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Sueblinvong V, Zhang S, Varga P. Atrial Arrhythmia and Bradycardia as a Presentation of Congenital Long QT Syndrome. Pediatr Cardiol 2024:10.1007/s00246-024-03577-8. [PMID: 38990321 DOI: 10.1007/s00246-024-03577-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2024] [Accepted: 07/02/2024] [Indexed: 07/12/2024]
Abstract
We present a term newborn with atrial arrhythmia on the first day of life (DOL). An echocardiogram showed normal structure and normal function; laboratory testing showed normal electrolytes and thyroid function. After initiation of flecainide, the EKG on DOL 2 showed significant and increasing bradycardia with atrial arrhythmia and extremely prolonged QTc interval. Flecainide was stopped and esmolol started. After 6 h of treatment, atrial tachycardia was suppressed, and the rhythm converted to sinus. Genetic testing found variants of unknown significance in the ALPK3 gene and KCNQ1 gene, which has been associated with long QT syndrome (LQTs). LQTs in infants can present as bradycardia, 2:1 AV block, or torsades de pointes. Our review of the literature found only one other case report of atrial arrhythmia in a newborn with congenital LQTs. Diagnosis of LQTs via EKG alone is difficult in neonates since the ST segment and T wave on the first DOL are usually flattened, making correct measurement of the QTc interval difficult. β-blockers, the first line of treatment for LQTs, are known to shorten QTc intervals and prevent arrhythmia events. As in our patient, β-blockers may be helpful for atrial arrhythmia prevention in patients with adrenergically mediated atrial tachycardia. In conclusion, atrial arrhythmia with bradycardia can be a presentation of congenital LQTs and be difficult to recognize. For neonates with this presentation with no evidence of myocarditis, congenital heart disease, or significant respiratory illness, genetic congenital LQTs should be highly suspected, especially when associated with low resting heart rates.
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Affiliation(s)
| | - Samantha Zhang
- Department of Pediatrics, University of Illinois, Chicago, USA.
| | - Peter Varga
- Department of Pediatric Cardiology, University of Illinois, Chicago, USA
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Wang H, Wu T, Huang Z, Huang J, Geng Z, Cui B, Yan Y, Zhang Y, Wang Y. Channel HCN4 mutation R666Q associated with sporadic arrhythmia decreases channel electrophysiological function and increases protein degradation. J Biol Chem 2022; 298:102599. [PMID: 36244448 PMCID: PMC9663530 DOI: 10.1016/j.jbc.2022.102599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Revised: 10/06/2022] [Accepted: 10/10/2022] [Indexed: 11/07/2022] Open
Abstract
Mutations in the hyperpolarization-activated nucleotide-gated channel 4 (HCN4) are known to be associated with arrhythmias in which QT prolongation (delayed ventricular repolarization) is rare. Here, we identified a HCN4 mutation, HCN4-R666Q, in two sporadic arrhythmia patients with sinus bradycardia, QT prolongation, and short bursts of ventricular tachycardia. To determine the functional effect of the mutation, we conducted clinical, genetic, and functional analyses using whole-cell voltage-clamp, qPCR, Western blot, confocal microscopy, and co-immunoprecipitation. The mean current density of HEK293T cells transfected with HCN4-R666Q was lower in 24 to 36 h after transfection and was much lower in 36 to 48 h after transfection relative to cells transfected with wildtype HCN4. Additionally, we determined that the HCN4-R666Q mutant was more susceptible to ubiquitin-proteasome system–mediated protein degradation than wildtype HCN4. This decreased current density for HCN4-R666Q could be partly rescued by treatment with a proteasome inhibitor. Therefore, we conclude that HCN4-R666Q had an effect on HCN4 function in two aspects, including decreasing the current density of the channel as a biophysical effect and weakening its protein stability. Our findings provide new insights into the pathogenesis of the HCN4-R666Q mutation.
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Hsu YT, Lee PC, Chen YH, Yeh SJ, Chen MR, Hsu KH, Chang CI, Lai WT, Hung WL. Resuscitated Sudden Cardiac Arrest of a Neonate with Congenital LQT Syndrome-Associated Torsades de Pointes: A Case Report and Literature Review. J Cardiovasc Dev Dis 2022; 9:jcdd9060184. [PMID: 35735813 PMCID: PMC9225216 DOI: 10.3390/jcdd9060184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 05/30/2022] [Accepted: 06/07/2022] [Indexed: 11/25/2022] Open
Abstract
Sudden infant death syndrome (SIDS), the most common cause of infant death in developed countries, is attributed to diverse trigger factors. Malignant cardiac dysrhythmias are potentially treatable etiologies, and congenital long QT syndrome (LQTS) is the most common cardiac ionic channelopathy confronted. β-Blockers or class Ib agents are the drugs of choice for the control of arrhythmias, and an implantable cardioverter defibrillator (ICD) should be considered for secondary prevention in survivors of lethal cardiac death. We report the case of a 4-day old neonate, later genetically confirmed as LQT type 3 (LQT3), who survived a pulseless torsades de pointes (TdP) attack and was successfully treated with propranolol, mexiletine, and ICD implantation.
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Affiliation(s)
- Yen-Teng Hsu
- Department of Pediatric Cardiology, Mackay Children’s Hospital, Taipei 104217, Taiwan; (Y.-T.H.); (Y.-H.C.); (S.-J.Y.); (M.-R.C.)
| | - Pi-Chang Lee
- Department of Medical Education, Taichung Veterans General Hospital, Taichung 40705, Taiwan;
| | - Yu-Hsuan Chen
- Department of Pediatric Cardiology, Mackay Children’s Hospital, Taipei 104217, Taiwan; (Y.-T.H.); (Y.-H.C.); (S.-J.Y.); (M.-R.C.)
| | - Shu-Jen Yeh
- Department of Pediatric Cardiology, Mackay Children’s Hospital, Taipei 104217, Taiwan; (Y.-T.H.); (Y.-H.C.); (S.-J.Y.); (M.-R.C.)
| | - Ming-Ren Chen
- Department of Pediatric Cardiology, Mackay Children’s Hospital, Taipei 104217, Taiwan; (Y.-T.H.); (Y.-H.C.); (S.-J.Y.); (M.-R.C.)
| | - Kung-Hong Hsu
- Department of Surgery, Division of Cardiovascular Surgery, Mackay Memorial Hospital, Taipei 104217, Taiwan; (K.-H.H.); (C.-I.C.)
| | - Chung-I Chang
- Department of Surgery, Division of Cardiovascular Surgery, Mackay Memorial Hospital, Taipei 104217, Taiwan; (K.-H.H.); (C.-I.C.)
| | - Wei-Ting Lai
- Department of Pediatrics, Division of Pediatric Cardiology, Hung Chi Women and Children’s Hospital, Taoyuan 320675, Taiwan;
| | - Wei-Li Hung
- Department of Pediatric Cardiology, Mackay Children’s Hospital, Taipei 104217, Taiwan; (Y.-T.H.); (Y.-H.C.); (S.-J.Y.); (M.-R.C.)
- Correspondence: ; Tel.: +886-2-2543-3535
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Taylor C, Stambler BS. Management of Long QT Syndrome in Women Before, During, and After Pregnancy. US CARDIOLOGY REVIEW 2021. [DOI: 10.15420/usc.2021.02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Congenital long QT syndrome (LQTS) is a primary genetic and electrical disorder that increases risk for torsades de pointes, syncope, and sudden death. Post-pubertal women with LQTS require specialized multidisciplinary management before, during, and after pregnancy involving cardiology and obstetrics to reduce risk for cardiac events in themselves and their fetuses and babies. The risk of potentially life-threatening events is lower during pregnancy but increases significantly during the 9-month postpartum period. Treatment of women with LQTS with a preferred β-blocker at optimal doses along with close monitoring are indicated throughout pregnancy and during the high-risk postpartum period.
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Affiliation(s)
- Caroline Taylor
- Cardiac Electrophysiology, Piedmont Heart Institute, Atlanta, GA
| | - Bruce S Stambler
- Cardiac Electrophysiology, Piedmont Heart Institute, Atlanta, GA
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Yuan SM. Fetal Arrhythmias: Genetic Background and Clinical Implications. Pediatr Cardiol 2019; 40:247-256. [PMID: 30478614 DOI: 10.1007/s00246-018-2008-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Accepted: 10/11/2018] [Indexed: 02/06/2023]
Abstract
Fetal arrhythmias are a common phenomenon of pregnancies. However, debates remain with regard to the etiologies and early treatment of choices for severe fetal arrhythmias. The gene regulatory networks govern cardiac conduction system development to produce distinct nodal and fast conduction phenotypes. The slow conduction properties of nodes that display automaticity are determined by the cardiac ion channel genes, whereas the fast conduction properties are regulated by the transcription factors. Mutations of genes specific for the developmental processes and/or functional status of cardiac conduction system including ion channel promoter (minK-lacZ), GATA family of zinc finger proteins (GATA4), the homeodomain transcription factor (Nkx2.5), the homeodomain-only protein (Hop) and the T-box transcription factors (Tbx2, Tbx3 and Tbx5), hyperpolarization-activated cyclic nucleotide-gated channel 4 (HCN4) and connexins, may cause fetal arrhythmias. It is expected that development of investigational antiarrhythmic agents based on genetic researches on cardiac conduction system, and clinical application of percutaneously implantable fetal pacemaker for the treatment of fetal arrhythmias would come to true.
