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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Pregnancy is becoming more common in older women with an increased risk of associated chronic conditions such as hypertension&#44; diabetes and hypercholesterolemia or who already show evidence of atherosclerotic vascular disease&#46; Additionally&#44; the successful treatment of heart disease in infants and children has resulted in more women with congenital heart disease surviving into adulthood and being capable of having a successful pregnancy&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">1&#44;2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Maternal mortality remains an important healthcare problem&#59; no major improvements have been noted in recent decades in most developed countries&#44; with cardiovascular disease being the leading cause of pregnancy-related deaths&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Arrhythmias are one of the most frequent cardiac problems reported in pregnancy&#46; Proarrhythmic mechanisms related to hemodynamic&#44; autonomic and hormonal changes make pregnancy a high-risk state for the occurrence of new-onset arrhythmias or the recurrence of pre-existing arrhythmias&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Data on the exact prevalence of rhythm disorders during pregnancy are conflicting and difficult to assess&#44; since in addition to palpitations being a common complaint&#44; heart rate progressively increases by 10&#8211;25&#37; from pre-pregnancy levels&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">1&#44;2</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Supraventricular arrhythmias are more common than ventricular arrhythmias and life-threatening arrhythmias seem to be relatively rare&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">In normal hearts&#44; apart from sinus tachycardia&#44; the most common rhythm abnormalities in pregnancy are simple ventricular and atrial ectopies &#40;reported in 50&#8211;60&#37; of pregnant women&#41;&#44; which generally do not lead to hospital admission and resolve spontaneously after delivery&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">4</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">In women with structural heart disease&#44; arrhythmias&#44; particularly atrial fibrillation and ventricular tachycardia&#44; are more common during pregnancy and can lead to cardiac decompensation&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">When arrhythmic disorders lead to hospitalization&#44; there is an increased risk of both maternal and fetal complications&#44; including maternal mortality&#46; Management may be further complicated because many antiarrhythmic and other cardiac drugs can have teratogenic effects in the first eight weeks of pregnancy and fetal growth and development issues thereafter&#46; Additionally&#44; most cardiologists lack experience in treating and managing these patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">1&#8211;5</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">In this issue of the <span class="elsevierStyleItalic">Journal</span>&#44; Mu&#241;oz-Ortiza et al&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">6</span></a> analyze arrhythmic events during pregnancy in a single-center registry and their impact on cardiac&#44; obstetric and neonatal outcomes&#46; They report data on a cohort of 92 consecutive women diagnosed with tachy- or bradyarrhythmias during pregnancy and referred to a dedicated cardio-obstetric team in a tertiary center in Colombia&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">The main findings were that rhythm disorders were the most common cause of cardiac referral and that the most common arrhythmias were premature ventricular and atrial contractions&#44; which accounted for 45&#37; of all cases&#44; followed by 15&#37; for paroxysmal re-entrant supraventricular tachycardias&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">There were few cases of ventricular tachycardia and atrial flutter and&#44; surprisingly&#44; no cases of atrial fibrillation&#44; which is probably related to the fact that only 8&#46;7&#37; of the patients had structural heart disease and were mostly in class I and II of the modified WHO classification&#46; There were no maternal deaths and only one patient required ablation during pregnancy&#46; Although it was not the case in this report&#44; it should be emphasized that today the majority of ablations can be performed safely with minimal radiation exposure or even without using fluoroscopy&#44; thanks to advances in three-dimensional electroanatomical mapping systems and&#47;or intracardiac echocardiography&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">7</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Ten percent of the women presented with second- or third-degree atrioventricular block&#44; two of whom were implanted with a pacemaker&#46; Opting for permanent device implantation in such a young population is an approach that probably will be less and less used&#44; particularly due to the efficacy and accessibility of treatments like cardioneuroablation in selected cases&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">2</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">There were considerable delays between patient referral and consultation in the cardio-obstetric program&#44; with a median gestation of 31&#46;5 weeks by the time of the first medical assessment&#46; This delay was pointed out by the authors and explained by local contingencies of the healthcare system and accessibility&#44; but may have led to underestimation of important outcomes during pregnancy&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Nevertheless&#44; the authors are to be commended for their research in this patient population&#44; on which there is a lack of real-world information&#44; particularly in Latin American countries&#46; Collaboration and standardization of data collection should be encouraged to facilitate comparison of outcomes from different cardio-obstetric programs&#46; 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Arrhythmias in pregnancy: Is there anything else than just sinus tachycardia?
Arritmias na gravidez – existe algo mais além de taquicardia sinusal?
