1
|
Kukla P, Podlejska B, Wiliński J. Congenital Complete Heart Block-To Stimulate (When?) or Not to Stimulate? Healthcare (Basel) 2024; 12:1158. [PMID: 38921273 PMCID: PMC11203115 DOI: 10.3390/healthcare12121158] [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: 04/29/2024] [Revised: 06/02/2024] [Accepted: 06/05/2024] [Indexed: 06/27/2024] Open
Abstract
This article presents the case of a 27-year-old female patient with idiopathic congenital complete heart block who does not consent to the implantation of a cardiac pacemaker but was referred by her primary care physician for cardiological evaluation. The conduction disturbance was recognized at the age of 6 and was asymptomatic. The professional disqualification from pacemaker implantation included a detailed history of a patient's symptoms, an echocardiographic assessment of the heart, exercise testing and ECG Holter monitoring. The aid of salbutamol administered orally was also useful.
Collapse
Affiliation(s)
- Piotr Kukla
- Department of Internal Medicine and Cardiology, Specialist Hospital H. Klimontowicza, 38-300 Gorlice, Poland;
| | - Beata Podlejska
- Department of Internal Medicine and Cardiology, Specialist Hospital H. Klimontowicza, 38-300 Gorlice, Poland;
| | - Jerzy Wiliński
- Center for Invasive Cardiology, Electrotherapy and Angiology, 33-300 Nowy Sącz, Poland;
- Department of Internal Medicine with Cardiology Subdivision, Blessed Marta Wiecka District Hospital, 32-700 Bochnia, Poland
| |
Collapse
|
2
|
Joglar JA, Kapa S, Saarel EV, Dubin AM, Gorenek B, Hameed AB, Lara de Melo S, Leal MA, Mondésert B, Pacheco LD, Robinson MR, Sarkozy A, Silversides CK, Spears D, Srinivas SK, Strasburger JF, Tedrow UB, Wright JM, Zelop CM, Zentner D. 2023 HRS expert consensus statement on the management of arrhythmias during pregnancy. Heart Rhythm 2023; 20:e175-e264. [PMID: 37211147 DOI: 10.1016/j.hrthm.2023.05.017] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 05/12/2023] [Indexed: 05/23/2023]
Abstract
This international multidisciplinary expert consensus statement is intended to provide comprehensive guidance that can be referenced at the point of care to cardiac electrophysiologists, cardiologists, and other health care professionals, on the management of cardiac arrhythmias in pregnant patients and in fetuses. This document covers general concepts related to arrhythmias, including both brady- and tachyarrhythmias, in both the patient and the fetus during pregnancy. Recommendations are provided for optimal approaches to diagnosis and evaluation of arrhythmias; selection of invasive and noninvasive options for treatment of arrhythmias; and disease- and patient-specific considerations when risk stratifying, diagnosing, and treating arrhythmias in pregnant patients and fetuses. Gaps in knowledge and new directions for future research are also identified.
Collapse
Affiliation(s)
- José A Joglar
- The University of Texas Southwestern Medical Center, Dallas, Texas
| | | | - Elizabeth V Saarel
- St. Luke's Health System, Boise, Idaho, and Cleveland Clinic Lerner College of Medicine at Case Western Reserve University, Cleveland, Ohio
| | | | | | | | | | | | | | - Luis D Pacheco
- The University of Texas Medical Branch at Galveston, Galveston, Texas
| | | | - Andrea Sarkozy
- University Hospital of Antwerp, University of Antwerp, Antwerp, Belgium
| | | | - Danna Spears
- University Health Network, Toronto, Ontario, Canada
| | - Sindhu K Srinivas
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | | | | | | | - Carolyn M Zelop
- The Valley Health System, Ridgewood, New Jersey; New York University Grossman School of Medicine, New York, New York
| | | |
Collapse
|
3
|
Mikulski MF, Well A, Shmorhun D, Fraser CD, Mery CM, Fenrich AL. Pacemaker Management and In-Hospital Outcomes in Neonatal Congenital Atrioventricular Block. JACC Clin Electrophysiol 2023; 9:1977-1986. [PMID: 37354188 DOI: 10.1016/j.jacep.2023.05.003] [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: 04/04/2023] [Revised: 04/27/2023] [Accepted: 05/01/2023] [Indexed: 06/26/2023]
Abstract
BACKGROUND Neonatal congenital atrioventricular block (nCAVB) is rare, causes bradycardia, confers high mortality, and frequently requires pacing. In-hospital outcomes and pacemaker management in nCAVB are limited. OBJECTIVES The purpose of this study was to analyze pacing and outcomes of nCAVB with and without congenital heart disease (CHD) using a multicenter database. METHODS A Pediatric Health Information System database review from January 1, 2004, to June 30, 2022. Patients <31 days of age with a nCAVB International Classification of Diseases-9th/10th Revision diagnosis code and no cardiac surgeries except pacemaker were included. Pacing and in-hospital mortality were analyzed using univariate and multivariable logistic statistics and competing risk and event-free survival models. RESULTS Of 1,146 patients with nCAVB, 659 (57.5%) were girls and 506 (44.2%) were premature. Among the 326 (28.4%) with CHD, 134 (41.1%) underwent pacemaker insertion as initial intervention and 56 (17.2%) had temporary pacing wires. In-hospital mortality occurred in 118 (36.2%), with increased adjusted odds with temporary pacing wires placed at 0 to 1 or 2 to 7 days of age relative to no wires, and with decreased odds among pacemakers placed at 2 to 7 or 8+ days of age relative to no pacemaker. Of 820 (71.6%) without CHD, 334 (40.7%) underwent pacemaker insertion as the initial intervention and 81 (9.9%) had temporary pacing wires. In-hospital mortality occurred in 69 (8.4%) with increased adjusted odds in prematurity and decreased odds among pacemaker placement at 2 to 7 days of age relative to no pacemaker. CONCLUSIONS Over 18.5 years, in-hospital mortality occurred in 36.2% of nCAVB patients with CHD and 8.4% with non-CHD. Associations with increased in-hospital mortality included CHD and prematurity and decreased with pacemaker placement. Prospective registries are needed to better characterize and standardize management of this rare but high-mortality disease.
Collapse
Affiliation(s)
- Matthew F Mikulski
- Texas Center for Pediatric and Congenital Heart Disease, UT Health Austin/Dell Children's Medical Center, Austin, Texas, USA; Department of Surgery and Perioperative Care, Dell Medical School, The University of Texas at Austin, Austin, Texas, USA.
| | - Andrew Well
- Texas Center for Pediatric and Congenital Heart Disease, UT Health Austin/Dell Children's Medical Center, Austin, Texas, USA; Department of Surgery and Perioperative Care, Dell Medical School, The University of Texas at Austin, Austin, Texas, USA
| | - Daniel Shmorhun
- Texas Center for Pediatric and Congenital Heart Disease, UT Health Austin/Dell Children's Medical Center, Austin, Texas, USA; Department of Pediatrics, Dell Medical School, The University of Texas at Austin, Austin, Texas, USA
| | - Charles D Fraser
- Texas Center for Pediatric and Congenital Heart Disease, UT Health Austin/Dell Children's Medical Center, Austin, Texas, USA; Department of Surgery and Perioperative Care, Dell Medical School, The University of Texas at Austin, Austin, Texas, USA
| | - Carlos M Mery
- Texas Center for Pediatric and Congenital Heart Disease, UT Health Austin/Dell Children's Medical Center, Austin, Texas, USA; Department of Surgery and Perioperative Care, Dell Medical School, The University of Texas at Austin, Austin, Texas, USA
| | - Arnold L Fenrich
- Texas Center for Pediatric and Congenital Heart Disease, UT Health Austin/Dell Children's Medical Center, Austin, Texas, USA; Department of Pediatrics, Dell Medical School, The University of Texas at Austin, Austin, Texas, USA
| |
Collapse
|
4
|
Samples S, Fitt C, Satzer M, Wakai R, Strasburger J, Patel S. Fetal Congenital Complete Heart Block: A Rare Case with an Extremely Low Ventricular Rate and Review of Current Management Strategies. CHILDREN (BASEL, SWITZERLAND) 2023; 10:1132. [PMID: 37508630 PMCID: PMC10378391 DOI: 10.3390/children10071132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 06/22/2023] [Accepted: 06/27/2023] [Indexed: 07/30/2023]
Abstract
Congenital complete heart block (CCHB) is associated with high intrauterine and post-natal mortality. Prenatal detection and management, as well as appropriate delivery planning, may improve the outcomes in CCHB. We describe a rare case of CCHB that initially presented with fetal ascites and high-grade second-degree heart block noted on fetal echocardiography. The mother was noted to be positive for anti-SSA antibodies, and treatment with maternal steroids was started in an effort to reverse the fetal cardiac conduction abnormality. However, the fetal cardiac rhythm progressed to complete heart block by the follow up evaluation and the fetus had a continual declination of heart rate throughout the pregnancy to a low fetal heart rate of 25 beats per minute (bpm). This case demonstrates the lowest fetal ventricular rate documented in the literature and illustrates a severe presentation of a rare disease process. An overview of the existing knowledge related to etiology, prenatal evaluation with fetal echocardiography and fetal magnetocardiography, prenatal management, and delivery planning in fetuses with prenatally detected CCHB is included.
Collapse
Affiliation(s)
- Stefani Samples
- Pediatric Cardiology, Ann & Robert Lurie Children's Hospital of Chicago, Chicago, IL 60611, USA
| | - Catherine Fitt
- Pediatric Cardiology, Ann & Robert Lurie Children's Hospital of Chicago, Chicago, IL 60611, USA
| | - Michael Satzer
- Pediatric Cardiology, Ann & Robert Lurie Children's Hospital of Chicago, Chicago, IL 60611, USA
| | - Ronald Wakai
- Department of Medical Physics, University of Wisconsin, Madison, WI 53705, USA
| | - Janette Strasburger
- Pediatric Cardiology, Children's Hospital of Wisconsin, Milwaukee, WI 53226, USA
| | - Sheetal Patel
- Pediatric Cardiology, Ann & Robert Lurie Children's Hospital of Chicago, Chicago, IL 60611, USA
| |
Collapse
|
5
|
Haxel CS, Johnson JN, Hintz S, Renno MS, Ruano R, Zyblewski SC, Glickstein J, Donofrio MT. Care of the Fetus With Congenital Cardiovascular Disease: From Diagnosis to Delivery. Pediatrics 2022; 150:189887. [PMID: 36317976 DOI: 10.1542/peds.2022-056415c] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/29/2022] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND The majority of congenital cardiovascular disease including structural cardiac defects, abnormalities in cardiac function, and rhythm disturbances can be identified prenatally using screening obstetrical ultrasound with referral for fetal echocardiogram when indicated. METHODS Diagnosis of congenital heart disease in the fetus should prompt assessment for extracardiac abnormalities and associated genetic abnormalities once maternal consent is obtained. Pediatric cardiologists, in conjunction with maternal-fetal medicine, neonatology, and cardiothoracic surgery subspecialists, should counsel families about the details of the congenital heart defect as well as prenatal and postnatal management. RESULTS Prenatal diagnosis often leads to increased maternal depression and anxiety; however, it decreases morbidity and mortality for many congenital heart defects by allowing clinicians the opportunity to optimize prenatal care and plan delivery based on the specific lesion. Changes in prenatal care can include more frequent assessments through the remainder of the pregnancy, maternal medication administration, or, in selected cases, in utero cardiac catheter intervention or surgical procedures to optimize postnatal outcomes. Delivery planning may include changing the location, timing or mode of delivery to ensure that the neonate is delivered in the most appropriate hospital setting with the required level of hospital staff for immediate postnatal stabilization. CONCLUSIONS Based on the specific congenital heart defect, prenatal echocardiogram assessment in late gestation can often aid in predicting the severity of postnatal instability and guide the medical or interventional level of care needed for immediate postnatal intervention to optimize the transition to postnatal circulation.
