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Montanaro C, Boyle S, Wander G, Johnson MR, Roos-Hesselink JW, Patel R, Rafiq I, Silversides CK, Gatzoulis MA. Pregnancy in patients with the Fontan operation. Eur J Prev Cardiol 2024; 31:1336-1344. [PMID: 38669446 DOI: 10.1093/eurjpc/zwae157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2024] [Revised: 04/03/2024] [Accepted: 04/22/2024] [Indexed: 04/28/2024]
Abstract
Improved survival rates for patients with a Fontan circulation has allowed more women with this complex cardiac physiology to contemplate pregnancy. However, pregnancy in women with a Fontan circulation is associated with a high risk of adverse maternal and foetal outcomes, high rates of miscarriage, and preterm delivery. Factors associated with a successful pregnancy outcome are younger age, normal body weight, absence of significant functional limitation, no Fontan-related complications, and well-functioning single ventricle physiology. Appropriate care with timely preconception counselling and regular, frequent clinical reviews by a multidisciplinary team based at a tertiary centre improves the chance of a successful pregnancy. Empowerment of patients with education on their specific congenital cardiac condition and its projected trajectory helps them make informed choices regarding their health, reproductive choices, and assists them to achieve their life goals.
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Affiliation(s)
- Claudia Montanaro
- Adult Congenital Heart Centre and National Centre for Pulmonary Hypertension, Royal Brompton Hospital, Guy's and St Thomas's NHS Foundation Trust, Sydney Street, London SW3 6NP, UK
- National Heart and Lung Institute, Imperial College, Dovehouse St, London, SW3 6LY, UK
| | - Siobhan Boyle
- Adult Congenital Heart Centre and National Centre for Pulmonary Hypertension, Royal Brompton Hospital, Guy's and St Thomas's NHS Foundation Trust, Sydney Street, London SW3 6NP, UK
- Department of Cardiology, Logan Hospital, Queensland, Australia
| | - Gurleen Wander
- Obstetrics and Gynaecology Department, Chelsea and Westminster Hospital, 369 Fulham Road, London SW10 9NH, UK
| | - Mark R Johnson
- National Heart and Lung Institute, Imperial College, Dovehouse St, London, SW3 6LY, UK
- Obstetrics and Gynaecology Department, Chelsea and Westminster Hospital, 369 Fulham Road, London SW10 9NH, UK
| | | | - Roshni Patel
- National Heart and Lung Institute, Imperial College, Dovehouse St, London, SW3 6LY, UK
- Obstetrics and Gynaecology Department, Chelsea and Westminster Hospital, 369 Fulham Road, London SW10 9NH, UK
| | - Isma Rafiq
- Adult Congenital Heart Centre and National Centre for Pulmonary Hypertension, Royal Brompton Hospital, Guy's and St Thomas's NHS Foundation Trust, Sydney Street, London SW3 6NP, UK
| | - Candice K Silversides
- Congenital Cardiac Centre for Adults, Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
| | - Michael A Gatzoulis
- Adult Congenital Heart Centre and National Centre for Pulmonary Hypertension, Royal Brompton Hospital, Guy's and St Thomas's NHS Foundation Trust, Sydney Street, London SW3 6NP, UK
- National Heart and Lung Institute, Imperial College, Dovehouse St, London, SW3 6LY, UK
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2
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van der Stuijt W, Kooiman KM, de Veld JA, Pepplinkhuizen S, Olde Nordkamp LRA, Oudijk MA, Wilde AAM, Smeding L, Knops RE. Is it safe to give birth with an activated implantable cardioverter-defibrillator: A multicentre observational study. BJOG 2024; 131:1290-1295. [PMID: 38326282 DOI: 10.1111/1471-0528.17777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Revised: 01/17/2024] [Accepted: 01/21/2024] [Indexed: 02/09/2024]
Abstract
OBJECTIVE Data and guidelines are lacking, so implantable cardioverter-defibrillators (ICDs) are often deactivated during labour to prevent inappropriate shocks. This study aimed to ascertain the safety of an activated ICD during labour. DESIGN An observational study was performed. SETTING Dutch hospitals. POPULATION OR SAMPLE A total of 41 childbirths were included of 26 patients who gave birth between February 2009 and November 2018 after receiving an ICD in our tertiary hospital. Five of these childbirths were attended by the research team between December 2018 and August 2020, during which the ICD remained active. METHODS Groups were made based on ICD status during labour. Patients who gave birth with an activated ICD at least once were stratified to the activated ICD group. Patients' files were checked and patients received a questionnaire about childbirth perceptions and treatment preferences. The differences in ordinal data resulting from the questionnaire were calculated using a chi-square or Fisher's exact test. MAIN OUTCOME MEASURES Primary outcome was inappropriate ICD therapy and occurrence of ventricular arrhythmias requiring treatment. RESULTS During the 41 childbirths, no inappropriate shocks or ventricular arrhythmias occurred during labour. All patients in the activated ICD group (n = 13) preferred this setting, while 8 of the 13 patients in the deactivated ICD group preferred activation (p = 0.002). Reasons included avoiding hemodynamic monitoring, magnet placement, or labour induction to facilitate technician availability. CONCLUSIONS This study shows no evidence that labour and birth in women with an activated ICD are unsafe, as there were no ventricular arrhythmias or inappropriate therapy. In addition, most patients prefer an activated ICD during labour.
