Ablation of severe drug-resistant tachyarrhythmia during pregnancy

An Overview of Arrhythmias in Pregnancy

Cardiovascular disease significantly jeopardizes pregnancies in the United States, impacting 1% to 4% of pregnancies annually. Among complications, cardiac arrhythmias are prevalent, posing concerns for maternal and fetal health. The incidence of arrhythmias during pregnancy is rising, partly due to advances in congenital heart surgery and a growing population of women with structural heart disease. While most arrhythmias are benign, the increasing prevalence of more serious arrhythmias warrants a proactive approach. Guidance and reassurance suffice in many cases, but persistent symptoms require cautious use of antiarrhythmic drugs or other therapies for a safe outcome. Managing more serious arrhythmias requires a comprehensive, multidisciplinary approach involving specialists, including maternal-fetal medicine physicians, cardiologists, electrophysiologists, and anesthesiologists.

Pregnancy Arrhythmias: Management in the Emergency Department and Critical Care

Pregnancy is closely associated with an elevated risk of arrhythmias, constituting the predominant cardiovascular complication during this period. Pregnancy may induce the exacerbation of previously controlled arrhythmias and, in some instances, arrhythmias may present for the first time in pregnancy. The most important proarrhythmic mechanisms during pregnancy are the atrial and ventricular stretching, coupled with increased sympathetic activity. Notably, arrhythmias, particularly those originating in the ventricles, heighten the likelihood of syncope, increasing the potential for sudden cardiac death. The effective management of arrhythmias during the peripartum period requires a comprehensive, multidisciplinary approach from the prepartum to the postpartum period. The administration of antiarrhythmic drugs during pregnancy necessitates meticulous attention to potential alterations in pharmacokinetics attributable to maternal physiological changes, as well as the potential for fetal adverse effects. Electric cardioversion is a safe and effective intervention during pregnancy and should be performed immediately in patients with hemodynamic instability. This review discusses the pathophysiology of arrythmias in pregnancy and their management.

Comparison of minimal versus zero-fluoroscopic catheter ablation in gestational supraventricular arrhythmias

BACKGROUND

The management of symptomatic gestational supraventricular tachycardia (SVT) is challenging and requires a multidisciplinary approach for optimal management. Catheter ablation during pregnancy has traditionally been considered a last option due to procedural safety and ionizing radiation risks. Recent advances including intracardiac echocardiography and multi-electrode electroanatomic mapping have greatly enhanced the safety and efficacy profile to successfully perform ablations with minimal to no fluoroscopy even during pregnancy. This is the first review to compare the efficacy, safety, and aggregate outcomes of purely zero-fluoroscopic and minimal fluoroscopic approaches in gestational SVT.

METHODS

A literature search was performed for catheter ablations in the past 15 years for gestational arrhythmias that used minimal or no fluoroscopy. Sixteen cases describing catheter ablations with zero-fluoroscopy were compared to twenty-four cases using minimal fluoroscopy, defined as total documented exposure time of less than 10 min.

RESULTS

Analysis of both groups demonstrated that zero-fluoroscopic approaches have comparable efficacy and procedural safety outcomes with the utilization of earlier trimester ablations and in older maternal ages. The utilization of electroanatomic mapping with or without concomitant intracardiac echocardiography in the zero-fluoroscopy group further demonstrated equal efficacy rates of successful ablation when compared to the control group. Furthermore, there were no reported immediate or long-term periprocedural complications in either group, including delivery outcomes.

CONCLUSION

Our review demonstrates that zero-fluoroscopy catheter ablation for SVT in pregnancy is both effective and safe when compared to minimal fluoroscopy ablations while eliminating the theoretical risks of ionizing radiation.

Racial, ethnic, and sex disparities in atrial fibrillation management: rate and rhythm control

BACKGROUND

Atrial fibrillation (AF) affects around 6 million Americans. AF management involves pharmacologic therapy and/or interventional procedures to control rate and rhythm, as well as anticoagulation for stroke prevention. Different populations may respond differently to distinct management strategies. This review will describe disparities in rate and rhythm control and their impact on outcomes among women and historically underrepresented racial and/or ethnic groups.

METHODS

This is a narrative review exploring the topic of sex and racial and/or ethnic disparities in rate and rhythm management of AF. We describe basic terminology, summarize AF epidemiology, discuss diversity in clinical research, and review landmark clinical trials.

