Case Report
Catheter Ablation of Supraventricular Tachycardia Without Fluoroscopy During Pregnancy Amee M. Bigelow, MD, Stephen S. Crane, MD, Fadi R. Khoury, MD, and John M. Clark, MD BACKGROUND: Although uncommon, supraventricular tachycardia is difficult to manage during pregnancy. Catheter ablation traditionally has been deferred owing to radiation exposure risks. Three-dimensional mapping is a new tool in cardiac electrophysiology, which is being utilized to eliminate fluoroscopy during catheter ablation. We report a case of ablation of supraventricular tachycardia during pregnancy without using fluoroscopy. CASE: A 27-year-old woman with a 22-week twin gestation was referred for incessant supraventricular tachycardia. Medical management with propranolol and flecainide was unsuccessful. An electrophysiology study was performed with catheter navigation guided by a three-dimensional mapping system instead of fluoroscopy. The patient underwent successful cryoablation. The procedure was performed without fluoroscopy or sedation. The patient delivered healthy twins at 35 weeks of gestation without complications. On follow-up at 26 months, she showed no evidence of recurrence.
From the Department of Cardiology, The Heart Center, and the Department of Pediatrics, Maternal-Fetal Medicine, Akron Children’s Hospital, Akron, Ohio, and the Department of Obstetrics and Gynecology, Cleveland Clinic Foundation, Cleveland, Ohio. The authors thank the Rebecca D. Considine Research Institute for their administrative support. Presented at the 2014 American College of Obstetricians and Gynecologists Annual Clinical and Scientific Meeting, April 26–30, 2014, Chicago, Illinois. Corresponding author: John M. Clark, MD, Department of Cardiology, The Heart Center, Pediatric Cardiology/Electrophysiology, Director, Arrhythmia Center, One Perkins Square, Akron, OH 44308; e-mail: [email protected]. Financial Disclosure The authors did not report any potential conflicts of interest. © 2015 by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0029-7844/15
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Teaching Points 1. Supraventricular tachycardia during pregnancy presents a difficult therapeutic challenge owing to risks from either medications or radiation. 2. Technological advances now offer the possibility of curing arrhythmias in pregnancy without exposure to radiation.
CONCLUSION: New tools in electrophysiology now make curative procedures more readily available to pregnant women and safer for the fetus. (Obstet Gynecol 2015;125:1338–41) DOI: 10.1097/AOG.0000000000000601
A
n increased incidence of cardiac arrhythmias has been reported in pregnancy with and without identifiable heart disease compared with nonpregnant women of childbearing age.1,2 Most studies had been anecdotal case reports until Tawam et al published a retrospective case–control data analysis of 60 women.3 In 13 patients (22%), supraventricular tachycardia (SVT) was new during pregnancy. In this study, the relative risk of onset of symptomatic SVT during pregnancy compared with the nonpregnant state was 5.1 (P,.001). However, Lee et al4 determined the first onset of SVT during pregnancy was rare at only 3.9%, but symptoms were exacerbated during pregnancy. The association of SVT and pregnancy still remains unclear. Most cardiac arrhythmias in pregnancy however, are benign.5,6 When a hemodynamically significant arrhythmia does occur, medical management is complicated by several factors, including: severity of the arrhythmia, the hemodynamic consequences to the mother, the evolving degree of increased cardiac output required during pregnancy, the effect on the fetus, and the gestation of pregnancy. There are two primary treatment options for symptomatic arrhythmias: 1) antiarrhythmic medications and 2) catheter ablation. Most antiarrhythmic medications are U.S. Food and Drug Administration pregnancy categories C or D.7 Catheter ablation by the traditional approach using fluoroscopy carries the risk of exposing both the mother and fetus to radiation, which may have longterm effects.8,9 Therefore, conservative management is the treatment of choice whenever the clinical scenario allows. When conservative management is not an option, antiarrhythmic medications have been the preferred therapy.