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Affiliation(s)
- Willeke van der Stuijt
- Heart Centre: Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, location AMC, Amsterdam, The Netherlands
| | - Kirsten M Kooiman
- Heart Centre: Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, location AMC, Amsterdam, The Netherlands
| | - Jolien A de Veld
- Heart Centre: Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, location AMC, Amsterdam, The Netherlands
| | - Shari Pepplinkhuizen
- Heart Centre: Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, location AMC, Amsterdam, The Netherlands
| | - Louise R A Olde Nordkamp
- Heart Centre: Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, location AMC, Amsterdam, The Netherlands
| | - Martijn A Oudijk
- Department of Obstetrics and Gynaecology, Amsterdam UMC, location VUmc, Amsterdam, The Netherlands
- Amsterdam Reproduction and Development, Amsterdam, The Netherlands
| | - Arthur A M Wilde
- Heart Centre: Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, location AMC, Amsterdam, The Netherlands
| | - Lonneke Smeding
- Heart Centre: Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, location AMC, Amsterdam, The Netherlands
| | - Reinoud E Knops
- Heart Centre: Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, location AMC, Amsterdam, The Netherlands
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3
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Strasburger JF. Technologies in fetal rhythm assessment. Heart Rhythm 2024; 21:1454-1455. [PMID: 39084713 DOI: 10.1016/j.hrthm.2024.04.094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2024] [Revised: 04/25/2024] [Accepted: 04/26/2024] [Indexed: 08/02/2024]
Affiliation(s)
- Janette F Strasburger
- Medical College of Wisconsin, Milwaukee, Wisconsin; Children's Wisconsin - Milwaukee, Milwaukee, Wisconsin.
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4
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Ventrella N, Schiavone M, Bianchini L, Sicuso R, Dessanai MA, Di Biase L, Tondo C. Catheter ablation for focal atrial tachycardias during pregnancy: A systematic review. Int J Cardiol 2024; 413:132333. [PMID: 38972492 DOI: 10.1016/j.ijcard.2024.132333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2024] [Revised: 05/29/2024] [Accepted: 07/01/2024] [Indexed: 07/09/2024]
Abstract
OBJECTIVE Pregnancy can trigger maternal tachycardias, and the onset of recurrent or incessant focal atrial tachycardia (AT) can lead to tachycardia-induced cardiomyopathy. Medical interventions are commonly employed, but they carry potential fetal and maternal risks. Catheter ablation (CA), particularly with non-fluoroscopic navigation systems, may be considered as an alternative. This systematic review aims to explore the feasibility and outcomes of CA for focal AT during pregnancy. METHODS A thorough literature search was conducted until September 30th, 2023, on PubMed, Embase, and Cochrane databases. Included articles described maternal focal ATs diagnosed through electrophysiological studies and treated with CA. Data derived from these studies were organized into tables and subsequently analyzed. RESULTS Out of 278 papers reviewed, 15 articles involving 24 patients were retrieved. CA, utilizing radiofrequency energy achieved acute success in 95.8% of cases. Sixteen patients (66.7%) underwent complete fluoroless procedures, with two adverse events directly related to the procedure reported. Long-term follow-up revealed minimal AT recurrences, with a 0.06% arrhythmia burden in one case. CONCLUSION Focal ATs during pregnancy can be incessant and refractory to medical intervention, precipitating an acute decline in left ventricular ejection fraction. In this setting, CA emerges as an efficacious treatment modality, particularly in cases of tachycardia-induced cardiomyopathies. Whenever feasible, it is advisable to perform these procedures with minimal or no fluoroscopy guidance. Larger studies are needed to establish the safety and the efficacy of CA for focal ATs during pregnancy, as current research consists of case reports or small case series.
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Affiliation(s)
- Nicoletta Ventrella
- Department of Clinical Electrophysiology & Cardiac Pacing, Centro Cardiologico Monzino, IRCCS, Milan, Italy; Department of Clinical Sciences and Community Health, Cardiovascular Section, University of Milan, Milan, Italy.
