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Aimo A, Morfino P, Arzilli C, Vergaro G, Spini V, Fabiani I, Castiglione V, Rapezzi C, Emdin M. Disease features and management of cardiomyopathies in women. Heart Fail Rev 2024; 29:663-674. [PMID: 38308002 PMCID: PMC11035404 DOI: 10.1007/s10741-024-10386-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/24/2024] [Indexed: 02/04/2024]
Abstract
Over the last years, there has been a growing interest in the clinical manifestations and outcomes of cardiomyopathies in women. Peripartum cardiomyopathy is the only women-specific cardiomyopathy. In cardiomyopathies with X-linked transmission, women are not simply healthy carriers of the disorder, but can show a wide spectrum of clinical manifestations ranging from mild to severe manifestations because of heterogeneous patterns of X-chromosome inactivation. In mitochondrial disorders with a matrilinear transmission, cardiomyopathy is part of a systemic disorder affecting both men and women. Even some inherited cardiomyopathies with autosomal transmission display phenotypic and prognostic differences between men and women. Notably, female hormones seem to exert a protective role in hypertrophic cardiomyopathy (HCM) and variant transthyretin amyloidosis until the menopausal period. Women with cardiomyopathies holding high-risk features should be referred to a third-level center and evaluated on an individual basis. Cardiomyopathies can have a detrimental impact on pregnancy and childbirth because of the associated hemodynamic derangements. Genetic counselling and a tailored cardiological evaluation are essential to evaluate the likelihood of transmitting the disease to the children and the possibility of a prenatal or early post-natal diagnosis, as well as to estimate the risk associated with pregnancy and delivery, and the optimal management strategies.
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Affiliation(s)
- Alberto Aimo
- Scuola Superiore Sant'Anna, Pisa, Italy.
- Cardiology Division, Fondazione Toscana Gabriele Monasterio, Pisa, Italy.
| | | | - Chiara Arzilli
- Cardiology Division, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Giuseppe Vergaro
- Scuola Superiore Sant'Anna, Pisa, Italy
- Cardiology Division, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Valentina Spini
- Cardiology Division, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Iacopo Fabiani
- Cardiology Division, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | | | - Claudio Rapezzi
- Cardiologic Centre, University of Ferrara, Ferrara, Italy
- Maria Cecilia Hospital, GVM Care & Research, Cotignola (Ravenna), Ravenna, Italy
| | - Michele Emdin
- Scuola Superiore Sant'Anna, Pisa, Italy
- Cardiology Division, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
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2
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Albertini L, Spears DA. Management of arrythmias during pregnancy. Heart 2023:heartjnl-2023-322746. [PMID: 37993263 DOI: 10.1136/heartjnl-2023-322746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2023] Open
Affiliation(s)
- Lisa Albertini
- Cardiology, Toronto General Hospital, Toronto, Ontario, Canada
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3
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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4
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DeFilippis EM, Bhagra C, Casale J, Ging P, Macera F, Punnoose L, Rasmusson K, Sharma G, Sliwa K, Thorne S, Walsh MN, Kittleson MM. Cardio-Obstetrics and Heart Failure: JACC: Heart Failure State-of-the-Art Review. JACC Heart Fail 2023; 11:1165-1180. [PMID: 37678960 DOI: 10.1016/j.jchf.2023.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 05/26/2023] [Accepted: 07/05/2023] [Indexed: 09/09/2023]
Abstract
Heart failure and cardiomyopathy are significant contributors to pregnancy-related deaths, as maternal morbidity and mortality have been increasing over time. In this setting, the role of the multidisciplinary cardio-obstetrics team is crucial to optimizing maternal, obstetrical and fetal outcomes. Although peripartum cardiomyopathy is the most common cardiomyopathy experienced by pregnant individuals, the hemodynamic changes of pregnancy may unmask a pre-existing cardiomyopathy leading to clinical decompensation. Additionally, there are unique management considerations for women with pre-existing cardiomyopathy as well as for those women with advanced heart failure who may be on left ventricular assist device support or have undergone heart transplantation. The purpose of this review is to discuss: 1) preconception counseling; 2) risk stratification and management strategies for pregnant women extending to the postpartum "fourth trimester" with pre-existing heart failure or "pre-heart failure;" 3) the safety of heart failure medications during pregnancy and lactation; and 4) management of pregnancy for women on left ventricular assist device support or after heart transplantation.
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Affiliation(s)
- Ersilia M DeFilippis
- Division of Cardiology, NewYork-Presbyterian Columbia University Irving Medical Center, New York, New York, USA
| | - Catriona Bhagra
- Department of Cardiology, Cambridge University and Royal Papworth NHS Foundation Trusts, Cambridge, United Kingdom
| | - Jillian Casale
- Department of Pharmacy Services, Cooperman Barnabas Medical Center, Livingston, New Jersey, USA
| | - Patricia Ging
- Department of Pharmacy, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Francesca Macera
- De Gasperis Cardio Center and Transplant Center, Niguarda Hospital, Milan, Italy; Department of Cardiology, Cliniques Universitaires de Bruxelles - Hôpital Erasme, Brussels, Belgium
| | - Lynn Punnoose
- Vanderbilt Heart and Vascular Institute, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Kismet Rasmusson
- Intermountain Heart Institute, Intermountain Medical Center, Salt Lake City, Utah, USA
| | - Garima Sharma
- Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Karen Sliwa
- Cape Heart Institute, Department of Medicine, Division of Cardiology, Faculty of Health Sciences, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Sara Thorne
- Division of Cardiology, Pregnancy & Heart Disease Program, Mount Sinai Hospital & University Health Network, University of Toronto, Toronto, Ontario, Canada
| | | | - Michelle M Kittleson
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA.
