Abstract
Introduction : Management of gestational supraventricular tachycardia (SVT) is challenging and requires a multidisciplinary approach for optimal management. Antiarrhythmic pharmacologic therapy has variable efficacy and carries potential risks to both mother and fetus. Catheter ablation during pregnancy has traditionally been considered a last option due to procedural safety and ionizing radiation risks. Recent advances including intracardiac echocardiography and multi-electrode electroanatomic mapping have greatly enhanced the safety and efficacy profile to successfully perform ablations with minimal to no fluoroscopy even during pregnancy; however, most of the literature publications are case reports. Though the use of fluoroscopy-guided catheter ablations for refractory cardiac arrhythmias in pregnancy have been extensively studied, there are still a paucity of data about the efficacy, safety, and aggregate outcomes of purely zero-fluoroscopic ablations in comparison to minimal fluoroscopic approaches.
Methods : A literature search was performed for catheter ablations in the past fifteen years for gestational arrhythmias that used minimal or no fluoroscopy. Sixteen cases describing catheter ablations with zero-fluoroscopy were compared to twenty-four cases using minimal fluoroscopy, defined as total documented exposure time of less than 10 minutes. Baseline characteristics, techniques, and outcomes of both groups were compared.
Results: Analysis of both groups demonstrated that zero-fluoroscopic approaches for treatment of gestational SVT, though underutilized, have comparable successful outcomes without additional risk compared to minimally fluoroscopic procedures. Utilization of electroanatomic mapping with or without concomitant intracardiac echocardiography in the zero-fluoroscopy group further demonstrated equal efficacy rates of successful ablation when compared to the control group. Furthermore, there were no reported immediate or long term periprocedural complications in either group, including delivery outcomes.
Conclusions : Zero-fluoroscopy catheter ablation for SVT in pregnancy appears to be as effective and safe when compared to minimal fluoroscopy ablations while eliminating the theoretical risks of ionizing radiation.
Key Words:
Introduction :
Supraventricular tachycardia poses a clinical challenge during pregnancy and necessitates careful risk-benefit considerations to both mother and fetus. Though non-sustained arrhythmias are common in pregnancy, symptomatic tachyarrhythmias warrant careful investigation. The mechanism of increased arrhythmia burden remains unclear though hormonal and autonomic changes likely play key roles in physiologic changes precipitating to arrhythmias. Furthermore, studies have shown that patients with pre-existing SVT may experience exacerbations during pregnancy due to stretching of atrial and ventricular myocytes, resulting in early after depolarizations, shortened refractoriness, slowed conduction, and spatial dispersion through activation of stretch-activated ion channels1.
Catheter ablation is an alternative to pharmacologic therapy and advancements in electrophysiology techniques have allowed for successful ablations during pregnancy. However, one area of concern is the exposure of ionizing radiation to both mother and fetus. With the more widespread use of electroanatomic mapping and intracardiac echocardiography, fluoroscopy-free ablations are now feasible, though rarely described in the literature. Here, we review the characteristics of supraventricular tachyarrhythmias and outcomes of pregnant women who underwent zero-fluoroscopy ablations in comparison with cases of the more traditional minimal fluoroscopy approach.
Methods :
A Pub-Med, Medline, and Embase search were performed for catheter ablations in the past fifteen years for gestational arrhythmias that used minimal or no fluoroscopy. Sixteen cases describing catheter ablations with zero-fluoroscopy were compared to twenty-four cases using minimal fluoroscopy, defined as total documented exposure time of less than 10 minutes. The following data points were analyzed: maternal and gestational age, prior pharmacological therapy, presenting symptoms, arrhythmia etiology, and location. Cases describing cases of ventricular arrhythmias or arrhythmias secondary to recent surgical complications were not included in the data analysis. EKG findings, ablation procedure techniques, use of anesthesia, and complications were also included in the data.
Means and standard deviations along with the proportions of baseline clinical characteristics are reported with respect to the total number of patients in both the zero-fluoroscopy and minimal fluoroscopy groups. Mean gestational and maternal age at time ablations were analyzed. A comparative analysis of arrhythmias in both groups including subtype and left versus right-sided etiologies were completed. A 2-sample t-test was performed for continuous variables and a Chi-squared test was used for categorical variables when comparing parameters between the minimal fluoroscopy group and the zero-fluoroscopy group. A p-value of less than 0.05 was considered statistically significant.