| | - Marco Schiavone
- Department of Clinical Electrophysiology & Cardiac Pacing, Centro Cardiologico Monzino, IRCCS, Milan, Italy
| | - Lorenzo Bianchini
- Department of Clinical Electrophysiology & Cardiac Pacing, Centro Cardiologico Monzino, IRCCS, Milan, Italy
| | - Rita Sicuso
- Department of Clinical Electrophysiology & Cardiac Pacing, Centro Cardiologico Monzino, IRCCS, Milan, Italy
| | - Maria Antonietta Dessanai
- Department of Clinical Electrophysiology & Cardiac Pacing, Centro Cardiologico Monzino, IRCCS, Milan, Italy
| | - Luigi Di Biase
- Cardiac Arrhythmia Center, Division of Cardiology, Department of Medicine, Montefiore-Einstein Center for Heart and Vascular Care, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Claudio Tondo
- Department of Clinical Electrophysiology & Cardiac Pacing, Centro Cardiologico Monzino, IRCCS, Milan, Italy; Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy
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5
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Bekiaridou A, Coleman KM, Sharma N, George D, Liu Y, Gianos E, Rosen S, Mieres JH, Mountantonakis SE. Clinical Significance of Supraventricular Tachycardia During Pregnancy in Healthy Women. JACC Clin Electrophysiol 2024; 10:1304-1312. [PMID: 38661600 DOI: 10.1016/j.jacep.2024.03.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Revised: 02/06/2024] [Accepted: 03/07/2024] [Indexed: 04/26/2024]
Abstract
BACKGROUND Supraventricular tachycardias (SVT) are the most frequently encountered arrhythmias in pregnancy with unclear clinical significance. OBJECTIVES This study sought to report the prevalence, describe the management, and explore the association between SVT and adverse obstetric outcomes. METHODS Cohort study of primiparous and multiparous women without history of Cesarean section (CS), and with structurally normal hearts admitted in labor. The study group consisted of women with at least 1 SVT episode during pregnancy, and the control group was randomly selected in a 4:1 ratio. RESULTS Of 141,769 women meeting the inclusion criteria, SVT diagnosis was confirmed in 122. A total of 76 (age 33.2 ± 4.8 years) had at least 1 symptomatic and documented episode during pregnancy. In women with a known SVT diagnosis before pregnancy, medical therapy was not associated with a lower risk of SVT recurrence (OR: 1.07; 95% CI: 0.41-2.80). However, catheter ablation before pregnancy was associated with significantly lower risk of SVT recurrence (OR: 0.09; 95% CI: 0.04-0.23). Women with SVT during pregnancy had higher incidence of CS (39.5% vs 27.0%; P = 0.03), and preterm labor (PTL) (30.3% vs 8.6%; P < 0.001). Adjusting for age and parity, SVT during pregnancy was an independent predictor of CS (OR: 1.80; 95% CI: 1.03-3.10), particularly planned CS (OR: 2.89; 95% CI: 1.06-7.89) and PTL (OR: 4.37; 95% CI: 2.30-8.31). CONCLUSIONS SVT during pregnancy is associated with increased risk for CS and PTL in healthy women. History of SVT should be sought as early as preconception counseling, and a multidisciplinary approach is warranted for both prevention and management of SVT occurrence.
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Affiliation(s)
- Alexandra Bekiaridou
- Northwell Health, New Hyde Park, New York, USA; Elmezzi Graduate School of Molecular Medicine, Manhasset, New York, USA; Feinstein Institute for Medical Research, Manhasset, New York, USA
| | - Kristie M Coleman
- Northwell Health, New Hyde Park, New York, USA; Northwell Cardiovascular Institute, New York, New York, USA; Lenox Hill Hospital, New York, New York, USA. https://twitter.com/keepinrhythm
| | - Nikhil Sharma
- Northwell Health, New Hyde Park, New York, USA; Feinstein Institute for Medical Research, Manhasset, New York, USA; Northwell Cardiovascular Institute, New York, New York, USA
| | - Deepika George
- Northwell Health, New Hyde Park, New York, USA; Feinstein Institute for Medical Research, Manhasset, New York, USA
| | - Yan Liu
- Northwell Health, New Hyde Park, New York, USA; Feinstein Institute for Medical Research, Manhasset, New York, USA
| | - Eugenia Gianos
- Northwell Health, New Hyde Park, New York, USA; Northwell Cardiovascular Institute, New York, New York, USA; Lenox Hill Hospital, New York, New York, USA
| | - Stacey Rosen
- Northwell Health, New Hyde Park, New York, USA; Northwell Cardiovascular Institute, New York, New York, USA
| | - Jennifer H Mieres
- Northwell Health, New Hyde Park, New York, USA; Northwell Cardiovascular Institute, New York, New York, USA
| | - Stavros E Mountantonakis
- Northwell Health, New Hyde Park, New York, USA; Northwell Cardiovascular Institute, New York, New York, USA; Lenox Hill Hospital, New York, New York, USA.
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6
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Albertini L, Spears DA. Management of arrythmias during pregnancy. Heart 2024; 110:916-925. [PMID: 37993263 DOI: 10.1136/heartjnl-2023-322746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2023] Open
Affiliation(s)
- Lisa Albertini
- Cardiology, Toronto General Hospital, Toronto, Ontario, Canada
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7
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Martin G, Narvaez-Guerra O, Aurigemma G, Kovell L. Peripartum ventricular tachycardia and PVC-induced cardiomyopathy: delivering optimal care when it's time to deliver. BMJ Case Rep 2024; 17:e259075. [PMID: 38839415 DOI: 10.1136/bcr-2023-259075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2024] Open
Abstract
Ventricular tachycardia (VT) is a rare but potentially fatal complication in pregnancy. We present a case of a pregnant woman with cardiomyopathy due to frequent premature ventricular complexes (PVCs) and VT originating from the left ventricular outflow tract. After presenting late in the third trimester, the decision was made to deliver the fetus after 4 days of medication titration due to continued sustained episodes of VT. After delivery, the patient continued to have frequent PVCs and VT several months after discharge, and she ultimately underwent a PVC ablation with dramatic reduction in PVC burden and improvement in cardiomyopathy. Multidisciplinary planning with a pregnancy heart team led to appropriate contingency planning and a successful delivery. This case highlights how multidisciplinary management is best practice in pregnancy complicated by VT and the need for better diagnostic guidelines for PVC-induced cardiomyopathy in the setting of pregnancy.
