Predictors of arrhythmia during pregnancy in adults with congenital heart disease
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.
References (26)
- et al.
Pregnancy outcomes after the Fontan repair
J. Am. Coll. Cardiol.
(Sep 1996) - et al.
Maternal comorbidities and complications of delivery in pregnant women with congenital heart disease
J. Am. Coll. Cardiol.
(May 7 2019) - et al.
Outcome of pregnancy in women with congenital heart disease: a literature review
J. Am. Coll. Cardiol.
(Jun 19 2007) - et al.
Cardiac and pregnancy outcomes of pregnant patients with congenital heart disease according to risk classification system
Am. J. Cardiol.
(Dec 15 2021) - et al.
Incidence of arrhythmias in normal pregnancy and relation to palpitations, dizziness, and syncope
Am. J. Cardiol.
(Apr 15 1997) - et al.
Pregnancy outcomes in women with heart disease: the CARPREG II study
J. Am. Coll. Cardiol.
(May 29 2018) - et al.
Cardiovascular and neonatal outcomes in pregnant women with high-risk congenital heart disease
Am. J. Cardiol.
(May 15 2016) - et al.
Mechanisms and predictors of recurrent tachycardia after catheter ablation for d-transposition of the great arteries after the mustard or Senning operation
Heart Rhythm.
(Mar 2017) - et al.
Electrophysiological characteristics of atrial tachycardia recurrence: relevance to catheter ablation strategies in adults with congenital heart disease
Heart Rhythm.
(Feb 2022) - et al.
Lifetime prevalence of congenital heart disease in the general population from 2000 to 2010
Circulation.
(Aug 26 2014)
Management of pregnancy in patients with complex congenital heart disease: a scientific statement for healthcare professionals from the american heart association
Circulation
Secular trends in pregnancy rates, delivery outcomes, and related health care utilization among women with congenital heart disease
Congenit. Heart Dis.
Predictors of pregnancy complications in women with congenital heart disease
Eur. Heart J.
Cited by (1)
Predicting antepartum arrhythmias in congenital heart disease: A step forward?
2023, International Journal of Cardiology
- 1
This author takes responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation.