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Wallet T, Legrand L, Isnard R, Gandjbakhch E, Pousset F, Proukhnitzky J, Dommergues M, Nizard J, Charron P. Pregnancy and cardiac maternal outcomes in women with inherited cardiomyopathy: interest of the CARPREG II risk score. ESC Heart Fail 2024; 11:1506-1514. [PMID: 38361389 PMCID: PMC11098662 DOI: 10.1002/ehf2.14694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Revised: 12/21/2023] [Accepted: 01/09/2024] [Indexed: 02/17/2024] Open
Abstract
AIMS Inherited cardiomyopathies are relatively rare but carry a high risk of cardiac maternal morbidity and mortality during pregnancy and postpartum. However, data for risk stratification are scarce. The new CARPREG II score improves prediction of prognosis in pregnancies associated with heart disease, though its role in inherited cardiomyopathies is unclear. We aim to describe characteristics and cardiac maternal outcomes in patients with inherited cardiomyopathy during pregnancy, and to evaluate the interest of the CARPREG II risk score in this population. METHODS AND RESULTS In this retrospective single-centre study, 90 consecutive pregnancies in 74 patients were included (mean age 32 ± 5 years), including 28 cases of dilated cardiomyopathy (DCM), 46 of hypertrophic cardiomyopathy, 11 of arrhythmogenic right ventricular cardiomyopathy and 5 of left ventricular noncompaction, excluding peripartum cardiomyopathy. The discriminatory power of several risk scores was assessed by the area under the receiver-operating characteristic curve (AUC). Median CARPREG II score was 2 [0;3] and was higher in the DCM subgroup. A severe cardiac maternal complication was observed in 18 (20%) pregnancies, mainly driven by arrhythmia and heart failure (each event in 10 pregnancies), with 3 cardiovascular deaths. Forty-three pregnancies (48%) presented foetal/neonatal complications (18 premature delivery, 3 foetal/neonatal death). CARPREG II was significantly associated with cardiac maternal complications (P < 0.05 for all) and showed a higher AUC (0.782) than CARPREG (0.755), mWHO (0.697) and ZAHARA (0.604). CONCLUSIONS Pregnancy in women with inherited cardiomyopathy carries a high risk of maternal cardiovascular complications. CARPREG II is the most efficient predictor of cardiovascular complications in this population.
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Affiliation(s)
- Thomas Wallet
- Department of Cardiology, APHP, ICAN (Institute of CardioMetabolism and Nutrition), Pitié‐Salpêtrière HospitalACTION Study groupParisFrance
- Sorbonne UniversityParisFrance
| | - Lise Legrand
- Department of Cardiology, APHP, ICAN (Institute of CardioMetabolism and Nutrition), Pitié‐Salpêtrière HospitalACTION Study groupParisFrance
| | - Richard Isnard
- Department of Cardiology, APHP, ICAN (Institute of CardioMetabolism and Nutrition), Pitié‐Salpêtrière HospitalACTION Study groupParisFrance
- Sorbonne UniversityParisFrance
| | - Estelle Gandjbakhch
- Department of Cardiology, APHP, ICAN (Institute of CardioMetabolism and Nutrition), Pitié‐Salpêtrière HospitalACTION Study groupParisFrance
- Sorbonne UniversityParisFrance
| | - Françoise Pousset
- Department of Cardiology, APHP, ICAN (Institute of CardioMetabolism and Nutrition), Pitié‐Salpêtrière HospitalACTION Study groupParisFrance
| | - Julie Proukhnitzky
- Department of Cardiology, APHP, ICAN (Institute of CardioMetabolism and Nutrition), Pitié‐Salpêtrière HospitalACTION Study groupParisFrance
- Sorbonne UniversityParisFrance
- Department of GeneticsAPHP, National Referral Center for Inherited Cardiac Diseases, Inserm UMR_1166ParisFrance
| | - Marc Dommergues
- Sorbonne UniversityParisFrance
- Department of Gynecology and ObstetricsAPHP, Pitié‐Salpêtrière HospitalParisFrance
| | - Jacky Nizard
- Sorbonne UniversityParisFrance
- Department of Gynecology and ObstetricsAPHP, Pitié‐Salpêtrière HospitalParisFrance
| | - Philippe Charron
- Department of Cardiology, APHP, ICAN (Institute of CardioMetabolism and Nutrition), Pitié‐Salpêtrière HospitalACTION Study groupParisFrance
- Sorbonne UniversityParisFrance
- Department of GeneticsAPHP, National Referral Center for Inherited Cardiac Diseases, Inserm UMR_1166ParisFrance
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2
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Joglar JA, Kapa S, Saarel EV, Dubin AM, Gorenek B, Hameed AB, Lara de Melo S, Leal MA, Mondésert B, Pacheco LD, Robinson MR, Sarkozy A, Silversides CK, Spears D, Srinivas SK, Strasburger JF, Tedrow UB, Wright JM, Zelop CM, Zentner D. 2023 HRS expert consensus statement on the management of arrhythmias during pregnancy. Heart Rhythm 2023; 20:e175-e264. [PMID: 37211147 DOI: 10.1016/j.hrthm.2023.05.017] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 05/12/2023] [Indexed: 05/23/2023]
Abstract
This international multidisciplinary expert consensus statement is intended to provide comprehensive guidance that can be referenced at the point of care to cardiac electrophysiologists, cardiologists, and other health care professionals, on the management of cardiac arrhythmias in pregnant patients and in fetuses. This document covers general concepts related to arrhythmias, including both brady- and tachyarrhythmias, in both the patient and the fetus during pregnancy. Recommendations are provided for optimal approaches to diagnosis and evaluation of arrhythmias; selection of invasive and noninvasive options for treatment of arrhythmias; and disease- and patient-specific considerations when risk stratifying, diagnosing, and treating arrhythmias in pregnant patients and fetuses. Gaps in knowledge and new directions for future research are also identified.
