Maternal arrhythmia in structurally normal heart: Prevalence and feasibility of catheter ablation without fluoroscopy

Case series of catheter-based arrhythmia ablation in 13 pregnant women

BACKGROUND

Catheter ablation is a rarely used procedure to treat arrhythmias during pregnancy.

HYPOTHESIS

In the case of maternal arrhythmia during pregnancy, zero-fluoroscopic catheter ablation is preferable to medical treatment.

METHODS

Between April 2014 and September 2021, we examined the demographic data, procedural parameters, and fetal and maternal outcomes in pregnant women undergoing ablation at the Gottsegen National Cardiovascular Center and University of Pécs Medical School, Heart Institute.

RESULTS

Fourteen procedures (14 electrophysiological studies [EPS], 13 ablations) performed on 13 pregnant women (age 30.3 ± 5.2 years, primipara n = 6) were studied. During EPS, 12 patients had inducible arrhythmias. Atrial tachycardia was confirmed in three, atrioventricular re-entry tachycardia via manifest accessory pathway (AP) in three, and via concealed AP in one case. Atrioventricular nodal re-entry tachycardia was confirmed in three and sustained monomorphic ventricular tachycardia in two cases. Eleven radiofrequency ablation (84.6%) and two cryoablation (15.4%) were performed. The electroanatomical mapping system was used in all cases. Transseptal puncture was performed in two cases (15.4%) due to left lateral APs. The mean procedure time was 76.0±33.0 minutes. All procedures were performed without fluoroscopy. No complications occurred. During the follow-up, arrhythmia-free survival was achieved in all cases, but in two patients, we used antiarrhythmic drugs (AADs) to achieve it. APGAR score was within the normal range in all cases [median (interquartile range), 9.0/10.0 (9.0-10.0/9.3-10.0)].

CONCLUSIONS

Zero-fluoroscopic catheter ablation was an effective and safe treatment option for our 13 pregnant patients. Catheter ablation may have less side effects on fetal development than the use of AADs during pregnancy.

Intracardiac echocardiography Chinese expert consensus

In recent years, percutaneous catheter interventions have continuously evolved, becoming an essential strategy for interventional diagnosis and treatment of many structural heart diseases and arrhythmias. Along with the increasing complexity of cardiac interventions comes ever more complex demands for intraoperative imaging. Intracardiac echocardiography (ICE) is well-suited for these requirements with real-time imaging, real-time monitoring for intraoperative complications, and a well-tolerated procedure. As a result, ICE is increasingly used many types of cardiac interventions. Given the lack of relevant guidelines at home and abroad and to promote and standardize the clinical applications of ICE, the members of this panel extensively evaluated relevant research findings, and they developed this consensus document after discussions and correlation with front-line clinical work experience, aiming to provide guidance for clinicians and to further improve interventional cardiovascular diagnosis and treatment procedures.

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

The prevalence of CVD in pregnant people is estimated to be around 1 to 4%, and it is imperative that clinicians that care for obstetric patients can promptly and accurately diagnose and manage common cardiovascular conditions as well as understand when to promptly refer to a high-risk obstetrics team for a multidisciplinary approach for managing more complex patients. In pregnant patients with CVD, arrhythmias and heart failure (HF) are the most common complications that arise. The difficulty in the management of these patients arises from variable degrees of severity of both arrhythmia and heart failure presentation. For example, arrhythmia-based complications in pregnancy can range from isolated premature ventricular contractions to life-threatening arrhythmias such as sustained ventricular tachycardia. HF also has variable manifestations in pregnant patients ranging from mild left ventricular impairment to patients with advanced heart failure with acute decompensated HF. In high-risk patients, a collaboration between the general obstetrics, maternal-fetal medicine, and cardiovascular teams (which may include cardio-obstetrics, electrophysiology, adult congenital, or advanced HF)—physicians, nurses and allied professionals—can provide the multidisciplinary approach necessary to properly risk-stratify these women and provide appropriate management to improve outcomes.

Arrhythmias in Pregnancy

Increasing maternal mortality and incidence of arrhythmias in pregnancy have been noted over the past 2 decades in the United States. Pregnancy is associated with a greater risk of arrhythmias, and patients with a history of arrhythmias are at significant risk of arrhythmia recurrence during pregnancy. The incidence of atrial fibrillation in pregnancy is rising. This review discusses the management of tachyarrhythmias and bradyarrhythmias in pregnancy, including management of cardiac arrest. Management of fetal arrhythmias are also reviewed. For patients without structural heart disease, β-blocker therapy, especially propranolol and metoprolol, and antiarrhythmic drugs, such as flecainide and sotalol, can be safely used to treat tachyarrhythmias. As a last resort, catheter ablation with minimal fluoroscopy can be performed. Device implantation can be safely performed with minimal fluoroscopy and under echocardiographic or ultrasound guidance in patients with clear indications for devices during pregnancy. Because of rising maternal mortality in the United States, which is partly driven by increasing maternal age and comorbidities, a multidisciplinary and/or integrative approach to arrhythmia management from the prepartum to the postpartum period is needed.

