Pregnancy following atrial-switch repair.

Abstract

One of the early repairs for complete transposition of the great arteries was the atrial-switch (Mustard or Senning) operation. This operation involved the re-direction of venous return using inter-atrial baffles. Patients with atrial-switch operations are at risk of developing a number of late complications of pregnancy, including dysfunction of the subaortic right ventricle, atrioventricular valve (AV) regurgitation, and arrhythmias. Pregnancy imposes additional haemodynamic stress on the subaortic right ventricle that can result in ventricular remodelling and deterioration in the systolic function of the ventricle. There is limited data on late effects of pregnancy on the subaortic right ventricle and the AV valve. Understanding the impact of pregnancy on maternal cardiac health is important in order for women with heart conditions to make informed pregnancy decisions. An early study examining pregnancy outcomes in this population (Guedes et al. J Am Coll Cardiol 2004;44:433–37) suggested that deterioration in subaortic ventricular function and AV valve regurgitation was common after pregnancy; however, no control group was available to determine whether this deterioration represented the natural history of the disease or the accelerated effects of pregnancy on the suboaortic right ventricle. In 2013, Bowater et al. (Congenit Heart Dis 2013;8:302–7) reported on 18 women (31 pregnancies) over a 4–5 year period and compared outcomes with 23 female and 28 male controls. In the postpartum period, pregnant women showed significant deterioration in both subaortic ventricular function and New York Heart Association (NYHA) functional status. In late follow-up, although the deterioration of subaortic ventricular function in all three groups was similar, the difference in NYHA functional status persisted in pregnant women when compared with controls. In this issue of BJOG, Cataldo et al. compare 10–year outcome data for 23 women (34 pregnancies) with atrial-switch repair with 15 female controls. In late follow-up, all women remained free of clinical heart failure and the rates of late maternal cardiac complications and deterioration of cardiac function were similar for both groups (cases versus controls). When compared with controls, however, pregnant women had a greater incidence of worsening AV valve regurgitation. In addition to adverse maternal cardiac outcomes, fetal and neonatal complications were notable, as were the high rates of labour induction for cardiac deterioration or concerns for fetal wellbeing, highlighting the impact of maternal health on fetal outcomes. Although the current study is limited by its retrospective nature, small numbers, and qualitative assessment of ventricular function, it contributes to our understanding of the late outcomes after pregnancy in this population. Although pregnancy in women with atrial-switch operations is usually well tolerated, this study and others suggest that, over the long-term, the haemodynamic stress of pregnancy may have adverse late effects on the heart, including worsening NYHA functional class and AV valve regurgitation. None declared. Completed disclosure of interests form available to view online as supporting information. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.