International Journal of Cardiology 179 (2015) 323–324
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
Implantation of a defibrillator in a pregnant woman with hypertrophic cardiomyopathy under echocardiographic guidance: A case report Skevos Sideris a,⁎,1, Alexandros Kasiakogias a,1, Constantina Aggeli b,1, Kostas Manakos a,1, George Trantalis a,1, Konstantinos Gatzoulis b,1, Dimitrios Tousoulis b,1, Ioannis Kallikazaros a,1 a b
State Cardiology Division, Hippokration Hospital, Athens, Greece First Cardiology Clinic, University of Athens, Hippokation Hospital, Athens, Greece
a r t i c l e
i n f o
Article history: Received 6 November 2014 Accepted 8 November 2014 Available online 11 November 2014 Keywords: Electronic device Ventricular tachycardia Pregnancy
Hypertrophic cardiomyopathy (HCM) is a predominantly inherited disease with an estimated annual incidence of cardiac mortality of 1– 2% [1]. The presence of episodes of non-sustained ventricular tachycardia (NSVT) is considered as an independent predictor of sudden cardiac death. During pregnancy, episodes of arrhythmias may become more often while implantation of an implantable cardioverter-defibrillator (ICD) may be needed. Concerns of performing such a procedure under fluoroscopic guidance during pregnancy have been variably posed. The purpose of this report is to describe the case of a pregnant patient with hypertrophic cardiomyopathy in whom an ICD with the guidance of transesophageal echocardiography was implanted. A 26 year old woman at 24 weeks of gestation referred to our clinic because of increasing episodes of palpitations. The patient had been diagnosed with HCM at the age of 13 years, had an ejection fraction over 60% and did not report any symptoms of heart failure. She was a high risk patient as she had a positive family history of sudden cardiac death, an abnormal response to exercise and recorded episodes of NSVT. Implantation of an ICD had been consistently advised but the patient had refused due to the invasive nature of the treatment. At the age of 24 years she became pregnant for the first time and was closely monitored by her cardiologist. That pregnancy was completed without complications and no arrhythmias were recorded during that time. After ⁎ Corresponding author at: State Cardiology Division, Hippokration Hospital, 114 Vasilissis Sofias St., 115 28 Athens, Greece. E-mail address: [email protected] (S. Sideris). 1 All authors take responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation.
http://dx.doi.org/10.1016/j.ijcard.2014.11.091 0167-5273/© 2014 Elsevier Ireland Ltd. All rights reserved.
presentation at our clinic, the patient underwent several 24-hour ambulatory rhythm monitorings that confirmed multiple episodes of NSVT with an increasing frequency. The estimated risk of sudden cardiac death was more than 10% [2]. Accordingly, after a thorough consultation when the risks for the patient and the fetus were again clearly presented, the patient eventually accepted to undergo ICD implantation. The patient was informed about the possible dangers of fluoroscopy in the setting of pregnancy, and the alternative of transesophageal echocardiography during the procedure was decided to be followed. Implantation of the ICD was performed under general anesthesia by using medications which would not adversely affect the fetus. Midazolam 5 mg and Propofol 100 mg were introduced once for induction of anesthesia while a Propofol infusion at the rate of 60 mg/h was applied for maintenance. An ICD pocket was formed in the region of the left pectoral muscle and a defibrillator lead was inserted into the left subclavian vein by percutaneous puncture and then advanced through the superior vena cava to the right heart chambers. Transesophageal ultrasound (Phillips iE33, 2.5 MHz s5-1 transducer) was used to guide implantation of the lead in the right ventricle. By applying the four chamber view (Fig. 1), the transgastric view (Figs. 2 and 3) and the short axis view at the level of the aortic valve, the electrode was inserted in the right ventricular apex. At the final positioning, the ICD lead tip was clearly visualized in place and there was no need to perform further visualization with fluoroscopy. Appropriate parameters regarding impedance, sensing, pacing threshold and defibrillation threshold were then tested. The duration of the procedure was approximately 65 min. The post-operative check did not identify any pericardial effusion or other intraoperative or postoperative complications. The patient was discharged after two days of hospitalization. In a 6 month follow-up visit, no episodes of ventricular tachycardia or defibrillator discharge were recorded during ICD interrogation. A chest X-ray was also performed where the right position of the electrode was clearly observed. As echocardiography is now a widely available diagnostic method, and genetic as well as family screening are being more often performed, an increasing number of women of child-bearing potential are diagnosed with HCM. In the pregnant patient, apart from the possible development or progression of symptoms or clinical heart failure that are attributed partly to the hemodynamic changes during this period, a risk of sudden cardiac death is also to be considered [3]. A previous out-of-hospital arrest, non-sustained or sustained ventricular tachycardia, family history
324
S. Sideris et al. / International Journal of Cardiology 179 (2015) 323–324
Fig. 1. Four-chamber view showing hypertrophy of the left ventricular apex and the interventricular septum.