Transition in cardiology 2: Maternal and fetal congenital heart disease

The number of women with congenital heart disease (CHD) reaching reproductive age has been increasing. Many women with CHDs are desirous of pregnancy, but they face issues regarding preconception, antepartum, and postpartum management. On the other hand, the fetal diagnosis of CHD has improved with advances in the technique and equipment for fetal echocardiography. Recently, experiences with fetal intervention have been reported in patients with severe CHD, such as critical aortic stenosis. Nevertheless, some types of CHD are challenge to diagnose prenatally, resulting in adverse outcomes. Medical care is part of the transitional care for women and fetuses with CHD during the perinatal period. Pre-conceptional and prenatal counseling play an important role in transitional care. Sex and reproductive education need to be performed as early as possible. We herein review the current status, important issues to be resolved, and the future of maternal and fetal CHD to relevant caregivers.

Intracardiac Echocardiography to Guide Non-fluoroscopic Electrophysiology Procedures

Intracardiac echocardiography (ICE) is the most practical method for online imaging during electrophysiological procedures. It allows guiding of complex catheter ablation procedures together with electroanatomical mapping systems, either with minimal or with zero fluoroscopy exposure. Besides safe and reproducible transseptal puncture, ICE helps to assess location and contact of the tip of the ablation catheter relative to specific anatomical structures. Another option is visualization of the arrhythmogenic substrate in patients with ventricular arrhythmias. This article describes the clinical utility of ICE in non-fluoroscopic electrophysiology procedures more in detail.

Atrial fibrillation during pregnancy: a 9-month period with limited options

Pregnancy is a physiological condition with reversible hemodynamic, neurohormonal and coagulation changes to the maternal body during this 9‑month period. The occurrence of atrial fibrillation (AF) is altogether rare among pregnant women, but necessitates immediate treatment und further work-up. Despite numerous pharmacological and invasive therapeutic modalities for AF in non-pregnant patients, very few options are considered safe enough for the fetus and the mother during pregnancy. Commonly used medications such as beta blockers, calcium channel antagonists, antiarrhythmic drugs and anticoagulation therapy must be carefully individualized according to the week of gestation and possible underlying comorbidities of the mother, thus highlighting the importance of an interdisciplinary evaluation by a cardiologist and a gynecologist. The current review summarizes the existing knowledge and treatment options for AF in pregnancy and suggests a simplified algorithm for this clinical constellation.

Catheter mapping and ablation during pregnancy

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.

Maternal focal atrial tachycardia during pregnancy: A systematic review

INTRODUCTION

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

METHODS AND RESULTS

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

CONCLUSIONS

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

Cardiac arrhythmias in pregnant women: need for mother and offspring protection

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.

Zero-fluoroscopy transseptal puncture guided by right atrial electroanatomical mapping combined with intracardiac echocardiography: A single-center experience

Background

Right atrial electroanatomical mapping may be combined with SoundStar 3D diagnostic ultrasound catheter (EAM‐ICE) as a zero‐fluoroscopy procedure for radiofrequency catheter ablation (RFCA). We aimed to evaluate the efficiency and safety of zero‐fluoroscopy transseptal puncture guided by EAM‐ICE and fluoroscopy combined with intracardiac echocardiography (F‐ICE) in patients with paroxysmal atrial fibrillation (PAF).

Hypothesis

Zero‐fluoroscopy transseptal puncture is an effective and safe procedure.

Methods

This study had a prospective design. A total of 57 patients with PAF were enrolled and assigned to two groups. Twenty‐seven patients were enrolled in the EAM‐ICE group, and 30 patients were enrolled in the F‐ICE group.

Results

There were no statistically significant differences in baseline patient characteristics between groups. Transseptal puncture was successful in all patients (57/57, 100%). Total procedure time and duration of transseptal puncture were lower in the F‐ICE group (199.4 ± 26.0 minutes vs 150.7 ± 22.1 minutes, P = 0.000; 118.4 ± 19.7 vs 70.5 ± 13.5 minutes, P = 0.000). There was no use of fluoroscopy in the EAM‐ICE group (0 mGy vs 70.5 ± 13.5 mGy); the duration of fluoroscopy in the EAM‐ICE group was negligible (0 minutes vs 5.4 ± 1.9 minutes). No procedural complication occurred in either group.

Conclusions

EAM‐ICE guided zero‐fluoroscopy transseptal puncture is an effective and safe procedure.