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Lazzerini PE, Hamilton RM, Boutjdir M. Editorial: Cardioimmunology: Inflammation and Immunity in Cardiovascular Disease. Front Cardiovasc Med 2019; 6:181. [PMID: 31850376 PMCID: PMC6901670 DOI: 10.3389/fcvm.2019.00181] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Accepted: 11/19/2019] [Indexed: 12/16/2022] Open
Affiliation(s)
- Pietro Enea Lazzerini
- Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Robert Murray Hamilton
- The Labatt Heart Centre and Translational Medicine, The Hospital for Sick Children and University of Toronto, Toronto, ON, Canada
| | - Mohamed Boutjdir
- VA New York Harbor Healthcare System, SUNY Downstate Medical Center, New York, NY, United States.,NYU School of Medicine, New York, NY, United States
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Mohanasundaram K, Govindaraj A. Raccoon eyes in cutaneous neonatal lupus syndrome. Eur J Rheumatol 2019; 7:92-93. [PMID: 31782723 DOI: 10.5152/eurjrheum.2019.19042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Accepted: 06/12/2019] [Indexed: 11/22/2022] Open
Affiliation(s)
- Kavitha Mohanasundaram
- Department of Rheumatology, Saveetha University Saveetha Medical College and Hospital, Chennai, Tamil Nadu, India
| | - Ashok Govindaraj
- Department of Cardiology, Chettinad Hospital and Research Institute, Kanchipuram, Tamil Nuda, India
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Costedoat-Chalumeau N, Morel N, Fischer-Betz R, Levesque K, Maltret A, Khamashta M, Brucato A. Routine repeated echocardiographic monitoring of fetuses exposed to maternal anti-SSA antibodies: time to question the dogma. THE LANCET. RHEUMATOLOGY 2019; 1:e187-e193. [PMID: 38229394 DOI: 10.1016/s2665-9913(19)30069-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Revised: 09/06/2019] [Accepted: 09/09/2019] [Indexed: 11/21/2022]
Abstract
In around 1% of exposed pregnancies, anti-Ro/SSA and anti-La/SSB antibodies lead to congenital heart block, the main feature of neonatal lupus syndrome. As such, echocardiographic screening to detect congenital heart block, done every other week from 16 weeks to at least 24 weeks gestation, is widely recommended for anti-SSA-positive pregnant women. Such screening is now routinely done in many centres worldwide. In this Viewpoint, we call this dogma into question for several reasons. Even if congenital heart block is discovered (which is rare), the usefulness of treatment with fluorinated steroids has not been shown, whereas the associated side-effects are well known. The discovery of congenital heart block very early in the pregnancy does not modify obstetric management, and at least 500 ultrasounds are needed to find one case of congenital heart block, which would ultimately be found by other means. Finally, this screening strategy misses most cases of congenital heart block because most affected women are not known to have anti-SSA antibodies, and thus are not screened. Accordingly, except in the context of research protocols, which are certainly needed and are outside the scope of this Viewpoint, overturning the dogma of routine repeated screenings for congenital heart block could save money and health-care staff time and prevent maternal stress without substantial clinical consequences.
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Affiliation(s)
- Nathalie Costedoat-Chalumeau
- Assistance Publique - Hôpitaux de Paris, Cochin Hospital, Internal Medicine Department, Referral Center for Rare Autoimmune and Systemic Diseases, Paris, France; Centre of Research in Epidemiology and Statistics, Institut National de la Santé et de la Recherche Médicale, Institut National de la Recherche Agronomique, Université de Paris, Paris, France.
| | - Nathalie Morel
- Assistance Publique - Hôpitaux de Paris, Cochin Hospital, Internal Medicine Department, Referral Center for Rare Autoimmune and Systemic Diseases, Paris, France
| | - Rebecca Fischer-Betz
- Policlinic of Rheumatology and Hiller Research Unit Rheumatology, Medical Faculty, Heinrich-Heine-University, Dusseldorf, Germany
| | - Kateri Levesque
- Service Médecine Interne Gynéco-obstétricale, Centre Hospitalier Universitaire Sainte-Justine, Université de Montréal, Canada
| | - Alice Maltret
- Assistance Publique - Hôpitaux de Paris, Service de Cardiologie, Hôpital Necker, Paris, France
| | - Munther Khamashta
- Lupus Clinic Rheumatology Department, Dubai Hospital, Dubai, United Arab Emirates
| | - Antonio Brucato
- Dipartimento di Scienze Biomediche e Cliniche, Università degli Studi di Milano, Ospedale Fatebenefratelli, Milano, Italy
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104
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Wainwright B, Bhan R, Trad C, Cohen R, Saxena A, Buyon J, Izmirly P. Autoimmune-mediated congenital heart block. Best Pract Res Clin Obstet Gynaecol 2019; 64:41-51. [PMID: 31685414 DOI: 10.1016/j.bpobgyn.2019.09.001] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Accepted: 09/09/2019] [Indexed: 12/17/2022]
Abstract
Autoimmune-mediated congenital heart block (CHB) is a severe manifestation of neonatal lupus in which conduction tissues of the fetal heart are damaged. This occurs due to passive transference of maternal anti-SSA/Ro and anti-SSB/La autoantibodies and subsequent inflammation and fibrosis of the atrioventricular (AV) node. Notably, the disease manifests after the fetal heart has structurally developed, ruling out other anatomical abnormalities that could otherwise contribute to the block of conduction. Complete AV block is irreversible and the most common manifestation of CHB, although other cardiac complications such as endocardial fibroelastosis (EFE), dilated cardiomyopathy, and valvular insufficiency have been observed. In this review, we detail the classification, prevalence, pathogenesis, and clinical management recommendations for autoimmune CHB.
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Affiliation(s)
| | - Rohit Bhan
- NYU School of Medicine, New York, NY, USA
| | | | | | | | - Jill Buyon
- NYU School of Medicine, New York, NY, USA
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105
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Autoimmune and inflammatory K+ channelopathies in cardiac arrhythmias: Clinical evidence and molecular mechanisms. Heart Rhythm 2019; 16:1273-1280. [DOI: 10.1016/j.hrthm.2019.02.017] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Indexed: 12/30/2022]
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106
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Sonesson SE, Ambrosi A, Wahren-Herlenius M. Benefits of fetal echocardiographic surveillance in pregnancies at risk of congenital heart block: single-center study of 212 anti-Ro52-positive pregnancies. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2019; 54:87-95. [PMID: 30620419 DOI: 10.1002/uog.20214] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Revised: 11/15/2018] [Accepted: 11/16/2018] [Indexed: 06/09/2023]
Abstract
OBJECTIVES Assuming that autoimmune congenital heart block (CHB) is a progressive disease amenable to therapeutic modulation, we introduced a surveillance program for at-risk pregnancies with the dual aim of investigating if fetal atrioventricular block (AVB) could be detected and treated before becoming complete and irreversible, and to establish the incidence of AVB I, II and III in a large prospective cohort. METHODS This was a prospective study of 212 anti-Ro52 antibody-exposed pregnancies at risk of fetal AVB that were followed weekly between 18 and 24 weeks' gestation at our tertiary fetal cardiology center from 2000 to 2015. A 12-lead electrocardiogram (ECG) was recorded within 1 week after birth. Fetal Doppler atrioventricular (AV) intervals were converted to Z-scores using reference standard values derived from normal pregnancies. Each fetus was represented by the average value of the two recordings, obtained at two consecutive visits, which resulted in the longest AV interval. AV interval values were classified into normal AV conduction (Z-score ≤ 2.0) and three levels of delayed AV conduction: Z-score > 2.0 and ≤ 3.0, Z-score > 3.0 and ≤ 4.0, and Z-score > 4.0. RESULTS AVB II or III developed in 6/204 (2.9%) pregnancies without a CHB history and 1/8 (12.5%) of those with a CHB history. AV intervals > 2 and ≤ 3, > 3 and ≤ 4, and > 4 were detected in 16.0%, 7.5% and 2.8% of cases, respectively, and were related to the PR interval on 185 available ECGs. Three of the five cases with AVB III and one of two cases with 2:1 AVB II developed within 1 week of AV interval Z-score of 1.0, 1.9, 2.8 and 1.9, respectively. Transplacental treatment with betamethasone was associated with restoration of 1:1 AV conduction in the two fetuses with AVB II, with a better long-term result (normal ECG vs AVB I or II) observed in the case in which treatment was started within 1 week after AVB developed. Betamethasone treatment did not reverse AVB III, although a temporary effect on AV conduction was observed in 1/5 cases. Notably, the three cases in which treatment was started within 1 week after AVB III development responded with a higher ventricular rate than the other two cases and did not require pacemaker implantation until a later age (2-5 years vs 1.5-2 months). CONCLUSION Fetal AV interval is a poor predictor of CHB progression, but CHB surveillance still allows detection of fetuses with AVB II or III shortly after its development, allowing for timely treatment initiation and potentially better outcome. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- S-E Sonesson
- Department of Women's and Children's Health, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - A Ambrosi
- Department of Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - M Wahren-Herlenius
- Department of Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
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Congenital heart block: Pace earlier (Childhood) than later (Adulthood). Trends Cardiovasc Med 2019; 30:275-286. [PMID: 31262557 DOI: 10.1016/j.tcm.2019.06.006] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2019] [Revised: 06/16/2019] [Accepted: 06/17/2019] [Indexed: 12/22/2022]
Abstract
Congenital complete heart block (CCHB) occurs in 2-5% of pregnancies with positive anti-Ro/SSA and/or anti-La/SSB antibodies, and has a recurrence rate of 12-25% in a subsequent pregnancy. After trans-placental passage, these autoantibodies attack and destroy the atrioventricular (AV) node in susceptible fetuses with the highest-risk period observed between 16 and 28 weeks' gestational age. Many mothers are asymptomatic carriers, while <1/3 have a preexisting diagnosis of a rheumatic disease. The mortality of CCHB is predominant in utero and in the first months of life, reaching 15-30%. The diagnosis of CCHB can be confirmed by fetal echocardiography before birth and by electrocardiography after birth. Whether early in-utero detection and treatment might prevent or reverse this condition remains controversial. In addition to autoantibody-associated CCHB, there is also an isolated (absent structural heart disease) nonimmune early- or late-onset heart block detected later in childhood that may be associated with specific genetic markers or other pathogenic mechanisms. In isolated immune or non-immune CCHB, cardiac pacemakers are implanted in symptomatic patients, however, data on the natural history of CCHB in the adult life indicate that all patients, even if asymptomatic, should receive a pacemaker when first diagnosed. However, important issues have emerged in these patients wherein life-long conventional right ventricular apical pacing may produce left ventricular dysfunction (pacing-induced cardiomyopathy) necessitating a priori alternate site pacing or subsequent upgrading to biventricular pacing. All these issues are herein reviewed and two algorithms are proposed for diagnosis and management of CCHB in the fetus and in the older individual.
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108
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Michael A, Radwan AA, Ali AK, Abd-Elkariem AY, Shazly SA. Use of antenatal fluorinated corticosteroids in management of congenital heart block: Systematic review and meta-analysis. Eur J Obstet Gynecol Reprod Biol X 2019; 4:100072. [PMID: 31517303 PMCID: PMC6728741 DOI: 10.1016/j.eurox.2019.100072] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Revised: 06/11/2019] [Accepted: 06/12/2019] [Indexed: 01/18/2023] Open
Abstract
Objective To evaluate outcomes of fluorinated corticosteroids, with or without other medications, for treatment of congenital heart block in-utero. Study design A search was conducted through MEDLINE, EMBASE, WEB OF SCIENCE and SCOPUS from inception to October 2017. Only comparative studies are considered eligible. Outcomes include fetal death, downgrade of heart block, neonatal death, need for neonatal pacing, fetal and maternal complications. Random effects model was used. Results Out of 923 articles, 12 studies were eligible. Compared to no treatment, there was no significant difference in incidence of fetal death (OR 1.10, 95%CI 0.65–1.84), neonatal death (OR 0.98, 95%CI 0.41–2.33), or need for pacing (OR 1.46, 95%CI 0.78–2.74). Heart block downgrade was significantly higher in treatment group (9.48%vs.1.76%, OR 3.27, 95%CI 1.23–8.71). Conclusion antenatal fluorinated corticosteroids do not improve fetal/neonatal morbidity or mortality of congenital heart block and are associated with higher incidence of fetal and maternal complications.