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5
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Curtis SL, Belham M, Bennett S, James R, Harkness A, Gamlin W, Thilaganathan B, Giorgione V, Douglas H, Carroll A, Kitt J, Colebourn C, Ribeiro I, Fairbairn S, Augustine DX, Robinson S, Thorne SA. Transthoracic Echocardiographic Assessment of the Heart in Pregnancy-a position statement on behalf of the British Society of Echocardiography and the United Kingdom Maternal Cardiology Society. Echo Res Pract 2023; 10:7. [PMID: 37076874 PMCID: PMC10116662 DOI: 10.1186/s44156-023-00019-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Accepted: 03/30/2023] [Indexed: 04/21/2023] Open
Abstract
Pregnancy is a dynamic process associated with profound hormonally mediated haemodynamic changes which result in structural and functional adaptations in the cardiovascular system. An understanding of the myocardial adaptations is important for echocardiographers and clinicians undertaking or interpreting echocardiograms on pregnant and post-partum women. This guideline, on behalf of the British Society of Echocardiography and United Kingdom Maternal Cardiology Society, reviews the expected echocardiographic findings in normal pregnancy and in different cardiac disease states, as well as echocardiographic signs of decompensation. It aims to lay out a structure for echocardiographic scanning and surveillance during and after pregnancy as well as suggesting practical advice on scanning pregnant women.
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Affiliation(s)
- Stephanie L Curtis
- University Hospitals Bristol and Weston NHS Trust, Bristol Heart Institute, Marlborough Street, Bristol, BS2 8HW, UK.
| | - Mark Belham
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Sadie Bennett
- University Hospitals of North Midlands, Stoke-On-Trent, UK
| | - Rachael James
- University Hospitals Sussex NHS FT, Brighton, UK
- United Kingdom's Maternal Cardiology Society, London, UK
| | - Allan Harkness
- East Suffolk and North Essex NHS Foundation Trust, Essex, UK
| | - Wendy Gamlin
- North West Heart Centre, Wythenshawe Hospital, Manchester, UK
| | | | | | | | | | - Jamie Kitt
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | | | - Isabel Ribeiro
- University Hospitals Bristol and Weston NHS Trust, Bristol Heart Institute, Marlborough Street, Bristol, BS2 8HW, UK
| | - Sarah Fairbairn
- University Hospitals Bristol and Weston NHS Trust, Bristol Heart Institute, Marlborough Street, Bristol, BS2 8HW, UK
| | - Daniel X Augustine
- Royal United Hospitals Bath NHS Foundation Trust, Bath, UK
- Department for Health, University of Bath, Bath, UK
| | | | - Sara A Thorne
- University Health Network Toronto, Toronto General Hospital & Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
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6
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Bariani R, Bueno Marinas M, Rigato I, Veronese P, Celeghin R, Cipriani A, Cason M, Pergola V, Mattesi G, Deola P, Zorzi A, Limongelli G, Iliceto S, Corrado D, Basso C, Pilichou K, Bauce B. Pregnancy in Women with Arrhythmogenic Left Ventricular Cardiomyopathy. J Clin Med 2022; 11:jcm11226735. [PMID: 36431211 PMCID: PMC9698035 DOI: 10.3390/jcm11226735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Revised: 10/26/2022] [Accepted: 11/09/2022] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND In the last few years, a phenotypic variant of arrhythmogenic cardiomyopathy (ACM) labeled arrhythmogenic left ventricular cardiomyopathy (ALVC) has been defined and researched. This type of cardiomyopathy is characterized by a predominant left ventricular (LV) involvement with no or minor right ventricular (RV) abnormalities. Data on the specific risk and management of pregnancy in women affected by ALVC are, thus far, not available. We have sought to characterize pregnancy course and outcomes in women affected by ALVC through the evaluation of a series of childbearing patients. METHODS A series of consecutive female ALVC patients were analyzed in a cross-sectional, retrospective study. Study protocol included 12-lead ECG assessments, 24-h Holter ECG evaluations, 2D-echocardiogram tests, cardiac magnetic resonance assessments, and genetic analysis. Furthermore, the long-term disease course of childbearing patients was compared with a group of nulliparous ALVC women. RESULTS A total of 35 patients (mean age 45 ± 9 years, 51% probands) were analyzed. Sixteen women (46%) reported a pregnancy, for a total of 27 singleton viable pregnancies (mean age at first childbirth 30 ± 9 years). Before pregnancy, all patients were in the NYHA class I and none of the patients reported a previous heart failure (HF) episode. No significant differences were found between childbearing and nulliparous women regarding ECG features, LV dimensions, function, and extent of late enhancement. Overall, 7 patients (20%, 4 belonging to the childbearing group) experienced a sustained ventricular tachycardia and 2 (6%)-one for each group-showed heart failure (HF) episodes. The analysis of arrhythmia-free survival patients did not show significant differences between childbearing and nulliparous women. CONCLUSIONS In a cohort of ALVC patients without previous episodes of HF, pregnancy was well tolerated, with no significant influence on disease progression and degree of electrical instability. Further studies on a larger cohort of women with different degrees of disease extent and genetic background are needed in order to achieve a more comprehensive knowledge regarding the outcome of pregnancy in ALVC patients.
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Affiliation(s)
- Riccardo Bariani
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, 35122 Padua, Italy
| | - Maria Bueno Marinas
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, 35122 Padua, Italy
| | - Ilaria Rigato
- Azienda Ospedaliera di Padova, Via Giustiniani, 2, 35128 Padova, Italy
| | - Paola Veronese
- Azienda Ospedaliera di Padova, Via Giustiniani, 2, 35128 Padova, Italy
| | - Rudy Celeghin
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, 35122 Padua, Italy
| | - Alberto Cipriani
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, 35122 Padua, Italy
| | - Marco Cason
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, 35122 Padua, Italy
| | - Valeria Pergola
- Azienda Ospedaliera di Padova, Via Giustiniani, 2, 35128 Padova, Italy
| | - Giulia Mattesi
- Azienda Ospedaliera di Padova, Via Giustiniani, 2, 35128 Padova, Italy
| | - Petra Deola
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, 35122 Padua, Italy
| | - Alessandro Zorzi
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, 35122 Padua, Italy
| | - Giuseppe Limongelli
- Department of Translational Sciences, University della Campania “Luigi Vanvitelli”, 80138 Naples, Italy
| | - Sabino Iliceto
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, 35122 Padua, Italy
| | - Domenico Corrado
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, 35122 Padua, Italy
| | - Cristina Basso
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, 35122 Padua, Italy
| | - Kalliopi Pilichou
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, 35122 Padua, Italy
- Correspondence: (K.P.); (B.B.)
| | - Barbara Bauce
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, 35122 Padua, Italy
- Correspondence: (K.P.); (B.B.)