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Affiliation(s)
- Gabrielle Martin
- Medicine, UMass Chan Medical School, Worcester, Massachusetts, USA
| | - Offdan Narvaez-Guerra
- Cardiovascular Medicine, UMass Memorial Medical Center, Worcester, Massachusetts, USA
| | - Gerard Aurigemma
- Cardiovascular Medicine, UMass Memorial Medical Center, Worcester, Massachusetts, USA
| | - Lara Kovell
- Cardiovascular Medicine, UMass Memorial Medical Center, Worcester, Massachusetts, USA
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8
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Cha YM, Bhakta D, Barbhaiya CR, Chung EH, Fisher JD, Fix AM, Ghia KK, Glikson M, Hart SA, Hushcha SV, Kannankeril PJ, Kramer DB, Mendenhall GS, Morin DP, Ottoboni LK, Pathak RK, Pillarisetti J, Rajagopalan B, Russo AM, See VY, Shah MJ, Sridhar ARM, Patton KK. Heart Rhythm Society Scientific and Clinical Documents Committee Viewpoint. Heart Rhythm 2024; 21:975-977. [PMID: 38816149 DOI: 10.1016/j.hrthm.2024.02.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Revised: 02/06/2024] [Accepted: 02/06/2024] [Indexed: 06/01/2024]
Affiliation(s)
| | - Deepak Bhakta
- Indiana University School of Medicine, Indianapolis, Indiana
| | | | - Eugene H Chung
- Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | | | - Angela M Fix
- Heart Rhythm Society, Washington, District of Columbia
| | | | - Michael Glikson
- Shaare Zedek Medical Center and Hebrew University, Jerusalem, Israel
| | | | | | | | | | | | | | - Linda K Ottoboni
- Stanford Health Care and Stanford University, Stanford, California
| | - Rajeev Kumar Pathak
- Australian National University and Canberra Heart Rhythm, Canberra, Australia
| | | | | | | | - Vincent Y See
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Maully J Shah
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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9
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Killen SAS, Strasburger JF. Diagnosis and Management of Fetal Arrhythmias in the Current Era. J Cardiovasc Dev Dis 2024; 11:163. [PMID: 38921663 PMCID: PMC11204159 DOI: 10.3390/jcdd11060163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Revised: 05/18/2024] [Accepted: 05/20/2024] [Indexed: 06/27/2024] Open
Abstract
Diagnosis and management of fetal arrhythmias have changed over the past 40-50 years since propranolol was first used to treat fetal tachycardia in 1975 and when first attempts were made at in utero pacing for complete heart block in 1986. Ongoing clinical trials, including the FAST therapy trial for fetal tachycardia and the STOP-BLOQ trial for anti-Ro-mediated fetal heart block, are working to improve diagnosis and management of fetal arrhythmias for both mother and fetus. We are also learning more about how "silent arrhythmias", like long QT syndrome and other inherited channelopathies, may be identified by recognizing "subtle" abnormalities in fetal heart rate, and while echocardiography yet remains the primary tool for diagnosing fetal arrhythmias, research efforts continue to advance the clinical envelope for fetal electrocardiography and fetal magnetocardiography. Pharmacologic management of fetal arrhythmias remains one of the most successful achievements of fetal intervention. Patience, vigilance, and multidisciplinary collaboration are key to successful diagnosis and treatment.
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Affiliation(s)
- Stacy A. S. Killen
- Thomas P. Graham Jr. Division of Pediatric Cardiology, Department of Pediatrics, Vanderbilt University Medical Center, Monroe Carell Jr. Children’s Hospital at Vanderbilt, 2200 Children’s Way, Suite 5230, Nashville, TN 37232, USA
| | - Janette F. Strasburger
- Division of Cardiology, Departments of Pediatrics and Biomedical Engineering, Children’s Wisconsin, Herma Heart Institute, Medical College of Wisconsin, Milwaukee, WI 53226, USA;
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10
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Kohli U, Hassan S, Mercer C, Rhodes L. Permanent junctional reciprocating tachycardia due to an atypical retrograde slow conducting decremental left posterolateral accessory pathway and tachycardia-induced cardiomyopathy in a pregnant adolescent. Pacing Clin Electrophysiol 2024. [PMID: 38491748 DOI: 10.1111/pace.14959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Revised: 01/28/2024] [Accepted: 02/13/2024] [Indexed: 03/18/2024]
Abstract
Permanent junctional reciprocating tachycardia (PJRT) is a rare form of supraventricular tachycardia (SVT) due to a retrograde slow conducting decremental accessory pathway (AP) which is often incessant and can lead to tachycardia-induced cardiomyopathy (TIC). We report the challenging clinical course of a pregnant adolescent with PJRT due to an atypical retrograde slow conducting decremental left posterolateral AP. Pregnancy is known to exacerbate supraventricular arrhythmias and can lead to adverse maternal and fetal outcomes. To the best of our knowledge, there are no prior reports on the clinical course of rare incessant and difficult-to-treat arrhythmias such as PJRT in a pregnant adolescent patient.