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Affiliation(s)
- José A Joglar
- The University of Texas Southwestern Medical Center, Dallas, Texas
| | | | - Elizabeth V Saarel
- St. Luke's Health System, Boise, Idaho, and Cleveland Clinic Lerner College of Medicine at Case Western Reserve University, Cleveland, Ohio
| | | | | | | | | | | | | | - Luis D Pacheco
- The University of Texas Medical Branch at Galveston, Galveston, Texas
| | | | - Andrea Sarkozy
- University Hospital of Antwerp, University of Antwerp, Antwerp, Belgium
| | | | - Danna Spears
- University Health Network, Toronto, Ontario, Canada
| | - Sindhu K Srinivas
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | | | | | | | - Carolyn M Zelop
- The Valley Health System, Ridgewood, New Jersey; New York University Grossman School of Medicine, New York, New York
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3
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Arbelo E, Protonotarios A, Gimeno JR, Arbustini E, Barriales-Villa R, Basso C, Bezzina CR, Biagini E, Blom NA, de Boer RA, De Winter T, Elliott PM, Flather M, Garcia-Pavia P, Haugaa KH, Ingles J, Jurcut RO, Klaassen S, Limongelli G, Loeys B, Mogensen J, Olivotto I, Pantazis A, Sharma S, Van Tintelen JP, Ware JS, Kaski JP. 2023 ESC Guidelines for the management of cardiomyopathies. Eur Heart J 2023; 44:3503-3626. [PMID: 37622657 DOI: 10.1093/eurheartj/ehad194] [Citation(s) in RCA: 220] [Impact Index Per Article: 220.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/26/2023] Open
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4
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Zeppenfeld K, Tfelt-Hansen J, de Riva M, Winkel BG, Behr ER, Blom NA, Charron P, Corrado D, Dagres N, de Chillou C, Eckardt L, Friede T, Haugaa KH, Hocini M, Lambiase PD, Marijon E, Merino JL, Peichl P, Priori SG, Reichlin T, Schulz-Menger J, Sticherling C, Tzeis S, Verstrael A, Volterrani M. 2022 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death. Eur Heart J 2022; 43:3997-4126. [PMID: 36017572 DOI: 10.1093/eurheartj/ehac262] [Citation(s) in RCA: 686] [Impact Index Per Article: 343.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
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5
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Delgado-Vega AM, Kommata V, Svennblad B, Wisten A, Hagström E, Stattin EL. Family History and Warning Symptoms Precede Sudden Cardiac Death in Arrhythmogenic Right Ventricular Cardiomyopathy (from a Nationwide Study in Sweden). Am J Cardiol 2022; 178:124-130. [PMID: 35835598 DOI: 10.1016/j.amjcard.2022.05.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 04/20/2022] [Accepted: 05/19/2022] [Indexed: 11/01/2022]
Abstract
Arrhythmogenic right ventricular cardiomyopathy (ARVC) is an inherited cardiac disease explaining about 4% of sudden cardiac death (SCD) cases in the young in Sweden. This study aimed to describe the circumstances preceding SCD in all victims <35 years of age who received an autopsy-confirmed diagnosis of ARVC from January 1, 2000, to December 31, 2010, in Sweden (n = 22). Data on demographics, medical and family history, circumstances of death, and anatomopathological findings were collected from several compulsory national health registries, clinical records, family interviews, and autopsy reports. Registry-based data were compared with age-matched, gender-matched, and geographically-matched population controls. During the 6 months preceding SCD, 15 cases (68%) had experienced symptoms of cardiac origin, mainly syncope or presyncope (54%) and chest discomfort (27%). A total of 8 cases (36%) had sought medical care because of cardiac symptoms. The occurrence of hospital visits was significantly increased in cases compared with controls (odds ratio 4.62 [1.35 to 15.8]). A total of 10 cases (45%) had a family history of SCD. The most common activity at the time of death was exercise (41%). A complete cardiac investigation was seldom performed; only 1 case was diagnosed with ARVC before death. In conclusion, in this nationwide study, we observed a high prevalence of symptoms of cardiac origin, healthcare use, and family history of SCD preceding SCD in the young caused by ARVC. Increased awareness of these warning signals in younger patients is critical to improving risk stratification and early disease detection.
