Management of Implantable Cardioverter-Defibrillators during Pregnancy-A Systematic Review

Cardiac implantable electronic devices in pregnancy: A position statement

The aim of this document is to provide guidance for the management of women and birthing people with a permanent pacemaker (PPM) or implantable cardioverter defibrillator (ICD). Cardiac devices are becoming more common in obstetric practice and a reference document for contemporary evidence-based practice is required. Where evidence is limited, expert consensus has established recommendations. The purpose is to improve safety and reduce the risk of adverse events relating to implanted cardiac devices during pregnancy, birth and the postnatal period.

Guidelines for Scrutiny of Death Associated With Surgery and Anesthesia

The death of a patient in the operating room frequently causes great distress to the patient's family, and the surgical team members who performed the procedure typically feel uneasy about it afterward. Anesthetic death is characterized as a death that happens 24 hours after anesthesia is administered and is caused by anesthetic-related factors. However, death can come much later because of its complications. This review thoroughly explains mortality resulting from surgery and anesthesia, including autopsy reports, investigative data, analytical techniques, and conclusions. Following surgery and anesthesia-related death, in case of death after surgery, an autopsy determines the cause of death and if the procedure had any impact on it. Individuals who pass away during or after surgery may do so for a wide range of reasons, such as a generally natural condition, an early or late surgical complication, an anesthetic problem, or an error during the operation or anesthesia. The pathologist should take the results of the examination into account while looking into an anesthetic death. In the majority of anesthesia-related deaths, autopsies reveal little diagnostic information with the absence of an underlying cause of death. The analyses help determine and estimate the dosage of medication given, as well as the amount of anesthetic agent overdose provided before death. The best consensus opinion to provide the investigative authorities and courts of law for the cause of death investigation may come from a discussion amongst forensic pathologists, surgeons, and anesthetists. In conclusion, the family and friends of the deceased are greatly affected by an unexpected or unexplained death, and the organizations entrusted with determining the cause of death bear a great deal of responsibility. Science and technology are becoming more and more important in death investigations. Following precise and well-founded procedures is one of the science's defining characteristics.

Is it safe to give birth with an activated implantable cardioverter-defibrillator: A multicentre observational study

OBJECTIVE

Data and guidelines are lacking, so implantable cardioverter-defibrillators (ICDs) are often deactivated during labour to prevent inappropriate shocks. This study aimed to ascertain the safety of an activated ICD during labour.

DESIGN

An observational study was performed.

SETTING

Dutch hospitals.

POPULATION OR SAMPLE

A total of 41 childbirths were included of 26 patients who gave birth between February 2009 and November 2018 after receiving an ICD in our tertiary hospital. Five of these childbirths were attended by the research team between December 2018 and August 2020, during which the ICD remained active.

METHODS

Groups were made based on ICD status during labour. Patients who gave birth with an activated ICD at least once were stratified to the activated ICD group. Patients' files were checked and patients received a questionnaire about childbirth perceptions and treatment preferences. The differences in ordinal data resulting from the questionnaire were calculated using a chi-square or Fisher's exact test.

MAIN OUTCOME MEASURES

Primary outcome was inappropriate ICD therapy and occurrence of ventricular arrhythmias requiring treatment.

RESULTS

During the 41 childbirths, no inappropriate shocks or ventricular arrhythmias occurred during labour. All patients in the activated ICD group (n = 13) preferred this setting, while 8 of the 13 patients in the deactivated ICD group preferred activation (p = 0.002). Reasons included avoiding hemodynamic monitoring, magnet placement, or labour induction to facilitate technician availability.

CONCLUSIONS

This study shows no evidence that labour and birth in women with an activated ICD are unsafe, as there were no ventricular arrhythmias or inappropriate therapy. In addition, most patients prefer an activated ICD during labour.

Care for the Obstetric Patient with Complex Cardiac Disease

The prevalence of cardiac disease-related maternal morbidity and mortality is on the rise in the United States. To ensure safe management of pregnancy in patients with cardiovascular disease, pre-delivery evaluation by a multidisciplinary Pregnancy Heart Team should occur. Appropriate anesthetic, cardiac, and obstetric care are essential. Risk stratification tools evaluate the etiology and severity of cardiovascular disease to determine the appropriate hospital type and location for delivery and anesthetic management. Intrapartum hemodynamic monitoring may need to be intensified, and neuraxial analgesia and anesthesia are generally appropriate. The anesthesiologist must be prepared for obstetric and cardiac emergencies.