Collapse
Affiliation(s)
- Caitlin S Haxel
- The University of Vermont Children's Hospital, Burlington, Vermont
| | | | - Susan Hintz
- Stanford University, Lucille Salter Packard Children's Hospital, Palo Alto, California
| | - Markus S Renno
- University Arkansas for Medical Sciences, Little Rock, Arkansas
| | | | | | - Julie Glickstein
- Columbia University Vagelos School of Medicine, Morgan Stanley Children's Hospital, New York, New York
| | | |
Collapse
|
6
|
Strasburger JF, Eckstein G, Butler M, Noffke P, Wacker-Gussmann A. Fetal Arrhythmia Diagnosis and Pharmacologic Management. J Clin Pharmacol 2022; 62 Suppl 1:S53-S66. [PMID: 36106782 PMCID: PMC9543141 DOI: 10.1002/jcph.2129] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 07/25/2022] [Indexed: 11/24/2022]
Abstract
One of the most successful achievements of fetal intervention is the pharmacologic management of fetal arrhythmias. This management usually takes place during the second or third trimester. While most arrhythmias in the fetus are benign, both tachy‐ and bradyarrhythmias can lead to fetal hydrops or cardiac dysfunction and require treatment under certain conditions. This review will highlight precise diagnosis by fetal echocardiography and magnetocardiography, the 2 primary means of diagnosing fetuses with arrhythmia. Additionally, transient or hidden arrhythmias such as bundle branch block, QT prolongation, and torsades de pointes, which can lead to cardiomyopathy and sudden unexplained death in the fetus, may also need pharmacologic treatment. The review will address the types of drug therapies; current knowledge of drug usage, efficacy, and precautions; and the transition to neonatal treatments when indicated. Finally, we will highlight new assessments, including the role of the nurse in the care of fetal arrhythmias. The prognosis for the human fetus with arrhythmias continues to improve as we expand our ability to provide intensive care unit–like monitoring, to better understand drug treatments, to optimize subsequent pregnancy monitoring, to effectively predict timing for delivery, and to follow up these conditions into the neonatal period and into childhood. Coordinated initiatives that facilitate clinical fetal research are needed to address gaps in knowledge and to facilitate fetal drug and device development.
Collapse
Affiliation(s)
- Janette F Strasburger
- Division of Cardiology, Departments of Pediatrics and Biomedical Engineering, Children's Wisconsin, Herma Heart Institute, and Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Gretchen Eckstein
- Division of Cardiology, Departments of Pediatrics and Biomedical Engineering, Children's Wisconsin, Herma Heart Institute, and Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Mary Butler
- College of Nursing, University of Wisconsin-Oshkosh, Oshkosh, Wisconsin, USA
| | - Patrick Noffke
- Division of Cardiology, Departments of Pediatrics and Biomedical Engineering, Children's Wisconsin, Herma Heart Institute, and Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Annette Wacker-Gussmann
- German Heart Center, Department of Congenital Heart Disease and Pediatric Cardiology Munich, Munchen, Bavaria, Germany
| |
Collapse
|
7
|
Wacker-Gussmann A, Strasburger JF, Wakai RT. Contribution of Fetal Magnetocardiography to Diagnosis, Risk Assessment, and Treatment of Fetal Arrhythmia. J Am Heart Assoc 2022; 11:e025224. [PMID: 35904205 PMCID: PMC9375504 DOI: 10.1161/jaha.121.025224] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Fetal echocardiography has been the mainstay of fetal arrhythmia diagnosis; however, fetal magnetocardiography (fMCG) has recently become clinically available. We sought to determine to what extent fMCG contributed to the precision and accuracy of fetal arrhythmia diagnosis and risk assessment, and in turn, how this altered pregnancy management. Methods and Results We reviewed fMCG tracings and medical records of 215 pregnancies referred to the Biomagnetism Laboratory, UW‐Madison, over the last 10 years, because of fetal arrhythmia or risk of arrhythmia. We compared referral diagnosis and treatment with fMCG diagnosis using a rating scale and restricted our review to the 144 subjects from the tachycardia, bradycardia/AV block, and familial long QT syndrome categories. Additional fMCG findings beyond those of the referring echocardiogram, or an alternative diagnosis were seen in 117/144 (81%), and 81 (56%) were critical changes. Eight (5.5%) had resolution of arrhythmia before fMCG. At least moderate changes in management were seen in 109/144 (76%) fetuses, of which 35/144 (24%) were major. The most diverse fMCG presentation was long QT syndrome, present in all 3 referral categories. Four of 5 stillbirths were seen with long QT syndrome. Nine fetuses showed torsades de pointes ventricular tachycardia, of which only 2 were recognized before fMCG. Conclusions FMCG has a significant impact on prenatal diagnosis and management of arrhythmias or familial arrhythmia risk, which cannot be fully met by existing technology. The combination of fMCG and fetal echocardiography in fetal care centers will be needed in the future to optimize care.
Collapse
Affiliation(s)
- Annette Wacker-Gussmann
- Department of Congential Heart Disease and Pediatric Cardiology German Heart Center Munich Germany
| | - Janette F Strasburger
- Departments of Pediatrics and Biomedical Engineering Children's Wisconsin and Herma Heart Institute Milwaukee WI
| | - Ronald T Wakai
- Department of Medical Physics University of Wisconsin-Madison Madison WI
| |
Collapse
|
8
|
Kaplinski M, Cuneo BF. Novel approaches to the surveillance and management of fetuses at risk for anti-Ro/SSA mediated atrioventricular block. Semin Perinatol 2022; 46:151585. [PMID: 35410713 DOI: 10.1016/j.semperi.2022.151585] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Approximately one percent of pregnant women will produce anti-Sjogren's syndrome-related antigen A (anti-Ro/SSA) antibodies. Of these pregnancies, one to three percent will have a fetus that develops atrioventricular (AV) block. Earlier stages of AV block (1° or 2°) may respond to anti-inflammatory treatment, but complete (3°) AV block, which can occur within 24 hours of a normal fetal rhythm, is likely irreversible and carries substantial risk for significant morbidity and for mortality. Emerging data has shown that ambulatory fetal heart rhythm monitoring can detect the transition period from normal rhythm to 2° AV block, the time during which treatment with IVIG and dexamethasone can potentially restore normal sinus rhythm. Weekly or biweekly fetal echocardiograms occur too infrequently to detect this transition period but may still be useful in diagnosing extranodal anti-Ro antibody mediated cardiac disease. In this review, we evaluate the most innovative methods for surveillance and treatment of this disease.
Collapse
Affiliation(s)
- Michelle Kaplinski
- Division of Cardiology, Department of Pediatrics, Stanford University School of Medicine, Lucile Packard Children's Hospital, Palo Alto, CA, USA.
| | - Bettina F Cuneo
- Division of Cardiology, Departments of Pediatrics and Obstetrics, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, CO, USA
| |
Collapse
|
9
|
Meisgen S, Hedlund M, Ambrosi A, Folkersen L, Ottosson V, Forsberg D, Thorlacius GE, Biavati L, Strandberg L, Mofors J, Ramskold D, Ruhrmann S, Meneghel L, Nyberg W, Espinosa A, Hamilton RM, Franco-Cereceda A, Hamsten A, Olsson T, Greene L, Eriksson P, Gemzell-Danielsson K, Salomonsson S, Kuchroo VK, Herlenius E, Kockum I, Sonesson SE, Wahren-Herlenius M. Auxilin is a novel susceptibility gene for congenital heart block which directly impacts fetal heart function. Ann Rheum Dis 2022; 81:1151-1161. [PMID: 35470161 PMCID: PMC9279836 DOI: 10.1136/annrheumdis-2021-221714] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 04/11/2022] [Indexed: 11/03/2022]
Abstract
OBJECTIVE Neonatal lupus erythematosus (NLE) may develop after transplacental transfer of maternal autoantibodies with cardiac manifestations (congenital heart block, CHB) including atrioventricular block, atrial and ventricular arrhythmias, and cardiomyopathies. The association with anti-Ro/SSA antibodies is well established, but a recurrence rate of only 12%-16% despite persisting maternal autoantibodies suggests that additional factors are required for CHB development. Here, we identify fetal genetic variants conferring risk of CHB and elucidate their effects on cardiac function. METHODS A genome-wide association study was performed in families with at least one case of CHB. Gene expression was analysed by microarrays, RNA sequencing and PCR and protein expression by western blot, immunohistochemistry, immunofluorescence and flow cytometry. Calcium regulation and connectivity were analysed in primary cardiomyocytes and cells induced from pleuripotent stem cells. Fetal heart performance was analysed by Doppler/echocardiography. RESULTS We identified DNAJC6 as a novel fetal susceptibility gene, with decreased cardiac expression of DNAJC6 associated with the disease risk genotype. We further demonstrate that fetal cardiomyocytes deficient in auxilin, the protein encoded by DNAJC6, have abnormal connectivity and Ca2+ homoeostasis in culture, as well as decreased cell surface expression of the Cav1.3 calcium channel. Doppler echocardiography of auxilin-deficient fetal mice revealed cardiac NLE abnormalities in utero, including abnormal heart rhythm with atrial and ventricular ectopias, as well as a prolonged atrioventricular time intervals. CONCLUSIONS Our study identifies auxilin as the first genetic susceptibility factor in NLE modulating cardiac function, opening new avenues for the development of screening and therapeutic strategies in CHB.
Collapse
Affiliation(s)
- Sabrina Meisgen
- Department of Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Malin Hedlund
- Department of Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Aurelie Ambrosi
- Department of Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Lasse Folkersen
- Department of Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden.,Technical University of Denmark, Lyngby, Denmark
| | - Vijole Ottosson
- Department of Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - David Forsberg
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Gudny Ella Thorlacius
- Department of Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Luca Biavati
- Department of Physiology and Experimental Medicine, Hospital for Sick Children, Washington, DC, USA
| | - Linn Strandberg
- Department of Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Johannes Mofors
- Department of Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Daniel Ramskold
- Department of Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Sabrina Ruhrmann
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Lauro Meneghel
- Department of Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - William Nyberg
- Department of Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Alexander Espinosa
- Department of Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | | | | | - Anders Hamsten
- Department of Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Tomas Olsson
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Lois Greene
- National Institutes of Health, Bethesda, Maryland, USA
| | - Per Eriksson
- Department of Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | | | - Stina Salomonsson
- Department of Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Vijay K Kuchroo
- Evergrande Center for Immunologic Diseases, Harvard Medical School, Boston, Massachusetts, USA
| | - Eric Herlenius
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Ingrid Kockum
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Sven-Erik Sonesson
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Marie Wahren-Herlenius
- Department of Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden .,Broegelmann Research Laboratory, Department of Clinical Science, University of Bergen, Bergen, Norway
| |
Collapse
|
10
|
Suzuki Y, Kiyosawa M. Cardiac Hypertrophy May Be a Risk Factor for the Development and Severity of Glaucoma. Biomedicines 2022; 10:biomedicines10030677. [PMID: 35327479 PMCID: PMC8945816 DOI: 10.3390/biomedicines10030677] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Revised: 03/09/2022] [Accepted: 03/13/2022] [Indexed: 02/05/2023] Open
Abstract
The purpose of this study was to examine the relationship between glaucoma and cardiac abnormalities. We evaluated 581 patients with open-angle glaucoma (285 men and 296 women) and 595 individuals without glaucoma (273 men and 322 women). All of the participants underwent visual field testing using a Humphrey Visual Field Analyzer (30-2 program), an electrocardiogram (ECG), and blood pressure measurement. We examined the ECG abnormalities and other factors (age, intraocular pressure (IOP) and systemic hypertension) involved in the development and severity of glaucoma. Logistic regression analyses revealed significant correlations of glaucoma with IOP (OR = 1.43; 95% CI: 1.36−1.51; p < 0.00001), atrial fibrillation (OR = 2.02; 95% CI: 1.01−4.04; p = 0.04), left ventricular hypertrophy (LVH) (OR = 2.21; 95% CI: 1.15−4.25; p = 0.02), and bradycardia (OR = 2.19; 95% CI: 1.25−4.70; p = 0.02). Regression analyses revealed significant correlations of the mean deviation of the visual field with age (t = −6.22; 95% CI: −0.15, −0.08; p < 0.00001), IOP (t = −6.47; 95% CI: −0.42, −0.23; p < 0.00001), and LVH (t = −2.15; 95% CI: −3.36, −0.29; p = 0.02). Atrial fibrillation, LVH and bradycardia may decrease the cerebral blood flow, and may also affect the ocular blood flow. Cardiac abnormalities may be associated with the development and severity of glaucoma.
