rates of female vaccinations are achieved, and the issues of overall costs.

In separate interviews, Dr. Carol A. Ford and Dr. Marianne E. Felice both felt comfortable with the recommendation to vaccinate both boys and girls against HPV.

“When you look at cost-effectiveness analyses, it is important to figure out whether you are including negative outcomes for men and women, or just for men. STDs affect both partners, so it's an interesting discussion whether you look at the burden of the sexually transmitted disease for both men and women or if you try to isolate it to one partner or the other,” said Dr. Ford, director of the adolescent medicine program at the University of North Carolina at Chapel Hill and director of the N.C. Multisite Adolescent Research Consortium for Health.

“There are men that we are vaccinating at our clinics in North Carolina so we are taking seriously the recommendation that this is a vaccination that is appropriate for both men and women. My sense is that we're protecting both men and women in doing this,” she said.

Dr. Marianne E. Felice, professor and chair of the department of pediatrics at the University of Massachusetts, Worcester, said in an interview, “Frankly, I think we should just vaccinate all boys. At the division of adolescent medicine at UMass, we are giving the vaccine to boys and most of the parents want their kids to have it. I think if you vaccinate the boys along with the girls, even if they aren't having sex with other boys, this is a way to protect them as well as the girls. They're not going to get warts from someone and then give it to a girl. It's herd immunity.”

Disclosures: Dr. Rosenthal disclosed grants from Merck & Co. Dr. Ford, Dr. Felice, and Dr. Remafedi reported no disclosures.

TORONTO — Genital warts and human papillomavirus-related cancers in men are costly and emotionally burdensome conditions that should be prevented with HPV vaccination, according to Susan Rosenthal, Ph.D.

“Vaccinating males also represents a more equitable public health policy in that it recognizes that both genders contribute to the transmission of HPV,” Dr. Rosenthal said at the annual meeting of the Society for Adolescent Health and Medicine (SAHM).

The Food and Drug Administration approved the quadrivalent HPV vaccine (Gardasil) for boys aged 9–26 years in October 2009. Since then, the Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices has given a permissive recommendation for vaccination for boys at the discretion of the physician, a recommendation that is supported by a SAHM position paper, said Dr. Rosenthal, whose research has focused on adolescent sexual health and vaccine acceptability.

Although 13 HPV types cause cervical cancer—a well-known bit of information—Dr. Rosenthal pointed out that in a 2006 study, HPV-16 was determined to cause several other cancers, including vulvar, vaginal, anal, penile, and oropharyngeal cancers. There is some evidence also linking HPV-16 to laryngeal and nonmelanoma skin cancer, said Dr. Rosenthal, a pediatric psychologist at Columbia University Medical Center and Morgan Stanley Children's Hospital of New York-Presbyterian.

“So we know that HPV causes cancer in men,” said Dr. Rosenthal. Indeed, based on 2008 estimates of the annual number of new cases of HPV-related cancers in U.S. men, of the 38,260 cases involving the oral cavity and oropharynx, larynx, anus, and penis, 10,969 (28.6%) were attributed to HPV infection, according to data from the American Cancer Society and other sources.

In a recent study (New England Journal of Medicine, in press, 2010), the HPV vaccine was found to be 90% effective in preventing external genital lesions, a category that included external genital warts, penile/perianal/perineal intraepithelial neoplasia, and penile/perianal/perineal cancers. Of the 1,397 men and women who received the vaccine, there were only three cases of external genital lesions, all three of which were condyloma.

“It's not fun to have these diseases or the work-up for these diseases. If we use a female-only strategy, we will not protect men who have sex with men, and we don't know at [age] 11 who are the men who have sex with men. And this is a prophylactic vaccine,” said Dr. Rosenthal.

In the discussion following Dr. Rosenthal's presentation, some controversy erupted over whether all boys should receive the HPV vaccine or only boys who are likely to have sex with other males should be vaccinated.

“Historically, at least in this country, we're terrible at gender-based vaccination, we don't have high uptake when we try to do risk-based strategies. Vaccinating men will also be the fastest way to achieve protection for women, and vaccinating males is an arguably more equitable public health policy because it recognizes that both genders contribute to the transmission of HPV,” argued Dr. Rosenthal.

Audience member Dr. Gary Remafedi of the University of Minnesota Amplatz Children's Hospital, Minneapolis, countered: “There is observational data indicating the benefits of immunizing young men who have sex with men, but we're still awaiting comparable data for the general male population. As we await that data, I believe it would be a disservice not to immunize young men who have sex with men as soon as they are identified as at least being likely to have sex with men. It is absolutely the job of the physician to identify these people.”

“I can't predict sexual behavior in the young male. … I think a lot of 11-, and 12-, and 13-year-olds, which is the age at which I think we should immunize, are not clear in their own minds whether they want to have sex with other men,” responded Dr. Rosenthal.

Some of the reasons for not vaccinating males, she said, include the questionable cost effectiveness, particularly if high rates of female vaccinations are achieved, and the issues of overall costs.

In separate interviews, Dr. Carol A. Ford and Dr. Marianne E. Felice both felt comfortable with the recommendation to vaccinate both boys and girls against HPV.

“When you look at cost-effectiveness analyses, it is important to figure out whether you are including negative outcomes for men and women, or just for men. STDs affect both partners, so it's an interesting discussion whether you look at the burden of the sexually transmitted disease for both men and women or if you try to isolate it to one partner or the other,” said Dr. Ford, director of the adolescent medicine program at the University of North Carolina at Chapel Hill and director of the N.C. Multisite Adolescent Research Consortium for Health.

“There are men that we are vaccinating at our clinics in North Carolina so we are taking seriously the recommendation that this is a vaccination that is appropriate for both men and women. My sense is that we're protecting both men and women in doing this,” she said.

Dr. Marianne E. Felice, professor and chair of the department of pediatrics at the University of Massachusetts, Worcester, said in an interview, “Frankly, I think we should just vaccinate all boys. At the division of adolescent medicine at UMass, we are giving the vaccine to boys and most of the parents want their kids to have it. I think if you vaccinate the boys along with the girls, even if they aren't having sex with other boys, this is a way to protect them as well as the girls. They're not going to get warts from someone and then give it to a girl. It's herd immunity.”

Disclosures: Dr. Rosenthal disclosed grants from Merck & Co. Dr. Ford, Dr. Felice, and Dr. Remafedi reported no disclosures.

TORONTO — In patients with mild heart failure, cardiac resynchronization therapy improved composite clinical response scores at 18 months, was associated with left ventricular reverse remodeling, reduced the risk of heart failure hospitalization, and lowered the combined risk of morbidity and mortality, compared with optimal medical therapy.

The 18-month data from the European cohort of the Resynchronization Reverses Remodeling in Systolic Left Ventricular Dysfunction (REVERSE) trial supported secondary conclusions from the previously reported 12-month analysis, which, although it indicated that the trial missed its primary clinical composite end point, showed evidence of remodeling and clinical benefit with CRT in mild heart failure (HF).

“Ongoing CRT trials in New York Heart Association class I and II patients may confirm these observations and expand the indication for CRT to this population of heart failure patients,” said Dr. William T. Abraham, who presented the data at the annual meeting of the Heart Failure Society of America.

The REVERSE trial was a multinational prospective effort involving 610 patients with mild or asymptomatic HF and ventricular dyssynchrony. All patients received a CRT device in addition to optimal medical therapy; 191 were randomized to have the device turned on and 419 were randomized to have it turned off.

Eligible patients had left ventricular ejection fractions below 40%, had QRS durations of at least 120 milliseconds, and were already on optimal medical therapy.

