To the Editor,
We greatly enjoyed reading the article by Roscani et al. (11. Roscani MG, Zanati SG, Salmazo PS, Carvalho FC, Magalhães CG, Borges VT, et al.
Congenital aneurysmal circumflex coronary artery fistula in a pregnant woman. Clinics.
2012;67(12):1523-5, http://dx.doi.org/10.6061/clinics/2012(12)30.
http://dx.doi.org/10.6061/clinics/2012(1...
) titled “Congenital aneurysmal circumflex coronary artery fistula in a pregnant woman.” In
the article, the authors presented a case report of a congenital aneurysmal coronary artery fistula
to the right ventricle in a pregnant woman and discussed the appropriate management. We have some
concerns about the article.
During pregnancy, immediate invasive cardiac procedures have highly time-responsive benefits, and
these benefits might be lost due to unnecessary delays. Thus, these procedures should not be
completely denied; rather, whether they are performed should depend on the state of the pregnancy.
Concerns related to the safety of these invasive tests must be balanced against the importance of
accurate diagnosis and proper assessment of the pathologic state (22. Pradhan AD, Visweswaran GK, Gilchrist IC. Coronary angiography and percutaneous
interventions in pregnancy. Minerva Ginecol. 2012;64(5):345-59.). Additionally, cardiologists must consider the clear indications and limitations of each
type of diagnostic imaging test and avoid potentially harmful effects to protect the fetus.
Potential adverse outcomes due to radiation exposure during pregnancy include teratogenicity,
genetic damage, intrauterine death and increased risk of malignancy, especially increased risk to
the fetal thyroid from radioiodine exposure after 12 weeks of gestation (33. Lowe SA. Diagnostic radiography in pregnancy: risks and reality.
Aust N Z J Obstet Gynaecol. 2004;44(3):191-6.). The need for invasive radiological procedures in the diagnosis of cardiac
diseases has been markedly reduced due to developments in imaging technologies that use non-ionizing
energies. Nonetheless, imaging modalities that do not use ionizing radiation, such as magnetic
resonance imaging (MRI), are preferred for pregnant women (44. Patel SJ, Reede DL, Katz DS, Subramaniam R, Amorosa JK. Imaging the pregnant
patient for nonobstetric conditions: algorithms and radiation dose considerations. Radiographics.
2007;27(6):1705-22, http://dx.doi.org/10.1148/rg.276075002.
http://dx.doi.org/10.1148/rg.276075002...
).
The benefit-risk balance assessment for cardiac catheterization during pregnancy should be
performed properly for both mother and fetus. MRI should be considered for cases in which the
results of echocardiography are inconclusive and patient management mainly depends on results from
further imaging modalities (22. Pradhan AD, Visweswaran GK, Gilchrist IC. Coronary angiography and percutaneous
interventions in pregnancy. Minerva Ginecol. 2012;64(5):345-59.). Contrast media should only be
given intravenously when a compulsive clinical indication exists and the potential benefit to the
mother overbalances the potential risk to the fetus (55. Siegmann KC, Heuschmid M, Claussen CD. Diagnostic imaging during pregnancy. Dtsch
Med Wochenschr. 2009;134(14):686-9, http://dx.doi.org/10.1055/s-0029-1208106.
http://dx.doi.org/10.1055/s-0029-1208106...
). In
the above-mentioned case report, the authors did not report any potential benefits of cardiac
catheterization to detect an asymptomatic coronary fistula in a pregnant woman. Therefore, we
strongly believe the use of cardiac catheterization should have been postponed until delivery
because the patient was asymptomatic and did not have any signs of cardiac failure. Aspirin and
endocarditis prophylaxis could have been considered, especially if the level of clinical suspicion
in the case was high.
REFERENCES
-
1Roscani MG, Zanati SG, Salmazo PS, Carvalho FC, Magalhães CG, Borges VT, et al. Congenital aneurysmal circumflex coronary artery fistula in a pregnant woman. Clinics. 2012;67(12):1523-5, http://dx.doi.org/10.6061/clinics/2012(12)30.
» http://dx.doi.org/10.6061/clinics/2012(12)30 -
2Pradhan AD, Visweswaran GK, Gilchrist IC. Coronary angiography and percutaneous interventions in pregnancy. Minerva Ginecol. 2012;64(5):345-59.
-
3Lowe SA. Diagnostic radiography in pregnancy: risks and reality. Aust N Z J Obstet Gynaecol. 2004;44(3):191-6.
-
4Patel SJ, Reede DL, Katz DS, Subramaniam R, Amorosa JK. Imaging the pregnant patient for nonobstetric conditions: algorithms and radiation dose considerations. Radiographics. 2007;27(6):1705-22, http://dx.doi.org/10.1148/rg.276075002.
» http://dx.doi.org/10.1148/rg.276075002 -
5Siegmann KC, Heuschmid M, Claussen CD. Diagnostic imaging during pregnancy. Dtsch Med Wochenschr. 2009;134(14):686-9, http://dx.doi.org/10.1055/s-0029-1208106.
» http://dx.doi.org/10.1055/s-0029-1208106
-
No potential conflict of interest was reported.
Publication Dates
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Publication in this collection
Apr 2013