Usage of the wearable cardioverter-defibrillator during pregnancy

Background

Pregnancy can trigger or aggravate the risk for life-threating arrhythmias in cardiac diseases. Pregnancy is associated with reluctance for implantable cardioverter-defibrillators (ICD) due to concerns about radiation. Thus, the wearable cardioverter-defibrillator (WCD) might be an option during pregnancy. Aim of the study was to collect experiences about the use of WCD in pregnancy.

Methods and results

This study retrospectively included eight women who received a WCD during pregnancy. They suffered from ventricular tachycardia (VT) without known cardiac disease (n = 3), Brugada syndrome (n = 1), hypertrophic cardiomyopathy (n = 1), dilated cardiomyopathy (n = 1), non-compaction (n = 1), and survived sudden cardiac arrest during a preceding pregnancy (n = 1). WCD usage was started between 13 and 28 weeks of gestation. WCD wearing period ranged from 3 days to 30.9 weeks, WCD wearing time ranged from 13.0 to 23.7 h per day. Two women (25%) abandoned WCD already during pregnancy. Neither appropriate nor inappropriate WCD shocks were recorded. Antiarrhythmic management included beta-blockers (n = 5) and flecainide (n = 2). After delivery, ICD were implanted (n = 4), refused (n = 2) and estimated not necessary after successful catheter ablation (n = 2).

Conclusion

Uneventful pregnancy is possible in women at risk for sudden cardiac death by interdisciplinary monitoring and diligent pharmacotherapy protected by the WCD. Since no WCD shocks were recorded, the effectiveness of WCD during pregnancy is still unclear. However, arrhythmia detection by WCD was very good despite the changed anatomy in pregnancy. Nevertheless, further studies are necessary to assess effectiveness of WCD in pregnant women. Furthermore, efforts should be made to increase the wearing adherence of WCD during pregnancy.

Peripartum anesthetic management in patients with left ventricular noncompaction: a case series and review of the literature

BACKGROUND

This retrospective review focuses on peripartum anesthetic management and outcome of a series of five pregnant women with left ventricular noncompaction (LVNC).

METHODS

The Mayo Clinic Advanced Cohort Explorer medical database was utilized to identify women diagnosed with LVNC who had been admitted for delivery at the Mayo Clinic in Rochester, Minnesota between January 2001 and September 2021. Echocardiograms were independently reviewed by two board-certified echocardiographers, and those determined by both to meet the Jenni criteria and/or having compatible findings on magnetic resonance imaging (MRI) were included. Electronic medical records were reviewed for information pertaining to cardiac function, labor, delivery, and postpartum management.

RESULTS

We identified 44 patients whose medical record included the term "noncompaction" or "hypertrabeculation" and who had delivered at our institution during the study period. Upon detailed review of the medical records, 36 did not meet criteria for LVNC, and three additional patients did not receive the diagnosis until after delivery, leaving five patients with confirmed LVNC who had undergone six deliveries during the study interval. All five patients had a history of arrhythmias or had developed arrhythmias during pregnancy. One patient underwent emergency cesarean delivery due to sustained ventricular tachycardia requiring three intra-operative cardioversions.

CONCLUSIONS

This case series adds new evidence to that already available about pregnancies among women with LVNC. Favorable obstetrical outcomes were achievable when multidisciplinary teams were prepared to manage the maternal and fetal consequences of intrapartum cardiac arrhythmias and hemodynamic instability.

Pregnancy and Delivery in a 27-Year-Old ICD Carrier

Implantable cardiac devices represent the first line treatment option used not only for secondary prevention of sudden cardiac death but also for primary prevention in patients with cardiac pathologies considered at risk of sudden cardiac death caused by ventricular tachycardia or ventricular fibrillation. The number of women with implantable cardiac devices reaching child bearing age is expected to increase more and more in the next years. Despite this tendency, there are only a few reported cases of pregnancies in implantable cardiac defibrillator carriers, leading to insufficient evidence and clear guideline recommendations on how to manage and monitor pregnancy in patients with this type of cardiac pathology. Closely monitoring within a multidisciplinary team consisting of an obstretician, electrophysiologist and anesthesiologist is required for this group of pregnant patients in order to achieve the best maternal and neonatal results. The present study describes the case of succesful outcome in a 27-year-old implantable cardiac defibrillator carrier implanted after an aborted cardiac arrest and reccurent polymorphic ventricular tachycardia due to myocarditis eight years prior to pregnancy, with an aim to emphasize the monitoring particularities and management during pregnancy.