The study's main results were published online in the Journal of the American College of Cardiology in September (doi:10.1016/j.jacc.2008.08.027

At this meeting, Dr. Abraham presented the 18-month results from 262 patients in the European cohort, for whom follow-up is continuing to 24 months. These patients, he noted, differed significantly from the North American cohort in their baseline characteristics: They were younger, less likely to have ischemic cardiomyopathy, and less likely to have an implantable cardioverter defibrillator. The European patients had similar ejection fractions to the North American cohort, but had a bit more left ventricular enlargement and slightly longer QRS durations.

In this study population the primary end point significantly favored CRT therapy at 18 months, reported Dr. Abraham, director of the division of cardiovascular medicine at the Ohio State University, Columbus. The proportion of patients who had worsened at 18 months was 29% in the control group vs. 15% in the CRT group, a highly significant difference.

LVESVI improvements seen at 12 months were sustained at 18 months. Also, left ventricular end-diastolic volume index and ejection fraction were both improved in CRT patients, compared with controls.

Furthermore, all-cause mortality did not differ between treatments, while a “remarkable” 58% reduction was seen in the risk of HF hospitalization in the CRT group at 18 months. The absolute rates of hospitalization at 18 months were 13.5% in the control arm and 5.5% in the CRT arm. The combined risk of first HF hospitalization and death was reduced 50% with CRT. Rates of non-HF hospitalization were identical in the CRT on and off groups.

These results “show that there is a favorable impact on remodeling that continues beyond 12 months and that there is a favorable impact on heart failure outcomes … and no signal of an adverse effect on mortality,” commented Dr. William G. Stevenson of Brigham and Women's Hospital in Boston.

REVERSE was sponsored by Medtronic Inc. Dr. Abraham reports research grants, speaker honoraria, and consulting fees from Medtronic, St. Jude Medical Inc., and Biotronik GmbH.

TORONTO — In patients with mild heart failure, cardiac resynchronization therapy improved composite clinical response scores at 18 months, was associated with left ventricular reverse remodeling, reduced the risk of heart failure hospitalization, and lowered the combined risk of morbidity and mortality, compared with optimal medical therapy.

The 18-month data from the European cohort of the Resynchronization Reverses Remodeling in Systolic Left Ventricular Dysfunction (REVERSE) trial supported secondary conclusions from the previously reported 12-month analysis, which, although it indicated that the trial missed its primary clinical composite end point, showed evidence of remodeling and clinical benefit with CRT in mild heart failure (HF).

“Ongoing CRT trials in New York Heart Association class I and II patients may confirm these observations and expand the indication for CRT to this population of heart failure patients,” said Dr. William T. Abraham, who presented the data at the annual meeting of the Heart Failure Society of America.

The REVERSE trial was a multinational prospective effort involving 610 patients with mild or asymptomatic HF and ventricular dyssynchrony. All patients received a CRT device in addition to optimal medical therapy; 191 were randomized to have the device turned on and 419 were randomized to have it turned off.

Eligible patients had left ventricular ejection fractions below 40%, had QRS durations of at least 120 milliseconds, and were already on optimal medical therapy.

The study's main results were published online in the Journal of the American College of Cardiology in September (doi:10.1016/j.jacc.2008.08.027

At this meeting, Dr. Abraham presented the 18-month results from 262 patients in the European cohort, for whom follow-up is continuing to 24 months. These patients, he noted, differed significantly from the North American cohort in their baseline characteristics: They were younger, less likely to have ischemic cardiomyopathy, and less likely to have an implantable cardioverter defibrillator. The European patients had similar ejection fractions to the North American cohort, but had a bit more left ventricular enlargement and slightly longer QRS durations.

In this study population the primary end point significantly favored CRT therapy at 18 months, reported Dr. Abraham, director of the division of cardiovascular medicine at the Ohio State University, Columbus. The proportion of patients who had worsened at 18 months was 29% in the control group vs. 15% in the CRT group, a highly significant difference.

LVESVI improvements seen at 12 months were sustained at 18 months. Also, left ventricular end-diastolic volume index and ejection fraction were both improved in CRT patients, compared with controls.

Furthermore, all-cause mortality did not differ between treatments, while a “remarkable” 58% reduction was seen in the risk of HF hospitalization in the CRT group at 18 months. The absolute rates of hospitalization at 18 months were 13.5% in the control arm and 5.5% in the CRT arm. The combined risk of first HF hospitalization and death was reduced 50% with CRT. Rates of non-HF hospitalization were identical in the CRT on and off groups.

These results “show that there is a favorable impact on remodeling that continues beyond 12 months and that there is a favorable impact on heart failure outcomes … and no signal of an adverse effect on mortality,” commented Dr. William G. Stevenson of Brigham and Women's Hospital in Boston.

REVERSE was sponsored by Medtronic Inc. Dr. Abraham reports research grants, speaker honoraria, and consulting fees from Medtronic, St. Jude Medical Inc., and Biotronik GmbH.

TORONTO — In patients with mild heart failure, cardiac resynchronization therapy improved composite clinical response scores at 18 months, was associated with left ventricular reverse remodeling, reduced the risk of heart failure hospitalization, and lowered the combined risk of morbidity and mortality, compared with optimal medical therapy.

The 18-month data from the European cohort of the Resynchronization Reverses Remodeling in Systolic Left Ventricular Dysfunction (REVERSE) trial supported secondary conclusions from the previously reported 12-month analysis, which, although it indicated that the trial missed its primary clinical composite end point, showed evidence of remodeling and clinical benefit with CRT in mild heart failure (HF).

“Ongoing CRT trials in New York Heart Association class I and II patients may confirm these observations and expand the indication for CRT to this population of heart failure patients,” said Dr. William T. Abraham, who presented the data at the annual meeting of the Heart Failure Society of America.

The REVERSE trial was a multinational prospective effort involving 610 patients with mild or asymptomatic HF and ventricular dyssynchrony. All patients received a CRT device in addition to optimal medical therapy; 191 were randomized to have the device turned on and 419 were randomized to have it turned off.

Eligible patients had left ventricular ejection fractions below 40%, had QRS durations of at least 120 milliseconds, and were already on optimal medical therapy.

The study's main results were published online in the Journal of the American College of Cardiology in September (doi:10.1016/j.jacc.2008.08.027

At this meeting, Dr. Abraham presented the 18-month results from 262 patients in the European cohort, for whom follow-up is continuing to 24 months. These patients, he noted, differed significantly from the North American cohort in their baseline characteristics: They were younger, less likely to have ischemic cardiomyopathy, and less likely to have an implantable cardioverter defibrillator. The European patients had similar ejection fractions to the North American cohort, but had a bit more left ventricular enlargement and slightly longer QRS durations.

In this study population the primary end point significantly favored CRT therapy at 18 months, reported Dr. Abraham, director of the division of cardiovascular medicine at the Ohio State University, Columbus. The proportion of patients who had worsened at 18 months was 29% in the control group vs. 15% in the CRT group, a highly significant difference.

LVESVI improvements seen at 12 months were sustained at 18 months. Also, left ventricular end-diastolic volume index and ejection fraction were both improved in CRT patients, compared with controls.

Furthermore, all-cause mortality did not differ between treatments, while a “remarkable” 58% reduction was seen in the risk of HF hospitalization in the CRT group at 18 months. The absolute rates of hospitalization at 18 months were 13.5% in the control arm and 5.5% in the CRT arm. The combined risk of first HF hospitalization and death was reduced 50% with CRT. Rates of non-HF hospitalization were identical in the CRT on and off groups.

These results “show that there is a favorable impact on remodeling that continues beyond 12 months and that there is a favorable impact on heart failure outcomes … and no signal of an adverse effect on mortality,” commented Dr. William G. Stevenson of Brigham and Women's Hospital in Boston.

REVERSE was sponsored by Medtronic Inc. Dr. Abraham reports research grants, speaker honoraria, and consulting fees from Medtronic, St. Jude Medical Inc., and Biotronik GmbH.

