Case Reports

Arrhythmogenic Right Ventricular Cardiomyopathy in Pregnancy

A Case Report and Review of the Literature
Aysen Agir,1 MD, Serdar Bozyel,1 MD, Umut Celikyurt,1 MD, Onur Argan,1 MD,
Irem Yilmaz,1 MD, Kurtulus Karauzum,1 MD, and Ahmet Vural,1 MD

Summary
Arrhythmogenic right ventricular cardiomyopathy (ARVC) is predominantly a genetically determined heart muscle
disorder that is characterized by fibro-fatty replacement of the right ventricular (RV) myocardium.1) The clinical spec-
trum of ARVC may represent from asymptomatic premature ventricular complexes to ventricular tachycardia (VT) and
sudden cardiac death (SCD). It is a well-known leading cause of SCD in young adults.2,3)
There is no general consensus on the management of ARVC in pregnancy, and the preferred mode of delivery is
uncertain. Herein, we report a case of ARVC diagnosed at 20 weeks of gestation following a sustained VT and treated
with an implantable cardiac defibrillator (ICD). We also reviewed the current knowledge and approach to ARVC in preg-
nancy since the literature on this condition is based on case reports. (Int Heart J 2014; 55: 372-376)

Key words: Implantable cardioverter defibrillator

A
 RVC is a primary disease of the myocardium charac-
terized by fibro-adipocytic replacement of myocytes,
mostly in the right ventricle. It should be suspected
in a young or middle aged adult who has ventricular arrhyth-
mias with left bundle-branch block (LBBB) morphology and
does not have any other cardiac disease. Following the diagno-
sis of ARVC, the most important management decision is
whether or not to implant an ICD for the treatment of sustained
ventricular arrhythmias for prevention of SCD. It is now a
standard practice for ARVC patients presenting with sustained
VT and/or ventricular fibrillation (VF) to undergo placement
of an ICD because of a high risk of recurrent VT and/or
SCD.4-6)
The number of woman with ARVC reportedly continues
to increase and due to insufficient published data, it is rather
difficult to evaluate the risk and management of ARVC during
pregnancy and delivery. The diagnosis of ARVC based on de-
velopment of VT during pregnancy and subsequent ICD im-
plantation is a rarely seen situation.
Here we describe a patient diagnosed as ARVC at 20
weeks of gestation and managed with ICD placement during
pregnancy.
Case Report
A-30-year-old woman (gravida 3, para 2), was admitted
to Gynaecology and Obstetrics Hospital due to heart palpita-
tions at 20 weeks of gestation. She had been asymptomatic un-
til 20 weeks. When cardiac monitoring showed wide QRS
complex regular tachycardia, she was transferred to our emer-
gency department without any treatment by an ambulance in
10 minutes. She had no history of cardiovascular or any other
disease. The patient was not on any medication but was taking
supportive multivitamins. There was a history of smoking, but
no alcohol consumption or illicit drug use. She had not experi-
enced any problems during her previous pregnancies or deliv-
eries. Her father had coronary artery disease but there was no
family history of SCD among young adults.
In the admission period, she was hemodynamically sta-
ble. On physical examination, her blood pressure was 110/60
mmHg and heart rate was 200-210 bpm. Electrocardiography
(ECG) showed sustained VT with inferior axis and negative
concordance (Figure 1). In the emergency department, she was
given adenosine 6 mg and then 12 mg intravenously (IV) in
order to distinguish the tachycardia origin. However, sinus
rhythm could not be restored so she was referred to us. The
spontaneous sinus rhythm was established when we evaluated
the patient. She was then admitted to the coronary intensive
care unit.
Ventricular tachycardia (VT), at a rate of 200-210/min,
that neither disturbed the hemodynamics nor caused any symp-
toms other than palpitations, occurred during admission to the
coronary intensive care unit. Initially, 5 mg (IV) metoprolol
was given followed by a second dose of 5 mg as sinus rhythm
was not restored. Approximately 4 minutes after achieving a
short period of sinus rhythm, VT at a rate of 190-200/min oc-
curred again, causing no change in the hemodynamics. As VT
was terminated and reoccurred again and again with the re-
peated dose of metoprolol 5 mg, amiodarone 150 mg (IV) was

