Arrhythmic risk during pregnancy in patients with congenital heart disease

Arrhythmierisiko in der Schwangerschaft bei Patientinnen mit angeborenem Herzfehler

Abstract

Arrhythmias play a significant role in the morbidity and mortality of patients with adult congenital heart disease (CHD). Pregnancy-associated physiological changes in hormonal status, hemodynamics, and myocardial structure further enhance arrhythmic risk in CHD patients, leading to increased adverse maternal and foetal events and making arrhythmias one of the most common complications during pregnancy. Nearly all CHD patients are affected by asymptomatic rhythm disturbances during the ante-, peri-, or post-partum periods, and almost one tenth of patients develop sustained, symptomatic arrhythmias requiring treatment. The majority of arrhythmias originate from the atrium, mostly in the form of supraventricular tachycardia or atrial fibrillation. Patients with CHD often tolerate these even more poorly during pregnancy than before pregnancy. Sustained ventricular tachycardia or ventricular fibrillation are rare, but potentially life-threatening for mother and foetus. Risk stratification models developed specifically for arrhythmias during pregnancy in CHD patients are lacking, but direct or indirect signs of heart failure, previous history of arrhythmia, and complex CHD may be associated with higher arrhythmic risk in these patients. Rigorous individual assessment before, and careful monitoring during pregnancy in a multidisciplinary team is crucial to ensure the best possible pregnancy outcome for patients with CHD.

Zusammenfassung

Arrhythmien haben einen signifikanten Einfluss auf die Morbidität und Mortalität erwachsener Patientinnen und Patienten mit angeborenen Herzfehlern (AHF). Physiologische Veränderungen des Hormonstatus, der Hämodynamik und der myokardialen Struktur während der Schwangerschaft steigern das Risiko für Herzrhythmusstörungen zusätzlich, sodass Arrhythmien eine der häufigsten Komplikationen während der Schwangerschaft darstellen und maternale und fetale Komplikationsraten signifikant erhöht sind. Fast alle Patientinnen mit AHF sind von asymptomatischen Herzrhythmusstörungen in der ante-, peri- oder postpartalen Phase betroffen, und etwa jede Zehnte erfährt symptomatische, anhaltende Arrhythmien, die einer Therapie bedürfen. Die meisten Arrhythmien gehen vom Vorhof aus, überwiegend als supraventrikuläre Tachykardie oder Vorhofflimmern. Diese atrialen Arrhythmien werden von Patientinnen mit AHF während der Schwangerschaft häufig noch schlechter toleriert als zuvor. Anhaltende ventrikuläre Tachykardien oder Kammerflimmern sind selten, jedoch potenziell lebensbedrohlich für Mutter und Fetus. Modelle zur Risikostratifizierung speziell für Arrhythmien in der Schwangerschaft bei Patientinnen mit AHF fehlen, es bestehen jedoch Hinweise, dass direkte und indirekte Zeichen der Herzinsuffizienz, vorangegangene Arrhythmien und komplexe AHF mit einem erhöhten Arrhythmierisiko bei diesen Patientinnen vergesellschaftet sind. Eine gründliche individuelle Evaluierung vor und ein sorgfältiges Monitoring während der Schwangerschaft in einem interdisziplinären Team sind unabdingbar, um einen bestmöglichen Schwangerschaftsverlauf für Patientinnen mit AHF zu ermöglichen.

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References

  1. 1.

    Balci A, Sollie-Szarynska KM, van der Bijl AGL et al (2014) Prospective validation and assessment of cardiovascular and offspring risk models for pregnant women with congenital heart disease. Heart 100:1373–1381. https://doi.org/10.1136/heartjnl-2014-305597

    Article  PubMed  Google Scholar 

  2. 2.

    Balint OH, Siu SC, Mason J et al (2010) Cardiac outcomes after pregnancy in women with congenital heart disease. Heart 96:1656–1661. https://doi.org/10.1136/hrt.2010.202838

    Article  PubMed  Google Scholar 

  3. 3.

    Capeless EL, Clapp JF (1989) Cardiovascular changes in early phase of pregnancy. Am J Obstet Gynecol 161:1449–1453. https://doi.org/10.1016/0002-9378(89)90902-

    CAS  Article  PubMed  Google Scholar 

  4. 4.

    Chapman AB, Abraham WT, Zamudio S et al (1998) Temporal relationships between hormonal and Hemodynamic changes in early human pregnancy. Kidney Int 54:2056–2063. https://doi.org/10.1046/j.1523-1755.1998.00217.x

    CAS  Article  PubMed  Google Scholar 

  5. 5.

    Drenthen W, Boersma E, Balci A et al (2010) Predictors of pregnancy complications in women with congenital heart disease. Eur Heart J 31:2124–2132. https://doi.org/10.1093/eurheartj/ehq200

    Article  PubMed  Google Scholar 

  6. 6.

    El Khoury N, Mathieu S, Marger L et al (2013) Upregulation of the hyperpolarization-activated current increases pacemaker activity of the sinoatrial node and heart rate during pregnancy in mice. Circulation 127:2009–2020. https://doi.org/10.1161/CIRCULATIONAHA.113.001689

    Article  PubMed  Google Scholar 

  7. 7.