Fig. 3. Transgastric view showing the ICD lead inserted in the left ventricular apex (arrow). RV, right ventricle.
of sudden death, severe septal hypertrophy and abnormal blood pressure response during exercise have been reported to be relevant risk factors [1] . Therefore risk stratification should be a sine qua non for the patient wishing to become pregnant [2]. The prevalence of young women suffering from cardiomyopathies and carrying an ICD that become pregnant is increasing. Current evidence, derived primarily from retrospective studies, generally supports that presence of ICDs, in contrast to the underlying cardiac condition, is not accompanied by a greater risk of adverse complications during pregnancy [4]. ICD shocks have traditionally been considered safe for the fetus, even though in a recent report such a shock was associated with a miscarriage [4]. Nevertheless, benefits from ICD implantation, when indications are identified and followed as per guidelines, should far outweigh any risks for the female patient and fetus. A challenging clinical scenario is however when a defibrillator is indicated while the patient is already pregnant, especially with respect to the application of ionizing radiation. It is widely accepted that exposure of the pregnant woman and fetus to procedures that involve fluoroscopy, radiation or radioactive material administration should be minimized [5]. Any risk for the fetus is dependent on the amount of radiation and the gestational age. In any case, most diagnostic procedures expose the fetus to radiation levels of less than 50 mSv that pose a negligible risk with respect to birth defects or miscarriage, even during the delicate period of embryogenesis and organogenesis. In practice, even the positioning of a lead sheath on the abdomen of the pregnant woman only minimally reduces the radiation dose absorbed by the fetus [6].
Few reports exist regarding the use of alternative methods to fluoroscopy in order to guide device implantation during pregnancy. In one of the earliest reported cases, implantation was performed only with the use of 2-D echocardiography [7]. Implantation of a pacemaker or a defibrillator, guided by transesophageal echocardiography and followed by only a short fluoroscopic view in the end, has been reported [8,9]. More recently, implantations of defibrillators with the help of electroanatomical mapping and three-dimensional navigation systems have been successfully performed [10]. In total, the gestational age, the age of the patient, the experience of the operator, the available facilities, the complexity of the required device and the possible financial issues should be considered when choosing the appropriate guiding technique for device implantation in such patients. To conclude, implantation of an ICD under guidance with transesophageal echocardiography only is a safe and effective method that should be considered in pregnant patients with HCM. The steps of careful patient evaluation, risk stratification for sudden cardiac death as well as proper consultation of the patient are crucial for the optimal management of this delicate patient group.
Fig. 2. Transgastric view showing the ICD lead crossing the tricuspid valve. The electrode appears as a highly echogenic structure (arrow). RA, right atrium; RV, right ventricle.