RESULTS

Despite having higher rates of traditional AF risk factors, Black and Hispanic adults have lower risk of AF than non-Hispanic White (NHW) patients, although those with AF experience more severe symptoms and report lower quality-of-life scores than NHW patients with AF. NHW patients receive antiarrhythmic drugs, cardioversions, and invasive therapies more frequently than Black and Hispanic patients. Women have lower rates of AF than men, but experience more severe symptoms, heart failure, stroke, and death after AF diagnosis. Women and people from diverse racial and ethnic backgrounds are inadequately represented in AF trials; prevalence findings may be a result of underdetection.

CONCLUSION

Race, ethnicity, and gender are social determinants of health that may impact the prevalence, evolution, and management of AF. This impact reflects differences in biology as well as disparities in treatment and representation in clinical trials.

Arrhythmias and Heart Failure in Pregnancy: A Dialogue on Multidisciplinary Collaboration

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.

Efficacy and Safety of Zero-Fluoroscopy Approach during Catheter Ablation of Accessory Pathway

Background: Catheter ablation (CA) is a safe and efficient treatment in patients with an atrioventricular accessory pathway (AP). Electroanatomical mapping (EAM) systems are useful during CA of AP, especially for reducing fluoroscopy. There are limited data about the feasibility of CA procedures performed with the use of the EAM system entirely without fluoroscopy in adults with AP. The aim of the study is to assess the feasibility, efficacy and safety of CA with the use of EAM without fluoroscopy, compared to CA with EAM and fluoroscopy in patients with AP. Methods: The study included 83 consecutive patients (age 38.25 ± 15.8 years), who were subjected to CA for AP. In 40 patients CA was performed with the use of EAM without fluoroscopy (EAM group), and in 43 patients CA was performed with EAM and fluoroscopy (control group). Baseline characteristics, procedure parameters and complications were obtained from the medical records. Data on permanent success rate was obtained after the mean follow-up time of 1 year. Primary outcomes were acute procedural success rate, long term success rate at 1-year follow-up and complications. Secondary outcomes were the procedure time and number of applications. Results: There were no statistically significant differences in baseline characteristics between the groups, except for the AP locations. Right-sided AP was more common in the EAM group, while left-sided AP was more common in the control group (p = 0.007 and p = 0.004, respectively). Acute procedural success was achieved in 38 patients (95.0%) in the EAM group and in 39 patients (90.7%) in the control group (p = 0.449). Long term success rate was achieved in 36 patients (90.0%) in the EAM group and in 36 (83.7%) patients in the control group (p = 0.399). There was one minor complication in the form of RBBB in the EAM group (p = 0.138). The mean procedure time was shorter in the EAM group compared to the control group (93.0 ± 58.3 min vs. 127.6 ± 57.5 min; p = 0.009). Conclusions: CA of both right-sided and left-sided AP completely guided by EAM without the use of fluoroscopy is feasible, safe and effective.

Pregnancy-related inappropriate sinus tachycardia: A cohort analysis of maternal and fetal outcomes

Background

Little literature exists regarding the syndrome of inappropriate sinus tachycardia during pregnancy. We aimed to further understand the natural history of inappropriate sinus tachycardia in pregnancy, and to explore maternal and fetal outcomes.

Methods

A retrospective, observational cohort analysis of 19 pregnant women who presented with inappropriate sinus tachycardia.

Results

42% attended the emergency department on more than one occasion with symptoms of inappropriate sinus tachycardia; 32% required hospital admission and 26% required pharmacological therapy. There were no maternal deaths, instances of heart failure or acute coronary syndrome, and no thromboembolic or haemorrhagic complications during pregnancy. Rates of caesarean section were similar to the background rate of our unit (32% and 27%, respectively). Rates of induction were notably elevated (58% vs 25%).

Conclusion

Inappropriate sinus tachycardia in pregnancy is associated with high rates of hospitalization and induction of labour, which may not be mandatory given the clinical findings in this group of women.

Maternal focal atrial tachycardia during pregnancy: A systematic review

INTRODUCTION

The presentation and optimal management of maternal focal atrial tachycardia (AT) during pregnancy are unknown. The objective of this study is to conduct a comprehensive summary of the existing evidence.

