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Guo J, Ling W, Dang T, Guo S, Ma H, Huang Q, Zeng L, Weng Z, Wu Q. Prenatal transposition of great arteries diagnosis and management: a Chinese single-center study. Front Cardiovasc Med 2024; 11:1341005. [PMID: 38510199 PMCID: PMC10951393 DOI: 10.3389/fcvm.2024.1341005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2023] [Accepted: 02/26/2024] [Indexed: 03/22/2024] Open
Abstract
Objective This study aimed to assess the diagnostic value of prenatal echocardiography for identifying transposition of the great arteries (TGA) during pregnancy and evaluating the associated outcomes. Methods We conducted a retrospective analysis of 121 prenatally diagnosed patients with TGA at our hospital between January 2012 and September 2022. This analysis included prenatal ultrasound, prenatal screening, clinical management and follow-up procedures. Results Among the 103 fetuses considered in the study, 90 (87.4%) were diagnosed with complete transposition of the great arteries (D-TGA), while 13 (12.6%) exhibited corrected transposition of the great arteries (CC-TGA). Diagnoses were distributed across the trimester, with 8 D-TGA and 2 CC-TGA patients identified in the first trimester, 68 D-TGA patients and 9 CC-TGA patients in the second trimester, and 14 D-TGA and 2 CC-TGA patients referred for diagnosis in the third trimester. Induction of labour was pursued for 76 D-TGA patients (84.4%) and 11 CC-TGA patients (84.6%), and 14 D-TGA patients (15.6%) and 2 CC-TGA patients (15.4%) continued pregnancy until delivery. Among the D-TGA patients, 9 fetuses (10.0%) underwent surgery, two of which were inadvertent fatality, while the remaining seven experienced positive outcomes. Additionally, seven TGA patients received palliative care, leading to four fatalities among D-TGA patients (5.2%), whereas 1 D-TGA patients and 2 CC-TGA patients survived. Conclusion This study underscores the feasibility of achieving an accurate prenatal diagnosis of TGA during early pregnancy. The utility of prenatal ultrasound in the development of personalized perinatal plans and the application of multidisciplinary treatment during delivery are conducive.
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Affiliation(s)
- Jie Guo
- Department of Medical Ultrasonics, Fujian Maternity and Child Health Hospital, College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China
| | - Wen Ling
- Department of Medical Ultrasonics, Fujian Maternity and Child Health Hospital, College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China
| | - Tingting Dang
- Department of Medical Ultrasonics, Fujian Maternity and Child Health Hospital, College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China
| | - Shan Guo
- Department of Medical Ultrasonics, Fujian Maternity and Child Health Hospital, College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China
| | - Hong Ma
- Department of Pathology, Fujian Maternity and Child Health Hospital, College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China
| | - Qiong Huang
- Department of Medical Ultrasonics, Fujian Maternity and Child Health Hospital, College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China
| | - Liqin Zeng
- Department of Medical Ultrasonics, Fujian Maternity and Child Health Hospital, College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China
| | - Zongjie Weng
- Department of Medical Ultrasonics, Fujian Maternity and Child Health Hospital, College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China
| | - Qiumei Wu
- Department of Medical Ultrasonics, Fujian Maternity and Child Health Hospital, College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China
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Holmes S, Hornberger LK, Jaeggi E, Howley L, Moon-Grady AJ, Uzun O, Kaizer A, Gilicze O, Cuneo BF. Treatment, not delivery, of the late preterm and term fetus with supraventricular arrhythmia. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2023; 62:552-557. [PMID: 37128167 DOI: 10.1002/uog.26239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 03/31/2023] [Accepted: 04/18/2023] [Indexed: 05/03/2023]
Abstract
OBJECTIVE While in-utero treatment of sustained fetal supraventricular arrhythmia (SVA) is standard practice in the previable and preterm fetus, data are limited on best practice for late preterm (34 + 0 to 36 + 6 weeks), early term (37 + 0 to 38 + 6 weeks) and term (> 39 weeks) fetuses with SVA. We reviewed the delivery and postnatal outcomes of fetuses at ≥ 35 weeks of gestation undergoing treatment rather than immediate delivery. METHODS This was a retrospective case series of fetuses presenting at ≥ 35 weeks of gestation with sustained SVA and treated transplacentally at six institutions between 2012 and 2022. Data were collected on gestational age at presentation and delivery, SVA diagnosis (short ventriculoatrial (VA) tachycardia, long VA tachycardia or atrial flutter), type of antiarrhythmic medication used, interval between treatment and conversion to sinus rhythm and postnatal SVA recurrence. RESULTS Overall, 37 fetuses presented at a median gestational age of 35.7 (range, 35.0-39.7) weeks with short VA tachycardia (n = 20), long VA tachycardia (n = 7) or atrial flutter (n = 10). Four (11%) fetuses were hydropic. In-utero treatment led to restoration of sinus rhythm in 35 (95%) fetuses at a median of 2 (range, 1-17) days; this included three of the four fetuses with hydrops. Antiarrhythmic medications included flecainide (n = 11), digoxin (n = 7), sotalol (n = 11) and dual therapy (n = 8). Neonates were liveborn at 36-41 weeks via spontaneous vaginal delivery (23/37 (62%)) or Cesarean delivery (14/37 (38%)). Cesarean delivery was indicated for fetal SVA in two fetuses, atrial ectopy or sinus bradycardia in three fetuses and obstetric reasons in nine fetuses that were in sinus rhythm at the time of delivery. Twenty-one (57%) cases were treated for recurrent SVA after birth. CONCLUSION In-utero treatment of the near term and term (≥ 35-week) SVA fetus is highly successful even in the presence of hydrops, with the majority of cases delivered vaginally closer to term, thereby avoiding unnecessary Cesarean section. © 2023 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- S Holmes
