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Sabzwari SRA, Tzou WS. Systemic Diseases and Heart Block. Rheum Dis Clin North Am 2024; 50:381-408. [PMID: 38942576 DOI: 10.1016/j.rdc.2024.03.008] [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: 06/30/2024]
Abstract
Systemic diseases can cause heart block owing to the involvement of the myocardium and thereby the conduction system. Younger patients (<60) with heart block should be evaluated for an underlying systemic disease. These disorders are classified into infiltrative, rheumatologic, endocrine, and hereditary neuromuscular degenerative diseases. Cardiac amyloidosis owing to amyloid fibrils and cardiac sarcoidosis owing to noncaseating granulomas can infiltrate the conduction system leading to heart block. Accelerated atherosclerosis, vasculitis, myocarditis, and interstitial inflammation contribute to heart block in rheumatologic disorders. Myotonic, Becker, and Duchenne muscular dystrophies are neuromuscular diseases involving the myocardium skeletal muscles and can cause heart block.
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Affiliation(s)
- Syed Rafay A Sabzwari
- University of Colorado Anschutz Medical Campus, 12631 East 17th Avenue, Mail Stop B130, Aurora, CO 80045, USA
| | - Wendy S Tzou
- Cardiac Electrophysiology, University of Colorado Anschutz Medical Campus, 12401 E 17th Avenue, MS B-136, Aurora, CO 80045, USA.
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2
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Lazzerini PE, Bertolozzi I, Cartocci A, Ginjupalli VKM, Teneggi PA, Pica D, Merico G, Bogazzi I, Salvini V, Accioli R, Salvadori F, Marzotti T, Cevenini G, Capecchi M, Cantara S, Cantore A, Infantino M, Bisogno S, Finizola F, D'ascenzi F, Laghi-Pasini F, Acampa M, Capecchi PL, Boutjdir M. Advanced Atrioventricular Block in Athletes: Prevalence and Role of Anti-Ro/Sjögren Syndrome-Related Antigen A Antibodies. J Am Heart Assoc 2024; 13:e034893. [PMID: 38879447 DOI: 10.1161/jaha.124.034893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Accepted: 04/15/2024] [Indexed: 06/19/2024]
Abstract
BACKGROUND Advanced atrioventricular block (AVB), that is, higher than second-degree Mobitz-1, is an abnormal finding in athletes. Despite intensive investigation, in several cases the pathogenesis remains unknown, but frequently pacemaker implantation is still indicated. Increasing evidence points to circulating anti-Ro/Sjögren syndrome-related antigen A (SSA) antibodies cross-reacting with L-type calcium channel and inhibiting the related current as an epidemiologically relevant and potentially reversible cause of isolated AVB in adults. The aim of the study was to determine the prevalence of anti-Ro/SSA-associated advanced AVBs in a large sample of young athletes. METHODS AND RESULTS A total of 2536 consecutive athletes aged <40 years without a history of cardiac diseases/interventions were enrolled in a cross-sectional study. Resting and exercise electrocardiography was performed, and those presenting any AVB were further evaluated by 24-hour Holter ECG. Athletes with second-degree AVBs and their mothers underwent anti-Ro/SSA testing. Moreover, purified immunoglobulin G from subjects with anti-Ro/SSA-positive and anti-Ro/SSA-negative advanced AVB were tested on L-type calcium current and L-type-calcium channel expression using tSA201 cells. The global prevalence of advanced AVB in the overall sample was ≈0.1%, but the risk considerably increased (2%) when intensely trained postpubertal male subjects were selectively considered. While none of the athletes with advanced AVB showed heart abnormalities, in 100% of cases anti-Ro/SSA antibodies were detected. Ex vivo experiments showed that immunoglobulin G from anti-Ro/SSA-positive but not -negative subjects with advanced AVB acutely inhibit L-type calcium current and chronically downregulate L-type-calcium channel expression. CONCLUSIONS Our study provides evidence that advanced AVB occurs in young athletes, in most cases associated with anti-Ro/SSA antibodies blocking L-type calcium channels. These findings may open new avenues for immunomodulating therapies to reduce the risk of life-threatening events in athletes, avoiding or delaying pacemaker implantation.
