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Ventrella N, Schiavone M, Bianchini L, Sicuso R, Dessanai MA, Di Biase L, Tondo C. Catheter ablation for focal atrial tachycardias during pregnancy: A systematic review. Int J Cardiol 2024; 413:132333. [PMID: 38972492 DOI: 10.1016/j.ijcard.2024.132333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2024] [Revised: 05/29/2024] [Accepted: 07/01/2024] [Indexed: 07/09/2024]
Abstract
OBJECTIVE Pregnancy can trigger maternal tachycardias, and the onset of recurrent or incessant focal atrial tachycardia (AT) can lead to tachycardia-induced cardiomyopathy. Medical interventions are commonly employed, but they carry potential fetal and maternal risks. Catheter ablation (CA), particularly with non-fluoroscopic navigation systems, may be considered as an alternative. This systematic review aims to explore the feasibility and outcomes of CA for focal AT during pregnancy. METHODS A thorough literature search was conducted until September 30th, 2023, on PubMed, Embase, and Cochrane databases. Included articles described maternal focal ATs diagnosed through electrophysiological studies and treated with CA. Data derived from these studies were organized into tables and subsequently analyzed. RESULTS Out of 278 papers reviewed, 15 articles involving 24 patients were retrieved. CA, utilizing radiofrequency energy achieved acute success in 95.8% of cases. Sixteen patients (66.7%) underwent complete fluoroless procedures, with two adverse events directly related to the procedure reported. Long-term follow-up revealed minimal AT recurrences, with a 0.06% arrhythmia burden in one case. CONCLUSION Focal ATs during pregnancy can be incessant and refractory to medical intervention, precipitating an acute decline in left ventricular ejection fraction. In this setting, CA emerges as an efficacious treatment modality, particularly in cases of tachycardia-induced cardiomyopathies. Whenever feasible, it is advisable to perform these procedures with minimal or no fluoroscopy guidance. Larger studies are needed to establish the safety and the efficacy of CA for focal ATs during pregnancy, as current research consists of case reports or small case series.
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Affiliation(s)
- Nicoletta Ventrella
- Department of Clinical Electrophysiology & Cardiac Pacing, Centro Cardiologico Monzino, IRCCS, Milan, Italy; Department of Clinical Sciences and Community Health, Cardiovascular Section, University of Milan, Milan, Italy.
| | - Marco Schiavone
- Department of Clinical Electrophysiology & Cardiac Pacing, Centro Cardiologico Monzino, IRCCS, Milan, Italy
| | - Lorenzo Bianchini
- Department of Clinical Electrophysiology & Cardiac Pacing, Centro Cardiologico Monzino, IRCCS, Milan, Italy
| | - Rita Sicuso
- Department of Clinical Electrophysiology & Cardiac Pacing, Centro Cardiologico Monzino, IRCCS, Milan, Italy
| | - Maria Antonietta Dessanai
- Department of Clinical Electrophysiology & Cardiac Pacing, Centro Cardiologico Monzino, IRCCS, Milan, Italy
| | - Luigi Di Biase
- Cardiac Arrhythmia Center, Division of Cardiology, Department of Medicine, Montefiore-Einstein Center for Heart and Vascular Care, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Claudio Tondo
- Department of Clinical Electrophysiology & Cardiac Pacing, Centro Cardiologico Monzino, IRCCS, Milan, Italy; Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy
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Bekiaridou A, Coleman KM, Sharma N, George D, Liu Y, Gianos E, Rosen S, Mieres JH, Mountantonakis SE. Clinical Significance of Supraventricular Tachycardia During Pregnancy in Healthy Women. JACC Clin Electrophysiol 2024; 10:1304-1312. [PMID: 38661600 DOI: 10.1016/j.jacep.2024.03.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Revised: 02/06/2024] [Accepted: 03/07/2024] [Indexed: 04/26/2024]
Abstract
BACKGROUND Supraventricular tachycardias (SVT) are the most frequently encountered arrhythmias in pregnancy with unclear clinical significance. OBJECTIVES This study sought to report the prevalence, describe the management, and explore the association between SVT and adverse obstetric outcomes. METHODS Cohort study of primiparous and multiparous women without history of Cesarean section (CS), and with structurally normal hearts admitted in labor. The study group consisted of women with at least 1 SVT episode during pregnancy, and the control group was randomly selected in a 4:1 ratio. RESULTS Of 141,769 women meeting the inclusion criteria, SVT diagnosis was confirmed in 122. A total of 76 (age 33.2 ± 4.8 years) had at least 1 symptomatic and documented episode during pregnancy. In women with a known SVT diagnosis before pregnancy, medical therapy was not associated with a lower risk of SVT recurrence (OR: 1.07; 95% CI: 0.41-2.80). However, catheter ablation before pregnancy was associated with significantly lower risk of SVT recurrence (OR: 0.09; 95% CI: 0.04-0.23). Women with SVT during pregnancy had higher incidence of CS (39.5% vs 27.0%; P = 0.03), and preterm labor (PTL) (30.3% vs 8.6%; P < 0.001). Adjusting for age and parity, SVT during pregnancy was an independent predictor of CS (OR: 1.80; 95% CI: 1.03-3.10), particularly planned CS (OR: 2.89; 95% CI: 1.06-7.89) and PTL (OR: 4.37; 95% CI: 2.30-8.31). CONCLUSIONS SVT during pregnancy is associated with increased risk for CS and PTL in healthy women. History of SVT should be sought as early as preconception counseling, and a multidisciplinary approach is warranted for both prevention and management of SVT occurrence.