TORONTO — There is much to be done to assist women with congenital heart disease in having healthy pregnancies and healthy babies, but this area is fraught with unknowns and requires expertise on the part of a multidisciplinary health care team.

At a session dedicated to the issue of pregnancy during the 18th International Symposium on Adult Congenital Heart Disease, several experts addressed the sticky issues of risk stratification and management before, during, and after pregnancy in women with congenital heart defects.

All speakers stressed the importance of extensive prepregnancy counseling. “Females with congenital heart disease (CHD) should have age-appropriate preconception counseling beginning in adolescence,” said Dr. Samuel Siu, the Gunton Professor of Medicine and chair of cardiology at the University of Western Ontario, London. This counseling should include careful discussion of the risk of pregnancy to both the mother and the fetus, the recurrent risk of CHD in offspring, and antepartum and peripartum management, he noted.

Several congenital conditions carry an excessively high mortality risk during pregnancy, and affected women should avoid pregnancy, said Dr. Siu. Marfan syndrome and aortopathy, Eisenmenger's syndrome (an advanced form of pulmonary artery hypertension), peripartum cardiomyopathy with residual left ventricular dysfunction, severe aortic stenosis, and mechanical valves are all associated with high maternal and fetal death rates, and pregnancy in women with these conditions should be avoided and possibly electively terminated when it does occur, urged the experts.

One particularly sensitive issue is the life expectancy of women with repaired heart defects, taking into account that motherhood is generally at least an 18-year job.

“What is difficult to discuss, and difficult to predict, is the likely longevity of the mother,” said Dr. Carole Warnes, director of adult congenital heart disease at the Mayo Clinic in Rochester, Minn. “Is she going to live another 10 years or 18 years to see this baby going off to college? This is a painful discussion for all of us but I think it's one we have to have as we gaze into our crystal balls.”

Dr. Matthew Sermer, an ob.gyn. from Mount Sinai Hospital in Toronto, stressed the importance of proactive rather than reactive management of this patient group. “Any institution opting to look after this often complex patient population must establish policies and practices that ensure optimal perinatal outcomes,” he said. This should include establishing a multidisciplinary team composed of not only cardiologists and perinatologists, but also a neonatologist, a hematologist, an anesthetist, and nursing staff.

“Nurses must be kept in the loop,” he added. “They are on the front lines and are often the ones seeing a patient crashing. They have to know what to look for and who to tell.”

Patient education is also important, Dr. Sermer noted. “There's no point in having your patient sitting at home in heart failure and waiting for it to go away,” he said.

Fontan Palliation Has Myriad Risks

Pregnant women who have undergone Fontan repair face myriad risks, to themselves and to their fetuses. Cardiac and obstetric complications are common, including New York Heart Association functional class deterioration, atrial fibrillation, gestational hypertension, premature rupture of the membranes, and fetal growth retardation.

Although data are scarce, fetal loss in patients with a Fontan is high, likely approaching 30%, Dr. Warnes said in a discussion of risk stratification and management of pregnant women post-Fontan palliation.

Prepregnancy counseling should include a discussion of the genetic risks to the fetus and a discussion of the patient's drug regimen. “Many of these patients, of course, are on ACE inhibitors and angiotensin receptor blockers that are contraindicated in pregnancy,” Dr. Warnes said.

TORONTO — There is much to be done to assist women with congenital heart disease in having healthy pregnancies and healthy babies, but this area is fraught with unknowns and requires expertise on the part of a multidisciplinary health care team.

At a session dedicated to the issue of pregnancy during the 18th International Symposium on Adult Congenital Heart Disease, several experts addressed the sticky issues of risk stratification and management before, during, and after pregnancy in women with congenital heart defects.

All speakers stressed the importance of extensive prepregnancy counseling. “Females with congenital heart disease (CHD) should have age-appropriate preconception counseling beginning in adolescence,” said Dr. Samuel Siu, the Gunton Professor of Medicine and chair of cardiology at the University of Western Ontario, London. This counseling should include careful discussion of the risk of pregnancy to both the mother and the fetus, the recurrent risk of CHD in offspring, and antepartum and peripartum management, he noted.

Several congenital conditions carry an excessively high mortality risk during pregnancy, and affected women should avoid pregnancy, said Dr. Siu. Marfan syndrome and aortopathy, Eisenmenger's syndrome (an advanced form of pulmonary artery hypertension), peripartum cardiomyopathy with residual left ventricular dysfunction, severe aortic stenosis, and mechanical valves are all associated with high maternal and fetal death rates, and pregnancy in women with these conditions should be avoided and possibly electively terminated when it does occur, urged the experts.

One particularly sensitive issue is the life expectancy of women with repaired heart defects, taking into account that motherhood is generally at least an 18-year job.

“What is difficult to discuss, and difficult to predict, is the likely longevity of the mother,” said Dr. Carole Warnes, director of adult congenital heart disease at the Mayo Clinic in Rochester, Minn. “Is she going to live another 10 years or 18 years to see this baby going off to college? This is a painful discussion for all of us but I think it's one we have to have as we gaze into our crystal balls.”

Dr. Matthew Sermer, an ob.gyn. from Mount Sinai Hospital in Toronto, stressed the importance of proactive rather than reactive management of this patient group. “Any institution opting to look after this often complex patient population must establish policies and practices that ensure optimal perinatal outcomes,” he said. This should include establishing a multidisciplinary team composed of not only cardiologists and perinatologists, but also a neonatologist, a hematologist, an anesthetist, and nursing staff.

“Nurses must be kept in the loop,” he added. “They are on the front lines and are often the ones seeing a patient crashing. They have to know what to look for and who to tell.”

Patient education is also important, Dr. Sermer noted. “There's no point in having your patient sitting at home in heart failure and waiting for it to go away,” he said.

Fontan Palliation Has Myriad Risks

Pregnant women who have undergone Fontan repair face myriad risks, to themselves and to their fetuses. Cardiac and obstetric complications are common, including New York Heart Association functional class deterioration, atrial fibrillation, gestational hypertension, premature rupture of the membranes, and fetal growth retardation.

Although data are scarce, fetal loss in patients with a Fontan is high, likely approaching 30%, Dr. Warnes said in a discussion of risk stratification and management of pregnant women post-Fontan palliation.

Prepregnancy counseling should include a discussion of the genetic risks to the fetus and a discussion of the patient's drug regimen. “Many of these patients, of course, are on ACE inhibitors and angiotensin receptor blockers that are contraindicated in pregnancy,” Dr. Warnes said.

TORONTO — There is much to be done to assist women with congenital heart disease in having healthy pregnancies and healthy babies, but this area is fraught with unknowns and requires expertise on the part of a multidisciplinary health care team.

At a session dedicated to the issue of pregnancy during the 18th International Symposium on Adult Congenital Heart Disease, several experts addressed the sticky issues of risk stratification and management before, during, and after pregnancy in women with congenital heart defects.

All speakers stressed the importance of extensive prepregnancy counseling. “Females with congenital heart disease (CHD) should have age-appropriate preconception counseling beginning in adolescence,” said Dr. Samuel Siu, the Gunton Professor of Medicine and chair of cardiology at the University of Western Ontario, London. This counseling should include careful discussion of the risk of pregnancy to both the mother and the fetus, the recurrent risk of CHD in offspring, and antepartum and peripartum management, he noted.

Several congenital conditions carry an excessively high mortality risk during pregnancy, and affected women should avoid pregnancy, said Dr. Siu. Marfan syndrome and aortopathy, Eisenmenger's syndrome (an advanced form of pulmonary artery hypertension), peripartum cardiomyopathy with residual left ventricular dysfunction, severe aortic stenosis, and mechanical valves are all associated with high maternal and fetal death rates, and pregnancy in women with these conditions should be avoided and possibly electively terminated when it does occur, urged the experts.

