Systemic Right Ventricle Often Not a Barrier to Successful Pregnancy

NEW YORK (Reuters Health) – Despite previous concerns, pregnancy in most women with a systemic right ventricle appears to be relatively safe for mother and child, an international registry study shows.

None of the 162 women in the study died, only one experienced a fetal loss and no neonatal mortality was seen, researchers report in the journal Heart.

Still, heart failure was seen in about 10% and arrhythmias in about 7% of the participants during their pregnancies. A systemic ejection fraction of less than 40% and clinical signs of heart failure before pregnancy were found to be risk factors for major adverse cardiac events during pregnancy, but a first-time pregnancy reduced that risk.

“Our results can reassure providers and patients with a systemic right ventricle that pregnancy is well tolerated if reduced ventricular function and clinical signs of heart failure are absent,” Dr. Jolien W. Roos-Hesselink of Erasmus Medical Center, in Rotterdam, the Netherlands, and colleagues write.

The study encompassed cases of systemic right ventricle (sRV) both after the atrial-switch procedure for transposition of the great arteries (TGA) and congenitally corrected TGA (CCTGA).

The researchers believe theirs is the first large prospective study of pregnancy in women with sRV.

They drew data from the European Society of Cardiology’s international, prospective, observational registry of pregnant patients with cardiac disease. This analysis encompassed all pregnancies in patients with sRV enrolled between 2007 and 2018.

Of these 162 women, 121 had TGA after atrial switch and 41 had CCTGA. Their mean age was 28, and 86 women were pregnant for the first time. Most were asymptomatic or had only mild cardiac symptoms before pregnancy.

During pregnancy, hospital admission for a cardiac reason was required in 9.8% of participants, significantly more often in women with CCTGA than TGA (19.5% vs. 6.6%). In both groups, the main reason for such admissions was heart failure; most episodes occurred in the second and third trimesters.

Except for cardiac-based hospital admissions, there were no significant differences in maternal or fetal outcomes between women with CCTGA and TGA.

None of the women died during pregnancy or through six months after delivery. One fetal death was reported, in a woman with TGA. The most frequent fetal morbidities were premature birth (20.9%) and low birth weight (17.8%).

In an email to Reuters Health, Dr. Roos-Hesselink emphasized that it’s crucial for a woman with sRV to discuss her pregnancy with her cardiologist.

“These are patients with moderately complex heart disease,” she explained. “In some women it might be better to do an intervention before pregnancy, or we need to stop medication, or we have to advise this individual lady to NOT become pregnant because of diminished cardiac function, for instance.”

Dr. Ewa Kowalik of the department of congenital heart diseases at the National Institute of Cardiology, in Warsaw, told Reuters Health by email that “no clear pregnancy-related deterioration of sRV was observed” in the new study.

Although the overall complication rate was low and outcomes were generally favorable, she continued, individualized preconception counseling is the key to success. Several factors should be taken into account, such as functional status before pregnancy, ventricular function, severity of the concomitant lesions, previous or planned surgery (especially valve replacement), pharmacological treatment and history of previous cardiac events.

Dr. Kowalik, who was not involved in the study, also highlighted the finding that a first pregnancy was associated with reduced risk of major adverse cardiac events. “It is difficult to say whether the sRV copes worse with subsequent pregnancies, or is this phenomenon related simply to sRV deterioration over time, regardless of pregnancies?”

Either way, she said, this issue of timing and the number of pregnancies is important when discussing the risk of pregnancy in women with sRV.

Finally, Dr. Kowalik said, “One should note that fetal echocardiography is recommended in every woman with sRV, usually at 19 to 22 weeks gestation.”

SOURCE: Heart, online April 28, 2021.

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