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Affiliation(s)
- Shi-Min Yuan
- Department of Cardiothoracic Surgery, The First Hospital of Putian, Teaching Hospital, Fujian Medical University, 389 Longdejing Street, Chengxiang District, Putian, 351100, Fujian Province, People's Republic of China.
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6
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Yuan SM. Fetal arrhythmias: Surveillance and management. Hellenic J Cardiol 2018; 60:72-81. [PMID: 30576831 DOI: 10.1016/j.hjc.2018.12.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Revised: 12/04/2018] [Accepted: 12/11/2018] [Indexed: 10/27/2022] Open
Abstract
Fetal arrhythmias warrant sophisticated surveillance and management, especially for the high-risk pregnancies. Clinically, fetal arrhythmias can be categorized into 3 types: premature contractions, tachyarrhythmias, and bradyarrhythmias. Fetal arrhythmias include electrocardiography, cardiotocography, echocardiography and magnetocardiography. Oxygen saturation monitoring can be an effective way of fetal surveillance for congenital complete AV block or SVT during labor. Genetic surveillance of fetal arrhythmias may facilitate the understanding of the mechanisms of the arrhythmias and provide theoretical basis for diagnosis and treatment. For fetal benign arrhythmias, usually no treatment but a close follow-up is need, while persistant fetal arrhythmias with congestive heart dysfunction or hydrops fetalis, intrauterine or postnatal treatments are required. The prognoses of fetal arrhythmias depend on the type and severity of fetal arrhythmias and the associated fetal conditions. Responses of fetal arrhythmias to individual treatments and clinical schemes are heterogeneous, and the prognoses are poor particularly under such circumstances.
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Affiliation(s)
- Shi-Min Yuan
- Department of Cardiothoracic Surgery, The First Hospital of Putian, Teaching Hospital, Fujian Medical University, Putian, Fujian Province, People's Republic of China.
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2017 AHA/ACC/HRS guideline for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death. Heart Rhythm 2018; 15:e73-e189. [DOI: 10.1016/j.hrthm.2017.10.036] [Citation(s) in RCA: 177] [Impact Index Per Article: 29.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Indexed: 02/07/2023]
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Al-Khatib SM, Stevenson WG, Ackerman MJ, Bryant WJ, Callans DJ, Curtis AB, Deal BJ, Dickfeld T, Field ME, Fonarow GC, Gillis AM, Granger CB, Hammill SC, Hlatky MA, Joglar JA, Kay GN, Matlock DD, Myerburg RJ, Page RL. 2017 AHA/ACC/HRS Guideline for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. Circulation 2018; 138:e272-e391. [PMID: 29084731 DOI: 10.1161/cir.0000000000000549] [Citation(s) in RCA: 249] [Impact Index Per Article: 41.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
| | - William G Stevenson
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. †ACC/AHA Representative. ‡HRS Representative. §ACC/AHA Task Force on Performance Measures Liaison/HFSA Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison
| | - Michael J Ackerman
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. †ACC/AHA Representative. ‡HRS Representative. §ACC/AHA Task Force on Performance Measures Liaison/HFSA Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison
| | - William J Bryant
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. †ACC/AHA Representative. ‡HRS Representative. §ACC/AHA Task Force on Performance Measures Liaison/HFSA Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison
| | - David J Callans
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. †ACC/AHA Representative. ‡HRS Representative. §ACC/AHA Task Force on Performance Measures Liaison/HFSA Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison
| | - Anne B Curtis
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. †ACC/AHA Representative. ‡HRS Representative. §ACC/AHA Task Force on Performance Measures Liaison/HFSA Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison
| | - Barbara J Deal
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. †ACC/AHA Representative. ‡HRS Representative. §ACC/AHA Task Force on Performance Measures Liaison/HFSA Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison
| | - Timm Dickfeld
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. †ACC/AHA Representative. ‡HRS Representative. §ACC/AHA Task Force on Performance Measures Liaison/HFSA Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison
| | - Michael E Field
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. †ACC/AHA Representative. ‡HRS Representative. §ACC/AHA Task Force on Performance Measures Liaison/HFSA Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison
| | - Gregg C Fonarow
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. †ACC/AHA Representative. ‡HRS Representative. §ACC/AHA Task Force on Performance Measures Liaison/HFSA Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison
| | - Anne M Gillis
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. †ACC/AHA Representative. ‡HRS Representative. §ACC/AHA Task Force on Performance Measures Liaison/HFSA Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison
| | - Christopher B Granger
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. †ACC/AHA Representative. ‡HRS Representative. §ACC/AHA Task Force on Performance Measures Liaison/HFSA Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison
| | - Stephen C Hammill
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. †ACC/AHA Representative. ‡HRS Representative. §ACC/AHA Task Force on Performance Measures Liaison/HFSA Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison
| | - Mark A Hlatky
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. †ACC/AHA Representative. ‡HRS Representative. §ACC/AHA Task Force on Performance Measures Liaison/HFSA Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison
| | - José A Joglar
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. †ACC/AHA Representative. ‡HRS Representative. §ACC/AHA Task Force on Performance Measures Liaison/HFSA Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison
| | - G Neal Kay
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. †ACC/AHA Representative. ‡HRS Representative. §ACC/AHA Task Force on Performance Measures Liaison/HFSA Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison
| | - Daniel D Matlock
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. †ACC/AHA Representative. ‡HRS Representative. §ACC/AHA Task Force on Performance Measures Liaison/HFSA Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison
| | - Robert J Myerburg
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. †ACC/AHA Representative. ‡HRS Representative. §ACC/AHA Task Force on Performance Measures Liaison/HFSA Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison
| | - Richard L Page
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. †ACC/AHA Representative. ‡HRS Representative. §ACC/AHA Task Force on Performance Measures Liaison/HFSA Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison
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Al-Khatib SM, Stevenson WG, Ackerman MJ, Bryant WJ, Callans DJ, Curtis AB, Deal BJ, Dickfeld T, Field ME, Fonarow GC, Gillis AM, Granger CB, Hammill SC, Hlatky MA, Joglar JA, Kay GN, Matlock DD, Myerburg RJ, Page RL. 2017 AHA/ACC/HRS Guideline for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol 2018; 72:e91-e220. [PMID: 29097296 DOI: 10.1016/j.jacc.2017.10.054] [Citation(s) in RCA: 692] [Impact Index Per Article: 115.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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10
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Wilders R, Verkerk AO. Long QT Syndrome and Sinus Bradycardia-A Mini Review. Front Cardiovasc Med 2018; 5:106. [PMID: 30123799 PMCID: PMC6085426 DOI: 10.3389/fcvm.2018.00106] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Accepted: 07/16/2018] [Indexed: 12/16/2022] Open
Abstract
Congenital long-QT syndrome (LQTS) is an inherited cardiac disorder characterized by the prolongation of ventricular repolarization, susceptibility to Torsades de Pointes (TdP), and a risk for sudden death. Various types of congenital LQTS exist, all due to specific defects in ion channel-related genes. Interestingly, almost all of the ion channels affected by the various types of LQTS gene mutations are also expressed in the human sinoatrial node (SAN). It is therefore not surprising that LQTS is frequently associated with a change in basal heart rate (HR). However, current data on how the LQTS-associated ion channel defects result in impaired human SAN pacemaker activity are limited. In this mini-review, we provide an overview of known LQTS mutations with effects on HR and the underlying changes in expression and kinetics of ion channels. Sinus bradycardia has been reported in relation to a large number of LQTS mutations. However, the occurrence of both QT prolongation and sinus bradycardia on a family basis is almost completely limited to LQTS types 3 and 4 (LQT3 and Ankyrin-B syndrome, respectively). Furthermore, a clear causative role of this sinus bradycardia in cardiac events seems reserved to mutations underlying LQT3.