André Viveiros Monteiro
Cardiology Department, Hospital do Divino Espírito Santo, Ponta Delgada, Açores, Portugal
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Pregnancy is becoming more common in older women with an increased risk of associated chronic conditions such as hypertension&#44; diabetes and hypercholesterolemia or who already show evidence of atherosclerotic vascular disease&#46; Additionally&#44; the successful treatment of heart disease in infants and children has resulted in more women with congenital heart disease surviving into adulthood and being capable of having a successful pregnancy&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">1&#44;2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Maternal mortality remains an important healthcare problem&#59; no major improvements have been noted in recent decades in most developed countries&#44; with cardiovascular disease being the leading cause of pregnancy-related deaths&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Arrhythmias are one of the most frequent cardiac problems reported in pregnancy&#46; Proarrhythmic mechanisms related to hemodynamic&#44; autonomic and hormonal changes make pregnancy a high-risk state for the occurrence of new-onset arrhythmias or the recurrence of pre-existing arrhythmias&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Data on the exact prevalence of rhythm disorders during pregnancy are conflicting and difficult to assess&#44; since in addition to palpitations being a common complaint&#44; heart rate progressively increases by 10&#8211;25&#37; from pre-pregnancy levels&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">1&#44;2</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Supraventricular arrhythmias are more common than ventricular arrhythmias and life-threatening arrhythmias seem to be relatively rare&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">In normal hearts&#44; apart from sinus tachycardia&#44; the most common rhythm abnormalities in pregnancy are simple ventricular and atrial ectopies &#40;reported in 50&#8211;60&#37; of pregnant women&#41;&#44; which generally do not lead to hospital admission and resolve spontaneously after delivery&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">4</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">In women with structural heart disease&#44; arrhythmias&#44; particularly atrial fibrillation and ventricular tachycardia&#44; are more common during pregnancy and can lead to cardiac decompensation&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">When arrhythmic disorders lead to hospitalization&#44; there is an increased risk of both maternal and fetal complications&#44; including maternal mortality&#46; Management may be further complicated because many antiarrhythmic and other cardiac drugs can have teratogenic effects in the first eight weeks of pregnancy and fetal growth and development issues thereafter&#46; Additionally&#44; most cardiologists lack experience in treating and managing these patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">1&#8211;5</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">In this issue of the <span class="elsevierStyleItalic">Journal</span>&#44; Mu&#241;oz-Ortiza et al&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">6</span></a> analyze arrhythmic events during pregnancy in a single-center registry and their impact on cardiac&#44; obstetric and neonatal outcomes&#46; They report data on a cohort of 92 consecutive women diagnosed with tachy- or bradyarrhythmias during pregnancy and referred to a dedicated cardio-obstetric team in a tertiary center in Colombia&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">The main findings were that rhythm disorders were the most common cause of cardiac referral and that the most common arrhythmias were premature ventricular and atrial contractions&#44; which accounted for 45&#37; of all cases&#44; followed by 15&#37; for paroxysmal re-entrant supraventricular tachycardias&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">There were few cases of ventricular tachycardia and atrial flutter and&#44; surprisingly&#44; no cases of atrial fibrillation&#44; which is probably related to the fact that only 8&#46;7&#37; of the patients had structural heart disease and were mostly in class I and II of the modified WHO classification&#46; There were no maternal deaths and only one patient required ablation during pregnancy&#46; Although it was not the case in this report&#44; it should be emphasized that today the majority of ablations can be performed safely with minimal radiation exposure or even without using fluoroscopy&#44; thanks to advances in three-dimensional electroanatomical mapping systems and&#47;or intracardiac echocardiography&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">7</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Ten percent of the women presented with second- or third-degree atrioventricular block&#44; two of whom were implanted with a pacemaker&#46; Opting for permanent device implantation in such a young population is an approach that probably will be less and less used&#44; particularly due to the efficacy and accessibility of treatments like cardioneuroablation in selected cases&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">2</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">There were considerable delays between patient referral and consultation in the cardio-obstetric program&#44; with a median gestation of 31&#46;5 weeks by the time of the first medical assessment&#46; This delay was pointed out by the authors and explained by local contingencies of the healthcare system and accessibility&#44; but may have led to underestimation of important outcomes during pregnancy&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Nevertheless&#44; the authors are to be commended for their research in this patient population&#44; on which there is a lack of real-world information&#44; particularly in Latin American countries&#46; Collaboration and standardization of data collection should be encouraged to facilitate comparison of outcomes from different cardio-obstetric programs&#46; This could contribute to more comprehensive pre-pregnancy counseling&#44; early recognition&#44; careful delivery planning and close postpartum follow-up&#44; and therefore to improved care for these patients&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0075" class="elsevierStylePara elsevierViewall">The author has no conflicts of interest to declare&#46;</p></span></span>"
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