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Affiliation(s)
- Pietro Enea Lazzerini
- Department of Medical Sciences Surgery and Neurosciences, Division of Internal Medicine and Geriatrics, Electroimmunology Unit University of Siena Siena Italy
| | - Iacopo Bertolozzi
- Cardiology Intensive Therapy Unit Department of Internal Medicine Nuovo Ospedale San Giovanni di Dio Florence Italy
- Former Cardiology Intensive Therapy Unit, Department of Internal Medicine Hospital of Carrara Carrara Italy
| | | | | | | | - Davide Pica
- Center for Sports Medicine of Carrara ASL Nord-Ovest Toscana Massa-Carrara Italy
| | - Giovanni Merico
- Center for Sports Medicine of Carrara ASL Nord-Ovest Toscana Massa-Carrara Italy
| | - Irene Bogazzi
- Emergency Department Nuovo Ospedale Apuano ASL Nord-Ovest Toscana Massa-Carrara Italy
| | - Viola Salvini
- Department of Medical Sciences Surgery and Neurosciences, Division of Internal Medicine and Geriatrics, Electroimmunology Unit University of Siena Siena Italy
| | - Riccardo Accioli
- Department of Medical Sciences Surgery and Neurosciences, Division of Internal Medicine and Geriatrics, Electroimmunology Unit University of Siena Siena Italy
| | - Fabio Salvadori
- Department of Medical Sciences Surgery and Neurosciences, Division of Internal Medicine and Geriatrics, Electroimmunology Unit University of Siena Siena Italy
| | - Tommaso Marzotti
- Department of Medical Sciences Surgery and Neurosciences, Division of Internal Medicine and Geriatrics, Electroimmunology Unit University of Siena Siena Italy
| | - Gabriele Cevenini
- Department of Medical Biotechnologies University of Siena Siena Italy
| | - Matteo Capecchi
- Department of Medical Sciences Surgery and Neurosciences, Division of Internal Medicine and Geriatrics, Electroimmunology Unit University of Siena Siena Italy
| | - Silvia Cantara
- Department of Medical Sciences Surgery and Neurosciences, Division of Internal Medicine and Geriatrics, Electroimmunology Unit University of Siena Siena Italy
- Laboratory of Clinical and Translational Research University Hospital of Siena Siena Italy
| | - Anna Cantore
- Department of Medical Sciences Surgery and Neurosciences, Division of Internal Medicine and Geriatrics, Electroimmunology Unit University of Siena Siena Italy
| | - Maria Infantino
- Immunology and Allergology Laboratory Unit S. Giovanni di Dio Hospital Florence Italy
| | - Stefania Bisogno
- Department of Medical Sciences Surgery and Neurosciences, Division of Internal Medicine and Geriatrics, Electroimmunology Unit University of Siena Siena Italy
| | - Francesco Finizola
- Internal Medicine Department Sant'Antonio Abate Hospital of Fivizzano ASL Nord-Ovest Toscana Massa-Carrara Italy
| | - Flavio D'ascenzi
- Department of Medical Biotechnologies Sports Cardiology and Rehabilitation Unit University of Siena Siena Italy
| | - Franco Laghi-Pasini
- Department of Medical Sciences Surgery and Neurosciences, Division of Internal Medicine and Geriatrics, Electroimmunology Unit University of Siena Siena Italy
| | | | - Pier Leopoldo Capecchi
- Department of Medical Sciences Surgery and Neurosciences, Division of Internal Medicine and Geriatrics, Electroimmunology Unit University of Siena Siena Italy
| | - Mohamed Boutjdir
- Department of Medical Biotechnologies University of Siena Siena Italy
- New York University Grossman School of Medicine New York NY USA
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Duman D, Tunca Sahin G, Stuart G, Walsh M, Caputo M, Parry A, Beattie B, Conner C, Uzun O. Influence of improved antenatal detection on the outcomes of complete atrioventricular block diagnosed in fetal-neonatal life and childhood periods - a single-centre experience in South Wales for 55 years. Cardiol Young 2024; 34:412-420. [PMID: 38149337 DOI: 10.1017/s1047951123003967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2023]
Abstract
OBJECTIVE This study aimed to analyse the influence of improved antenatal detection on the course, contemporary outcomes, and mortality risk factors of the complete atrioventricular block during fetal-neonatal and childhood periods in South Wales. METHODS The clinical characteristics and outcomes of complete atrioventricular block in patients without structural heart disease at the University Hospital of Wales from January 1966 to April 2021 were studied. Patients were divided into two groups according to their age at diagnosis: I-fetal-neonatal and II-childhood. Contemporary outcomes during the post-2001 era were compared with historical data preceding fetal service development and hence earlier detection. RESULTS There were 64 patients: 26 were identified in the fetal-neonatal period and the remaining 38 in the childhood period. Maternal antibodies/systemic lupus erythematosus disease (anti-Ro/Sjögren's-syndrome-related Antigen A and/or anti-La/Sjögren's-syndrome-related Antigen B) were present in 15 (57.7%) of the fetal-neonatal. Fetal/neonatal and early diagnosis increased after 2001 with an incidence of 1:25000 pregnancies. Pacemaker implantation was required in 34 patients, of whom 13 were diagnosed in the fetal-neonatal group. Survival rates in cases identified before 2001 were at 96.3% (26/27), whereas it was 83.8% (31/37) in patients diagnosed after 2001 (P > 0.05). Other mortality risk factors comprised a lower gestational week at birth, maternal antibodies, and an average ventricular heart rate of < 55 bpm. CONCLUSIONS Fetal diagnosis of complete atrioventricular block is still portends high fetal and neonatal mortality and morbidity despite significantly improved antenatal detection after 2001. Pacemaker intervention is needed earlier in the fetal-neonatal group. Whether routine antenatal medical treatment might alter this outcome calls for further prospective multicentre studies.