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Affiliation(s)
- Utkarsh Kohli
- Division of Pediatric Cardiology, Department of Pediatrics, West Virginia University School of Medicine and West Virginia University Children's Heart Center, Morgantown, Washington, USA
| | - Sohail Hassan
- Department of Cardiac Electrophysiology, Ascension St. John Hospital, Detroit, Michigan, USA
| | - Christopher Mercer
- Division of Pediatric Cardiology, Department of Pediatrics, West Virginia University School of Medicine and West Virginia University Children's Heart Center, Morgantown, Washington, USA
| | - Larry Rhodes
- Division of Pediatric Cardiology, Department of Pediatrics, West Virginia University School of Medicine and West Virginia University Children's Heart Center, Morgantown, Washington, USA
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11
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Tamirisa KP, Oliveros E, Paulraj S, Mares AC, Volgman AS. An Overview of Arrhythmias in Pregnancy. Methodist Debakey Cardiovasc J 2024; 20:36-50. [PMID: 38495654 PMCID: PMC10941715 DOI: 10.14797/mdcvj.1325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2023] [Accepted: 12/27/2023] [Indexed: 03/19/2024] Open
Abstract
Cardiovascular disease significantly jeopardizes pregnancies in the United States, impacting 1% to 4% of pregnancies annually. Among complications, cardiac arrhythmias are prevalent, posing concerns for maternal and fetal health. The incidence of arrhythmias during pregnancy is rising, partly due to advances in congenital heart surgery and a growing population of women with structural heart disease. While most arrhythmias are benign, the increasing prevalence of more serious arrhythmias warrants a proactive approach. Guidance and reassurance suffice in many cases, but persistent symptoms require cautious use of antiarrhythmic drugs or other therapies for a safe outcome. Managing more serious arrhythmias requires a comprehensive, multidisciplinary approach involving specialists, including maternal-fetal medicine physicians, cardiologists, electrophysiologists, and anesthesiologists.
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12
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Conti E, Cascio ND, Paluan P, Racca G, Longhitano Y, Savioli G, Tesauro M, Leo R, Racca F, Zanza C. Pregnancy Arrhythmias: Management in the Emergency Department and Critical Care. J Clin Med 2024; 13:1095. [PMID: 38398407 PMCID: PMC10888682 DOI: 10.3390/jcm13041095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Revised: 02/09/2024] [Accepted: 02/13/2024] [Indexed: 02/25/2024] Open
Abstract
Pregnancy is closely associated with an elevated risk of arrhythmias, constituting the predominant cardiovascular complication during this period. Pregnancy may induce the exacerbation of previously controlled arrhythmias and, in some instances, arrhythmias may present for the first time in pregnancy. The most important proarrhythmic mechanisms during pregnancy are the atrial and ventricular stretching, coupled with increased sympathetic activity. Notably, arrhythmias, particularly those originating in the ventricles, heighten the likelihood of syncope, increasing the potential for sudden cardiac death. The effective management of arrhythmias during the peripartum period requires a comprehensive, multidisciplinary approach from the prepartum to the postpartum period. The administration of antiarrhythmic drugs during pregnancy necessitates meticulous attention to potential alterations in pharmacokinetics attributable to maternal physiological changes, as well as the potential for fetal adverse effects. Electric cardioversion is a safe and effective intervention during pregnancy and should be performed immediately in patients with hemodynamic instability. This review discusses the pathophysiology of arrythmias in pregnancy and their management.
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Affiliation(s)
- Elena Conti
- Division of Anesthesia and Critical Care Medicine, Azienda Ospedaliera Ordine Mauriziano, 10128 Turin, Italy; (E.C.); (N.D.C.); (P.P.); (F.R.)
| | - Nunzio Dario Cascio
- Division of Anesthesia and Critical Care Medicine, Azienda Ospedaliera Ordine Mauriziano, 10128 Turin, Italy; (E.C.); (N.D.C.); (P.P.); (F.R.)
| | - Patrizia Paluan
- Division of Anesthesia and Critical Care Medicine, Azienda Ospedaliera Ordine Mauriziano, 10128 Turin, Italy; (E.C.); (N.D.C.); (P.P.); (F.R.)
| | - Giulia Racca
- Division of Anesthesia and Critical Care Medicine, Azienda Ospedaliera Ordine Mauriziano, 10128 Turin, Italy; (E.C.); (N.D.C.); (P.P.); (F.R.)
| | - Yaroslava Longhitano
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, PA 15260, USA
- Department of Emergency Medicine—Emergency Medicine Residency Program, Humanitas University-Research Hospital, 20089 Rozzano, Italy
| | - Gabriele Savioli
- Emergency Medicine and Surgery, IRCCS Fondazione Policlinico San Matteo, 27100 Pavia, Italy
| | - Manfredi Tesauro
- Geriatric Medicine Residency Program, University of Rome “Tor Vergata”, 00133 Rome, Italy
- Department of Systems Medicine, University of Rome “Tor Vergata”, 00133 Rome, Italy
| | - Roberto Leo
- Department of Systems Medicine, University of Rome “Tor Vergata”, 00133 Rome, Italy
| | - Fabrizio Racca
- Division of Anesthesia and Critical Care Medicine, Azienda Ospedaliera Ordine Mauriziano, 10128 Turin, Italy; (E.C.); (N.D.C.); (P.P.); (F.R.)
