Wide Variation in Post-Heart Transplant Pregnancy Practice Patterns

By Lisa Rapaport

April 24, 2020

(Reuters Health) - Practice patterns surrounding pregnancy after heart transplantation vary widely in the U.S. and many clinicians mistakenly believe that pregnancy is contraindicated in all cases, a recent survey suggests.

"I believe practice patterns vary widely because post-transplant pregnancy is a relatively rare event, partly because women of childbearing age are less likely to undergo heart transplantation and partly because they must meet certain criteria of stability for post-transplant pregnancy to be considered," said co-author Dr. Michelle Kittleson, director of heart failure research at the Smidt Heart Institute at Cedars-Sinai Medical Center in Los Angeles.

"Transplantation does not necessarily exclude the possibility of future pregnancy," Dr. Kittleson said by email.

Earlier this year, in fact, a separate team reported in the Journal of Heart and Lung Transplantation on 91 heart recipients who had 157 pregnancies. Two-thirds of the pregnancies were successful. (https://bit.ly/2Y1mt5A)

For the current study, researchers conducted a web-based survey, sent electronically to 1,643 heart transplant providers in the U.S. between June and August 2019. There were 122 responses, the majority from cardiologists (70%) and nurse or transplant coordinators (18%), followed by surgeons (6%), and advanced practice providers (nurse practitioners and physician's assistants (5%)).

The largest proportion of respondents (39%) practiced at institutions performing 20 to 39 heart transplants per year, while 11% practiced at institutions performing 80 or more transplants annually. Most respondents (60%) reported their programs had at least one heart transplant recipient who had become pregnant.

Overall, 37 respondents (31%) said that pregnancy should be avoided in all transplant recipients. Only 52 survey participants (43%) said their medical center had a formal policy regarding pregnancy following heart transplant.

The most commonly cited contraindications included nonadherence (89%), reduced left ventricular ejection fraction (85%), coronary allograft vasculopathy (70%), prior rejection (62%), presence of donor-specific antibodies (57%), and prior peripartum cardiomyopathy pre-transplant (47%).

Respondent sex, specialty, transplant volume, or prior experience with pregnancy after heart transplant were not associated with recommendations to avoid posttransplant pregnancy.

Among the 84 respondents who supported pregnancy in heart transplant recipients, 50% would recommend preconception genetic counseling for all patients. An additional 36% would consider genetic counseling if the patient had a genetic cause for their heart failure or cardiomyopathy.

Sixty-eight percent of respondents who supported pregnancy felt that any decision about breastfeeding should be deferred to the gynecologist or maternal fetal medicine specialist. However, 21% felt it was not safe and should not be allowed.

A majority of participants who supported pregnancy (69%) said they would endorse the use of assisted reproductive technologies if recommended by a fertility specialist.

International Society for Heart and Lung Transplantation (ISHLT) guidelines recommend a multidisciplinary approach to reproductive health after heart transplant, the study authors note in Circulation: Heart Failure.

Multiple factors should be considered, including preconception counseling, genetic counseling if the patient is unclear on the underlying etiology of heart failure, safety of immunosuppression, comorbid conditions, and the hemodynamic effects of pregnancy on the allograft, according to the ISHLT guidelines.

One major difference between pregnancy in an abdominal versus thoracic organ transplant recipient is that the normal hemodynamic effects of pregnancy may directly impact or be influenced by graft function, the study team notes.

The low response rate is one limitation of the study. Another is that respondents were not asked to identify their transplant center affiliation, allowing for the possibility that responses from certain institutions could skew results.

"There is wide variation between programs but also within institutions," said Dr. Anique Ducharme, director of the heart failure clinic at the University of Montreal.

"Some of my colleagues (mostly older males) still consider pregnancy an absolute contraindication for all our cardiac transplant patients," Dr. Ducharme, who wasn't involved in the study, said by email. "Our nurse coordinators know this fact and just schedule the patients accordingly."

Patients should be up front with their transplant team if they are considering pregnancy or if they become pregnant, said Dr. David Baran, System Director, Advanced Heart Failure, Transplant and MCS at Eastern Virginia Medical School and Sentara Heart Hospital in Norfolk, Virginia.

"In a way, the transplant team is another set of parents - we may not be happy with all your choices, but like most parents, we are here to support you through these times," Dr. Baran, who wasn't involved in the study, said by email. "The earlier the transplant team may be involved, the better."

SOURCE: https://bit.ly/2RZD45M Circulation: Heart Failure, online April 2, 2020.