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Affiliation(s)
| | - Varvara Kommata
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden
| | - Bodil Svennblad
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Aase Wisten
- Department of Community Medicine and Rehabilitation, Sunderby Research Unit, Umeå University, Umeå, Sweden
| | - Emil Hagström
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden
| | - Eva-Lena Stattin
- Department of Immunology, Genetics, and Pathology, Uppsala University, Uppsala, Sweden
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6
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Arrhythmias and Heart Failure in Pregnancy: A Dialogue on Multidisciplinary Collaboration. J Cardiovasc Dev Dis 2022; 9:jcdd9070199. [PMID: 35877562 PMCID: PMC9320047 DOI: 10.3390/jcdd9070199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 06/17/2022] [Accepted: 06/18/2022] [Indexed: 02/04/2023] Open
Abstract
The prevalence of CVD in pregnant people is estimated to be around 1 to 4%, and it is imperative that clinicians that care for obstetric patients can promptly and accurately diagnose and manage common cardiovascular conditions as well as understand when to promptly refer to a high-risk obstetrics team for a multidisciplinary approach for managing more complex patients. In pregnant patients with CVD, arrhythmias and heart failure (HF) are the most common complications that arise. The difficulty in the management of these patients arises from variable degrees of severity of both arrhythmia and heart failure presentation. For example, arrhythmia-based complications in pregnancy can range from isolated premature ventricular contractions to life-threatening arrhythmias such as sustained ventricular tachycardia. HF also has variable manifestations in pregnant patients ranging from mild left ventricular impairment to patients with advanced heart failure with acute decompensated HF. In high-risk patients, a collaboration between the general obstetrics, maternal-fetal medicine, and cardiovascular teams (which may include cardio-obstetrics, electrophysiology, adult congenital, or advanced HF)—physicians, nurses and allied professionals—can provide the multidisciplinary approach necessary to properly risk-stratify these women and provide appropriate management to improve outcomes.
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7
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Approach to inherited arrhythmias in pregnancy. INTERNATIONAL JOURNAL OF CARDIOLOGY CONGENITAL HEART DISEASE 2021. [DOI: 10.1016/j.ijcchd.2021.100264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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8
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van der Voorn SM, Te Riele ASJM, Basso C, Calkins H, Remme CA, van Veen TAB. Arrhythmogenic cardiomyopathy: pathogenesis, pro-arrhythmic remodelling, and novel approaches for risk stratification and therapy. Cardiovasc Res 2021; 116:1571-1584. [PMID: 32246823 PMCID: PMC7526754 DOI: 10.1093/cvr/cvaa084] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Revised: 03/10/2020] [Accepted: 03/30/2020] [Indexed: 02/07/2023] Open
Abstract
Arrhythmogenic cardiomyopathy (ACM) is a life-threatening cardiac disease caused by mutations in genes predominantly encoding for desmosomal proteins that lead to alterations in the molecular composition of the intercalated disc. ACM is characterized by progressive replacement of cardiomyocytes by fibrofatty tissue, ventricular dilatation, cardiac dysfunction, and heart failure but mostly dominated by the occurrence of life-threatening arrhythmias and sudden cardiac death (SCD). As SCD appears mostly in apparently healthy young individuals, there is a demand for better risk stratification of suspected ACM mutation carriers. Moreover, disease severity, progression, and outcome are highly variable in patients with ACM. In this review, we discuss the aetiology of ACM with a focus on pro-arrhythmic disease mechanisms in the early concealed phase of the disease. We summarize potential new biomarkers which might be useful for risk stratification and prediction of disease course. Finally, we explore novel therapeutic strategies to prevent arrhythmias and SCD in the early stages of ACM.