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Affiliation(s)
- Ronald Wilders
- Department of Medical Biology, Amsterdam University Medical Centers, Amsterdam, Netherlands
| | - Arie O Verkerk
- Department of Medical Biology, Amsterdam University Medical Centers, Amsterdam, Netherlands.,Department of Experimental Cardiology, Amsterdam University Medical Centers, Amsterdam, Netherlands
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12
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Baruteau AE, Perry JC, Sanatani S, Horie M, Dubin AM. Evaluation and management of bradycardia in neonates and children. Eur J Pediatr 2016; 175:151-61. [PMID: 26780751 DOI: 10.1007/s00431-015-2689-z] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2015] [Revised: 12/02/2015] [Accepted: 12/30/2015] [Indexed: 10/22/2022]
Abstract
UNLABELLED Heart rate is commonly used in pediatric early warning scores. Age-related changes in the anatomy and physiology of infants and children produce normal ranges for electrocardiogram features that differ from adults and vary with age. Bradycardia is defined as a heart rate below the lowest normal value for age. Pediatric bradycardia most commonly manifests as sinus bradycardia, junctional bradycardia, or atrioventricular block. As a result of several different etiologies, it may occur in an entirely structurally normal heart or in association with concomitant congenital heart disease. Genetic variants in multiple genes have been described to date in the pathogenesis of inherited sinus node dysfunction or progressive cardiac conduction disorders. Management and eventual prognosis of bradycardia in the young are entirely dependent upon the underlying cause. Reasons to intervene for bradycardia are the association of related symptoms and/or the downstream risk of heart failure or pause-dependent tachyarrhythmia. The simplest aspect of severe bradycardia management is reflected in the Pediatric and Advanced Life Support (PALS) guidelines. CONCLUSION Early diagnosis and appropriate management are critical in many cases in order to prevent sudden death, and this review critically assesses our current practice for evaluation and management of bradycardia in neonates and children. WHAT IS KNOWN Bradycardia is defined as a heart rate below the lowest normal value for age. Age related changes in the anatomy and physiology of infants and children produce normal ranges for electrocardiogram features that differ from adults and vary with age. Pediatric bradycardia most commonly manifests as sinus bradycardia, junctional bradycardia, or atrioventricular block. WHAT IS NEW Management and eventual prognosis of bradycardia in the young are entirely dependent upon the underlying cause. Bradycardia may occur in a structurally normal heart or in association with congenital heart disease. Genetic variants in multiple genes have been described. Reasons to intervene for bradycardia are the association of related symptoms and/or the downstream risk of heart failure or pause-dependent tachyarrhythmia. Early diagnosis and appropriate management are critical in order to prevent sudden death.
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Affiliation(s)
- Alban-Elouen Baruteau
- Morgan Stanley Children's Hospital, Division of Pediatric Cardiology, New York Presbyterian Hospital, Columbia University Medical Center, New York, NY, USA. .,LIRYC Institute (Electrophysiology and Heart Modeling Institute), Division of Pediatric Cardiology, Hôpital Cardiologique du Haut Lévèque, Bordeaux-2 University, Bordeaux, France. .,L'Institut du Thorax, INSERM UMR1087, CNRS UMR6291, Nantes University, Nantes, France. .,Division of Pediatric Cardiology, Morgan Stanley Children's Hospital, New York Presbyterian / Columbia University Medical Center, 3959 Broadway, New York, NY, 10032, USA.
| | - James C Perry
- Rady Children's Hospital, Department of Pediatrics, Division of Cardiology, University of California, San Diego, San Diego, CA, USA.
| | - Shubhayan Sanatani
- British Columbia Children's Hospital, Department of Pediatric Cardiology, University of British Columbia, Vancouver, BC, Canada.
| | - Minoru Horie
- Department of Cardiovascular and Respiratory Medicine, Shiga University of Medical Sciences, Otsu, Japan.
| | - Anne M Dubin
- Lucile Packard Children's Hospital, Division of Pediatric Electrophysiology, Stanford University, Palo Alto, CA, USA.
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Winbo A, Fosdal I, Lindh M, Diamant UB, Persson J, Wettrell G, Rydberg A. Third Trimester Fetal Heart Rate Predicts Phenotype and Mutation Burden in the Type 1 Long QT Syndrome. Circ Arrhythm Electrophysiol 2015; 8:806-14. [DOI: 10.1161/circep.114.002552] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2014] [Accepted: 05/08/2015] [Indexed: 11/16/2022]
Affiliation(s)
- Annika Winbo
- From the Department of Clinical Sciences, Pediatrics (A.W., M.L., J.P., A.R.) and Department of Public Health and Clinical Medicine, Heart Centre (U.-B.D.), Umeå University, Umeå, Sweden; Pediatric Clinic, Visby Hospital, Visby, Sweden (I.F.); Department of Pediatrics and Pediatric Cardiology, University of Lund, Lund, Sweden (G.W.); and Department of Physiology, University of Auckland, Auckland, New Zealand (A.W.)
| | - Inger Fosdal
- From the Department of Clinical Sciences, Pediatrics (A.W., M.L., J.P., A.R.) and Department of Public Health and Clinical Medicine, Heart Centre (U.-B.D.), Umeå University, Umeå, Sweden; Pediatric Clinic, Visby Hospital, Visby, Sweden (I.F.); Department of Pediatrics and Pediatric Cardiology, University of Lund, Lund, Sweden (G.W.); and Department of Physiology, University of Auckland, Auckland, New Zealand (A.W.)
| | - Maria Lindh
- From the Department of Clinical Sciences, Pediatrics (A.W., M.L., J.P., A.R.) and Department of Public Health and Clinical Medicine, Heart Centre (U.-B.D.), Umeå University, Umeå, Sweden; Pediatric Clinic, Visby Hospital, Visby, Sweden (I.F.); Department of Pediatrics and Pediatric Cardiology, University of Lund, Lund, Sweden (G.W.); and Department of Physiology, University of Auckland, Auckland, New Zealand (A.W.)
| | - Ulla-Britt Diamant
- From the Department of Clinical Sciences, Pediatrics (A.W., M.L., J.P., A.R.) and Department of Public Health and Clinical Medicine, Heart Centre (U.-B.D.), Umeå University, Umeå, Sweden; Pediatric Clinic, Visby Hospital, Visby, Sweden (I.F.); Department of Pediatrics and Pediatric Cardiology, University of Lund, Lund, Sweden (G.W.); and Department of Physiology, University of Auckland, Auckland, New Zealand (A.W.)
| | - Johan Persson
- From the Department of Clinical Sciences, Pediatrics (A.W., M.L., J.P., A.R.) and Department of Public Health and Clinical Medicine, Heart Centre (U.-B.D.), Umeå University, Umeå, Sweden; Pediatric Clinic, Visby Hospital, Visby, Sweden (I.F.); Department of Pediatrics and Pediatric Cardiology, University of Lund, Lund, Sweden (G.W.); and Department of Physiology, University of Auckland, Auckland, New Zealand (A.W.)
| | - Göran Wettrell
- From the Department of Clinical Sciences, Pediatrics (A.W., M.L., J.P., A.R.) and Department of Public Health and Clinical Medicine, Heart Centre (U.-B.D.), Umeå University, Umeå, Sweden; Pediatric Clinic, Visby Hospital, Visby, Sweden (I.F.); Department of Pediatrics and Pediatric Cardiology, University of Lund, Lund, Sweden (G.W.); and Department of Physiology, University of Auckland, Auckland, New Zealand (A.W.)
| | - Annika Rydberg
- From the Department of Clinical Sciences, Pediatrics (A.W., M.L., J.P., A.R.) and Department of Public Health and Clinical Medicine, Heart Centre (U.-B.D.), Umeå University, Umeå, Sweden; Pediatric Clinic, Visby Hospital, Visby, Sweden (I.F.); Department of Pediatrics and Pediatric Cardiology, University of Lund, Lund, Sweden (G.W.); and Department of Physiology, University of Auckland, Auckland, New Zealand (A.W.)
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Perin F, Rodríguez Vázquez del Rey M, Deiros Bronte L, Ferrer Menduiña Q, Rueda Nuñez F, Zabala Arguelles J, García de la Calzada D, Teodoro Marin S, Centeno Malfaz F, Galindo Izquierdo A. Foetal bradycardia: A retrospective study in 9 Spanish centres. An Pediatr (Barc) 2014. [DOI: 10.1016/j.anpede.2013.12.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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15
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Carvalho JS. Primary bradycardia: keys and pitfalls in diagnosis. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2014; 44:125-130. [PMID: 25088508 DOI: 10.1002/uog.13451] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Affiliation(s)
- J S Carvalho
- Brompton Centre for Fetal Cardiology, Royal Brompton Hospital, Sydney Street, London, SW3 6NP, UK; Fetal Medicine Unit, St George's Hospital, St George's University of London, London, SW17 0QT, UK.
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Anuwutnavin S, Wanitpongpan P, Chungsomprasong P, Soongswang J, Srisantiroj N, Wataganara T. Fetal long QT syndrome manifested as atrioventricular block and ventricular tachycardia: a case report and a review of the literature. Pediatr Cardiol 2014; 34:1955-62. [PMID: 22987108 DOI: 10.1007/s00246-012-0507-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2012] [Accepted: 08/26/2012] [Indexed: 11/30/2022]
Abstract
Fetal onset of congenital long QT syndrome (LQTS) is a rare manifestation, and prenatal diagnosis is difficult. This report describes a boy who presented with both atrioventricular (AV) block and ventricular tachycardia during the antenatal period. The early postnatal electrocardiogram showed prolongation of the QT interval and AV block, subsequently leading to a polymorphic ventricular tachycardia torsade de pointes. This unique feature of congenital LQTS has a poor outcome, but the boy was successfully treated with beta-blockers and implantation of an automated cardioverter-defibrillator. The intrauterine manifestation of fetal AV block and ventricular tachycardia should raise a high suspicion of congenital LQTS, and the strong association with a malignant clinical course should warrant special evaluation. The literature on the prenatal diagnosis, fetal therapy, and neonatal outcome of this condition also are reviewed.
