Ventricular tachyarrhythmia during pregnancy in women with heart disease: data from the ROPAC

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1 Ventricular tachyarrhythmia during pregnancy in women with heart disease: data from the ROPAC Ebru Ertekin MD, Iris M. Van Hagen MD, Amar M. Salam MD, Titia P.E. Ruys MD PhD, Jolien W. Roos-Hesselink MD PhD Erasmus Medical Center Rotterdam, The Netherlands February 29 th 2016, CPP congress, Las Vegas EURObservational Research Programme

2 Ventricular arrhythmia in pregnancy Ventricular tachyarrhythmia may be associated with maternal hemodynamic compromise with adverse consequences for mother and fetus Incidence of ventricular tachyarrhythmia In healthy women: 2/ pregnancies ( %) ¹ In women with heart disease: up to 1.4% ² ¹ Li JM, et al. Clin Cardiol 2008 ² Siu SC, et al. Circulation 1997

3 Objectives Ventricular tachyarrhythmia (VTA) in pregnant women with heart disease Incidence Onset Predictors Outcome

4 Registry On Pregnancy And Cardiac disease (ROPAC) participating countries

5 ROPAC: 39 countries, 99 centers 2966 pregnant women with structural heart disease January October 2013 Follow-up at one week after delivery Clinically relevant VTA: patients who were symptomatic or needed treatment for VTA

6 Cardiac diagnoses in ROPAC (n=2966) Congenital (n=1655) Valvular (n=947) Cardiomyopathy (n=202) Aortic pathology (n=101) Ischemic (n=47) Pulmonary hypertension (n=13)

7 Results - Incidence Clinically relevant VTA in pregnancy: 42 patients (1.4%) 41 ventricular tachycardia, 1 ventricular fibrillation Diagnoses: 20 congenital, 12 cardiomyopathy, 6 valvular, 3 aortic pathology, 1 ischemic heart disease 39 pts were in sinus rhythm, 3 pts had pacemakerdependent rhythm

8 Baseline characteristics [1/2] Patients with VTA (n=42) Patients without VTA (n=2924) p-value Mean age in years (SD) 28.9 (5.7) 29.3 (5.6) 0.78 Clinical signs of heart failure (%) Hypertension (%) Developing countries (%) Type of heart disease Congenital heart disease (%) Valvular heart disease (%) Cardiomyopathy (%) 29 7 <0.001 Aortic pathology (%) Ischemic heart disease (%)

9 Baseline characteristics [2/2] Patients with VTA (n=42) Patients without VTA (n=2924) p-value NYHA functional class NYHA 1 (%) NYHA 2 (%) NYHA 3 (%) NYHA 4 (%) 0 0.3

10 Results - Onset 1 st trimester 2 nd trimester 3 rd trimester 17% 26% 48%

11 Results Pre-pregnancy predictors of VTA Multivariable analysis OR 95% CI Cardiomyopathy 2.7 ( ) NYHA class >1 2.6 ( ) Clinical signs of heart failure 0.9 ( ) Systemic ventricular dysfunction 2.3 ( )

12 Results Maternal outcome Patients with VTA (n=42) Patients without VTA (n=2924) p-value Maternal mortality (%) Heart failure (%) Bleeding during pregnancy (%) Pregnancy induced hypertension (%) Intra-uterine growth retardation (%) Caesarean section (%)

13 Results Fetal outcome Patients with VTA (n=42) Patients without VTA (n=2924) p-value Late fetal death (>24 weeks; %) Neonatal death (%) Median pregnancy duration (weeks) <0.001 Apgar score <7 (%) Preterm birth (<37 weeks; %) Low birthweight <2500g (%) Corrected mean birthweight (g)* *Corrected for: gestational age, fetal sex, maternal age and diabetes

14 Discussion Incidence of VTA during pregnancy Previous studies This study Heart disease 1.0%, 1.4%¹, ² 1.4% Congenital 0.4, 1.6% ¹, ² 1.2% Valvular 1.5%¹, ³ 0.7% Cardiomyopathy 3% dilated cardiomyopathy 4 5.9% Ischemic - 2.1% ¹ Siu SC et al. Circulation 2001 ² Siu SC et al. Circulation 1997 ³ Lesniak-Sobelga, et al. Int J Cardiol Grewal J et al. J Am Coll Cardiol 2009

15 Limitations Missing data in the registry: 0-4% Incidence is low, numbers are small Severity of VTA was not reported in detail

16 Conclusion VTA occurred in 1.4 % of pregnant women with heart disease Mainly in the third trimester Higher rates of neonatal death, preterm birth, low birthweight and poor Apgar score

17 Acknowledgements Special thanks to our co-authors: Dr. M.R. Johnson (UK) Prof. dr. R. Hall (UK) Prof. dr. G. Veldtman (USA) Dr. J. Popelová (Czech Republic) Prof. dr. A. Shotan (Isreal) Prof. dr. Z. Ashour (Egypt) Prof. dr. W. Parsonage (Australia) Dr. J.M. Oliver (Spain)

18 Thank you for your attention Erasmus Medical Center Rotterdam, The Netherlands

19 Results Pre-pregnancy predictors of VTA Univariable OR 95% CI Cardiomyopathy 5.8 ( ) NYHA class >1 3.0 ( ) Clinical signs of heart failure 2.6 ( ) Systemic ventricular dysfunction 4.6 ( ) Nulliparity 1.5 ( ) Hypertension 0.7 ( )

20 Results Mode of delivery in VTA patients Vaginal delivery: 14/42 patients (32%) Planned Caesarean section: 20/42 patients (48%) Emergency Caesarean section: 8/42 patients (20%)

21 Discussion Pre-pregnancy predictors of VTA NYHA class>1 women with limited exercise tolerance are at higher risk of developing complications in pregnancy Cardiomyopathy associated with ventricular arrhythmias as it is often associated with diminished ventricular function¹ ¹ ACC/AHA/ESC 2006 guidelines for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death. J Am Coll Cardiol 2006