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7
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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8
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Bariani R, Brunetti G, Cipriani A, Rigato I, Celeghin R, De Gaspari M, Pilichou K, Bauce B. Clinical management of a pregnant woman with Filamin C cardiomyopathy. J Cardiovasc Med (Hagerstown) 2022; 23:198-202. [PMID: 35013052 PMCID: PMC10079294 DOI: 10.2459/jcm.0000000000001294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 09/29/2021] [Accepted: 12/09/2021] [Indexed: 11/05/2022]
Affiliation(s)
- Riccardo Bariani
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
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9
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Albertini L, Spears D. Approach to inherited arrhythmias in pregnancy. International Journal of Cardiology Congenital Heart Disease 2021; 5:100264. [DOI: 10.1016/j.ijcchd.2021.100264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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10
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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: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [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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11
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Cheung CC, Roston T, Davies B, Grewal J, Laksman ZW, Krahn AD. Process of Care and a Practical Toolkit for Evaluating and Managing Arrhythmic Risk in the Cardiogenetic Pregnant Patient. Can J Cardiol 2021:S0828-282X(21)00647-4. [PMID: 34416260 DOI: 10.1016/j.cjca.2021.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [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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12
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Williams DS, Mikhova K, Sodhi S. Arrhythmias and Pregnancy: Management of Preexisting and New-Onset Maternal Arrhythmias. Cardiol Clin 2021; 39:67-75. [PMID: 33222815 DOI: 10.1016/j.ccl.2020.09.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Arrhythmias are the most common cardiovascular complication of pregnancy in women with and without structural heart disease. Appropriate maternal diagnosis and management is of utmost importance to optimize maternal and fetal outcomes. A multidisciplinary care approach with cardiology, maternal fetal medicine, anesthesia, and pediatrics is important for preconceptional, pregnancy, and delivery planning.
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Affiliation(s)
- Dominique S Williams
- Cardiovascular Division, John T. Milliken Department of Internal Medicine, Washington University School of Medicine, 660 South Euclid Avenue, Campus Box 8086, St Louis, MO 63110, USA.
| | - Krasimira Mikhova
- Cardiovascular Division, Electrophysiology, John T. Milliken Department of Internal Medicine, Washington University School of Medicine, 660 South Euclid Avenue, Campus Box 8086, St Louis, MO 63110, USA
| | - Sandeep Sodhi
- Department of Medicine, Cardiovascular Division, John T. Milliken Department of Medicine, Washington University School of Medicine, 660 South Euclid Avenue, Campus Box 8086, St Louis, MO 63110, USA
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13
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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14
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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: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [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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15
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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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16
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Abstract
Heart failure (HF) is a leading cause of morbidity and mortality in pregnant women in the United States. Although peripartum cardiomyopathy is the most common diagnosis for pregnant women with HF, women with preexisting cardiomyopathies and systolic dysfunction are also at risk as the hemodynamic demands of pregnancy can lead to decompensation, arrhythmia, and rarely death. The differential diagnosis of HF in pregnancy is broad and includes Takotsubo or stress cardiomyopathy, exacerbation of a preexisting cardiomyopathy, such as familial cardiomyopathy, hypertrophic cardiomyopathy, arrhythmogenic right ventricular cardiomyopathy, or left ventricular noncompaction. This review will explore the implications of pregnancy in women with preexisting cardiomyopathies and de novo HF, risk assessment and preconception planning, decisions about contraception, the safety of HF medications and implantable cardioverter-defibrillators during pregnancy, pregnancy in women with left ventricular assist devices and following heart transplantation.
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Affiliation(s)
- Ersilia M DeFilippis
- Division of Cardiology, New York Presbyterian-Columbia University Irving Medical Center (E.M.D., J.H.H.)
| | - Jennifer H Haythe
- Division of Cardiology, New York Presbyterian-Columbia University Irving Medical Center (E.M.D., J.H.H.)
| | | | - Michelle M Kittleson
- Division of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA (M.M.K.)
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17
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Topf A, Bacher N, Kopp K, Mirna M, Larbig R, Brandt MC, Kraus J, Hoppe UC, Motloch LJ, Lichtenauer M. Management of Implantable Cardioverter-Defibrillators during Pregnancy-A Systematic Review. J Clin Med 2021; 10:jcm10081675. [PMID: 33919684 PMCID: PMC8069958 DOI: 10.3390/jcm10081675] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Revised: 03/28/2021] [Accepted: 03/29/2021] [Indexed: 12/28/2022] Open
Abstract
Background: With the advent of implantable cardioverter-defibrillator (ICD) technology in recent decades, patients with inherited or congenital cardiomyopathy have a greater chance of survival into adulthood. Women with ICDs in this group are now more likely to reach reproductive age. However, pregnancy represents a challenge for clinicians, as no guidelines for the treatment of pregnant women with an ICD are currently available. Methods: To analyze this issue, we performed a systematic screening of the literature using the keywords: pregnancy with ICD, lead fracture in pregnancy, lead thrombi in pregnancy, ventricular tachycardia in pregnancy, inappropriate shocks in pregnancy, ICD discharge in pregnancy and ICD shock in pregnancy. Of 1101 publications found, 27 publications were eligible for further analysis (four retrospective trials and 23 case reports). Results: According to physiological changes in pregnancy, resulting in an increase in heart rate and cardiac output, a vulnerability for malignant arrhythmias and device-related complications in ICD carriers might be suspected. While the literature is limited on this issue, maternal complications including arrhythmia burden with following ICD therapies, thromboembolic events and lead complications as well as inappropriate shock therapy have been reported. According to the limited available studies, associated risk seems not to be more frequent than in the general population and depends on the underlying cardiac pathology. Furthermore, worsening of heart failure and related cardiovascular disease have been reported with associated risk of preterm delivery. These observations are exaggerated by restricted applications of diagnostics and treatment due to the risk of fetal harm in this population. Conclusions: Due to limited data on management of ICDs during pregnancy, further scientific investigations are required. Consequently, careful risk assessment with individual risk evaluation and close follow ups with interdisciplinary treatment are recommended in pregnant ICD carriers.