OBSTETRICS & GYNECOLOGY
Copyright ª by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Traditionally, fluoroscopy has been utilized for visualization of catheters during an ablation procedure. In recent years, three-dimensional mapping systems allow visualization of catheters without the use of fluoroscopy. Skin electrodes generate electrical fields along three orthogonal axes, which allow the creation of a three-dimensional image of the structures. In some centers, catheter ablation of cardiac rhythm abnormalities is now routinely performed without radiation exposure utilizing threedimensional mapping.10,11 EnSite Velocity Cardiac Mapping System (a three-dimensional mapping system) is our primary imaging modality for all uncomplicated SVT ablations (Fig. 1). We report a case of successful ablation of SVT during pregnancy without the use of fluoroscopy.
CASE A 27-year-old previously healthy woman with a 22-week monozygotic twin gestation presented with palpitations. Her initial 12-lead electrocardiogram showed SVT at 185 beats per minute. The cardiovascular examination exhibited a normal sinus rhythm with frequent runs of SVT that converted with vagal maneuvers. Abdominal examination was consistent with a 22-week twin pregnancy. The remaining examination was unremarkable. She had no cardiac history and no history of palpitations. An echocardiogram indicated normal function. A 24-hour Holter monitor recorded SVT 50% of the time. Medical management with propranolol and flecainide was unsuccessful. Therefore, she was referred for catheter ablation without fluoroscopy.
The procedure was performed without general anesthesia. Local anesthetic was used to infiltrate the right femoral groin. Three sheaths were placed (8 French, 6 French, and 5 French) in the right femoral vein. Catheter navigation was guided by the three-dimensional mapping system. Using a decapolar catheter, appropriate geometry was drawn to allow for completion of the procedure (Fig. 2). Atrial pacing protocols demonstrated dual atrioventricular (AV) nodal physiology consistent with AV nodal reentrant tachycardia and inducible atypical AV nodal reentrant tachycardia. Because the procedure was done in an awake state and the mechanism of tachycardia was AV nodal, cryoenergy was preferred over radiofrequency. The earliest atrial activation during tachycardia was located in the low atrial septum just anterior to the coronary sinus os. Cryolesions were delivered in this region. The patient showed no inducible SVT after the first lesion. Additional cryolesions were placed just superior to the coronary sinus os. The entire procedure was performed without sedation or fluoroscopy and there were no procedural complications. The total procedure time was 3 hours 6 minutes, which is a typical procedure time for a no-fluoroscopy ablation. A limited examination of each fetal heart by ultrasonography was obtained preprocedure and postprocedure and showed good fetal heart activity. The patient’s postprocedure electrocardiogram showed a normal sinus rhythm and her echocardiogram was normal. It is our practice to use anticoagulants after all procedures. In this instance, the patient was discharged with 40 mg Lovenox daily for 1 week owing to instrumentation of her femoral vein as well as the hypercoagulable state associated with pregnancy. The patient delivered healthy female twins at 35 weeks of gestation by cesarean delivery without complications. On followup at 26 months postablation, she showed no evidence of recurrence either during the antepartum or postpartum period.
DISCUSSION
Fig. 1. Geometry that can be drawn by using the threedimensional mapping system. Easily recognized are the superior vena cava, inferior vena cava, right atrium, right ventricle, and pulmonary arteries. Most procedures do not require this degree of detail. Bigelow. Catheter Ablation in Pregnancy. Obstet Gynecol 2015.
VOL. 125, NO. 6, JUNE 2015
The acute management of symptomatic SVT in pregnancy remains a clinical challenge without established guidelines or algorithms for standardized treatment. The U.S. Food and Drug Administration approved catheter ablation for routine use in 1991. Because of the very low complication rate and the procedure’s minimally invasive nature, it quickly became the treatment of choice for SVT therapy in the general population of adults. This was not the case, however, for pregnant patients. Because catheter ablation previously required radiation to visualize the catheters, it carried an additional risk of oncogenic or teratogenic consequences. Although many studies show a typical catheter ablation procedure results inminimal increased risk of harmful effects to the fetus, practices vary among institutions.12,13 Prenatal exposure to ionizing radiation during a cardiac catheter
Bigelow et al
Catheter Ablation in Pregnancy 1339
Copyright ª by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Fig. 2. Typical geometry drawn for most procedures. Identifiable structures include the superior vena cava, inferior vena cava, right atrium, tricuspid valve annulus, and coronary sinus. Also localized is the location of the His bundle. Anteroposterior view (A) and lateral view (B). Bigelow. Catheter Ablation in Pregnancy. Obstet Gynecol 2015.