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Affiliation(s)
- Sanitra Anuwutnavin
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Prannok Road, Bangkoknoi, Bangkok, 10700, Thailand,
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[Fetal bradycardia: a retrospective study in 9 Spanish centers]. An Pediatr (Barc) 2014; 81:275-82. [PMID: 24548871 DOI: 10.1016/j.anpedi.2013.12.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2013] [Revised: 12/09/2013] [Accepted: 12/26/2013] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE The aim of this study is to review the current management and outcomes of fetal bradycardia in 9 Spanish centers. METHODS Retrospective multicenter study: analysis of all fetuses with bradycardia diagnosed between January 2008 and September 2010. Underlying mechanisms of fetal bradyarrhythmias were studied with echocardiography. RESULTS A total of 37 cases were registered: 3 sinus bradycardia, 15 blocked atrial bigeminy, and 19 high grade atrioventricular blocks. Sinus bradycardia: 3 cases (100%) were associated with serious diseases. Blocked atrial bigeminy had an excellent outcome, except for one case with post-natal tachyarrhythmia. Of the atrioventricular blocks, 16% were related to congenital heart defects with isomerism, 63% related to the presence of maternal SSA/Ro antibodies, and 21% had unclear etiology. Overall mortality was 20% (37%, if terminations of pregnancy are taken into account). Risk factors for mortality were congenital heart disease, hydrops and/or ventricular dysfunction. Management strategies differed among centers. Steroids were administrated in 73% of immune-mediated atrioventricular blocks, including the only immune-mediated IInd grade block. More than half (58%) of atrioventricular blocks had a pacemaker implanted in a follow-up of 18 months. CONCLUSIONS Sustained fetal bradycardia requires a comprehensive study in all cases, including those with sinus bradycardia. Blocked atrial bigeminy has a good prognosis, but tachyarrhythmias may develop. Heart block has significant mortality and morbidity rates, and its management is still highly controversial.
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Nawathe PA, Kryukova Y, Oren RV, Milanesi R, Clancy CE, Lu JT, Moss AJ, Difrancesco D, Robinson RB. An LQTS6 MiRP1 mutation suppresses pacemaker current and is associated with sinus bradycardia. J Cardiovasc Electrophysiol 2013; 24:1021-7. [PMID: 23631727 DOI: 10.1111/jce.12163] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2012] [Revised: 12/20/2012] [Accepted: 03/13/2013] [Indexed: 01/20/2023]
Abstract
BACKGROUND Sinus node (SN) dysfunction is observed in some long-QT syndrome (LQTS) patients, but has not been studied as a function of LQTS genotype. LQTS6 involves mutations in the hERG β-subunit MiRP1, which also interacts with hyperpolarization-activated, cyclic nucleotide gated (HCN) channels-the molecular correlate of SN pacemaker current (If ). An LQTS registry search identified a 55-year male with M54T MiRP1 mutation, history of sinus bradycardia (39-56 bpm), and prolonged QTc. OBJECTIVE We tested if LQTS6 incorporates sinus bradycardia due to abnormal If . METHODS We transiently co-transfected neonatal rat ventricular myocytes (to study currents in a myocyte background) with human HCN4 (hHCN4, primary SN isoform) or human HCN2 (hHCN2) and one of the following: empty vector, wild-type hMiRP1 (WT), M54T hMiRP1 (M54T). Current amplitude, voltage dependence, and kinetics were measured by whole cell patch clamp. RESULTS M54T co-expression decreased HCN4 current density by 80% compared to hHCN4 alone or with WT, and also slowed HCN4 activation at physiologically relevant voltages. Neither WT nor M54T altered HCN4 voltage dependence. A computer simulation predicts that these changes in HCN4 current would decrease rate and be additive with published effects of M54T mutation on hERG kinetics on rate. CONCLUSIONS We conclude that M54T LQTS6 mutation can cause sinus bradycardia through effects on both hERG and HCN currents. Patients with other LQTS6 mutations should be examined for SN dysfunction, and the effect on HCN current determined.
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Mitchell JL, Cuneo BF, Etheridge SP, Horigome H, Weng HY, Benson DW. Fetal Heart Rate Predictors of Long QT Syndrome. Circulation 2012; 126:2688-95. [DOI: 10.1161/circulationaha.112.114132] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Background—
Fetal long QT syndrome (LQTS) is associated with complex arrhythmias including torsades de pointes and 2° atrioventricular block. Sinus bradycardia has also been associated with fetal LQTS, but little is known of this rhythm manifestation. Our purpose was to characterize the fetal heart rate (FHR)/gestational age (GA) profile of fetal LQTS.
Methods and Results—
We ascertained fetal LQTS subjects by family history (Group 1) or fetal arrhythmia referral (Group 2). We compared FHR in LQTS subjects versus normal fetuses. To identify FHR predictors of LQTS, we calculated a bradycardia index as % of LQTS FHR recordings either ≤110 beats per minute (obstetric standard) or ≤3
rd
percentile for GA. Among 42 LQTS subjects, 26 were in Group 1 and 16 in Group 2. There were 536 normal fetuses. The bradycardia index was only 15% for FHR ≤110 beats per minute, but 66% for FHR ≤3rd percentile for GA. Ten fetuses with complex arrhythmias also had severe and sustained sinus bradycardia throughout gestation. Identifying a fetal proband in Group 2 resulted in LQTS diagnosis in 9 unsuspected members of 6 families.
Conclusions—
FHR varies by GA in both normal and LQTS fetuses. Postnatal evaluation of neonates with FHR ≤3
rd
percentile for GA may improve ascertainment of LQTS in fetuses, neonates, and undiagnosed family members.
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Affiliation(s)
- Jason L. Mitchell
- From the Heart Institute for Children, Oak Lawn, IL (J.L.M., B.F.C.); Primary Children's Medical Center, The University of Utah, Salt Lake City (S.P.E., H.-Y.W.); the Department of Pediatrics, University of Tskuba, Tskuba, Ibaraki, Japan (H.H.); and Cincinnati Children's Hospital Medical Center, The University of Cincinnati Medical School, Cincinnati, OH (D.W.B.)
| | - Bettina F. Cuneo
- From the Heart Institute for Children, Oak Lawn, IL (J.L.M., B.F.C.); Primary Children's Medical Center, The University of Utah, Salt Lake City (S.P.E., H.-Y.W.); the Department of Pediatrics, University of Tskuba, Tskuba, Ibaraki, Japan (H.H.); and Cincinnati Children's Hospital Medical Center, The University of Cincinnati Medical School, Cincinnati, OH (D.W.B.)
| | - Susan P. Etheridge
- From the Heart Institute for Children, Oak Lawn, IL (J.L.M., B.F.C.); Primary Children's Medical Center, The University of Utah, Salt Lake City (S.P.E., H.-Y.W.); the Department of Pediatrics, University of Tskuba, Tskuba, Ibaraki, Japan (H.H.); and Cincinnati Children's Hospital Medical Center, The University of Cincinnati Medical School, Cincinnati, OH (D.W.B.)
| | - Hitoshi Horigome
- From the Heart Institute for Children, Oak Lawn, IL (J.L.M., B.F.C.); Primary Children's Medical Center, The University of Utah, Salt Lake City (S.P.E., H.-Y.W.); the Department of Pediatrics, University of Tskuba, Tskuba, Ibaraki, Japan (H.H.); and Cincinnati Children's Hospital Medical Center, The University of Cincinnati Medical School, Cincinnati, OH (D.W.B.)
| | - Hsin-Yi Weng
- From the Heart Institute for Children, Oak Lawn, IL (J.L.M., B.F.C.); Primary Children's Medical Center, The University of Utah, Salt Lake City (S.P.E., H.-Y.W.); the Department of Pediatrics, University of Tskuba, Tskuba, Ibaraki, Japan (H.H.); and Cincinnati Children's Hospital Medical Center, The University of Cincinnati Medical School, Cincinnati, OH (D.W.B.)
| | - D. Woodrow Benson
- From the Heart Institute for Children, Oak Lawn, IL (J.L.M., B.F.C.); Primary Children's Medical Center, The University of Utah, Salt Lake City (S.P.E., H.-Y.W.); the Department of Pediatrics, University of Tskuba, Tskuba, Ibaraki, Japan (H.H.); and Cincinnati Children's Hospital Medical Center, The University of Cincinnati Medical School, Cincinnati, OH (D.W.B.)
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Chabaneix J, Andelfinger G, Fournier A, Fouron JC, Raboisson MJ. Prenatal diagnosis of long QT syndrome with the superior vena cava-aorta Doppler approach. Am J Obstet Gynecol 2012; 207:e3-7. [PMID: 22917482 DOI: 10.1016/j.ajog.2012.06.058] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2012] [Revised: 06/15/2012] [Accepted: 06/29/2012] [Indexed: 10/28/2022]
Abstract
We describe a fetus at 36 weeks with long QT syndrome presenting with variable types of atrioventricular blocks, ventricular premature beats, and torsades de pointes. All these diagnoses were made with the superior vena cava-aorta Doppler approach and confirmed with postnatal electrocardiography.