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Affiliation(s)
| | | | | | - Mark Walsh
- Bristol Royal Children's Hospital, Bristol, UK
| | | | | | | | | | - Orhan Uzun
- University Hospital of Wales, Cardiff, UK
- Cardiff University, School of Medicine, Cardiff, UK
- Swansea University, School of Engineering and Sport Sciences, Swansea, UK
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Lazzerini PE, Murthy Ginjupalli VK, Srivastava U, Bertolozzi I, Bacarelli MR, Verrengia D, Salvini V, Accioli R, Carbone SF, Santoro A, Cartocci A, Cevenini G, Cantara S, Cantore A, Bisogno S, Brucato A, Laghi-Pasini F, Acampa M, Capecchi PL, Boutjdir M. Anti-Ro/SSA Antibodies Blocking Calcium Channels as a Potentially Reversible Cause of Atrioventricular Block in Adults. JACC Clin Electrophysiol 2023; 9:1631-1648. [PMID: 37227349 DOI: 10.1016/j.jacep.2023.03.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 03/10/2023] [Accepted: 03/10/2023] [Indexed: 05/26/2023]
Abstract
BACKGROUND In ∼50% of severe atrioventricular blocks (AVBs) occurring in adults <50 years, the underlying etiology remains unknown. Preliminary evidence from case reports suggests that autoimmunity, specifically the presence of circulating anti-Ro/SSA antibodies in the patient (acquired form), in the patient's mother (late-progressive congenital form), or in both (mixed form), could be involved in a fraction of idiopathic AVBs in adults by possibly targeting the L-type calcium channel (Cav1.2) and inhibiting the related current (ICaL). OBJECTIVES The purpose of this study was to evaluate whether anti-Ro/SSA antibodies are causally implicated in the development of isolated AVBs in adults. METHODS Thirty-four consecutive patients with isolated AVB of unknown origin and 17 available mothers were prospectively enrolled in a cross-sectional study. Anti-Ro/SSA antibodies were assessed by fluoroenzyme-immunoassay, immuno-Western blotting, and line-blot immunoassay. Purified immunoglobulin-G (IgG) from anti-Ro/SSA-positive and anti-Ro/SSA-negative subjects were tested on ICaL and Cav1.2 expression using tSA201 and HEK293 cells, respectively. Moreover, in 13 AVB patients, the impact of a short course of steroid therapy on AV conduction was evaluated. RESULTS Anti-Ro/SSA antibodies, particularly anti-Ro/SSA-52kD, were found in 53% of AVB-patients and/or in their mothers, most commonly an acquired or mixed form (two-thirds of cases) without history of autoimmune diseases. Purified IgG from anti-Ro/SSA-positive but not anti-Ro/SSA-negative AVB patients acutely inhibited ICaL and chronically down-regulated Cav1.2 expression. Moreover, anti-Ro/SSA-positive sera showed high reactivity with peptides corresponding to the Cav1.2 channel pore-forming region. Finally, steroid therapy rapidly improved AV conduction in AVB-patients with circulating anti-Ro/SSA antibodies but not in those without. CONCLUSIONS Our study points to anti-Ro/SSA antibodies as a novel, epidemiologically relevant and potentially reversible cause of isolated AVB in adults, via an autoimmune-mediated functional interference with the L-type calcium channels. These findings have significant impact on antiarrhythmic therapies by avoiding or delaying pacemaker implantation.
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Affiliation(s)
- Pietro Enea Lazzerini
- Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Siena, Italy.
| | | | - Ujala Srivastava
- VA New York Harbor Healthcare System, SUNY Downstate Health Science University, New York, New York, USA
| | - Iacopo Bertolozzi
- Cardiology Intensive Therapy Unit, Department of Internal Medicine, Nuovo Ospedale San Giovanni di Dio, Florence, Italy
| | - Maria Romana Bacarelli
- Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Decoroso Verrengia
- Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Viola Salvini
- Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Riccardo Accioli
- Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Siena, Italy
| | | | - Amato Santoro
- Cardio-thoracic Department, University Hospital of Siena, Siena, Italy
| | | | - Gabriele Cevenini
- Department of Medical Biotechnologies, University of Siena, Siena, Italy
| | - Silvia Cantara
- Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Siena, Italy; Laboratory of Clinical and Translational Research, University Hospital of Siena, Siena, Italy
| | - Anna Cantore
- Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Stefania Bisogno
- Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Antonio Brucato
- Department of Biomedical and Clinical Sciences, University of Milan, Milan, Italy
| | - Franco Laghi-Pasini
- Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Siena, Italy
| | | | - Pier Leopoldo Capecchi
- Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Mohamed Boutjdir
- VA New York Harbor Healthcare System, SUNY Downstate Health Science University, New York, New York, USA; NYU Grossman School of Medicine, New York, New York, USA
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Sabzwari SRA, Tzou WS. Systemic Diseases and Heart Block. Cardiol Clin 2023; 41:429-448. [PMID: 37321693 DOI: 10.1016/j.ccl.2023.03.008] [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] [Indexed: 06/17/2023]
Abstract
Systemic diseases can cause heart block owing to the involvement of the myocardium and thereby the conduction system. Younger patients (<60) with heart block should be evaluated for an underlying systemic disease. These disorders are classified into infiltrative, rheumatologic, endocrine, and hereditary neuromuscular degenerative diseases. Cardiac amyloidosis owing to amyloid fibrils and cardiac sarcoidosis owing to noncaseating granulomas can infiltrate the conduction system leading to heart block. Accelerated atherosclerosis, vasculitis, myocarditis, and interstitial inflammation contribute to heart block in rheumatologic disorders. Myotonic, Becker, and Duchenne muscular dystrophies are neuromuscular diseases involving the myocardium skeletal muscles and can cause heart block.
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Affiliation(s)
- Syed Rafay A Sabzwari
- University of Colorado Anschutz Medical Campus, 12631 East 17th Avenue, Mail Stop B130, Aurora, CO 80045, USA
| | - Wendy S Tzou
- Cardiac Electrophysiology, University of Colorado Anschutz Medical Campus, 12401 E 17th Avenue, MS B-136, Aurora, CO 80045, USA.