One particularly sensitive issue is the life expectancy of women with repaired heart defects, taking into account that motherhood is generally at least an 18-year job.

“What is difficult to discuss, and difficult to predict, is the likely longevity of the mother,” said Dr. Carole Warnes, director of adult congenital heart disease at the Mayo Clinic in Rochester, Minn. “Is she going to live another 10 years or 18 years to see this baby going off to college? This is a painful discussion for all of us but I think it's one we have to have as we gaze into our crystal balls.”

Dr. Matthew Sermer, an ob.gyn. from Mount Sinai Hospital in Toronto, stressed the importance of proactive rather than reactive management of this patient group. “Any institution opting to look after this often complex patient population must establish policies and practices that ensure optimal perinatal outcomes,” he said. This should include establishing a multidisciplinary team composed of not only cardiologists and perinatologists, but also a neonatologist, a hematologist, an anesthetist, and nursing staff.

“Nurses must be kept in the loop,” he added. “They are on the front lines and are often the ones seeing a patient crashing. They have to know what to look for and who to tell.”

Patient education is also important, Dr. Sermer noted. “There's no point in having your patient sitting at home in heart failure and waiting for it to go away,” he said.

Fontan Palliation Has Myriad Risks

Pregnant women who have undergone Fontan repair face myriad risks, to themselves and to their fetuses. Cardiac and obstetric complications are common, including New York Heart Association functional class deterioration, atrial fibrillation, gestational hypertension, premature rupture of the membranes, and fetal growth retardation.

Although data are scarce, fetal loss in patients with a Fontan is high, likely approaching 30%, Dr. Warnes said in a discussion of risk stratification and management of pregnant women post-Fontan palliation.

Prepregnancy counseling should include a discussion of the genetic risks to the fetus and a discussion of the patient's drug regimen. “Many of these patients, of course, are on ACE inhibitors and angiotensin receptor blockers that are contraindicated in pregnancy,” Dr. Warnes said.

TORONTO — Pregnant women with congenital heart defects are not able to ramp up their cardiac output to handle the stresses of pregnancy, according to a small study out of the Netherlands. Dr. Jolien Roos-Hesselink reported the study results in a poster presentation at the 18th International Symposium on Adult Congenital Heart Disease.

“We know that cardiac output generally rises during pregnancy and we felt it important to see what happens in women with congenital heart disease as a means of perhaps explaining the increased risk of complications seen in these women and their offspring,” Dr. Roos-Hesselink, a cardiologist, said in an interview. “We suspected that maybe cardiac output wasn't increasing enough in these patients.”

Pregnancy is a major issue in the management of women with congenital heart disease, complicated by a greater risk of fetal growth retardation, premature birth, and perinatal mortality. Normally, cardiac output increases by 40%–50% during pregnancy.

Dr. Roos-Hesselink's team at the Thoraxcenter of Erasmus Medical Center in Rotterdam, the Netherlands, studied eight patients before, during, and after pregnancy. Subjects had a variety of congenital heart defects, including aortic valve replacement, tetralogy of Fallot, Ebstein anomaly, ventricular septal defect, atrioventricular septal defect, and pulmonary stenosis. Subjects underwent cardiac magnetic resonance imaging (cMRI) at 20 weeks' gestation and again at 32 weeks. Measurements were compared with measurements taken 6–12 months preconception and post partum.

“In the first eight patients we studied, we saw that in seven of the patients, cardiac output did not rise as the pregnancy progressed, but rather fell,” reported Dr. Roos-Hesselink.

Although the data presented are limited, Dr. Roos-Hesselink notes that they have now tested 25 patients and will be presenting further data soon.

Previous echocardiography studies have hinted at the issue of cardiac output in pregnancy complicated by coronary heart disease, but until cMRI was determined to be safe for women in pregnancy, there was no means of accurately measuring cardiac output during gestation, said Dr. Roos-Hesselink.

“It seems to be that the ventricular function in these women is not capable of handling the stress of pregnancy, although it does increase from baseline during the first trimester.”

After increasing appropriately from pre-and postpregnancy baseline values up to 20 weeks' gestation, cardiac output decreased significantly, from 6.9 L/min at 20 weeks to 5.4 L/min at 32 weeks of gestation. In addition, a significant reduction in end-diastolic volume and stroke volume between 20 and 32 weeks of gestation was observed, along with a decline in left ventricular ejection fraction from 53% to 49%. Left ventricular mass increased from 87.5 grams at 20 weeks to 94.4 grams at 32 weeks.

Said Dr. Roos-Hesselink, “These findings could add to our ability to risk-stratify these patients and could explain many of the complications we see in this patient subgroup. We haven't yet tested cardiac output with MRI during exercise prepregnancy, but if women at risk are tested before or during pregnancy and cardiac output is found to be lacking, this might be an indication to treat them more intensively, maybe with diuretics or other medications.”

ELSEVIER GLOBAL MEDICAL NEWS

TORONTO — Pregnant women with congenital heart defects are not able to ramp up their cardiac output to handle the stresses of pregnancy, according to a small study out of the Netherlands. Dr. Jolien Roos-Hesselink reported the study results in a poster presentation at the 18th International Symposium on Adult Congenital Heart Disease.

“We know that cardiac output generally rises during pregnancy and we felt it important to see what happens in women with congenital heart disease as a means of perhaps explaining the increased risk of complications seen in these women and their offspring,” Dr. Roos-Hesselink, a cardiologist, said in an interview. “We suspected that maybe cardiac output wasn't increasing enough in these patients.”

Pregnancy is a major issue in the management of women with congenital heart disease, complicated by a greater risk of fetal growth retardation, premature birth, and perinatal mortality. Normally, cardiac output increases by 40%–50% during pregnancy.

Dr. Roos-Hesselink's team at the Thoraxcenter of Erasmus Medical Center in Rotterdam, the Netherlands, studied eight patients before, during, and after pregnancy. Subjects had a variety of congenital heart defects, including aortic valve replacement, tetralogy of Fallot, Ebstein anomaly, ventricular septal defect, atrioventricular septal defect, and pulmonary stenosis. Subjects underwent cardiac magnetic resonance imaging (cMRI) at 20 weeks' gestation and again at 32 weeks. Measurements were compared with measurements taken 6–12 months preconception and post partum.

“In the first eight patients we studied, we saw that in seven of the patients, cardiac output did not rise as the pregnancy progressed, but rather fell,” reported Dr. Roos-Hesselink.

Although the data presented are limited, Dr. Roos-Hesselink notes that they have now tested 25 patients and will be presenting further data soon.

Previous echocardiography studies have hinted at the issue of cardiac output in pregnancy complicated by coronary heart disease, but until cMRI was determined to be safe for women in pregnancy, there was no means of accurately measuring cardiac output during gestation, said Dr. Roos-Hesselink.

“It seems to be that the ventricular function in these women is not capable of handling the stress of pregnancy, although it does increase from baseline during the first trimester.”

After increasing appropriately from pre-and postpregnancy baseline values up to 20 weeks' gestation, cardiac output decreased significantly, from 6.9 L/min at 20 weeks to 5.4 L/min at 32 weeks of gestation. In addition, a significant reduction in end-diastolic volume and stroke volume between 20 and 32 weeks of gestation was observed, along with a decline in left ventricular ejection fraction from 53% to 49%. Left ventricular mass increased from 87.5 grams at 20 weeks to 94.4 grams at 32 weeks.

Said Dr. Roos-Hesselink, “These findings could add to our ability to risk-stratify these patients and could explain many of the complications we see in this patient subgroup. We haven't yet tested cardiac output with MRI during exercise prepregnancy, but if women at risk are tested before or during pregnancy and cardiac output is found to be lacking, this might be an indication to treat them more intensively, maybe with diuretics or other medications.”