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Affiliation(s)
- Alexandra Bekiaridou
- Northwell Health, New Hyde Park, New York, USA; Elmezzi Graduate School of Molecular Medicine, Manhasset, New York, USA; Feinstein Institute for Medical Research, Manhasset, New York, USA
| | - Kristie M Coleman
- Northwell Health, New Hyde Park, New York, USA; Northwell Cardiovascular Institute, New York, New York, USA; Lenox Hill Hospital, New York, New York, USA. https://twitter.com/keepinrhythm
| | - Nikhil Sharma
- Northwell Health, New Hyde Park, New York, USA; Feinstein Institute for Medical Research, Manhasset, New York, USA; Northwell Cardiovascular Institute, New York, New York, USA
| | - Deepika George
- Northwell Health, New Hyde Park, New York, USA; Feinstein Institute for Medical Research, Manhasset, New York, USA
| | - Yan Liu
- Northwell Health, New Hyde Park, New York, USA; Feinstein Institute for Medical Research, Manhasset, New York, USA
| | - Eugenia Gianos
- Northwell Health, New Hyde Park, New York, USA; Northwell Cardiovascular Institute, New York, New York, USA; Lenox Hill Hospital, New York, New York, USA
| | - Stacey Rosen
- Northwell Health, New Hyde Park, New York, USA; Northwell Cardiovascular Institute, New York, New York, USA
| | - Jennifer H Mieres
- Northwell Health, New Hyde Park, New York, USA; Northwell Cardiovascular Institute, New York, New York, USA
| | - Stavros E Mountantonakis
- Northwell Health, New Hyde Park, New York, USA; Northwell Cardiovascular Institute, New York, New York, USA; Lenox Hill Hospital, New York, New York, USA.
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You J, Pagan E, Mitra R. Comparison of minimal versus zero-fluoroscopic catheter ablation in gestational supraventricular arrhythmias. J Interv Card Electrophysiol 2023; 66:1423-1429. [PMID: 36495414 DOI: 10.1007/s10840-022-01444-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Accepted: 11/28/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND The management of symptomatic gestational supraventricular tachycardia (SVT) is challenging and requires a multidisciplinary approach for optimal management. Catheter ablation during pregnancy has traditionally been considered a last option due to procedural safety and ionizing radiation risks. Recent advances including intracardiac echocardiography and multi-electrode electroanatomic mapping have greatly enhanced the safety and efficacy profile to successfully perform ablations with minimal to no fluoroscopy even during pregnancy. This is the first review to compare the efficacy, safety, and aggregate outcomes of purely zero-fluoroscopic and minimal fluoroscopic approaches in gestational SVT. METHODS A literature search was performed for catheter ablations in the past 15 years for gestational arrhythmias that used minimal or no fluoroscopy. Sixteen cases describing catheter ablations with zero-fluoroscopy were compared to twenty-four cases using minimal fluoroscopy, defined as total documented exposure time of less than 10 min. RESULTS Analysis of both groups demonstrated that zero-fluoroscopic approaches have comparable efficacy and procedural safety outcomes with the utilization of earlier trimester ablations and in older maternal ages. The utilization of electroanatomic mapping with or without concomitant intracardiac echocardiography in the zero-fluoroscopy group further demonstrated equal efficacy rates of successful ablation when compared to the control group. Furthermore, there were no reported immediate or long-term periprocedural complications in either group, including delivery outcomes. CONCLUSION Our review demonstrates that zero-fluoroscopy catheter ablation for SVT in pregnancy is both effective and safe when compared to minimal fluoroscopy ablations while eliminating the theoretical risks of ionizing radiation.
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Affiliation(s)
- Joseph You
- Department of Internal Medicine, North Shore University Hospital, Manhasset, NY, USA
| | - Eric Pagan
- Department of Cardiology, Zucker School of Medicine at Hofstra/Northwell, North Shore University Hospital, Manhasset, NY, USA
| | - Raman Mitra
- Department of Cardiology, Zucker School of Medicine at Hofstra/Northwell, North Shore University Hospital, Manhasset, NY, USA.