ablation includes increased risks of childhood cancers and genetic defects.8,14 Therefore, if the arrhythmia can be tolerated, observation is the treatment of choice. In women with more significant arrhythmias, antiarrhythmic medications were preferred over ablation. However, antiarrhythmic medications also carry risks. The most commonly used antiarrhythmic medications are classified as pregnancy categories C and D and may have harmful effects on the fetus.7 Some antiarrhythmic medications have been associated with low birth weight, fetal demise, and proarrhythmic effects. Not all arrhythmias can be treated conservatively during pregnancy. Patients with tachycardia more than 30% of the time are at risk for developing a dilated cardiomyopathy. Also, blood pressure is lower than normal during SVT, which can result in poor placental perfusion as well as pose a risk to fetal health. In the present case, the patient’s density of SVT was significant enough to present risk to both the mother and fetus. She failed control with standard antiarrhythmic medications and, therefore, catheter ablation became the treatment of choice. Eliminating fluoroscopy removes all the short- and long-term risks of teratogenicity and oncogenicity. There may be potential complications related to fluoroless ablations. However, in our own unpublished database of more than 1,400 procedures, no additional complications have been noted. Zero fluoroscopy catheter ablations are relatively new, with the first report in 2002, but safe and effective in the elimination of cardiac arrhythmias, as evidenced by many single-centered experiences.11,15 In this case report, cryoablation was preferred over radiofrequency. Cryoablation is safer near the AV node. Radiofrequency ablation carries a roughly 1% risk of heart block, requiring a pacemaker, whereas
1340
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Catheter Ablation in Pregnancy
cryoablation reduces that risk to almost zero. Cryoablation is also painless and is therefore easily performed in an awake patient. The procedure was performed without sedation, which eliminates the systemic hypotension risk and potential for poor placental perfusion. New tools in electrophysiology now make curative ablation procedures more readily available to pregnant women and safer for the fetus. Threedimensional mapping has the potential to alter the traditional treatment strategy for clinically significant arrhythmias during pregnancy, away from medications and toward cure. With proper training, ablation can be performed successfully without fluoroscopy or sedation and should be considered in pregnant patients with arrhythmias refractory to medical treatment. REFERENCES 1. Mendelson CL. Disorders of the heartbeat during pregnancy. Am J Obstet Gynecol 1956;72:1268–301. 2. Hair TE Jr, Eagan JT, Orgain ES. Paroxysmal ventricular tachycardia in the absence of demonstrable heart disease. Am J Cardiol 1962;9:209–14. 3. Tawam M, Levine J, Mendelson M, Goldberger J, Dyer A, Kadish A. Effect of pregnancy on paroxysmal supraventricular tachycardia. Am J Cardiol 1993;72:838–40. 4. Lee SH, Chen SA, Wu TJ, Chiang CE, Cheng CC, Tai CC, et al. Effects of pregnancy on first onset and symptoms of paroxysmal supraventricular tachycardia. Am J Cardiol 1995;76: 675–8. 5. Ostrezega E, Mehra A, Widerhorn J. Evidence for increased incidence of arrhythmias during pregnancy: a study of 104 pregnant women with symptoms of palpitations, dizziness or syncope. J Am Coll Cardiol 1992;19:125. 6. Shotan A, Ostrzega E, Mehra A, Johnson JV, Elkayam U. Incidence of arrhythmias in normal pregnancy and relation to palpitations, dizziness, and syncope. Am J Cardiol 1997;79: 1061–4.