    Garcia Ropero A, Baskar S, Roos Hesselink JW et al (2018) Pregnancy in women with a Fontan circulation. Circ Cardiovasc Qual Outcomes 11:e4575. https://doi.org/10.1161/CIRCOUTCOMES.117.004575

    Article  PubMed  Google Scholar 

  8. 8.

    Gatzoulis MA, Balaji S, Webber SA et al (2000) Risk factors for arrhythmia and sudden cardiac death late after repair of tetralogy of fallot: a multicentre study. Lancet 356:975–981. https://doi.org/10.1016/S0140-6736(00)02714-8

    CAS  Article  PubMed  Google Scholar 

  9. 9.

    van Hagen IM, Boersma E, Johnson MR et al (2016) Global cardiac risk assessment in the registry of pregnancy and cardiac disease: results of a registry from the European Society of Cardiology. Eur J Heart Fail 18:523–533. https://doi.org/10.1002/ejhf.501

    Article  PubMed  Google Scholar 

  10. 10.

    Hayward RM, Foster E, Tseng ZH (2017) Maternal and fetal outcomes of admission for delivery in women with congenital heart disease. JAMA Cardiol 2:664–671. https://doi.org/10.1001/jamacardio.2017.0283

    Article  PubMed  PubMed Central  Google Scholar 

  11. 11.

    Hernández-Madrid A, Paul T, Abrams D et al (2018) Arrhythmias in Congenital Heart Disease: A Position Paper of the European Heart Rhythm Association (EHRA), Association for European Paediatric and Congenital Cardiology (AEPC), and the European Society of Cardiology (ESC) Working Group on Grown-up Congenital Heart Disease, Endorsed by HRS, PACES, APHRS, and SOLAECE. EP Eur 20:1719–1753. https://doi.org/10.1093/europace/eux380

    Article  Google Scholar 

  12. 12.

    Kampman MAM, Balci A, Groen H et al (2015) Cardiac function and cardiac events 1‑year postpartum in women with congenital heart disease. Am Heart J 169:298–304. https://doi.org/10.1016/j.ahj.2014.11.010

    Article  PubMed  Google Scholar 

  13. 13.

    Kampman MAM, Balci A, van Veldhuisen DJ et al (2014) N‑terminal pro-B-type Natriuretic peptide predicts cardiovascular complications in pregnant women with congenital heart disease. Eur Heart J 35:708–715. https://doi.org/10.1093/eurheartj/eht526

    CAS  Article  PubMed  Google Scholar 

  14. 14.

    Khairy P (2019) Arrhythmias in adults with congenital heart disease: what the practicing cardiologist needs to know. Can J Cardiol 35:1698–1707. https://doi.org/10.1016/j.cjca .2019.07.009

    Article  Google Scholar 

  15. 15.

    Khairy P, Ionescu-Ittu R, Mackie AS et al (2010) Changing mortality in congenital heart disease. J Am Coll Cardiol 56:1149–1157. https://doi.org/10.1016/j.jacc.2010.03.085

    Article  PubMed  Google Scholar 

  16. 16.

    Khairy P, Ouyang DW, Fernandes SM et al (2006) Pregnancy outcomes in women with congenital heart disease. Circulation 113:517–524. https://doi.org/10.1161/CIRCULATIONAHA.105.589655

    Article  PubMed  Google Scholar 

  17. 17.

    Kim YY, Goldberg LA, Awh K et al (2019) Accuracy of risk prediction scores in pregnant women with congenital heart disease. Congenit Heart Dis 14:470–478. https://doi.org/10.1111/chd.12750

    Article  PubMed  PubMed Central  Google Scholar 

  18. 18.

    Lee JCR, Wetzel G, Shannon K (2004) Maternal arrhythmia management during pregnancy in patients with structural heart disease. Prog Pediatr Cardiol 19:71–82. https://doi.org/10.1016/j.ppedcard.2003.09.002

    Article  Google Scholar 

  19. 19.

    Lee SH, Chen SA, Wu TJ et al (1995) Effects of pregnancy on first onset and symptoms of paroxysmal Supraventricular tachycardia. Am J Cardiol 76:675–678. https://doi.org/10.1016/s0002-9149(99)80195-7

    CAS  Article  PubMed  Google Scholar 

  20. 20.

    Li J, Nguyen C, Joglar JA et al (2008) Frequency and outcome of arrhythmias complicating admission during pregnancy: experience from a high-volume and ethnically-diverse obstetric service. Clin Cardiol 31:538–541. https://doi.org/10.1002/clc.20326

    Article  PubMed  PubMed Central  Google Scholar 

  21. 21.

    Meah VL, Cockcroft JR, Backx K et al (2016) Cardiac output and related haemodynamics during pregnancy: a series of meta-analyses. Heart 102:518–526. https://doi.org/10.1136/heartjnl-2015-308476

    CAS  Article  PubMed  Google Scholar 

  22. 22.