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Catheter ablation for tachyarrhythmias during pregnancy. Adv Cardiol 2022; 18:206-216. [PMID: 36751286 PMCID: PMC9885226 DOI: 10.5114/aic.2022.122032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Accepted: 11/26/2022] [Indexed: 12/24/2022]
Abstract
Introduction Refractory arrhythmias during pregnancy pose challenges to physicians. Aim To give an overview of catheter ablation for tachyarrhythmias during pregnancy, and to discuss the indications of the procedure and the outcomes of both mother and fetus. Material and methods The study materials were based on comprehensive literature retrieval of the pertinent articles published since 2000. Results The indications for catheter ablation were refractory arrhythmias unresponsive to drug therapy in most of the cases followed by requirement of cardioversion. Atrioventricular nodal reentrant tachycardia was the most common arrhythmia developed during pregnancy. Pregnancy complications were present in 2.4% of the cases. There was no mortality among the pregnant patients. Fetal adverse events occurred in 3.1% of the cases, more in the fluoroscopy than in the zero-fluoroscopy group. The patient cohort with a radiation dose of > 50 mGy in one-third of the cases had a 14.3% fetal adverse event rate. Fetal adverse events occurred only in the second trimester, not in the other two trimesters. Conclusions Drug-refractory and poorly tolerated tachycardias in pregnant patients warrant catheter ablation. Zero-fluoroscopy technique under guidance with three-dimensional mapping systems is preferred and strict minimal fluoroscopy is only used in extreme necessity. As ablation in the second trimester was associated with a probable higher fetal adverse event rate, it is suggested that ablation is preferably performed in the third trimester.
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Ibetoh CN, Stratulat E, Liu F, Wuni GY, Bahuva R, Shafiq MA, Gattas BS, Gordon DK. Supraventricular Tachycardia in Pregnancy: Gestational and Labor Differences in Treatment. Cureus 2021; 13:e18479. [PMID: 34659918 PMCID: PMC8494174 DOI: 10.7759/cureus.18479] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 10/04/2021] [Indexed: 11/28/2022] Open
Abstract
Supraventricular tachycardia (SVT) is a tachyarrhythmia characterized by a heart rate above 120 beats per minute (BPM). Patients with SVT exhibit the following symptoms: palpitations, shortness of breath, chest pain, hemodynamic instability, or possibly asymptomatic. The increase in cardiac output and the increase in resting heart rate during pregnancy predispose pregnant women to SVT. The management of SVT in pregnancy, although remarkably similar, varies slightly based on the trimester of pregnancy. Atenolol and verapamil are effective methods of treating SVT, which can be used during the second and third trimesters. Both medications are contraindicated in the first trimester. At the same time, intravenous adenosine can be used in all three trimesters, including labor. Electrical cardioversion is an effective treatment method for hemodynamically unstable or drug-refractory patients, which has proven to be safe in all three trimesters, including labor but can result in pre-term labor in the third trimester. Non-fluoroscopic ablation proved to be the only treatment method that definitively resolved SVT without recurrence.
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Affiliation(s)
- Crystal N Ibetoh
- Family Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Eugeniu Stratulat
- Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Fan Liu
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - George Y Wuni
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Ronak Bahuva
- Internal Medicine, California Institute of Behavioral Neuroscience & Psychology, Fairfield, USA
- Internal Medicine, University at Buffalo, Buffalo, USA
| | - Muhammad A Shafiq
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
- Internal Medicine, Rawalpindi Medical University, Islamabad, PAK
| | - Boula S Gattas
- Internal Medicine, California Institute of Behavioral Neuroscience & Psychology, Fairfield, USA
| | - Domonick K Gordon
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
- Internal Medicine, Scarborough General Hospital, Scarborough, TTO
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Greyling A, Vlachou C, Ailoaei S, Buchholz T, Toth B, Ernst S. Catheter mapping and ablation during pregnancy. Herzschrittmacherther Elektrophysiol 2021; 32:164-173. [PMID: 33782753 DOI: 10.1007/s00399-021-00756-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 03/18/2021] [Indexed: 11/25/2022]
Abstract
A substantial number of pregnant women at some point experience cardiac arrhythmia, which is mostly treated by antiarrhythmic medication. In some instances, arrhythmias can be drug-resistant and pose a relevant risk to both mother and unborn child as they can result in hemodynamic compromise. In recent years, invasive electrophysiology procedures have been carried out with ever reducing exposure to ionising radiation, and multiple techniques have been established to achieve ZERO exposure. Of course, these techniques should all be applied when contemplating an invasive mapping and ablation procedure during pregnancy. The role of the cardio-obstetrics team in planning and performing such procedures is paramount. Careful assessment of the pregnant mother and her unborn child is mandatory. Only with good preparation is a complete understanding of both cardiac anatomy and physiology achievable, which is a pre-requisite of a successful ablation outcome. Various aspects of the ablation procedure itself are discussed and evaluated from the perspective of all team members involved, including the obstetrician, the anaesthetist and the electrophysiologist. This review aims to inform the reader about the techniques available and reports on the published outcomes for ablations during pregnancy in the last decade.