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Affiliation(s)
- Albert Topf
- Department of Internal Medicine II, Paracelsus Medical University Salzburg, 5020 Salzburg, Austria; (N.B.); (K.K.); (M.M.); (M.C.B.); (J.K.); (U.C.H.); (L.J.M.); (M.L.)
- Correspondence:
| | - Nina Bacher
- Department of Internal Medicine II, Paracelsus Medical University Salzburg, 5020 Salzburg, Austria; (N.B.); (K.K.); (M.M.); (M.C.B.); (J.K.); (U.C.H.); (L.J.M.); (M.L.)
| | - Kristen Kopp
- Department of Internal Medicine II, Paracelsus Medical University Salzburg, 5020 Salzburg, Austria; (N.B.); (K.K.); (M.M.); (M.C.B.); (J.K.); (U.C.H.); (L.J.M.); (M.L.)
| | - Moritz Mirna
- Department of Internal Medicine II, Paracelsus Medical University Salzburg, 5020 Salzburg, Austria; (N.B.); (K.K.); (M.M.); (M.C.B.); (J.K.); (U.C.H.); (L.J.M.); (M.L.)
| | - Robert Larbig
- Division of Cardiology, Hospital Maria Hilf Mönchengladbach, 41063 Mönchengladbach, Germany;
- Division of Electrophysiology, Department of Cardiovascular Medicine, University of Münster, 48149 Münster, Germany
| | - Mathias C. Brandt
- Department of Internal Medicine II, Paracelsus Medical University Salzburg, 5020 Salzburg, Austria; (N.B.); (K.K.); (M.M.); (M.C.B.); (J.K.); (U.C.H.); (L.J.M.); (M.L.)
| | - Johannes Kraus
- Department of Internal Medicine II, Paracelsus Medical University Salzburg, 5020 Salzburg, Austria; (N.B.); (K.K.); (M.M.); (M.C.B.); (J.K.); (U.C.H.); (L.J.M.); (M.L.)
| | - Uta C. Hoppe
- Department of Internal Medicine II, Paracelsus Medical University Salzburg, 5020 Salzburg, Austria; (N.B.); (K.K.); (M.M.); (M.C.B.); (J.K.); (U.C.H.); (L.J.M.); (M.L.)
| | - Lukas J. Motloch
- Department of Internal Medicine II, Paracelsus Medical University Salzburg, 5020 Salzburg, Austria; (N.B.); (K.K.); (M.M.); (M.C.B.); (J.K.); (U.C.H.); (L.J.M.); (M.L.)
| | - Michael Lichtenauer
- Department of Internal Medicine II, Paracelsus Medical University Salzburg, 5020 Salzburg, Austria; (N.B.); (K.K.); (M.M.); (M.C.B.); (J.K.); (U.C.H.); (L.J.M.); (M.L.)
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18
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Sliwa K, van der Meer P, Petrie MC, Frogoudaki A, Johnson MR, Hilfiker-Kleiner D, Hamdan R, Jackson AM, Ibrahim B, Mbakwem A, Tschöpe C, Regitz-Zagrosek V, Omerovic E, Roos-Hesselink J, Gatzoulis M, Tutarel O, Price S, Heymans S, Coats AJS, Müller C, Chioncel O, Thum T, de Boer RA, Jankowska E, Ponikowski P, Lyon AR, Rosano G, Seferovic PM, Bauersachs J. Risk stratification and management of women with cardiomyopathy/heart failure planning pregnancy or presenting during/after pregnancy: a position statement from the Heart Failure Association of the European Society of Cardiology Study Group on Peripartum Cardiomyopathy. Eur J Heart Fail 2021; 23:527-540. [PMID: 33609068 DOI: 10.1002/ejhf.2133] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 01/22/2021] [Accepted: 02/17/2021] [Indexed: 12/12/2022] Open
Abstract
This position paper focusses on the pathophysiology, diagnosis and management of women diagnosed with a cardiomyopathy, or at risk of heart failure (HF), who are planning to conceive or present with (de novo or previously unknown) HF during or after pregnancy. This includes the heterogeneous group of heart muscle diseases such as hypertrophic, dilated, arrhythmogenic right ventricular and non-classified cardiomyopathies, left ventricular non-compaction, peripartum cardiomyopathy, Takotsubo syndrome, adult congenital heart disease with HF, and patients with right HF. Also, patients with a history of chemo-/radiotherapy for cancer or haematological malignancies need specific pre-, during and post-pregnancy assessment and counselling. We summarize the current knowledge about pathophysiological mechanisms, including gene mutations, clinical presentation, diagnosis, and medical and device management, as well as risk stratification. Women with a known diagnosis of a cardiomyopathy will often require continuation of drug therapy, which has the potential to exert negative effects on the foetus. This position paper assists in balancing benefits and detrimental effects.
