Pregnancy Outcomes in Women After the Arterial Switch Operation

Outcome of Pregnancy in Women With D-Transposition of the Great Arteries: A Systematic Review

Background Information on maternal and fetal outcomes of pregnancy in women with D-transposition of the great arteries is limited. We conducted a systematic literature review on pregnancies in women with transposition of the great arteries after atrial and arterial switch operations to better define maternal and fetal risk. Methods and Results A systematic review was performed on studies between 2000 and 2021 that identified 676 pregnancies in 444 women with transposition of the great arteries. A total of 556 pregnancies in women with atrial switch operation were tolerated by most cases with low mortality (0.6%). Most common maternal complications, however, were arrhythmias (9%) and heart failure (8%) associated with serious morbidity in some patients. Worsening functional capacity, right ventricular function, and tricuspid regurgitation occurred in ≈20% of the cases. Rate of fetal and neonatal mortality was 1.4% and 0.8%, respectively, and rate of prematurity was 32%. A total of 120 pregnancies in women with arterial switch operation were associated with no maternal mortality, numerically lower rates of arrhythmias and heart failure (6% and 5%, respectively), significantly lower rate of prematurity (11%; P<0.001), and only 1 fetal loss. Conclusions Pregnancy is tolerated by most women with transposition of the great arteries and atrial switch operation with low mortality but important morbidity. Most common maternal complications were arrhythmias, heart failure, worsening of right ventricular function, and tricuspid regurgitation. There was also a high incidence of prematurity and increased rate of fetal loss and neonatal mortality. Outcome of pregnancy in women after arterial switch operations is more favorable, with reduced incidence of maternal complications and fetal outcomes similar to women without underlying cardiac disease.

Intrapartum cardiotocography in pregnancies with and without fetal CHD

OBJECTIVES

Congenital heart defects (CHD) are the most common inherited abnormalities. Intrapartum cardiotocography (CTG) is still considered a "gold standard" during labor. However, there is a lack of evidence regarding the interpretation of intrapartum CTG in fetuses with CHD. Therefore, the study aimed to compare intrapartum CTG in normal fetuses and fetuses with CHD and describe the association between CTG and neonatal outcomes.

METHODS

The present study is a retrospective analysis of the CTG of 395 fetuses. There were three study groups: Group 1: 185 pregnancies with a prenatal diagnosis of CHD, Group 2: 132 high-risk pregnancies without CHD, and Group 3: 78 low-risk pregnancies without CHD.

RESULTS

Abnormal CTG was present statistically OR=3.4 (95%CI: 1.61-6.95) more often in Group 1. The rate of the emergency CS was higher in this group OR=3 (95%CI: 1.3-3.1). Fetuses with CHD and abnormal CTG were more often scored ≤7 Apgar, with no difference in acidemia. The multivariate regression model for Group 1 does not show clinical differences between Apgar scores or CTG assessment in neonatal acidemia prediction.

CONCLUSIONS

CTG in fetuses with CHD should be interpreted individually according to the type of CHD and conduction abnormalities. Observed abnormalities in CTG are associated with the fetal heart defect itself. Preterm delivery and rapid cesarean delivery lead to a higher rate of neonatal complications. Health practitioners should consider this fact during decision-making regarding delivery in cases complicated with fetal cardiac problems.

The Coronary Arteries in Adults after the Arterial Switch Operation: A Systematic Review

Coronary artery status in adults long after the arterial switch operation (ASO) is unclear. We conducted a systematic review to provide an overview of coronary complications during adulthood and to evaluate the value of routine coronary imaging in adults after ASO, in light of current guidelines. Articles were screened for the inclusion of adult ASO patients and data on coronary complications and findings of coronary imaging were collected. A total of 993 adults were followed with a median available follow-up of only 2.0 years after reaching adulthood. Myocardial ischemia was suspected in 17/192 patients (8.9%). The number of coronary interventions was four (0.4%), and coronary death was reported in four (0.4%) patients. A lack of ischemia-related symptoms cannot be excluded because innervation studies indicated deficient cardiac innervation after ASO, although data is limited. Anatomical high-risk features found by routine coronary computed tomography (cCT) included stenosis (4%), acute angle (40%), kinking (24%) and inter-arterial course (11%). No coronary complications were reported during pregnancy (n = 45), although, remarkably, four (9%) patients developed heart failure. The 2020 European Society of Cardiology (ESC) guidelines state that routine screening for coronary pathologies is questionable. Based on current findings and in line with the 2018 American ACC/AHA guidelines a baseline assessment of the coronary arteries in all ASO adults seems justifiable. Thereafter, an individualized coronary follow-up strategy is advisable at least until significant duration of follow-up is available.

Management of Women With Congenital or Inherited Cardiovascular Disease From Pre-Conception Through Pregnancy and Postpartum: JACC Focus Seminar 2/5

Maternal morbidity and mortality continue to rise in the United States, with cardiovascular disease as the leading cause of maternal deaths. Congenital heart disease is now the most common cardiovascular condition encountered during pregnancy, and its prevalence will continue to grow. In tandem with these trends, maternal cardiovascular health is becoming increasingly complex. The identification of women at highest risk for cardiovascular complications is essential, and a team-based approach is recommended to optimize maternal and fetal outcomes. This document, the second of a 5-part series, will provide practical guidance from pre-conception through postpartum for cardiovascular conditions that are predominantly congenital or heritable in nature, including aortopathies, congenital heart disease, pulmonary hypertension, and valvular heart disease.

Pregnancy Outcomes in Women After Arterial Switch Operation for Transposition of the Great Arteries: Results From ROPAC (Registry of Pregnancy and Cardiac Disease) of the European Society of Cardiology EURObservational Research Programme

Background In the past 3 decades, the arterial switch procedure has replaced the atrial switch procedure as treatment of choice for transposition of the great arteries. Although survival is superior after the arterial switch procedure, data on pregnancy outcomes are scarce and transposition of the great arteries after arterial switch is not yet included in the modified World Health Organization classification of maternal cardiovascular risk. Methods and Results The ROPAC (Registry of Pregnancy and Cardiac disease) is an international prospective registry of pregnant women with cardiac disease, part of the European Society of Cardiology EURObservational Research Programme. Pregnancy outcomes in all women after an arterial switch procedure for transposition of the great arteries are described. The primary end point was a major adverse cardiovascular event, defined as combined end point of maternal death, supraventricular or ventricular arrhythmias requiring treatment, heart failure, aortic dissection, endocarditis, ischemic coronary events, and thromboembolic events. Altogether, 41 pregnant women (mean age, 26.7±3.9 years) were included, and there was no maternal mortality. A major adverse cardiovascular event occurred in 2 women (4.9%): heart failure in one (2.4%) and ventricular tachycardia in another (2.4%). One woman experienced fetal loss, whereas no neonatal mortality was observed. Conclusions Women after an arterial switch procedure for transposition of the great arteries tolerate pregnancy well, with a favorable maternal and fetal outcome. During counseling, most women should be reassured that the risk of pregnancy is low. Classification as modified World Health Organization risk class II seems appropriate.

Pregnancy in Women with Adult Congenital Heart Disease

Women with congenital heart disease are pursuing pregnancy in increasing numbers. Counseling about genetic transmission, medication management, maternal and fetal risks, and maternal longevity should be initiated well before pregnancy is considered. Although preconception medical and surgical optimization as well as coordinated multidisciplinary care throughout pregnancy decrease maternal and fetal risks, the rate of complications remains increased compared with the general population. Lesion-specific risk stratification and care throughout pregnancy further improve outcomes and decrease unnecessary interventions.