OBSTETRICS & GYNECOLOGY
Copyright ª by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
7. Joglar JA, Page RL. Treatment of cardiac arrhythmias during pregnancy: safety considerations. Drug Saf 1999;20:85–94. 8. Doll R, Wakeford R. Risk of childhood cancer from fetal irradiation. Br J Radiol 1997;70:130–9. 9. Wakeford R, Little MP. Risk coefficients for childhood cancer after intrauterine irradiation: a review. Int J Radiat Biol 2003; 79:293–309. 10. Smith G, Clark JM. Elimination of fluoroscopy use in a pediatric electrophysiology laboratory utilizing three-dimensional mapping. Pacing Clin Electrophysiol 2007;30:510–8. 11. Tuzcu V. Significant reduction of fluoroscopy in pediatric catheter ablation procedures: long-term experience from a single center. Pacing Clin Electrophysiol 2012;35:1067–73.
12. Berruezo A, Díez GR, Berne P, Esteban M, Mont L, Brugada J. Low exposure radiation with conventional guided radiofrequency catheter ablation in pregnant women. Pacing Clin Electrophysiol 2007;30:1299–302. 13. Damilakis J, Theocharopoulos N, Perisinakis K, Manios E, Dimitriou P, Vardas P, et al. Conceptus radiation dose and risk from cardiac catheter ablation procedures. Circulation 2001; 104:893–7. 14. Shore RE. Issues and epidemiological evidence regarding radiation-induced thyroid cancer. Radiat Res 1992;131:98–111. 15. Bigelow AM, Smith G, Clark JM. Catheter ablation without fluoroscopy: current techniques and future direction. J Atrial Fib 2014;6:7–12.
Serve As a Reviewer for Obstetrics & Gynecology The Editors of Obstetrics & Gynecology are looking for new peer reviewers. Sign up to become a peer reviewer by going to ong.editorialmanager.com and downloading the “Reviewer Contact Information Update Form” (see “Files and Resources”). Please complete the form electronically and submit it by e-mail to the editorial office ([email protected]). In recognition of their time, effort, and expertise, reviewers of manuscripts for Obstetrics & Gynecology are eligible to receive continuing medical education credits. rev 11/2014
VOL. 125, NO. 6, JUNE 2015
Bigelow et al
Catheter Ablation in Pregnancy 1341
Copyright ª by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Catheter Ablation of Supraventricular Tachycardia Without Fluoroscopy During Pregnancy Amee M. Bigelow, MD, Stephen S. Crane, MD, Fadi R. Khoury, MD, and John M. Clark, MD BACKGROUND: Although uncommon, supraventricular tachycardia is difficult to manage during pregnancy. Catheter ablation traditionally has been deferred owing to radiation exposure risks. Three-dimensional mapping is a new tool in cardiac electrophysiology, which is being utilized to eliminate fluoroscopy during catheter ablation. We report a case of ablation of supraventricular tachycardia during pregnancy without using fluoroscopy. CASE: A 27-year-old woman with a 22-week twin gestation was referred for incessant supraventricular tachycardia. Medical management with propranolol and flecainide was unsuccessful. An electrophysiology study was performed with catheter navigation guided by a three-dimensional mapping system instead of fluoroscopy. The patient underwent successful cryoablation. The procedure was performed without fluoroscopy or sedation. The patient delivered healthy twins at 35 weeks of gestation without complications. On follow-up at 26 months, she showed no evidence of recurrence.
From the Department of Cardiology, The Heart Center, and the Department of Pediatrics, Maternal-Fetal Medicine, Akron Children’s Hospital, Akron, Ohio, and the Department of Obstetrics and Gynecology, Cleveland Clinic Foundation, Cleveland, Ohio. The authors thank the Rebecca D. Considine Research Institute for their administrative support. Presented at the 2014 American College of Obstetricians and Gynecologists Annual Clinical and Scientific Meeting, April 26–30, 2014, Chicago, Illinois. Corresponding author: John M. Clark, MD, Department of Cardiology, The Heart Center, Pediatric Cardiology/Electrophysiology, Director, Arrhythmia Center, One Perkins Square, Akron, OH 44308; e-mail: [email protected]. Financial Disclosure The authors did not report any potential conflicts of interest. © 2015 by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0029-7844/15
1338
VOL. 125, NO. 6, JUNE 2015
Teaching Points 1. Supraventricular tachycardia during pregnancy presents a difficult therapeutic challenge owing to risks from either medications or radiation. 2. Technological advances now offer the possibility of curing arrhythmias in pregnancy without exposure to radiation.