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109
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Radin M, Schreiber K, Cuadrado MJ, Cecchi I, Andreoli L, Franceschini F, Caleiro T, Andrade D, Gibbone E, Khamashta M, Buyon J, Izmirly P, Aguirre MA, Benedetto C, Roccatello D, Marozio L, Sciascia S. Pregnancy outcomes in mixed connective tissue disease: a multicentre study. Rheumatology (Oxford) 2019; 58:2000-2008. [DOI: 10.1093/rheumatology/kez141] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Revised: 03/17/2019] [Indexed: 11/14/2022] Open
Abstract
Abstract
Objectives
In this study we aimed to investigate foetal and maternal pregnancy outcomes from a large multicentre cohort of women diagnosed with MCTD and anti-U1RNP antibodies.
Methods
This multicentre retrospective cohort study describes the outcomes of 203 pregnancies in 94 consecutive women ever pregnant who fulfilled the established criteria for MCTD with confirmed U1RNP positivity.
Results
The foetal outcomes in 203 pregnancies were as follows: 146 (71.9%) live births, 38 (18.7%) miscarriages (first trimester pregnancy loss of <12 weeks gestation), 18 (8.9%) stillbirths (pregnancy loss after 20 weeks gestation) and 11 (5.4%) cases with intrauterine growth restriction. Maternal pregnancy outcomes were as follows: 8 (3.9%) developed pre-eclampsia, 2 (0.9%) developed eclampsia, 31 (15.3%) developed gestational hypertension and 3 (1.5%) developed gestational diabetes. Women with MCTD and aPL and pulmonary or muscular involvement had worse foetal outcomes compared with those without. Moreover, we report a case of complete congenital heart block (0.45%) and a case of cutaneous neonatal lupus, both born to a mother with positive isolated anti-U1RNP and negative anti-Ro/SSA antibodies.
Conclusion
In our multicentre cohort, women with MCTD had a live birth rate of 72%. While the true frequency of heart block associated with anti-U1RNP remains to be determined, this study might raise the consideration of echocardiographic surveillance in this setting. Pregnancy counselling should be considered in women with MCTD.
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Affiliation(s)
- Massimo Radin
- Center of Research of Immunopathology and Rare Diseases, Coordinating Center of Piemonte and Valle d’Aosta Network for Rare Diseases, Department of Clinical and Biological Sciences and SCDU Nephrology and Dialysis, S. Giovanni Bosco Hospital and University of Turin, Turin, Italy
| | - Karen Schreiber
- Center of Research of Immunopathology and Rare Diseases, Coordinating Center of Piemonte and Valle d’Aosta Network for Rare Diseases, Department of Clinical and Biological Sciences and SCDU Nephrology and Dialysis, S. Giovanni Bosco Hospital and University of Turin, Turin, Italy
- Center of Research of Immunopathology and Rare Diseases, Coordinating Center of Piemonte and Valle d’Aosta Network for Rare Diseases, Department of Clinical and Biological Sciences and SCDU Nephrology and Dialysis, S. Giovanni Bosco Hospital and University of Turin, Turin, Italy
| | - Maria José Cuadrado
- Center of Research of Immunopathology and Rare Diseases, Coordinating Center of Piemonte and Valle d’Aosta Network for Rare Diseases, Department of Clinical and Biological Sciences and SCDU Nephrology and Dialysis, S. Giovanni Bosco Hospital and University of Turin, Turin, Italy
| | - Irene Cecchi
- Center of Research of Immunopathology and Rare Diseases, Coordinating Center of Piemonte and Valle d’Aosta Network for Rare Diseases, Department of Clinical and Biological Sciences and SCDU Nephrology and Dialysis, S. Giovanni Bosco Hospital and University of Turin, Turin, Italy
| | - Laura Andreoli
- Center of Research of Immunopathology and Rare Diseases, Coordinating Center of Piemonte and Valle d’Aosta Network for Rare Diseases, Department of Clinical and Biological Sciences and SCDU Nephrology and Dialysis, S. Giovanni Bosco Hospital and University of Turin, Turin, Italy
| | - Franco Franceschini
- Center of Research of Immunopathology and Rare Diseases, Coordinating Center of Piemonte and Valle d’Aosta Network for Rare Diseases, Department of Clinical and Biological Sciences and SCDU Nephrology and Dialysis, S. Giovanni Bosco Hospital and University of Turin, Turin, Italy
| | - Teresa Caleiro
- Center of Research of Immunopathology and Rare Diseases, Coordinating Center of Piemonte and Valle d’Aosta Network for Rare Diseases, Department of Clinical and Biological Sciences and SCDU Nephrology and Dialysis, S. Giovanni Bosco Hospital and University of Turin, Turin, Italy
| | - Danieli Andrade
- Center of Research of Immunopathology and Rare Diseases, Coordinating Center of Piemonte and Valle d’Aosta Network for Rare Diseases, Department of Clinical and Biological Sciences and SCDU Nephrology and Dialysis, S. Giovanni Bosco Hospital and University of Turin, Turin, Italy
| | - Elena Gibbone
- Center of Research of Immunopathology and Rare Diseases, Coordinating Center of Piemonte and Valle d’Aosta Network for Rare Diseases, Department of Clinical and Biological Sciences and SCDU Nephrology and Dialysis, S. Giovanni Bosco Hospital and University of Turin, Turin, Italy
| | - Munther Khamashta
- Center of Research of Immunopathology and Rare Diseases, Coordinating Center of Piemonte and Valle d’Aosta Network for Rare Diseases, Department of Clinical and Biological Sciences and SCDU Nephrology and Dialysis, S. Giovanni Bosco Hospital and University of Turin, Turin, Italy
| | - Jill Buyon
- Center of Research of Immunopathology and Rare Diseases, Coordinating Center of Piemonte and Valle d’Aosta Network for Rare Diseases, Department of Clinical and Biological Sciences and SCDU Nephrology and Dialysis, S. Giovanni Bosco Hospital and University of Turin, Turin, Italy
| | - Peter Izmirly
- Center of Research of Immunopathology and Rare Diseases, Coordinating Center of Piemonte and Valle d’Aosta Network for Rare Diseases, Department of Clinical and Biological Sciences and SCDU Nephrology and Dialysis, S. Giovanni Bosco Hospital and University of Turin, Turin, Italy
| | - Maria Angeles Aguirre
- Center of Research of Immunopathology and Rare Diseases, Coordinating Center of Piemonte and Valle d’Aosta Network for Rare Diseases, Department of Clinical and Biological Sciences and SCDU Nephrology and Dialysis, S. Giovanni Bosco Hospital and University of Turin, Turin, Italy
| | - Chiara Benedetto
- Center of Research of Immunopathology and Rare Diseases, Coordinating Center of Piemonte and Valle d’Aosta Network for Rare Diseases, Department of Clinical and Biological Sciences and SCDU Nephrology and Dialysis, S. Giovanni Bosco Hospital and University of Turin, Turin, Italy
| | - Dario Roccatello
- Center of Research of Immunopathology and Rare Diseases, Coordinating Center of Piemonte and Valle d’Aosta Network for Rare Diseases, Department of Clinical and Biological Sciences and SCDU Nephrology and Dialysis, S. Giovanni Bosco Hospital and University of Turin, Turin, Italy
| | - Luca Marozio
- Center of Research of Immunopathology and Rare Diseases, Coordinating Center of Piemonte and Valle d’Aosta Network for Rare Diseases, Department of Clinical and Biological Sciences and SCDU Nephrology and Dialysis, S. Giovanni Bosco Hospital and University of Turin, Turin, Italy
| | - Savino Sciascia
- Center of Research of Immunopathology and Rare Diseases, Coordinating Center of Piemonte and Valle d’Aosta Network for Rare Diseases, Department of Clinical and Biological Sciences and SCDU Nephrology and Dialysis, S. Giovanni Bosco Hospital and University of Turin, Turin, Italy
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Envain F, Vandendriessche D, Mehros W, Houfflin-Debarge V, Garabedian C, Rakza T. Discordant immune complete heart block and growth restriction in dichorionic twin pregnancy with permanent pacemaker implantation of an 1140 g neonate. J Gynecol Obstet Hum Reprod 2019; 48:699-701. [PMID: 31075433 DOI: 10.1016/j.jogoh.2019.05.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Revised: 04/16/2019] [Accepted: 05/02/2019] [Indexed: 10/26/2022]
Abstract
Fetal atrioventricular block is a rare pathology, mostly due to placental transmission of maternal SSA/Ro and SSB/La antibodies, and can lead to severe fetal or neonatal outcomes. We report a case of dichorionic, diamniotic twin pregnancy, with maternal SSA/Ro antibodies. Isolated complete atrioventricular block was diagnosed at 23 weeks in one fetus (Twin A), while the second fetus (Twin B) remained in normal sinus rhythm. Severe asymmetric intrauterine growth restriction occurred in Twin A. Delivery was by caesarean section at 32 + 2 weeks. Neonatal permanent pacemaker was inserted on the first day after birth in 1140 g neonate. Discordant heart block in twin pregnancy has already been reported in a few dichorionic pregnancies, but the pathway of discordant disease expression remains unclear. Extraction decision is a dilemma between cardiac failure prevention and prematurity associated twin morbidity. This case shows a successful pacing in a very low birth weight neonate.
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Affiliation(s)
- François Envain
- Hôpital Jeanne de Flandre, clinique d'obstétrique, CHU de Lille, 59037 Lille Cedex, France.
| | - David Vandendriessche
- Hôpital Jeanne de Flandre, clinique d'obstétrique, CHU de Lille, 59037 Lille Cedex, France
| | - Wala Mehros
- Hôpital Jeanne de Flandre, clinique d'obstétrique, CHU de Lille, 59037 Lille Cedex, France
| | | | - Charles Garabedian
- Hôpital Jeanne de Flandre, clinique d'obstétrique, CHU de Lille, 59037 Lille Cedex, France
| | - Thameur Rakza
- Hôpital Jeanne de Flandre, clinique d'obstétrique, CHU de Lille, 59037 Lille Cedex, France; Hôpital Jeanne de Flandre, Service de pédiatrie en maternité, CHU de Lille 59037, Lille Cedex, France; Hôpital Jeanne de Flandre, Service de cardiologie pédiatrique et foetale, France
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111
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Qu YS, Lazzerini PE, Capecchi PL, Laghi-Pasini F, El Sherif N, Boutjdir M. Autoimmune Calcium Channelopathies and Cardiac Electrical Abnormalities. Front Cardiovasc Med 2019; 6:54. [PMID: 31119135 PMCID: PMC6507622 DOI: 10.3389/fcvm.2019.00054] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Accepted: 04/16/2019] [Indexed: 12/24/2022] Open
Abstract
Patients with autoimmune diseases are at increased risk for developing cardiovascular diseases, and abnormal electrocardiographic findings are common. Voltage-gated calcium channels play a major role in the cardiovascular system and regulate cardiac excitability and contractility. Particularly, by virtue of their localization and expression in the heart, calcium channels modulate pace making at the sinus node, conduction at the atrioventricular node and cardiac repolarization in the working myocardium. Consequently, emerging evidence suggests that calcium channels are targets to autoantibodies in autoimmune diseases. Autoimmune-associated cardiac calcium channelopathies have been recognized in both sinus node dysfunction atrioventricular block in patients positive for anti-Ro/La antibodies, and ventricular arrhythmias in patients with dilated cardiomyopathy. In this review, we discuss mechanisms of autoimmune-associated calcium channelopathies and their relationship with the development of cardiac electrical abnormalities.
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Affiliation(s)
- Yongxia Sarah Qu
- Department of Cardiology, New York Presbyterian Brooklyn Methodist Hospital, Brooklyn, NY, United States.,VA New York Harbor Healthcare System and State University of New York Downstate Medical Center, Brooklyn, NY, United States
| | - Pietro Enea Lazzerini
- Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Pier Leopoldo Capecchi
- Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Franco Laghi-Pasini
- Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Nabil El Sherif
- VA New York Harbor Healthcare System and State University of New York Downstate Medical Center, Brooklyn, NY, United States
| | - Mohamed Boutjdir
- VA New York Harbor Healthcare System and State University of New York Downstate Medical Center, Brooklyn, NY, United States.,NYU School of Medicine, New York, NY, United States
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Larosa M, Del Ross T, Calligaro A, Favaro M, Zanatta E, Iaccarino L, Doria A. Clinical outcomes and predictors of maternal and fetal complications in pregnancies of patients with systemic lupus erythematosus. Expert Rev Clin Immunol 2019; 15:617-627. [PMID: 30933534 DOI: 10.1080/1744666x.2019.1601557] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Systemic Lupus Erythematosus (SLE) mostly affects women during their childbearing years. Fertility is preserved in SLE patients, but pregnancy is often characterized by a high number of maternal and fetal complications. Adverse pregnancy outcomes (APO) have been widely studied over the last decades and several investigators have focused on the potential clinical and serological predictors of maternal and fetal complications. Areas covered: In this review, we analyzed maternal and fetal complications in SLE patients and predictors of APO. Active disease in the 6 months before conception, lupus nephritis, anti-phospholipid (aPL), anti-SSA/Ro and/or anti-SSB/La antibodies have been identified as the most consistent predictors of maternal and fetal complications to date. However, molecular mechanisms and underlying immunological pathways involved in APO still remain elusive. Expert opinion: Difficulties in assessing prevalence and predictors of APO in SLE patients are due to lack of uniformity in the definitions and methods used in the different studies. In addition, some maternal and fetal complications are difficult to diagnose and to differentiate from each other. Preconception counseling is paramount to prevent APO, and it should consider four main factors: disease activity/lupus nephritis, safety of drugs, aPL, anti-SSA/Ro, and/or anti-SSB/La antibodies.