Collapse
Affiliation(s)
- Yukihisa Suzuki
- Department of Ophthalmology, Japan Community Health Care Organization, Mishima General Hospital, Shizuoka 411-0801, Japan
- Research Team for Neuroimaging, Tokyo Metropolitan Institute of Gerontology, Tokyo 173-0015, Japan
- Correspondence: ; Tel.: +81-55-975-3031; Fax: +81-55-973-3647
| | | |
Collapse
|
11
|
Gozar L, Gabor-Miklosi D, Toganel R, Fagarasan A, Gozar H, Toma D, Cerghit-Paler A. Fetal Tachyarrhythmia Management from Digoxin to Amiodarone-A Review. J Clin Med 2022; 11:jcm11030804. [PMID: 35160256 PMCID: PMC8836967 DOI: 10.3390/jcm11030804] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 01/26/2022] [Accepted: 01/31/2022] [Indexed: 11/21/2022] Open
Abstract
Sustained fetal tachycardias are rare but represent a high risk of mortality and morbidity. Consensus has yet to be found regarding their optimal management. The aim of this narrative review is to summarize the data available in the current literature regarding the efficacy and safety of medications used in the management of intrauterine tachyarrhythmias and to provide possible treatment protocols. In this review, we would like to emphasize the importance of a thorough evaluation of both the fetus and the mother, prior to transplacental antiarrhythmic drug initiation. Factors such as the hemodynamic status of the fetus, possible mechanisms of fetal arrhythmia, and concomitant maternal conditions are of primordial importance. As a possible treatment protocol, we would like to recommend the following: due to the risk of sustained supraventricular tachycardia (SVT), fetuses with frequent premature atrial beats should be evaluated more frequently by echocardiography. A careful hemodynamic evaluation of a fetus with tachycardia is primordial in forestalling the appearance of hydrops. In the case of atrial flutter (AFL), sotalol therapy could represent a first choice, whereas when dealing with SVT patients, flecainide should be considered, especially for hydropic patients. These data require consolidation through larger scale, non-randomized studies and should be handled with caution.
Collapse
Affiliation(s)
- Liliana Gozar
- Department of Pediatrics, “George Emil Palade” University of Medicine, Pharmacy, Science, and Technology of Târgu-Mureș, 540139 Târgu-Mureș, Romania; (L.G.); (R.T.); (A.F.); (D.T.); (A.C.-P.)
- Pediatric Cardiology, Emergency Institute of Cardiovascular Diseases and Transplantation, 540139 Târgu-Mureș, Romania
| | - Dorottya Gabor-Miklosi
- Pediatric Cardiology, Emergency Institute of Cardiovascular Diseases and Transplantation, 540139 Târgu-Mureș, Romania
- Correspondence: ; Tel.: +40-740-371-322
| | - Rodica Toganel
- Department of Pediatrics, “George Emil Palade” University of Medicine, Pharmacy, Science, and Technology of Târgu-Mureș, 540139 Târgu-Mureș, Romania; (L.G.); (R.T.); (A.F.); (D.T.); (A.C.-P.)
- Pediatric Cardiology, Emergency Institute of Cardiovascular Diseases and Transplantation, 540139 Târgu-Mureș, Romania
| | - Amalia Fagarasan
- Department of Pediatrics, “George Emil Palade” University of Medicine, Pharmacy, Science, and Technology of Târgu-Mureș, 540139 Târgu-Mureș, Romania; (L.G.); (R.T.); (A.F.); (D.T.); (A.C.-P.)
- Pediatric Cardiology, Emergency Institute of Cardiovascular Diseases and Transplantation, 540139 Târgu-Mureș, Romania
| | - Horea Gozar
- Department of Pediatric Surgery, “George Emil Palade” University of Medicine, Pharmacy, Science, and Technology of Târgu-Mureș, 540139 Târgu-Mureș, Romania;
| | - Daniela Toma
- Department of Pediatrics, “George Emil Palade” University of Medicine, Pharmacy, Science, and Technology of Târgu-Mureș, 540139 Târgu-Mureș, Romania; (L.G.); (R.T.); (A.F.); (D.T.); (A.C.-P.)
- Pediatric Cardiology, Emergency Institute of Cardiovascular Diseases and Transplantation, 540139 Târgu-Mureș, Romania
| | - Andreea Cerghit-Paler
- Department of Pediatrics, “George Emil Palade” University of Medicine, Pharmacy, Science, and Technology of Târgu-Mureș, 540139 Târgu-Mureș, Romania; (L.G.); (R.T.); (A.F.); (D.T.); (A.C.-P.)
- Pediatric Cardiology, Emergency Institute of Cardiovascular Diseases and Transplantation, 540139 Târgu-Mureș, Romania
| |
Collapse
|
12
|
Wang X, Liu XW, Han L, Li MT, Zhao JL, Sun L, Han JC, Zeng XF, Tian XP, Zhao Y, He YH. Cardiac manifestations in a Chinese cohort of fetuses from mothers with anti-Ro and anti-La antibodies. Front Pediatr 2022; 10:904138. [PMID: 35967560 PMCID: PMC9371606 DOI: 10.3389/fped.2022.904138] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Accepted: 07/11/2022] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVES To analyze the clinical characteristics, echocardiographic features, and prognosis of fetuses based on three groups of cardiac manifestations associated with maternal anti-Ro and anti-La antibodies in China. This study included three groups: the isolated-arrhythmia, isolated-endocardial fibroelastosis (EFE), and mixed groups. METHODS We prospectively evaluated 36 fetuses with cardiac manifestations due to maternal anti-Ro and anti-La antibodies from our center between 2016 and 2020 in China. Clinical and echocardiographic data were collected. RESULTS There were 13 patients (36%) in the isolated-arrhythmia group, eight (22%) in the isolated-EFE group, and 15 (42%) in the mixed group. All patients in the isolated-EFE group presented with mild EFE. Severe EFE was identified in four patients (27%) in the mixed group. Atrioventricular block (AVB) was more common in the isolated-arrhythmia group (13, 100%) than in the mixed group (6, 40%; p = 0.001). Moderate-severe mitral regurgitation (p = 0.006), dilated cardiomyopathy (DCM, p = 0.017), and low cardiovascular profile scores (p = 0.013) were more common in the mixed group than in the other two groups. Twenty-one mothers decided to terminate the pregnancy and 15 fetuses were born with regular perinatal treatment. They all survived at 1 year of age. One patient in the isolated-arrhythmia group and two in the mixed group required a pacemaker due to third-degree AVB or atrioventricular junctional rhythm. Five patients in the isolated-EFE group and five in the mixed group had no DCM or heart failure and the location of mild EFE was significantly reduced. CONCLUSION Fetal cardiac manifestations due to maternal anti-Ro and anti-La antibodies can be divided into three groups, i.e., the isolated-arrhythmia, isolated-EFE, and mixed groups. AVB usually occurs in the isolated-arrhythmia group. Severe EFE, moderate-severe mitral regurgitation, and DCM mainly appear in the mixed group. Location of mild EFE significantly reduces after birth and the outcome of fetuses with mild EFE depends on the presence of arrhythmia and its subtypes.
Collapse
Affiliation(s)
- Xin Wang
- Echocardiography Medical Center, Maternal-Fetal Medicine Center in Fetal Heart Disease, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Xiao-Wei Liu
- Echocardiography Medical Center, Maternal-Fetal Medicine Center in Fetal Heart Disease, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Ling Han
- Department of Pediatric Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Meng-Tao Li
- Department of Rheumatology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, National Clinical Research Center for Dermatologic and Immunologic Diseases, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Jiu-Liang Zhao
- Department of Rheumatology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, National Clinical Research Center for Dermatologic and Immunologic Diseases, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Lin Sun
- Echocardiography Medical Center, Maternal-Fetal Medicine Center in Fetal Heart Disease, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Jian-Cheng Han
- Echocardiography Medical Center, Maternal-Fetal Medicine Center in Fetal Heart Disease, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Xiao-Feng Zeng
- Department of Rheumatology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, National Clinical Research Center for Dermatologic and Immunologic Diseases, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Xin-Ping Tian
- Department of Rheumatology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, National Clinical Research Center for Dermatologic and Immunologic Diseases, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Ying Zhao
- Echocardiography Medical Center, Maternal-Fetal Medicine Center in Fetal Heart Disease, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Yi-Hua He
- Echocardiography Medical Center, Maternal-Fetal Medicine Center in Fetal Heart Disease, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| |
Collapse
|
13
|
Karmegaraj B. Sinoatrial nodal disease presenting with tachy-bradycardia syndrome in a fetus of anti-SSA/SSB-positive mother. Ann Pediatr Cardiol 2022; 15:67-69. [PMID: 35847395 PMCID: PMC9280093 DOI: 10.4103/apc.apc_9_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 05/13/2021] [Accepted: 05/21/2021] [Indexed: 11/24/2022] Open
Abstract
Tachy-bradycardia syndrome (TBS) has been reported rarely in the fetus. We present here an unusual dominant involvement of sinoatrial node in a fetus presenting with TBS of anti-Sjögren'syndrome-related antigen A (SS-A) and antigen B (SS-B) autoantibodies positive mother. Prenatal imaging findings, Doppler hemodynamics, and outcomes are described.
Collapse
Affiliation(s)
- Balaganesh Karmegaraj
- Sowmi Fetal and Pediatric Heart Centre, Tirunelveli, Tamilnadu, India,Department of Pediatric Cardiology, Amrita Institute of Medical Sciences, Kochi, Kerala, India,Address for correspondence: Dr. Balaganesh Karmegaraj, Amrita Institute of Medical Sciences, Kochi, Kerala, India. E-mail:
| |
Collapse
|
14
|
Gropler MR, von Alvensleben J, Benson DW, Cuneo BF. Classic and atypical Wenckebach periodicity in a late gestation fetus with maternal anti-Ro/SSA antibodies. HeartRhythm Case Rep 2021; 7:611-614. [PMID: 34552853 PMCID: PMC8441196 DOI: 10.1016/j.hrcr.2021.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- Melanie R.F. Gropler
- Division of Cardiology, Department of Pediatrics, Children’s Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado
| | - Johannes von Alvensleben
- Division of Cardiology, Department of Pediatrics, Children’s Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado
| | | | - Bettina F. Cuneo
- Division of Cardiology, Department of Pediatrics, Children’s Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado
- Address reprint requests and correspondence: Dr Bettina F. Cuneo, Children’s Hospital Colorado, 13123 East 16th Ave, B100, Aurora, CO 80045.
| |
Collapse
|
15
|
Treatment of Fetal Arrhythmias. J Clin Med 2021; 10:jcm10112510. [PMID: 34204066 PMCID: PMC8201238 DOI: 10.3390/jcm10112510] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Revised: 06/01/2021] [Accepted: 06/01/2021] [Indexed: 11/16/2022] Open
Abstract
Fetal arrhythmias are mostly benign and transient. However, some of them are associated with structural defects or can cause heart failure, fetal hydrops, and can lead to intrauterine death. The analysis of fetal heart rhythm is based on ultrasound (M-mode and Doppler echocardiography). Irregular rhythm due to atrial ectopic beats is the most common type of fetal arrhythmia and is generally benign. Tachyarrhythmias are diagnosed when the fetal heart rate is persistently above 180 beats per minute (bpm). The most common fetal tachyarrhythmias are paroxysmal supraventricular tachycardia and atrial flutter. Most fetal tachycardias can be terminated or controlled by transplacental or direct administration of anti-arrhythmic drugs. Fetal bradycardia is diagnosed when the fetal heart rate is slower than 110 bpm. Persistent bradycardia outside labor or in the absence of placental pathology is mostly due to atrioventricular (AV) block. Approximately half of fetal heart blocks are in cases with structural heart defects, and AV block in cases with structurally normal heart is often caused by maternal anti-Ro/SSA antibodies. The efficacy of prenatal treatment for fetal AV block is limited. Our review aims to provide a practical guide for the diagnosis and management of common fetal arrythmias, from the joint perspective of the fetal medicine specialist and the cardiologist.