- The Heart Institute, Children's Hospital Colorado, University of Colorado, Aurora, CO, USA
| | - L K Hornberger
- Division of Cardiology, Department of Pediatrics, Stollery Children's Hospital, University of Alberta, Edmonton, AB, Canada
| | - E Jaeggi
- Division of Cardiology, Department of Pediatrics, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - L Howley
- Children's Hospital Minnesota, Minneapolis, MN, USA
| | - A J Moon-Grady
- University of California San Francisco, San Francisco, CA, USA
| | - O Uzun
- School of Medicine and University Hospital of Wales, Cardiff, UK
| | - A Kaizer
- Department of Biostatistics and Informatics, University of Colorado, Aurora, CO, USA
| | - O Gilicze
- University of California San Francisco, San Francisco, CA, USA
| | - B F Cuneo
- The Heart Institute, Children's Hospital Colorado, University of Colorado, Aurora, CO, USA
- Colorado Fetal Care Center, Children's Hospital Colorado, University of Colorado, Aurora, CO, USA
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Leoni L, Bronzetti G, Colonna D, Porcedda G, Rimini A, Silvetti MS. Diagnosis and treatment of fetal and pediatric age patients (0-12 years) with Wolff-Parkinson-White syndrome and atrioventricular accessory pathways. J Cardiovasc Med (Hagerstown) 2023; 24:589-601. [PMID: 37409656 PMCID: PMC10836786 DOI: 10.2459/jcm.0000000000001484] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 04/16/2023] [Indexed: 07/07/2023]
Abstract
Overt or concealed accessory pathways are the anatomic substrates of ventricular preexcitation (VP), Wolff-Parkinson-White syndrome (WPW) and paroxysmal supraventricular tachycardia (PSVT). These arrhythmias are commonly observed in pediatric age. PSVT may occur at any age, from fetus to adulthood, and its symptoms range from none to syncope or heart failure. VP too can range from no symptoms to sudden cardiac death. Therefore, these arrhythmias frequently need risk stratification, electrophysiologic study, drug or ablation treatment. In this review of the literature, recommendations are given for diagnosis and treatment of fetal and pediatric age (≤12 years) WPW, VP, PSVT, and criteria for sport participation.
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Affiliation(s)
- Loira Leoni
- Cardiology, Department of Cardio-Thoracic-Vascular Sciences and Public Health, University Hospital of Padua, European Reference Network for Rare and Low Prevalence Complex Disease of the Heart (ERN GUARD-Heart), Padua
| | - Gabriele Bronzetti
- Cardio-Thoraco-Vascular Department, Sant’Orsola Hospital, University Hospital of Bologna IRCCS, Bologna
| | - Diego Colonna
- Adult Congenital Heart Disease Unit, Monaldi Hospital, Naples
| | - Giulio Porcedda
- Unit of Pediatric Cardiology, Anna Meyer Children's Hospital, Florence
| | | | - Massimo Stefano Silvetti
- Pediatric Cardiology and Cardiac Arrhythmia/Syncope Unit, and Bambino Gesù Children's Hospital, IRCCS, European Reference Network for Rare and Low Prevalence Complex Disease of the Heart (ERN GUARD-Heart). Rome, Italy
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Palmen R, Sandritter T, Malloy-Walton L, Follansbee C, Wagner JB. Case report: Use of therapeutic drug monitoring and pharmacogenetic testing as opportunities to individualize care in a case of flecainide toxicity after fetal supraventricular tachycardia. Front Pediatr 2023; 11:1168619. [PMID: 37449265 PMCID: PMC10337585 DOI: 10.3389/fped.2023.1168619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 06/12/2023] [Indexed: 07/18/2023] Open
Abstract
Flecainide is a class IC antiarrhythmic utilized in prophylaxis of refractory paroxysmal supraventricular tachycardias in pediatric populations. Despite being a highly effective agent, its narrow therapeutic index increases the risk of toxicity and proarrhythmic events, including wide-complex tachycardia. In the absence of direct plasma sampling in the fetus to quantitate flecainide systemic concentrations, clinicians typically make drug dosing decisions from maternal plasma concentrations and QRS duration on maternal ECGs. There remains a paucity of standard guidelines and data to inform the timing and frequency of the aforementioned test in pregnancy and timing of flecainide discontinuation prior to childbirth. Flecainide primarily undergoes metabolism via cytochrome P450 (CYP). Given the variance of CYP-mediated metabolism at the level of the individual patient, pharmacogenomics can be considered in patients who present with flecainide toxicity to determine the maternal vs. fetal factors as an etiology for the event. Finally, pharmacogenetic testing can be utilized as an adjunct to guide flecainide dosing decisions, but must be done with caution in neonates <2 weeks of age. This case report highlights utilization of pharmacogenomic testing and therapeutic drug monitoring as adjuncts to guide therapy for a newborn with refractory supraventricular tachycardia, who experienced flecainide toxicity immediately post-partum and was trialed unsuccessfully on multiple alternative antiarrhythmics without rhythm control.
