To the Editor:

The numbers of young women living with an implantable cardioverter defibrillator (ICD) due to congenital anomaly or inherited cardiomyopathy have increased, and they are reaching reproductive ages.1-4 As far back as 1997, a study reported that 86% of women with an ICD (n = 44; age 14-36 years) experienced an uneventful pregnancy, even though cardiovascular disease (CVD) is the leading cause of pregnancy-related mortality in the United States and has steadily increased over the past decades, with an incidence of 7.2 to 17.2.5 The most recent data show that CVD is responsible for 26.5% of all pregnancy-related deaths in the United States,5 and women with preexisting heart disease are at increased risk for poor outcomes, including intrauterine growth restriction, low-birth-weight babies, neonatal hypoglycemia, and maternal death.6 Thus, women who have an ICD can expect better pregnancy outcomes compared with women with CVD. Recent guidelines from the American Heart Association focus on the management of cardiovascular conditions in pregnant individuals with pre-existing CVD and advocate for a multidisciplinary team to evaluate and mitigate cardiovascular, maternal, and fetal risk for that individual spanning from preconception to postpartum.1 The guidelines, however, lack specific recommendations for women with preexisting heart disease and an ICD. The basis for this lack of specific recommendations is unclear, as well as whether pregnancy with an ICD is considered a low-risk state. Furthermore, we lack consensus between cardiac and obstetric providers whether the ICD is considered a treatment or additional risk for a CVD event.5

In addition to needing foundational knowledge of the physiological effects of pregnancy on the cardiovascular system, cardio-obstetric team professionals, including cardiac and obstetrical nurses, midwives, and other advanced practice providers, need training and empirically based clinical guidelines for appropriate treatments and interventions for this population.1 The cardio-obstetric team may focus on promoting wellness or mitigating the risks of the underlying heart disease throughout the perinatal period by titrating dosages of antiarrhythmic drugs, stopping medications that may be teratogenic, regularly monitoring the functioning of the ICD, monitoring fetal growth, preparing for birth and parenting, and counseling for healthy lifestyles.1 However, clinicians convey the need for further training in preconception communication to be able to support individuals' considerations surrounding pregnancy, especially their anxiety and fear related to their device.1,3 Pregnancy is a significant life event and developmental milestone of adulthood, so individuals will likely seek guidance from their cardio-obstetric care team given their high-risk pregnancies, complex medical histories, comorbidities, and own past experiences with their ICD.1

This paucity of research, linked to the rarity of this population, precludes empirical evidence needed to develop comprehensive interventions to improve how these individuals consider pregnancy. Given the complexity of navigating pregnancy along with heart disease and an ICD, multidisciplinary efforts are critical in addressing these issues to mitigate the risks of poor outcomes and to support individuals from preconception to postpartum.4 Future research is needed to examine the specific concerns related to ICDs and pregnancy, such as anxiety and fear associated with ICD shocks and how such concerns are further compromised by the advancement of pregnancy and postpartum fatigue. These concerns may then be addressed by the cardio-obstetric team with the goal of promoting overall wellness and improved reproductive health and outcomes.

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