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Affiliation(s)
- Karen Sliwa
- Hatter Institute for Cardiovascular Research in Africa & CHI, Department of Cardiology and Medicine, University of Cape Town, Cape Town, South Africa
| | - Peter van der Meer
- Department of Cardiology, University Medical Center Groningen, Groningen, The Netherlands
| | - Mark C Petrie
- Department of Cardiology, Institute of Cardiovascular and Medical Sciences, Glasgow University, Glasgow, UK
| | - Alexandra Frogoudaki
- Adult Congenital Heart Disease Clinic, Second Cardiology Department ATTIKON University Hospital, Athens, Greece
| | - Mark R Johnson
- Department of Obstetrics, Imperial College School of Medicine, Chelsea and Westminster Hospital, London, UK
| | | | - Righab Hamdan
- Department of Cardiology, Beirut Cardiac Institute, Beirut, Lebanon
| | - Alice M Jackson
- Department of Cardiology, Institute of Cardiovascular and Medical Sciences, Glasgow University, Glasgow, UK
| | - Bassem Ibrahim
- Consultant Cardiologist & Heart Failure Lead. North Cumbria University Hospitals, Cumbria, UK
| | - Amam Mbakwem
- Department of Medicine, College of Medicine, University of Lagos, Lagos, Nigeria
| | - Carsten Tschöpe
- Berlin- Institute of Health (BIH), Berlin-Brandenburger Center for Regenerative Therapies (BCRT), Department of Cardiology (CVK), German Centre for Cardiovascular Research (DZHK) Partner Site Berlin, Charité University, Berlin, Germany
| | | | - Elmir Omerovic
- Department of Cardiology, Sahlgrenska University Hospital University of Gothenburg, Gothenburg, Sweden
| | - Jolien Roos-Hesselink
- Department of Adult Congenital Heart Disease, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - Michael Gatzoulis
- Adult Congenital Heart Centre and Centre for Pulmonary Hypertension, Royal Brompton Hospital and Imperial College, London, UK
| | - Oktay Tutarel
- Adult Congenital Heart Disease, TUM School of Medicine, Munich, Germany
| | - Susanna Price
- Division of Cardiology and Metabolism, National Heart and Lung Institute, Royal Brompton Hospital, London, UK
| | - Stephane Heymans
- Department of Cardiology, Maastricht University, CARIM School for Cardiovascular Diseases, Maastricht, The Netherlands.,Centre for Molecular and Vascular Biology, Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
| | | | - Christian Müller
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland
| | - Ovidiu Chioncel
- Emergency Institute for Cardiovascular Diseases 'Prof. Dr. C.C. Iliescu' and University of Medicine Carol Davila, Bucuresti, Romania
| | - Thomas Thum
- Institute of Molecular and Translational Therapeutic Strategies, Hannover Medical School, Hannover, Germany
| | - Rudolf A de Boer
- Department of Cardiology, University Medical Center Groningen, Groningen, The Netherlands
| | - Ewa Jankowska
- Centre for Heart Diseases, Faculty of Health Sciences, Wrocław Medical University, Wrocław, Poland
| | - Piotr Ponikowski
- Centre for Heart Diseases, Faculty of Health Sciences, Wrocław Medical University, Wrocław, Poland
| | - Alexander R Lyon
- National Heart and Lung Institute, Imperial College London and Royal Brompton Hospital, London, UK
| | - Giuseppe Rosano
- Centre for Molecular and Vascular Biology, Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium.,Cardiology Clinical Academic Group, St George's Hospitals NHS Trust University of London, London, UK
| | - Petar M Seferovic
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia.,Serbian Academy of Sciences and Arts, Belgrade, Serbia
| | - Johann Bauersachs
- Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
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19
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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20
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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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21
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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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22
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Abstract
The most common arrhythmias detected during pregnancy include sinus tachycardia, sinus bradycardia, and sinus arrhythmia, identified in 0.1% of pregnancies. Isolated premature atrial or ventricular arrhythmias are observed in 0.03% of pregnancies. Arrhythmias may become more frequent during pregnancy or may manifest for the first time.
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Affiliation(s)
| | - Danna A Spears
- University Health Network - Toronto General Hospital, Toronto, Canada
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23
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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24
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Wu L, Liang E, Fan S, Zheng L, Hu F, Liu S, Liu L, Hu Z, Li G, Yao Y. Effect of Pregnancy in Arrhythmogenic Right Ventricular Cardiomyopathy. Am J Cardiol 2020; 125:613-7. [PMID: 31836129 DOI: 10.1016/j.amjcard.2019.11.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [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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Phan D, Duan L, Ng A, Shen AY, Lee MS. Characteristics and outcomes of pregnant women with cardiomyopathy stratified by etiologies: A population-based study. Int J Cardiol 2020; 305:87-91. [PMID: 31889561 DOI: 10.1016/j.ijcard.2019.12.027] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2019] [Revised: 11/21/2019] [Accepted: 12/12/2019] [Indexed: 01/24/2023]
Abstract
BACKGROUND Heart failure is an uncommon diagnosis among pregnant women with limited data on this condition. We sought to describe the characteristics and outcomes of pregnant women with heart failure stratified by etiologies of cardiomyopathy. METHODS This is a retrospective population-based cohort study across medical centers in Southern California in the United States. Pregnant women with heart failure were identified using ICD-9 codes and adjudicated by manual review of the medical records. Obstetric complications, fetal birthweight, and maternal mortality outcomes were evaluated. RESULTS Between 2003 and 2014, there were 488 pregnancies (0.1% of all pregnancies) complicated by heart failure, of which 333 (68.2%) were due to peripartum cardiomyopathy (PPCM) and 155 (31.8%) were due to other etiologies (non-PPCM). Compared to patients with non-PPCM, patients with PPCM were more likely to be Black Americans (26.7% vs 15.5%) or Asian Americans (16.8% vs 7.1%). A high proportion of PPCM patients had preeclampsia (11.1% vs 5.2%, p = 0.04). Infants born to mothers with non-PPCM were more likely to be small for gestational age (SGA) (SGA <3% 4.1% vs 9.7%, p < 0.001; SGA <10% 20% vs 8.8%, p = 0.001). No significant difference in maternal mortality was observed between PPCM and non-PPCM patients. CONCLUSIONS PPCM is the most common etiology of HF during pregnancy. Infants born to mothers with PPCM were likely to be small for gestational age.