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Affiliation(s)
- Ronald Palmen
- Children’s Mercy, Kansas City, MO, United States
- Department of Pediatrics, University of Missouri-Kansas City School of Medicine, Kansas City, MO, United States
- University of Missouri-Kansas City School of Medicine, Kansas City, MO, United States
| | - Tracy Sandritter
- Children’s Mercy, Kansas City, MO, United States
- University of Missouri-Kansas City School of Pharmacy, Kansas City, MO, United States
| | - Lindsey Malloy-Walton
- Children’s Mercy, Kansas City, MO, United States
- Department of Pediatrics, University of Missouri-Kansas City School of Medicine, Kansas City, MO, United States
- Ward Family Heart Center, Kansas City, MO, United States
| | - Christopher Follansbee
- Children’s Mercy, Kansas City, MO, United States
- Department of Pediatrics, University of Missouri-Kansas City School of Medicine, Kansas City, MO, United States
- Ward Family Heart Center, Kansas City, MO, United States
| | - Jonathan B. Wagner
- Children’s Mercy, Kansas City, MO, United States
- Department of Pediatrics, University of Missouri-Kansas City School of Medicine, Kansas City, MO, United States
- University of Missouri-Kansas City School of Medicine, Kansas City, MO, United States
- Ward Family Heart Center, Kansas City, MO, United States
- Division of Clinical Pharmacology, Toxicology and Therapeutic Innovation, Kansas City, MO, United States
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Miyoshi T, Maeno Y, Matsuda T, Ito Y, Inamura N, Kim KS, Shiraishi I, Kurosaki K, Ikeda T, Sago H. Neurodevelopmental outcome after antenatal therapy for fetal supraventricular tachyarrhythmia: 3-year follow-up of multicenter trial. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2023; 61:49-58. [PMID: 36350016 DOI: 10.1002/uog.26113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Revised: 09/30/2022] [Accepted: 10/20/2022] [Indexed: 05/27/2023]
Abstract
OBJECTIVES Although many studies have supported the efficacy of transplacental treatment for fetal supraventricular tachyarrhythmia, the long-term neurodevelopmental outcome after antenatal antiarrhythmic treatment is not well understood. The aim of this study was to investigate the prognosis and neurodevelopmental outcome at 36 months of corrected age and the incidence of tachyarrhythmia after birth, following protocol-defined antenatal therapy for fetal supraventricular tachyarrhythmia. METHODS This was a 3-year follow-up study of a multicenter trial that evaluated the efficacy and safety of protocol-defined transplacental treatment for fetal supraventricular tachycardia (SVT) and atrial flutter (AFL). The primary endpoints were mortality and neurodevelopmental impairment (NDI) at 36 months of corrected age. NDI was defined as any of the following outcomes: cerebral palsy, bilateral blindness, bilateral deafness or neurodevelopmental delay. Neurodevelopmental delay was evaluated using appropriate developmental quotient scales, mainly the Kyoto Scale of Psychological Development, or examination by pediatric neurologists. The detection rate of tachyarrhythmia at birth and at 18 and 36 months of corrected age was also evaluated as the secondary endpoint. In addition, the association of NDI at 36 months with perinatal and postnatal factors was analyzed. RESULTS Of 50 patients enrolled in the original trial, one withdrew consent and in two there was fetal death, leaving 47 patients available for enrollment in this follow-up study. Of these, 45 cases were available for analysis after two infants were lost to follow-up. The mortality rate was 2.2% (1/45) during a median follow-up of 3.2 (range, 2.1-9.4) years. The infant died at the age of 2.1 years. Another infant had missing neurodevelopmental assessment data. In the remaining 43 infants, at 36 months of corrected age, NDI was detected in 9.3% (4/43) overall and in two of three (66.7%) cases with fetal hydrops with subcutaneous edema. Cerebral palsy was noted in two infants with severe subcutaneous edema or ascites at an early gestational age. Neurodevelopmental delay was found in two infants with severe congenital abnormalities (one with tuberous sclerosis and the other with heterotaxy syndrome). Tachyarrhythmia was present in 31.9% (15/47) cases in the neonatal period and decreased to 8.9% (4/45) and 4.5% (2/44) at 18 and 36 months of corrected age, respectively. The median ventricular rate at diagnosis was significantly higher in infants with NDI compared to those without (265 vs 229 bpm; P = 0.003). In infants with NDI, compared to those without, fetal hydrops with subcutaneous edema at diagnosis was more common (50.0% vs 2.6%; P = 0.019) and the duration of fetal effusion was longer (median, 10.5 vs 0 days; P = 0.013). Postnatal arrhythmia and physical development abnormalities were not associated with NDI. CONCLUSIONS This multicenter 3-year follow-up study is the first to demonstrate the long-term mortality and morbidity of infants born following protocol-defined transplacental treatment for fetal SVT and AFL. NDI was associated with the presence of fetal hydrops with subcutaneous edema at diagnosis and longer duration of fetal effusion. Neurodevelopmental delay was detected only in infants with severe congenital abnormalities. Therefore, in infants that have undergone antenatal treatment for fetal tachyarrhythmia and in which there are no comorbidities, the risk of NDI is low. However, in those with fetal hydrops with subcutaneous edema and/or associated severe congenital abnormalities, the risk for long-term neurologic morbidity might be considered somewhat increased. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- T Miyoshi
- Department of Regenerative Medicine and Tissue Engineering, National Cerebral and Cardiovascular Center, Suita, Japan
- Clinical Research Center, National Center for Child Health and Development, Tokyo, Japan
| | - Y Maeno