ELSEVIER GLOBAL MEDICAL NEWS

TORONTO — Pregnant women with congenital heart defects are not able to ramp up their cardiac output to handle the stresses of pregnancy, according to a small study out of the Netherlands. Dr. Jolien Roos-Hesselink reported the study results in a poster presentation at the 18th International Symposium on Adult Congenital Heart Disease.

“We know that cardiac output generally rises during pregnancy and we felt it important to see what happens in women with congenital heart disease as a means of perhaps explaining the increased risk of complications seen in these women and their offspring,” Dr. Roos-Hesselink, a cardiologist, said in an interview. “We suspected that maybe cardiac output wasn't increasing enough in these patients.”

Pregnancy is a major issue in the management of women with congenital heart disease, complicated by a greater risk of fetal growth retardation, premature birth, and perinatal mortality. Normally, cardiac output increases by 40%–50% during pregnancy.

Dr. Roos-Hesselink's team at the Thoraxcenter of Erasmus Medical Center in Rotterdam, the Netherlands, studied eight patients before, during, and after pregnancy. Subjects had a variety of congenital heart defects, including aortic valve replacement, tetralogy of Fallot, Ebstein anomaly, ventricular septal defect, atrioventricular septal defect, and pulmonary stenosis. Subjects underwent cardiac magnetic resonance imaging (cMRI) at 20 weeks' gestation and again at 32 weeks. Measurements were compared with measurements taken 6–12 months preconception and post partum.

“In the first eight patients we studied, we saw that in seven of the patients, cardiac output did not rise as the pregnancy progressed, but rather fell,” reported Dr. Roos-Hesselink.

Although the data presented are limited, Dr. Roos-Hesselink notes that they have now tested 25 patients and will be presenting further data soon.

Previous echocardiography studies have hinted at the issue of cardiac output in pregnancy complicated by coronary heart disease, but until cMRI was determined to be safe for women in pregnancy, there was no means of accurately measuring cardiac output during gestation, said Dr. Roos-Hesselink.

“It seems to be that the ventricular function in these women is not capable of handling the stress of pregnancy, although it does increase from baseline during the first trimester.”

After increasing appropriately from pre-and postpregnancy baseline values up to 20 weeks' gestation, cardiac output decreased significantly, from 6.9 L/min at 20 weeks to 5.4 L/min at 32 weeks of gestation. In addition, a significant reduction in end-diastolic volume and stroke volume between 20 and 32 weeks of gestation was observed, along with a decline in left ventricular ejection fraction from 53% to 49%. Left ventricular mass increased from 87.5 grams at 20 weeks to 94.4 grams at 32 weeks.

Said Dr. Roos-Hesselink, “These findings could add to our ability to risk-stratify these patients and could explain many of the complications we see in this patient subgroup. We haven't yet tested cardiac output with MRI during exercise prepregnancy, but if women at risk are tested before or during pregnancy and cardiac output is found to be lacking, this might be an indication to treat them more intensively, maybe with diuretics or other medications.”

ELSEVIER GLOBAL MEDICAL NEWS

TORONTO — There are three main reasons to send an adult with tetralogy of Fallot for pulmonary valve replacement: moderate to severe pulmonary regurgitation, evidence of right ventricular overload, and a clinical context suggesting the need for the procedure.

Pulmonary valve replacement (PVR) should only be undertaken in patients in whom all three reasons are present, Dr. Gary Webb said at the 18th International Symposium on Adult Congenital Heart Disease.

The clinical situations that might drive a decision to replace a leaky pulmonary valve include exercise intolerance attributable to the pulmonary regurgitation or congenital heart defect, sustained atrial flutter or fibrillation, sustained ventricular tachycardia or resuscitated sudden death, or an asymptomatic patient with “excessive” right ventricular dilation.

“Ten years ago, we replaced the pulmonary valve for exercise intolerance, sustained arrhythmias, and 'progressive' right ventricular dysfunction,” said Dr. Webb, the director of the Philadelphia Adult Congenital Heart Center. “However, using these criteria for surgery, we learned that we had waited too long for many of these patients, and in the end they had suboptimal results.”

The decision of when to intervene in pulmonary regurgitation has evolved and continues to evolve, said Dr. Webb. “Even mild left ventricular systolic dysfunction is an indication for surgery for aortic and mitral regurgitation, so ideally, if we could see that right ventricular systolic function was declining from normal, then we could apply the same criteria. But, of course, it doesn't work in tetralogy patients because the right ventricle is not normal.”

Efforts to risk-stratify these patients, therefore, have focused instead on right ventricular diastolic volumes.

Although there are risks to waiting too long before PVR, Dr. Webb does not think a low threshold for replacing a leaking pulmonary valve is wise. Indeed, 10-year and 30-year survival after repair of tetralogy of Fallot in one large study was 97% and 89% in patients surviving at least 1 year (J. Am. Coll. Cardiol 1997; 30:1374–83).

“If we have 11% mortality over 30 years in this cohort of survivors we don't want to be pulling the trigger too impulsively on these patients,” he said.

TORONTO — There are three main reasons to send an adult with tetralogy of Fallot for pulmonary valve replacement: moderate to severe pulmonary regurgitation, evidence of right ventricular overload, and a clinical context suggesting the need for the procedure.

Pulmonary valve replacement (PVR) should only be undertaken in patients in whom all three reasons are present, Dr. Gary Webb said at the 18th International Symposium on Adult Congenital Heart Disease.

The clinical situations that might drive a decision to replace a leaky pulmonary valve include exercise intolerance attributable to the pulmonary regurgitation or congenital heart defect, sustained atrial flutter or fibrillation, sustained ventricular tachycardia or resuscitated sudden death, or an asymptomatic patient with “excessive” right ventricular dilation.

“Ten years ago, we replaced the pulmonary valve for exercise intolerance, sustained arrhythmias, and 'progressive' right ventricular dysfunction,” said Dr. Webb, the director of the Philadelphia Adult Congenital Heart Center. “However, using these criteria for surgery, we learned that we had waited too long for many of these patients, and in the end they had suboptimal results.”

The decision of when to intervene in pulmonary regurgitation has evolved and continues to evolve, said Dr. Webb. “Even mild left ventricular systolic dysfunction is an indication for surgery for aortic and mitral regurgitation, so ideally, if we could see that right ventricular systolic function was declining from normal, then we could apply the same criteria. But, of course, it doesn't work in tetralogy patients because the right ventricle is not normal.”

Efforts to risk-stratify these patients, therefore, have focused instead on right ventricular diastolic volumes.

Although there are risks to waiting too long before PVR, Dr. Webb does not think a low threshold for replacing a leaking pulmonary valve is wise. Indeed, 10-year and 30-year survival after repair of tetralogy of Fallot in one large study was 97% and 89% in patients surviving at least 1 year (J. Am. Coll. Cardiol 1997; 30:1374–83).

“If we have 11% mortality over 30 years in this cohort of survivors we don't want to be pulling the trigger too impulsively on these patients,” he said.

TORONTO — There are three main reasons to send an adult with tetralogy of Fallot for pulmonary valve replacement: moderate to severe pulmonary regurgitation, evidence of right ventricular overload, and a clinical context suggesting the need for the procedure.

Pulmonary valve replacement (PVR) should only be undertaken in patients in whom all three reasons are present, Dr. Gary Webb said at the 18th International Symposium on Adult Congenital Heart Disease.

The clinical situations that might drive a decision to replace a leaky pulmonary valve include exercise intolerance attributable to the pulmonary regurgitation or congenital heart defect, sustained atrial flutter or fibrillation, sustained ventricular tachycardia or resuscitated sudden death, or an asymptomatic patient with “excessive” right ventricular dilation.