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21
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Arythmies cardiaques fœtales : diagnostic et prise en charge. ARCHIVES OF CARDIOVASCULAR DISEASES SUPPLEMENTS 2012. [DOI: 10.1016/s1878-6480(12)70824-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Ishikawa S, Yamada T, Kuwata T, Morikawa M, Yamada T, Matsubara S, Minakami H. Fetal presentation of long QT syndrome--evaluation of prenatal risk factors: a systematic review. Fetal Diagn Ther 2012; 33:1-7. [PMID: 22776830 DOI: 10.1159/000339150] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2012] [Accepted: 04/23/2012] [Indexed: 12/14/2022]
Abstract
OBJECTIVE This systematic review evaluated the existence of risk factors for the fetal manifestation of long QT syndrome (LQTS). METHODS Prenatal cardiac findings suggestive of fetal LQTS were studied using 30 English literature reports extracted from the Pubmed database (1979 to December 2011) using the search terms 'long QT syndrome', 'fetal arrhythmia' and 'congenital heart disease'. RESULTS LQTS accounted for 15-17% of fetal bradycardias <110 bpm among fetuses with a normally structured heart. Of the patients with significant prenatal findings of LQTS, 17-35% exhibited a reduced baseline fetal heart rate (FHR) of 110-120 bpm on electronic cardiotocography. Other prenatal signs were sinus or intermittent bradycardia <110 bpm arising from atrioventricular block, tachyarrhythmias, pleural effusion and hydrops. More than 30% of Japanese infants with LQTS born at or after the mid-1980s exhibited the above-mentioned in utero signs. CONCLUSIONS Fetal factors including a slightly reduced baseline FHR of 110-120 bpm, bradycardia <110 bpm, tachyarrhythmias or clinical signs of heart failure, such as pleural effusion and hydrops, were associated with a higher frequency of LQTS. The use of these signs may help to increase the perinatal diagnosis of LQTS.
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Developmentally regulated SCN5A splice variant potentiates dysfunction of a novel mutation associated with severe fetal arrhythmia. Heart Rhythm 2011; 9:590-7. [PMID: 22064211 DOI: 10.1016/j.hrthm.2011.11.006] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2011] [Indexed: 11/23/2022]
Abstract
BACKGROUND Congenital long-QT syndrome (LQTS) may present during fetal development and can be life-threatening. The molecular mechanism for the unusual early onset of LQTS during fetal development is unknown. OBJECTIVE We sought to elucidate the molecular basis for severe fetal LQTS presenting at 19 weeks' gestation, the earliest known presentation of this disease. METHODS Fetal magnetocardiography was used to demonstrated torsades de pointes and a prolonged rate-corrected QT interval. In vitro electrophysiological studies were performed to determine functional consequences of a novel SCN5A mutation found in the fetus. RESULTS The fetus presented with episodes of ventricular ectopy progressing to incessant ventricular tachycardia and hydrops fetalis. Genetic analysis disclosed a novel, de novo heterozygous mutation (L409P) and a homozygous common variant (R558 in SCN5A). In vitro electrophysiological studies demonstrated that the mutation in combination with R558 caused significant depolarized shifts in the voltage dependence of inactivation and activation, faster recovery from inactivation, and a 7-fold higher level of persistent current. When the mutation was engineered in a fetal-expressed SCN5A splice isoform, channel dysfunction was markedly potentiated. Also, R558 alone in the fetal splice isoform evoked a large persistent current, and hence both alleles were dysfunctional. CONCLUSION We report the earliest confirmed diagnosis of symptomatic LQTS and present evidence that mutant cardiac sodium channel dysfunction is potentiated by a developmentally regulated alternative splicing event in SCN5A. Our findings provide a plausible mechanism for the unusual severity and early onset of cardiac arrhythmia in fetal LQTS.
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Abstract
The human fetal heart develops arrhythmias and conduction disturbances in response to ischemia, inflammation, electrolyte disturbances, altered load states, structural defects, inherited genetic conditions, and many other causes. Yet sinus rhythm is present without altered rate or rhythm in some of the most serious electrophysiological diseases, which makes detection of diseases of the fetal conduction system challenging in the absence of magnetocardiographic or electrocardiographic recording techniques. Life-threatening changes in QRS or QT intervals can be completely unrecognized if heart rate is the only feature to be altered. For many fetal arrhythmias, echocardiography alone can assess important clinical parameters for diagnosis. Appropriate treatment of the fetus requires awareness of arrhythmia characteristics, mechanisms, and potential associations. Criteria to define fetal bradycardia specific to gestational age are now available and may allow detection of ion channelopathies, which are associated with fetal and neonatal bradycardia. Ectopic beats, once thought to be entirely benign, are now recognized to have important pathologic associations. Fetal tachyarrhythmias can now be defined precisely for mechanism-specific therapy and for subsequent monitoring of response. This article reviews the current and future diagnostic techniques and pharmacologic treatments for fetal arrhythmia.
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Fukushima A, Nakai K, Matsumoto A, Strasburger J, Sugiyama T. Prenatal diagnosis of polymorphic ventricular tachycardia using 64-channel magnetocardiography. Heart Vessels 2010; 25:270-3. [DOI: 10.1007/s00380-009-1195-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2008] [Accepted: 08/14/2009] [Indexed: 11/28/2022]
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Horigome H, Nagashima M, Sumitomo N, Yoshinaga M, Ushinohama H, Iwamoto M, Shiono J, Ichihashi K, Hasegawa S, Yoshikawa T, Matsunaga T, Goto H, Waki K, Arima M, Takasugi H, Tanaka Y, Tauchi N, Ikoma M, Inamura N, Takahashi H, Shimizu W, Horie M. Clinical Characteristics and Genetic Background of Congenital Long-QT Syndrome Diagnosed in Fetal, Neonatal, and Infantile Life. Circ Arrhythm Electrophysiol 2010; 3:10-7. [DOI: 10.1161/circep.109.882159] [Citation(s) in RCA: 90] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Hitoshi Horigome
- From the Department of Child Health (H.H.), Graduate School of Comprehensive Human Sciences, University of Tsukuba, Tsukuba, Japan; the Department of Cardiology (M.N.), Aichi Children’s Health and Medical Center, Ohbu, Japan; the Department of Pediatrics and Child Health (N.S.), Nihon University School of Medicine, Tokyo, Japan; the Department of Pediatrics (M.Y.), National Hospital Organization Kagoshima Medical Center, Kagoshima, Japan; the Department of Cardiology (H.U.), Fukuoka Children’s
| | - Masami Nagashima
- From the Department of Child Health (H.H.), Graduate School of Comprehensive Human Sciences, University of Tsukuba, Tsukuba, Japan; the Department of Cardiology (M.N.), Aichi Children’s Health and Medical Center, Ohbu, Japan; the Department of Pediatrics and Child Health (N.S.), Nihon University School of Medicine, Tokyo, Japan; the Department of Pediatrics (M.Y.), National Hospital Organization Kagoshima Medical Center, Kagoshima, Japan; the Department of Cardiology (H.U.), Fukuoka Children’s
| | - Naokata Sumitomo
- From the Department of Child Health (H.H.), Graduate School of Comprehensive Human Sciences, University of Tsukuba, Tsukuba, Japan; the Department of Cardiology (M.N.), Aichi Children’s Health and Medical Center, Ohbu, Japan; the Department of Pediatrics and Child Health (N.S.), Nihon University School of Medicine, Tokyo, Japan; the Department of Pediatrics (M.Y.), National Hospital Organization Kagoshima Medical Center, Kagoshima, Japan; the Department of Cardiology (H.U.), Fukuoka Children’s
| | - Masao Yoshinaga
- From the Department of Child Health (H.H.), Graduate School of Comprehensive Human Sciences, University of Tsukuba, Tsukuba, Japan; the Department of Cardiology (M.N.), Aichi Children’s Health and Medical Center, Ohbu, Japan; the Department of Pediatrics and Child Health (N.S.), Nihon University School of Medicine, Tokyo, Japan; the Department of Pediatrics (M.Y.), National Hospital Organization Kagoshima Medical Center, Kagoshima, Japan; the Department of Cardiology (H.U.), Fukuoka Children’s
| | - Hiroya Ushinohama
- From the Department of Child Health (H.H.), Graduate School of Comprehensive Human Sciences, University of Tsukuba, Tsukuba, Japan; the Department of Cardiology (M.N.), Aichi Children’s Health and Medical Center, Ohbu, Japan; the Department of Pediatrics and Child Health (N.S.), Nihon University School of Medicine, Tokyo, Japan; the Department of Pediatrics (M.Y.), National Hospital Organization Kagoshima Medical Center, Kagoshima, Japan; the Department of Cardiology (H.U.), Fukuoka Children’s
| | - Mari Iwamoto
- From the Department of Child Health (H.H.), Graduate School of Comprehensive Human Sciences, University of Tsukuba, Tsukuba, Japan; the Department of Cardiology (M.N.), Aichi Children’s Health and Medical Center, Ohbu, Japan; the Department of Pediatrics and Child Health (N.S.), Nihon University School of Medicine, Tokyo, Japan; the Department of Pediatrics (M.Y.), National Hospital Organization Kagoshima Medical Center, Kagoshima, Japan; the Department of Cardiology (H.U.), Fukuoka Children’s
| | - Junko Shiono
- From the Department of Child Health (H.H.), Graduate School of Comprehensive Human Sciences, University of Tsukuba, Tsukuba, Japan; the Department of Cardiology (M.N.), Aichi Children’s Health and Medical Center, Ohbu, Japan; the Department of Pediatrics and Child Health (N.S.), Nihon University School of Medicine, Tokyo, Japan; the Department of Pediatrics (M.Y.), National Hospital Organization Kagoshima Medical Center, Kagoshima, Japan; the Department of Cardiology (H.U.), Fukuoka Children’s
| | - Koh Ichihashi