- Department of Pediatrics and Child Health, Kurume University School of Medicine, Kurume, Japan
| | - T Matsuda
- Department of Pediatrics, Yonaha Okanoue Hospital, Kuwana, Japan
| | - Y Ito
- Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - N Inamura
- Department of Pediatric Cardiology, Osaka Women's and Children's Hospital, Izumi, Japan
| | - K-S Kim
- Department of Cardiology, Kanagawa Children's Medical Center, Yokohama, Japan
| | - I Shiraishi
- Department of Pediatric Cardiology, NCVC, Suita, Japan
| | - K Kurosaki
- Department of Pediatric Cardiology, NCVC, Suita, Japan
| | - T Ikeda
- Department of Obstetrics and Gynecology, Mie University, Tsu, Japan
| | - H Sago
- Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
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Qin J, Deng Z, Tang C, Zhang Y, Hu R, Li J, Hua Y, Li Y. Efficacy and Safety of Various First-Line Therapeutic Strategies for Fetal Tachycardias: A Network Meta-Analysis and Systematic Review. Front Pharmacol 2022; 13:935455. [PMID: 35770083 PMCID: PMC9235149 DOI: 10.3389/fphar.2022.935455] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 05/24/2022] [Indexed: 11/26/2022] Open
Abstract
Background: Fetal arrhythmias are common cardiac abnormalities associated with high mortality due to ventricular dysfunction and heart failure, particularly when accompanied by hydrops. Although several types of common fetal tachycardias have been relatively identified medications, such as digoxin, flecainide, and sotalol, there is no first-line drug treatment protocol established for the treatment of various types of fetal tachycardias. Methods: We conducted a network meta-analysis using a Bayesian hierarchical framework to obtain a model for integrating both direct and indirect evidence. All tachycardia types (Total group), supraventricular tachycardia (SVT subgroup), atrial flutter (AF subgroup), hydrops subgroup, and non-hydrops subgroup fetuses were analyzed, and five first-line regimens were ranked according to treatment outcomes: digoxin monotherapy (D), flecainide monotherapy (F), sotalol monotherapy (S), digoxin plus flecainide combination therapy (DF), and digoxin plus sotalol combination therapy (DS). Effectiveness and safety were determined according to the cardioversion rate and intrauterine death rate. Results: The pooled data indicated that DF combination therapy was always superior to D monotherapy, regardless of the tachycardia type or the presence of hydrops: Total, 2.44 (95% CrI: 1.59, 3.52); SVT, 2.77 (95% CrI: 1.59, 4.07); AF, 67.85 (95% CrI: 14.25, 168.68); hydrops, 6.03 (95% CrI: 2.54, 10.68); and non-hydrops, 5.06 (95% CrI: 1.87, 9.88). DF and F had a similar effect on control of fetal tachycardias. No significant differences were observed when comparing S, DS with D therapies across the subgroup analyses for the SVT, hydrops, and non-hydrops groups. No significant differences in mortality risks were among the various treatment regimens for the total group. And no significant differences were found in rates of intrauterine death rates at the same cardioversion amount. Conclusion The flecainide monotherapy and combination of digoxin and flecainide should be considered the most superior therapeutic strategies for fetal tachycardia. Systematic Review Registration: (https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=288997), identifier (288997).
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Affiliation(s)
- Jiangwei Qin
- Key Laboratory of Birth Defects and Related Diseases of Women and Children of MOE, Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Zhengrong Deng
- Key Laboratory of Birth Defects and Related Diseases of Women and Children of MOE, Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Changqing Tang
- Department of Pediatric Cardiology, Children’s Hospital of Soochow University, Suzhou, China
| | - Yunfan Zhang
- Key Laboratory of Birth Defects and Related Diseases of Women and Children of MOE, Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Ruolan Hu
- Key Laboratory of Birth Defects and Related Diseases of Women and Children of MOE, Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Jiawen Li
- Key Laboratory of Birth Defects and Related Diseases of Women and Children of MOE, Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Yimin Hua
- Key Laboratory of Birth Defects and Related Diseases of Women and Children of MOE, Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Yifei Li
- Key Laboratory of Birth Defects and Related Diseases of Women and Children of MOE, Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China
- *Correspondence: Yifei Li,
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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.
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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
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Persistent Fetal SVT in a COVID-19 Positive Pregnancy. Case Rep Obstet Gynecol 2022; 2022:9933520. [PMID: 35013695 PMCID: PMC8742150 DOI: 10.1155/2022/9933520] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2021] [Revised: 08/23/2021] [Accepted: 11/20/2021] [Indexed: 11/23/2022] Open
Abstract
Background Rapid introduction and spread of SARS-CoV-2 have posed unique challenges in understanding the disease, role in vertical transmission, and in developing management. We present a case of a patient with COVID-19 infection and fetus with new-onset fetal SVT. Case A 26-year-old gravida 4 para 2012 with third trimester COVID-19 infection was diagnosed with new onset fetal SVT. Successful cardioversion was achieved with flecainide. The patient was followed outpatient until induction of labor at 39 and 3/7 weeks of gestational age resulting in an uncomplicated vaginal delivery. Postpartum course was uncomplicated. Conclusion Fetal SVT is a potential complication of maternal COVID-19 infection. The use of transplacental therapy with flecainide is an appropriate alternative to digoxin in these cases.
