Elsevier

International Journal of Cardiology

Volume 386, 1 September 2023, Pages 37-44
International Journal of Cardiology

Predictors of arrhythmia during pregnancy in adults with congenital heart disease

https://doi.org/10.1016/j.ijcard.2023.05.015Get rights and content

Highlights

  • Most antepartum arrhythmias in congenital heart disease occur in the second trimester

  • Prior arrhythmia, physiologic class and Fontan palliation predict arrhythmia during pregnancy

  • Novel risk score predicts arrhythmia in pregnant women with congenital heart disease

  • Preconception catheter ablation did not impact future risk of antepartum arrhythmia, though index arrhythmia did not recur during pregnancy

Abstract

Background

Risk prediction of arrhythmia during pregnancy in adult congenital heart disease (ACHD) patients is currently lacking, and the impact of preconception catheter ablation on future antepartum arrhythmia has not been studied.

Methods

We conducted a single-center, retrospective cohort study of pregnancies in ACHD patients. Clinically significant arrhythmia events during pregnancy were described, predictors of arrhythmia were analyzed, and a risk score devised. The impact of preconception catheter ablation on antepartum arrhythmia was assessed.

Results

The study included 172 pregnancies in 137 patients. Arrhythmia events occurred in 25 (15%) of pregnancies, with 64% of events occurring in the second trimester and sustained supraventricular tachycardia being the most common rhythm. Univariate predictors of arrhythmia were history of tachyarrhythmia (OR 20.33, 95% CI 6.95–59.47, p < 0.001, Fontan circulation (OR 11.90, 95% CI 2.60–53.70, p < 0.001), baseline physiologic class C/D (OR 3.72, 95% CI 1.54–9.01, p = 0.002) and history of multiple valve interventions (OR 3.10, 95% CI 1.20–8.20, p = 0.017). Three risk factors (excluding multiple valve interventions) were used to formulate a risk score, with a cutoff of ≥2 points predicting antepartum arrhythmia with sensitivity and specificity of 84%. While recurrence of the index arrhythmia was not observed following successful catheter ablation, preconception ablation did not impact odds of antepartum arrhythmia.

Conclusions

We provide a novel risk stratification scheme for predicting antepartum arrhythmia in ACHD patients. The role of contemporary preconception catheter ablation in risk reduction needs further refinement with multicenter investigation.

Introduction

Survival of patients with congenital heart disease (CHD) has improved dramatically over the past several decades, with the majority of the CHD population now comprised of adult patients [1]. The increase in the number of CHD patients reaching childbearing age has paralleled advancements in obstetric care and in our knowledge of risk and tolerability of pregnancy even in high-risk CHD lesions [2,3]. As a result, the annual number of pregnancies in women with CHD continues to increase steadily [4].

Arrhythmia is known to be the most common adverse cardiovascular event in pregnancy in patients with adult congenital heart disease (ACHD) [5,6], with several studies demonstrating increased antepartum arrhythmia in ACHD patients compared to non-ACHD controls [[6], [7], [8], [9]]. There however remain significant gaps in the knowledge base regarding this important clinical problem. There is significant heterogeneity among the definition of arrhythmia events in the literature, and granular data regarding the subtypes and clinical course of arrhythmia occurring during pregnancy are limited [5,[10], [11], [12]]. Crucially, risk stratification models for predicting arrhythmia in pregnant ACHD patients are lacking; this represents an unmet need for the ACHD cardiologist and obstetrician alike as it pertains to preconception counseling and ante−/ peripartum monitoring of these patients. Finally, despite significant advances in ACHD arrhythmia management and demonstrable efficacy of catheter ablation during pregnancy, the benefit of preconception catheter ablation on incident arrhythmia risk during pregnancy has not been investigated in the ACHD population [13].

The objectives of our study included (1) comprehensive description of incidence, subtypes and management of antepartum arrhythmia, (2) creation of a risk stratification scheme for predicting occurrence of arrhythmia during pregnancy and (3) description of the therapeutic efficacy and impact of catheter ablation on the risk of future antepartum arrhythmia in patients with ACHD.

Section snippets

Methods

We conducted a retrospective cohort study comprising all patients seen at the Ahmanson/ UCLA Adult Congenital Heart Disease Center with documented pregnancy between 1995 and 2021. All pregnancies with available data were included as separate events, including more than one pregnancy in the same patient. Any patients seen at our center without known CHD were excluded. Data regarding each pregnancy were primarily gathered from retrospective review of the electronic medical record and supplemented

Baseline characteristics

A total of 172 pregnancies in 137 women were included in the study. Median age at pregnancy was 31 years (IQR 26–34) with 44% of the pregnancies in primigravid women. Conception occurred using assisted reproductive technology in 6% of pregnancies, while 3% were twin pregnancies. The most common co-morbidity was history of maternal heart failure, present in 28% of the pregnancies, while preconception alcohol use and hypertension were documented in 20% and 16% respectively.

CHD characteristics are

Discussion

Our study reveals multiple insights which address important deficits in the current knowledge and understanding of antepartum arrhythmia in ACHD patients. Arrhythmia events during pregnancy in ACHD have been widely reported with an incidence of 3–13% in published cohorts, yet most studies do not specify what constituted an arrhythmia event, i.e. whether only symptomatic arrhythmias were included or asymptomatic abnormalities on ambulatory electrocardiographic (ECG) monitoring including

Conclusion

Arrhythmia during pregnancy in patients with ACHD is a major clinical problem that often requires urgent treatment in the acute setting and is most common in the second trimester. Prior arrhythmia is most predictive, followed by the presence of a Fontan circulation. Our data demonstrate the importance of the physiologic class as a modifiable risk factor for arrhythmia, which appears more important than anatomic complexity. We present a three-factor risk score which predicts arrhythmia with a

Disclosures

None of the authors have any relevant disclosures.

Funding

No source of funding was utilized.

CRediT authorship contribution statement

Prashanth Venkatesh: Methodology, Investigation, Formal analysis, Project administration, Writing – original draft. Jeannette P. Lin: Conceptualization, Methodology, Writing – review & editing. Amanda Nguyen: Investigation, Data curation, Writing – review & editing. Joshua Rezkalla: Investigation. Jeremy P. Moore: Conceptualization, Methodology, Supervision, Formal analysis, Writing – review & editing.

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    This author takes responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation.

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