- From the Department of Child Health (H.H.), Graduate School of Comprehensive Human Sciences, University of Tsukuba, Tsukuba, Japan; the Department of Cardiology (M.N.), Aichi Children’s Health and Medical Center, Ohbu, Japan; the Department of Pediatrics and Child Health (N.S.), Nihon University School of Medicine, Tokyo, Japan; the Department of Pediatrics (M.Y.), National Hospital Organization Kagoshima Medical Center, Kagoshima, Japan; the Department of Cardiology (H.U.), Fukuoka Children’s
| | - Satoshi Hasegawa
- From the Department of Child Health (H.H.), Graduate School of Comprehensive Human Sciences, University of Tsukuba, Tsukuba, Japan; the Department of Cardiology (M.N.), Aichi Children’s Health and Medical Center, Ohbu, Japan; the Department of Pediatrics and Child Health (N.S.), Nihon University School of Medicine, Tokyo, Japan; the Department of Pediatrics (M.Y.), National Hospital Organization Kagoshima Medical Center, Kagoshima, Japan; the Department of Cardiology (H.U.), Fukuoka Children’s
| | - Tadahiro Yoshikawa
- From the Department of Child Health (H.H.), Graduate School of Comprehensive Human Sciences, University of Tsukuba, Tsukuba, Japan; the Department of Cardiology (M.N.), Aichi Children’s Health and Medical Center, Ohbu, Japan; the Department of Pediatrics and Child Health (N.S.), Nihon University School of Medicine, Tokyo, Japan; the Department of Pediatrics (M.Y.), National Hospital Organization Kagoshima Medical Center, Kagoshima, Japan; the Department of Cardiology (H.U.), Fukuoka Children’s
| | - Tamotsu Matsunaga
- From the Department of Child Health (H.H.), Graduate School of Comprehensive Human Sciences, University of Tsukuba, Tsukuba, Japan; the Department of Cardiology (M.N.), Aichi Children’s Health and Medical Center, Ohbu, Japan; the Department of Pediatrics and Child Health (N.S.), Nihon University School of Medicine, Tokyo, Japan; the Department of Pediatrics (M.Y.), National Hospital Organization Kagoshima Medical Center, Kagoshima, Japan; the Department of Cardiology (H.U.), Fukuoka Children’s
| | - Hiroko Goto
- From the Department of Child Health (H.H.), Graduate School of Comprehensive Human Sciences, University of Tsukuba, Tsukuba, Japan; the Department of Cardiology (M.N.), Aichi Children’s Health and Medical Center, Ohbu, Japan; the Department of Pediatrics and Child Health (N.S.), Nihon University School of Medicine, Tokyo, Japan; the Department of Pediatrics (M.Y.), National Hospital Organization Kagoshima Medical Center, Kagoshima, Japan; the Department of Cardiology (H.U.), Fukuoka Children’s
| | - Kenji Waki
- From the Department of Child Health (H.H.), Graduate School of Comprehensive Human Sciences, University of Tsukuba, Tsukuba, Japan; the Department of Cardiology (M.N.), Aichi Children’s Health and Medical Center, Ohbu, Japan; the Department of Pediatrics and Child Health (N.S.), Nihon University School of Medicine, Tokyo, Japan; the Department of Pediatrics (M.Y.), National Hospital Organization Kagoshima Medical Center, Kagoshima, Japan; the Department of Cardiology (H.U.), Fukuoka Children’s
| | - Masaki Arima
- From the Department of Child Health (H.H.), Graduate School of Comprehensive Human Sciences, University of Tsukuba, Tsukuba, Japan; the Department of Cardiology (M.N.), Aichi Children’s Health and Medical Center, Ohbu, Japan; the Department of Pediatrics and Child Health (N.S.), Nihon University School of Medicine, Tokyo, Japan; the Department of Pediatrics (M.Y.), National Hospital Organization Kagoshima Medical Center, Kagoshima, Japan; the Department of Cardiology (H.U.), Fukuoka Children’s
| | - Hisashi Takasugi
- From the Department of Child Health (H.H.), Graduate School of Comprehensive Human Sciences, University of Tsukuba, Tsukuba, Japan; the Department of Cardiology (M.N.), Aichi Children’s Health and Medical Center, Ohbu, Japan; the Department of Pediatrics and Child Health (N.S.), Nihon University School of Medicine, Tokyo, Japan; the Department of Pediatrics (M.Y.), National Hospital Organization Kagoshima Medical Center, Kagoshima, Japan; the Department of Cardiology (H.U.), Fukuoka Children’s
| | - Yasuhiko Tanaka
- From the Department of Child Health (H.H.), Graduate School of Comprehensive Human Sciences, University of Tsukuba, Tsukuba, Japan; the Department of Cardiology (M.N.), Aichi Children’s Health and Medical Center, Ohbu, Japan; the Department of Pediatrics and Child Health (N.S.), Nihon University School of Medicine, Tokyo, Japan; the Department of Pediatrics (M.Y.), National Hospital Organization Kagoshima Medical Center, Kagoshima, Japan; the Department of Cardiology (H.U.), Fukuoka Children’s
| | - Nobuo Tauchi
- From the Department of Child Health (H.H.), Graduate School of Comprehensive Human Sciences, University of Tsukuba, Tsukuba, Japan; the Department of Cardiology (M.N.), Aichi Children’s Health and Medical Center, Ohbu, Japan; the Department of Pediatrics and Child Health (N.S.), Nihon University School of Medicine, Tokyo, Japan; the Department of Pediatrics (M.Y.), National Hospital Organization Kagoshima Medical Center, Kagoshima, Japan; the Department of Cardiology (H.U.), Fukuoka Children’s
| | - Masanobu Ikoma
- From the Department of Child Health (H.H.), Graduate School of Comprehensive Human Sciences, University of Tsukuba, Tsukuba, Japan; the Department of Cardiology (M.N.), Aichi Children’s Health and Medical Center, Ohbu, Japan; the Department of Pediatrics and Child Health (N.S.), Nihon University School of Medicine, Tokyo, Japan; the Department of Pediatrics (M.Y.), National Hospital Organization Kagoshima Medical Center, Kagoshima, Japan; the Department of Cardiology (H.U.), Fukuoka Children’s
| | - Noboru Inamura
- From the Department of Child Health (H.H.), Graduate School of Comprehensive Human Sciences, University of Tsukuba, Tsukuba, Japan; the Department of Cardiology (M.N.), Aichi Children’s Health and Medical Center, Ohbu, Japan; the Department of Pediatrics and Child Health (N.S.), Nihon University School of Medicine, Tokyo, Japan; the Department of Pediatrics (M.Y.), National Hospital Organization Kagoshima Medical Center, Kagoshima, Japan; the Department of Cardiology (H.U.), Fukuoka Children’s
| | - Hideto Takahashi
- From the Department of Child Health (H.H.), Graduate School of Comprehensive Human Sciences, University of Tsukuba, Tsukuba, Japan; the Department of Cardiology (M.N.), Aichi Children’s Health and Medical Center, Ohbu, Japan; the Department of Pediatrics and Child Health (N.S.), Nihon University School of Medicine, Tokyo, Japan; the Department of Pediatrics (M.Y.), National Hospital Organization Kagoshima Medical Center, Kagoshima, Japan; the Department of Cardiology (H.U.), Fukuoka Children’s
| | - Wataru Shimizu
- From the Department of Child Health (H.H.), Graduate School of Comprehensive Human Sciences, University of Tsukuba, Tsukuba, Japan; the Department of Cardiology (M.N.), Aichi Children’s Health and Medical Center, Ohbu, Japan; the Department of Pediatrics and Child Health (N.S.), Nihon University School of Medicine, Tokyo, Japan; the Department of Pediatrics (M.Y.), National Hospital Organization Kagoshima Medical Center, Kagoshima, Japan; the Department of Cardiology (H.U.), Fukuoka Children’s
| | - Minoru Horie
- From the Department of Child Health (H.H.), Graduate School of Comprehensive Human Sciences, University of Tsukuba, Tsukuba, Japan; the Department of Cardiology (M.N.), Aichi Children’s Health and Medical Center, Ohbu, Japan; the Department of Pediatrics and Child Health (N.S.), Nihon University School of Medicine, Tokyo, Japan; the Department of Pediatrics (M.Y.), National Hospital Organization Kagoshima Medical Center, Kagoshima, Japan; the Department of Cardiology (H.U.), Fukuoka Children’s
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QT interval prolongation and risk for cardiac events in genotyped LQTS-index children. Eur J Pediatr 2009; 168:1107-15. [PMID: 19101729 DOI: 10.1007/s00431-008-0896-6] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2008] [Accepted: 12/01/2008] [Indexed: 10/21/2022]
Abstract
Congenital long-QT syndrome (LQTS) is an inherited cardiac disorder with a disturbance in repolarization characterized by a prolonged QT interval on the surface electrocardiogram and life-threatening ventricular tachycardia. Publications from the International LQTS Registry have provided information that the cardiac risk may be influenced by gender, genotype, exposure to arrhythmia triggers, and previous cardiac events. In children, early-onset of disease, changes in life style, and medical treatment is a sensitive issue and significant, gender-related differences of a first life-threatening event were reported. Thus, we investigated the clinical features of a large genotyped population of LQTS-index children (age < or =16 years) upon a single-center experience and determined risk factors for symptoms. Of 83 children [mean corrected QT interval (QTc) 510 +/- 74 ms], 89% had LQT1, -2, or -3. Nine patients (11%) were identified as having Jervell and Lange-Nielsen syndrome. Among symptomatic children (n = 51, 61%), syncope was the most prevalent symptom at initial presentation (49%); however, aborted cardiac arrest (ACA) occurred in 33% and sudden cardiac death (SCD) in 18%, respectively, as the initial manifestation. During a mean follow-up period of 5.9 +/- 4.7 years, 31% of the children developed symptoms while on therapy (86% syncope, 9% ACA, 5% SCD). Statistical analyses of risk factors for cardiac events showed that the QTc >500 ms was a strong and significant predictor for cardiac events during follow-up (p = 0.02). Furthermore, a prior syncope [hazard ratio (HR), 4.05; 95% confidence interval (CI), 1.1 to 15.0; p = 0.03] or an ACA (HR, 11.7; 95% CI, 3.1 to 43.4; p = <0.001) identified children with an increased risk for recurrent cardiac events compared to asymptomatic LQT children. LQTS-index children manifest with a high percentage of severe symptoms. Among presently validated risk factors for LQTS, a QTc interval >500 ms and a history of prior syncope or ACA were strong predictors for recurrent cardiac events.