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Purkayastha S, Weinreich M, Fontes J, Lau JF, Wolfe DS, Bortnick AE. Fetal Supraventricular Tachycardia: What the Adult Cardiologist Needs to Know. Cardiol Rev 2022; 30:31-37. [PMID: 33165088 PMCID: PMC8715790 DOI: 10.1097/crd.0000000000000370] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Fetal supraventricular tachycardia management is challenging, with consequences for both the fetus and the mother. If left untreated, fetal hydrops may ensue, at which point delivery and treatment of the arrhythmia is preferred. However, if the fetus is not at term nor near-term, significant doses of antiarrhythmics may be needed to achieve adequate transplacental bioavailability. Although digoxin has classically been the mainstay of treatment, the use of flecainide or sotalol as monotherapy or in combination with digoxin is being studied. Interdisciplinary team management and shared decision-making between the physician and patient are key to achieving successful outcomes. Adult cardiologists, particularly inpatient consultation services or through burgeoning cardio-obstetrics programs, may, in some practice settings, be asked to evaluate or comanage pregnant women with fetal arrhythmia.
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Affiliation(s)
- Sutopa Purkayastha
- Department of Medicine, Maternal Fetal Medicine-Cardiology Joint Program at Montefiore Health System and Albert Einstein College of Medicine, Bronx, NY
| | - Michael Weinreich
- Department of Medicine, Maternal Fetal Medicine-Cardiology Joint Program at Montefiore Health System and Albert Einstein College of Medicine, Bronx, NY
| | - Joao Fontes
- Department of Medicine, Maternal Fetal Medicine-Cardiology Joint Program at Montefiore Health System and Albert Einstein College of Medicine, Bronx, NY
| | - Joe F. Lau
- Department of Cardiology, Long Island Jewish Medical Center, Northwell Health, New Hyde Park, NY
| | - Diana S. Wolfe
- Division of Geriatrics, Maternal Fetal Medicine-Cardiology Joint Program at Montefiore Health System and Albert Einstein College of Medicine, Bronx, NY
- Department of Obstetrics and Gynecology, Montefiore Medical Center, and Albert Einstein College of Medicine, Bronx, NY
| | - Anna E. Bortnick
- Department of Medicine, Maternal Fetal Medicine-Cardiology Joint Program at Montefiore Health System and Albert Einstein College of Medicine, Bronx, NY
- Division of Cardiology, Maternal Fetal Medicine-Cardiology Joint Program at Montefiore Health System and Albert Einstein College of Medicine, Bronx, NY
- Division of Geriatrics, Maternal Fetal Medicine-Cardiology Joint Program at Montefiore Health System and Albert Einstein College of Medicine, Bronx, NY
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10
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Broom E, Thomas JT, Petersen S, Gooi A, Ward C, Gardener G, Kostner K, Lee-Tannock A, Kumar S. Management of Fetal Supraventricular Tachycardia: Case Series from a Tertiary Perinatal Cardiac Center. Fetal Diagn Ther 2021; 48:794-800. [PMID: 34753148 DOI: 10.1159/000519911] [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: 06/03/2021] [Accepted: 08/16/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Fetal supraventricular tachycardia is a relatively uncommon cardiac rhythm abnormality which is often associated with adverse perinatal outcomes if untreated. Although there are several treatment modalities and protocols in use globally, there is no consensus as to the most effective antiarrhythmic to manage this condition. AIM This study aimed to evaluate perinatal outcomes following prenatal maternal therapy for fetal supraventricular tachycardia. MATERIALS AND METHODS This was a 20-year retrospective cohort study. Institutional records were reviewed for antenatal therapy choice and maternal and fetal outcomes. RESULTS Sixty-nine cases met diagnostic criteria for fetal SVT, of which 56 (81%) received maternal antiarrhythmic therapy. Digoxin was the most common, but least effective, first-line therapy in 28 patients, achieving successful rate reversion in 35.7%. Thirty-one patients (55%) required second-line therapy, and this was most successful with digoxin and flecainide polytherapy achieving rate reversion in 17 of 18 cases (94.5%) at a median of 3 days (1.5-7). Hydrops was present in 23 (33%) cases at initial presentation, 16 of which achieved rate reversion. There was minimal difference in treatment efficacy comparing single- or multiple-agent treatment in the setting of hydrops (50% vs. 42.8%). Side effects occurred in 14/56 treated patients (25%) but were severe in only 8 (14.3%) women, most commonly with digoxin and flecainide polytherapy (6 of 8 cases). There were 3 (4%) fetal deaths amongst the study cohort. CONCLUSIONS Digoxin and flecainide polytherapy were well tolerated and successfully achieved rhythm and rate control in fetuses with prenatally diagnosed supraventricular tachycardia. The presence of hydrops was a poor prognostic feature.