| | - Christian Zanza
- Geriatric Medicine Residency Program, University of Rome “Tor Vergata”, 00133 Rome, Italy
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13
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Polic A, Killen SA, Strasburger JF, Kannankeril PJ, Wakai RT, Patel SS. Low Baseline Fetal Heart Rate Leads to Diagnosis of Long QT Syndrome Type 1. JACC Case Rep 2024; 29:102183. [PMID: 38361570 PMCID: PMC10865115 DOI: 10.1016/j.jaccas.2023.102183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 11/27/2023] [Accepted: 12/01/2023] [Indexed: 02/17/2024]
Abstract
A low baseline fetal heart rate at 20 weeks' gestation was detected in a fetus without cardiac structural anomalies. Fetal echocardiography and magnetocardiography were used to diagnose congenital long QT syndrome. It was confirmed in the neonate, and the same pathogenic variant in KCNQ1 was subsequently identified in the mother.
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Affiliation(s)
- Aleksandra Polic
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Stacy A.S. Killen
- Division of Cardiology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Janette F. Strasburger
- Division of Cardiology, Medical College of Wisconsin, Childrens Wisconsin-Milwaukee, Milwaukee, Wisconsin, USA
| | - Prince J. Kannankeril
- Division of Cardiology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Ronald T. Wakai
- Department of Medical Physics, University of Wisconsin, Milwaukee, Wisconsin, USA
| | - Soha S. Patel
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Viveiros Monteiro A. Arrhythmias in pregnancy: Is there anything else than just sinus tachycardia? Rev Port Cardiol 2024; 43:75-76. [PMID: 38122896 DOI: 10.1016/j.repc.2023.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Accepted: 12/18/2023] [Indexed: 12/23/2023] Open
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Joglar JA, Chung MK, Armbruster AL, Benjamin EJ, Chyou JY, Cronin EM, Deswal A, Eckhardt LL, Goldberger ZD, Gopinathannair R, Gorenek B, Hess PL, Hlatky M, Hogan G, Ibeh C, Indik JH, Kido K, Kusumoto F, Link MS, Linta KT, Marcus GM, McCarthy PM, Patel N, Patton KK, Perez MV, Piccini JP, Russo AM, Sanders P, Streur MM, Thomas KL, Times S, Tisdale JE, Valente AM, Van Wagoner DR. 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2024; 83:109-279. [PMID: 38043043 PMCID: PMC11104284 DOI: 10.1016/j.jacc.2023.08.017] [Citation(s) in RCA: 66] [Impact Index Per Article: 66.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2023]
Abstract
AIM The "2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Patients With Atrial Fibrillation" provides recommendations to guide clinicians in the treatment of patients with atrial fibrillation. METHODS A comprehensive literature search was conducted from May 12, 2022, to November 3, 2022, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. Additional relevant studies, published through November 2022, during the guideline writing process, were also considered by the writing committee and added to the evidence tables, where appropriate. STRUCTURE Atrial fibrillation is the most sustained common arrhythmia, and its incidence and prevalence are increasing in the United States and globally. Recommendations from the "2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" and the "2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing atrial fibrillation and thromboembolic risk assessment, anticoagulation, left atrial appendage occlusion, atrial fibrillation catheter or surgical ablation, and risk factor modification and atrial fibrillation prevention have been developed.
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Alken FA, Scherschel K, Zhu E, Kahle AK, Meyer C. [Long-term results of catheter ablation for AV nodal reentry tachycardias and accessory pathways]. Herzschrittmacherther Elektrophysiol 2023; 34:278-285. [PMID: 37861731 DOI: 10.1007/s00399-023-00965-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2023] [Accepted: 09/20/2023] [Indexed: 10/21/2023]
Abstract
Atrioventricular nodal reentrant tachycardia (AVNRT) and atrioventricular reentrant tachycardia in patients with accessory pathways (AP) are common supraventricular tachycardias. High long-term efficacy of about 97% (AVNRT) and 92% (AP) has been observed in children and adults. The risk of occurring atrioventricular block is low (0.4-0.8% during AVNRT, 0.1-0.2% for AP). Catheter ablation shows a lower efficacy of 87-93% and elevated atrioventricular block risk up to 10% in patient groups with complex congenital heart disease. Nonsynchronized ventricular activation during preexcitation or permanent reentrant tachycardias can induce heart failure, and remission of left ventricular function can be expected in > 90% after successful catheter ablation. Therefore, catheter ablation is the long-term therapy of choice for AVNRT and AP with high efficacy and safety for most patient populations.