CONCLUSION: New tools in electrophysiology now make curative procedures more readily available to pregnant women and safer for the fetus. (Obstet Gynecol 2015;125:1338–41) DOI: 10.1097/AOG.0000000000000601
A
n increased incidence of cardiac arrhythmias has been reported in pregnancy with and without identifiable heart disease compared with nonpregnant women of childbearing age.1,2 Most studies had been anecdotal case reports until Tawam et al published a retrospective case–control data analysis of 60 women.3 In 13 patients (22%), supraventricular tachycardia (SVT) was new during pregnancy. In this study, the relative risk of onset of symptomatic SVT during pregnancy compared with the nonpregnant state was 5.1 (P,.001). However, Lee et al4 determined the first onset of SVT during pregnancy was rare at only 3.9%, but symptoms were exacerbated during pregnancy. The association of SVT and pregnancy still remains unclear. Most cardiac arrhythmias in pregnancy however, are benign.5,6 When a hemodynamically significant arrhythmia does occur, medical management is complicated by several factors, including: severity of the arrhythmia, the hemodynamic consequences to the mother, the evolving degree of increased cardiac output required during pregnancy, the effect on the fetus, and the gestation of pregnancy. There are two primary treatment options for symptomatic arrhythmias: 1) antiarrhythmic medications and 2) catheter ablation. Most antiarrhythmic medications are U.S. Food and Drug Administration pregnancy categories C or D.7 Catheter ablation by the traditional approach using fluoroscopy carries the risk of exposing both the mother and fetus to radiation, which may have longterm effects.8,9 Therefore, conservative management is the treatment of choice whenever the clinical scenario allows. When conservative management is not an option, antiarrhythmic medications have been the preferred therapy.
OBSTETRICS & GYNECOLOGY
Copyright ª by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Traditionally, fluoroscopy has been utilized for visualization of catheters during an ablation procedure. In recent years, three-dimensional mapping systems allow visualization of catheters without the use of fluoroscopy. Skin electrodes generate electrical fields along three orthogonal axes, which allow the creation of a three-dimensional image of the structures. In some centers, catheter ablation of cardiac rhythm abnormalities is now routinely performed without radiation exposure utilizing threedimensional mapping.10,11 EnSite Velocity Cardiac Mapping System (a three-dimensional mapping system) is our primary imaging modality for all uncomplicated SVT ablations (Fig. 1). We report a case of successful ablation of SVT during pregnancy without the use of fluoroscopy.
CASE A 27-year-old previously healthy woman with a 22-week monozygotic twin gestation presented with palpitations. Her initial 12-lead electrocardiogram showed SVT at 185 beats per minute. The cardiovascular examination exhibited a normal sinus rhythm with frequent runs of SVT that converted with vagal maneuvers. Abdominal examination was consistent with a 22-week twin pregnancy. The remaining examination was unremarkable. She had no cardiac history and no history of palpitations. An echocardiogram indicated normal function. A 24-hour Holter monitor recorded SVT 50% of the time. Medical management with propranolol and flecainide was unsuccessful. Therefore, she was referred for catheter ablation without fluoroscopy.