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Fujimoto Y, Matsumoto T, Honda N, Tojo R, Furuya M, Kasai K, Saito S, Mochimaru F, Ishikawa Y. Prenatal diagnosis of long QT syndrome by non-invasive fetal electrocardiography. J Obstet Gynaecol Res 2009; 35:555-61. [PMID: 19527399 DOI: 10.1111/j.1447-0756.2008.00982.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Long QT syndrome is a high-risk condition associated with arrhythmia due to its sudden cause of death. Prenatal diagnosis of long QT syndrome, however, is impossible using the fetal echocardiogram. Here we present the first reported case of long QT syndrome in which a prenatal diagnosis was made using non-invasive fetal electrocardiogram. We consider that the non-invasive fetal electrocardiogram may be a good method for diagnosing fetal QT prolongation.
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Affiliation(s)
- Yoshinobu Fujimoto
- Department of Obstetrics and Gynecology, Hiratsuka City Hospital, Hiratsuka, Kanagawa, Japan.
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Abstract
Fetal cardiac dysrhythmias are potentially life-threatening conditions. However, intermittent extrasystoles, which are frequently encountered in clinical practice, do not require treatment. Sustained forms of brady- and tachyarrhythmias might require fetal intervention. Fetal echocardiography is essential not only to establish the diagnosis but also to monitor fetal response to therapy. In the last decade, improvements in ultrasound methodology and new diagnostic tools have contributed to better diagnostic accuracy and to a greater understanding of the electrophysiological mechanisms involved in fetal cardiac dysrhythmias. The most common form of supraventricular tachycardia - that caused by an atrioventricular re-entry circuit - should be differentiated from other forms of tachyarrhythmias, such as atrial flutter and atrial ectopic tachycardia. Ventricular tachycardia is rare in the fetus. Sustained tachycardias, intermittent or not, might be associated with the development of congestive heart failure and hydrops fetalis. Prompt treatment with either anti-arrhythmic drugs or delivery must be considered. Persistent fetal bradycardias associated with complete heart block are also potentially dangerous, whereas bradyarrhythmia due to blocked ectopy is well tolerated in pregnancy. Heart block can be associated with maternal anti-Ro/La autoantibodies or develop in fetuses with left atrial isomerism or with malformations involving the atrioventricular junction. The treatment of fetuses with immune-mediated heart block remains debatable. The use of antenatal steroid therapy is not widely accepted and there is concern over the risks and benefits of its use in the fetus. Direct fetal cardiac pacing has rarely been attempted.
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Abstract
The final common pathway to death in all of us is an arrhythmia, yet we still know far too little about the contribution of conduction abnormalities and arrhythmias to the compromised states of the human fetus. At no other time in the human life cycle is the human being at more risk of unexplained and unexpected death than during the prenatal period. The risk of sudden death from 20-40 weeks gestation is 6-12 deaths/1000 fetuses/year. This is equal to, and in some ethnic groups HIGHER than, the risk of death in the adult population with known coronary artery disease over the same time frame (6-12 deaths/1000 patients/year). Because only a small percentage of the United States population is pregnant each year, because fetal demise is not often acknowledged through public displays such as funerals, and finally because fetal death is culturally accepted to a much greater extent than it should be, this critically important area of women's healthcare has not had the technological advances that have been seen in adult cardiac intensive care and other areas of medicine. Fetal cardiac deaths may be preventable and the diseases that lead to these deaths are often treatable, especially if the sophistication of our modern ICU's could somehow be translated to the prenatal monitoring arena. This review article will outline recent advances in evaluating fetal electrophysiology, helping the perinatologist to better understand the nuances of fetal arrhythmias.
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Affiliation(s)
- Janette F Strasburger
- Children's Hospital of Wisconsin - Fox Valley, 200 Theda Clark Medical Plaza, Suite 480, Neenah, WI 54956-2884, USA.
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Papantoniou N, Katsoulis I, Papageorgiou I, Antsaklis A. Hereditary long QT syndrome in pregnancy: antenatal and intrapartum management options. J Matern Fetal Neonatal Med 2007; 20:419-21. [PMID: 17674248 DOI: 10.1080/14767050701286626] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Long QT syndrome is a rare but severe cardiac arrhythmia. We report the antenatal and intrapartum management of a primigravida carrying the hereditary form of the disease and specifically the Romano-Ward syndrome. A multidisciplinary approach and close obstetric surveillance are mandatory for a good maternal and perinatal outcome. Follow-up of the neonate is equally important.
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Abstract
Fetal bradycardia may herald fetal demise. This article highlights arrhythmic fetal bradycardia rather than bradycardia caused by perinatal distress. We briefly examine the embryonic conduction system's development and physiology and we review the classification, aetiology, evaluation, and approach to fetal bradycardia. Our aim is to provide the clinician with practical information about fetal bradycardia that enlightens causative conditions and aids management.
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Medeiros-Domingo A, Iturralde-Torres P, Ackerman MJ. Clínica y genética en el síndrome de QT largo. Rev Esp Cardiol 2007. [DOI: 10.1157/13108280] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
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Beery TA, Shooner KA, Benson DW. Neonatal Long QT Syndrome Due to a De Novo Dominant Negative hERG Mutation. Am J Crit Care 2007. [DOI: 10.4037/ajcc2007.16.4.416] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
A 4-day-old girl with ventricular tachyarrhythmias, sinus bradycardia, and 2:1 atrioventricular block had prolongation of the QT interval. She was symptomatic with arching, gasping, and cyanosis presumably due to a life-threatening ventricular tachyarrhythmia such as torsades de pointes. Molecular genetic studies indicated a heterozygous, de novo, dominant negative mutation in hERG, a gene that encodes a protein in a potassium ion channel. The parents do not have the mutation. The patient’s clinical scenario was produced by the convergence of 3 events: a de novo mutation occurred in hERG, the mutation was dominant negative, and the action of the mutation resulted in neonatal long QT syndrome. The child was treated aggressively and is doing well at age 6 years.
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Affiliation(s)
- Theresa A. Beery
- Theresa A. Beery is an associate professor at the University of Cincinnati, Cincinnati, Ohio. D.Woodrow Benson is the director of cardiovascular genetics and Kerry A. Shooner is a genetic counselor at Cincinnati Children’s Hospital Medical Center, University of Cincinnati
| | - Kerry A. Shooner
- Theresa A. Beery is an associate professor at the University of Cincinnati, Cincinnati, Ohio. D.Woodrow Benson is the director of cardiovascular genetics and Kerry A. Shooner is a genetic counselor at Cincinnati Children’s Hospital Medical Center, University of Cincinnati
| | - D. Woodrow Benson
- Theresa A. Beery is an associate professor at the University of Cincinnati, Cincinnati, Ohio. D.Woodrow Benson is the director of cardiovascular genetics and Kerry A. Shooner is a genetic counselor at Cincinnati Children’s Hospital Medical Center, University of Cincinnati
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Presta G, Rosati E, Giannuzzi R, Del Vecchio A, Lozupone A, Criscuolo M, Verrotti A, Latini G, De Felice C. Prolonged fetal bradycardia as the presenting clinical sign in Streptococcus agalactiae chorioamnionitis. J Perinat Med 2005; 32:535-7. [PMID: 15576278 DOI: 10.1515/jpm.2004.125] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Group B Streptococcus remains a leading infectious cause of neonatal morbidity and mortality. We report a case of a 37 weeks' gestation infant with severe birth asphyxia, status epilepticus and GBS chorioamnionitis, in which a prolonged fetal bradycardia was the only prenatal clinical sign.