Collapse
|
16
|
Whole-Exome Sequencing Identifies a Novel TRPM4 Mutation in a Chinese Family with Atrioventricular Block. BIOMED RESEARCH INTERNATIONAL 2021; 2021:9247541. [PMID: 33959666 PMCID: PMC8075657 DOI: 10.1155/2021/9247541] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 09/24/2020] [Accepted: 02/02/2021] [Indexed: 11/17/2022]
Abstract
Atrioventricular block (AVB) is a leading cause of sudden cardiac death, and most of AVB cases are presented as autosomal dominant. The electrocardiogram of AVB patients presents an abnormal progressive cardiac conduction disorder between atria and ventricles. Transient receptor potential melastatin 4 (TRPM4) is a nonselective Ca2+-activated cation channel gene defined as a novel disease-causing gene of AVB. So far, 47 mutations of TRPM4 have been recorded in Human Gene Mutation Database. The aim of this study was to explore the relationship between TRPM4 mutation and pathogenesis of AVB. We investigated a Chinese family with AVB by whole-exome sequencing. An arrhythmia-related gene filtering strategy was used to analyze the disease-causing mutations. Three different bioinformatics programs were used to predict the effects of the mutation result. A novel mutation of TRPM4 was identified (c.2455C>T/p.R819C) and cosegregated in the affected family members. The three bioinformatics programs predicted that the novel mutation may lead to damage. Our study will contribute to expand the spectrum of TRPM4 mutations and supply accurate genetic testing information for further research and the clinical therapy of AVB.
Collapse
|
17
|
Milazzo R, Ligato E, Laoreti A, Ferri G, Basili L, Serati L, Brucato A, Cetin I. Home fetal heart rate monitoring in anti Ro/SSA positive pregnancies: Literature review and case report. Eur J Obstet Gynecol Reprod Biol 2021; 259:1-6. [PMID: 33556767 DOI: 10.1016/j.ejogrb.2021.01.031] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Accepted: 01/18/2021] [Indexed: 10/22/2022]
Abstract
Anti-Ro/SSA antibodies are associated with a risk of 1-2 % to develop complete atrioventricular block (AVB) in fetuses of positive mothers. Complete AVB is irreversible, but studies suggest that anti-inflammatory treatment during the transition period from a normal fetal heart rate (FHR) to an AVB might stop this progression and restore sinus rhythm. The most efficient method for diagnostic evaluation of this arrhythmia is the pulsed-Doppler fetal echocardiography. However, weekly or bi-weekly recommended fetal echocardiographic surveillance can rarely identify an AVB in time for treatment success, also because the transition from a normal rhythm to a third degree AVB is very fast. Daily FHR monitoring in a medical facility could increase the chances of identifying the AVB onset but is difficult to realize. For this reason, an alternative method of FHR monitoring, performed directly by mothers in their home context, has been recently proposed. We present a case report utilizing this approach and review the current evidence about this condition.
Collapse
Affiliation(s)
- Roberta Milazzo
- Department of Woman, Mother and Neonate, "V. Buzzi" Children Hospital, ASST Fatebenefratelli Sacco, Milan, Italy.
| | - Elisa Ligato
- Department of Woman, Mother and Neonate, "V. Buzzi" Children Hospital, ASST Fatebenefratelli Sacco, Milan, Italy
| | - Arianna Laoreti
- Department of Woman, Mother and Neonate, "V. Buzzi" Children Hospital, ASST Fatebenefratelli Sacco, Milan, Italy
| | - Giulia Ferri
- Department of Woman, Mother and Neonate, "V. Buzzi" Children Hospital, ASST Fatebenefratelli Sacco, Milan, Italy
| | - Ludovica Basili
- Department of Woman, Mother and Neonate, "V. Buzzi" Children Hospital, ASST Fatebenefratelli Sacco, Milan, Italy
| | - Lisa Serati
- Internal Medicine, Fatebenefratelli Hospital, Milan, Italy
| | | | - Irene Cetin
- Department of Woman, Mother and Neonate, "V. Buzzi" Children Hospital, ASST Fatebenefratelli Sacco, Milan, Italy; Department of Biomedical and Clinical Sciences "Luigi Sacco", University of Milan, Milan, Italy
| |
Collapse
|
18
|
Ambrosi A, Thorlacius GE, Sonesson SE, Wahren-Herlenius M. Interferons and innate immune activation in autoimmune congenital heart block. Scand J Immunol 2021; 93:e12995. [PMID: 33188653 DOI: 10.1111/sji.12995] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Revised: 10/26/2020] [Accepted: 11/06/2020] [Indexed: 12/12/2022]
Abstract
Autoimmune congenital heart block (CHB) may develop in foetuses of women carrying anti-Ro/SSA and La/SSB autoantibodies and is characterized by disruption of signal conduction at the atrioventricular (AV) node, resulting in partial or complete AV block. If not fatal in utero, complete CHB typically requires lifelong cardiac pacing. No treatment has so far been unequivocally demonstrated to prevent or treat autoimmune CHB, and the relatively low incidence (1%-5%) and recurrence (12%-16%) rates of second/third-degree AV block add to the complexity of managing pregnancies in women with anti-Ro/La antibodies. Altogether, a better understanding of events leading to development of autoimmune CHB is needed to improve surveillance and treatment strategies. In the past decade, studies have started to look beyond the role of maternal autoantibodies in disease pathogenesis to assess other contributing factors such as foetal genetics and, more recently, immune responses in foetuses and neonates of anti-Ro/La antibody-positive women. In this review, we provide an update on the epidemiology, clinical presentation and current treatment approaches of autoimmune CHB, summarize the previously proposed pathogenic mechanisms implicating maternal autoantibodies, and discuss the recent findings of type I interferon (IFN) and innate immune activation in foetuses with autoimmune CHB and in neonates of anti-Ro/La antibody-positive mothers, and how these may contribute to autoimmune CHB pathogenesis.
Collapse
Affiliation(s)
- Aurelie Ambrosi
- Division of Rheumatology, Department of Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Gudny Ella Thorlacius
- Division of Rheumatology, Department of Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Sven-Erik Sonesson
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Marie Wahren-Herlenius
- Division of Rheumatology, Department of Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden.,Broegelmann Research Laboratory, Department of Clinical Science, University of Bergen, Bergen, Norway
| |
Collapse
|
19
|
Strasburger JF, Wacker-Gussmann A. Congenital Heart Block in Subsequent Pregnancies of SSA/Ro-Positive Mothers: Cutting Recurrence in Half. J Am Coll Cardiol 2020; 76:303-305. [PMID: 32674793 PMCID: PMC7357977 DOI: 10.1016/j.jacc.2020.05.052] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Accepted: 05/27/2020] [Indexed: 11/04/2022]
Affiliation(s)
- Janette F Strasburger
- Department of Pediatrics, Division of Cardiology, Children's Wisconsin, Milwaukee, Wisconsin.
| | - Annette Wacker-Gussmann
- Department of Pediatric Cardiology and Congenital Heart Disease, German Heart Center, Munich, Germany
| |
Collapse
|
20
|
Su PC, Miller S, Idriss S, Barker P, Wu HT. Recovery of the fetal electrocardiogram for morphological analysis from two trans-abdominal channels via optimal shrinkage. Physiol Meas 2019; 40:115005. [PMID: 31585453 DOI: 10.1088/1361-6579/ab4b13] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVE We propose a novel algorithm to recover fetal electrocardiogram (ECG) for both the fetal heart rate analysis and morphological analysis of its waveform from two or three trans-abdominal maternal ECG channels. APPROACH We design an algorithm based on the optimal-shrinkage under the wave-shape manifold model. For the fetal heart rate analysis, the algorithm is evaluated on publicly available database, 2013 PhyioNet/Computing in Cardiology Challenge, set A (CinC2013). For the morphological analysis, we analyze CinC2013 and another publicly available database, non-invasive fetal ECG arrhythmia database (nifeadb), and propose to simulate semi-real databases by mixing the MIT-BIH normal sinus rhythm database and MITDB arrhythmia database. MAIN RESULTS For the fetal R peak detection, the proposed algorithm outperforms all algorithms under comparison. For the morphological analysis, the algorithm provides an encouraging result in recovery of the fetal ECG waveform, including PR, QT and ST intervals, even when the fetus has arrhythmia, both in real and simulated databases. SIGNIFICANCE To the best of our knowledge, this is the first work focusing on recovering the fetal ECG for morphological analysis from two or three channels with an algorithm potentially applicable for continuous fetal electrocardiographic monitoring, which creates the potential for long term monitoring purpose.
Collapse
Affiliation(s)
- Pei-Chun Su
- Department of Mathematics, Duke University, Durham, NC, United States of America
| | | | | | | | | |
Collapse
|
21
|
Strand S, Lutter W, Strasburger JF, Shah V, Baffa O, Wakai RT. Low-Cost Fetal Magnetocardiography: A Comparison of Superconducting Quantum Interference Device and Optically Pumped Magnetometers. J Am Heart Assoc 2019; 8:e013436. [PMID: 31394997 PMCID: PMC6759914 DOI: 10.1161/jaha.119.013436] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Fetal magnetocardiography (fMCG) is a highly effective technique for evaluation of fetuses with life-threatening arrhythmia, but its dissemination has been constrained by the high cost and complexity of Superconducting Quantum Interference Device (SQUID) instrumentation. Optically pumped magnetometers (OPMs) are a promising new technology that can replace SQUIDs for many applications. This study compares the performance of an fMCG system, utilizing OPMs operating in a person-sized magnetic shield, to that of a conventional fMCG system, utilizing SQUID magnetometers operating in a magnetically shielded room. Methods and Results fMCG recordings were made in 24 subjects using the SQUID system with the mother lying supine in a magnetically shielded room and the OPM system with the mother lying prone in a person-sized, cylindrical shield. Signal-to-noise ratios of the OPM and SQUID recordings were not statistically different and were adequate for diagnostic purposes with both technologies. Although the environmental noise was higher using the small open-ended shield, this was offset by the higher signal amplitude achieved with prone positioning, which reduced the distance between the fetus and sensors and improved patient comfort. In several subjects, fMCG provided a differential diagnosis that was more precise and/or definitive than was possible with echocardiography alone. Conclusions The OPM-based system was portable, improved patient comfort, and performed as well as the SQUID-based system at a small fraction of the cost. Electrophysiological assessment of fetal rhythm is now practical and will have a major impact on management of fetuses with long QT syndrome and other life-threatening arrhythmias.