The procedure was performed without general anesthesia. Local anesthetic was used to infiltrate the right femoral groin. Three sheaths were placed (8 French, 6 French, and 5 French) in the right femoral vein. Catheter navigation was guided by the three-dimensional mapping system. Using a decapolar catheter, appropriate geometry was drawn to allow for completion of the procedure (Fig. 2). Atrial pacing protocols demonstrated dual atrioventricular (AV) nodal physiology consistent with AV nodal reentrant tachycardia and inducible atypical AV nodal reentrant tachycardia. Because the procedure was done in an awake state and the mechanism of tachycardia was AV nodal, cryoenergy was preferred over radiofrequency. The earliest atrial activation during tachycardia was located in the low atrial septum just anterior to the coronary sinus os. Cryolesions were delivered in this region. The patient showed no inducible SVT after the first lesion. Additional cryolesions were placed just superior to the coronary sinus os. The entire procedure was performed without sedation or fluoroscopy and there were no procedural complications. The total procedure time was 3 hours 6 minutes, which is a typical procedure time for a no-fluoroscopy ablation. A limited examination of each fetal heart by ultrasonography was obtained preprocedure and postprocedure and showed good fetal heart activity. The patient’s postprocedure electrocardiogram showed a normal sinus rhythm and her echocardiogram was normal. It is our practice to use anticoagulants after all procedures. In this instance, the patient was discharged with 40 mg Lovenox daily for 1 week owing to instrumentation of her femoral vein as well as the hypercoagulable state associated with pregnancy. The patient delivered healthy female twins at 35 weeks of gestation by cesarean delivery without complications. On followup at 26 months postablation, she showed no evidence of recurrence either during the antepartum or postpartum period.
DISCUSSION
Fig. 1. Geometry that can be drawn by using the threedimensional mapping system. Easily recognized are the superior vena cava, inferior vena cava, right atrium, right ventricle, and pulmonary arteries. Most procedures do not require this degree of detail. Bigelow. Catheter Ablation in Pregnancy. Obstet Gynecol 2015.
VOL. 125, NO. 6, JUNE 2015
The acute management of symptomatic SVT in pregnancy remains a clinical challenge without established guidelines or algorithms for standardized treatment. The U.S. Food and Drug Administration approved catheter ablation for routine use in 1991. Because of the very low complication rate and the procedure’s minimally invasive nature, it quickly became the treatment of choice for SVT therapy in the general population of adults. This was not the case, however, for pregnant patients. Because catheter ablation previously required radiation to visualize the catheters, it carried an additional risk of oncogenic or teratogenic consequences. Although many studies show a typical catheter ablation procedure results inminimal increased risk of harmful effects to the fetus, practices vary among institutions.12,13 Prenatal exposure to ionizing radiation during a cardiac catheter
Bigelow et al
Catheter Ablation in Pregnancy 1339
Copyright ª by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Fig. 2. Typical geometry drawn for most procedures. Identifiable structures include the superior vena cava, inferior vena cava, right atrium, tricuspid valve annulus, and coronary sinus. Also localized is the location of the His bundle. Anteroposterior view (A) and lateral view (B). Bigelow. Catheter Ablation in Pregnancy. Obstet Gynecol 2015.
ablation includes increased risks of childhood cancers and genetic defects.8,14 Therefore, if the arrhythmia can be tolerated, observation is the treatment of choice. In women with more significant arrhythmias, antiarrhythmic medications were preferred over ablation. However, antiarrhythmic medications also carry risks. The most commonly used antiarrhythmic medications are classified as pregnancy categories C and D and may have harmful effects on the fetus.7 Some antiarrhythmic medications have been associated with low birth weight, fetal demise, and proarrhythmic effects. Not all arrhythmias can be treated conservatively during pregnancy. Patients with tachycardia more than 30% of the time are at risk for developing a dilated cardiomyopathy. Also, blood pressure is lower than normal during SVT, which can result in poor placental perfusion as well as pose a risk to fetal health. In the present case, the patient’s density of SVT was significant enough to present risk to both the mother and fetus. She failed control with standard antiarrhythmic medications and, therefore, catheter