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Vergani P, Mariani E, Ciriello E, Locatelli A, Strobelt N, Galli M, Ghidini A. Fetal arrhythmias: natural history and management. ULTRASOUND IN MEDICINE & BIOLOGY 2005; 31:1-6. [PMID: 15653224 DOI: 10.1016/j.ultrasmedbio.2004.10.001] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/29/2004] [Revised: 09/28/2004] [Accepted: 10/05/2004] [Indexed: 05/24/2023]
Abstract
The aim was to delineate the significance and natural history of fetal arrhythmias and provide information about their management. A cohort of 114 infants with fetal arrhythmias detected during prenatal ultrasound (US) screening were studied. All subjects underwent echocardiography and were treated as clinically indicated. Postnatal outcome was obtained in 100% of infants until 1 year of age. The incidence of fetal arrhythmias was 0.3%. Among the 87 fetuses with atrial extrasystoles, 2.3% developed supraventricular tachycardia (SVT) in utero. Of the 10 SVT cases, only five required antiarrhythmic therapy in utero with digoxin and propafenone, which successfully restored sinus rhythm in 100% of fetuses, both nonhydropic and hydropic. Sinus bradycardia was associated with structural anomalies in 5 of 6 patients and only 2 of 4 fetuses with atrioventricular block survived. It is concluded that prognosis is good for most fetal tachyarrhythmias, whereas it is less favorable for bradyarrhythmias.
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Affiliation(s)
- Patrizia Vergani
- Department of Obstetrics and Gynecology, University of Milano-Bicocca, Monza, Italy.
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Larmay HJ, Strasburger JF. Differential diagnosis and management of the fetus and newborn with an irregular or abnormal heart rate. Pediatr Clin North Am 2004; 51:1033-50, x. [PMID: 15275987 DOI: 10.1016/j.pcl.2004.03.013] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
This article separately discusses the differential diagnosis and management of irregular or abnormal heart rate in both the fetus and the newborn. Conditions covered include ectopic beats, tachyarrythmias,atrial flutter, bradyarrythmias, tachycardia, congenital atrioventricular block, long QT syndrome, and bradycardias,among others.
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Affiliation(s)
- Heather J Larmay
- Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI 53226, USA
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Oudijk MA, Kwee A, Visser GHA, Blad S, Meijboom EJ, Rosén KG. The effects of intrapartum hypoxia on the fetal QT interval. BJOG 2004; 111:656-60. [PMID: 15198754 DOI: 10.1111/j.1471-0528.2004.00178.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND The morphology of the fetal ECG complex provides information on the fetal condition during labour, such as the ST segment and T-wave configuration. We hypothesised that the intrapartum fetal QT interval may provide additional information on the condition of the fetus, as it is known that the QT interval reacts to situations of stress and exercise. DESIGN Retrospective study. SETTING Data were substracted from a European community multicentre trial. METHODS The intrapartum QT interval was measured in 68 fetuses who were acidemic at birth (pH <7.05 and BD (ecf) >12 mmol/L) and in a control group of similar size. All of these cases were monitored by STAN S21. Measurements were performed at the start of the recording at baseline heart rate, during variable decelerations and at the end of the recording. The QTc was calculated using Bazett's formula: QT/ radical RR. The intervals were compared using the Wilcoxon signed ranks test. MAIN OUTCOME MEASURES Fetal QT interval, and the corrected QT interval: QTc. RESULTS In the acidemic fetuses, there was a significant shortening of the QTc interval at the end of the recording compared with the start of the recording (397 ms at the end vs 359.3 ms at start; P < 0.001), in association with a significantly lowered heart rate (136.3 vs 110.9 bpm, P < 0.001). Measurements of QT and QTc during variable decelerations at the start and end of the recording also showed a shortening of the QT interval (301.9 vs 273.3 ms, P< or = 0.001) and QTc interval (381.6 vs 340.3, P < 0.001), and this was not dependent on heart rate. In the control cases, no differences in FHR, QT and QTc intervals were present. CONCLUSIONS In intrapartum hypoxia, resulting in metabolic acidosis, a significant shortening of the fetal QT and QTc is present, irrespective of changes in heart rate. In control cases, this shortening does not occur. The intrapartum fetal QT interval may therefore provide additional information on the condition of the fetus.
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Affiliation(s)
- Martijn A Oudijk
- Department of Obstetrics, University Medical Center Utrecht, The Netherlands
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40
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Beinder E, Buheitel G, Hofbeck M. Are some cases of sudden intrauterine unexplained death due to the long QT syndrome? Prenat Diagn 2004; 23:1097-8. [PMID: 14692000 DOI: 10.1002/pd.702] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Tester DJ, McCormack J, Ackerman MJ. Prenatal molecular genetic diagnosis of congenital long QT syndrome by strategic genotyping. Am J Cardiol 2004; 93:788-91. [PMID: 15019897 DOI: 10.1016/j.amjcard.2003.11.061] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2003] [Revised: 11/19/2003] [Accepted: 11/19/2003] [Indexed: 11/15/2022]
Abstract
We demonstrate how genetic testing enabled a molecular prenatal diagnosis of congenital long QT syndrome in a 20-week fetus presenting with fetal bradycardia in the setting of maternal beta-blocker therapy. Before prenatal testing, strategic genotyping, based on a family history of a near drowning, was performed on a 3-generation family with clinically diagnosed long QT syndrome in which the affected mother was pregnant.
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Affiliation(s)
- David J Tester
- Departments of Medicine, Pediatrics, and Molecular Pharmacology, Divisions of Cardiovascular Diseases and Pediatric Cardiology, Mayo Clinic College of Medicine, Rochester, Minnesota 55905, USA
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Langheinrich U, Vacun G, Wagner T. Zebrafish embryos express an orthologue of HERG and are sensitive toward a range of QT-prolonging drugs inducing severe arrhythmia☆. Toxicol Appl Pharmacol 2003; 193:370-82. [PMID: 14678746 DOI: 10.1016/j.taap.2003.07.012] [Citation(s) in RCA: 188] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
A wide range of drugs has been shown to prolong the QT interval of the electrocardiogram by blocking the pore-forming subunit of the rapidly activating delayed rectifier K+ channel, HERG (ether-à-go-go-related gene), sometimes leading to life-threatening arrhythmia. In this paper we describe cloning, sequence, and expression of the zebrafish orthologue of HERG, Zerg. Further, we studied effects of Zerg inhibition in zebrafish embryos caused by drugs or by an antisense approach. Zerg is expressed specifically in both heart chambers of zebrafish embryos, is composed of six transmembrane domains, and shows an especially high degree of amino acid conservation in the S6 and pore domain (99% identity). Several QT-prolonging drugs added to the bathing medium elicited bradycardia and arrhythmia in zebrafish embryos. The arrhythmia induced ranged from an atrioventricular 2:1 block, the ventricle beating half as often as the atrium, to more severe irregular arrhythmia with higher concentrations of the drugs. These effects were highly specific, reproducible, and rapid, e.g., 10 microM astemizole caused a 2:1 heartbeat within a minute after addition of the compound in all the embryos studied. Morpholino antisense oligonucleotides targeting Zerg were injected into zebrafish embryos and elicited similar dose-sensitive and specific arrhythmia as the QT-prolonging drugs, suggesting an evolutionarily conserved role for Erg in regulating heartbeat rate and rhythm. Further, we identified a mutation in the Per-Arnt-Sim domain of the Zerg channel in the breakdance mutant, also characterized by a 2:1 atrioventricular block. In conclusion, the zebrafish could be a tractable model organism for the study of Erg function and modulation but might also have a value in the field of cardiovascular pharmacology, e.g., as an early preclinical model for testing drugs under development for potential QT prolongation.
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Cuneo BF, Ovadia M, Strasburger JF, Zhao H, Petropulos T, Schneider J, Wakai RT. Prenatal diagnosis and in utero treatment of torsades de pointes associated with congenital long QT syndrome. Am J Cardiol 2003; 91:1395-8. [PMID: 12767447 DOI: 10.1016/s0002-9149(03)00343-6] [Citation(s) in RCA: 79] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Affiliation(s)
- Bettina F Cuneo
- Department of Pediatrics, The Heart Institute for Children, Hope Children's Hospital, 4440 West 95th Street, Chicago, IL 60644, USA.
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Current awareness. Prenat Diagn 2002; 22:168-74. [PMID: 11857634 DOI: 10.1002/pd.265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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