Collapse
Affiliation(s)
- Sarah Strand
- Department of Medical Physics University of Wisconsin Madison WI
| | - William Lutter
- Department of Medical Physics University of Wisconsin Madison WI
| | - Janette F Strasburger
- Division of Cardiology Department of Pediatrics Children's Hospital of Wisconsin- Milwaukee Milwaukee WI
| | | | - Oswaldo Baffa
- Department of Physics FFCLRP Ribeirao Preto, University of Sao Paulo Brazil
| | - Ronald T Wakai
- Department of Medical Physics University of Wisconsin Madison WI
| |
Collapse
|
22
|
Abstract
BACKGROUND Fetal magnetocardiography (fMCG) is the most direct and precise method of assessing fetal rhythm and conduction. Although the utility of fMCG for evaluation of fetuses with serious arrhythmia is generally acknowledged, many aspects of fetal rhythm and conduction are relatively unstudied. OBJECTIVE To record fMCG in a large group of normal fetuses in order to provide a more comprehensive evaluation of fMCG waveform characteristics, including waveform intervals, amplitudes, and morphology. METHODS The subjects were 132 healthy women with uncomplicated singleton pregnancies, studied at 15.7-39.9 (mean 28.9) weeks' gestation in 259 sessions. The P, PR, QRS, QT, QTc, and RR intervals and the P/QRS and T/QRS amplitude ratios were measured. MAIN RESULTS The P, PR, QRS, and RR intervals increased with gestational age, but QT and QTc did not. U-waves were seen in 11% of fetuses. The T-waves were often flat with low T/QRS amplitude ratios. Equiphasic QRS complexes were associated with tall P-waves. The PR, QRS, and QT intervals showed a power law dependence on RR interval with power law exponents 0.445, 0.363, and 0.381, respectively. SIGNIFICANCE The data establish prediction intervals for fMCG waveform intervals and amplitudes in normal fetuses. This is critical for identification of fetuses with abnormal rhythm. Our study is the first to document the incidence of U-waves and flat T-waves in the fetus, both of which are uncommon postnatally. The association of tall P-waves with equiphasic QRS complexes provides a useful means of improving the resolution of fetal P-waves.
Collapse
Affiliation(s)
- Sarah A Strand
- Department of Medical Physics, University of Wisconsin-Madison, 1111 Highland Ave. Rm. 1005, Madison, WI 53705, United States of America
| | | | | |
Collapse
|
23
|
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.
Collapse
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
| |
Collapse
|
24
|
Magnetocardiography on an isolated animal heart with a room-temperature optically pumped magnetometer. Sci Rep 2018; 8:16218. [PMID: 30385784 PMCID: PMC6212485 DOI: 10.1038/s41598-018-34535-z] [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: 07/04/2018] [Accepted: 10/12/2018] [Indexed: 11/08/2022] Open
Abstract
Optically pumped magnetometers are becoming a promising alternative to cryogenically-cooled superconducting magnetometers for detecting and imaging biomagnetic fields. Magnetic field detection is a completely non-invasive method, which allows one to study the function of excitable human organs with a sensor placed outside the human body. For instance, magnetometers can be used to detect brain activity or to study the activity of the heart. We have developed a highly sensitive miniature optically pumped magnetometer based on cesium atomic vapor kept in a paraffin-coated glass container. The magnetometer is optimized for detection of biological signals and has high temporal and spatial resolution. It is operated at room- or human body temperature and can be placed in contact with or at a mm-distance from a biological object. With this magnetometer, we detected the heartbeat of an isolated guinea-pig heart, which is an animal widely used in biomedical studies. In our recordings of the magnetocardiogram, we can detect the P-wave, QRS-complex and T-wave associated with the cardiac cycle in real time. We also demonstrate that our device is capable of measuring the cardiac electrographic intervals, such as the RR- and QT-interval, and detecting drug-induced prolongation of the QT-interval, which is important for medical diagnostics.
Collapse
|
25
|
Abstract
This article reviews important features for improving the diagnosis of fetal arrhythmias by ultrasound in prenatal cardiac screening and echocardiography. Transient fetal arrhythmias are more common than persistent fetal arrhythmias. However, persistent severe bradycardia and sustained tachycardia may cause fetal hydrops, preterm delivery, and higher perinatal morbidity and mortality. Hence, the diagnosis of these arrhythmias during the routine obstetric ultrasound, before the progression to hydrops, is crucial and represents a challenge that involves a team of specialists and subspecialists on fetal ultrasonography. The images in this review highlight normal cardiac rhythms as well as pathologic cases consistent with premature atrial and ventricular contractions, heart block, supraventricular tachycardia (VT), atrial flutter, and VT. In this review, the details of a variety of arrhythmias in fetuses were provided by M-mode and Doppler ultrasound/echocardiography with high-quality imaging, enhancing diagnostic accuracy. Moreover, an update on the intrauterine management and treatment of many arrhythmias is provided, focusing on improving outcomes to enable planned delivery and perinatal management.
Collapse
Affiliation(s)
| | - Luciane Alves Rocha
- Department of Obstetrics, Paulista School of Medicine, Federal University of São Paulo (EPM-UNIFESP), São Paulo, Brazil
| | | | - Edward Araujo Júnior
- Department of Obstetrics, Paulista School of Medicine, Federal University of São Paulo (EPM-UNIFESP), São Paulo, Brazil
| |
Collapse
|
26
|
Zaidi SJ, Siddiqui S, Cuneo BF, Strasburger JF, McDuffie R, Wakai RT. Prenatal diagnosis and management of junctional ectopic tachycardia. HeartRhythm Case Rep 2018; 3:503-508. [PMID: 29387539 PMCID: PMC5778096 DOI: 10.1016/j.hrcr.2017.07.022] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Affiliation(s)
- S. Javed Zaidi
- The Heart Institute for Children, Advocate Children’s Hospital, Oak Lawn, Illinois
| | - Saad Siddiqui
- The Heart Institute for Children, Advocate Children’s Hospital, Oak Lawn, Illinois
- Rosalind Franklin School of Medicine, North Chicago, Illinois
| | - Bettina F. Cuneo
- The Heart Institute, Children’s Hospital Colorado, Aurora, Colorado
- University of Colorado School of Medicine, Aurora, Colorado
| | - Janette F. Strasburger
- Herma Heart Center, Children’s Hospital of Wisconsin, Milwaukee, Wisconsin
- Medical College of Wisconsin, Milwaukee, Wisconsin
- Address reprint requests and correspondence: Dr Janette F. Strasburger, Children’s Hospital of Wisconsin, Herma Heart Center, MS 713, 9000 W. Wisconsin Ave, Milwaukee, WI 53226.Children’s Hospital of WisconsinHerma Heart CenterMS 713, 9000 W. Wisconsin AveMilwaukeeWI53226
| | - Robert McDuffie
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Colorado School of Medicine, Aurora, Colorado
| | - Ronald T. Wakai
- Department of Medical Physics, University of Wisconsin, Biomagnetism Laboratory, Wisconsin Institutes for Medical Research, Madison, Wisconsin
| |
Collapse
|
27
|
Murta LO, Guzo MG, Moraes ER, Baffa O, Wakai RT, Comani S. Segmented independent component analysis for improved separation of fetal cardiac signals from nonstationary fetal magnetocardiograms. ACTA ACUST UNITED AC 2017; 60:235-44. [PMID: 25781658 DOI: 10.1515/bmt-2014-0114] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2014] [Accepted: 01/27/2015] [Indexed: 11/15/2022]
Abstract
Fetal magnetocardiograms (fMCGs) have been successfully processed with independent component analysis (ICA) to separate the fetal cardiac signals, but ICA effectiveness can be limited by signal nonstationarities due to fetal movements. We propose an ICA-based method to improve the quality of fetal signals separated from fMCG affected by fetal movements. This technique (SegICA) includes a procedure to detect signal nonstationarities, according to which the fMCG recordings are divided in stationary segments that are then processed with ICA. The first and second statistical moments and the signal polarity reversal were used at different threshold levels to detect signal transients. SegICA effectiveness was assessed in two fMCG datasets (with and without fetal movements) by comparing the signal-to-noise ratio (SNR) of the signals extracted with ICA and with SegICA. Results showed that the SNR of fetal signals affected by fetal movements improved with SegICA, whereas the SNR gain was negligible elsewhere. The best measure to detect signal nonstationarities of physiological origin was signal polarity reversal at threshold level 0.9. The first statistical moment also provided good results at threshold level 0.6. SegICA seems a promising method to separate fetal cardiac signals of improved quality from nonstationary fMCG recordings affected by fetal movements.
Collapse
|
28
|
Eswaran H, Escalona-Vargas D, Bolin EH, Wilson JD, Lowery CL. Fetal magnetocardiography using optically pumped magnetometers: a more adaptable and less expensive alternative? Prenat Diagn 2017; 37:193-196. [PMID: 27891637 DOI: 10.1002/pd.4976] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Revised: 11/16/2016] [Accepted: 11/21/2016] [Indexed: 11/10/2022]
Abstract
Fetal magnetocardiography provides the requisite precision for diagnostic measurement of electrophysiological events in the fetal heart. Despite its significant benefits, this technique with current cryogenic based sensors has been limited to few centers, due to high cost of maintenance. In this study, we show that a less expensive non-cryogenic alternative, optically pumped magnetometers, can provide similar electrophysiological and quantitative characteristics when subjected to direct comparison with the current technology. Further research can potentially increase its clinical use for fetal magnetocardiography. © 2016 John Wiley & Sons, Ltd.
Collapse
Affiliation(s)
- Hari Eswaran
- Department of Obstetrics and Gynecology, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Diana Escalona-Vargas
- Department of Obstetrics and Gynecology, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Elijah H Bolin
- Department of Pediatric Cardiology, University of Arkansas for Medical Sciences, Arkansas Children's Hospital, Little Rock, AR, USA
| | - James D Wilson
- Department of Obstetrics and Gynecology, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Curtis L Lowery
- Department of Obstetrics and Gynecology, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| |
Collapse
|
29
|
Lazzaroni MG, Dall’Ara F, Fredi M, Nalli C, Reggia R, Lojacono A, Ramazzotto F, Zatti S, Andreoli L, Tincani A. A comprehensive review of the clinical approach to pregnancy and systemic lupus erythematosus. J Autoimmun 2016; 74:106-117. [DOI: 10.1016/j.jaut.2016.06.016] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2016] [Accepted: 06/27/2016] [Indexed: 01/23/2023]
|
30
|
Late Outcome and Predictors of Adverse Events Related to the Implantation of a Permanent Pacemaker in Patients with Isolated Congenital Atrioventricular Block. Pediatr Cardiol 2016; 37:1319-27. [PMID: 27335082 DOI: 10.1007/s00246-016-1437-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2016] [Accepted: 06/17/2016] [Indexed: 10/21/2022]
Abstract
Isolated congenital atrioventricular block (ICAVB) is a rare, and pacemaker implantation is the only effective treatment. We sought to identify the predictive factors of adverse events related to pacemaker implantation in ICAVB. This is a cohort study of patients diagnosed with ICAVB who underwent pacemaker implantation from 1980 to 2014 in a single center. During the studied period, a total of 647 patients underwent implantation of their first permanent cardiac pacemaker before 30 years of age. Of these, only 62 (9.5 %) were diagnosed with ICAVB. This condition was diagnosed in utero in 15 (24.2 %) cases, 5 (8.1 %) in the neonatal period, 32 (51.6 %) during childhood, and 10 (16.1 %) during adolescence and young adulthood. The presence of autoantibodies (anti-Ro/SSA) was observed in 41 % of mothers who underwent serological evaluation. Age at the time of the initial pacemaker implant was 9.8 ± 9 years. During a mean follow-up time of 15 years, 1 (1.7 %) death occurred due to infectious endocarditis. Complications related to pacemaker implant were reported in 24 patients (38.7 %). The number of complications was significantly higher in the group with an epimyocardial implantation site (HR 6; CI 2.45-14.95). Ventricular dysfunction occurred in 6 (11.7 %) patients; however, we were not able to identify any predictors of it. Our results showed a low mortality rate after permanent therapy. However, these patients exhibited high morbidity related to the pacemaker system, and the epimyocardial implant site was an independent predictor of complications. Predictors of left ventricular dysfunction were not found in the present study.
Collapse
|
31
|
Wacker-Gussmann A, Wakai RT, Strasburger JF. Importance of Fetal Arrhythmias to the Neonatologist and Pediatrician. Neoreviews 2016; 17:e568-e578. [PMID: 28042286 PMCID: PMC5193162 DOI: 10.1542/neo.17-10-e568] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Sudden, unexplained death during the perinatal period remains a major, longstanding challenge. Recent advances in diagnostic techniques and genetic testing has provided evidence that a significant fraction of these deaths may result from lethal cardiac arrhythmias. In this paper, we review current methods of diagnosing arrhythmia in the fetus and strategies for management of life-threatening arrhythmia throughout the perinatal period, including transitional care at the time of delivery.