METHODS AND RESULTS

A systematic review of all reported cases of maternal focal AT during pregnancy was performed. The primary search queried PubMed using the MeSH terms "supraventricular tachycardia" and "pregnancy." A stepwise ancillary search included article bibliographies, citations listed by the Google internet search engine, and PubMed using the MeSH terms "atrial tachycardia" and "pregnancy." In total, 28 citations that described 32 patients were retrieved. A case from our institution was added. Detailed information was available for 30 patients. Clinical characteristics at presentation included a mean ± standard deviation of 28.3 ± 5.7 years for maternal age and 24.6 ± 7.7 weeks for gestation age. Suspected tachycardia-induced cardiomyopathy was present in 20 of 30 (67%) patients and left ventricular ejection fraction improved in 15 of 15 (100%) patients with follow-up measurements. Medication failure was common. Focal AT resolved spontaneously after delivery in eight of nine (89%) patients treated with only medications. Automaticity was suggested by discrete electrograms at sites of origin and lack of reported inducibility and termination with programmed stimulation in all patients who underwent electrophysiology studies. There were nine cases of successful catheter ablation with zero fluoroscopy since 2010.

CONCLUSIONS

Automaticity is the dominant mechanism for patients with maternal focal AT during pregnancy. Catheter ablation with zero fluoroscopy is an emerging therapy for medically refractory cases.

State of Fluoroless Procedures in Cardiac Electrophysiology Practice

In the past decade, the use of interventional electrophysiological (EP) procedures for the diagnosis and treatment of cardiac arrhythmias has exponentially increased. These procedures usually require fluoroscopy to guide the advancement and frequent repositioning of intracardiac catheters, resulting in both the patient and the operator being subjected to a considerable degree of radiation exposure. Although shielding options such as lead gowns, glasses, and pull-down shields are useful for protecting the operator, they do not lessen the patient’s level of exposure. Furthermore, the prolonged use of lead gowns can exponentiate the onset of orthopedic problems among operators. Recent advancements in three-dimensional cardiac mapping systems and the use of radiation-free imaging technologies such as magnetic resonance imaging and intracardiac ultrasound allow operators to perform EP procedures with minimal or even no fluoroscopy. In this review, we sought to describe the state of fluoroless procedures in EP practice.

Flecainide is a safe and effective treatment for pre-excited atrial fibrillation rapidly conducted to the ventricle in pregnant women: a case series

Background

Pregnancy is associated with an increased incidence of cardiac arrhythmias likely due to hormonal, haemodynamic, and autonomic changes. Yet, there is little data available regarding the efficacy and safety of anti-arrhythmic agents to prevent pre-excited atrial fibrillation (AF) in pregnant women.

Case summary

We report on three pregnant women who developed AF rapidly conducted to the ventricle through an overt accessory pathway as the first manifestation of Wolff–Parkinson–White syndrome.

Discussion

All patients were treated with flecainide with neither arrhythmias recurrence nor adverse events of the treatment. Mechanisms of action and clinical efficacy of flecainide are discussed.

Non-fluoroscopic catheter ablation: A randomized trial

Background

Catheter ablation provides curative treatment for tachyarrhythmias. Fluoroscopy, the method used for this, presents several risks. The electroanatomical mapping (MEA) presents a three-dimensional image without using X-rays, and may be adjunct to fluoroscopy.

Objectives

We evaluated the possibility of performing catheter ablation with the exclusive use of electroanatomical mapping (MEA), dispensing with fluoroscopy. We compared the total time of procedure and success rates against the technique using fluoroscopy (RX) with emission of X-rays.

Methods

Randomized, unicentric, uni-blind study of patients referred for tachyarrhythmia ablation.

Results

Twelve patients were randomized to the XR group and 11 to the EAM group. The mean age was 48.5 (±12.6) vs 46.3 (±16.6) (P = ns). Success occurred in 11 patients (91.7%) in the RX group and 9 (81.8%) in the MEA group (P = 0.46). The procedure time in minutes was higher in the MEA group than in the RX group (79-47-125min vs 49-30-100min; P = 0.006). The mean fluoroscopy time was 11 ± 9 min versus zero (RX vs MEA: P < 0.001). The mean radiofrequency applications were lower in the RX group against the MEA group (6 ± 3.5 × 13.2 ± 18.2 p < 0.019). There were no complications.

Conclusion

MEA opened new therapeutic possibilities for patients with arrhythmias, reducing the risk of radiation. In this study, it was possible to demonstrate that it is feasible to perform ablation only with the use of MEA, with similar success with fluoroscopy, at the expense of a longer procedure time.

Successful fluoroless radiofrequency catheter ablation of supraventricular tachycardia during pregnancy

Even in the absence of underlying heart disease, pregnancy is known to increase susceptibility supraventricular tachycardia (SVT). This brings a management challenge, mainly due to concerns about pharmacotherapy and radiation to the fetus. This case highlights the capability of using fluoroless mapping technologies to treat refractory arrhythmia cases safely and successful.

Inappropriate sinus tachycardia in pregnancy: a benign phenomena?