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Affiliation(s)
- Maddalena Larosa
- a Department of Medicine - DIMED, Division of Rheumatology , University of Padova , Padova , Italy
| | - Teresa Del Ross
- a Department of Medicine - DIMED, Division of Rheumatology , University of Padova , Padova , Italy
| | - Antonia Calligaro
- a Department of Medicine - DIMED, Division of Rheumatology , University of Padova , Padova , Italy
| | - Maria Favaro
- a Department of Medicine - DIMED, Division of Rheumatology , University of Padova , Padova , Italy
| | - Elisabetta Zanatta
- a Department of Medicine - DIMED, Division of Rheumatology , University of Padova , Padova , Italy
| | - Luca Iaccarino
- a Department of Medicine - DIMED, Division of Rheumatology , University of Padova , Padova , Italy
| | - Andrea Doria
- a Department of Medicine - DIMED, Division of Rheumatology , University of Padova , Padova , Italy
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Robbins A, Hentzien M, Toquet S, Didier K, Servettaz A, Pham BN, Giusti D. Diagnostic Utility of Separate Anti-Ro60 and Anti-Ro52/TRIM21 Antibody Detection in Autoimmune Diseases. Front Immunol 2019; 10:444. [PMID: 30915082 PMCID: PMC6423153 DOI: 10.3389/fimmu.2019.00444] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Accepted: 02/19/2019] [Indexed: 01/09/2023] Open
Abstract
Anti-SS-A antibodies are often sought for in autoimmune diseases diagnosis. Two different target proteins have actually been identified: Ro52 and Ro60. Clinical and immunological associations seem different depending on anti-Ro52 or anti-Ro60 antibodies presence. However, due to a heterogeneous presentation in the literature, some immunology laboratories in France have stopped providing anti-Ro52 antibody findings. We report here a new hospital study designed to determine the diagnostic utility of the separate detection of anti-Ro52 and anti-Ro60 antibodies. We conducted a retrospective, observational study, including every adult patient with positive antinuclear antibodies (ANA) tested in our immunology laboratory, and associated with anti-Ro52 and/or anti-Ro60 antibodies, between 2011 and 2014. Out of 13032 sera tested for ANA, 399 adults had antibodies to Ro52 and/or Ro60; 81.7% were female, with a mean age of 54.5 ± 17.0 years. Anti-Ro52 antibodies were found in 75.7% of the patients and anti-Ro60 antibodies in 56.9%. Among them, 43.1% were classified in the Ro52 + Ro60- group, 32.6% in the Ro52 + Ro60 + group and 24.3% in the Ro52-Ro60+ group. In the Ro52-Ro60+ group, systemic lupus was the most frequent diagnosis (48.5%), with a possible association with antiphospholipid antibodies (anti-cardiolipin antibodies: OR 2.5 (CI95 [1.0-5.0], p = 0.05) and lupus anticoagulant {OR 3.6 (CI95 [1.10-10.0] p = 0.02)}. In the Ro52+Ro60+, primary Sjögren Syndrome was the most likely (OR 4.2 95% CI [2.1-8.3] p < 10-4), especially in patients Ro52+Ro60+La+. Patients with isolated anti-Ro52 had a wider variety of diseases associated, but among auto-immune diseases they were more prone to inflammatory myositis (OR 10.5 [1.4-81.7], p = 0.02) and inflammatory rheumatism (OR 4.6 [1.6-13.8], p = 0.006) in contrast to systemic lupus (OR 0.2 [0.1-0.3], p < 10-4) or primary Sjögren's syndrome (OR 0.1 [0.06-0.2], p < 10-4). We therefore suggest that, when anti-ENA antibodies are prescribed, it should include separate anti-Ro52 and anti-Ro60 antibodies determination. To go even further, we would like to suggest a change in ENA nomenclature to avoid confusion, abandoning the anti-SS-A label in favor of the anti-Ro52/TRIM21 or anti-Ro60 antibody for a clearer designation.
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Affiliation(s)
- Ailsa Robbins
- Department of Internal Medicine, Infectious Diseases, and Clinical Immunology, Robert Debré Hospital, Reims University Hospitals, Reims, France
| | - Maxime Hentzien
- Department of Internal Medicine, Infectious Diseases, and Clinical Immunology, Robert Debré Hospital, Reims University Hospitals, Reims, France
| | - Segolene Toquet
- Department of Internal Medicine, Robert Debré Hospital, Reims University Hospitals, Reims, France
| | - Kevin Didier
- Department of Internal Medicine, Infectious Diseases, and Clinical Immunology, Robert Debré Hospital, Reims University Hospitals, Reims, France.,Laboratory of Dermatology, Faculty of Medicine, University of Reims Champagne-Ardenne, Reims, France
| | - Amelie Servettaz
- Department of Internal Medicine, Infectious Diseases, and Clinical Immunology, Robert Debré Hospital, Reims University Hospitals, Reims, France.,Laboratory of Dermatology, Faculty of Medicine, University of Reims Champagne-Ardenne, Reims, France
| | - Bach-Nga Pham
- Laboratory of Dermatology, Faculty of Medicine, University of Reims Champagne-Ardenne, Reims, France.,Laboratory of Immunology, Reims University Hospital, University of Reims Champagne-Ardenne, Reims, France
| | - Delphine Giusti
- Laboratory of Dermatology, Faculty of Medicine, University of Reims Champagne-Ardenne, Reims, France.,Laboratory of Immunology, Reims University Hospital, University of Reims Champagne-Ardenne, Reims, France
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114
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Systemic Lupus Erythematosus and Pregnancy: A Brief Review. J Obstet Gynaecol India 2019; 69:104-109. [PMID: 30956462 DOI: 10.1007/s13224-019-01212-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Accepted: 02/21/2019] [Indexed: 01/21/2023] Open
Abstract
Systemic lupus erythematosus is a chronic multisystemic autoimmune disease that predominantly affects young women of childbearing age group. There is a complex immunologic interplay during pregnancy in patients with systemic lupus erythematosus. The pregnancy has direct impact on the disease where an increased rate of flares is noted, and lupus leads to increased risk of hypertensive diseases of pregnancy, preterm birth as well as miscarriages, particularly those with antiphospholipid antibodies. Neonates born to patients with lupus are at increased risk of neonatal lupus as well as heart block if born to patients with positive SSA/SSB. Despite the increased risk of morbidity, recent data suggest improved outcomes in pregnant patients with lupus. A multidisciplinary approach with careful monitoring of pregnancy and lupus could reduce adverse outcomes in these patients. This requires careful pregnancy planning, defining the clinical and serologic involvement of lupus, careful monitoring the patient for adverse pregnancy outcome as well as lupus flares and comprehensive understanding of the drugs that can be safely used in pregnancy. Fetuses should be carefully monitored for heart and neonates for neonatal lupus. Hydroxychloroquine, azathioprine and corticosteroids can be used during pregnancy and may reduce the risk of adverse outcomes. Similarly, appropriate therapy needs to be instituted for hypertensive diseases in pregnancy. Anticoagulant therapy may be necessary for patients with antiphospholipid syndrome.
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115
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Kumthekar RN, Opfermann JD, Mass P, Clark BC, Moak JP, Sherwin ED, Whitman T, Marshall M, Berul CI. Minimally invasive percutaneous epicardial placement of a prototype miniature pacemaker with a leadlet under direct visualization: A feasibility study in an infant porcine model. Heart Rhythm 2019; 16:1261-1267. [PMID: 30826423 DOI: 10.1016/j.hrthm.2019.02.033] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Indexed: 11/17/2022]
Abstract
BACKGROUND Pacemaker implantation in infants is limited to epicardial lead placement and an abdominal generator pocket. We propose a minimally invasive solution using a prototype miniature pacemaker with a steroid-eluting leadlet that can affix against the epicardium under thoracoscopy. OBJECTIVE The purpose of this study was to evaluate the safety and feasibility of acute implantation of a prototype miniature pacemaker in an infant porcine model. METHODS A self-anchoring 2-channel access port was inserted into a 1-cm incision left of the subxiphoid space. A rigid thoracoscope with variable viewing angle was inserted through the main channel to visualize the heart under insufflation. An 18-G needle through the second channel accessed the pericardial space, which was secured with a 7-F sheath. The leadlet was affixed against the epicardium using a distal helical side-biting electrode. The sheath, thoracoscope, and port were removed, and the pacemaker was tucked into the incision. Ventricular sensing, lead impedances, and capture thresholds were measured. RESULTS Twelve piglets (weight 4.8 ± 1.9 kg) had successful device implantation. The median time from incision to leadlet fixation was 21 minutes (interquartile range [IQR] 18-31 minutes). The median lead impedance was 510 Ω (IQR 495-620 Ω). The median R-wave amplitude was 5.7 mV (IQR 4.2-7.0 mV). The median capture threshold was 1.63 V (IQR 1.32-2.97 V) at 0.4 ms pulse width and 1.50 V (IQR 1.16-2.38 V) at 1.0 ms pulse width. There were no complications. CONCLUSION Minimally invasive epicardial placement of a prototype miniature pacemaker under thoracoscopy was safe and avoided open chest surgery and creation of an abdominal generator pocket.
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Affiliation(s)
- Rohan N Kumthekar
- Division of Cardiology, Children's National Health System, Washington, District of Columbia
| | - Justin D Opfermann
- Sheikh Zayed Institute for Pediatric Surgical Innovation, Washington, District of Columbia
| | - Paige Mass
- Sheikh Zayed Institute for Pediatric Surgical Innovation, Washington, District of Columbia
| | - Bradley C Clark
- Division of Cardiology, Children's Hospital at Montefiore, Bronx, New York
| | - Jeffrey P Moak
- Division of Cardiology, Children's National Health System, Washington, District of Columbia; Department of Pediatrics, George Washington University School of Medicine, Washington, District of Columbia
| | - Elizabeth D Sherwin
- Division of Cardiology, Children's National Health System, Washington, District of Columbia; Department of Pediatrics, George Washington University School of Medicine, Washington, District of Columbia
| | | | | | - Charles I Berul
- Division of Cardiology, Children's National Health System, Washington, District of Columbia; Department of Pediatrics, George Washington University School of Medicine, Washington, District of Columbia.
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116
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Pruetz JD, Miller JC, Loeb GE, Silka MJ, Bar-Cohen Y, Chmait RH. Prenatal diagnosis and management of congenital complete heart block. Birth Defects Res 2019; 111:380-388. [PMID: 30821931 DOI: 10.1002/bdr2.1459] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Accepted: 01/04/2019] [Indexed: 01/03/2023]
Abstract
Congenital complete heart block (CCHB) is a life-threatening medical condition in the unborn fetus with insufficiently validated prenatal interventions. Maternal administration of medications aimed at decreasing the immune response in the fetus and beta-agonists intended to increase fetal cardiac output have shown only marginal benefits. Anti-inflammatory therapies cannot reverse CCHB, but may decrease myocarditis and improve heart function. Advances in prenatal diagnosis and use of strict surveillance protocols for delivery timing have demonstrated small improvements in morbidity and mortality. Ambulatory surveillance programs and wearable fetal heart rate monitors may afford early identification of evolving fetal heart block allowing for emergent treatment. There is also preliminary data suggesting a roll for prevention of CCHB with hydroxychloroquine, but the efficacy and safety is still being studied. To date, intrauterine fetal pacing has not been successful due to the high-risk invasive placement techniques and potential problems with lead dislodgement. The development of a fully implantable micropacemaker via a minimally invasive approach has the potential to pace fetal patients with CCHB and thus delay delivery and allow fetal hydrops to resolve. The challenge remains to establish accepted prenatal interventions capable of successfully managing CCHB in utero until postnatal pacemaker placement is successfully achieved.