    Niwa K, Tateno S, Akagi T et al (2007) Arrhythmia and reduced heart rate variability during pregnancy in women with congenital heart disease and previous reparative surgery. Int J Cardiol 122:143–148. https://doi.org/10.1016/j.ijcard.2006.11.045

    Article  PubMed  Google Scholar 

  23. 23.

    Opotowsky AR, Siddiqi OK, D’Souza B et al (2012) Maternal cardiovascular events during childbirth among women with congenital heart disease. Heart 98:145–151. https://doi.org/10.1136/heartjnl-2011-300828

    Article  Google Scholar 

  24. 24.

    Owens A, Yang J, Nie L et al (2018) Neonatal and maternal outcomes in pregnant women with cardiac disease. J Am Heart Assoc 7:e9395. https://doi.org/10.1161/JAHA.118.009395

    Article  PubMed  PubMed Central  Google Scholar 

  25. 25.

    Pillutla P, Nguyen T, Markovic D et al (2016) Cardiovascular and neonatal outcomes in pregnant women with high-risk congenital heart disease. Am J Cardiol 117:1672–1677. https://doi.org/10.1016/j.amjcard.2016.02.045

    Article  PubMed  Google Scholar 

  26. 26.

    Regitz-Zagrosek V, Roos-Hesselink JW, Bauersachs J et al (2018) 2018 ESC guidelines for the management of cardiovascular diseases during pregnancy. Eur Heart J 39:3165–3241. https://doi.org/10.1093/eurheartj/ehy340

    Article  Google Scholar 

  27. 27.

    Savu O, Jurcuţ R, Giuşcă S et al (2012) Morphological and functional adaptation of the maternal heart during pregnancy. Circ Cardiovasc Imaging 5:289–297. https://doi.org/10.1161/CIRCIMAGING.111.970012

    Article  PubMed  Google Scholar 

  28. 28.

    Silversides CK, Grewal J, Mason J et al (2018) Pregnancy outcomes in women with heart disease: the CARPREG II study. J Am Coll Cardiol 71:2419–2430. https://doi.org/10.1016/j.jacc.2018.02.076

    Article  PubMed  Google Scholar 

  29. 29.

    Silversides CK, Harris L, Haberer K et al (2006) Recurrence rates of arrhythmias during pregnancy in women with previous tachyarrhythmia and impact on fetal and neonatal outcomes. Am J Cardiol 97:1206–1212. https://doi.org/10.1016/j.amjcard.2005.11.041

    Article  PubMed  Google Scholar 

  30. 30.

    Siu SC, Sermer M, Colman JM et al (2001) Prospective multicenter study of pregnancy outcomes in women with heart disease. Circulation 104:515–521. https://doi.org/10.1161/hc3001.093437

    CAS  Article  PubMed  Google Scholar 

  31. 31.

    Stein PK, Hagley MT, Cole PL et al (1999) Changes in 24-hour heart rate variability during normal pregnancy. Am J Obstet Gynecol 180:978–985. https://doi.org/10.1016/S0002-9378(99)70670-8

    CAS  Article  PubMed  Google Scholar 

  32. 32.

    Tateno S, Niwa K, Nakazawa M et al (2003) Arrhythmia and conduction disturbances in patients with congenital heart disease during pregnancy. Circ J 67:992–997. https://doi.org/10.1253/circj.67.992

    Article  PubMed  Google Scholar 

  33. 33.

    Warnes CA (2015) Pregnancy and delivery in women with congenital heart disease. Circ J 79:1416–1421. https://doi.org/10.1253/circj.CJ-15-0572

    CAS  Article  PubMed  Google Scholar 

  34. 34.

    Wu M‑H, Lu C‑W, Chen H‑C et al (2018) Adult Congenital Heart Disease in a Nationwide Population 2000–2014: Epidemiological Trends, Arrhythmia, and Standardized Mortality Ratio. J Am Heart Assoc 7:e7907. https://doi.org/10.1161/JAHA.117.007907

    Article  PubMed  PubMed Central  Google Scholar 

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Acknowledgements

The authors thank Prof. Peter Kohl and Dr. Eva Rog-Zielinska for their critical review of the manuscript.

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Correspondence to Hannah E. Fürniss.

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H.E. Fürniss and B. Stiller declare that they have no competing interests.

For this article no studies with human participants or animals were performed by any of the authors. All studies mentioned were performed in accordance with the ethical standards indicated in each case.

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Fürniss, H.E., Stiller, B. Arrhythmic risk during pregnancy in patients with congenital heart disease. Herzschr Elektrophys (2021). https://doi.org/10.1007/s00399-021-00754-7

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Keywords

  • Adult CHD
  • Arrhythmia
  • Obstetric status
  • Adverse maternal/foetal events
  • Risk prediction

Schlüsselwörter

  • Angeborene Herzfehler bei Erwachsenen
  • Herzrhythmusstörungen
  • Schwangerschaftsstatus
  • Maternale/fetale Komplikationen
  • Risikostratifizierung