Collapse
Affiliation(s)
- Annette Wacker-Gussmann
- Institute of Preventive Pediatrics, Faculty of Sport and Health Sciences, and German Heart Center, Department of Pediatric Cardiology and Congenital Heart Defects, Munich, Germany
| | - Ronald T Wakai
- Department of Medical Physics, University of Wisconsin-Madison, Madison, Wisconsin 53706, USA
| | - Janette F Strasburger
- Department of Pediatrics, Division of Cardiology, Children's Hospital of Wisconsin- Milwaukee and Fox Valley, 9000 W Wisconsin Avenue, Milwaukee, Wisconsin 53226, USA
| |
Collapse
|
32
|
Baruteau AE, Pass RH, Thambo JB, Behaghel A, Le Pennec S, Perdreau E, Combes N, Liberman L, McLeod CJ. Congenital and childhood atrioventricular blocks: pathophysiology and contemporary management. Eur J Pediatr 2016; 175:1235-1248. [PMID: 27351174 PMCID: PMC5005411 DOI: 10.1007/s00431-016-2748-0] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2016] [Revised: 06/13/2016] [Accepted: 06/16/2016] [Indexed: 02/07/2023]
Abstract
UNLABELLED Atrioventricular block is classified as congenital if diagnosed in utero, at birth, or within the first month of life. The pathophysiological process is believed to be due to immune-mediated injury of the conduction system, which occurs as a result of transplacental passage of maternal anti-SSA/Ro-SSB/La antibodies. Childhood atrioventricular block is therefore diagnosed between the first month and the 18th year of life. Genetic variants in multiple genes have been described to date in the pathogenesis of inherited progressive cardiac conduction disorders. Indications and techniques of cardiac pacing have also evolved to allow safe permanent cardiac pacing in almost all patients, including those with structural heart abnormalities. CONCLUSION Early diagnosis and appropriate management are critical in many cases in order to prevent sudden death, and this review critically assesses our current understanding of the pathogenetic mechanisms, clinical course, and optimal management of congenital and childhood AV block. WHAT IS KNOWN • Prevalence of congenital heart block of 1 per 15,000 to 20,000 live births. AV block is defined as congenital if diagnosed in utero, at birth, or within the first month of life, whereas childhood AV block is diagnosed between the first month and the 18th year of life. As a result of several different etiologies, congenital and childhood atrioventricular block may occur in an entirely structurally normal heart or in association with concomitant congenital heart disease. Cardiac pacing is indicated in symptomatic patients and has several prophylactic indications in asymptomatic patients to prevent sudden death. • Autoimmune, congenital AV block is associated with a high neonatal mortality rate and development of dilated cardiomyopathy in 5 to 30 % cases. What is New: • Several genes including SCN5A have been implicated in autosomal dominant forms of familial progressive cardiac conduction disorders. • Leadless pacemaker technology and gene therapy for biological pacing are promising research fields. In utero percutaneous pacing appears to be at high risk and needs further development before it can be adopted into routine clinical practice. Cardiac resynchronization therapy is of proven value in case of pacing-induced cardiomyopathy.
Collapse
Affiliation(s)
- Alban-Elouen Baruteau
- Cardiovascular and Cell Sciences Research Center, St George’s University of London, London, UK
- LIRYC Institute, CHU Bordeaux, Department of Pediatric Cardiology, Bordeaux-II University, Bordeaux, France
- Service de Cardiologie Pédiatrique, Hôpital du Haut Lévèque, Institut Hospitalo-Universitaire LIRYC (Electrophysiology and Heart Modeling Institute), 5 avenue de Magellan, 33600 Pessac, France
| | - Robert H. Pass
- Division of Pediatric Electrophysiology, Albert Einstein College of Medicine, Montefiore Children’s Hospital, Bronx, NY USA
| | - Jean-Benoit Thambo
- LIRYC Institute, CHU Bordeaux, Department of Pediatric Cardiology, Bordeaux-II University, Bordeaux, France
| | - Albin Behaghel
- CHU Rennes, Department of Cardiology, LTSI, INSERM 1099, Rennes-1 University, Rennes, France
| | - Solène Le Pennec
- CHU Rennes, Department of Cardiology, LTSI, INSERM 1099, Rennes-1 University, Rennes, France
| | - Elodie Perdreau
- LIRYC Institute, CHU Bordeaux, Department of Pediatric Cardiology, Bordeaux-II University, Bordeaux, France
| | - Nicolas Combes
- Department of Cardiology, Clinique Pasteur, Toulouse, France
| | - Leonardo Liberman
- Morgan Stanley Children’s Hospital, Division of Pediatric Cardiology, New York Presbyterian Hospital, Columbia University Medical Center, New York, NY USA
| | - Christopher J. McLeod
- Mayo Clinic, Division of Cardiovascular Diseases, Mayo Clinic College of Medicine, Rochester, MN USA
| |
Collapse
|
33
|
Cuneo BF, Strasburger JF, Wakai RT. The natural history of fetal long QT syndrome. J Electrocardiol 2016; 49:807-813. [PMID: 27539165 DOI: 10.1016/j.jelectrocard.2016.07.023] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2016] [Indexed: 01/13/2023]
Abstract
INTRODUCTION Fetal magnetocardiography (fMCG), the magnetic analog of ECG, has provided invaluable insight into the mechanisms of fetal arrhythmias. In the past 15years, we have evaluated over 300 fetuses with arrhythmia by fMCG. We review the unique characteristics and natural history of the long QT syndrome (LQTS) rhythms. METHODS We reviewed the fMCGs of subjects referred with suspected LQTS based on either a positive family history or echo diagnosis of the LQTS rhythms (sinus bradycardia, ventricular tachycardia, or 2:1 AV conduction) to the Biomagnetism laboratory in the Department of Medical Physics, UW-Madison. We recorded fMCGs using a 37-channel (Magnes, 4D Neuroimaging, Inc., San Diego, CA) superconducting quantum interference device (SQUID) biomagnetometer, housed in a magnetically-shielded room for 1200-6000s. Signal processing was used to remove maternal interference. Cardiac intervals (R-R, p, QRS, QT) were measured and compared to published normals. We correlated fetal heart rate (FHR) patterns and effects of fetal movement on FHR and rhythm using actocardiography. RESULTS Thirty-nine fetuses were studied at a mean of 28 (19-38) weeks of gestation. All had structurally normal hearts. One was on amiodarone for suspected supraventricular tachycardia and hydrops. Five had serial fMCGs. Isolated sinus bradycardia with a QTc >490ms was found in 35: 33 had a KCNQ1 mutation There was one false positive and one false negative LQTS diagnosis. Four fetuses had torsades de pointes (TdP) and 3 had periods of 2:1 conduction and either KCNH2 or SCN5A mutations. TdP was rarely initiated with a preceding long-short pattern and did not degenerate into ventricular fibrillation. One fetus with TdP died in utero, 2 with fetal TdP had postnatal cardiac arrest. CONCLUSION Fetal LQTS is diagnosed by an fMCG QTc >490ms with an 89% sensitivity and specificity. TdP are seen with uncharacterized, KCNH2 or SCN5A R1623q mutations. Fetal TdP occurs when QTc ≥620ms. Identifying fetal LQTS and defining its rhythms by fMCG risk stratifies postnatal management.
Collapse
Affiliation(s)
- Bettina F Cuneo
- Children's Hospital Colorado, Department of Pediatrics, Heart Institute, University of Colorado School of Medicine, Aurora, CO.
| | - Janette F Strasburger
- Children's Hospital of Wisconsin Department of Pediatrics, Section of Cardiology, the Medical College of Wisconsin, Milwaukee, WI
| | - Ronald T Wakai
- The Biomagnetism Laboratory, Department of Medical Physics, University of Wisconsin, Madison, WI
| |
Collapse
|
34
|
Sonesson SE, Acharya G. Hemodynamics in fetal arrhythmia. Acta Obstet Gynecol Scand 2015; 95:697-709. [PMID: 26660845 DOI: 10.1111/aogs.12837] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2015] [Accepted: 12/03/2015] [Indexed: 10/22/2022]
Abstract
Fetal arrhythmias are among the few conditions that can be managed in utero. However, accurate diagnosis is essential for appropriate management. Ultrasound-based imaging methods can be used to study fetal heart structure and function noninvasively and help to understand fetal cardiovascular pathophysiology, and they remain the mainstay of evaluating fetuses with arrhythmias in clinical settings. Hemodynamic evaluation using Doppler echocardiography allows the elucidation of the electrophysiological mechanism and helps to make an accurate diagnosis. It can also be used as a tool to understand fetal cardiac pathophysiology, for assessing fetal condition and monitoring the effect of antiarrhythmic treatment. This narrative review describes Doppler techniques that are useful for evaluating fetal cardiac rhythms to refine diagnosis and provides an overview of hemodynamic changes observed in different types of fetal arrhythmia.
Collapse
Affiliation(s)
- Sven-Erik Sonesson
- Pediatric Cardiology Unit, Department of Women's and Children's Health, Karolinska Institute, Stockholm, Sweden
| | - Ganesh Acharya
- Women's Health and Perinatology Research Group, Department of Clinical Medicine, Faculty of Health Sciences, UiT - The Arctic University of Norway, Tromsø, Norway.,Department of Obstetrics and Gynecology, University Hospital of Northern Norway, Tromsø, Norway.,Department of Clinical Sciences, Intervention and Technology, Karolinska Institute, Stockholm, Sweden
| |
Collapse
|
35
|
Kuleva M, Le Bidois J, Decaudin A, Villain E, Costedoat-Chalumeau N, Lemercier D, Dumez Y, Ville Y, Bonnet D, Salomon LJ. Clinical course and outcome of antenatally detected atrioventricular block: experience of a single tertiary centre and review of the literature. Prenat Diagn 2015; 35:354-61. [PMID: 25487821 DOI: 10.1002/pd.4547] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2014] [Revised: 12/03/2014] [Accepted: 12/03/2014] [Indexed: 01/20/2023]
Abstract
OBJECTIVE The objective is to study the course and outcome of fetuses with congenital atrioventricular block (AVB) in a single centre. METHODS Retrospective analysis of cases diagnosed prenatally with second and third degree AVB. The clinical characteristics and outcome of fetal AVB were evaluated including in utero treatment. RESULTS Sixty-two cases were studied. AVB was associated with a congenital heart defect (CHD-AVB) in 17 cases (27%), whereas it was isolated (i-AVB) in 45 (73%), 42 of which were associated with maternal antibodies. There were nine (52.9%) live births in the CHD-AVB group, five of which (55%) resulted in infant deaths. In the i-AVB group, there were 40/45 (88.9%) live births and 1/40 (2.5%) infant death; 36 (90%) babies required a permanent pacemaker. The only factor predictive of postnatal death was the presence of CHD (5/9 vs 1/39 or 48.7 [3.6; 1457.7], p < 0.001). Nineteen fetuses (40.5%) with i-AVB received steroids in utero. No difference in outcome was found between the AVB treated in utero versus the no-treatment group in terms of permanent pacemaker placement, postnatal death or development of dilated cardiomyopathy. CONCLUSION The most important prognostic factor for congenital AVB is the association with CHD. In utero treatment remains questionable.