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Affiliation(s)
- Jay D Pruetz
- Department of Pediatrics/Division of Pediatric Cardiology, Children's Hospital Los Angeles, Los Angeles, California.,Keck School of Medicine of USC, Los Angeles, California
| | - Jennifer C Miller
- Department of Pediatrics/Division of Pediatric Cardiology, Children's Hospital Los Angeles, Los Angeles, California.,Keck School of Medicine of USC, Los Angeles, California
| | - Gerald E Loeb
- Department of Biomedical Engineering, University of Southern California (USC), Los Angeles, California
| | - Michael J Silka
- Department of Pediatrics/Division of Pediatric Cardiology, Children's Hospital Los Angeles, Los Angeles, California.,Keck School of Medicine of USC, Los Angeles, California
| | - Yaniv Bar-Cohen
- Department of Pediatrics/Division of Pediatric Cardiology, Children's Hospital Los Angeles, Los Angeles, California.,Keck School of Medicine of USC, Los Angeles, California
| | - Ramen H Chmait
- Department of Obstetrics and Gynecology/Division of Maternal Fetal Medicine, Keck School of Medicine of USC, Los Angeles, California
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Fredi M, Andreoli L, Bacco B, Bertero T, Bortoluzzi A, Breda S, Cappa V, Ceccarelli F, Cimaz R, De Vita S, Di Poi E, Elefante E, Franceschini F, Gerosa M, Govoni M, Hoxha A, Lojacono A, Marozio L, Mathieu A, Meroni PL, Minniti A, Mosca M, Muscarà M, Padovan M, Piga M, Priori R, Ramoni V, Ruffatti A, Tani C, Tonello M, Trespidi L, Zatti S, Calza S, Tincani A, Brucato A. First Report of the Italian Registry on Immune-Mediated Congenital Heart Block (Lu.Ne Registry). Front Cardiovasc Med 2019; 6:11. [PMID: 30873413 PMCID: PMC6404544 DOI: 10.3389/fcvm.2019.00011] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Accepted: 01/31/2019] [Indexed: 12/12/2022] Open
Abstract
Objective: Neonatal Lupus (NL) is a rare syndrome caused by placental transfer of maternal anti-SSA/Ro and anti-La/SSB autoantibodies to the fetus. The rarity of this condition requires the establishment of multidisciplinary registries in order to improve our knowledge. Method: Inclusion criteria in this retrospective study were the maternal confirmed positivity for anti-SSA/Ro and/or anti-SSB/La antibodies, and the presence of II or III degree congenital heart block (CHB) in utero or neonatal period (up to 27 days after birth). Result: Eighty-nine cases of CHB were observed in 85 women with 88 pregnancies that occurred between 1969 and 2017. CHB was mostly detected in utero (84 cases, 94.2%), while five cases were observed in the neonatal period. A permanent pacemaker was implanted in 51 of 73 children born alive (69.8), whereas global mortality rate was 25.8% (23 cases): 16 in utero, five perinatal, and two during childhood. By univariate analysis, factors associated with fetal death were pleural effusion (p = 0.005, OR > 100; CI 95% 2.88->100 and hydrops (p = 0.003, OR = 14.09; CI 95% 2.01–122). Fluorinated steroids (FS) were administered in 71.4% pregnancies, and its use was not associated with better survival. Some centers treated all cases with fluorinated steroids and some centers did not treat any case. CHB was initially incomplete in 24 fetuses, and of them five cases of II degree block reverted to a lower degree block after treatments. Recurrence rate in subsequent pregnancies was 17.6% (3 out of 17). A prophylactic treatment was introduced in 10 of these 16 subsequent (58.8%) pregnancies, mostly with FS or high dose intravenous immunoglobulins. Conclusion: This is the first report from the Italian Registry of neonatal lupus/CHB. The live birth rate was nearly 80%, with nearly two thirds of the children requiring the implantation of a pacemaker. The management of fetuses diagnosed with CHB was heterogeneous across Italian Centers. The registry at present is mainly rheumatological, but involvement of pediatric cardiologists and gynecologists is planned.
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Affiliation(s)
- Micaela Fredi
- Rheumatology and Clinical Immunology Unit, Department of Clinical and Experimental Science, ASST Spedali Civili, University of Brescia, Brescia, Italy
| | - Laura Andreoli
- Rheumatology and Clinical Immunology Unit, Department of Clinical and Experimental Science, ASST Spedali Civili, University of Brescia, Brescia, Italy
| | - Beatrice Bacco
- S.S.d.D.U. Immunologia, Allergologia, A.O. Ordine Maurziano di Torino, Torino, Italy
| | - Tiziana Bertero
- S.S.d.D.U. Immunologia, Allergologia, A.O. Ordine Maurziano di Torino, Torino, Italy
| | - Alessandra Bortoluzzi
- UO e Sezione di Reumatologia, Dipartimento di Scienze Mediche, Universita' degli Studi di Ferrara, Cona, Italy
| | - Silvia Breda
- Struttura Complessa Medicina Interna, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Veronica Cappa
- Unit of Biostatistics, Biomathematics, and Bioinformatics, Department of Molecular and Translational Medicine, University of Brescia, Brescia, Italy
| | - Fulvia Ceccarelli
- UO Complessa Reumatologia, Policlinico Umberto I- University La Sapienza, Rome, Italy
| | - Rolando Cimaz
- Anna Meyer Children's Hospital, University of Firenze, Firenze, Italy
| | - Salvatore De Vita
- Clinica di Reumatologia, Azienda Sanitaria Universitaria Integrata di Udine, Udine, Italy
| | - Emma Di Poi
- Clinica di Reumatologia, Azienda Sanitaria Universitaria Integrata di Udine, Udine, Italy
| | - Elena Elefante
- UO Reumatologia, Dipartimento di Medicina Clinica e Sperimentale, Universita' di Pisa, Pisa, Italy
| | - Franco Franceschini
- Rheumatology and Clinical Immunology Unit, Department of Clinical and Experimental Science, ASST Spedali Civili, University of Brescia, Brescia, Italy
| | - Maria Gerosa
- Istituto Ortopedico Gaetano Pini, University of Milan, Milan, Italy
| | - Marcello Govoni
- UO e Sezione di Reumatologia, Dipartimento di Scienze Mediche, Universita' degli Studi di Ferrara, Cona, Italy
| | - Ariela Hoxha
- Unità di Reumatologia, Dipartimento di Medicina, Università di Padova, Padova, Italy
| | - Andrea Lojacono
- Department of Obstetrics and Gynecology, ASST Spedali Civili and University, Brescia, Italy
| | - Luca Marozio
- Ginecologia e Ostetricia 1, Dipartimento di Scienze Chirurgiche, Università di Torino, Turin, Italy
| | - Alessandro Mathieu
- Cattedra e Struttura Complessa di Reumatologia, Universita' degli Studi e AOU di Cagliari, Cagliari, Italy
| | - Pier Luigi Meroni
- Immunorheumatology Research Laboratory, Istituto Auxologico Italiano, Milan, Italy
| | - Antonina Minniti
- UO Complessa Reumatologia, Policlinico Umberto I- University La Sapienza, Rome, Italy
| | - Marta Mosca
- UO Reumatologia, Dipartimento di Medicina Clinica e Sperimentale, Universita' di Pisa, Pisa, Italy
| | | | - Melissa Padovan
- UO e Sezione di Reumatologia, Dipartimento di Scienze Mediche, Universita' degli Studi di Ferrara, Cona, Italy
| | - Matteo Piga
- Cattedra e Struttura Complessa di Reumatologia, Universita' degli Studi e AOU di Cagliari, Cagliari, Italy
| | - Roberta Priori
- UO Complessa Reumatologia, Policlinico Umberto I- University La Sapienza, Rome, Italy
| | - Véronique Ramoni
- Rheumatology, IRCCS Policlinico San Matteo Foundation, University of Pavia, Padova, Italy
| | - Amelia Ruffatti
- Unità di Reumatologia, Dipartimento di Medicina, Università di Padova, Padova, Italy
| | - Chiara Tani
- UO Reumatologia, Dipartimento di Medicina Clinica e Sperimentale, Universita' di Pisa, Pisa, Italy
| | - Marta Tonello
- Unità di Reumatologia, Dipartimento di Medicina, Università di Padova, Padova, Italy
| | - Laura Trespidi
- Dipartimento per la Salute della Donna, Bambino e Neonato, Fondazione Ospedale Maggiore, Milan, Italy
| | - Sonia Zatti
- Department of Obstetrics and Gynecology, ASST Spedali Civili and University, Brescia, Italy
| | - Stefano Calza
- Unit of Biostatistics, Biomathematics, and Bioinformatics, Department of Molecular and Translational Medicine, University of Brescia, Brescia, Italy
| | - Angela Tincani
- Rheumatology and Clinical Immunology Unit, Department of Clinical and Experimental Science, ASST Spedali Civili, University of Brescia, Brescia, Italy
| | - Antonio Brucato
- Struttura Complessa Medicina Interna, ASST Papa Giovanni XXIII, Bergamo, Italy.,Dipartimento di Scienze Biomediche e Cliniche "Sacco", Università degli Studi di Milano, Milan, Italy
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Mofors J, Eliasson H, Ambrosi A, Salomonsson S, Skog A, Fored M, Ekbom A, Bergman G, Sonesson SE, Wahren-Herlenius M. Comorbidity and long-term outcome in patients with congenital heart block and their siblings exposed to Ro/SSA autoantibodies in utero. Ann Rheum Dis 2019; 78:696-703. [DOI: 10.1136/annrheumdis-2018-214406] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Revised: 01/26/2019] [Accepted: 02/01/2019] [Indexed: 11/04/2022]
Abstract
ObjectiveCongenital heart block (CHB) may develop in fetuses of Ro/SSA autoantibody-positive women. Given the rarity of CHB, information on comorbidity and complications later in life is difficult to systematically collect for large groups of patients. We therefore used nation-wide healthcare registers to investigate comorbidity and outcomes in patients with CHB and their siblings.MethodsData from patients with CHB (n= 119) and their siblings (n= 128), all born to anti-Ro/SSA-positive mothers, and from matched healthy controls (n= 1,190) and their siblings (n= 1,071), were retrieved from the Swedish National Patient Register. Analyses were performed by Cox proportional hazard modelling.ResultsIndividuals with CHB had a significantly increased risk of cardiovascular comorbidity, with cardiomyopathy and/or heart failure observed in 20 (16.8%) patients versus 3 (0.3%) controls, yielding a HR of 70.0 (95% CI 20.8 to 235.4), and with a HR for cerebral infarction of 39.9 (95% CI 4.5 to 357.3). Patients with CHB also had a higher risk of infections. Pacemaker treatment was associated with a decreased risk of cerebral infarction but increased risks of cardiomyopathy/heart failure and infection. The risk of systemic connective tissue disorder was also increased in patients with CHB (HR 11.8, 95% CI 4.0 to 11.8), and both patients with CHB and their siblings had an increased risk to develop any of 15 common autoimmune conditions (HR 5.7, 95% CI 2.83 to 11.69 and 3.6, 95% CI 1.7 to 8.0, respectively).ConclusionsThe data indicate an increased risk of several cardiovascular, infectious and autoimmune diseases in patients with CHB, with the latter risk shared by their siblings.