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Schiavone M, Calcagnino M, Mazzanti A, Bonanomi C. Outcomes and management of arrhythmogenic right ventricular cardiomyopathy in pregnancy: a case report. Eur Heart J Case Rep 2019; 3:1-5. [PMID: 31911980 PMCID: PMC6939797 DOI: 10.1093/ehjcr/ytz208] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Revised: 05/22/2019] [Accepted: 10/30/2019] [Indexed: 01/08/2023]
Abstract
Background Arrhythmogenic right ventricular cardiomyopathy (ARVC) is an inherited disease with an estimated prevalence of up to 1:5000 in the general population. Few cases of ARVC during pregnancy are described in literature. Case summary A 32-year-old primigravida was referred to our clinic during the 32nd gestational week. Arrhythmogenic right ventricular cardiomyopathy diagnosis with biventricular involvement was made according to Task Force criteria. Beta-blocker therapy was started and an elective caesarean section was planned, during the 37th gestational week; no complications occurred. Thirteen months after delivery, the patient was readmitted in our hospital due to an episode of pre-syncope and after team discussion, an implantable cardioverter-defibrillator (ICD) was implanted. Discussion This case suggests that the absence of signs and symptoms of heart failure (HF) at a first evaluation plays a major role to predict maternal and foetal outcome in ARVC. Our experience is consistent with the evidence that indicates a favourable outcome in asymptomatic patients treated with optimal medical therapy during pregnancy. In our case, despite no major HF or arrhythmic complications during pregnancy, delivery, and puerperium, we observed an arrhythmic disease progression more likely independent from pregnancy, leading to ICD implantation.
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Affiliation(s)
- Marco Schiavone
- Department of Cardiology, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Via F. Sforza, 35, 20122 Milan, Italy.,University of Milan, Via Festa del Perdono, 7, 20122 Milan, Italy
| | - Margherita Calcagnino
- Department of Cardiology, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Via F. Sforza, 35, 20122 Milan, Italy
| | - Andrea Mazzanti
- Molecular Cardiology, IRCCS ICS Maugeri, Via S. Maugeri, 10, 27100 Pavia, Italy
| | - Carla Bonanomi
- Department of Cardiology, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Via F. Sforza, 35, 20122 Milan, Italy
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Roston TM, van der Werf C, Cheung CC, Grewal J, Davies B, Wilde AAM, Krahn AD. Caring for the pregnant woman with an inherited arrhythmia syndrome. Heart Rhythm 2020; 17:341-8. [PMID: 31400520 DOI: 10.1016/j.hrthm.2019.08.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2019] [Indexed: 01/03/2023]
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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Castrini AI, Lie ØH, Leren IS, Estensen ME, Stokke MK, Klæboe LG, Edvardsen T, Haugaa KH. Number of pregnancies and subsequent phenotype in a cross-sectional cohort of women with arrhythmogenic cardiomyopathy. Eur Heart J Cardiovasc Imaging 2019; 20:192-198. [PMID: 29659777 PMCID: PMC6343080 DOI: 10.1093/ehjci/jey061] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Accepted: 03/22/2018] [Indexed: 12/14/2022] Open
Abstract
Aims We aimed to assess the relation between number of pregnancies and cardiac structure, function, and arrhythmic events in women with arrhythmogenic cardiomyopathy (AC). Methods and results We included female AC patients in a cross-sectional study. Number of pregnancies and pregnancy related symptoms were recorded. Ventricular arrhythmias were defined as aborted cardiac arrest, sustained ventricular tachycardia, or appropriate implantable cardioverter-defibrillator therapy. Right and left ventricular dimensions and function, including strain analyses, were assessed by echocardiography and magnetic resonance imaging. We created a new AC severity score to grade the severity of AC disease. We included 77 women (age 47 ± 16, 43 probands and 34 AC mutation positive female relatives), 19 ± 14 years after last pregnancy. Median number of pregnancies was 2 (0–4); 19 had no previous pregnancies, 16 had 1 pregnancy, 30 had 2, and 12 had ≥3 pregnancies. Presence of a definite AC diagnosis (P = 0.36), severity of AC disease (P = 0.53), and arrhythmic events (P = 0.25) did not differ between groups of pregnancies. Number of pregnancies was related to increased right ventricular outflow tract diameter in single variable analyses [odds ratio (OR) 1.76, 95% confidence interval (CI) 1.08–2.87; P = 0.02], but not when adjusted for body surface area and age (OR 1.56, 95% CI 0.91–2.66; P = 0.11). The number of pregnancies was not associated with any other measures of cardiac structure and function. Conclusion Higher number of pregnancies did not seem to relate to a worse phenotype in women with AC.
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Affiliation(s)
- Anna I Castrini
- Department of Cardiology and Center for Cardiological Innovation, Oslo University Hospital, Rikshospitalet, Sognsvannsveien 20, Oslo, Norway
| | - Øyvind H Lie
- Department of Cardiology and Center for Cardiological Innovation, Oslo University Hospital, Rikshospitalet, Sognsvannsveien 20, Oslo, Norway.,Institute for Clinical Medicine, University of Oslo, Oslo, Norway
| | - Ida S Leren
- Department of Cardiology and Center for Cardiological Innovation, Oslo University Hospital, Rikshospitalet, Sognsvannsveien 20, Oslo, Norway.,Institute for Clinical Medicine, University of Oslo, Oslo, Norway
| | - Mette E Estensen
- Department of Cardiology and Center for Cardiological Innovation, Oslo University Hospital, Rikshospitalet, Sognsvannsveien 20, Oslo, Norway
| | - Mathis K Stokke
- Department of Cardiology and Center for Cardiological Innovation, Oslo University Hospital, Rikshospitalet, Sognsvannsveien 20, Oslo, Norway
| | - Lars G Klæboe
- Department of Cardiology and Center for Cardiological Innovation, Oslo University Hospital, Rikshospitalet, Sognsvannsveien 20, Oslo, Norway.,Institute for Clinical Medicine, University of Oslo, Oslo, Norway
| | - Thor Edvardsen
- Department of Cardiology and Center for Cardiological Innovation, Oslo University Hospital, Rikshospitalet, Sognsvannsveien 20, Oslo, Norway.,Institute for Clinical Medicine, University of Oslo, Oslo, Norway.,Institute for Surgical Research, Oslo University Hospital, Rikshospitalet, Sognsvannsveien 20, Oslo, Norway
| | - Kristina H Haugaa
- Department of Cardiology and Center for Cardiological Innovation, Oslo University Hospital, Rikshospitalet, Sognsvannsveien 20, Oslo, Norway.,Institute for Clinical Medicine, University of Oslo, Oslo, Norway.,Institute for Surgical Research, Oslo University Hospital, Rikshospitalet, Sognsvannsveien 20, Oslo, Norway
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Wang W, James CA, Calkins H. Diagnostic and therapeutic strategies for arrhythmogenic right ventricular dysplasia/cardiomyopathy patient. Europace 2019; 21:9-21. [PMID: 29688316 PMCID: PMC6321962 DOI: 10.1093/europace/euy063] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Accepted: 03/16/2018] [Indexed: 12/21/2022] Open
Abstract
Arrhythmogenic right ventricular dysplasia/cardiomyopathy (ARVD/C) is a rare inherited heart muscle disease characterized by ventricular tachyarrhythmia, predominant right ventricular dysfunction, and sudden cardiac death. Its pathophysiology involves close interaction between genetic mutations and exposure to physical activity. Mutations in genes encoding desmosomal protein are the most common genetic basis. Genetic testing plays important roles in diagnosis and screening of family members. Syncope, palpitation, and lightheadedness are the most common symptoms. The 2010 Task Force Criteria is the standard for diagnosis today. Implantation of a defibrillator in high-risk patients is the only therapy that provides adequate protection against sudden death. Selection of patients who are best candidates for defibrillator implantation is challenging. Exercise restriction is critical in affected individuals and at-risk family members. Antiarrhythmic drugs and ventricular tachycardia ablation are valuable but palliative components of the management. This review focuses on the current diagnostic and therapeutic strategies in ARVD/C and outlines the future area of development in this field.
