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Caruso E, Farruggio S, Guccione P. Calmodulin mutation in long QT syndrome 15 associated with congenital heart defects further complicated by a functional 2:1 atrioventricular block: Management from foetal life to postpartum. Indian Pacing Electrophysiol J 2024; 24:150-154. [PMID: 38281621 PMCID: PMC11143731 DOI: 10.1016/j.ipej.2024.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 12/27/2023] [Accepted: 01/17/2024] [Indexed: 01/30/2024] Open
Abstract
We report a long QT syndrome 15 whose diagnosis was suspected during foetal life and confirmed at birth and was associated with congenital heart disease. Genetic testing revealed a rare mutation associated with the CALM2 gene. At 23 weeks of gestation, severe foetal sinus bradycardia (∼100 bpm) was detected. In the third trimester, the foetus developed severe right ventricular hypertrophy. At birth, the electrocardiogram showed a long QT interval of 640 ms, and after 1 hour, the newborn showed functional 2:1 atrioventricular block at ventricular rate of 50 bpm. After further pharmacological therapies, epicardial wires were surgically implanted for transient pacing in VVI mode at 90 bpm. Echocardiogram showed aneurysmatic left atrial appendage, dilated right segments, hypertrophied right ventricle, ostium secundum type atrial septal defect, and muscular ventricular septal defect. At two weeks of postpartum, a permanent dual-chamber pacemaker was implanted in the DDD mode and the patient was discharged with a prescription of beta-blockers and calcium therapy.
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Affiliation(s)
- Elio Caruso
- Mediterranean Pediatric Cardiology Center "Bambino Gesù", San Vincenzo Hospital, Taormina, ME, Italy
| | - Silvia Farruggio
- Mediterranean Pediatric Cardiology Center "Bambino Gesù", San Vincenzo Hospital, Taormina, ME, Italy.
| | - Paolo Guccione
- Mediterranean Pediatric Cardiology Center "Bambino Gesù", San Vincenzo Hospital, Taormina, ME, Italy
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Prats P, Izquierdo MT, Rodríguez MÁ, Rodríguez I, Rodríguez-Melcón A, Serra B, Albaiges G. Assessment of fetal cardiac function in early fetal life: feasibility, reproducibility, and early fetal nomograms. AJOG GLOBAL REPORTS 2024; 4:100325. [PMID: 38586615 PMCID: PMC10994973 DOI: 10.1016/j.xagr.2024.100325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/09/2024] Open
Abstract
BACKGROUND Fetal cardiology has shown a rapid development in the past decades. Fetal echocardiography is not only used for the detection of structural anomalies but also to assess fetal cardiac function. Assessment of the fetal cardiac function is performed mostly in the second and third trimesters. The study of fetal cardiac function at the end of first trimester has not been investigated properly, and there is a lack of reference values at early gestational weeks. OBJECTIVE This study aimed to assess if the measurement of time-related parameters of cardiac function in the left ventricle of the fetal heart is feasible and reproducible at the end of the first trimester. If possible, we provide nomograms of these parameters from 11 to 13+6 gestational weeks. STUDY DESIGN We conducted a prospective observational study from March to September 2022. The study was carried out in 2 hospitals (Hospital Universitari Dexeus, Barcelona, and Hospital VITAHS 9 Octubre, Valencia, Spain). The scans were performed by 3 specialists in fetal medicine. The exclusion criteria were fetal cardiac rhythm abnormalities, abnormal nuchal translucency, abnormal ductus venosus, fetal malformations, stillbirth, estimated fetal weight <10 percentile, diabetes, and gestational hypertensive disorders. The cardiac function parameters studied in the left ventricle were isovolumetric contraction time, isovolumetric relaxation time, ejection time, filling time, cycle time, myocardial performance index, ejection time fraction, and filling time fraction. We study the feasibility and intra- and interobserver reproducibility of these parameters using the interclass correlation coefficient. Nomograms were created and the percentiles of the values of the different parameters were calculated. RESULTS A total of 409 cases were recruited but only 296 could be included in the statistical analysis once the exclusion criteria were applied. The intraobserver reproducibility study was excellent (interclass correlation coefficient >0.900), and the interobserver reproducibility study was good (interclass correlation coefficient >0.700). The data regression analysis showed that cycle time, filling time, isovolumetric contraction time, and filling time fraction increased with gestational age, whereas ejection time fraction decreased with gestational age and myocardial performance index (mean, 0.43±0.08), isovolumetric relaxation time (mean, 0.04±0.01), and ejection time (mean, 0.16±0.01) remained constant from 11 to 13 weeks. CONCLUSION The study of fetal cardiac function is feasible and reproducible at 11 to 13+6 gestational weeks. Nomograms of the studied parameters are provided.