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Affiliation(s)
- Fares-Alexander Alken
- Klinik für Kardiologie/Angiologie/Intensivmedizin, cNEP, cardiac Neuro- and Electrophysiology research group, Evangelisches Krankenhaus Düsseldorf, Kirchfeldstraße 40, 40217, Düsseldorf, Deutschland
| | - Katharina Scherschel
- Klinik für Kardiologie/Angiologie/Intensivmedizin, cNEP, cardiac Neuro- and Electrophysiology research group, Evangelisches Krankenhaus Düsseldorf, Kirchfeldstraße 40, 40217, Düsseldorf, Deutschland
- Institut für Neuro- und Sinnesphysiologie, Medizinische Fakultät, Heinrich-Heine-Universität Düsseldorf, Universitätsklinikum Düsseldorf, Universitätsstraße 1, 40225, Düsseldorf, Deutschland
| | - Ernan Zhu
- Klinik für Kardiologie/Angiologie/Intensivmedizin, cNEP, cardiac Neuro- and Electrophysiology research group, Evangelisches Krankenhaus Düsseldorf, Kirchfeldstraße 40, 40217, Düsseldorf, Deutschland
| | - Ann-Kathrin Kahle
- Klinik für Kardiologie/Angiologie/Intensivmedizin, cNEP, cardiac Neuro- and Electrophysiology research group, Evangelisches Krankenhaus Düsseldorf, Kirchfeldstraße 40, 40217, Düsseldorf, Deutschland
- Klinik für Kardiologie, Pneumologie und Angiologie, Medizinische Fakultät, Heinrich-Heine-Universität Düsseldorf, Universitätsklinikum Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Deutschland
| | - Christian Meyer
- Klinik für Kardiologie/Angiologie/Intensivmedizin, cNEP, cardiac Neuro- and Electrophysiology research group, Evangelisches Krankenhaus Düsseldorf, Kirchfeldstraße 40, 40217, Düsseldorf, Deutschland.
- Institut für Neuro- und Sinnesphysiologie, Medizinische Fakultät, Heinrich-Heine-Universität Düsseldorf, Universitätsklinikum Düsseldorf, Universitätsstraße 1, 40225, Düsseldorf, Deutschland.
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Orenshtein S, Sheiner E, Sergienko R, Wainstock T. Syncope in pregnancy, immediate pregnancy outcomes, and offspring long-term neurologic health. Am J Obstet Gynecol MFM 2023; 5:101190. [PMID: 37838012 DOI: 10.1016/j.ajogmf.2023.101190] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 09/26/2023] [Accepted: 10/09/2023] [Indexed: 10/16/2023]
Abstract
BACKGROUND There are limited data regarding the perinatal consequences of maternal syncope during pregnancy, and even less is known about the potential long-term effect on offspring health. OBJECTIVE This study aimed to examine perinatal outcomes as well as long-term offspring neurologic morbidity associated with prenatal maternal syncope, and the possible differential effect by trimester of first syncope episode. STUDY DESIGN A retrospective cohort study was conducted, including all singleton deliveries occurring between 1991 and 2021 at a large tertiary medical center. Multivariable analyses were applied to study the associations between prenatal maternal syncope and various perinatal outcomes as well as offspring neurologic morbidity up to the age of 18 years, while adjusting for clinically relevant factors. Analyses were further conducted by trimester of first syncope episode. RESULTS The study population included 232,475 pregnancies, 774 (0.3%) were affected by maternal syncope, which most frequently first occurred during the second trimester (44.5%), followed by the first trimester (31.8%) and finally the third trimester (27.7%). Maternal syncope was independently associated with increased risk for intrauterine growth restriction (adjusted odds ratio, 1.52; 95% confidence interval, 1.01-2.29), which appeared to be mainly driven by first trimester syncope occurrence; as well as with increased risk for cesarean delivery (adjusted odds ratio, 1.33; 95% confidence interval, 1.10-1.61), and for long-term offspring neurologic morbidity (adjusted hazard ratio, 1.79; 95% confidence interval, 1.65-2.08), regardless of the trimester of syncope occurrence. CONCLUSION Prenatal maternal syncope is an independent risk factor for intrauterine growth restriction, cesarean delivery, and for long-term offspring neurologic morbidity.
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Affiliation(s)
- Shani Orenshtein
- Faculty of Health Sciences, Department of Epidemiology, Biostatistics and Community Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel (Ms Orenshtein, Mr Sergienko, and Dr Wainstock).
| | - Eyal Sheiner
- Department of Obstetrics and Gynecology, Soroka University Medical Center, Ben-Gurion University of the Negev, Beer-Sheva, Israel (Prof Sheiner)
| | - Ruslan Sergienko
- Faculty of Health Sciences, Department of Epidemiology, Biostatistics and Community Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel (Ms Orenshtein, Mr Sergienko, and Dr Wainstock)
| | - Tamar Wainstock
- Faculty of Health Sciences, Department of Epidemiology, Biostatistics and Community Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel (Ms Orenshtein, Mr Sergienko, and Dr Wainstock)
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18
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Kaizer AM, Winbo A, Clur SAB, Etheridge SP, Ackerman MJ, Horigome H, Herberg U, Dagradi F, Spazzolini C, Killen SAS, Wacker-Gussmann A, Wilde AAM, Sinkovskaya E, Abuhamad A, Torchio M, Ng CA, Rydberg A, Schwartz PJ, Cuneo BF. Effects of cohort, genotype, variant, and maternal β-blocker treatment on foetal heart rate predictors of inherited long QT syndrome. Europace 2023; 25:euad319. [PMID: 37975542 PMCID: PMC10655062 DOI: 10.1093/europace/euad319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 10/16/2023] [Indexed: 11/19/2023] Open
Abstract
AIMS In long QT syndrome (LQTS), primary prevention improves outcome; thus, early identification is key. The most common LQTS phenotype is a foetal heart rate (FHR) < 3rd percentile for gestational age (GA) but the effects of cohort, genotype, variant, and maternal β-blocker therapy on FHR are unknown. We assessed the influence of these factors on FHR in pregnancies with familial LQTS and developed a FHR/GA threshold for LQTS. METHODS AND RESULTS In an international cohort of pregnancies in which one parent had LQTS, LQTS genotype, familial variant, and maternal β-blocker effects on FHR were assessed. We developed a testing algorithm for LQTS using FHR and GA as continuous predictors. Data included 1966 FHRs at 7-42 weeks' GA from 267 pregnancies/164 LQTS families [220 LQTS type 1 (LQT1), 35 LQTS type 2 (LQT2), and 12 LQTS type 3 (LQT3)]. The FHRs were significantly lower in LQT1 and LQT2 but not LQT3 or LQTS negative. The LQT1 variants with non-nonsense and severe function loss (current density or β-adrenergic response) had lower FHR. Maternal β-blockers potentiated bradycardia in LQT1 and LQT2 but did not affect FHR in LQTS negative. A FHR/GA threshold predicted LQT1 and LQT2 with 74.9% accuracy, 71% sensitivity, and 81% specificity. CONCLUSION Genotype, LQT1 variant, and maternal β-blocker therapy affect FHR. A predictive threshold of FHR/GA significantly improves the accuracy, sensitivity, and specificity for LQT1 and LQT2, above the infant's a priori 50% probability. We speculate this model may be useful in screening for LQTS in perinatal subjects without a known LQTS family history.