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Affiliation(s)
- Weijia Wang
- Division of Cardiology, Department of Medicine, Johns Hopkins University, 600 N. Wolfe Street, Sheikh Zayed Tower 7125R, Baltimore, MD, USA
| | - Cynthia A James
- Division of Cardiology, Department of Medicine, Johns Hopkins University, 600 N. Wolfe Street, Sheikh Zayed Tower 7125R, Baltimore, MD, USA
| | - Hugh Calkins
- Division of Cardiology, Department of Medicine, Johns Hopkins University, 600 N. Wolfe Street, Sheikh Zayed Tower 7125R, Baltimore, MD, USA
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Regitz-Zagrosek V, Roos-Hesselink JW, Bauersachs J, Blomström-Lundqvist C, Cífková R, De Bonis M, Iung B, Johnson MR, Kintscher U, Kranke P, Lang IM, Morais J, Pieper PG, Presbitero P, Price S, Rosano GMC, Seeland U, Simoncini T, Swan L, Warnes CA. 2018 ESC Guidelines for the management of cardiovascular diseases during pregnancy. Eur Heart J 2018; 39:3165-3241. [PMID: 30165544 DOI: 10.1093/eurheartj/ehy340] [Citation(s) in RCA: 1052] [Impact Index Per Article: 175.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
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Abstract
Arrhythmogenic right ventricular cardiomyopathy (ARVC) is a progressive cardiomyopathy characterized by fibrofatty infiltration of the myocardium, ventricular arrhythmias, sudden death, and heart failure. ARVC may be an important cause of syncope, sudden death, ventricular arrhythmias, and/or wall motion abnormalities, especially in the young. As the first symptom is sudden death or cardiac arrest in many cases, an early diagnosis and risk stratification are important. Recent advances in diagnostic modalities will be helpful in the early diagnosis and proper management of patients at risk. Restriction of strenuous exercise and implantation of implantable cardioverter-defibrillators are important in addition to medical treatment and catheter ablation of ventricular tachycardia. Recently introduced genetic screening may help to identify asymptomatic carriers with a risk of a disease progression and sudden death.
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Affiliation(s)
- Yongkeun Cho
- Department of Internal MedicineKyungpook National University HospitalDaeguKorea
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Abstract
PURPOSE OF REVIEWS In this review, the challenges of managing cardiac arrhythmias and syncope in the setting of pregnancy will be discussed. RECENT FINDINGS Arrhythmias in pregnancy are increasing, as diagnostic and therapeutic options have advanced and women are older at the time of gestation. Atrial fibrillation has become the most common arrhythmia in pregnancy. Inherited arrhythmia has become a more common entity, with advances in treatments and genetic testing, and require specialized treatments in pregnancy. The majority of arrhythmias in pregnancy are benign. The potential risk of increased cardiac morbidity and mortality exists for mother and fetus, especially in women with structural heart disease, which is becoming increasingly common. Early evaluation, diagnosis, and appropriate treatment are necessary to achieve optimal outcomes for both mother and fetus.
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Affiliation(s)
- Ciorsti MacIntyre
- Department of Medicine, Halifax, Queen Elizabeth II Health Sciences Center, 1796 Summer Street, Room 2501D, Halifax, NS, B3H 4S9, Canada
| | - Chinyere Iwuala
- Department of Medicine, Halifax, Queen Elizabeth II Health Sciences Center, 1796 Summer Street, Room 2501D, Halifax, NS, B3H 4S9, Canada
| | - Ratika Parkash
- Department of Medicine, Halifax, Queen Elizabeth II Health Sciences Center, 1796 Summer Street, Room 2501D, Halifax, NS, B3H 4S9, Canada.