Conflict of interest None for all authors. References [1] P.M. Elliott, A. Anastasakis, M.A. Borger, et al., 2014 ESC Guidelines on Diagnosis and Management of Hypertrophic Cardiomyopathy: the Task Force for the Diagnosis and Management of Hypertrophic Cardiomyopathy of the European Society of Cardiology (ESC), Eur. Heart J. 35 (39) (2014) 2733–2779. [2] C. O'Mahony, F. Jichi, M. Pavlou, et al., A novel clinical risk prediction model for sudden cardiac death in hypertrophic cardiomyopathy (HCM Risk-SCD), Eur. Heart J. 35 (30) (2014) 2010–2020. [3] K. Stergiopoulos, E. Shiang, T. Bench, Pregnancy in patients with pre-existing cardiomyopathies, J. Am. Coll. Cardiol. 58 (4) (2011) 337–350. [4] S. Boulé, L. Ovart, C. Marquié, et al., Pregnancy in women with an implantable cardioverter-defibrillator: is it safe? Europace 16 (11) (2014) 1587–1594. [5] P.M. Colletti, K.H. Lee, U. Elkayam, Cardiovascular imaging of the pregnant patient, AJR Am. J. Roentgenol. 200 (3) (2013) 515–521. [6] J. Damilakis, N. Theocharopoulos, K. Perisinakis, et al., Conceptus radiation dose and risk from cardiac catheter ablation procedures, Circulation 104 (2001) 893–897. [7] M. Güdal, C. Kervancioğlu, D. Oral, T. Gürel, C. Erol, A. Sonel, Permanent pacemaker implantation in a pregnant woman with the guidance of ECG and two-dimensional echocardiography, Pacing Clin. Electrophysiol. 10 (3 Pt 1) (1987) 543–545. [8] D. Antonelli, L. Bloch, T. Rosenfeld, Implantation of permanent dual chamber pacemaker in a pregnant woman by transesophageal echocardiographic guidance, Pacing Clin. Electrophysiol. 22 (3) (1999) 534–535. [9] M. Abello, R. Peinado, J.L. Merino, et al., Cardioverter defibrillator implantation in a pregnant woman guided with transesophageal echocardiography, Pacing Clin. Electrophysiol. 26 (9) (2003) 1913–1914. [10] V. Tuzcu, O.U. Kilinc, Implantable cardioverter defibrillator implantation without using fluoroscopy in a pregnant patient, Pacing Clin. Electrophysiol. 35 (9) (2012) e265–e266.
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
Implantation of a defibrillator in a pregnant woman with hypertrophic cardiomyopathy under echocardiographic guidance: A case report Skevos Sideris a,⁎,1, Alexandros Kasiakogias a,1, Constantina Aggeli b,1, Kostas Manakos a,1, George Trantalis a,1, Konstantinos Gatzoulis b,1, Dimitrios Tousoulis b,1, Ioannis Kallikazaros a,1 a b
State Cardiology Division, Hippokration Hospital, Athens, Greece First Cardiology Clinic, University of Athens, Hippokation Hospital, Athens, Greece
a r t i c l e
i n f o
Article history: Received 6 November 2014 Accepted 8 November 2014 Available online 11 November 2014 Keywords: Electronic device Ventricular tachycardia Pregnancy
Hypertrophic cardiomyopathy (HCM) is a predominantly inherited disease with an estimated annual incidence of cardiac mortality of 1– 2% [1]. The presence of episodes of non-sustained ventricular tachycardia (NSVT) is considered as an independent predictor of sudden cardiac death. During pregnancy, episodes of arrhythmias may become more often while implantation of an implantable cardioverter-defibrillator (ICD) may be needed. Concerns of performing such a procedure under fluoroscopic guidance during pregnancy have been variably posed. The purpose of this report is to describe the case of a pregnant patient with hypertrophic cardiomyopathy in whom an ICD with the guidance of transesophageal echocardiography was implanted. A 26 year old woman at 24 weeks of gestation referred to our clinic because of increasing episodes of palpitations. The patient had been diagnosed with HCM at the age of 13 years, had an ejection fraction over 60% and did not report any symptoms of heart failure. She was a high risk patient as she had a positive family history of sudden cardiac death, an abnormal response to exercise and recorded episodes of NSVT. Implantation of an ICD had been consistently advised but the patient had refused due to the invasive nature of the treatment. At the age of 24 years she became pregnant for the first time and was closely monitored by her cardiologist. That pregnancy was completed without complications and no arrhythmias were recorded during that time. After ⁎ Corresponding author at: State Cardiology Division, Hippokration Hospital, 114 Vasilissis Sofias St., 115 28 Athens, Greece. E-mail address: [email protected] (S. Sideris). 1 All authors take responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation.