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Affiliation(s)
- Alexander M Kaizer
- Biostatistics and Informatics, Colorado School of Public Health, University of Colorado-Anschutz Medical Campus, Aurora, CO, USA
| | - Annika Winbo
- Department of Clinical Sciences, Pediatrics, Umeå University, Umea, Sweden
- Department of Physiology, University of Auckland, Auckland, New Zealand
| | - Sally-Ann B Clur
- Department of Pediatric Cardiology, Emma Children’s Hospital, Amsterdam University Medical Centers, Amsterdam, The Netherlands
- Department of Cardiology, University Medical Center, Amsterdam, The Netherlands
| | - Susan P Etheridge
- Department of Pediatrics, Division of Cardiology, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Michael J Ackerman
- Department of Cardiovascular Medicine, Division of Heart Rhythm Services, Mayo Clinic, Rochester, MN, USA
- Department of Pediatric and Adolescent Medicine, Division of Pediatric Cardiology, Mayo Clinic, Rochester, MN, USA
- Department of Molecular Pharmacology & Experimental Therapeutics, Mayo Clinic, Rochester, MN, USA
- Windland Smith Rice Genetic Heart Rhythm Clinic and Windland Smith Rice Sudden Death Genomics Laboratory, Mayo Clinic, Rochester, MN, USA
| | - Hitoshi Horigome
- Department of Pediatrics, Section of Cardiology, Tsukuba University, Tsukuba, Japan
| | - Ulrike Herberg
- Department of Pediatric Cardiology, RWTH University Hospital Aachen, Aachen, Germany
- Department of Pediatric Cardiology, University Hospital Bonn, Bonn, Germany
| | - Federica Dagradi
- Center for Cardiac Arrhythmias of Genetic Origin and Laboratory of Cardiovascular Genetics, IRCCS Istituto Auxologico Italiano, Via Pier Lombardo 22, 2015 Milan, Italy
| | - Carla Spazzolini
- Center for Cardiac Arrhythmias of Genetic Origin and Laboratory of Cardiovascular Genetics, IRCCS Istituto Auxologico Italiano, Via Pier Lombardo 22, 2015 Milan, Italy
| | - Stacy A S Killen
- Department of Pediatrics, Division of Cardiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Annette Wacker-Gussmann
- Department of Congenital Heart Disease and Paediatric Cardiology, German Heart Center, Munich, Germany
| | - Arthur A M Wilde
- Department of Cardiology, University Medical Center, Amsterdam, The Netherlands
- Department of Cardiology, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
- Department of Cardiology, Amseterdam University Medical Center, Amsterdam, The Netherlands
| | - Elena Sinkovskaya
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Eastern Virginia Medical School, Norfolk, VA, USA
| | - Alfred Abuhamad
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Eastern Virginia Medical School, Norfolk, VA, USA
| | - Margherita Torchio
- Center for Cardiac Arrhythmias of Genetic Origin and Laboratory of Cardiovascular Genetics, IRCCS Istituto Auxologico Italiano, Via Pier Lombardo 22, 2015 Milan, Italy
| | - Chai-Ann Ng
- Mark Cowley Lidwill Research Program in Cardiac Electrophysiology, Victor Chang Cardiac Research Institute, Darlinghurst, New South Wales, Australia
- The School of Clinical Medicine, UNSW Sydney, Darlinghurst, New South Wales, Australia
| | - Annika Rydberg
- Department of Clinical Sciences, Pediatrics, Umeå University, Umea, Sweden
- Department of Cardiology, University Medical Center, Amsterdam, The Netherlands
| | - Peter J Schwartz
- Center for Cardiac Arrhythmias of Genetic Origin and Laboratory of Cardiovascular Genetics, IRCCS Istituto Auxologico Italiano, Via Pier Lombardo 22, 2015 Milan, Italy
| | - Bettina F Cuneo
- Department of Pediatrics, Section of Cardiology, University of Denver School of Medicine, 13123 16th Ave, Box 100, Aurora, CO 80045, USA
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