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Affiliation(s)
- Elisha Broom
- Mater Centre for Maternal Fetal Medicine, Mater Mother's Hospital, South Brisbane, Queensland, Australia
| | - Joseph T Thomas
- Mater Centre for Maternal Fetal Medicine, Mater Mother's Hospital, South Brisbane, Queensland, Australia.,Mater Research Institute-University of Queensland, Aubigny Place, Raymond Terrace, South Brisbane, Queensland, Australia
| | - Scott Petersen
- Mater Centre for Maternal Fetal Medicine, Mater Mother's Hospital, South Brisbane, Queensland, Australia.,Mater Research Institute-University of Queensland, Aubigny Place, Raymond Terrace, South Brisbane, Queensland, Australia
| | - Alex Gooi
- Qld Paediatric Cardiac Service, Queensland Children's Hospital, South Brisbane, Queensland, Australia
| | - Cameron Ward
- Qld Paediatric Cardiac Service, Queensland Children's Hospital, South Brisbane, Queensland, Australia
| | - Glenn Gardener
- Mater Centre for Maternal Fetal Medicine, Mater Mother's Hospital, South Brisbane, Queensland, Australia.,Mater Research Institute-University of Queensland, Aubigny Place, Raymond Terrace, South Brisbane, Queensland, Australia
| | - Karam Kostner
- Department of Adult Cardiology, Mater Health Services, South Brisbane, Queensland, Australia
| | - Alison Lee-Tannock
- Mater Centre for Maternal Fetal Medicine, Mater Mother's Hospital, South Brisbane, Queensland, Australia
| | - Sailesh Kumar
- Mater Centre for Maternal Fetal Medicine, Mater Mother's Hospital, South Brisbane, Queensland, Australia.,Mater Research Institute-University of Queensland, Aubigny Place, Raymond Terrace, South Brisbane, Queensland, Australia.,Department of Obstetrics and Gynaecology, Faculty of Medicine, The University of Queensland, Herston, Queensland, Australia
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11
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Miyoshi T, Maeno Y, Hamasaki T, Inamura N, Yasukochi S, Kawataki M, Horigome H, Yoda H, Taketazu M, Nii M, Hagiwara A, Kato H, Shimizu W, Shiraishi I, Sakaguchi H, Ueda K, Katsuragi S, Yamamoto H, Sago H, Ikeda T. Antenatal Therapy for Fetal Supraventricular Tachyarrhythmias: Multicenter Trial. J Am Coll Cardiol 2020; 74:874-885. [PMID: 31416531 DOI: 10.1016/j.jacc.2019.06.024] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Revised: 06/05/2019] [Accepted: 06/10/2019] [Indexed: 01/30/2023]
Abstract
BACKGROUND Standardized treatment of fetal tachyarrhythmia has not been established. OBJECTIVES This study sought to evaluate the safety and efficacy of protocol-defined transplacental treatment for fetal supraventricular tachycardia (SVT) and atrial flutter (AFL). METHODS In this multicenter, single-arm trial, protocol-defined transplacental treatment using digoxin, sotalol, and flecainide was performed for singleton pregnancies from 22 to <37 weeks of gestation with sustained fetal SVT or AFL ≥180 beats/min. The primary endpoint was resolution of fetal tachyarrhythmia. Secondary endpoints were fetal death, pre-term birth, and neonatal arrhythmia. Adverse events (AEs) were also assessed. RESULTS A total of 50 patients were enrolled at 15 institutions in Japan from 2010 to 2017; short ventriculoatrial (VA) SVT (n = 17), long VA SVT (n = 4), and AFL (n = 29). One patient with AFL was excluded because of withdrawal of consent. Fetal tachyarrhythmia resolved in 89.8% (44 of 49) of cases overall and in 75.0% (3 of 4) of cases of fetal hydrops. Pre-term births occurred in 20.4% (10 of 49) of patients. Maternal AEs were observed in 78.0% (39 of 50) of patients. Serious AEs occurred in 1 mother and 4 fetuses, thus resulting in discontinuation of protocol treatment in 4 patients. Two fetal deaths occurred, mainly caused by heart failure. Neonatal tachyarrhythmia was observed in 31.9% (15 of 47) of neonates within 2 weeks after birth. CONCLUSIONS Protocol-defined transplacental treatment for fetal SVT and AFL was effective and tolerable in 90% of patients. However, it should be kept in mind that serious AEs may take place in fetuses and that tachyarrhythmias may recur within the first 2 weeks after birth.
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Affiliation(s)
- Takekazu Miyoshi
- Department of Perinatology and Gynecology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Yasuki Maeno
- Department of Pediatrics and Child Health, Kurume University School of Medicine, Kurume, Japan.
| | - Toshimitsu Hamasaki
- Department of Data Science, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Noboru Inamura
- Department of Pediatric Cardiology, Osaka Women's and Children's Hospital, Izumi, Japan
| | - Satoshi Yasukochi
- Department of Cardiology, Nagano Children's Hospital, Azumino, Japan
| | - Motoyoshi Kawataki
- Department of Gynecology and Obstetrics, Tohoku University Graduate School of Medicine, Sendai, Japan
| | | | - Hitoshi Yoda
- Department of Neonatology, Toho University Omori Medical Center, Tokyo, Japan
| | - Mio Taketazu
- Department of Pediatric Cardiology, Saitama Medical University International Medical Center, Hidaka, Japan
| | - Masaki Nii
- Department of Cardiology, Shizuoka Children's Hospital, Shizuoka, Japan
| | - Akiko Hagiwara
- Department of Internal Medicine, Kanagawa Children's Medical Center, Yokohama, Japan
| | - Hitoshi Kato
- Department of Pediatric Cardiology, National Center for Child Health and Development, Tokyo, Japan
| | - Wataru Shimizu
- Department of Cardiovascular Medicine, Nippon Medical School, Tokyo, Japan
| | - Isao Shiraishi
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Heima Sakaguchi
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Keiko Ueda
- Department of Perinatology and Gynecology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Shinji Katsuragi
- Department of Perinatology and Gynecology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Haruko Yamamoto
- Department of Advanced Medical Technology Development, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Haruhiko Sago
- Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Tomoaki Ikeda
- Department of Obstetrics and Gynecology, Mie University, Tsu, Japan
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12
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Yuan SM, Xu ZY. Fetal arrhythmias: prenatal evaluation and intrauterine therapeutics. Ital J Pediatr 2020; 46:21. [PMID: 32050988 PMCID: PMC7017517 DOI: 10.1186/s13052-020-0785-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Accepted: 02/03/2020] [Indexed: 11/24/2022] Open
Abstract
Introduction Fetal arrhythmias are a common phenomenon with rather complicated etiologies. Debates remain regarding prenatal diagnosis and treatment of fetal arrhythmias. Methods The literature reporting on prenatal diagnosis and treatment of fetal arrhythmias published in the recent two decades were retrieved, collected and analyzed. Results Both fetal magnetocardiogram and electrocardiogram provide information of cardiac time intervals, including the QRS and QT durations. M-mode ultrasound detects the AV and VA intervals, fetal heart rate, and AV conduction. By using Doppler ultrasound, simultaneous recording of the atrial and ventricular waves can be obtained. Benign fetal arrhythmias, including premature contractions and sinus tachycardia, do not need any treatment before and after birth. Sustained fetal arrhythmias that predispose to the occurrence of hydrops fetalis, cardiac dysfunction or eventual fetal demise require active treatments. Intrauterine therapy of fetal tachyarrhythmias has been carried out by the transplacental route. If maternal transplacental treatment fails, intraumbilical, intraperitoneal, or direct fetal intramuscular injection of antiarrhythmic agents can be attempted. Conclusions The outcomes of intrauterine therapy of fetal tachyarrhythmias depend on the types or etiology of fetal arrhythmias and fetal conditions. Most are curable to a transplacental treatment by the first-line antiarrhythmic agents. Fetal cardiac pacings are effective methods to restore sinus rhythm in drug-resistant or hemodynamically compromised cases. Immediate postnatal pacemaker implantation is warranted in refractory cases.