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Affiliation(s)
- Stephanie M van der Voorn
- Division of Heart and Lungs, Department of Medical Physiology, University Medical Center Utrecht, PO Box 85060, Utrecht 3508 AB, The Netherlands
| | - Anneline S J M Te Riele
- Division of Heart and Lungs, Department of Cardiology, University Medical Center Utrecht, PO Box 85060, Utrecht 3508 AB, The Netherlands
| | - Cristina Basso
- Cardiovascular Pathology Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua Medical School, Via A. Gabelli, 61 35121 Padova, Italy
| | - Hugh Calkins
- Johns Hopkins Hospital, Sheikh Zayed Tower 7125R, Baltimore, MD 21287, USA
| | - Carol Ann Remme
- Department of Clinical and Experimental Cardiology, Heart Centre, Amsterdam UMC, Location Academic Medical Center, University of Amsterdam, Amsterdam 1105AZ, The Netherlands
| | - Toon A B van Veen
- Division of Heart and Lungs, Department of Medical Physiology, University Medical Center Utrecht, PO Box 85060, Utrecht 3508 AB, The Netherlands
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9
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Process of Care and a Practical Toolkit for Evaluating and Managing Arrhythmic Risk in the Cardiogenetic Pregnant Patient. Can J Cardiol 2021; 37:2001-2013. [PMID: 34416260 DOI: 10.1016/j.cjca.2021.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 07/26/2021] [Accepted: 08/04/2021] [Indexed: 11/22/2022] Open
Abstract
Patients with inherited arrhythmia syndromes (IASs) and inherited cardiomyopathies (ICs) are periodically encountered in both general and specialist practices. These syndromes include long QT syndrome, catecholaminergic polymorphic ventricular tachycardia, Brugada syndrome, early repolarisation syndrome, and hypertrophic and arrhythmogenic cardiomyopathies. In general, the presence of an IAS or IC is not a contraindication to pregnancy, but does require additional expertise and patient engagement. In this review, we summarise the various pregnancy-related considerations in patients with IAS and IC, including the impact of physiologic/hemodynamic changes on heart failure progression or arrhythmia propensity, maternal and fetal pregnancy risk stratification, prenatal genetic testing, and the specialised care and monitoring required through pregnancy, labour, and delivery and into the postpartum period. Management of patients with IASs and IC during pregnancy and the postpartum period requires collaboration between patient and provider, with a shared understanding of the general safety and potential risks during the pregnancy and postpartum periods. Patients should be aware of the safety of various medications throughout pregnancy, and those with implantable cardioverter-defibrillators should be managed according to device guidelines. A peripartum care and delivery plan should be established, with multidisciplinary input from various specialists including obstetrics, cardiac obstetrics, and inherited arrhythmia specialists wherever appropriate.
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10
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Dodeja AK, Siegel F, Dodd K, Ma'ayeh M, Mehta LS, Fuchs MM, Rood KM, Mah ML, Bradley EA. Heart failure in pregnancy: what is the long-term impact of pregnancy on cardiac function? A tertiary care centre experience and systematic review. Open Heart 2021; 8:openhrt-2021-001587. [PMID: 34344721 PMCID: PMC8336161 DOI: 10.1136/openhrt-2021-001587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Accepted: 07/15/2021] [Indexed: 11/04/2022] Open
Abstract
Background Women with cardiomyopathy (CM) are often advised against pregnancy due to risk for major adverse cardiovascular events (MACE). However, the impact of CM subtype on maternal MACE is not understood, and so we sought to evaluate the influence of CM phenotype on maternal outcomes, as well as the effect on immediate and late left ventricular function. Methods We evaluated all pregnant women in our high-risk maternal cardiovascular programme (2009–2019). Composite maternal MACE included: death, inotrope use, left ventricular assist device, orthotopic heart transplant and/or escalation in transplant listing status, acute decompensated heart failure and sustained ventricular arrhythmia. Results Among 875 women followed, 32 had CM (29±7 years old, left ventricular ejection fraction (LVEF) 41%±12%): 3 ischaemic CM (ICM), 10 peripartum CM (PPCM) and 19 non-ICM (NICM). MACE events occurred in 6 (18%) women (PPCM: 2 (33%), NICM: 4 (67%)). There was no difference in LVEF at baseline, however, women with MACE had significantly lower LVEF both early (LVEF: 27±5% vs. 41±2%, p<0.05) and late post partum (LVEF: 28±5% vs. 44±2%, p<0.01). Conclusions In this contemporary cohort of women with CM, maternal MACE rates were lower than previously reported, and were less common in PPCM as compared with ICM and NICM. Heart function in women with MACE was negatively impacted immediately after delivery and in late postpartum follow-up, suggesting that pregnancy itself likely has influence on future left ventricular function in women with underlying CM.
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Affiliation(s)
- Anudeep K Dodeja
- Division of Cardiology, Nationwide Children's Hospital, Columbus, Ohio, USA .,Department of Internal Medicine, Division of Cardiovascular Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Francesca Siegel
- The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Katherine Dodd
- Department of Internal Medicine, Division of Cardiovascular Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Marwan Ma'ayeh
- Department of Obstetrics & Gynecology, Division of Maternal Fetal Medicine, The Ohio State University, Columbus, OH, USA
| | - Laxmi S Mehta
- Department of Internal Medicine, Division of Cardiovascular Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Margaret M Fuchs
- Mayo Clinic Division of Cardiovascular Diseases, Rochester, Minnesota, USA
| | - Kara M Rood
- Department of Obstetrics & Gynecology, Division of Maternal Fetal Medicine, The Ohio State University, Columbus, OH, USA
| | - May Ling Mah
- Division of Cardiology, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Elisa A Bradley
- Department of Internal Medicine, Division of Cardiovascular Medicine, The Ohio State University, Columbus, Ohio, USA
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11
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Asher C, Thomas T, Rinaldi CA, Carr‐White G. A case of mistaken arrhythmogenic identity during pregnancy. Clin Case Rep 2021; 9:e04561. [PMID: 34386235 PMCID: PMC8344966 DOI: 10.1002/ccr3.4561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Revised: 06/03/2021] [Accepted: 06/16/2021] [Indexed: 11/26/2022] Open
Abstract
Atypical LVOT ectopy can present with an RVOT morphology on ECG and differentiation to reveal this focus is in favor of benign idiopathic ventricular ectopy over an arrhythmogenic cardiomyopathy.