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35
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Gandjbakhch E, Varlet E, Duthoit G, Fressart V, Charron P, Himbert C, Maupain C, Bordet C, Hidden-lucet F, Nizard J. Pregnancy and newborn outcomes in arrhythmogenic right ventricular cardiomyopathy/dysplasia. Int J Cardiol 2018; 258:172-8. [DOI: 10.1016/j.ijcard.2017.11.067] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Revised: 11/03/2017] [Accepted: 11/20/2017] [Indexed: 11/18/2022]
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36
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Billebeau G, Etienne M, Cheikh-khelifa R, Vauthier-brouzes D, Gandjbakhch E, Isnard R, Nizard J, Komajda M, Dommergues M, Charron P. Pregnancy in women with a cardiomyopathy: Outcomes and predictors from a retrospective cohort. Arch Cardiovasc Dis 2018; 111:199-209. [DOI: 10.1016/j.acvd.2017.05.010] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2017] [Accepted: 05/29/2017] [Indexed: 12/28/2022]
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37
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Camargo-Ariza WA, Galvis-Blanco SJ, Camacho-Enciso TDP, Quiroz-Romero CA, Bermudez-Echeverry JJ. [Arrhythmogenic right ventricular cardiomyopathy/dysplasia. Literature review and case report]. Arch Cardiol Mex 2017. [PMID: 28623036 DOI: 10.1016/j.acmx.2017.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
Arrhythmogenic right ventricular cardiomyopathy/dysplasia is an inherited autosomal dominant disease, with an estimated prevalence of 1:2,500 to 1:5,000, being higher in males (3:1). It is characterised histologically by the substitution of cardiomyocytes for fibrous-adipose tissue, which predisposes to ventricular arrhythmias, right ventricular failure, and sudden cardiac death. The main aim of treatment is to reduce the risk of sudden death and improve the quality of life of patients. The case is presented of a 23 year old woman whose clinical symptoms started with palpitations, chest pain with physical activity, syncope, and headache, 6 years ago during her first pregnancy. Due to an increase in symptomatology, a stress test was performed, during which she collapsed with a sustained monomorphic ventricular tachycardia. A cardiac magnetic resonance scan showed dilation, an increase in trabeculae, and decreased function of the right ventricle. A 3-dimensional mapping and ablation was performed, and during the isoproterenol infusion test, a polymorphic ventricular flutter was generated that required electrical cardioversion. The decision was made to implant a dual chamber cardioverter defibrillator and perform stellate ganglion ablation as secondary prevention. After her discharge, the patient re-consulted many times due to discharges of the device associated with palpitations. A comprehensive review of the patient's medical records was performed, finding characteristics that may suggest arrhythmogenic right ventricular dysplasia. The Task Force criteria was applied, concluding that, as she met more than 2 major criteria, the patient had a definitive diagnosis of this disease.
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Affiliation(s)
| | | | | | | | - Juan José Bermudez-Echeverry
- Facultad de Medicina, Universidad Industrial de Santander, Bucaramanga, Santander, Colombia; Departamento de Electrofisiología, Fundación Cardiovascular de Colombia, Floridablanca, Santander, Colombia
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Vadysinghe AN, Jayasooriya RP, Gunatilake GKK, Sivasubramanium M. Unexpected sudden death in pregnancy - arrhythmogenic right ventricular cardiomyopathy/dysplasia: a case report. Forensic Sci Res 2017; 2:161-163. [PMID: 30483636 PMCID: PMC6197088 DOI: 10.1080/20961790.2017.1325548] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Accepted: 04/27/2017] [Indexed: 11/15/2022] Open
Abstract
Cardiovascular disease is an important contributor to maternal mortality in both developing and developed countries. Systematic search for cardiac disease is usually not performed during pregnancy despite hypertensive disease, undiagnosed pulmonary hypertension and cardiomyopathies being recognized as major health problems in these settings. This article reported a 27-year-old female who was normal on clinical examination and basic investigations, and on an antenatal visit was found collapsed in the toilet of her house and was pronounced dead on admission to hospital. She was found to be in the 11th week of pregnancy and had no history of significant illness in the past. Autopsy did not reveal any obvious macroscopic pathology except for a significant amount of epicardial fat infiltrating into myocardium of right ventricle. Detailed histopathological examination of the heart demonstrated fibro-fatty replacement of the heart muscle. The cause of death was arrhythmogenic right ventricular cardiomyopathy/dysplasia (ARVC/D). ARVC/D can cause unexpected sudden death during pregnancy. Therefore, it is recommended that an ECG and echocardiogram be included as screening tests during antenatal follow-up to minimize preventable cardiac deaths like ARVC/D.
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Blaskovics I, Valchanov K. Anaesthesia for patients with arrhythmogenic right ventricular dysplasia. World J Anesthesiol 2016; 5:44-53. [DOI: 10.5313/wja.v5.i3.44] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2016] [Revised: 09/14/2016] [Accepted: 11/02/2016] [Indexed: 02/06/2023] Open
Abstract
Arrhythmogenic right ventricular dysplasia (ARVD) is an inherited heart muscle disease. Myocyte apoptosis and fibro-fatty scar tissue predisposes patients to malignant ventricular arrhythmias. Patients may present to variety of surgical procedures with diagnosed ARVD. Surgical insult, catecholamine surge and physiological disturbance can be hazardous on the vulnerable myocardium and may result in life-threatening ventricular tachycardia or sudden cardiac death in the perioperative period. Anaesthetists have particular role in perioperative management of this patient population, meticulous perioperative planning, close haemodynamic monitoring and maintenance of physiological stability throughout helps to avoid devastating perioperative loss.
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Abstract
Pregnant women often complain of palpitations. The differential diagnosis for new-onset palpitations in pregnancy ranges from benign conditions to life-threatening arrhythmias. Maternal arrhythmias can occur in isolation or in the setting of underlying structural heart disease. Optimal management of maternal cardiac arrhythmias includes identification of the specific arrhythmia, diagnosis of comorbid conditions, and appropriate intervention. In general, management of maternal cardiac arrhythmias is similar to that of the general population. Special consideration must be given as to the effects of medications and procedures on both the mother and fetus to optimize outcomes. The importance of multidisciplinary care with cardiology, obstetrics, and anesthesia is emphasized.
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Affiliation(s)
- Torri D Metz
- Department of Obstetrics and Gynecology, University of Colorado School of Medicine, 12631 East 17th Avenue, Aurora, CO 80045, USA; Department of Obstetrics and Gynecology, Denver Health Medical Center, 777 Bannock Street, MC 0660, Denver, CO 80204, USA.
| | - Amber Khanna
- Division of Cardiology, Department of Medicine, University of Colorado School of Medicine, 12401 East 17th Avenue, Aurora, CO 80045, USA
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