“Ten years ago, we replaced the pulmonary valve for exercise intolerance, sustained arrhythmias, and 'progressive' right ventricular dysfunction,” said Dr. Webb, the director of the Philadelphia Adult Congenital Heart Center. “However, using these criteria for surgery, we learned that we had waited too long for many of these patients, and in the end they had suboptimal results.”

The decision of when to intervene in pulmonary regurgitation has evolved and continues to evolve, said Dr. Webb. “Even mild left ventricular systolic dysfunction is an indication for surgery for aortic and mitral regurgitation, so ideally, if we could see that right ventricular systolic function was declining from normal, then we could apply the same criteria. But, of course, it doesn't work in tetralogy patients because the right ventricle is not normal.”

Efforts to risk-stratify these patients, therefore, have focused instead on right ventricular diastolic volumes.

Although there are risks to waiting too long before PVR, Dr. Webb does not think a low threshold for replacing a leaking pulmonary valve is wise. Indeed, 10-year and 30-year survival after repair of tetralogy of Fallot in one large study was 97% and 89% in patients surviving at least 1 year (J. Am. Coll. Cardiol 1997; 30:1374–83).

“If we have 11% mortality over 30 years in this cohort of survivors we don't want to be pulling the trigger too impulsively on these patients,” he said.

TORONTO — Pregnant women with congenital heart defects are not able to ramp up their cardiac output to handle the stresses of pregnancy, according to a small study out of the Netherlands. Dr. Jolien Roos-Hesselink reported the study results in a poster presentation at the 18th International Symposium on Adult Congenital Heart Disease.

“We know that cardiac output generally rises during pregnancy and we felt it important to see what happens in women with congenital heart disease as a means of explaining the increased risk of complications seen in these women and their offspring,” Dr. Roos-Hesselink, a cardiologist, said in an interview. “We suspected that maybe cardiac output wasn't increasing enough in these patients,” she said.

Pregnancy is a major concern in the management of women with congenital heart disease, complicated by a greater risk of fetal growth retardation, premature birth, and perinatal mortality. Normally, cardiac output increases by 40%-50% during pregnancy.

Dr. Roos-Hesselink's team at the Thoraxcenter of Erasmus Medical Center in Rotterdam, the Netherlands, studied eight patients before, during, and after pregnancy. These patients had a variety of congenital heart defects, including aortic valve replacement, tetralogy of Fallot, Ebstein anomaly, ventricular septal defect, atrioventricular septal defect, and pulmonary stenosis. Subjects underwent cardiac MRI at 20 weeks' gestation and again at 32 weeks. Measurements were compared with measurements taken 6–12 months preconception and post partum.

“In the first eight patients we studied, we saw that in seven of the patients, cardiac output did not rise as the pregnancy progressed, but rather fell,” she reported.

Although the data presented are limited, Dr. Roos-Hesselink notes that they have now tested 25 patients and will be presenting further data soon.

Previous echocardiography studies have hinted at the issue of cardiac output in pregnancy complicated by coronary heart disease, but until cardiac MRI was determined to be safe for women in pregnancy, there was no means of accurately measuring cardiac output during gestation, said Dr. Roos-Hesselink. “It seems to be that the ventricular function in these women is not capable of handling the stress of pregnancy, although it does increase from baseline during the first trimester.”

After increasing appropriately from pre-and postpregnancy baseline values up to 20 weeks' gestation, cardiac output decreased significantly, from 6.9 L/min at 20 weeks to 5.4 L/min at 32 weeks of gestation. In addition, a significant reduction in end-diastolic volume and stroke volume between 20 and 32 weeks of gestation was observed, along with a decline in left ventricular ejection fraction from 53% to 49%. Left ventricular mass increased from 87.5 grams at 20 weeks to 94.4 grams at 32 weeks.

Said Dr. Roos-Hesselink, “These findings could add to our ability to risk-stratify these patients and could explain many of the complications we see in this patient subgroup. “We haven't yet tested cardiac output with MRI during exercise prepregnancy, but if women at risk are tested before or during pregnancy and cardiac output is found to be lacking, this might be an indication to treat them more intensively,” she added.

ELSEVIER GLOBAL MEDICAL NEWS

TORONTO — Pregnant women with congenital heart defects are not able to ramp up their cardiac output to handle the stresses of pregnancy, according to a small study out of the Netherlands. Dr. Jolien Roos-Hesselink reported the study results in a poster presentation at the 18th International Symposium on Adult Congenital Heart Disease.

“We know that cardiac output generally rises during pregnancy and we felt it important to see what happens in women with congenital heart disease as a means of explaining the increased risk of complications seen in these women and their offspring,” Dr. Roos-Hesselink, a cardiologist, said in an interview. “We suspected that maybe cardiac output wasn't increasing enough in these patients,” she said.

Pregnancy is a major concern in the management of women with congenital heart disease, complicated by a greater risk of fetal growth retardation, premature birth, and perinatal mortality. Normally, cardiac output increases by 40%-50% during pregnancy.

Dr. Roos-Hesselink's team at the Thoraxcenter of Erasmus Medical Center in Rotterdam, the Netherlands, studied eight patients before, during, and after pregnancy. These patients had a variety of congenital heart defects, including aortic valve replacement, tetralogy of Fallot, Ebstein anomaly, ventricular septal defect, atrioventricular septal defect, and pulmonary stenosis. Subjects underwent cardiac MRI at 20 weeks' gestation and again at 32 weeks. Measurements were compared with measurements taken 6–12 months preconception and post partum.

“In the first eight patients we studied, we saw that in seven of the patients, cardiac output did not rise as the pregnancy progressed, but rather fell,” she reported.

Although the data presented are limited, Dr. Roos-Hesselink notes that they have now tested 25 patients and will be presenting further data soon.

Previous echocardiography studies have hinted at the issue of cardiac output in pregnancy complicated by coronary heart disease, but until cardiac MRI was determined to be safe for women in pregnancy, there was no means of accurately measuring cardiac output during gestation, said Dr. Roos-Hesselink. “It seems to be that the ventricular function in these women is not capable of handling the stress of pregnancy, although it does increase from baseline during the first trimester.”

After increasing appropriately from pre-and postpregnancy baseline values up to 20 weeks' gestation, cardiac output decreased significantly, from 6.9 L/min at 20 weeks to 5.4 L/min at 32 weeks of gestation. In addition, a significant reduction in end-diastolic volume and stroke volume between 20 and 32 weeks of gestation was observed, along with a decline in left ventricular ejection fraction from 53% to 49%. Left ventricular mass increased from 87.5 grams at 20 weeks to 94.4 grams at 32 weeks.

Said Dr. Roos-Hesselink, “These findings could add to our ability to risk-stratify these patients and could explain many of the complications we see in this patient subgroup. “We haven't yet tested cardiac output with MRI during exercise prepregnancy, but if women at risk are tested before or during pregnancy and cardiac output is found to be lacking, this might be an indication to treat them more intensively,” she added.

ELSEVIER GLOBAL MEDICAL NEWS

TORONTO — Pregnant women with congenital heart defects are not able to ramp up their cardiac output to handle the stresses of pregnancy, according to a small study out of the Netherlands. Dr. Jolien Roos-Hesselink reported the study results in a poster presentation at the 18th International Symposium on Adult Congenital Heart Disease.

“We know that cardiac output generally rises during pregnancy and we felt it important to see what happens in women with congenital heart disease as a means of explaining the increased risk of complications seen in these women and their offspring,” Dr. Roos-Hesselink, a cardiologist, said in an interview. “We suspected that maybe cardiac output wasn't increasing enough in these patients,” she said.