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Makadia L, Izmirly P, Buyon JP, Phoon CKL. Autoimmune Congenital Complete Heart Block: How Late Can It Occur? AJP Rep 2023; 13:e29-e34. [PMID: 37168107 PMCID: PMC10166639 DOI: 10.1055/s-0043-1768708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 03/14/2023] [Indexed: 05/13/2023] Open
Abstract
Objective Maternal anti-Ro (SSA) and/or anti-La (SSB) antibodies are a risk factor for congenital complete heart block (CHB). Because detailed analysis of the incidence of CHB after 24 weeks of gestational age (GA) is lacking, we aimed to ascertain the risk of "later-onset" CHB among offspring of SSA/SSB-positive mothers in the published literature. Study Design Using search terms "neonatal lupus heart block" and "autoimmune congenital heart block" on PubMed and Ovid, we gathered prospective studies of SSA/SSB-positive mothers with fetal echo surveillance starting from before CHB diagnosis and retrospective cases of fetal CHB diagnosis after 24 weeks of GA (if there was prior normal heart rate) or after birth. Results Ten prospective studies included 1,248 SSA/SSB-positive pregnancies with 24 cases of CHB diagnosed during pregnancy (1.9%). Among these, three (12.5%) were after 24 weeks-at weeks 25, 26, and 28. Our retrospective studies revealed 50 patients with CHB diagnosis in late fetal life and neonatal period and 34 in the nonneonatal childhood period. An additional four cases were diagnosed after age 18 years. Conclusion Later-onset autoimmune CHB in offspring of SSA/SSB-positive mothers does occur. Our analysis suggests that prenatal surveillance should continue beyond 24 weeks of GA but is limited by inconsistent published surveillance data.
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Affiliation(s)
- Luv Makadia
- Division of Pediatric Cardiology, Department of Pediatrics, Hassenfeld Children's Hospital at NYU Langone and NYU Grossman School of Medicine, New York, New York
| | - Peter Izmirly
- Division of Rheumatology, Department of Medicine, NYU Langone Health and NYU Grossman School of Medicine, New York, New York
| | - Jill P. Buyon
- Division of Rheumatology, Department of Medicine, NYU Langone Health and NYU Grossman School of Medicine, New York, New York
| | - Colin K. L. Phoon
- Division of Pediatric Cardiology, Department of Pediatrics, Hassenfeld Children's Hospital at NYU Langone and NYU Grossman School of Medicine, New York, New York
- Address for correspondence Colin K. L. Phoon, MPhil, MD Division of Pediatric Cardiology, Department of Pediatrics, Hassenfeld Children's Hospital at NYU Langone and NYU Grossman School of Medicine150-160 East 32nd Street, New York, NY 10016
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Abstract
Systemic diseases can cause heart block owing to the involvement of the myocardium and thereby the conduction system. Younger patients (<60) with heart block should be evaluated for an underlying systemic disease. These disorders are classified into infiltrative, rheumatologic, endocrine, and hereditary neuromuscular degenerative diseases. Cardiac amyloidosis owing to amyloid fibrils and cardiac sarcoidosis owing to noncaseating granulomas can infiltrate the conduction system leading to heart block. Accelerated atherosclerosis, vasculitis, myocarditis, and interstitial inflammation contribute to heart block in rheumatologic disorders. Myotonic, Becker, and Duchenne muscular dystrophies are neuromuscular diseases involving the myocardium skeletal muscles and can cause heart block.
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8
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Bernard H, Rea C. Neonatal lupus presenting as a non-specific rash in primary care. BMJ Case Rep 2020; 13:13/12/e237463. [PMID: 33318248 PMCID: PMC7737015 DOI: 10.1136/bcr-2020-237463] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Neonatal lupus erythematosus is a rare autoimmune disease caused by passive transplacental acquisition of maternal autoantibodies manifesting in cutaneous, cardiac, haematological and hepatobiliary abnormalities. The hallmark dermatological finding is erythematous annular lesions with a predilection for photo-exposed areas of the skin. We present a case of a female infant born to a mother with Sjogren's syndrome, who initially presented to an ambulatory care setting with non-specific erythematous papules involving the face and scalp. Within 6 days the rash changed in appearance, consisting of widespread erythematous annular and polycyclic lesions with central violaceous clearing and atrophy. Serological tests revealed asymptomatic anemia and leukopenia, elevated liver enzymes, and positive antinuclear antibodies (ANA) and anti-SSb/La antibodies. Further cardiac evaluation was normal. She was managed conservatively in the outpatient setting with topical steroids, avoidance of sunlight and fluorescent light exposure, and primary care, rheumatological and dermatological follow-up.