From the 1 Department of Cardiology, Faculty of Medicine, Kocaeli University, Kocaeli, Turkey.
Address for correspondence:Aysen A. Agir, MD, Department of Cardiology, Faculty of Medicine, Kocaeli University, Umuttepe, 41380, Kocaeli, Turkey. E-mail:
aagacdiken@yahoo.com
Received for publication August 28, 2013. Revised and accepted January 2, 2014.
Released in advance online on J-STAGE June 5, 2014.
All rights reserved by the International Heart Journal Association.
372
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No 4 RIGHT VENTRICULAR CARDIOMYOPATHY IN PREGNANCY
Figure 1. ECG showed sustained ventricular tachycardia with inferior
axis and negative concordance.
Figure 2. 12-lead ECG demonstrated normal sinus rhythm with incom-
plete right bundle-branch block. Inverted T-waves in leads V1–V4 were
observed.
given. Instead of amiodarone, electrical cardioversion was con-
sidered, but a single dose of amiodarone was preferred for sta-
bilizing the rhythm as the patient refused electrical cardiover-
sion. Along with ongoing VT the patient reported feeling
dizzy. Shortly afterwards she had a severe vomiting episode
and then her blood pressure decreased notably. Subsequent to
the vomiting attack, the VT was noticed to be terminated with-
in seconds and the patient became hemodynamically stable.
Once the sinus rhythm was re-established, the follow-up was
uneventful.
A 12-lead ECG demonstrated normal sinus rhythm with
incomplete right bundle-branch block (RBBB). Inverted T-
waves in leads V1–V4 were apparent (Figure 2). CKMB levels
were modestly elevated and troponin I was weakly positive.
Serial cardiac enzymes were: CK-MB 2.7 – 5.1 – 8.7 (normal
2.0-7.2 ng/mL), troponin I 0.085–0.19–0.10 (normal 0.010-
0.023 ng/mL); other laboratory tests and chest X-rays were
normal. Transthoracic echocardiography showed enlargement
of RV (31 mm) and moderate tricuspid valve insufficiency. The
RV ejection fraction (EF) was 30% and the left ventricular EF
was normal. Twenty-four hour Holter monitoring demonstrat-
373
Figure 3. Cardiac MRI demonstrated the typical manifestation of ARVC;
(arrows) enlargement of right ventricle and atrium without enlargement of
left ventricle and atrium; note severely and globally hypokinetic right ven-
tricle with lateral wall akinesia.
ed normal sinus rhythm with frequent premature ventricular
complexes (PVC) (3995/day), ventricular couplets (400/day),
and triplets (30/day), and runs of non-sustained VT, up to 11
beats in duration (2 times/day, 11 salvos at maximum). Cardiac
MRI presented the typical manifestation of ARVC indicating
an enlargement of RV and right atrium without enlargement of
the left ventricle and atrium; the RV was severely globally hy-
pokinetic with lateral wall akinesia and the RV ejection frac-
tion was 19% (Figure 3). The diagnosis of ARVC was based
upon a set of major and minor criteria proposed by the Interna-
tional Task Force.7) She had two major criteria; 1) By MRI, her
right ventricle was severely hypokinetic with lateral wall aki-
nesia and the RV ejection fraction was 19%. 2) Her ECG dem-
onstrated inverted T-waves in leads V1–V4 in the absence of
complete RBBB. The patient also had one minor criterion; On
Holter analysis there were 3995 ventricular extrasystoles per
day. Thus, our patient fulfilled the latest criteria for definite
ARVC diagnosis.
A fetal echocardiogram was performed at the 21st week
of pregnancy and no abnormality was detected. Her other two
children were also evaluated by echocardiogram and no abnor-
mality was found. The relative benefits of ICD placement vs.
antiarrhythmics for the prevention of SCD were discussed with
the patient. After obtaining informed consent, a single chamber
ICD was placed under local anaesthesia without any complica-
tions of note at 21 weeks of gestation. The abdomen of the pa-
tient was protected by a lead blanket. The patient tolerated the
procedure well. The patient and fetus were monitored for 3
days after ICD implantation. In this period, numerous nonsus-
tained VT episodes were observed and metoprolol was given
to the patient to decrease her palpitations. A consultation with
the Department of Obstetrics about the usage and dosage of
metoprolol therapy revealed no contraindication to beta-block-
ers for her pregnancy. Finally, she was discharged on metopro-
lol (50 mg/day). She was monitored very closely for the re-
maining trimesters of her pregnancy. At 32 weeks of gestation,
an echocardiogram demonstrated no changes in her cardiac
functions and the device did not record any arrhythmias. She
had no further problems during the rest of her pregnancy.
She delivered her baby in the 37th week of pregnancy by

