Outcome of Pregnancy in Women with D-Transpositions of the Great Arteries: A
Systematic Review.
Pizyka J, Devera J, Ng TMH, et al.
J Am Heart Assoc. 2022;11(23): e026862.doi: 10.1161/JAHA.122.026862
Commentary from Dr. Anna Tsirka (Hartford, CT, USA), section editor of Pediatric and Fetal Cardiology Journal Watch
Take Home Message:
- Women after atrial switch operation had 0.6% mortality and high rate of complications. Most common maternal complications, however, were arrhythmias (9%) and heart failure (8%). Worsening functional capacity, right ventricular function, and tricuspid regurgitation occurred in ≈20% of the cases.
- Rate of fetal and neonatal mortality after atrial switch was 1.4% and 0.8%, respectively, and rate of prematurity was 32%.
- After arterial switch operation (n=120) there was no maternal mortality, with maternal complications of arrhythmias (6%) and heart failure (5%).
- After arterial switch operation the rate of prematurity was 11% and there was 1 fetal loss.
- Multidisciplinary evaluation is recommended preconception in women with D-transposition of the great arteries to identify and treat patients at high risk for complications during pregnancy.
- A close follow-up is required during pregnancy and early postpartum for early diagnosis and management of hemodynamic deterioration.
Introduction
The modified World Health Organization classification of maternal cardiovascular risk predicts significant increased risk of maternal mortality in women with complex congenital heart disease. This study aims to evaluate and quantify the magnitude of this risk.
Methods
This was a systematic review of the literature between 2000 and 2021 of transposition of the great arteries and pregnancy. Only studies in English language that reported more than 5 patients were included in the review.
Data extracted included demographic information, type of repair, history of cardiac complications and extra cardiac diseases. Maternal, obstetrical and neonatal outcomes were also
reviewed.
Descriptive statistics were obtained and comparison of maternal and fetal outcomes between arterial switch operation (ATSO) and atrial switch operation (ASO) cohorts were analyzed by χ2 test or stratified Fisher exact test.
Results
Out of 1028 studies evaluated, 17 were included in the review as displayed in the figure below.
Women had the following characteristics (absolute numbers and percentages reported). Note that the denominators differ, as not all parameters were noted in all studies:
Overall, as expected, complications were higher in the atrial switch group, although the differences reached statistical significance only regarding the incidence of prematurity. Several patients in the atrial switch group developed worsening RV dysfunction, which persisted long term in most cases.
One woman in the arterial switch group developed a serious thromboembolic complication that required surgery. Complications in the arterial switch group were associated with higher BNP levels prepregnancy.
The incidence of miscarriage was similar to that reported in pregnancies of healthy women, while the rate of prematurity was triple in the atrial switch group. Contrary to common belief, the infants did not have a higher incidence of CHD
Conclusions
Overall, pregnancy was well tolerated in asymptomatic or mildly symptomatic women with Dtransposition of the great arteries. Women with atrial switch operations have a higher incidence of mortality, arrhythmias an heart failure, as well as premature birth. Women who underwent arterial switch operation may develop non life-threatening arrhythmias and overall have rare maternal or neonatal complication rates.
The authors recommend multimodality evaluation preconception or early in pregnancy to identify the women at high risk for complications during pregnancy. They also suggest close follow-up is required during pregnancy and postpartum by a multi- disciplinary group experienced in the management of pregnant women with cardiac disease for prevention or early diagnosis and management of hemodynamic deterioration. Hemodynamic deterioration after the delivery should be anticipated and prevented by increased diuresis before and immediately after the delivery. Women should be made aware of the fact that fetal outcome can also be influenced by the underlying disease with an increase in the rate of prematurity and fetal death.