http://dx.doi.org/10.1016/j.ijcard.2014.11.091 0167-5273/© 2014 Elsevier Ireland Ltd. All rights reserved.
presentation at our clinic, the patient underwent several 24-hour ambulatory rhythm monitorings that confirmed multiple episodes of NSVT with an increasing frequency. The estimated risk of sudden cardiac death was more than 10% [2]. Accordingly, after a thorough consultation when the risks for the patient and the fetus were again clearly presented, the patient eventually accepted to undergo ICD implantation. The patient was informed about the possible dangers of fluoroscopy in the setting of pregnancy, and the alternative of transesophageal echocardiography during the procedure was decided to be followed. Implantation of the ICD was performed under general anesthesia by using medications which would not adversely affect the fetus. Midazolam 5 mg and Propofol 100 mg were introduced once for induction of anesthesia while a Propofol infusion at the rate of 60 mg/h was applied for maintenance. An ICD pocket was formed in the region of the left pectoral muscle and a defibrillator lead was inserted into the left subclavian vein by percutaneous puncture and then advanced through the superior vena cava to the right heart chambers. Transesophageal ultrasound (Phillips iE33, 2.5 MHz s5-1 transducer) was used to guide implantation of the lead in the right ventricle. By applying the four chamber view (Fig. 1), the transgastric view (Figs. 2 and 3) and the short axis view at the level of the aortic valve, the electrode was inserted in the right ventricular apex. At the final positioning, the ICD lead tip was clearly visualized in place and there was no need to perform further visualization with fluoroscopy. Appropriate parameters regarding impedance, sensing, pacing threshold and defibrillation threshold were then tested. The duration of the procedure was approximately 65 min. The post-operative check did not identify any pericardial effusion or other intraoperative or postoperative complications. The patient was discharged after two days of hospitalization. In a 6 month follow-up visit, no episodes of ventricular tachycardia or defibrillator discharge were recorded during ICD interrogation. A chest X-ray was also performed where the right position of the electrode was clearly observed. As echocardiography is now a widely available diagnostic method, and genetic as well as family screening are being more often performed, an increasing number of women of child-bearing potential are diagnosed with HCM. In the pregnant patient, apart from the possible development or progression of symptoms or clinical heart failure that are attributed partly to the hemodynamic changes during this period, a risk of sudden cardiac death is also to be considered [3]. A previous out-of-hospital arrest, non-sustained or sustained ventricular tachycardia, family history
324
S. Sideris et al. / International Journal of Cardiology 179 (2015) 323–324
Fig. 1. Four-chamber view showing hypertrophy of the left ventricular apex and the interventricular septum.
Fig. 3. Transgastric view showing the ICD lead inserted in the left ventricular apex (arrow). RV, right ventricle.
of sudden death, severe septal hypertrophy and abnormal blood pressure response during exercise have been reported to be relevant risk factors [1] . Therefore risk stratification should be a sine qua non for the patient wishing to become pregnant [2]. The prevalence of young women suffering from cardiomyopathies and carrying an ICD that become pregnant is increasing. Current evidence, derived primarily from retrospective studies, generally supports that presence of ICDs, in contrast to the underlying cardiac condition, is not accompanied by a greater risk of adverse complications during pregnancy [4]. ICD shocks have traditionally been considered safe for the fetus, even though in a recent report such a shock was associated with a miscarriage [4]. Nevertheless, benefits from ICD implantation, when indications are identified and followed as per guidelines, should far outweigh any risks for the female patient and fetus. A challenging clinical scenario is however when a defibrillator is indicated while the patient is already pregnant, especially with respect to the application of ionizing radiation. It is widely accepted that exposure of the pregnant woman and fetus to procedures that involve fluoroscopy, radiation or radioactive material administration should be minimized [5]. Any risk for the fetus is dependent on the amount of radiation and the gestational age. In any case, most diagnostic procedures expose the fetus to radiation levels of less than 50 mSv that pose a negligible risk with respect to birth defects or miscarriage, even during the delicate period of embryogenesis and organogenesis. In practice, even the positioning of a lead sheath on the abdomen of the pregnant woman only minimally reduces the radiation dose absorbed by the fetus [6].