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Affiliation(s)
- Clint Asher
- School of Biomedical Engineering and Imaging SciencesRayne InstituteKing’s College LondonSt Thomas HospitalLondonUK
- Department of CardiologyGuy’s and St Thomas’ NHS Foundation TrustLondonUK
| | - Tessa Thomas
- Department of Acute MedicineMaidstone and Tunbridge Wells NHS TrustKentUK
| | - Christopher A. Rinaldi
- School of Biomedical Engineering and Imaging SciencesRayne InstituteKing’s College LondonSt Thomas HospitalLondonUK
- Department of CardiologyGuy’s and St Thomas’ NHS Foundation TrustLondonUK
| | - Gerry Carr‐White
- School of Biomedical Engineering and Imaging SciencesRayne InstituteKing’s College LondonSt Thomas HospitalLondonUK
- Department of CardiologyGuy’s and St Thomas’ NHS Foundation TrustLondonUK
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12
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Platonov PG, Castrini AI, Svensson A, Christiansen MK, Gilljam T, Bundgaard H, Madsen T, Heliö T, Christensen AH, Åström MA, Carlson J, Edvardsen T, Jensen HK, Haugaa KH, Svendsen JH. Pregnancies, ventricular arrhythmias, and substrate progression in women with arrhythmogenic right ventricular cardiomyopathy in the Nordic ARVC Registry. Europace 2021; 22:1873-1879. [PMID: 32681178 DOI: 10.1093/europace/euaa136] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Accepted: 05/18/2020] [Indexed: 11/13/2022] Open
Abstract
AIMS Women with arrhythmogenic right ventricular cardiomyopathy (ARVC) are at relatively lower risk of ventricular arrhythmias (VAs) than men, but the physical burden associated with pregnancy on VA risk remains insufficiently studied. We aimed to assess the risk of VA in relation to pregnancies in women with ARVC. METHODS AND RESULTS We included 199 females with definite ARVC (n = 121) and mutation-positive family members without ascertained ARVC diagnosis (n = 78), of whom 120 had at least one childbirth. Ventricular arrhythmia-free survival after the latest childbirth was compared between women with one (n = 20), two (n = 67), and three or more (n = 37) childbirths. Cumulative probability of VA for each pregnancy (n = 261) was assessed from conception through 2 years after childbirth and compared between those pregnancies that occurred before (n = 191) or after (n = 19) ARVC diagnosis and in mutation-positive family members (n = 51). The nulliparous women had lower median age at ARVC diagnosis (38 vs. 42 years, P < 0.001) and first VA (22 vs. 41 years, P < 0.001). Ventricular arrhythmia-free survival after the latest childbirth was not related to the number of pregnancies. No pregnancy-related VA was reported among the family members. Women who gave birth after ARVC diagnosis had elevated risk of VA postpartum (hazard ratio 13.74, 95% confidence interval 2.9-63, P = 0.001), though only two events occurred during pregnancies. CONCLUSION In women with ARVC, pregnancy was uneventful for the overwhelming majority and the number of prior completed pregnancies was not associated with VA risk. Pregnancy-related VA was primarily related to the phenotypical severity rather than pregnancy itself.