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119
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Wang B, Hu S, Shi D, Bing Z, Li Z. Arrhythmia and/or Cardiomyopathy Related to Maternal Autoantibodies: Descriptive Analysis of a Series of 16 Cases From a Single Center. Front Pediatr 2019; 7:465. [PMID: 31824893 PMCID: PMC6879546 DOI: 10.3389/fped.2019.00465] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2019] [Accepted: 10/24/2019] [Indexed: 11/13/2022] Open
Abstract
Objective: To describe the clinical characteristics of maternal autoantibody-mediated arrhythmia and/or cardiomyopathy, and to explore the therapeutic role of glucocorticoids in these diseases. Methods: This was a retrospective observational study of 2 fetuses and 14 children who presented with autoantibody-mediated arrhythmia and/or cardiomyopathy in our hospital from September 2010 to December 2018. Results: In total, 16 patients were identified, including 2 fetuses, and 14 children. One mother suffered from Sjogren's syndrome, two suffered from systemic lupus erythematosus (SLE), and the remaining 13 were asymptomatic carriers of autoantibodies. Two fetuses were diagnosed with complete congenital heart block (CHB) and had mean heart rates of 45 and 50 bpm. In the 14 surviving children, third-degree CHB was detected in 4 children, second- to third-degree CHB in 4, corrected QT interval (QTc) prolongation in 1, atrioventricular dissociation, and junctional ectopic tachycardia in 1, complete left bundle branch block (CLBBB) with dilated cardiomyopathy (DCM) in 3, and endocardial fibroelastosis (EFE) in 1. All of the 14 surviving babies received intravenous immunoglobulin and glucocorticoids. None of the children received pacemaker implantation. During the follow-up, one 3-month-old girl who had complete CHB, DCM, and Torsades de pointes almost recovered after the administration of prednisone for ~8 years. Three cases with complete CHB had no improvement after 3-5 years of follow-up. One case with EFE and three cases with CLBBB and DCM were in stable condition now. Children with QTc prolongation and junctional ectopic tachycardia returned to a regular rhythm. Conclusions: Autoantibody-mediated arrhythmias and/or cardiomyopathy are severe complications related to maternal autoantibodies, and the administration of steroid may be beneficial in reversing complete CHB.
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Affiliation(s)
- Benzhen Wang
- School of Medicine, Shandong University, Jinan, China.,Heart Center, Qingdao Women and Children's Hospital, Affiliated to Qingdao University, Qingdao, China
| | - Sujuan Hu
- Department of Pediatrics, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Degong Shi
- Department of Pediatrics, The Traditional Chinese Medical Hospital of Huangdao District, Qingdao, China
| | - Zhen Bing
- Heart Center, Qingdao Women and Children's Hospital, Affiliated to Qingdao University, Qingdao, China
| | - Zipu Li
- School of Medicine, Shandong University, Jinan, China.,Heart Center, Qingdao Women and Children's Hospital, Affiliated to Qingdao University, Qingdao, China
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Sammaritano LR, Bermas BL. Management of pregnancy and lactation. Best Pract Res Clin Rheumatol 2018; 32:750-766. [DOI: 10.1016/j.berh.2019.03.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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121
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Lazzerini PE, Capecchi PL, El‐Sherif N, Laghi‐Pasini F, Boutjdir M. Emerging Arrhythmic Risk of Autoimmune and Inflammatory Cardiac Channelopathies. J Am Heart Assoc 2018; 7:e010595. [PMID: 30571503 PMCID: PMC6404431 DOI: 10.1161/jaha.118.010595] [Citation(s) in RCA: 67] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
| | | | - Nabil El‐Sherif
- Veterans Affairs New York Harbor Healthcare SystemState University of New York Downstate Medical CenterNew YorkNY
| | - Franco Laghi‐Pasini
- Department of Medical Sciences, Surgery and NeurosciencesUniversity of SienaItaly
| | - Mohamed Boutjdir
- Veterans Affairs New York Harbor Healthcare SystemState University of New York Downstate Medical CenterNew YorkNY
- New York University School of MedicineNew YorkNY
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122
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Jordan N. Management of pregnancy in systemic lupus erythematosus: What a GP should know. Lupus 2018; 27:40-43. [DOI: 10.1177/0961203318801746] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- N Jordan
- Rheumatology Department, Addenbrookes Hospital, Cambridge, UK and The London Lupus Centre, London Bridge Hospital, London, UK
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Stefanski AL, Tomiak C, Pleyer U, Dietrich T, Burmester GR, Dörner T. The Diagnosis and Treatment of Sjögren's Syndrome. DEUTSCHES ARZTEBLATT INTERNATIONAL 2018; 114:354-361. [PMID: 28610655 DOI: 10.3238/arztebl.2017.0354] [Citation(s) in RCA: 92] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Revised: 12/13/2016] [Accepted: 03/14/2017] [Indexed: 12/13/2022]
Abstract
BACKGROUND Sjögren's syndrome is one of the more common inflammatory rheumatological diseases, with a prevalence of at least 0.4% in Germany. METHODS This review is based on pertinent articles retrieved by a selective search in PubMed. Special attention is drawn to updated classification criteria and current treatment recommendations. RESULTS Sjögren's syndrome has a wide variety of presentations, ranging from the local involvement of exocrine glands with keratoconjunctivitis sicca and xerostomia (the leading signs of the disease) to the systemic, extraglandular involvement of multiple organs. Fatigue also markedly worsens the patients' quality of life. Serologic testing reveals antinuclear auto-antibodies (anti-Ro/ SSA and anti-La/SSB) as well as rheumatoid factors. The histological hallmark of the disease is focal lymphocytic infiltration in otherwise normal-appearing glandular acini. The disease also markedly elevates the risk of non-Hodgkin lymphoma of the B-cell series, which arises in about 5% of patients. Primary Sjögren's syndrome (pSS) differs from the secondary form (sSS), which appears in the setting of another autoimmune disease, particularly systemic lupus erythematosus (15-36%), rheumatoid arthritis (20-32%), and limited or progressive systemic sclerosis (11-24%). Disease-modifying therapy is reserved for patients with systemic involvement; there is limited evidence for its efficacy. Because of the complexity of this disease, some of its clinical manifestations may require interdisciplinary treatment. CONCLUSION The main considerations in the interdisciplinary care of patients with Sjögren's disease are measures to improve quality of life, pharmacological and non-pharmacological treatments to keep disease activity in check, and management of the risk of lymphoma. Future therapeutic approaches must take the heterogeneity of the disease into account.
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Affiliation(s)
- Ana-Luisa Stefanski
- Charité Center for Internal Medicine, Medical Department-Division of Rheumatology and Clinical Immunology, Berlin, Germany; University Clinic of Rheumatology, Immunology and Allergology, Inselspital Bern, Bern, Switzerland; BfA Wendelstein Rehabilitation Clinic, Rheumatology Center, AHB Clinic, Bad Aibling, Germany; Department of Ophthalmology, Charité Campus Virchow, Berlin, Germany; Oral Surgery, The School of Dentistry, University of Birmingham, United Kingdom
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124
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Meurer M, Günther C. [37-year-old male with confluent papules and arcuate erythematosquamous plaques on the upper trunk and arms : Preparation for the specialist examination: part 22]. Hautarzt 2018; 69:173-176. [PMID: 30374546 DOI: 10.1007/s00105-018-4297-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- M Meurer
- Stiftung zur Förderung der Hochschulmedizin in Dresden, Fetscherstr. 74, 01307, Dresden, Deutschland.
| | - C Günther
- Klinik und Poliklinik für Dermatologie, Universitätsklinikum Carl Gustav Carus, Dresden, Deutschland
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125
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Yockey LJ, Iwasaki A. Interferons and Proinflammatory Cytokines in Pregnancy and Fetal Development. Immunity 2018; 49:397-412. [PMID: 30231982 PMCID: PMC6152841 DOI: 10.1016/j.immuni.2018.07.017] [Citation(s) in RCA: 296] [Impact Index Per Article: 49.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2018] [Revised: 05/13/2018] [Accepted: 07/26/2018] [Indexed: 12/15/2022]
Abstract
Successful pregnancy requires carefully-coordinated communications between the mother and fetus. Immune cells and cytokine signaling pathways participate as mediators of these communications to promote healthy pregnancy. At the same time, certain infections or inflammatory conditions in pregnant mothers cause severe disease and have detrimental impacts on the developing fetus. In this review, we examine evidence for the role of maternal and fetal immune responses affecting pregnancy and fetal development, both under homeostasis and following infection. We discuss immune responses that are necessary to promote healthy pregnancy and those that lead to congenital disorders and pregnancy complications, with a particular emphasis on the role of interferons and cytokines. Understanding the contributions of the immune system in pregnancy and fetal development provides important insights into the pathogenesis underlying maternal and fetal diseases and sheds insights on possible targets for therapy.
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Affiliation(s)
- Laura J Yockey
- Department of Immunobiology, Yale University School of Medicine, New Haven, CT 06520, USA
| | - Akiko Iwasaki
- Department of Immunobiology, Yale University School of Medicine, New Haven, CT 06520, USA; Howard Hughes Medical Institute, Chevy Chase, MD 20815, USA.
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126
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Tarvin SE, O'Neil KM. Systemic Lupus Erythematosus, Sjögren Syndrome, and Mixed Connective Tissue Disease in Children and Adolescents. Pediatr Clin North Am 2018; 65:711-737. [PMID: 30031495 DOI: 10.1016/j.pcl.2018.04.001] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Juvenile systemic lupus erythematosus (jSLE), mixed connective tissue disease (jMCTD), and Sjögren syndrome (jSS) are systemic autoimmune and inflammatory disorders with distinct patterns of organ involvement. All are characterized by autoantibody formation, with antinuclear (ANA) and anti-double-stranded DNA common in jSLE, ANA with high-titer ribonucleoprotein antibody in jMCTD, and Sjögren syndrome A and Sjögren syndrome B antibodies + ANA in jSS. Recognition, monitoring, and management for primary care providers are discussed, focusing on the role of primary physicians in recognizing and helping maintain optimal health in children with these potentially life-threatening diseases.
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Affiliation(s)
- Stacey E Tarvin
- Division of Rheumatology, Department of Pediatrics, University of Indiana School of Medicine, Riley Hospital for Children at Indiana University Health, 699 Riley Hospital Drive, Riley Research 307, Indianapolis, IN 46202, USA
| | - Kathleen M O'Neil
- Division of Rheumatology, Department of Pediatrics, University of Indiana School of Medicine, Riley Hospital for Children at Indiana University Health, 699 Riley Hospital Drive, Riley Research 307, Indianapolis, IN 46202, USA.
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127
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Nahal SK, Selmi C, Gershwin ME. Safety issues and recommendations for successful pregnancy outcome in systemic lupus erythematosus. J Autoimmun 2018; 93:16-23. [PMID: 30056945 DOI: 10.1016/j.jaut.2018.07.016] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2018] [Revised: 07/19/2018] [Accepted: 07/19/2018] [Indexed: 02/07/2023]
Abstract
Systemic lupus erythematosus (SLE) primarily affects women of childbearing age. One of the major changes in SLE focuses on the timing of a successful pregnancy. In the past, pregnancy was strongly discouraged in SLE, especially in the presence of risk factors such as nephritis, use of immunosuppressive therapies, or positivity of specific autoantibodies such as anti-phospholipids and anti-Ro/SSA, La/SSBA. Thanks to our better knowledge on the disease and management, pregnancy success rates in SLE patients have significantly improved care by the a multidisciplinary team which fosters a successful pregnancy with minimal complications for the mother and fetus when the disease is inactive or in remission. This approach is based on a counseling phase before pregnancy, to assess SLE activity phase, specific medications, risk factors, and continues through pregnancy and lactation with significantly improved pregnancy outcomes. Further, we can now better define the risk of disease flares during pregnancy based on a better understanding of the changes in maternal immunity and its relationship with SLE-associated autoimmunity and chronic inflammation. There is wide consensus that women with SLE can have successful pregnancies as long as conception is planned in a phase of inactive disease, and when the patient is closely managed by a rheumatologist, high-risk OB/GYN, neonatologist, and other medical specialists as indicated. Preconception counseling is essential to assess the risk of both fetal and maternal complications as well as identify life-threatening contraindications. Particular attention should be used in those SLE cases that have nephritis, APS or positivity for aPL, pulmonary hypertension, and positive anti-Ro/SSA or anti-La/SSB antibodies. In conclusion, the use of specific guidelines on the management of SLE before and during pregnancy and lactation, and a better understanding of the use of immunosuppressive therapies have significantly increased pregnancy success.
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Affiliation(s)
- Simran Kaur Nahal
- Division of Rheumatology, Allergy, and Clinical Immunology, University of California, Davis, CA, USA
| | - Carlo Selmi
- Division of Rheumatology and Clinical Immunology, Humanitas Research Hospital, Rozzano, Milan, Italy; Department of Biomedical Science and Translational Medicine, University of Milan, Italy.
| | - M Eric Gershwin
- Division of Rheumatology, Allergy, and Clinical Immunology, University of California, Davis, CA, USA.