374 AGIR, ET AL
caesarean section due to fetal distress (oligohydramnios) under
spinal anaesthesia. The device was left off during delivery and
no complications, such as arrhythmias, were observed during
labour. The newborn was a healthy boy, with a birth weight of
3800 grams and APGAR score of 9/10 at the 1st and 5th min-
utes. Echocardiography of the baby was normal. After 3 days
of hospitalization, she was discharged with metoprolol (50 mg/
day) and continued breastfeeding for 6 months. The analysis of
stored electrograms revealed no significant ventricular arrhyth-
mia throughout the 6 months of ICD implantation.
Discussion
ARVC is characterized pathologically by myocardial at-
rophy, fibrofatty replacement, fibrosis and ultimate thinning of
the wall with chamber dilatation and aneurysm formation.8)
These changes consequently produce electrical instability pre-
cipitating VT and SCD.9) ARVC should be suspected in a
young patient with palpitations, syncope, or aborted SCD. VT
with LBBB morphology is the classic presentation. Other elec-
trocardiographic abnormalities such as inverted T waves in
right precordial leads (V1–V3) and frequent premature ven-
tricular complexes (PVCs), even in asymptomatic patients,
should arouse the suspicion for this cardiomyopathy.10) The
main goal of therapy is to prevent serious events, which re-
quires identifying high-risk patients for malignant arrhythmias
and SCD.11-13)
The diagnosis of ARVC is based upon a set of major and
minor criteria proposed by the International Task Force.7) Pa-
tients must either meet two major criteria, one major and two
minor criteria, or 4 minor criteria to be diagnosed as ARVC.
Two of the major and one of the minor diagnostic criteria for
ARVC according to the new Task Force Criteria were present
in our patient, ie, inverted T waves in leads V1-V4 in the ab-
sence of RBBB on ECG, severe hypokinesis of the right ven-
tricle with lateral wall akinesia and reduced ejection fraction
(19%) of the RV observed by MRI, and 3995 ventricular extra-
systoles per 24 hours on ECG Holter examination.
Pregnancies with dilated and hypertrophic cardiomyopa-
thies are common, but only a few cases of pregnancies with
ARVC have been reported.14-18) Therefore, it is difficult to as-
sess the risks of pregnancy and delivery in patients with
ARVC. Furthermore, sustained VT developed during the preg-
nancy in only one of these cases. In the patient mentioned in
this case, VT had developed following physical exercise at the
34th week of both her pregnancies. As sinus rhythm was
achieved spontaneously approximately 20 seconds later, there
was no need for medical or electrical cardioversion.18) In our
case VT developed in the 20th week, during rest and continued
for minutes. Sinus rhythm could be restored immediately by
medical cardioversion.
During pregnancy, plasma volume, cardiac output and
heart rate increase, hematocrit decreases, and physiologic ane-
mia is established. VT may be triggered during pregnancy as a
result of these hemodynamic changes.19,20) It is noteworthy that
the published reports have found that most of these patients
tolerate these conditional hemodynamic changes induced by
pregnancy. Although pregnancy alone is a physiological stress
factor, in our patient there was no other reason inducing the ar-
rhythmia. Nevertheless, it has been reported that exercise itself
Int Heart J
July 2014
can induce fatal arrhythmia in ARVC patients. The initiation of
VT was associated with a typical catecholamine surge seen on
exercise in the setting of the presence of arrhythmogenic sub-
strate characteristic of these patients.21,22) Therefore, as exercise
may increase heart rate in a pregnant woman with a diagnosis
of ARVC, it is better to recommend to avoid exercise.
Considering the paucity of reported data in regard to the
management of ARVC patients during pregnancy, it is still un-
known whether an arrhythmic event could be preventable by
any treatments. In a case reported by Iriyama, et al,18) the pro-
pranolol treatment that the patient had been taking was not
given during the pregnancy on her own request and VT oc-
curred at the 34th week. Similarly in the case of Güdücü, et
al,17) the patient taking regular metoprolol and propafenone
treatment for 3 years with the diagnosis of ARVC refused to
use the drugs on her own request and she became symptomatic
at the 32nd week. In her Holter ECG at the 32nd week, frequent
PVC attacks were detected. In our case, the patient was dis-
charged with metoprolol treatment after implantation of an
ICD at the 21st week and she was asymptomatic until delivery.
The analysis of stored electrograms revealed no significant
ventricular arrhythmia at 6 months post ICD implantation un-
der metoprolol treatment.
Treatment of ARVC is based on the prevention of ar-