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Affiliation(s)
- Heather Bernard
- Harvard Medical School, Boston, Massachusetts, USA,Boston Children's Hospital Division of General Pediatrics, Boston, Massachusetts, USA
| | - Corinna Rea
- Harvard Medical School, Boston, Massachusetts, USA,Boston Children's Hospital Division of General Pediatrics, Boston, Massachusetts, USA
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Mizuno M, Masumori C, Sakurai K, Nakano M, Aso K. Anti-Ro/SSA antibody-related atrioventricular block-induced torsade de pointes. Pediatr Int 2020; 62:1101-1103. [PMID: 32744378 DOI: 10.1111/ped.14232] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Revised: 03/09/2020] [Accepted: 03/12/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Masanori Mizuno
- Department of Pediatrics, St Marianna University School of Medicine, Kawasaki, Japan
| | - Chikako Masumori
- Department of Pediatrics, St Marianna University School of Medicine, Kawasaki, Japan
| | - Kenzo Sakurai
- Department of Pediatrics, St Marianna University School of Medicine, Kawasaki, Japan
| | - Marie Nakano
- Department of Pediatrics, St Marianna University School of Medicine, Kawasaki, Japan
| | - Kentaro Aso
- Department of Pediatrics, St Marianna University School of Medicine, Kawasaki, Japan
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Sonesson SE, Ambrosi A, Wahren-Herlenius M. Benefits of fetal echocardiographic surveillance in pregnancies at risk of congenital heart block: single-center study of 212 anti-Ro52-positive pregnancies. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2019; 54:87-95. [PMID: 30620419 DOI: 10.1002/uog.20214] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Revised: 11/15/2018] [Accepted: 11/16/2018] [Indexed: 06/09/2023]
Abstract
OBJECTIVES Assuming that autoimmune congenital heart block (CHB) is a progressive disease amenable to therapeutic modulation, we introduced a surveillance program for at-risk pregnancies with the dual aim of investigating if fetal atrioventricular block (AVB) could be detected and treated before becoming complete and irreversible, and to establish the incidence of AVB I, II and III in a large prospective cohort. METHODS This was a prospective study of 212 anti-Ro52 antibody-exposed pregnancies at risk of fetal AVB that were followed weekly between 18 and 24 weeks' gestation at our tertiary fetal cardiology center from 2000 to 2015. A 12-lead electrocardiogram (ECG) was recorded within 1 week after birth. Fetal Doppler atrioventricular (AV) intervals were converted to Z-scores using reference standard values derived from normal pregnancies. Each fetus was represented by the average value of the two recordings, obtained at two consecutive visits, which resulted in the longest AV interval. AV interval values were classified into normal AV conduction (Z-score ≤ 2.0) and three levels of delayed AV conduction: Z-score > 2.0 and ≤ 3.0, Z-score > 3.0 and ≤ 4.0, and Z-score > 4.0. RESULTS AVB II or III developed in 6/204 (2.9%) pregnancies without a CHB history and 1/8 (12.5%) of those with a CHB history. AV intervals > 2 and ≤ 3, > 3 and ≤ 4, and > 4 were detected in 16.0%, 7.5% and 2.8% of cases, respectively, and were related to the PR interval on 185 available ECGs. Three of the five cases with AVB III and one of two cases with 2:1 AVB II developed within 1 week of AV interval Z-score of 1.0, 1.9, 2.8 and 1.9, respectively. Transplacental treatment with betamethasone was associated with restoration of 1:1 AV conduction in the two fetuses with AVB II, with a better long-term result (normal ECG vs AVB I or II) observed in the case in which treatment was started within 1 week after AVB developed. Betamethasone treatment did not reverse AVB III, although a temporary effect on AV conduction was observed in 1/5 cases. Notably, the three cases in which treatment was started within 1 week after AVB III development responded with a higher ventricular rate than the other two cases and did not require pacemaker implantation until a later age (2-5 years vs 1.5-2 months). CONCLUSION Fetal AV interval is a poor predictor of CHB progression, but CHB surveillance still allows detection of fetuses with AVB II or III shortly after its development, allowing for timely treatment initiation and potentially better outcome. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- S-E Sonesson
- Department of Women's and Children's Health, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - A Ambrosi
- Department of Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - M Wahren-Herlenius
- Department of Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
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Abstract
Neonatal lupus results from the passive transfer of autoantibodies; however, this transfer is not sufficient to cause disease. This article reviews clinical presentation with a focus on autoimmune-mediated congenital heart disease. Recent data looking for additional disease mechanisms and biomarkers as well as latest information on interventions will be reviewed. Our understanding of this rare disease is often dependent on patient participation in disease registries and biorepositories. Future participation in registries including descriptive as well as biophysical data is critical to our knowledge.
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Affiliation(s)
- Marisa S Klein-Gitelman
- Division of Rheumatology, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, 225 E. Chicago Avenue, # 50, Chicago, IL, 60611, USA.
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12
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Sonesson SE, Hedlund M, Ambrosi A, Wahren-Herlenius M. Factors influencing fetal cardiac conduction in anti-Ro/SSA-positive pregnancies. Rheumatology (Oxford) 2017; 56:1755-1762. [DOI: 10.1093/rheumatology/kex263] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2017] [Indexed: 11/13/2022] Open
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13
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Lazzerini PE, Capecchi PL, Laghi-Pasini F, Boutjdir M. Autoimmune channelopathies as a novel mechanism in cardiac arrhythmias. Nat Rev Cardiol 2017; 14:521-535. [PMID: 28470179 DOI: 10.1038/nrcardio.2017.61] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Cardiac arrhythmias confer a considerable burden of morbidity and mortality in industrialized countries. Although coronary artery disease and heart failure are the prevalent causes of cardiac arrest, in 5-15% of patients, structural abnormalities at autopsy are absent. In a proportion of these patients, mutations in genes encoding cardiac ion channels are documented (inherited channelopathies), but, to date, the molecular autopsy is negative in nearly 70% of patients. Emerging evidence indicates that autoimmunity is involved in the pathogenesis of cardiac arrhythmias. In particular, several arrhythmogenic autoantibodies targeting specific calcium, potassium, or sodium channels in the heart have been identified. Experimental and clinical studies demonstrate that these autoantibodies can promote conduction disturbances and life-threatening tachyarrhythmias by inducing substantial electrophysiological changes. In this Review, we propose the term 'autoimmune cardiac channelopathies' to define this novel pathogenic mechanism of cardiac arrhythmias, which could be more frequent and clinically relevant than previously appreciated. Indeed, pathogenic autoantibodies against ion channels are detectable not only in patients with manifest autoimmune disease, but also in apparently healthy individuals, which suggests a causal role in some cases of unexplained arrhythmias and cardiac arrest. Considering this possibility and performing specific testing in patients with 'idiopathic' rhythm disturbances could create novel treatment opportunities.