The syndrome of inappropriate sinus tachycardia (IST) is a well-described and generally benign condition outside pregnancy. There is, however, little information in the literature about IST during pregnancy and nothing about the likely mechanism in such cases. Equally there is a paucity of information about the effects on maternal and fetal well-being in patients who develop IST during pregnancy. Here, we describe the case of a woman who developed IST for the first time during pregnancy. We have first given a brief clinical summary of events and then follow this with the patient's personal account which she has written herself specifically for this case report. We believe that this case highlights some of the important issues associated with the condition when it occurs during pregnancy. We hope that the publication of this case report will increase the awareness of IST during pregnancy. This is important as we believe that the correct diagnosis and understanding of the condition and its consequences will allow clinicians to manage women afflicted by the condition empathetically and appropriately.

Zero-fluoroscopy catheter ablation of severe drug-resistant arrhythmia guided by Ensite NavX system during pregnancy: Two case reports and literature review

BACKGROUND

Cardiac arrhythmias can occur during pregnancy. Owing to radiation exposure and other uncertain risks for the mother and fetus, catheter ablation has rarely been performed and is often delayed until the postpartum period. We reported 2 pregnant women who were experiencing severe arrhythmias and were successfully ablated without fluoroscopic guidance. We also carried out a literature review of cases of pregnant women who underwent zero-fluoroscopy ablation.

METHODS AND RESULTS

One woman had drug-resistant and poorly tolerated frequent premature ventricular contraction (PVC) and ventricular tachycardia (VT). The other one had persistent and hardly terminated supraventricular tachycardia (SVT) via a right accessory pathway. The 2 patients were successfully underwent zero-fluoroscopy ablation guided by Ensite NavX system. The procedure time was 42 and 71 minutes, respectively.

CONCLUSION

Catheter ablation of SVT or PVC/VT in pregnant patients can be safely and effectively performed with a completely zero-fluoroscopy approach guided by the Ensite NavX system. In the case of a drug refractory, life-threatening arrhythmia during pregnancy, catheter ablation may be considered.

Catheter Ablation Without Fluoroscopy: Current Techniques And Future Direction

Background: Catheter ablation is the treatment of choice for most forms of SVT. Traditionally, fluoroscopy has been the primary tool for visualizing catheter position. However, newer, 3-dimensional mapping technologies offer multiple options for minimizing fluoroscopy use. We review our 8 year experience of a zero-fluoroscopy approach using the Ensite system, and discuss our current techniques. Methods: From January 2006 to October 2013, we performed 524 catheter ablation procedures with a zero-fluoroscopy approach. The Ensite system was used exclusively. Early in the study, NavX mode was employed. In the later time period, Velocity mode was used. The Ensite system allowed easy access to all right sided arrhythmias. For left sided arrhythmias, TEE was added to aid with transseptal puncture. Results: Reviewing 524 consecutive procedures, mean age was 14 years (range 7 weeks to 65 years). Mean weight was 60.7 kg (range 3 to 174 kg). Mean procedure time was 142 minutes (range 42 - 402 minutes). There were no complications. Twenty -five patients required the use of fluoroscopy, mostly as part of simultaneous diagnostic or interventional cath procedures. There was only one instance in which fluoroscopy was used when not anticipated at the start of the procedure. With this data available, and seeing that fluoroscopy is rarely needed unexpectedly, we hypothesized that catheter ablation no longer requires a traditional cath lab. We present our early approach to ablation outside the catheterization lab. Conclusions: Three dimensional mapping systems can eliminate fluoroscopy use in virtually all routine ablation procedures. As technology improves, ablation procedures will shift beyond the traditional cath lab.

Normal heart ventricular tachycardia associated with pregnancy: successful treatment with catheter ablation

BACKGROUND

Normal heart ventricular arrhythmia occurring during pregnancy has been previously described. Whilst there are established reports of catheter ablation to treat supraventricular arrhythmia during pregnancy, there are no reports of ablation to treat ventricular tachycardia.

CASE

We present the case of a 36 year old women, 31 weeks into an otherwise uncomplicated pregnancy, experiencing significant, troublesome and drug refractory tachycardia emanating from the right ventricular outflow tract.

CONCLUSION

We describe a successful radio frequency ablation in the third trimester of pregnancy.