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Affiliation(s)
- Adele Greyling
- Department of Cardiology, Royal Brompton and Harefield NHS Foundation Trust, Royal Brompton and Harefield Hospital, Sydney Street, SW3 6NP, London, UK
- Department of Paediatric Cardiology, University of Stellenbosch, Cape Town, South Africa
| | - Caterina Vlachou
- Department of Anaesthesia, Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - Stefan Ailoaei
- Department of Cardiology, Royal Brompton and Harefield NHS Foundation Trust, Royal Brompton and Harefield Hospital, Sydney Street, SW3 6NP, London, UK
- National Heart and Lung Institute, Imperial College, London, UK
| | | | - Bettina Toth
- Universitätsklinik für Gynäkologische Endokrinologie und Reproduktionsmedizin, Department Frauenheilkunde, Medizinische Universitaet Innsbruck, Innsbruck, Austria
| | - Sabine Ernst
- Department of Cardiology, Royal Brompton and Harefield NHS Foundation Trust, Royal Brompton and Harefield Hospital, Sydney Street, SW3 6NP, London, UK.
- National Heart and Lung Institute, Imperial College, London, UK.
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Kugamoorthy P, Spears DA. Management of tachyarrhythmias in pregnancy - A review. Obstet Med 2020; 13:159-173. [PMID: 33343692 PMCID: PMC7726166 DOI: 10.1177/1753495x20913448] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Accepted: 02/16/2020] [Indexed: 11/16/2022] Open
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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Goya M, Frame D, Gache L, Ichishima Y, Tayar DO, Goldstein L, Lee SHY. The use of intracardiac echocardiography catheters in endocardial ablation of cardiac arrhythmia: Meta-analysis of efficiency, effectiveness, and safety outcomes. J Cardiovasc Electrophysiol 2020; 31:664-673. [PMID: 31976603 PMCID: PMC7078927 DOI: 10.1111/jce.14367] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Revised: 01/10/2020] [Accepted: 01/20/2020] [Indexed: 02/02/2023]
Abstract
Aims The optimal use of intracardiac echocardiography (ICE) may reduce fluoroscopy time and procedural complications during endocardial ablation of cardiac arrhythmias. Due to limited evidence in this area, we conducted the first systematic literature review and meta‐analysis to evaluate outcomes associated with the use of ICE. Methods and Results Studies reporting the use of ICE during ablation procedures vs without ICE were searched using PubMed/MEDLINE. A meta‐analysis was performed on the 19 studies (2186 patients) meeting inclusion criteria, collectively representing a broad range of arrhythmia mechanisms. Use of ICE was associated with significant reductions in fluoroscopy time (Hedges' g −1.06; 95% confidence interval [CI] −1.81 to −0.32; P < .01), fluoroscopy dose (Hedges' g −1.27; 95% CI −1.91 to −0.62; P < .01), and procedure time (Hedges' g −0.35; 95% CI −0.64 to −0.05; P = .02) vs ablation without ICE. A 6.95 minute reduction in fluoroscopy time and a 15.2 minute reduction in procedure time was observed between the ICE vs non‐ICE groups. These efficiency gains were not associated with any decreased effectiveness or safety. Sensitivity analyses limiting studies to an atrial fibrillation (AF) only population yielded similar results to the main analysis. Conclusion The use of ICE in the ablation of cardiac arrhythmias is associated with significantly lower fluoroscopy time, fluoroscopy dose, and shorter procedure time vs ablation without ICE. These efficiency improvements did not compromise the clinical effectiveness or safety of the procedure.
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Affiliation(s)
- Masahiko Goya
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Diana Frame
- Real World Evidence, CTI Clinical Trial & Consulting, Covington, Kentucky
| | - Larry Gache
- Real World Evidence, CTI Clinical Trial & Consulting, Covington, Kentucky
| | | | | | - Laura Goldstein
- Health Economics & Market Access, Johnson & Johnson Medical Devices, Irvine, California
| | - Stephanie Hsiao Yu Lee
- Health Economics & Market Access, Johnson & Johnson Medical Asia Pacific, Singapore, Singapore
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