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Affiliation(s)
- Pietro Enea Lazzerini
- Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Viale Bracci 16, Siena, 53100, Italy
| | - Pier Leopoldo Capecchi
- Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Viale Bracci 16, Siena, 53100, Italy
| | - Franco Laghi-Pasini
- Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Viale Bracci 16, Siena, 53100, Italy
| | - Mohamed Boutjdir
- VA New York Harbor Healthcare System, 800 Poly Place, Brooklyn, New York 11209, USA.,SUNY Downstate Medical Center, 450 Clarkson Avenue, Brooklyn, New York 11203, USA.,NYU School of Medicine, 550 1st Avenue, New York, New York 10016, USA
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14
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Khramaz M, Elkarimi S, Benzerroual D, Elhattaoui M, Aboutofail F, Boumzebra D, Elhaouati R. Diagnostic and Management Difficulties of Complete Atrioventricular Block In Children in Marrakech: A Report of Three Cases With a Review of the Literature. J Atr Fibrillation 2016; 9:1384. [PMID: 27909527 DOI: 10.4022/jafib.1384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Revised: 01/22/2016] [Accepted: 02/11/2016] [Indexed: 11/10/2022]
Abstract
Complete atrioventricular (AV) block is a rare affection in children. It is the consequence of abnormal conduction tissue within a cardiac malformation or it is due to cardiac injury. Yet the etiology of late complete atrioventricular block in child remains mostly unknown. The treatment of children's Complete atrioventricular block is the implantation of a pacemaker with immediate results satisfactory in the absence of associated cardiomyopathy. In this observation we will treat three cases.
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Affiliation(s)
- Mounia Khramaz
- Departement of Cardiology, Cadi Ayyad University, Lab. PCIM, Mohammed the 6th University Hospital, Marrakech, Morocco
| | - Salwa Elkarimi
- Departement of Cardiology, Cadi Ayyad University, Lab. PCIM, Mohammed the 6th University Hospital, Marrakech, Morocco
| | - Dounia Benzerroual
- Departement of Cardiology, Cadi Ayyad University, Lab. PCIM, Mohammed the 6th University Hospital, Marrakech, Morocco
| | - Mustapha Elhattaoui
- Departement of Cardiology, Cadi Ayyad University, Lab. PCIM, Mohammed the 6th University Hospital, Marrakech, Morocco
| | - Fahd Aboutofail
- Departement of Cardiovascular Surgery, Cadi Ayyad University, Lab. PCIM, Mohammed the 6th University Hospital, Marrakech, Morocco
| | - Drissi Boumzebra
- Departement of Cardiovascular Surgery, Cadi Ayyad University, Lab. PCIM, Mohammed the 6th University Hospital, Marrakech, Morocco
| | - Rachid Elhaouati
- Departement of Cardiovascular Surgery, Cadi Ayyad University, Lab. PCIM, Mohammed the 6th University Hospital, Marrakech, Morocco
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15
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Kaabour M, Cailleaux A, Massin M, Redant S. Bloc auriculoventriculaire de haut grade asymptomatique de l’enfant. ANNALES FRANCAISES DE MEDECINE D URGENCE 2016. [DOI: 10.1007/s13341-016-0682-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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16
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Brito-Zerón P, Izmirly PM, Ramos-Casals M, Buyon JP, Khamashta MA. Autoimmune congenital heart block: complex and unusual situations. Lupus 2016; 25:116-28. [PMID: 26762645 DOI: 10.1177/0961203315624024] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Autoimmune congenital heart block (ACHB) is an immune-mediated cardiac disease included among the manifestations collectively referred to as neonatal lupus. The placental transference of maternal Ro/La autoantibodies may damage the conduction tissues during fetal development leading to blocking of signal conduction at the atrioventricular (AV) node in an otherwise structurally normal heart. Irreversible complete AV block is the main cardiac manifestation of ACHB, but some babies may develop endocardial fibroelastosis, valvular insufficiency, and/or frank cardiomyopathies with significantly reduced cardiac function requiring transplant. The severity of ACHB is illustrated by a global mortality rate of 20% and pacemaker rates of at least 64%, often within the first year of life. This review analyses the main complex and/or unusual clinical situations associated with ACHB, including unusual maternal immunological profiles, infrequent maternal autoimmune diseases, cardiac damage unrelated to AV block, fetal invasive management, late complications after birth, risk of congenital heart block (CHB) in ovodonation and in vitro fertilization techniques, the role of maternal features other than autoimmunity, the influence of the birth order or the risk of CHB in twins and triplets.