Radiofrequency catheter ablation of incessant atrial tachycardia in pregnant women with minimal radiation exposure: Lessons from two case studies

During pregnancy, incessant tachyarrhythmias may result in hemodynamic compromise in both the expectant mother and the fetus. The use of antiarrhythmic drugs is typically not safe during pregnancy, and some tachycardias are refractory to pharmacologic treatment due to a significant autonomic imbalance. Catheter ablation is thought to be more effective than medical therapy, but carries the risk of radiation exposure to the fetus. We report two cases of hemodynamically unstable incessant atrial tachycardia (AT) in pregnant women. Both ATs resolved after three-dimensional electroanatomical mapping-guided radiofrequency catheter ablation with minimal fluoroscopic exposure. But one of the patients experienced a pulmonary embolism immediately after the procedure and miscarried. <Learning objective: Although catheter ablation using electroanatomical mapping is an effective treatment for incessant atrial tachycardia in pregnant women and minimizes radiation exposure to the fetus, patients should be closely monitored during the peri-procedural period due to the risk of pregnancy-associated complications such as pulmonary embolism.>.

Successful Non-fluoroscopic Radiofrequency Ablation of Incessant Atrial Tachycardia in a High Risk Twin Pregnancy

We describe a patient presenting with incessant ectopic atrial tachycardia during a high risk twin pregnancy. Tachycardia was resistant to escalating doses of beta-blockade with digoxin. Because of increasing left ventricular dysfunction early in the third trimester, catheter ablation was performed successfully at 30 weeks gestation. Electro-anatomic mapping permitted the entire procedure to be conducted without the use of ionizing radiation. The pregnancy proceeded to successful delivery near term and after three years the patient remains recurrence free with normal left ventricular function, off all medication.

"Rescue" ablation of electrical storm in arrhythmogenic right ventricular cardiomyopathy in pregnancy

Background

Radiofrequency ablation (RFCA) became a treatment of choice in patients with recurrent ventricular tachycardia, ventricular fibrillation, and appropriate interventions of implanted cardioverter-defibrillator (ICD), however, electrical storm (ES) ablation in a pregnant woman has not yet been reported.

Case presentation

We describe a case of a successful rescue ablation of recurrent ES in a 26-year-old Caucasian woman during her first pregnancy (23rd week). The arrhythmogenic right ventricular dysplasia/cardiomyopathy (ARVD/C) was diagnosed 3 years earlier and several drugs as well as 2 ablations failed to control recurrences of ventricular tachycardia. RFCA was performed on the day of the third electric storm. The use of electroanatomic mapping allowed very low X-ray exposure, and after applications in the right ventricular outflow tract, arrhythmia disappeared. Three months after ablation, a healthy girl was delivered without any complications. During twelve-month follow-up there was no recurrence of ventricular tachycardia or ICD interventions.

Conclusions

This case documents the first successful RFCA during ES due to recurrent unstable ventricular arrhythmias in a patient with ARVD/C in pregnancy. Current guidelines recommend metoprolol, sotalol and intravenous amiodarone for prevention of recurrent ventricular tachycardia in pregnancy, however, RFCA should be considered as a therapeutic option in selected cases. The use of 3D navigating system and near zero X-ray approach is associated with minimal radiation exposure for mother and fetus as well as low risk of procedural complication.

Catheter ablation of arrhythmias exclusively using electroanatomic mapping: a series of cases

Background

Catheter ablation is a treatment that can cure various cardiac arrhythmias. Fluoroscopy is used to locate and direct catheters to areas that cause arrhythmias. However, fluoroscopy has several risks. Electroanatomic mapping (EAM) facilitates three-dimensional imaging without X-rays, which reduces risks associated with fluoroscopy.

Objective

We describe a series of patient cases wherein cardiac arrhythmia ablation was exclusively performed using EAM.

Methods

Patients who presented with cardiac arrhythmias that were unresponsive to pharmacological therapy were prospectively selected between March 2011 and March 2012 for arrhythmia ablation exclusively through EAM. Patients with indications for a diagnostic electrophysiology study and ablation of atrial fibrillation, left atrial tachyarrhythmias as well as hemodynamically unstable ventricular arrhythmia were excluded. We documented the procedure time, success rate and complications as well as whether fluoroscopy was necessary during the procedure.

Results

In total, 11 patients were enrolled in the study, including seven female patients (63%). The mean age of the patients was 50 years (SD ±16.5). Indications for the investigated procedures included four cases (35%) of atrial flutter, three cases (27%) of pre-excitation syndrome, two cases (19%) of paroxysmal supraventricular tachycardia and two cases (19%) of ventricular extrasystoles. The mean procedure duration was 86.6 min (SD ± 26 min). Immediate success (at discharge) of the procedure was evident for nine patients (81%). There were no complications during the procedures.

Conclusion

This study demonstrates the feasibility of performing an arrhythmia ablation exclusively using EAM with satisfactory results.