Twin pregnancies in women with heart disease are complicated by high risk of heart failure: data from the EORP ROPAC Registry

Background: Cardiovascular adaptation to pregnancy is more marked in twin than singleton pregnancies and may result in a higher rate of adverse cardiac events in women with heart disease. The objective was to test the hypothesis that women with heart disease and a twin pregnancy have a higher rate of adverse cardiac events. Methods and results: Registry Of Pregnancy And Cardiac disease (ROPAC) is a prospective (2007–2018), global registry of pregnant women with heart disease. Pregnancy outcomes in twin (n=96) were compared with 5643 women with singleton pregnancies. At baseline, twin mothers were older (32.1 vs 29.5 years, p<0.001) and had fewer prior cardiac interventions (43% vs 55.5%, p=0.02). Cardiac diagnosis, New York Heart Association class, modified WHO class, country of origin, prior hypertension, diabetes mellitus, atrial fibrillation and signs of heart failure were similar. The risk of heart failure was significantly higher in twin pregnancies, with 24/96 developing heart failure vs 631/5643 singleton (25 vs 11.2%, p<0.001), but there were no differences in maternal mortality, arrhythmia, endocarditis, thrombosis, dissection, acute coronary syndrome or hospital admission for cardiac reasons. Multivariable analysis of the whole ROPAC population showed that twin pregnancy was a risk factor for heart failure, and that within the twin pregnancies, cardiomyopathy and prior heart failure were risk factors for development of heart failure. Women with valvular or congenital heart disease experienced heart failure during pregnancy, but those with cardiomyopathy experienced it during the peripartum period. Obstetric outcomes were worse in twins. Conclusions: Women with heart disease and a twin pregnancy have twice the risk of heart failure, particularly in those with a prior diagnosis of cardiomyopathy.