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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
| | - Zhi-Yang Xu
- 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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13
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Rapid Quantitation of Flecainide in Human Plasma for Therapeutic Drug Monitoring Using Liquid Chromatography and Time-of-Flight Mass Spectrometry. Ther Drug Monit 2020; 41:391-395. [PMID: 30520831 DOI: 10.1097/ftd.0000000000000586] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Measurement of flecainide is useful to optimize dosage and minimize risks of toxicity. Furthermore, there is a need for urgent sample analysis when flecainide is used in transplacental therapy for fetal tachycardia. To this end, we have developed and validated a rapid assay for the measurement of flecainide in human plasma or serum, using a small sample volume (50 µL). METHODS After a simple deproteination with zinc sulfate and methanol, prepared samples were injected onto a short (30 mm) analytical column and eluted using a rapid gradient elution. Detection was performed using time-of-flight mass spectrometry. Flecainide was quantified using flecainide-D4 as internal standard, with both compounds extracted from the total ion chromatogram using a ±5 ppm extraction window based on the theoretical m/z values for the protonated ions. RESULTS The assay was linear over a putative therapeutic range (100-1500 mcg/L). Between- and within-assay imprecision and accuracy were <4.6% and 94.8%-110.0%, respectively. Matrix effects were minimal and were compensated for by flecainide-D4. There were no effects due to hemolysis or lipemia, and no carryover was apparent. Total analysis time was just 1.2 minutes (72 seconds). CONCLUSIONS We have developed and validated a rapid method for the analysis of flecainide. The method is particularly suited for flecainide therapeutic drug monitoring, when analyzing samples from mothers receiving flecainide for the treatment of fetal tachycardia.
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14
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Refaat M, El Dick J, Sabra M, Bitar F, Tayeh C, Abutaqa M, Arabi M. Sotalol as an effective adjunct therapy in the management of supraventricular tachycardia induced fetal hydrops fetalis. J Neonatal Perinatal Med 2020; 13:267-273. [PMID: 31707376 DOI: 10.3233/npm-190268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Sustained fetal supraventricular tachycardia (SVT) complicated by hydrops fetalis carries a significant risk of morbidity and mortality. While there is no clear consensus on first- and second-line therapy options for the management of fetal SVT with or without hydrops fetalis, there exists significant nonrandomized experience with a number of antiarrhythmic agents that has founded the basis for management. Furthermore, recently published meta-analyses and ongoing multicenter prospective studies have aimed to bridge the gap in the literature. We report two cases of sustained fetal SVT with severe secondary hydrops fetalis managed successfully with flecainide-sotalol combination therapy in one case and sotalol-digoxin combination therapy in the second and review the literature for the management of fetal SVT.
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Affiliation(s)
- Marwan Refaat
- Department of Internal Medicine, American University of Beirut Medical Center, Division of Cardiology, Beirut, Lebanon
| | - Joud El Dick
- Department of Internal Medicine, American University of Beirut Medical Center, Division of Cardiology, Beirut, Lebanon
| | - Mohammad Sabra
- Department of Internal Medicine, American University of Beirut Medical Center, Division of Cardiology, Beirut, Lebanon
| | - Fadi Bitar
- Department of Pediatrics and Adolescent Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Christelle Tayeh
- Department of Pediatrics and Adolescent Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Mohamad Abutaqa
- Department of Pediatrics and Adolescent Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Mariam Arabi
- Department of Pediatrics and Adolescent Medicine, American University of Beirut Medical Center, Beirut, Lebanon
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15
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Flecainide: Electrophysiological properties, clinical indications, and practical aspects. Pharmacol Res 2019; 148:104443. [PMID: 31493514 DOI: 10.1016/j.phrs.2019.104443] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Revised: 08/03/2019] [Accepted: 09/03/2019] [Indexed: 12/19/2022]
Abstract
Over the last 35 years, flecainide proved itself one of the most commonly used arrhythmic drugs, expanding its original indication for ventricular arrhythmias and results nowadays as the cornerstone of the rhythm control strategy in atrial fibrillation management of patients without structural heart disease. While the increased mortality associated with flecainide in the Cardiac Arrhythmia Suppression Trial (CAST) still casts his shadow over flecainide clinical profile, this compound has subsequently demonstrated safe and is now used successfully for a plethora of indications, including pharmacological cardioversion of atrial fibrillation, cathecolaminergic polymorphic ventricular tachycardia, supraventricular tachyarrhythmias and ventricular pre-excitation. Moreover, the recent marketing of a controlled release formulation, along with the intravenous and immediate release formulations, increased the armamentarium to the clinician's disposal while improving patients' compliance. In the present paper, we offer a comprehensive review of the anti-arrhythmic effects of flecainide, detailing its electrophysiological properties, its effects on the conduction system, its clinical use and the major side effects and contraindications in clinical practice.