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Affiliation(s)
- P Brito-Zerón
- Josep Font Laboratory of Autoimmune Diseases, Department of Autoimmune Diseases, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
| | - P M Izmirly
- Division of Rheumatology, Department of Medicine, New York University School of Medicine, New York, USA
| | - M Ramos-Casals
- Josep Font Laboratory of Autoimmune Diseases, Department of Autoimmune Diseases, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
| | - J P Buyon
- Division of Rheumatology, Department of Medicine, New York University School of Medicine, New York, USA
| | - M A Khamashta
- Graham Hughes Lupus Research Laboratory, The Rayne Institute, Division of Women's Health, Kings College London St Thomas Hospital, United Kingdom
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17
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Baruteau AE, Pass RH, Thambo JB, Behaghel A, Le Pennec S, Perdreau E, Combes N, Liberman L, McLeod CJ. Congenital and childhood atrioventricular blocks: pathophysiology and contemporary management. Eur J Pediatr 2016; 175:1235-1248. [PMID: 27351174 PMCID: PMC5005411 DOI: 10.1007/s00431-016-2748-0] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2016] [Revised: 06/13/2016] [Accepted: 06/16/2016] [Indexed: 02/07/2023]
Abstract
UNLABELLED Atrioventricular block is classified as congenital if diagnosed in utero, at birth, or within the first month of life. The pathophysiological process is believed to be due to immune-mediated injury of the conduction system, which occurs as a result of transplacental passage of maternal anti-SSA/Ro-SSB/La antibodies. Childhood atrioventricular block is therefore diagnosed between the first month and the 18th year of life. Genetic variants in multiple genes have been described to date in the pathogenesis of inherited progressive cardiac conduction disorders. Indications and techniques of cardiac pacing have also evolved to allow safe permanent cardiac pacing in almost all patients, including those with structural heart abnormalities. CONCLUSION Early diagnosis and appropriate management are critical in many cases in order to prevent sudden death, and this review critically assesses our current understanding of the pathogenetic mechanisms, clinical course, and optimal management of congenital and childhood AV block. WHAT IS KNOWN • Prevalence of congenital heart block of 1 per 15,000 to 20,000 live births. AV block is defined as congenital if diagnosed in utero, at birth, or within the first month of life, whereas childhood AV block is diagnosed between the first month and the 18th year of life. As a result of several different etiologies, congenital and childhood atrioventricular block may occur in an entirely structurally normal heart or in association with concomitant congenital heart disease. Cardiac pacing is indicated in symptomatic patients and has several prophylactic indications in asymptomatic patients to prevent sudden death. • Autoimmune, congenital AV block is associated with a high neonatal mortality rate and development of dilated cardiomyopathy in 5 to 30 % cases. What is New: • Several genes including SCN5A have been implicated in autosomal dominant forms of familial progressive cardiac conduction disorders. • Leadless pacemaker technology and gene therapy for biological pacing are promising research fields. In utero percutaneous pacing appears to be at high risk and needs further development before it can be adopted into routine clinical practice. Cardiac resynchronization therapy is of proven value in case of pacing-induced cardiomyopathy.
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Affiliation(s)
- Alban-Elouen Baruteau
- Cardiovascular and Cell Sciences Research Center, St George’s University of London, London, UK
- LIRYC Institute, CHU Bordeaux, Department of Pediatric Cardiology, Bordeaux-II University, Bordeaux, France
- Service de Cardiologie Pédiatrique, Hôpital du Haut Lévèque, Institut Hospitalo-Universitaire LIRYC (Electrophysiology and Heart Modeling Institute), 5 avenue de Magellan, 33600 Pessac, France
| | - Robert H. Pass
- Division of Pediatric Electrophysiology, Albert Einstein College of Medicine, Montefiore Children’s Hospital, Bronx, NY USA
| | - Jean-Benoit Thambo
- LIRYC Institute, CHU Bordeaux, Department of Pediatric Cardiology, Bordeaux-II University, Bordeaux, France
| | - Albin Behaghel
- CHU Rennes, Department of Cardiology, LTSI, INSERM 1099, Rennes-1 University, Rennes, France
| | - Solène Le Pennec
- CHU Rennes, Department of Cardiology, LTSI, INSERM 1099, Rennes-1 University, Rennes, France
| | - Elodie Perdreau
- LIRYC Institute, CHU Bordeaux, Department of Pediatric Cardiology, Bordeaux-II University, Bordeaux, France
| | - Nicolas Combes
- Department of Cardiology, Clinique Pasteur, Toulouse, France
| | - Leonardo Liberman
- Morgan Stanley Children’s Hospital, Division of Pediatric Cardiology, New York Presbyterian Hospital, Columbia University Medical Center, New York, NY USA
| | - Christopher J. McLeod
- Mayo Clinic, Division of Cardiovascular Diseases, Mayo Clinic College of Medicine, Rochester, MN USA
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18
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Saxena A, Izmirly PM, Han SW, Briassouli P, Rivera TL, Zhong H, Friedman DM, Clancy RM, Buyon JP. Serum Biomarkers of Inflammation, Fibrosis, and Cardiac Function in Facilitating Diagnosis, Prognosis, and Treatment of Anti-SSA/Ro-Associated Cardiac Neonatal Lupus. J Am Coll Cardiol 2015; 66:930-9. [PMID: 26293764 DOI: 10.1016/j.jacc.2015.06.1088] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2015] [Revised: 06/11/2015] [Accepted: 06/15/2015] [Indexed: 02/03/2023]
Abstract