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128
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Zhou KY, Hua YM. Autoimmune-associated Congenital Heart Block: A New Insight in Fetal Life. Chin Med J (Engl) 2018; 130:2863-2871. [PMID: 29176145 PMCID: PMC5717867 DOI: 10.4103/0366-6999.219160] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVE Congenital heart block (CHB) is a rare but life-threatening disorder. More than half of CHB cases are associated with maternal autoimmune, which are termed as autoimmune-associated CHB. This review summarized the recent research findings in understanding autoimmune-associated CHB, discussed the current diagnostic approaches and management strategies, and summarized the problems and future directions for this disorder. DATA SOURCES We retrieved the articles published in English from the PubMed database up to January 2017, using the keywords including "Autoimmune-associated", "Autoimmune-mediated", and "Congenital heart block". STUDY SELECTION Articles about autoimmune-associated CHB were obtained and reviewed. RESULTS Observational studies consistently reported that transplacental maternal antibodies might recognize fetal or neonatal antigens in various tissues and result in immunological damages, but the molecular mechanisms underlying CHB pathogenesis still need illuminated. Multiple factors were involved in the process of atrioventricular block development and progression. While several susceptibility genes had been successfully defined, how these genes and their protein interact and impact each other remains to be explored. With currently available diagnostic tools, fetal ultrasound cardiography, and fetal magnetocardiography, most of CHB could be successfully diagnosed and comprehensively evaluated prenatally. The efficacy of current approaches for preventing the progression and recurrence of CHB and other autoimmune-mediated damages was still controversial. CONCLUSIONS This review highlighted the relationships between autoimmune injuries and CHB and strengthened the importance of perinatal management and therapy for autoimmune-associated CHB.
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Affiliation(s)
- Kai-Yu Zhou
- Department of Pediatric Cardiology, Key Laboratory of Obstetric and Gynecologic and Pediatric Diseases and Birth Defects of Ministry of Education, Key Laboratory of Obstetric and Gynecologic and Pediatric Diseases of Sichuan Province, West China Second University Hospital, Sichuan University, Chengdu, Sichuan 610041, China
| | - Yi-Min Hua
- Department of Pediatric Cardiology, Key Laboratory of Obstetric and Gynecologic and Pediatric Diseases and Birth Defects of Ministry of Education, Key Laboratory of Obstetric and Gynecologic and Pediatric Diseases of Sichuan Province, West China Second University Hospital, Sichuan University, Chengdu, Sichuan 610041, China
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129
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Clowse MEB, Eudy AM, Kiernan E, Williams MR, Bermas B, Chakravarty E, Sammaritano LR, Chambers CD, Buyon J. The prevention, screening and treatment of congenital heart block from neonatal lupus: a survey of provider practices. Rheumatology (Oxford) 2018; 57:v9-v17. [PMID: 30137589 PMCID: PMC6099126 DOI: 10.1093/rheumatology/key141] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Revised: 04/20/2018] [Indexed: 11/12/2022] Open
Abstract
Objective To survey an international sample of providers to determine their current practices for the prevention, screening, and treatment of congenital heart block (CHB) due to maternal Ro/SSA antibodies. Methods A survey was designed by the organizing committee of the 9th International Conference of Reproduction, Pregnancy and Rheumatic Diseases. It was sent to attendants of the conference and authors of recent publications or abstracts at ACR 2012, 2013 or 2014 on rheumatic diseases and pregnancy. Results In anti-Ro/SSA positive women, 80% of 49 respondents recommended screening by serial fetal echocardiogram (ECHO), with most starting at week 16 (59%) and stopping at week 28 (25%), although the time to stop varied widely. For women without a prior infant with neonatal lupus, respondents recommend every other week (44%) or weekly (28%) fetal ECHOs. For women with a prior infant with neonatal lupus, 80% recommend weekly fetal ECHOs. To prevent CHB, HCQ was recommended by 67% of respondents and most would start pre-pregnancy (62%). Respondents were asked about medications to treat varying degrees of CHB in a 20-week pregnant, anti-Ro and La positive SLE patient. For first degree, respondents recommended starting dexamethasone (53%) or HCQ (43%). For second degree, respondents recommended starting dexamethasone (88%). For third degree, respondents recommended starting dexamethasone (55%) or IVIg (33%), although 27% would not start treatment. Conclusion Despite the absence of official guidelines, many physicians with a focus on pregnancy and rheumatic disease have developed similar patterns in the screening, prevention and treatment of CHB.
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Affiliation(s)
- Megan E B Clowse
- Division of Rheumatology and Immunology, Duke University Medical Center, Durham, NC
| | - Amanda M Eudy
- Division of Rheumatology and Immunology, Duke University Medical Center, Durham, NC
| | - Elizabeth Kiernan
- Department of Pediatrics, Division of Dysmorphology and Teratology, University of California San Diego, San Diego, CA
| | - Matthew R Williams
- Pediatric Cardiology and Cardiovascular Surgery, Rady Children's Hospital, University of California San Diego, San Diego, CA
| | - Bonnie Bermas
- Division of Rheumatic Diseases, UT Southwestern, Dallas, TX
| | - Eliza Chakravarty
- Department of Arthritis and Clinical Immunology, Oklahoma Medical Research Foundation, Oklahoma City, OK
| | - Lisa R Sammaritano
- Division of Rheumatology, Hospital for Special Surgery, Weill Cornell Medicine, New York, NY
| | | | - Jill Buyon
- Division of Rheumatology, New York University School of Medicine, NY, USA
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130
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Tongprasert F, Sittiwangkul R, Lerthiranwong T, Tongsong T. Prenatal sonographic monitoring of progressive cardiac damages caused by anti-Ro antibodies: A case report. JOURNAL OF CLINICAL ULTRASOUND : JCU 2018; 46:347-350. [PMID: 29023775 DOI: 10.1002/jcu.22541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Revised: 08/07/2017] [Accepted: 08/16/2017] [Indexed: 06/07/2023]
Abstract
Maternal autoantibodies to Ro/SSA are often linked to congenital heart block and rarely associated with structural defects. We describe the case of a fetus with anti-Ro-mediated second-degree block at 19 weeks, which progressed to a complete block, fibroelastosis, atrioventricular valve insufficiency, and semilunar valve stenosis/insufficiency at 20, 22, 24, and 26 weeks, respectively, although the fetus received transplacental anti-arrhythmic drugs. The 2150-g fetus was vaginally delivered at 35 weeks. An external pacemaker was inserted immediately after birth and replaced with permanent pacemaker at the age of 3 months. The newborn has had a good outcome with well-controlled heart rate.
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Affiliation(s)
- Fuanglada Tongprasert
- Department of Obstetrics and Gynecology, Faculty of Medicine, Chiang Mai University, Thailand
| | - Rekwan Sittiwangkul
- Department of Pediatrics, Faculty of Medicine, Chiang Mai University, Thailand
| | - Thitikarn Lerthiranwong
- Department of Obstetrics and Gynecology, Faculty of Medicine, Chiang Mai University, Thailand
| | - Theera Tongsong
- Department of Obstetrics and Gynecology, Faculty of Medicine, Chiang Mai University, Thailand
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131
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Inhibitory Effects of iPSC-MSCs and Their Extracellular Vesicles on the Onset of Sialadenitis in a Mouse Model of Sjögren's Syndrome. Stem Cells Int 2018; 2018:2092315. [PMID: 29736173 PMCID: PMC5875028 DOI: 10.1155/2018/2092315] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2017] [Accepted: 01/21/2018] [Indexed: 02/06/2023] Open
Abstract
No effective treatment for Sjögren's syndrome (SS), a chronic autoimmune disease affecting mainly salivary and lacrimal glands, is available now. Systemic infusion of allogeneic mesenchymal stem cells (MSCs) isolated from tissues such as bone marrow (BM) alleviated SS in mouse models and a small clinical trial, but further research and application of this MSC therapy were hindered by limited expandability, significant donor variations, and safety concerns of tissue-derived MSCs. To circumvent these issues, we derived MSCs from human iPSCs using an optimized protocol that can be easily scaled up to produce a huge amount of standardized MSCs. Our iPSC-MSCs inhibited the onset of lymphocyte infiltration into salivary glands in the NOD mouse model of SS in the same way as BM-MSCs. Extracellular vesicles (EVs) carry bioactive molecules in the same way as their originating cells and are more stable and considered much safer than cells for therapies. We found that EVs derived from BM-MSCs and iPSC-MSCs suppressed activation of immune cells and expression of proinflammation factors essential for SS progression in vitro and that infusion of iPSC-MSC EVs at the predisease stage decreased the lymphocyte infiltration in salivary glands and serum autoantibody levels in the same way as infusion of BM-MSCs and iPSC-MSCs. These data suggested that iPSC-MSC EVs have the potential to prevent the progression of SS before the onset of sialadenitis.
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132
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Mattia E, Hoxha A, Tonello M, Favaro M, Del Ross T, Calligaro A, Ghirardello A, Ruffatti A. Detection of autoantibodies to the p200-epitope of SSA/Ro52 antigen. A comparison of two laboratory assays. ACTA ACUST UNITED AC 2018; 56:927-932. [DOI: 10.1515/cclm-2017-0704] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Accepted: 11/22/2017] [Indexed: 12/11/2022]
Abstract
Abstract
Background:
Anti-p200 antibodies have been receiving growing interest in view of findings associating their presence to risk of fetal autoimmune congenital heart block (CHB). The study compares and evaluates the performance of two assays currently being used for their detection.
Methods:
One hundred and sixteen pregnant women positive for anti-SSA/Ro52 antibodies were considered as the study population. Fifty women negative for anti-SSA/Ro52 antibodies were considered as the control population. Anti-p200 antibodies were analyzed using two home-made ELISA assays: one with biotinylated antigen and the other with free antigen.
Results:
The specificity of the p200-free assay was significantly higher with respect to that of the p200-biotin assay (p=0.023). Both methods showed a high area under curve (AUC), thus, a good accuracy. There was a significant prevalence of anti-p200 antibodies when the p200-free assay was used to analyze the sera of the pregnant women with CHB fetuses (p=0.007). Cohen’s κ and Spearman’s ρ coefficients showed a good concordance (0.71) and a high correlation (0.93), respectively.
Conclusions:
The p200-free assay with respect to the biotin-based method was more specific in detecting p200 antibodies in women positive for anti-SSA/Ro52 antibodies. In addition, only the p200-free method significantly found p200 antibodies in patients with fetal CHB.
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Affiliation(s)
- Elena Mattia
- Rheumatology Unit , Department of Medicine-DIMED , University of Padua , Padua , Italy
| | - Ariela Hoxha
- Rheumatology Unit , Department of Medicine-DIMED , University of Padua , Padua , Italy
| | - Marta Tonello
- Rheumatology Unit , Department of Medicine-DIMED , University of Padua , Padua , Italy
| | - Maria Favaro
- Rheumatology Unit , Department of Medicine-DIMED , University of Padua , Padua , Italy
| | - Teresa Del Ross
- Rheumatology Unit , Department of Medicine-DIMED , University of Padua , Padua , Italy
| | - Antonia Calligaro
- Rheumatology Unit , Department of Medicine-DIMED , University of Padua , Padua , Italy
| | - Anna Ghirardello
- Rheumatology Unit , Department of Medicine-DIMED , University of Padua , Padua , Italy
| | - Amelia Ruffatti
- Rheumatology Unit , Department of Medicine-DIMED , University of Padua , Padua , Italy
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133
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Incidence, risk factors, and mortality of neonatal and late-onset dilated cardiomyopathy associated with cardiac neonatal lupus. Int J Cardiol 2017; 248:263-269. [DOI: 10.1016/j.ijcard.2017.07.100] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2017] [Revised: 07/19/2017] [Accepted: 07/26/2017] [Indexed: 01/12/2023]
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134
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Vanoni F, Lava SAG, Fossali EF, Cavalli R, Simonetti GD, Bianchetti MG, Bozzini MA, Agostoni C, Milani GP. Neonatal Systemic Lupus Erythematosus Syndrome: a Comprehensive Review. Clin Rev Allergy Immunol 2017; 53:469-476. [DOI: 10.1007/s12016-017-8653-0] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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135
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Should we treat congenital heart block with fluorinated corticosteroids? Autoimmun Rev 2017; 16:1115-1118. [DOI: 10.1016/j.autrev.2017.09.005] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Accepted: 08/02/2017] [Indexed: 12/11/2022]
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136
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Abstract
Neonatal lupus results from the passive transfer of autoantibodies; however, this transfer is not sufficient to cause disease. This article reviews clinical presentation with a focus on autoimmune-mediated congenital heart disease. Recent data looking for additional disease mechanisms and biomarkers as well as latest information on interventions will be reviewed. Our understanding of this rare disease is often dependent on patient participation in disease registries and biorepositories. Future participation in registries including descriptive as well as biophysical data is critical to our knowledge.
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Affiliation(s)
- Marisa S Klein-Gitelman
- Division of Rheumatology, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, 225 E. Chicago Avenue, # 50, Chicago, IL, 60611, USA.