rhythmia with beta-blockers, especially with sotalol, which
prevents arrhythmia caused by ARVC in 60% to 70% of pa-
tients.23) Propafenone was reported to be safe in the treatment
of ventricular arrhythmia during pregnancy.24) Combination
therapy (Class IC drugs plus beta-blocking drugs, or amiodar-
one plus beta-blocking drugs) frequently is effective in pre-
venting recurrent VT. Unfortunately, amiodarone therapy dur-
ing pregnancy (category D) may cause fetal/neonatal
hypothyroidism and, less frequently, goiter.25) Thus, the use of
amiodarone in pregnancy should be limited to VTs which are
sustained, monomorphic, hemodynamically unstable, refracto-
ry to electrical cardioversion, or not responding to other
drugs.26) In our case, although the hemodynamics were stable,
by considering the fetal side effects, electrical cardioversion
which is reliable in every phase of pregnancy might have been
preferred instead of amiodarone. However, single dose-amio-
darone was preferred because the patient refused the electrical
cardioversion. Only a 150 mg-loading dose was given to the
patient and a maintenance infusion dose could not be adminis-
tered.
Prophylactic therapy with a cardioselective beta-blocking
agent, such as metoprolol, may be effective.26) There is consid-
erable experience with beta blockers and no teratogenicity has
been reported to date, even if in some cases intrauterine growth
delay and bradycardia have been reported.27) In our case, al-
though oligohydramnios was detected at the 37th week of preg-
nancy, intrauterine growth retardation was not evident in the
fetus and the baby was born healthy.
ICD use is recommended for patients who have a docu-
mented episode of sustained VT or cardiac arrest or who have
high-risk features for SCD. Recently, ICD therapy for the pre-
vention of SCD in patients with ARVC is becoming standard
treatment.3) However, little is known regarding the outcome of
pregnancy in women with ICD. We have found only one pub-
lished case of a patient diagnosed with ARVC during her preg-
nancy and treated with ICD placement.15) In the last years, only
a few studies of ICD therapy during pregnancy have found that
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No 4 RIGHT VENTRICULAR CARDIOMYOPATHY IN PREGNANCY
the majority of women completed and tolerated pregnancy and
delivered without serious complications.15,28-30) Thus, ICD
placement should be considered in pregnant woman with
ARVC to prevent episodes of SCD.
The preferred mode of delivery in women with ARVC is
uncertain. Bauce, et al 14) reported that a caesarean section was
performed in 4 of the 6 patients in whom the disease was con-
sidered to be more dangerous on the basis of both morphologi-
cal changes and the history of ventricular arrhythmias. The re-
maining two cases with only isolated PVC or no arrhythmias
underwent spontaneous vaginal delivery. Iriyama, et al 17) pre-
ferred to perform elective caesarean section due to a history of
major arrhythmias. Our patient delivered by caesarean section
due to fetal indication (oligohydramnios).
It remains unclear whether an ICD should be on or off
during delivery. Recurrence of VT may result in decreasing
placental perfusion due to maternal hypotension and could be
dangerous for the fetus. In contrast, ICD shocks are a concern
for the safety of the fetus, although the amount of energy trans-
ferred to the uterus is very small and the fetal heart has a high
fibrillatory threshold.28,31) In a few studies, no arrhythmias or
ICD discharges were precipitated during delivery.28,29) As the
status of the ICD during delivery appears to have no effect on
the overall outcome, in fact, leaving the device “on” during
vaginal delivery is recommended, whereas it should be “off” in
the case of caesarean section, because electrocautery is in-
volved.32) We left the device turned off during caesarean sec-
tion, since electrocautery was to be used.
Our case is the first report of an ARVC patient who had a
sustained VT that required medical cardioversion to be termi-
nated during pregnancy. This is also the second case of a preg-
nant ARVC patient who underwent ICD implantation during
her pregnancy. On the basis of other published studies and our
case report, it can be said that the pregnancy is well tolerated
in women affected by ARVC and can be managed successfully
with close monitoring and antiarrhythmic drugs when neces-
sary. ICD implantation also should be considered to prevent
SCD during pregnancy to protect the life of the mother. Preg-
nancy seems not to cause an increase in major ICD-related
complications. Despite all of these experiences, more case
studies are needed to establish the most appropriate manage-
ment of ARVC during pregnancy.
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