Pregnancy is a major concern in the management of women with congenital heart disease, complicated by a greater risk of fetal growth retardation, premature birth, and perinatal mortality. Normally, cardiac output increases by 40%-50% during pregnancy.

Dr. Roos-Hesselink's team at the Thoraxcenter of Erasmus Medical Center in Rotterdam, the Netherlands, studied eight patients before, during, and after pregnancy. These patients had a variety of congenital heart defects, including aortic valve replacement, tetralogy of Fallot, Ebstein anomaly, ventricular septal defect, atrioventricular septal defect, and pulmonary stenosis. Subjects underwent cardiac MRI at 20 weeks' gestation and again at 32 weeks. Measurements were compared with measurements taken 6–12 months preconception and post partum.

“In the first eight patients we studied, we saw that in seven of the patients, cardiac output did not rise as the pregnancy progressed, but rather fell,” she reported.

Although the data presented are limited, Dr. Roos-Hesselink notes that they have now tested 25 patients and will be presenting further data soon.

Previous echocardiography studies have hinted at the issue of cardiac output in pregnancy complicated by coronary heart disease, but until cardiac MRI was determined to be safe for women in pregnancy, there was no means of accurately measuring cardiac output during gestation, said Dr. Roos-Hesselink. “It seems to be that the ventricular function in these women is not capable of handling the stress of pregnancy, although it does increase from baseline during the first trimester.”

After increasing appropriately from pre-and postpregnancy baseline values up to 20 weeks' gestation, cardiac output decreased significantly, from 6.9 L/min at 20 weeks to 5.4 L/min at 32 weeks of gestation. In addition, a significant reduction in end-diastolic volume and stroke volume between 20 and 32 weeks of gestation was observed, along with a decline in left ventricular ejection fraction from 53% to 49%. Left ventricular mass increased from 87.5 grams at 20 weeks to 94.4 grams at 32 weeks.

Said Dr. Roos-Hesselink, “These findings could add to our ability to risk-stratify these patients and could explain many of the complications we see in this patient subgroup. “We haven't yet tested cardiac output with MRI during exercise prepregnancy, but if women at risk are tested before or during pregnancy and cardiac output is found to be lacking, this might be an indication to treat them more intensively,” she added.

ELSEVIER GLOBAL MEDICAL NEWS

TORONTO — Pregnant women with congenital heart defects are not able to ramp up their cardiac output to handle the stresses of pregnancy, according to a small study out of the Netherlands. Dr. Jolien Roos-Hesselink reported the study results in a poster presentation at the 18th International Symposium on Adult Congenital Heart Disease.

“We know that cardiac output generally rises during pregnancy, and we felt it important to see what happens in women with congenital heart disease as a means of perhaps explaining the increased risk of complications seen in these women and their offspring,” Dr. Roos-Hesselink, a cardiologist, said in an interview. “We suspected that maybe cardiac output wasn't increasing enough in these patients.”

Pregnancy is a major issue in the management of women with congenital heart disease, complicated by a greater risk of fetal growth retardation, premature birth, and perinatal mortality. Normally, cardiac output increases by 40%–50% during pregnancy.

Dr. Roos-Hesselink's team at the Thoraxcenter of Erasmus Medical Center in Rotterdam, the Netherlands, studied eight patients before, during, and after pregnancy. Subjects had a variety of congenital heart defects, including aortic valve replacement, tetralogy of Fallot, Ebstein anomaly, ventricular septal defect, atrio-ventricular septal defect, and pulmonary stenosis. Subjects underwent cardiac magnetic resonance imaging (cMRI) at 20 weeks' gestation and again at 32 weeks. Measurements were compared with measurements taken 6–12 months preconception and post partum.

“In the first eight patients we studied, we saw that in seven of the patients, cardiac output did not rise as the pregnancy progressed, but rather fell,” reported Dr. Roos-Hesselink.

Although the data presented are limited, Dr. Roos-Hesselink notes that they have now tested 25 patients and will be presenting further data soon.

Previous echocardiography studies have hinted at the issue of cardiac output in pregnancy complicated by coronary heart disease, but until cMRI was determined to be safe for women in pregnancy, there was no means of accurately measuring cardiac output during gestation, said Dr. Roos-Hesselink.

“It seems to be that the ventricular function in these women is not capable of handling the stress of pregnancy, although it does increase from baseline during the first trimester.”

After increasing appropriately from pre-and postpregnancy baseline values up to 20 weeks' gestation, cardiac output decreased significantly, from 6.9 L/min at 20 weeks to 5.4 L/min at 32 weeks of gestation. In addition, a significant reduction in end-diastolic volume and stroke volume between 20 and 32 weeks of gestation was observed, along with a decline in left ventricular ejection fraction from 53% to 49%. Left ventricular mass increased from 87.5 grams at 20 weeks to 94.4 grams at 32 weeks.

Said Dr. Roos-Hesselink, “These findings could add to our ability to risk-stratify these patients and could explain many of the complications we see in this patient subgroup. We haven't yet tested cardiac output with MRI during exercise prepregnancy, but if women at risk are tested before or during pregnancy and cardiac output is found to be lacking, this might be an indication to treat them more intensively, maybe with diuretics or other medications.

ELSEVIER GLOBAL MEDICAL NEWS

TORONTO — Pregnant women with congenital heart defects are not able to ramp up their cardiac output to handle the stresses of pregnancy, according to a small study out of the Netherlands. Dr. Jolien Roos-Hesselink reported the study results in a poster presentation at the 18th International Symposium on Adult Congenital Heart Disease.

“We know that cardiac output generally rises during pregnancy, and we felt it important to see what happens in women with congenital heart disease as a means of perhaps explaining the increased risk of complications seen in these women and their offspring,” Dr. Roos-Hesselink, a cardiologist, said in an interview. “We suspected that maybe cardiac output wasn't increasing enough in these patients.”

Pregnancy is a major issue in the management of women with congenital heart disease, complicated by a greater risk of fetal growth retardation, premature birth, and perinatal mortality. Normally, cardiac output increases by 40%–50% during pregnancy.

Dr. Roos-Hesselink's team at the Thoraxcenter of Erasmus Medical Center in Rotterdam, the Netherlands, studied eight patients before, during, and after pregnancy. Subjects had a variety of congenital heart defects, including aortic valve replacement, tetralogy of Fallot, Ebstein anomaly, ventricular septal defect, atrio-ventricular septal defect, and pulmonary stenosis. Subjects underwent cardiac magnetic resonance imaging (cMRI) at 20 weeks' gestation and again at 32 weeks. Measurements were compared with measurements taken 6–12 months preconception and post partum.

“In the first eight patients we studied, we saw that in seven of the patients, cardiac output did not rise as the pregnancy progressed, but rather fell,” reported Dr. Roos-Hesselink.

Although the data presented are limited, Dr. Roos-Hesselink notes that they have now tested 25 patients and will be presenting further data soon.

Previous echocardiography studies have hinted at the issue of cardiac output in pregnancy complicated by coronary heart disease, but until cMRI was determined to be safe for women in pregnancy, there was no means of accurately measuring cardiac output during gestation, said Dr. Roos-Hesselink.

“It seems to be that the ventricular function in these women is not capable of handling the stress of pregnancy, although it does increase from baseline during the first trimester.”

After increasing appropriately from pre-and postpregnancy baseline values up to 20 weeks' gestation, cardiac output decreased significantly, from 6.9 L/min at 20 weeks to 5.4 L/min at 32 weeks of gestation. In addition, a significant reduction in end-diastolic volume and stroke volume between 20 and 32 weeks of gestation was observed, along with a decline in left ventricular ejection fraction from 53% to 49%. Left ventricular mass increased from 87.5 grams at 20 weeks to 94.4 grams at 32 weeks.