Collapse
Affiliation(s)
- M Kuleva
- Department of Obstetrics and Gynecology, M3C-Necker, Hôpital Necker Enfants malades, 75015, Paris, France
| | | | | | | | | | | | | | | | | | | |
Collapse
|
36
|
Krishnan A, Arya B, Moak JP, Donofrio MT. Outcomes of fetal echocardiographic surveillance in anti-SSA exposed fetuses at a large fetal cardiology center. Prenat Diagn 2014; 34:1207-12. [PMID: 24989941 DOI: 10.1002/pd.4454] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2013] [Revised: 05/15/2014] [Accepted: 06/28/2014] [Indexed: 11/11/2022]
Abstract
BACKGROUND Echocardiography screening in anti-SSA antibody exposed fetuses is controversial. OBJECTIVE The aim of this study is to evaluate utility of fetal echocardiography in anti-SSA exposure. METHODS Echocardiograms performed over 9 years for maternal anti-SSA exposure were reviewed for atrioventricular (AV) block, cardiomyopathy, arrhythmias, effusion, valve abnormalities, or other abnormalities identified by the echocardiographer. Fetuses with AV block referred to our institution and subsequently found to be anti-SSA exposed were also identified. RESULTS Six hundred thirty six echocardiograms were performed on 140 fetuses (Cohort 1) of 134 women screened for maternal anti-SSA +/- anti-SSB antibodies. No fetuses developed second or third-degree AV block or cardiomyopathy (odds ratio 0.1, CI 0.0051 to 1.9410, p = 0.13). Dexamethasone was administered to three fetuses for sinus bradycardia, echogenicity near AV node, and ventricular systolic dysfunction with valve regurgitation; all normalized. Screening echocardiograms identified: sinus bradycardia (n = 1), PR prolongation (n = 5), premature atrial contractions (n = 3), valve regurgitation (n = 24), echogenic myocardium (n = 4), and pericardial effusion (n = 1). Isolated tricuspid regurgitation and first-degree AV block did not progress. Nine cases of SSA-mediated AV block (Cohort 2) were referred after heart block developed. CONCLUSIONS Serial fetal echocardiography in anti-SSA exposed fetuses did not detect AV block. In rare cases, dexamethasone treatment may have affected disease course.
Collapse
Affiliation(s)
- Anita Krishnan
- Department of Cardiology, Children's National Heart Institute, Children's National Medical Center, 111 Michigan Ave, NW, Washington, DC, 20010, USA
| | | | | | | |
Collapse
|
37
|
Abstract
AIMS Detection and careful stratification of fetal heart rate (FHR) is extremely important in all pregnancies. The most lethal cardiac rhythm disturbances occur during apparently normal pregnancies where FHR and rhythm are regular and within normal or low-normal ranges. These hidden depolarization and repolarization abnormalities, associated with genetic ion channelopathies cannot be detected by echocardiography, and may be responsible for up to 10% of unexplained fetal demise, prompting a need for newer and better fetal diagnostic techniques. Other manifest fetal arrhythmias such as premature beats, tachycardia, and bradycardia are commonly recognized. METHODS Heart rhythm diagnosis in obstetrical practice is usually made by M-mode and pulsed Doppler fetal echocardiography, but not all fetal cardiac time intervals are captured by echocardiographic methods. RESULTS AND CONCLUSIONS This article reviews different types of fetal arrhythmias, their presentation and treatment strategies, and gives an overview of the present and future diagnostic techniques.
Collapse
Affiliation(s)
| | - Janette F. Strasburger
- Division of Cardiology, Department of Pediatrics, Children’s Hospital of Wisconsin-Milwaukee and Fox Valley, Milwaukee, Wisconsin
| | - Bettina F. Cuneo
- Department of Pediatrics, Children’s Hospital Colorado, The Heart Institute, The University of Colorado School of Medicine, Denver, Colorado
| | - Ronald T. Wakai
- Department of Medical Physics, University of Wisconsin, Madison, Wisconsin
| |
Collapse
|
38
|
Sonesson SE, Eliasson H, Conner P, Wahren-Herlenius M. Doppler echocardiographic isovolumetric time intervals in diagnosis of fetal blocked atrial bigeminy and 2:1 atrioventricular block. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2014; 44:171-175. [PMID: 24585694 DOI: 10.1002/uog.13344] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/14/2013] [Revised: 01/17/2014] [Accepted: 02/14/2014] [Indexed: 06/03/2023]
Abstract
OBJECTIVE To distinguish between blocked atrial bigeminy (BB) and incomplete atrioventricular block with 2:1 conduction (2:1 AVB) can be very difficult, especially in the mid-term fetus. Making a correct diagnosis has important clinical implications, as their prognosis and management differ markedly. Our objective was to investigate whether analysis of isovolumetric time intervals could improve Doppler echocardiography in differentiating these conditions. METHODS Sixteen fetuses with sustained BB or isolated 2:1 AVB, diagnosed at our tertiary center from 2002 to 2012, were reviewed retrospectively. Doppler recordings of left ventricular in- and outflow, including mitral and aortic valve movements, were used to measure isovolumetric contraction (ICT) and relaxation (IRT) time intervals. ICT reference values obtained from 104 normal pregnancies were used for comparison. RESULTS Ten fetuses had BB and six 2:1 AVB. Five of the AVB cases were anti-Ro antibody positive and one had long QT syndrome (LQTS). ICT was systematically shorter in BB than in antibody-mediated 2:1 AVB. Nine of 10 cases with BB had an ICT below -2 SD and the five with antibody-mediated 2:1 AVB had values at or above +2 SD. All 15 fetuses with either BB or antibody-mediated AVB had an IRT of < 70 ms, as opposed to a markedly prolonged IRT (105 ms) in the LQTS case. CONCLUSION Measurement of ICT can improve the differential diagnosis between BB and antibody-mediated 2:1 AVB. Fetuses with BB or antibody-mediated AVB are unlikely to have IRT measurements exceeding 70 ms and, when this is observed, LQTS should be considered a more likely diagnosis.
Collapse
Affiliation(s)
- S-E Sonesson
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | | | | | | |
Collapse
|
39
|
Donofrio MT, Moon-Grady AJ, Hornberger LK, Copel JA, Sklansky MS, Abuhamad A, Cuneo BF, Huhta JC, Jonas RA, Krishnan A, Lacey S, Lee W, Michelfelder EC, Rempel GR, Silverman NH, Spray TL, Strasburger JF, Tworetzky W, Rychik J. Diagnosis and treatment of fetal cardiac disease: a scientific statement from the American Heart Association. Circulation 2014; 129:2183-242. [PMID: 24763516 DOI: 10.1161/01.cir.0000437597.44550.5d] [Citation(s) in RCA: 719] [Impact Index Per Article: 71.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND The goal of this statement is to review available literature and to put forth a scientific statement on the current practice of fetal cardiac medicine, including the diagnosis and management of fetal cardiovascular disease. METHODS AND RESULTS A writing group appointed by the American Heart Association reviewed the available literature pertaining to topics relevant to fetal cardiac medicine, including the diagnosis of congenital heart disease and arrhythmias, assessment of cardiac function and the cardiovascular system, and available treatment options. The American College of Cardiology/American Heart Association classification of recommendations and level of evidence for practice guidelines were applied to the current practice of fetal cardiac medicine. Recommendations relating to the specifics of fetal diagnosis, including the timing of referral for study, indications for referral, and experience suggested for performance and interpretation of studies, are presented. The components of a fetal echocardiogram are described in detail, including descriptions of the assessment of cardiac anatomy, cardiac function, and rhythm. Complementary modalities for fetal cardiac assessment are reviewed, including the use of advanced ultrasound techniques, fetal magnetic resonance imaging, and fetal magnetocardiography and electrocardiography for rhythm assessment. Models for parental counseling and a discussion of parental stress and depression assessments are reviewed. Available fetal therapies, including medical management for arrhythmias or heart failure and closed or open intervention for diseases affecting the cardiovascular system such as twin-twin transfusion syndrome, lung masses, and vascular tumors, are highlighted. Catheter-based intervention strategies to prevent the progression of disease in utero are also discussed. Recommendations for delivery planning strategies for fetuses with congenital heart disease including models based on classification of disease severity and delivery room treatment will be highlighted. Outcome assessment is reviewed to show the benefit of prenatal diagnosis and management as they affect outcome for babies with congenital heart disease. CONCLUSIONS Fetal cardiac medicine has evolved considerably over the past 2 decades, predominantly in response to advances in imaging technology and innovations in therapies. The diagnosis of cardiac disease in the fetus is mostly made with ultrasound; however, new technologies, including 3- and 4-dimensional echocardiography, magnetic resonance imaging, and fetal electrocardiography and magnetocardiography, are available. Medical and interventional treatments for select diseases and strategies for delivery room care enable stabilization of high-risk fetuses and contribute to improved outcomes. This statement highlights what is currently known and recommended on the basis of evidence and experience in the rapidly advancing and highly specialized field of fetal cardiac care.
Collapse
|
40
|
Atrioventricular conduction delay in the second trimester measured by fetal magnetocardiography. J Immunol Res 2014; 2014:753953. [PMID: 24741622 PMCID: PMC3987975 DOI: 10.1155/2014/753953] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2013] [Revised: 12/22/2013] [Accepted: 12/24/2013] [Indexed: 11/26/2022] Open
Abstract
Introduction. Fetal AV block in SSA/Ro pregnancies is generally not seen before 18-week gestation and onset is rare after 28-week gestation. If complete AV block appears, it is believed to be irreversible. The purpose of the study was to evaluate precise electrophysiological AV conduction from 18-week gestation onwards. Patients and Methods. 21 fetuses of pregnant women with collagen vascular diseases were included in the study group and 59 healthy fetuses served as controls. In addition to fetal echocardiography, fetal magnetocardiography (fMCG) was used to investigate precise electrophysiological fetal cardiac time intervals (fCTIs). Results. The PR segment (isoelectric segment between the end of the P wave and the start of the QRS complex) was significantly prolonged (P < 0.036 2nd trimester, P < 0.023 3rd trimester) in both trimesters within the study group. In fetuses less than 23-week gestational age, a nearly complete separation was found, where a PR segment of 60 ms or greater completely excluded control fetuses. All other fCTIs did not differ significantly. None of the fetuses progressed to a more advanced heart block. Conclusion. Slight antibody effects in pregnancy, leading to PR segment prolongation, can already be seen from 18-week gestation onwards by fMCG. Serial fetal Doppler echocardiography and additional fMCG can be useful methods to measure early and precise AV conduction time, to achieve best surveillance for these high-risk pregnancies.
Collapse
|
41
|
Ambrosi A, Sonesson SE, Wahren-Herlenius M. Molecular mechanisms of congenital heart block. Exp Cell Res 2014; 325:2-9. [PMID: 24434353 DOI: 10.1016/j.yexcr.2014.01.003] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2013] [Revised: 01/02/2014] [Accepted: 01/06/2014] [Indexed: 01/30/2023]
Abstract
Autoantibody-associated congenital heart block (CHB) is a passively acquired autoimmune condition associated with maternal anti-Ro/SSA antibodies and primarily affecting electric signal conduction at the atrioventricular node in the fetal heart. CHB occurs in 1-2% of anti-Ro/SSA antibody-positive pregancies and has a recurrence rate of 12-20% in a subsequent pregnancy. Despite the long-recognized association between maternal anti-Ro/SSA autoantibodies and CHB, the molecular mechanisms underlying CHB pathogenesis are not fully understood, but several targets for the maternal autoantibodies in the fetal heart have been suggested. Recent studies also indicate that fetal susceptibility genes determine whether an autoantibody-exposed fetus will develop CHB or not, and begin to identify such genes. In this article, we review the different lines of investigation undertaken to elucidate the molecular pathways involved in CHB development and reflect on the hypotheses put forward to explain CHB pathogenesis as well as on the questions left unanswered and that should guide future studies.