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137
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Miyasato-Isoda M, Waguri M, Yamada Y, Miyano A, Wada Y. Anti-Ro52 antibody level is an important marker of fetal congenital heart block risk in anti-Ro/SSA antibody positive pregnancy. Mod Rheumatol 2017; 28:690-696. [DOI: 10.1080/14397595.2017.1374235] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Mai Miyasato-Isoda
- Department of Obstetric Medicine, Osaka Women’s and Children’s Hospital, Osaka, Japan
| | - Masako Waguri
- Department of Obstetric Medicine, Osaka Women’s and Children’s Hospital, Osaka, Japan
| | - Yuko Yamada
- Department of Obstetric Medicine, Osaka Women’s and Children’s Hospital, Osaka, Japan
| | - Akira Miyano
- Department of Laboratory Medicine, Osaka Women’s and Children’s Hospital, Osaka, Japan
| | - Yoshinao Wada
- Department of Obstetric Medicine, Osaka Women’s and Children’s Hospital, Osaka, Japan
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138
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Abstract
INTRODUCTION Congenital complete heart block affects 1/15,000 live-born infants, predominantly due to atrioventricular nodal injury from maternal antibodies of mothers with systemic lupus erythermatosus or Sjogren's syndrome. The majority of these children will need a pacemaker implanted prior to becoming young adults. This article will review the various patient and technical factors that influence the type of pacemaker implanted, and the current literature on optimal pacing practices. Areas covered: A literature search was performed using PubMed, Embase and Web of Science. Data regarding epicardial versus transvenous implants, pacing-induced ventricular dysfunction, alternative pacing strategies (including biventricular pacing, left ventricular pacing, and His bundle pacing), and complications with pacemakers in the pediatric population were reviewed. Expert commentary: There are numerous pacing strategies available to children with congenital complete heart block. The risks and benefits of the initial implant should be weighed against the long-term issues inherent with a life-time of pacing.
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Affiliation(s)
- Stephanie F Chandler
- a Department of Cardiology , Boston Children's Hospital , Boston , MA , USA.,b Department of Pediatrics , Harvard Medical School , Boston , MA , USA
| | - Francis Fynn-Thompson
- c Department of Cardiovascular Surgery , Boston Children's Hospital , Boston , MA , USA.,d Department of Surgery , Harvard Medical School , Boston , MA , USA
| | - Douglas Y Mah
- a Department of Cardiology , Boston Children's Hospital , Boston , MA , USA.,b Department of Pediatrics , Harvard Medical School , Boston , MA , USA
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139
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Meisgen S, Tingström J, Skog Andreasson A, Sonesson SE, Kockum I, Wahren-Herlenius M. Environmental and lifestyle factors influencing risk of congenital heart block during pregnancy in anti-Ro/SSA-positive women. RMD Open 2017; 3:e000520. [PMID: 28955500 PMCID: PMC5604703 DOI: 10.1136/rmdopen-2017-000520] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Revised: 06/21/2017] [Accepted: 06/22/2017] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES Congenital heart block (CHB) occurs in 1%-2% of anti-Ro/SSA antibody-positive pregnancies. A population-based recurrence rate of 12% indicates that factors other than maternal autoantibodies influence CHB development. Here we report the first investigation to identify environmental and lifestyle factors influencing the risk of CHB. METHODS A questionnaire focused on environmental and lifestyle factors was distributed to anti-Ro/SSA antibody-positive women who had given birth to at least one child with CHB, and additional data were retrieved from national health registers. Statistical analysis was performed comparing pregnancies resulting in a child with CHB (n=81) and pregnancies resulting in unaffected siblings (n=108). RESULTS Analysis of maternal body mass index and weight gain during pregnancy as well as medication intake and sun exposure did not reveal significant differences between CHB-affected and non-CHB pregnancies. By contrast, we found that reports of infections and stressful events were significantly more frequent in CHB-affected pregnancies than in non-CHB affected pregnancies (OR 17.9, 95% CI 4.1 to 162.8, p<0.001 and OR 5.5, 95% CI 1.1 to 55.1, p<0.05, respectively). Notably, outdoor activity a few hours per day emerged as a protective factor (OR 0.52, 95% CI 0.27 to 0.99, p<0.05). The previously reported factor seasonal timing of pregnancy was confirmed (OR 2.2, 95% CI 1.1 to 4.2, p<0.05), and multivariate analysis revealed that this association was partly explained by infection and outdoor activity. CONCLUSIONS In this retrospective study, infections, stressful events and time spent with outdoor activities emerged as potential environmental and lifestyle factors influencing the risk of CHB, warranting confirmation in prospective studies.
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Affiliation(s)
- Sabrina Meisgen
- Department of Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Joanna Tingström
- Department of Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Amanda Skog Andreasson
- Department of Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Sven-Erik Sonesson
- Department of Women and Child Health, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Ingrid Kockum
- Department of Clinical Neuroscience, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Marie Wahren-Herlenius
- Department of Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
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140
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Demarchi J, Papasidero SB, Klajn D, Alba P, Babini AM, Durigan V, Gobbi C, Raiti L. Primary Sjögren's syndrome and pregnancy: A report of 18 cases. ACTA ACUST UNITED AC 2017; 15:109-112. [PMID: 28844688 DOI: 10.1016/j.reuma.2017.07.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Revised: 07/06/2017] [Accepted: 07/14/2017] [Indexed: 11/30/2022]
Abstract
Primary Sjögren's syndrome (pSS) is a condition that predominantly affects women. Reports of pregnancy outcome in these patients are limited and contradictory. OBJECTIVE To describe pregnancy characteristics and outcomes and newborn morbidity in women with pSS. MATERIAL AND METHODS We included women with pSS who became pregnant after the onset of the symptoms of the disease. Clinical and serological characteristics, risk factors and previous maternal comorbidities are described. For each pregnancy in a woman with pSS, we recorded pregnancy course and outcome and newborn condition. RESULTS We assessed 11 patients with 18 pregnancies after the onset of pSS symptoms. All of them presented FAN +; 10 anti-Ro / SSA + and 7 anti-La / SSB +. The mean age in years at the onset of symptoms was 24.9 (SD 6.9) and at the time of pregnancy was 30.3 (SD 5.4). Thirteen pregnancies happened before the diagnosis, reporting only one miscarriage. Two preterm births, 1 case of oligohydramnios, 2 of premature membrane rupture and 2 low birthweight babies were reported after the onset of pSS symptoms. There was 1 newborn with congenital atrioventricular block and another with neonatal cutaneous lupus. All the women with pregnancy complications (n=6) had anti-Ro/SSA antibodies. CONCLUSIONS Almost half of the pregnancies assessed in women with pSS were associated with complications not attributable to factors other than the disease.
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Affiliation(s)
- Julia Demarchi
- Servicio de Reumatología, Hospital General de Agudos Dr. Enrique Tornú, Ciudad Autónoma de Buenos Aires, Argentina.
| | - Silvia B Papasidero
- Servicio de Reumatología, Hospital General de Agudos Dr. Enrique Tornú, Ciudad Autónoma de Buenos Aires, Argentina
| | - Diana Klajn
- Servicio de Reumatología, Hospital General de Agudos Dr. Enrique Tornú, Ciudad Autónoma de Buenos Aires, Argentina
| | - Paula Alba
- Hospital Córdoba, Hospital Materno Neonatal Córdoba, Cátedra de Medicina I UHMN 3 UNC, Córdoba, Argentina
| | | | - Virginia Durigan
- Hospital Bernardino Rivadavia, Ciudad Autónoma de Buenos Aires, Argentina
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Thong B, Olsen NJ. Systemic lupus erythematosus diagnosis and management. Rheumatology (Oxford) 2017; 56:i3-i13. [PMID: 28013206 DOI: 10.1093/rheumatology/kew401] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Indexed: 01/07/2023] Open
Abstract
SLE presents many challenges for clinicians. The onset of disease may be insidious, with many different symptoms and signs, making early and accurate diagnosis challenging. Tests for SLE in the early stages lack specificity; those that are useful later often appear only after organ damage is manifest. Disease patterns are highly variable; flares are not predictable and not always associated with biomarkers. Children with SLE may have severe disease and present special management issues. Older SLE patients have complicating co-morbid conditions. Therapeutic interventions have improved over recent decades, but available drugs do not adequately control disease in many patients, and successful outcomes are limited by off-target effects; some of these become manifest with longer duration of treatment, now in part revealed by improved rates of survival. Despite all of these challenges, advances in understanding the biological basis of SLE have translated into more effective approaches to patient care. This review considers the current state of SLE diagnosis and management, with a focus on new approaches and anticipated advances.
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Affiliation(s)
- Bernard Thong
- Department of Rheumatology, Allergy and Immunology, Tan Tock Seng Hospital, Singapore, Republic of Singapore
| | - Nancy J Olsen
- Division of Rheumatology, Department of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA
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142
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Abstract
Maternal autoantibodies can cross the placenta and cause fetal damage. This article summarizes the development and management of fetal thyroid goiter in response to maternal Graves' disease and/or its treatment with antithyroid medication, fetal heart block due to maternal anti-Ro and anti-La antibodies, fetal athrogryposis multiplex congenita in association with maternal myasthenia gravis and fetal brain hemorrhage due to maternal autoimmune thrombocytopenia.
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Affiliation(s)
| | - Kypros Nicolaides
- a Fetal Medicine Research Institute , King's College Hospital , London , UK
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143
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Clancy RM, Markham AJ, Jackson T, Rasmussen SE, Blumenberg M, Buyon JP. Cardiac fibroblast transcriptome analyses support a role for interferogenic, profibrotic, and inflammatory genes in anti-SSA/Ro-associated congenital heart block. Am J Physiol Heart Circ Physiol 2017. [PMID: 28626076 DOI: 10.1152/ajpheart.00256.2017] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
The signature lesion of SSA/Ro autoantibody-associated congenital heart block (CHB) is fibrosis and a macrophage infiltrate, supporting an experimental focus on cues influencing the fibroblast component. The transcriptomes of human fetal cardiac fibroblasts were analyzed using two complementary approaches. Cardiac injury conditions were simulated in vitro by incubating human fetal cardiac fibroblasts with supernatants from macrophages transfected with the SSA/Ro-associated noncoding Y ssRNA. The top 10 upregulated transcripts in the stimulated fibroblasts reflected a type I interferon (IFN) response [e.g., IFN-induced protein 44-like (IFI44L), of MX dynamin-like GTPase (MX)1, MX2, and radical S-adenosyl methionine domain containing 2 (Rsad2)]. Within the fibrotic pathway, transcript levels of endothelin-1 (EDN1), phosphodiesterase (PDE)4D, chemokine (C-X-C motif) ligand (CXCL)2, and CXCL3 were upregulated, while others, including adenomedullin, RAP guanine nucleotide exchange factor 3 (RAPGEF3), tissue inhibitor of metalloproteinase (TIMP)1, TIMP3, and dual specificity phosphatase 1, were downregulated. Agnostic Database for Annotation, Visualization and Integrated Discovery analysis revealed a significant increase in inflammatory genes, including complement C3A receptor 1 (C3AR1), F2R-like thrombin/trypsin receptor 3, and neutrophil cytosolic factor 2. In addition, stimulated fibroblasts expressed high levels of phospho-MADS box transcription enhancer factor 2 [a substrate of MAPK5 (ERK5)], which was inhibited by BIX-02189, a specific inhibitor of ERK5. Translation to human disease leveraged an unprecedented opportunity to interrogate the transcriptome of fibroblasts freshly isolated and cell sorted without stimulation from a fetal heart with CHB and a matched healthy heart. Consistent with the in vitro data, five IFN response genes were among the top 10 most highly expressed transcripts in CHB fibroblasts. In addition, the expression of matrix-related genes reflected fibrosis. These data support the novel finding that cardiac injury in CHB may occur secondary to abnormal remodeling due in part to upregulation of type 1 IFN response genes.NEW & NOTEWORTHY Congenital heart block is a rare disease of the fetal heart associated with maternal anti-Ro autoantibodies which can result in death and for survivors, lifelong pacing. This study provides in vivo and in vitro transcriptome-support that injury may be mediated by an effect of Type I Interferon on fetal fibroblasts.