BACKGROUND Cardiac manifestations of neonatal lupus (cardiac NL) include congenital heart block and cardiomyopathy. Several candidate biomarkers were evaluated in cases at risk for cardiac NL on the basis of potential roles in inflammation, fibrosis, and cardiac dysfunction: C-reactive protein (CRP); NT-pro-B-type natriuretic peptide (NT-proBNP); troponin I; matrix metalloproteinase (MMP)-2; urokinase plasminogen activator (uPA); urokinase plasminogen activator receptor (uPAR); plasminogen; and vitamin D. OBJECTIVES Identification of maternal and fetal biomarkers associated with development and morbidity of cardiac NL should provide clues to pathogenesis with translational implications for management. METHODS Cord (139) and maternal (135) blood samples collected during pregnancies at risk for cardiac NL were available for study. Levels of cord and maternal CRP, cord NT-proBNP, and cord troponin I were evaluated using multiplex assays. Cord and maternal vitamin D were assessed by liquid chromatography-mass spectrometry. MMP-2, uPA, uPAR, and plasminogen were evaluated using ELISA. RESULTS Cord CRP, NT-proBNP, MMP-2, uPA, uPAR, and plasminogen levels were higher in cardiac NL-affected fetuses than in unaffected cases, independent of maternal rheumatic disease, season at highest risk of cardiac NL development, and medications taken during pregnancy. These biomarkers were positively associated with a disease severity score derived from known risk factors for mortality in cardiac NL. Maternal CRP and cord troponin I levels did not differ between the groups. Cord and maternal vitamin D levels were not significantly associated with cardiac NL, but average maternal vitamin D level during pregnancy was positively associated with longer time to postnatal pacemaker placement. CONCLUSIONS These data support the association of fetal reactive inflammatory and fibrotic components with development and morbidity of cardiac NL. Following CRP and NT-proBNP levels after birth can potentially monitor severity and progression of cardiac NL. MMP-2 and the uPA/uPAR/plasminogen cascade provide therapeutic targets to decrease fibrosis. Although decreased vitamin D did not confer increased risk, given the positive influence on postnatal outcomes, maternal levels should be optimized.
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Affiliation(s)
- Amit Saxena
- Division of Rheumatology, Department of Medicine, New York University School of Medicine, New York, New York.
| | - Peter M Izmirly
- Division of Rheumatology, Department of Medicine, New York University School of Medicine, New York, New York
| | - Sung Won Han
- Department of Population Health, New York University School of Medicine, New York, New York
| | - Paraskevi Briassouli
- Division of Rheumatology, Department of Medicine, New York University School of Medicine, New York, New York
| | - Tania L Rivera
- Division of Rheumatology, Department of Medicine, Scripps Memorial Hospital, La Jolla, San Diego, California
| | - Hua Zhong
- Department of Population Health, New York University School of Medicine, New York, New York
| | - Deborah M Friedman
- Division of Pediatric Cardiology, New York Medical College, Valhalla, New York
| | - Robert M Clancy
- Division of Rheumatology, Department of Medicine, New York University School of Medicine, New York, New York
| | - Jill P Buyon
- Division of Rheumatology, Department of Medicine, New York University School of Medicine, New York, New York
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19
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Lazzerini PE, Brucato A, Capecchi PL, Baldi L, Bacarelli MR, Nucci C, Moscadelli V, Morozzi G, Boutjdir M, Laghi-Pasini F. Isolated atrioventricular block of unknown origin in the adult and autoimmunity: diagnostic and therapeutic considerations exemplified by 3 anti-Ro/SSA-associated cases. HeartRhythm Case Rep 2015; 1:293-299. [PMID: 28491571 PMCID: PMC5419527 DOI: 10.1016/j.hrcr.2015.03.019] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Key Words
- ANA, Antinuclear antibodies
- AV, Atrioventricular
- AVB, Atrioventricular block
- Anti-Ro/SSA antibodies
- Autoimmunity
- CTD, Connective tissue disease
- Calcium channels
- ECG, Electrocardiogram
- ELISA, Enzyme-linked immunosorbent assay
- FEIA, Fluoroenzyme immunoassay
- III°AVB, Third-degree atrioventricular block
- II°AVB, Second-degree atrioventricular block
- Immunosuppressive therapy
- Isolated heart block in adults
- I°AVB, First-degree atrioventricular block
- anti-Ro/SSA, Anti-Ro/SSA antibody
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Affiliation(s)
- Pietro Enea Lazzerini
- Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Antonio Brucato
- Department of Internal Medicine, "Papa Giovanni XXIII" Hospital, Bergamo, Italy
| | - Pier Leopoldo Capecchi
- Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Lucia Baldi
- Department of Heart, Thorax and Vessels, University Hospital of Siena, Siena, Italy
| | - Maria Romana Bacarelli
- Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Claudia Nucci
- Department of Heart, Thorax and Vessels, University Hospital of Siena, Siena, Italy
| | - Valentina Moscadelli
- Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Gabriella Morozzi
- Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Mohamed Boutjdir
- Research Department, VA New York Harbor Healthcare System, New York, New York.,Departments of Medicine, Cell Biology and Pharmacology, State University of New York at Downstate Medical Center, New York, New York.,Department of Medicine, New York University School of Medicine, New York, New York
| | - Franco Laghi-Pasini
- Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Siena, Italy
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20
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Lazzerini PE, Capecchi PL, Laghi-Pasini F. Isolated atrioventricular block of unknown origin in adults and anti-Ro/SSA antibodies: clinical evidence, putative mechanisms, and therapeutic implications. Heart Rhythm 2014; 12:449-54. [PMID: 25444852 DOI: 10.1016/j.hrthm.2014.10.031] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2014] [Indexed: 02/07/2023]
Affiliation(s)
- Pietro Enea Lazzerini
- Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Siena, Italy.
| | - Pier Leopoldo Capecchi
- Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Franco Laghi-Pasini
- Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Siena, Italy
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