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Affiliation(s)
- Pyotr G Platonov
- Department of Cardiology, Clinical Sciences, Lund University, 22185 Lund, Sweden
| | - Anna I Castrini
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway.,Institute for clinical Medicine, University of Oslo, Oslo, Norway
| | - Anneli Svensson
- Department of Cardiology, Linköping University, Linköping, Sweden.,Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Morten K Christiansen
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Thomas Gilljam
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Henning Bundgaard
- Department of Cardiology, Centre of Cardiac-, Vascular-, Pulmonary- and Infectious Diseases, Rigshospitalet, Copenhagen, Denmark.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Trine Madsen
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
| | - Tiina Heliö
- Department of Cardiology, Helsinki University Hospital, Helsinki, Finland
| | - Alex H Christensen
- Department of Cardiology, Herlev-Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Meriam Aneq Åström
- Department of Clinical Physiology, Linköping University, Linköping, Sweden.,Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
| | - Jonas Carlson
- Department of Cardiology, Clinical Sciences, Lund University, 22185 Lund, Sweden
| | - Thor Edvardsen
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway.,Institute for clinical Medicine, University of Oslo, Oslo, Norway
| | - Henrik K Jensen
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Kristina H Haugaa
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway.,Institute for clinical Medicine, University of Oslo, Oslo, Norway
| | - Jesper H Svendsen
- Department of Cardiology, Centre of Cardiac-, Vascular-, Pulmonary- and Infectious Diseases, Rigshospitalet, Copenhagen, Denmark.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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13
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Wichter T, Milberg P, Wichter HD, Dechering DG. Pregnancy in arrhythmogenic cardiomyopathy. Herzschrittmacherther Elektrophysiol 2021; 32:186-198. [PMID: 34032905 PMCID: PMC8166670 DOI: 10.1007/s00399-021-00770-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Accepted: 04/06/2021] [Indexed: 12/11/2022]
Abstract
Arrhythmogenic cardiomyopathy (AC) is a rare heart muscle disease with a genetic background and autosomal dominant mode of transmission. The clinical manifestation is characterized by ventricular arrhythmias (VA), heart failure (HF) and the risk of sudden cardiac death (SCD). Pregnancy in young female patients with AC represents a challenging condition for the life and family planning of young affected women. In addition to genetic mechanisms that influence the complex pathophysiology of AC, experimental and clinical data have confirmed the pathogenetic role of strenuous exercise and competitive sports in the early onset and rapid progression of AC symptoms and complications. Pregnancy and exercise share a number of physiological aspects of adaptation. In AC, both result in ventricular volume overload and myocardial stretch. Therefore, pregnancy has been postulated as a potential risk factor for HF, VA, SCD, and pregnancy-related obstetric complications in patients with AC. However, the available evidence on pregnancy in AC does not confirm this hypothesis. In most women with AC, pregnancies are well tolerated, uneventful, and follow a benign course. Pregnancy-related symptoms (VA, syncope, HF) and mortality, as well as obstetric complications, are uncommon in AC patients and range in the order of background populations and cohorts with AC and no pregnancy. The number of completed pregnancies is not associated with an acceleration of AC pathology or an increased risk of VA or HF during pregnancy and follow-up. Accordingly, there is no medical indication to advise against pregnancy in patients with AC. Preconditions include stability of rhythm and hemodynamics at baseline, as well as clinical follow-ups and the availability of multidisciplinary expert consultation during pregnancy and postpartum. Genetic counseling is recommended prior to pregnancy for all couples and their families affected by AC.
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Affiliation(s)
- Thomas Wichter
- Klinik für Innere Medizin / Kardiologie, Niels-Stensen-Kliniken, Marienhospital Osnabrück, Herzzentrum Osnabrück/Bad Rothenfelde, Bischofsstr. 1, 49074, Osnabrück, Germany.
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14
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Khosla J, Golamari R, Cai A, Benson J, Aronow WS, Jain R, Jain R. Evidence-based management of arrhythmogenic right ventricular cardiomyopathy in pregnancy. Future Cardiol 2020; 17:693-703. [PMID: 33089714 DOI: 10.2217/fca-2020-0127] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Arrhythmogenic right ventricular cardiomyopathy (ARVC) is a genetic disorder resulting in fibrofatty replacement of the myocardium. Genetic mutations in genes encoding for desmosome proteins result in a ventricular myocardium prone to arrhythmias and heart failure. Although ARVC is known for a few decades, most of the outcomes in pregnancy are reported recently. Pregnancy leads to significant physiological changes with excess mechanical stress on the myocardium. All the retrospective studies suggest that pregnancy is well tolerated in these patients despite the high risk of arrhythmias and heart failure. Our review focuses on the most up-to-date evidence on the management of ARVC patients during the antepartum and postpartum period.
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Affiliation(s)
- Jagjit Khosla
- Department of Internal Medicine, Westchester Medical Center, Valhalla, New York, NY 10595, USA
| | - Reshma Golamari
- Penn State Health Milton S Hershey Medical Center, Hershey, PA 17033, USA
| | - Alice Cai
- Penn State University College of Medicine, PA 17033, USA
| | - Jamal Benson
- Penn State University College of Medicine, PA 17033, USA
| | - Wilbert S Aronow
- Department of Cardiology, Westchester Medical Center, Valhalla, NY 10595, USA
| | - Rahul Jain
- Department of Cardiology, Indiana University, IN 46202, USA
| | - Rohit Jain
- Penn State Health Milton S Hershey Medical Center, Hershey, PA 17033, USA
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Abstract
The cardiomyopathies are a diverse group of disorders characterized by structural abnormalities of heart muscle, many of which have a genetic component. They are associated with substantial morbidity and mortality in pregnancy. We review the distinct forms of cardiomyopathy (dilated, hypertrophic, and functional) which can be seen during pregnancy, discuss complications associated with each distinct group such as heart failure, arrhythmias, and transmission to offspring, and address management strategies for stable and unstable patients.