ablation became the treatment of choice. Eliminating fluoroscopy removes all the short- and long-term risks of teratogenicity and oncogenicity. There may be potential complications related to fluoroless ablations. However, in our own unpublished database of more than 1,400 procedures, no additional complications have been noted. Zero fluoroscopy catheter ablations are relatively new, with the first report in 2002, but safe and effective in the elimination of cardiac arrhythmias, as evidenced by many single-centered experiences.11,15 In this case report, cryoablation was preferred over radiofrequency. Cryoablation is safer near the AV node. Radiofrequency ablation carries a roughly 1% risk of heart block, requiring a pacemaker, whereas
1340
Bigelow et al
Catheter Ablation in Pregnancy
cryoablation reduces that risk to almost zero. Cryoablation is also painless and is therefore easily performed in an awake patient. The procedure was performed without sedation, which eliminates the systemic hypotension risk and potential for poor placental perfusion. New tools in electrophysiology now make curative ablation procedures more readily available to pregnant women and safer for the fetus. Threedimensional mapping has the potential to alter the traditional treatment strategy for clinically significant arrhythmias during pregnancy, away from medications and toward cure. With proper training, ablation can be performed successfully without fluoroscopy or sedation and should be considered in pregnant patients with arrhythmias refractory to medical treatment. REFERENCES 1. Mendelson CL. Disorders of the heartbeat during pregnancy. Am J Obstet Gynecol 1956;72:1268–301. 2. Hair TE Jr, Eagan JT, Orgain ES. Paroxysmal ventricular tachycardia in the absence of demonstrable heart disease. Am J Cardiol 1962;9:209–14. 3. Tawam M, Levine J, Mendelson M, Goldberger J, Dyer A, Kadish A. Effect of pregnancy on paroxysmal supraventricular tachycardia. Am J Cardiol 1993;72:838–40. 4. Lee SH, Chen SA, Wu TJ, Chiang CE, Cheng CC, Tai CC, et al. Effects of pregnancy on first onset and symptoms of paroxysmal supraventricular tachycardia. Am J Cardiol 1995;76: 675–8. 5. Ostrezega E, Mehra A, Widerhorn J. Evidence for increased incidence of arrhythmias during pregnancy: a study of 104 pregnant women with symptoms of palpitations, dizziness or syncope. J Am Coll Cardiol 1992;19:125. 6. Shotan A, Ostrzega E, Mehra A, Johnson JV, Elkayam U. Incidence of arrhythmias in normal pregnancy and relation to palpitations, dizziness, and syncope. Am J Cardiol 1997;79: 1061–4.
OBSTETRICS & GYNECOLOGY
Copyright ª by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
7. Joglar JA, Page RL. Treatment of cardiac arrhythmias during pregnancy: safety considerations. Drug Saf 1999;20:85–94. 8. Doll R, Wakeford R. Risk of childhood cancer from fetal irradiation. Br J Radiol 1997;70:130–9. 9. Wakeford R, Little MP. Risk coefficients for childhood cancer after intrauterine irradiation: a review. Int J Radiat Biol 2003; 79:293–309. 10. Smith G, Clark JM. Elimination of fluoroscopy use in a pediatric electrophysiology laboratory utilizing three-dimensional mapping. Pacing Clin Electrophysiol 2007;30:510–8. 11. Tuzcu V. Significant reduction of fluoroscopy in pediatric catheter ablation procedures: long-term experience from a single center. Pacing Clin Electrophysiol 2012;35:1067–73.
12. Berruezo A, Díez GR, Berne P, Esteban M, Mont L, Brugada J. Low exposure radiation with conventional guided radiofrequency catheter ablation in pregnant women. Pacing Clin Electrophysiol 2007;30:1299–302. 13. Damilakis J, Theocharopoulos N, Perisinakis K, Manios E, Dimitriou P, Vardas P, et al. Conceptus radiation dose and risk from cardiac catheter ablation procedures. Circulation 2001; 104:893–7. 14. Shore RE. Issues and epidemiological evidence regarding radiation-induced thyroid cancer. Radiat Res 1992;131:98–111. 15. Bigelow AM, Smith G, Clark JM. Catheter ablation without fluoroscopy: current techniques and future direction. J Atrial Fib 2014;6:7–12.
Serve As a Reviewer for Obstetrics & Gynecology The Editors of Obstetrics & Gynecology are looking for new peer reviewers. Sign up to become a peer reviewer by going to ong.editorialmanager.com and downloading the “Reviewer Contact Information Update Form” (see “Files and Resources”). Please complete the form electronically and submit it by e-mail to the editorial office ([email protected]). In recognition of their time, effort, and expertise, reviewers of manuscripts for Obstetrics & Gynecology are eligible to receive continuing medical education credits. rev 11/2014
VOL. 125, NO. 6, JUNE 2015
Bigelow et al
Catheter Ablation in Pregnancy 1341
Copyright ª by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