Few reports exist regarding the use of alternative methods to fluoroscopy in order to guide device implantation during pregnancy. In one of the earliest reported cases, implantation was performed only with the use of 2-D echocardiography [7]. Implantation of a pacemaker or a defibrillator, guided by transesophageal echocardiography and followed by only a short fluoroscopic view in the end, has been reported [8,9]. More recently, implantations of defibrillators with the help of electroanatomical mapping and three-dimensional navigation systems have been successfully performed [10]. In total, the gestational age, the age of the patient, the experience of the operator, the available facilities, the complexity of the required device and the possible financial issues should be considered when choosing the appropriate guiding technique for device implantation in such patients. To conclude, implantation of an ICD under guidance with transesophageal echocardiography only is a safe and effective method that should be considered in pregnant patients with HCM. The steps of careful patient evaluation, risk stratification for sudden cardiac death as well as proper consultation of the patient are crucial for the optimal management of this delicate patient group.
Fig. 2. Transgastric view showing the ICD lead crossing the tricuspid valve. The electrode appears as a highly echogenic structure (arrow). RA, right atrium; RV, right ventricle.
Conflict of interest None for all authors. References [1] P.M. Elliott, A. Anastasakis, M.A. Borger, et al., 2014 ESC Guidelines on Diagnosis and Management of Hypertrophic Cardiomyopathy: the Task Force for the Diagnosis and Management of Hypertrophic Cardiomyopathy of the European Society of Cardiology (ESC), Eur. Heart J. 35 (39) (2014) 2733–2779. [2] C. O'Mahony, F. Jichi, M. Pavlou, et al., A novel clinical risk prediction model for sudden cardiac death in hypertrophic cardiomyopathy (HCM Risk-SCD), Eur. Heart J. 35 (30) (2014) 2010–2020. [3] K. Stergiopoulos, E. Shiang, T. Bench, Pregnancy in patients with pre-existing cardiomyopathies, J. Am. Coll. Cardiol. 58 (4) (2011) 337–350. [4] S. Boulé, L. Ovart, C. Marquié, et al., Pregnancy in women with an implantable cardioverter-defibrillator: is it safe? Europace 16 (11) (2014) 1587–1594. [5] P.M. Colletti, K.H. Lee, U. Elkayam, Cardiovascular imaging of the pregnant patient, AJR Am. J. Roentgenol. 200 (3) (2013) 515–521. [6] J. Damilakis, N. Theocharopoulos, K. Perisinakis, et al., Conceptus radiation dose and risk from cardiac catheter ablation procedures, Circulation 104 (2001) 893–897. [7] M. Güdal, C. Kervancioğlu, D. Oral, T. Gürel, C. Erol, A. Sonel, Permanent pacemaker implantation in a pregnant woman with the guidance of ECG and two-dimensional echocardiography, Pacing Clin. Electrophysiol. 10 (3 Pt 1) (1987) 543–545. [8] D. Antonelli, L. Bloch, T. Rosenfeld, Implantation of permanent dual chamber pacemaker in a pregnant woman by transesophageal echocardiographic guidance, Pacing Clin. Electrophysiol. 22 (3) (1999) 534–535. [9] M. Abello, R. Peinado, J.L. Merino, et al., Cardioverter defibrillator implantation in a pregnant woman guided with transesophageal echocardiography, Pacing Clin. Electrophysiol. 26 (9) (2003) 1913–1914. [10] V. Tuzcu, O.U. Kilinc, Implantable cardioverter defibrillator implantation without using fluoroscopy in a pregnant patient, Pacing Clin. Electrophysiol. 35 (9) (2012) e265–e266.