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Manolis TA, Manolis AA, Apostolopoulos EJ, Papatheou D, Melita H, Manolis AS. Cardiac arrhythmias in pregnant women: need for mother and offspring protection. Curr Med Res Opin 2020; 36:1225-1243. [PMID: 32347120 DOI: 10.1080/03007995.2020.1762555] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Cardiac arrhythmias are the most common cardiac complication reported in pregnant women with and without structural heart disease (SHD); they are more frequent among women with SHD, such as cardiomyopathy and congenital heart disease (CHD). While older studies had indicated supraventricular tachycardia as the most common tachyarrhythmia in pregnancy, more recent data indicate an increase in the frequency of arrhythmias, with atrial fibrillation (AF) emerging as the most frequent arrhythmia in pregnancy, attributed to an increase in maternal age, cardiovascular risk factors and CHD in pregnancy. Importantly, the presence of any tachyarrhythmia during pregnancy may be associated with adverse maternal and fetal outcomes, including death. Thus, both the mother and the offspring need to be protected from such consequences. The use of antiarrhythmic drugs (AADs) depends on clinical presentation and on the presence of underlying SHD, which requires caution as it promotes pro-arrhythmia. In hemodynamically compromised women, electrical cardioversion is successful and safe to both mother and fetus. Use of beta-blockers appears quite safe; however, caution is advised when using other AADs, while no AAD should be used, if at all possible, during the first trimester when organogenesis takes place. Regarding the anticoagulation regimen in patients with AF, warfarin should be substituted with heparin during the first trimester, while direct oral anticoagulants are not indicated given the lack of data in pregnancy. Finally, for refractory arrhythmias, ablation and/or device implantation can be performed with current techniques in pregnant women, when needed, using minimal exposure to radiation. All these issues and relevant current guidelines are herein reviewed.
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Luo FY, Chadha R, Osborne C, Kealey A. Arrhythmogenic Right Ventricular Cardiomyopathy (ARVC) in pregnancy: a case series of nine patients and review of literature. J Matern Fetal Neonatal Med 2020; 35:1230-1238. [PMID: 32241198 DOI: 10.1080/14767058.2020.1745176] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Background: Arrhythmogenic right ventricular cardiomyopathy (ARVC) is a genetic cardiomyopathy characterized by myocardial necrosis and fibrofatty substitution of the myocardium, predominantly of the right ventricle. The evaluation of risk associated with gestation and delivery in patients with ARVC is difficult due to the small number of already reported cases. We present our experience of patients with ARVC who completed a pregnancy and delivery.Methods: A case series of nine women in Calgary, Canada, from 2013 to 2018, who were diagnosed with ARVC before or during pregnancy. Patients were identified using our Cardiac-Obstetrics database, and information was collected through electronic charts and patient recollection.Results: All pregnancies reported were singleton with an average maternal age of 31 years. Six patients had a related genetic mutation. Beta blockers were being used by eight, and five had an implantable cardioverter-defibrillator (ICD) prior to the pregnancy. None of the patients developed heart failure during pregnancy, but one had a complicated antepartum and postpartum course. All pregnancies delivered at term with eight receiving neuroaxial analgesia. Five patients delivered vaginally. Those without an ICD had continuous cardiac monitoring intrapartum. The incidence of small for gestational age (33%) was higher than the general population. All of the patients breastfed the newborns.Conclusions: Pregnancies in these patients with ARVC were generally well tolerated. Given the rarity of the disease and absence of any clinical guidelines, multidisciplinary care is essential in the management of these patients.