Collapse
Affiliation(s)
- Aurélie Ambrosi
- Unit of Experimental Rheumatology, Department of Medicine, Karolinska Institutet, 171 76 Stockholm, Sweden.
| | - Sven-Erik Sonesson
- Department of Women and Child Health, Karolinska Institutet, 171 76 Stockholm, Sweden.
| | - Marie Wahren-Herlenius
- Unit of Experimental Rheumatology, Department of Medicine, Karolinska Institutet, 171 76 Stockholm, Sweden.
| |
Collapse
|
42
|
Vogel T, Kitcharoensakkul M, Fotis L, Baszis K. The heart and pediatric rheumatology. Rheum Dis Clin North Am 2013; 40:61-85. [PMID: 24268010 DOI: 10.1016/j.rdc.2013.10.008] [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] [Indexed: 10/26/2022]
Abstract
Recent advances in Kawasaki disease have included attempts to define genes involved in its pathogenesis. There have been recent advances in the studies of rheumatic carditis, leading to a better understanding of the mechanism of the disease. Histologic evaluation of patients with neonatal lupus erythematosus has revealed fibrosis with collagen deposition and calcification of the atrioventricular node. Therapy for cardiac involvement in systemic juvenile idiopathic arthritis should involve treatment of the underlying disease and systemic inflammatory state, and typically includes nonsteroidal antiinflammatory drugs, corticosteroids, disease-modifying drugs, and biologic therapies targeting tumor necrosis factor-alpha, interleukin-1, and interleukin-6.
Collapse
Affiliation(s)
- Tiphanie Vogel
- Division of Rheumatology, Department of Pediatrics, Washington University School of Medicine, Box 8116, One Children's Place, St Louis, MO 63110, USA; Division of Rheumatology, Department of Medicine, Washington University School of Medicine, 660 South Euclid Avenue, St Louis, MO 63110, USA
| | | | | | | |
Collapse
|
43
|
Brugada J, Blom N, Sarquella-Brugada G, Blomstrom-Lundqvist C, Deanfield J, Janousek J, Abrams D, Bauersfeld U, Brugada R, Drago F, de Groot N, Happonen JM, Hebe J, Yen Ho S, Marijon E, Paul T, Pfammatter JP, Rosenthal E. Pharmacological and non-pharmacological therapy for arrhythmias in the pediatric population: EHRA and AEPC-Arrhythmia Working Group joint consensus statement. ACTA ACUST UNITED AC 2013; 15:1337-82. [DOI: 10.1093/europace/eut082] [Citation(s) in RCA: 217] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
|
44
|
Wiggins DL, Strasburger JF, Gotteiner NL, Cuneo B, Wakai RT. Magnetophysiologic and echocardiographic comparison of blocked atrial bigeminy and 2:1 atrioventricular block in the fetus. Heart Rhythm 2013; 10:1192-8. [PMID: 23619035 DOI: 10.1016/j.hrthm.2013.04.020] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2013] [Indexed: 11/28/2022]
Abstract
BACKGROUND Blocked atrial bigeminy (BAB) and second-degree atrioventricular block with 2:1 conduction block (2:1 AVB) both present as ventricular bradycardia and can be difficult to distinguish by echocardiography. Since the prognosis and clinical management of these rhythms are different, an accurate diagnosis is essential. OBJECTIVE To identify magnetic and mechanical heart rate and rhythm parameters that could reliably distinguish BAB from 2:1 AVB. METHODS A retrospective study of ten BAB and seven 2:1 AVB subjects was performed, using fMCG and pulsed Doppler ultrasound. RESULTS Distinguishing BAB from 2:1 AVB by using fMCG was relatively straightforward because in BAB the ectopic P wave (P') occurred early, resulting in a bigeminal (short-long) atrial rhythm. The normalized coupling interval of the ectopic beat (PP' of the blocked beat to PP of the conducted beat) was 0.29 ± 0.03. In contrast, the echocardiographic assessment of inflow-outflow gave a normalized mechanical coupling interval (AA'/AA) near 0.5, which made it difficult to distinguish BAB from 2:1 AVB. Heart rate distinguished most subjects with BAB from those with 2:1 AVB (82 ± 5.7 beats/min vs 69 ± 4.2 beats/min), but was not a completely reliable indicator. In most subjects, BAB alternated with sinus rhythm or other rhythms, resulting in complex heart rate and rhythm patterns. CONCLUSIONS Fetal BAB and 2:1 AV block can be difficult to distinguish using echocardiography because in many fetuses with BAB the mechanical rhythm does not accurately reflect the magnetic rhythm. fMCG provides a more reliable means of making a differential diagnosis.
Collapse
Affiliation(s)
- Delonia L Wiggins
- Department of Medical Physics, University of Wisconsin-Madison, Madison, Wisconsin 53705, USA
| | | | | | | | | |
Collapse
|
45
|
Abstract
BACKGROUND Fetal echocardiography plays a critical role in the diagnosis and management of structural, functional and rhythm-related fetal cardiovascular disease. OBJECTIVES/METHODS This article reviews the history of fetal echocardiography and the prenatal diagnosis of fetal cardiovascular disease as well as the evolution of the field of fetal cardiology. The clinical application of fetal echocardiography, including indications for referral, timing of referral and considerations in the diagnosis and serial assessment of fetal cardiovascular disease, is presented. CONCLUSIONS Newer directions in the field of fetal cardiology, including first trimester diagnoses and fetal intervention, will continue to expand its role in the evaluation and treatment of affected pregnancies in the future; however, equally as important are efforts to continue to improve prenatal detection rates.
Collapse
Affiliation(s)
- Lisa K Hornberger
- Professor of Pediatrics University of Alberta William C McKenzie Health Centre, Director of the Fetal & Neonatal Cardiology Program, Division of Cardiology, Department of Pediatrics & Obstetrics, 4C2.23, 8440 112th Street, Edmonton, Alberta T6G2B7, Canada +1 780 407 3952 ; +1 780 407 3954 ;
| |
Collapse
|
46
|
Wacker-Gußmann A, Brändle J, Weiss M, Muenssinger J, Zimmermann A, Abele H, Goelz R, Preissl H. The effect of routine magnesium supplementation on fetal cardiac time intervals: a fetal magnetocardiographic study. Eur J Obstet Gynecol Reprod Biol 2013; 168:151-4. [PMID: 23375902 DOI: 10.1016/j.ejogrb.2013.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2012] [Revised: 12/21/2012] [Accepted: 01/09/2013] [Indexed: 10/27/2022]
Abstract
OBJECTIVES Magnesium deficiency in pregnancy is frequent, and in consequence magnesium supplementation is widely used. As magnesium crosses the placental barrier and since the fetal kidney does not excrete magnesium as efficiently as the mature kidney, effects on fetal cardiac time intervals are probable, but still unknown. STUDY DESIGN Sixty pregnant women were included in an observational study: 31 patients received oral routine magnesium supplementation. In addition to routine fetal echocardiography, fetal magnetocardiography (fMCG) was used to investigate electrophysiological rhythm patterns with high temporal resolution. fMCG tracings were analyzed according to a predefined procedure for fetal cardiac time interval (CTI)-detection. fCTI findings (P-wave, PQ-segment, PR-interval, QRS complex, ST segment, T-wave and QTc interval) were registered. RESULTS Significant widening of the QRS-complex (p=0.004) was demonstrated in fetuses whose mothers received magnesium supplementation (240 mg/day) relative to the control group. CONCLUSION Magnesium exposed fetuses demonstrated a prolonged ventricular arousal, but healthy neonatal outcome was found in all exposed fetuses. Although fMCG is a preclinical method and limited in its availability, the procedure could help to monitor fetuses.
Collapse
|
47
|
Atrioventricular conduction delay in fetuses exposed to anti-SSA/Ro and anti-SSB/La antibodies: a magnetocardiography study. Clin Dev Immunol 2012; 2012:432176. [PMID: 23320018 PMCID: PMC3539448 DOI: 10.1155/2012/432176] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2012] [Revised: 11/27/2012] [Accepted: 11/27/2012] [Indexed: 12/23/2022]
Abstract
Background. The presence of anti-SSA/Ro and anti-SSB/La antibodies during pregnancy is associated with fetal congenital heart block (CHB), which is primarily diagnosed through fetal echocardiography. Conclusive information about the complete electrophysiology of the fetal cardiac conducting system is still lacking. In addition to echocardiography, fetal magnetocardiography (fMCG) can be used. fMCG is the magnetic analogue of the fetal electrocardiogram (ECG). Patients and Methods. Forty-eight pregnant women were enrolled in an observational study; 16 of them tested positive for anti-SSA/Ro and anti-SSB/La antibodies. In addition to routine fetal echocardiography, fMCG was used. Fetal cardiac time intervals (fCTIs) were extracted from the magnetic recordings by predefined procedures. ECGs in the neonates of the study group were performed within the first month after delivery. Results. The PQ segment of the fCTI was significantly prolonged in the study group (P = 0.007), representing a delay of the electrical impulse in the atrioventricular (AV) node. Other fCTIs were within normal range. None of the anti-SSA/Ro and/or anti-SSB/La fetuses progressed to a more advanced heart block during pregnancy or after birth. Conclusion. The study identified a low-risk population within antibody positive mothers, where PQ segment prolongation is associated with a lack of progression of the disease.
Collapse
|
48
|
Cardiac manifestations of neonatal lupus: a review of autoantibody-associated congenital heart block and its impact in an adult population. Cardiol Rev 2012; 20:72-6. [PMID: 22183063 DOI: 10.1097/crd.0b013e31823c808b] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Within the last decade the prevalence of adult patients living with congenital heart disease equals that seen in children. This expanding population poses a challenge to clinical cardiologists who will be caring for patients with the clinical manifestations of this condition. Neonatal lupus is a model of passively acquired autoimmunity and is responsible for the majority of clinical cases of congenital heart block (CHB). This review will focus on the presentation, pathophysiology, and the long-term follow-up of CHB associated with neonatal lupus, and discuss important diagnostic tests, familial implications, and pacemaker issues associated with the care of an adult with CHB.
Collapse
|
49
|
Tutschek B, Schmidt KG. Pulsed-wave tissue Doppler echocardiography for the analysis of fetal cardiac arrhythmias. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2011; 38:406-412. [PMID: 21656866 DOI: 10.1002/uog.9070] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
OBJECTIVES Rhythm analysis of the fetal heart is hampered by the inability to routinely obtain electrocardiographic recordings of the fetus. Doppler studies of fetal cardiac tissue movements, assessing cardiac movements both qualitatively and quantitatively, have recently been described. We used a conventional high-resolution ultrasound system to obtain rhythm data from pulsed-wave tissue Doppler signals of the fetal heart in normal cardiac rhythm and in a variety of fetal cardiac arrhythmias. METHODS Fifty-five fetuses with normal (sinus) rhythm, 45 fetuses with rhythm disturbances and two neonates (one with arrhythmia and one with normal sinus rhythm) were studied. Using a conventional high-resolution ultrasound system equipped for fetal studies, but without specific tissue Doppler hardware or software, we performed pulsed-wave tissue Doppler echocardiography (PW-TDE) of atrioventricular valve ring excursions to study the atrial and ventricular mechanical actions. In the neonates, electrocardiograms were also recorded. RESULTS PW-TDE in normal fetuses shows a typical pattern of tissue motion parallel to the long axis of the heart and in the opposite direction to the blood flow, both in systole and diastole. This pattern is easily obtained from the tricuspid valve annulus in normal sinus rhythm and shows characteristic changes in various fetal arrhythmias. CONCLUSION PW-TDE of atrioventricular valve annulus movement patterns may prove to be a valuable additional tool for assessing fetal cardiac arrhythmias.
Collapse
Affiliation(s)
- B Tutschek
- Department of Obstetrics and Gynecology, Bern University Hospital, Bern, Switzerland; Medical Faculty, Heinrich Heine University, Düsseldorf, Germany.
| | | |
Collapse
|
50
|
Abstract
Several recent studies have demonstrated the usefulness of fetal magnetocardiogram (fMCG) actography, a relatively new method of detecting fetal movement that can be performed in conjunction with fMCG assessment of fetal heart rate and rhythm. In this study, we formulate indices of fetal activity that incorporate information from all channels to achieve improved sensitivity. We also utilize statistical detection to provide an objective means of inferring significant fetal activity.
Collapse
Affiliation(s)
- William J Lutter
- Department of Medical Physics, University of Wisconsin, Madison, WI 53706, USA.
| | | |
Collapse
|