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16
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Abstract
Fetal arrhythmias are common, and they may resolve spontaneously in majority of the cases. Sustained fetal arrhythmias associated with major structural heart disorders, hydrops fetalis, and fetal heart failure warrant intrauterine pharmaceutical conversion of heart rhythm or early pacemaker implant in order to avoid fetal demise. Fetal atrial flutter (AF) and supraventricular tachycardia (SVT) resemble in terms of the effects of intrauterine therapies. Digoxin is more suitable for rhythm conversion of fetal AF and SVT in fetuses free of hydrops fetalis, while sotalol shows better effects for those with hydrops fetalis. In fetal cases of atrioventricular blocks, an etiological treatment for the maternal antibody exposure by steroids could be an alternative remedy. In this article, the clinical diagnosis and treatment of fetal arrhythmias are presented, and advantages and disadvantages of antiarrhythmic agents for fetal arrhythmias are compared.
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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, China
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17
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Carvalho JS. Fetal dysrhythmias. Best Pract Res Clin Obstet Gynaecol 2019; 58:28-41. [PMID: 30738635 DOI: 10.1016/j.bpobgyn.2019.01.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Revised: 12/31/2018] [Accepted: 01/07/2019] [Indexed: 11/18/2022]
Abstract
Fetal dysrhythmias are common abnormalities, usually manifesting as irregular rhythms. Although most irregularities are benign and caused by isolated atrial ectopics, in a few cases, rhythm irregularity may indicate partial atrioventricular block, which has different etiological and prognostic implications. We provide a flowchart for the initial management of irregular rhythm to help select cases requiring urgent specialist referral. Tachycardias and bradycardias are less frequent, can lead to hemodynamic compromise, and may require in utero therapy. Pharmacological treatment of tachycardia depends on the type (supraventricular tachycardia or atrial flutter) and presence of hydrops, with digoxin, flecainide, and sotalol being commonly used. An ongoing randomized trial may best inform about their efficacy. Bradycardia due to blocked bigeminy normally resolves spontaneously, but if it is due to established complete heart block, there is no effective treatment. Ongoing research suggests hydroxychloroquine may reduce the risk of autoimmune atrioventricular block. Sinus bradycardia (rate <3rd centile) may be a prenatal marker for long-QT syndrome.
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Affiliation(s)
- Julene S Carvalho
- Royal Brompton and Harefield NHS Foundation Trust, Sydney Street, London, SW3 6NP, UK; Fetal Medicine Unit, St George's University Hospital, Blackshaw Road, London, SW17 0QT, UK; Molecular and Clinical Sciences Research Institute, St George's, University of London, Cranmer Terrace, London, SW17 0RE, UK.
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18
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Hill GD, Kovach JR, Saudek DE, Singh AK, Wehrheim K, Frommelt MA. Transplacental treatment of fetal tachycardia: A systematic review and meta-analysis. Prenat Diagn 2018; 37:1076-1083. [PMID: 28833310 DOI: 10.1002/pd.5144] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Revised: 08/14/2017] [Accepted: 08/17/2017] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Multiple transplacental medications can be used to treat fetal tachycardia. We sought to perform a systematic review and meta-analysis to determine whether digoxin, flecainide, or sotalol was the most efficacious therapy for converting fetal tachycardia to sinus rhythm. METHOD We performed a systematic review and meta-analysis to compare digoxin, flecainide, or sotalol as first-line therapy for fetal tachycardia. Studies were identified by a search of PubMed (Medline), Web of Science, and Scopus. RESULTS There were 21 studies included. Flecainide (OR: 1.4, 95% CI: 1.1-2.0, I2 = 60%, P = 0.03) and sotalol (OR:1.4, 95% CI:1.1-2.0, I2 = 30%, P = 0.02) were superior to digoxin for conversion of fetal tachycardia to sinus rhythm. In those with hydrops, the benefit over digoxin was more notable for both flecainide (OR: 5.0, 95% CI: 2.5-10.0, I2 = 0%, P < 0.001) and sotalol (OR: 2.5, 95% CI: 1.7-5.0, I2 = 0%, P < 0.001). When limited to atrioventricular reentrant tachycardia, flecainide was superior to digoxin (OR:1.7, 95% CI:1.1-3.3, I2 = 62%, P = 0.03) and sotalol (OR:1.3, 95% CI:1.1-1.7, I2 = 0%, P = 0.01). CONCLUSION Digoxin should not be first-line therapy for fetal tachycardia, particularly in the presence of hydrops fetalis. Flecainide should be the first-line therapy of choice in atrioventricular reentrant tachycardia. Further study may identify further sub-populations responding differently.
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Affiliation(s)
- Garick D Hill
- Division of Cardiology, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Joshua R Kovach
- Division of Cardiology, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA
| | - David E Saudek
- Division of Cardiology, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Anoop K Singh
- Division of Cardiology, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Karla Wehrheim
- Division of Cardiology, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Michele A Frommelt
- Division of Cardiology, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA
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