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Affiliation(s)
- Robert M Clancy
- Division of Rheumatology, Department of Medicine, New York University School of Medicine, New York, New York
| | - Androo J Markham
- Division of Rheumatology, Department of Medicine, New York University School of Medicine, New York, New York
| | - Tanisha Jackson
- Division of Rheumatology, Department of Medicine, New York University School of Medicine, New York, New York
| | - Sara E Rasmussen
- Division of Rheumatology, Department of Medicine, New York University School of Medicine, New York, New York
| | - Miroslav Blumenberg
- Division of Rheumatology, Department of Medicine, New York University School of Medicine, New York, New York
| | - Jill P Buyon
- Division of Rheumatology, Department of Medicine, New York University School of Medicine, New York, New York
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144
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Fischer-Betz R, Specker C. Pregnancy in systemic lupus erythematosus and antiphospholipid syndrome. Best Pract Res Clin Rheumatol 2017; 31:397-414. [DOI: 10.1016/j.berh.2017.09.011] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Revised: 08/09/2017] [Accepted: 09/02/2017] [Indexed: 01/02/2023]
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145
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Lisney AR, Szelinski F, Reiter K, Burmester GR, Rose T, Dörner T. High maternal expression of SIGLEC1 on monocytes as a surrogate marker of a type I interferon signature is a risk factor for the development of autoimmune congenital heart block. Ann Rheum Dis 2017; 76:1476-1480. [DOI: 10.1136/annrheumdis-2016-210927] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Revised: 03/10/2017] [Accepted: 04/09/2017] [Indexed: 11/03/2022]
Abstract
ObjectivesAutoimmune congenital heart block (CHB) is associated with placental transcytosis of maternal autoantibodies directed against Ro/SS-A and La/SS-B. However, only about 2% of children born to mothers with the respective antibodies are affected, indicating that further risk factors exist, which are not yet fully understood. In this study, we investigated whether a maternal type I interferon (IFN) signature represents a risk factor for the development of CHB.MethodsBlood samples, clinical data and serological parameters from 9 women with CHB pregnancies, 14 pregnant women with antibodies against Ro/SS-A but without a CHB complication and another 30 healthy pregnant women as controls were studied. SIGLEC1 expression was measured by flow cytometry and was correlated to plasma IFN-α levels measured by ELISA, and IFN-γ-induced protein 10 (IP-10) levels measured by Bio-Plex technique.ResultsMothers of affected children had a significantly higher expression of SIGLEC1 (p=0.0034) and IFN-α (p=0.014), but not of IP-10 (p=0.14, all MWU) compared to mothers of unaffected children. SIGLEC1 and IFN-α expression were reduced by hydroxychloroquine and oral glucocorticoids.ConclusionsHigh expression of SIGLEC1 in pregnant women with autoantibodies against Ro/SS-A indicates an enhanced risk for CHB development, and these women may benefit especially from IFN-α directed therapy, for example with hydroxychloroquine.
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146
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Lazzerini PE, Capecchi PL, Laghi-Pasini F, Boutjdir M. Autoimmune channelopathies as a novel mechanism in cardiac arrhythmias. Nat Rev Cardiol 2017; 14:521-535. [PMID: 28470179 DOI: 10.1038/nrcardio.2017.61] [Citation(s) in RCA: 70] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Cardiac arrhythmias confer a considerable burden of morbidity and mortality in industrialized countries. Although coronary artery disease and heart failure are the prevalent causes of cardiac arrest, in 5-15% of patients, structural abnormalities at autopsy are absent. In a proportion of these patients, mutations in genes encoding cardiac ion channels are documented (inherited channelopathies), but, to date, the molecular autopsy is negative in nearly 70% of patients. Emerging evidence indicates that autoimmunity is involved in the pathogenesis of cardiac arrhythmias. In particular, several arrhythmogenic autoantibodies targeting specific calcium, potassium, or sodium channels in the heart have been identified. Experimental and clinical studies demonstrate that these autoantibodies can promote conduction disturbances and life-threatening tachyarrhythmias by inducing substantial electrophysiological changes. In this Review, we propose the term 'autoimmune cardiac channelopathies' to define this novel pathogenic mechanism of cardiac arrhythmias, which could be more frequent and clinically relevant than previously appreciated. Indeed, pathogenic autoantibodies against ion channels are detectable not only in patients with manifest autoimmune disease, but also in apparently healthy individuals, which suggests a causal role in some cases of unexplained arrhythmias and cardiac arrest. Considering this possibility and performing specific testing in patients with 'idiopathic' rhythm disturbances could create novel treatment opportunities.
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Affiliation(s)
- Pietro Enea Lazzerini
- Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Viale Bracci 16, Siena, 53100, Italy
| | - Pier Leopoldo Capecchi
- Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Viale Bracci 16, Siena, 53100, Italy
| | - Franco Laghi-Pasini
- Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Viale Bracci 16, Siena, 53100, Italy
| | - Mohamed Boutjdir
- VA New York Harbor Healthcare System, 800 Poly Place, Brooklyn, New York 11209, USA.,SUNY Downstate Medical Center, 450 Clarkson Avenue, Brooklyn, New York 11203, USA.,NYU School of Medicine, 550 1st Avenue, New York, New York 10016, USA
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147
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Rezazadeh S, Duff HJ. Genetic Determinants of Hereditary Bradyarrhythmias: A Contemporary Review of a Diverse Group of Disorders. Can J Cardiol 2017; 33:758-767. [PMID: 28545623 DOI: 10.1016/j.cjca.2017.03.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2017] [Revised: 03/03/2017] [Accepted: 03/10/2017] [Indexed: 11/25/2022] Open
Abstract
Bradyarrhythmia is a common clinical presentation. Although the majority of cases are acquired, genetic screening of families with bradyarrhythmia has led to the discovery of a growing number of causative hereditary mutations. These mutations can interfere with any of the steps required for the occurrence of each cardiac cycle, including generation of an action potential in the sinoatrial node, successful exit of the action potential from the node, propagation of the action potential throughout the atria until the depolarization waves reach the atrioventricular node, and finally transmission of the action potential to the ventricles through the His-Purkinje system. As expected, channelopathies are the predominant culprit for hereditary bradyarrhythmias, because they play a crucial role in action potential generation and propagation. Interestingly, there are an increasing number of genes that encode for various regulatory or structural cellular components that have been linked to hereditary bradyarrhythmias. Furthermore, population-based genetic screening has revealed that age-related conduction defects may in fact be caused by genetic predispositions rather than the simple process of aging. With recent advances in genetic testing and the creation of animal models, not only have we discovered new culprit genes but it has also has become evident that there are still significant gaps in our knowledge of cardiac pathophysiology. In this review, we discuss the clinical presentations of known hereditary bradyarrhythmias and their associated conditions in addition to detailing our current molecular understanding of the mechanisms by which they are manifested.
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Affiliation(s)
- Saman Rezazadeh
- Department of Cardiac Sciences and Libin Cardiovascular Institute of Alberta, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Henry J Duff
- Department of Cardiac Sciences and Libin Cardiovascular Institute of Alberta, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.
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148
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Abstract
Systemic lupus erythematosus (SLE) is an autoimmune disease with a strong female predilection. Pregnancy remains a commonly encountered but high-risk situation in this setting. Both maternal and fetal mortality and morbidity are still significantly increased despite improvements in outcomes. Maternal morbidity includes higher risk of disease flares, preeclampsia and other pregnancy-related complications. Fetal issues include higher rates of preterm birth, intrauterine growth restriction, and neonatal lupus syndromes. Treatment options during pregnancy are also limited and maternal benefit has to be weighed against fetal risk. A coordinated approach, with close monitoring by a multidisciplinary team, is essential for optimal outcomes.
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Affiliation(s)
- Aisha Lateef
- Division of Rheumatology, University Medicine Cluster, National University Hospital, National University Health System, 1E, Kent Ridge Road, Singapore 119074
| | - Michelle Petri
- Division of Rheumatology, Johns Hopkins Lupus Center, Johns Hopkins University School of Medicine, 1830 East Monument Street, Suite 7500, Baltimore, MD 21205, USA.
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149
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Heart sounds at home: feasibility of an ambulatory fetal heart rhythm surveillance program for anti-SSA-positive pregnancies. J Perinatol 2017; 37:226-230. [PMID: 27977016 DOI: 10.1038/jp.2016.220] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Revised: 10/12/2016] [Accepted: 10/14/2016] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Fetuses exposed to anti-SSA (Sjögren's) antibodies are at risk of developing irreversible complete atrioventricular block (CAVB), resulting in death or permanent cardiac pacing. Anti-inflammatory treatment during the transition period from normal heart rhythm (fetal heart rhythm (FHR)) to CAVB (emergent CAVB) can restore sinus rhythm, but detection of emergent CAVB is challenging, because it can develop in ⩽24 h. We tested the feasibility of a new technique that relies on home FHR monitoring by the mother, to surveil for emergent CAVB. STUDY DESIGN We recruited anti-SSA-positive mothers at 16 to 18 weeks gestation (baseline) from 8 centers and instructed them to monitor FHR two times a day until 26 weeks, using a Doppler device at home. FHR was also surveilled by weekly or every other week fetal echo. If FHR was irregular, the mother underwent additional fetal echo. We compared maternal stress/anxiety before and after monitoring. Postnatally, infants underwent a 12-lead electrocardiogram. RESULTS Among 133 recruited, 125 (94%) enrolled. Among those enrolled, 96% completed the study. Reasons for withdrawal (n=5) were as follows: termination of pregnancy, monitoring too time consuming or moved away. During home monitoring, 9 (7.5%) mothers detected irregular FHR diagnosed by fetal echo as normal (false positive, n=2) or benign atrial arrhythmia (n=7). No CAVB was undetected or developed after monitoring. Questionnaire analysis indicated mothers felt comforted by the experience and would monitor again in future pregnancies. CONCLUSION These data suggest ambulatory FHR surveillance of anti-SSA-positive pregnancies is feasible, has a low false positive rate and is empowering to mothers.
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150
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Tonello M, Hoxha A, Mattia E, Zambon A, Visentin S, Cerutti A, Ghirardello A, Milanesi O, Ruffatti A. Low titer, isolated anti Ro/SSA 60 kd antibodies is correlated with positive pregnancy outcomes in women at risk of congenital heart block. Clin Rheumatol 2017; 36:1155-1160. [PMID: 28204891 DOI: 10.1007/s10067-017-3572-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Revised: 02/03/2017] [Accepted: 02/04/2017] [Indexed: 11/30/2022]
Abstract
Congenital heart block (CHB) is an autoantibody mediated disorder presumably caused by placental transmission of maternal autoantibodies to Ro/SSA 52 kd, p200, Ro/SSA 60 kd, La/SSB ribonucleoproteins. This study investigated the clinical significance of isolated anti-Ro/SSA 52 kd, anti-p200, anti-Ro/SSA 60 kd, and anti-La/SSB antibodies in positive pregnant patients. One hundred sixty-three pregnant women positive to anti-Ro/SSA 52 kd and/or anti-Ro/SSA 60 kd and/or anti-La/SSB antibodies were prospectively enrolled in the study. Anti-Ro52, anti-Ro60, anti-p200, and anti-La antibodies were assayed using home-made ELISA assays. Isolated antibody positivity was found in 25 women (15.3%), while multiple antibody positivity in 138 (84.7%). Twenty-four developed CHB, and the 139 had a favorable pregnancy outcome. The prevalence of isolated anti-Ro/SSA 60 kd antibodies was significantly higher (p < 0.046) as the prevalence of lower mean antibody titers (p < 0.0001) in the later group. Confirmation of these results by large-scale studies could lead clinicians to recommend less stringent fetal echocardiography monitoring in women with isolated anti-Ro/SSA 60 kd antibodies.
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Affiliation(s)
- Marta Tonello
- Rheumatology Unit, Department of Medicine, University of Padua, Padua, Italy
| | - Ariela Hoxha
- Rheumatology Unit, Department of Medicine, University of Padua, Padua, Italy
| | - Elena Mattia
- Rheumatology Unit, Department of Medicine, University of Padua, Padua, Italy
| | - Alessandra Zambon
- Gynaecology and Obstetrics Unit, Department of Women's and Children's Health, University of Padua, Padua, Italy
| | - Silvia Visentin
- Gynaecology and Obstetrics Unit, Department of Women's and Children's Health, University of Padua, Padua, Italy
| | - Alessia Cerutti
- Paediatric Cardiology Unit, Department of Women's and Children's Health, University of Padua, Padua, Italy
| | - Anna Ghirardello
- Rheumatology Unit, Department of Medicine, University of Padua, Padua, Italy
| | - Ornella Milanesi
- Paediatric Cardiology Unit, Department of Women's and Children's Health, University of Padua, Padua, Italy
| | - Amelia Ruffatti
- Rheumatology Unit, Department of Medicine, University of Padua, Padua, Italy.
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