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Affiliation(s)
- Fang Yuan Luo
- Department of Obstetrics and Gynecology, University of Calgary, Calgary, Canada
| | - Rati Chadha
- Department of Obstetrics and Gynecology, Maternal Fetal Medicine, University of Calgary, Calgary, Canada
| | - Christine Osborne
- Department of Obstetrics and Gynecology, University of Calgary, Calgary, Canada
| | - Angela Kealey
- Department of Cardiac Sciences, University of Calgary, Calgary, Canada
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Effect of Pregnancy in Arrhythmogenic Right Ventricular Cardiomyopathy. Am J Cardiol 2020; 125:613-617. [PMID: 31836129 DOI: 10.1016/j.amjcard.2019.11.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2019] [Revised: 11/10/2019] [Accepted: 11/13/2019] [Indexed: 11/22/2022]
Abstract
Less is known about pregnancy in women with arrhythmogenic right ventricular cardiomyopathy (ARVC). From April 1995 to May 2018, 157 women with ARVC were retrospectively enrolled. Data on pregnancy and cardiac outcomes were analyzed. There were 224 pregnancies in 120 patients including 30 (13.4%) spontaneous and 2 (0.9%) medical abortions, 12 cardiac adverse events were recorded including new onset frequent premature ventricular contractions (PVC) in 3 (2.5%) patients, previous PVC numbers increased more than 100% in 5 (4.2%), syncope in 2 (1.7%), sustained ventricular tachycardia and heart failure required hospitalization each in one patient (0.8%). Women with cardiac events showed lower left ventricular ejection fraction (LVEF) (50.3 ± 2.7 vs 60.0 ± 7.3; p = 0.004). No significant change in cardiac structure and function was found at 1 year follow-up postpartum. At a median follow-up of 8 (1 to 32) years, 36 (22.9%) women died. Earlier symptom onset age (hazard ratio 1.046; 95% confidence interval 1.017 to 1.075; p = 0.002) and decreased LVEF (hazard ratio 1.127; 95% confidence interval 1.001 to 1.154; p = 0.041) increased the risk of all-cause mortality, pregnancy had no negative influence on survival. In all the 192 offsprings (mean age 26.3 ± 13.5 years), 2 died of sudden death, no definite ARVC was found. Pregnancy seemed to be acceptable in ARVC, decreased LVEF increased the risk of pregnancy and was associated with poorer long-term survival.
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Abstract
Pregnancy is a period of increased cardiovascular risk in a woman's life. In the setting of an inherited arrhythmia syndrome (IAS), cardiologists and obstetricians may be unfamiliar with cardiovascular optimization and risk stratification in pregnancy. Historically, there were little data addressing the safety of pregnancy in these rare disorders. Recent advances suggest that no type of IAS represents an absolute contraindication to pregnancy. However, it is imperative that obstetric and cardiovascular clinicians understand the major forms of IAS and how they affect the risks and course of pregnancy. This includes any disease-specific proarrhythmic triggers unique to pregnancy, such as the postpartum period in long QT syndrome (especially type 2), which poses the greatest risk of arrhythmias, and the adrenergic nature of labor and delivery, which is relevant to catecholaminergic polymorphic ventricular tachycardia. Fortunately, several effective antiarrhythmic options exist that pose little fetal risk. IAS-specific optimization of implantable cardioverter-defibrillator algorithms, drug therapy, and a maternal cardiac plan addressing the antepartum, labor, and delivery and postpartum periods reduces the risk. Where evidence does not exist, there are plausible mechanistic considerations to guide clinicians. To achieve optimal outcomes, early involvement of an expert pregnancy heart team comprising obstetrics, genetics, cardiology, and anesthesiology team members and a shared decision-making approach to IAS issues in pregnancy are needed.
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Abstract
Cardiomyopathy is a group of disorders in which the heart muscle is structurally and functionally abnormal in the absence of other diseases that could cause observed myocardial abnormality. The most common cardiomyopathies are hypertrophic and dilated cardiomyopathy. Rare types are arrhythmogenic right ventricular, restrictive, Takotsubo and left ventricular non-compaction cardiomyopathies. This review of cardiomyopathies in pregnancy shows that peripartum cardiomyopathy is the most common cardiomyopathy in pregnancy. Peripartum cardiomyopathy develops most frequently in the month before or after partum, whereas dilated cardiomyopathy often is known already or develops in the second trimester. Mortality in peripartum cardiomyopathy varies from <2% to 50%. Few reports on dilated cardiomyopathy and pregnancy exist, with only a limited number of patients. Ventricular arrhythmias, heart failure, stroke and death are found in 39%-60% of high-risk patients. However, patients with modest left ventricular dysfunction and good functional class tolerated pregnancy well. Previous studies on >700 pregnancies in 500 women with hypertrophic cardiomyopathy showed that prognosis was generally good, even though three deaths were reported in high-risk patients. Complications include different types of supraventricular and ventricular arrhythmias, heart failure and ischaemic stroke. Recent studies on 200 pregnancies in 100 women with arrhythmogenic right ventricular cardiomyopathy have reported symptoms, including heart failure in 18%-33% of pregnancies. Ventricular tachycardia was found in 0%-33% of patients and syncope in one patient. Information on rare cardiomyopathies is sparse and only presented in case reports. Close monitoring by multidisciplinary teams in referral centres that counsel patients before conception and follow them throughout gestation is recommended.
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Sex-related differences in cardiomyopathies. Int J Cardiol 2019; 286:239-243. [DOI: 10.1016/j.ijcard.2018.10.091] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2018] [Revised: 10/10/2018] [Accepted: 10/26/2018] [Indexed: 01/14/2023]
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Tsatsopoulou A. Arrhythmogenic right ventricular cardiomyopathy and pregnancy. Int J Cardiol 2018; 258:199-200. [PMID: 29544930 DOI: 10.1016/j.ijcard.2018.01.081] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Accepted: 01/18/2018] [Indexed: 12/24/2022]
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