Said Dr. Roos-Hesselink, “These findings could add to our ability to risk-stratify these patients and could explain many of the complications we see in this patient subgroup. We haven't yet tested cardiac output with MRI during exercise prepregnancy, but if women at risk are tested before or during pregnancy and cardiac output is found to be lacking, this might be an indication to treat them more intensively, maybe with diuretics or other medications.

ELSEVIER GLOBAL MEDICAL NEWS

TORONTO — Pregnant women with congenital heart defects are not able to ramp up their cardiac output to handle the stresses of pregnancy, according to a small study out of the Netherlands. Dr. Jolien Roos-Hesselink reported the study results in a poster presentation at the 18th International Symposium on Adult Congenital Heart Disease.

“We know that cardiac output generally rises during pregnancy, and we felt it important to see what happens in women with congenital heart disease as a means of perhaps explaining the increased risk of complications seen in these women and their offspring,” Dr. Roos-Hesselink, a cardiologist, said in an interview. “We suspected that maybe cardiac output wasn't increasing enough in these patients.”

Pregnancy is a major issue in the management of women with congenital heart disease, complicated by a greater risk of fetal growth retardation, premature birth, and perinatal mortality. Normally, cardiac output increases by 40%–50% during pregnancy.

Dr. Roos-Hesselink's team at the Thoraxcenter of Erasmus Medical Center in Rotterdam, the Netherlands, studied eight patients before, during, and after pregnancy. Subjects had a variety of congenital heart defects, including aortic valve replacement, tetralogy of Fallot, Ebstein anomaly, ventricular septal defect, atrio-ventricular septal defect, and pulmonary stenosis. Subjects underwent cardiac magnetic resonance imaging (cMRI) at 20 weeks' gestation and again at 32 weeks. Measurements were compared with measurements taken 6–12 months preconception and post partum.

“In the first eight patients we studied, we saw that in seven of the patients, cardiac output did not rise as the pregnancy progressed, but rather fell,” reported Dr. Roos-Hesselink.

Although the data presented are limited, Dr. Roos-Hesselink notes that they have now tested 25 patients and will be presenting further data soon.

Previous echocardiography studies have hinted at the issue of cardiac output in pregnancy complicated by coronary heart disease, but until cMRI was determined to be safe for women in pregnancy, there was no means of accurately measuring cardiac output during gestation, said Dr. Roos-Hesselink.

“It seems to be that the ventricular function in these women is not capable of handling the stress of pregnancy, although it does increase from baseline during the first trimester.”

After increasing appropriately from pre-and postpregnancy baseline values up to 20 weeks' gestation, cardiac output decreased significantly, from 6.9 L/min at 20 weeks to 5.4 L/min at 32 weeks of gestation. In addition, a significant reduction in end-diastolic volume and stroke volume between 20 and 32 weeks of gestation was observed, along with a decline in left ventricular ejection fraction from 53% to 49%. Left ventricular mass increased from 87.5 grams at 20 weeks to 94.4 grams at 32 weeks.

Said Dr. Roos-Hesselink, “These findings could add to our ability to risk-stratify these patients and could explain many of the complications we see in this patient subgroup. We haven't yet tested cardiac output with MRI during exercise prepregnancy, but if women at risk are tested before or during pregnancy and cardiac output is found to be lacking, this might be an indication to treat them more intensively, maybe with diuretics or other medications.

ELSEVIER GLOBAL MEDICAL NEWS

TORONTO — A critical period for the development of obesity in early childhood appears to be between the ages of 1 and 3 years, according to a study of inner-city youth presented at the annual meeting of the Pediatric Academic Societies.

In 1,713 children aged 1–5 years, overweight increased from a low of 4% in 1-year-olds to 21% in 5-year-olds. Obesity increased from a low of 8% in 1-year-olds to 30% in 5-year-olds, said Dr. Melissa Glassman, a pediatrician at Columbia University Medical Center and Morgan-Stanley Children's Hospital of New York-Presbyterian, both in New York.

The researchers saw significant increases in prevalence both between the ages of 1 and 2 years and between ages 2 and 3 years. No statistically significant increases in overweight or obesity prevalence occurred in 3- to 5-year-old children.

The largest increase in overweight and obesity prevalences occurred in children before the age of 3; overweight was 16% and obesity was 30% in 3-year-olds.

Overall, boys were slightly more likely to be obese than were girls. No significant differences were seen based on ethnicity. Dr. Glassman noted that Dominicans were the major subgroup in her study population and that these findings may not be generalizable to other populations. She said that a study based on 2003–2004 NHANES data found a rate of overweight and obesity among 2- to 5-year-old children of 26%.

“The critical age period encompasses a major transition period for children, when they develop and establish food preferences and eating behaviors,” Dr. Glassman said in a statement. When asked how physicians can help, she said that encouraging parents to make adjustments to their children's diet and exercise patterns would allow some of these children to “outgrow” their excess weight.

TORONTO — A critical period for the development of obesity in early childhood appears to be between the ages of 1 and 3 years, according to a study of inner-city youth presented at the annual meeting of the Pediatric Academic Societies.

In 1,713 children aged 1–5 years, overweight increased from a low of 4% in 1-year-olds to 21% in 5-year-olds. Obesity increased from a low of 8% in 1-year-olds to 30% in 5-year-olds, said Dr. Melissa Glassman, a pediatrician at Columbia University Medical Center and Morgan-Stanley Children's Hospital of New York-Presbyterian, both in New York.

The researchers saw significant increases in prevalence both between the ages of 1 and 2 years and between ages 2 and 3 years. No statistically significant increases in overweight or obesity prevalence occurred in 3- to 5-year-old children.

The largest increase in overweight and obesity prevalences occurred in children before the age of 3; overweight was 16% and obesity was 30% in 3-year-olds.

Overall, boys were slightly more likely to be obese than were girls. No significant differences were seen based on ethnicity. Dr. Glassman noted that Dominicans were the major subgroup in her study population and that these findings may not be generalizable to other populations. She said that a study based on 2003–2004 NHANES data found a rate of overweight and obesity among 2- to 5-year-old children of 26%.

“The critical age period encompasses a major transition period for children, when they develop and establish food preferences and eating behaviors,” Dr. Glassman said in a statement. When asked how physicians can help, she said that encouraging parents to make adjustments to their children's diet and exercise patterns would allow some of these children to “outgrow” their excess weight.

TORONTO — A critical period for the development of obesity in early childhood appears to be between the ages of 1 and 3 years, according to a study of inner-city youth presented at the annual meeting of the Pediatric Academic Societies.

In 1,713 children aged 1–5 years, overweight increased from a low of 4% in 1-year-olds to 21% in 5-year-olds. Obesity increased from a low of 8% in 1-year-olds to 30% in 5-year-olds, said Dr. Melissa Glassman, a pediatrician at Columbia University Medical Center and Morgan-Stanley Children's Hospital of New York-Presbyterian, both in New York.

The researchers saw significant increases in prevalence both between the ages of 1 and 2 years and between ages 2 and 3 years. No statistically significant increases in overweight or obesity prevalence occurred in 3- to 5-year-old children.

The largest increase in overweight and obesity prevalences occurred in children before the age of 3; overweight was 16% and obesity was 30% in 3-year-olds.

Overall, boys were slightly more likely to be obese than were girls. No significant differences were seen based on ethnicity. Dr. Glassman noted that Dominicans were the major subgroup in her study population and that these findings may not be generalizable to other populations. She said that a study based on 2003–2004 NHANES data found a rate of overweight and obesity among 2- to 5-year-old children of 26%.

“The critical age period encompasses a major transition period for children, when they develop and establish food preferences and eating behaviors,” Dr. Glassman said in a statement. When asked how physicians can help, she said that encouraging parents to make adjustments to their children's diet and exercise patterns would allow some of these children to “outgrow” their excess weight.