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Affiliation(s)
- Pilar Prats
- Fetal Medicine Unit, Obstetrics Service, Department of Obstetrics, Gynecology and Reproductive Medicine, Institut Universitari Dexeus, Barcelona, Spain (Drs Prats, Rodríguez, and Albaiges)
- Obstetrics Service, Department of Obstetrics, Gynecology and Reproductive Medicine, Institut Universitari Dexeus, Barcelona, Spain (Drs Prats, Rodríguez-Melcón, and Serra)
| | - M. Teresa Izquierdo
- Gynecologic and Obstetric Ultrasound Unit, Hospital VITHAS 9 Octubre, Valencia, Spain (Dr Izquierdo)
| | - M. Ángeles Rodríguez
- Fetal Medicine Unit, Obstetrics Service, Department of Obstetrics, Gynecology and Reproductive Medicine, Institut Universitari Dexeus, Barcelona, Spain (Drs Prats, Rodríguez, and Albaiges)
| | - Ignacio Rodríguez
- Epidemiological Unit, Department Obstetrics, Gynecology, Reproductive Medicine, Institut Universitari Dexeus, Barcelona, Spain (Mr Rodríguez)
| | - Alberto Rodríguez-Melcón
- Obstetrics Service, Department of Obstetrics, Gynecology and Reproductive Medicine, Institut Universitari Dexeus, Barcelona, Spain (Drs Prats, Rodríguez-Melcón, and Serra)
| | - Bernat Serra
- Obstetrics Service, Department of Obstetrics, Gynecology and Reproductive Medicine, Institut Universitari Dexeus, Barcelona, Spain (Drs Prats, Rodríguez-Melcón, and Serra)
| | - Gerard Albaiges
- Fetal Medicine Unit, Obstetrics Service, Department of Obstetrics, Gynecology and Reproductive Medicine, Institut Universitari Dexeus, Barcelona, Spain (Drs Prats, Rodríguez, and Albaiges)
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Mosimann B, Amylidi-Mohr S, Surbek D, Förger F, Raio L. Use of Polynomial Reference Ranges for Atrioventricular Intervals Assessed by Fetal Echocardiography in Anti-Ro/SSA Antibody-Positive Pregnancies to Exclude Fetal Heart Blocks: A Pilot Study. Fetal Diagn Ther 2023; 50:422-429. [PMID: 37497922 DOI: 10.1159/000531780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Accepted: 06/21/2023] [Indexed: 07/28/2023]
Abstract
INTRODUCTION Maternal anti-Ro/SSA antibodies can cause fetal atrioventricular blocks (AVB). This pilot study aims to apply previously published echocardiographic reference ranges of the fetal atrioventricular (AV) intervals in the setting of anti-Ro/SSA antibody-positive pregnancies in order to exclude a 1° AVB. MATERIALS AND METHODS Between January 2018 and September 2022, we included all women with known anti-Ro/SSA antibodies followed up at the prenatal ultrasound department of the University Hospital of Bern. AV intervals were serially measured by two previously reported methods and plotted against previously created reference ranges. RESULTS We included 23 pregnancies from 17 anti-Ro/SSA antibody-positive women with connective tissue diseases. 443 AV interval measurements were recorded between 16+3 and 38+4 weeks of gestation. 14 (3.2%) AV-intervals measured >150 ms, none measured >170 ms and 8 (1.8%) were found to be >95th percentile. In none of the pregnancies, serial AV-prolongations were noted. The postnatal electrocardiograms demonstrated normal sinus rhythm without AVB in all children. CONCLUSION AV intervals of pregnancies followed up for anti-Ro/SSA antibodies without neonatal AVB lie within our published polynomial reference ranges. While diagnosing a 1° AVB remains controversial, more data are needed to prove that our reference ranges are helpful exclude a 1° AVB.
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Affiliation(s)
- Beatrice Mosimann
- Department of Obstetrics and Gynaecology, University Hospital, University of Bern, Bern, Switzerland
| | - Sofia Amylidi-Mohr
- Department of Obstetrics and Gynaecology, University Hospital, University of Bern, Bern, Switzerland
| | - Daniel Surbek
- Department of Obstetrics and Gynaecology, University Hospital, University of Bern, Bern, Switzerland
| | - Frauke Förger
- Department of Rheumatology and Immunology, University Hospital, University of Bern, Bern, Switzerland
| | - Luigi Raio
- Department of Obstetrics and Gynaecology, University Hospital, University of Bern, Bern, Switzerland
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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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Matsubara Y, Fujita D, Inamura N, Fujita T. Measurement of fetal atrioventricular intervals in pregnant women with anti-SSA/Ro antibodies. J Med Ultrason (2001) 2022; 49:451-461. [PMID: 35653003 DOI: 10.1007/s10396-022-01226-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2021] [Accepted: 04/27/2022] [Indexed: 11/24/2022]
Abstract
PURPOSE The objective of our study was to compare and consider reference values of fetal atrioventricular (AV) intervals as measured by four different pulsed Doppler wave techniques (left ventricular inflow/outflow [LV in/out], pulmonary vein/pulmonary artery [PV/PA], innominate vein/ascending aorta [InnV/AA], and supra vena cava/ascending aorta [SVC/AA]) in pregnant women with anti-SSA/Ro antibodies. METHODS Between March 2014 and September 2020, 52 pregnant women with anti-SSA antibodies were enrolled. No bradyarrhythmia was observed in the group. A pulsed Doppler examination of the fetal heart was performed to obtain measurements of the mechanical Doppler AV interval. Doppler measurements were performed using four methods: LV in/out, PV/PA, InnV/AA, and SVC/AA. A statistical analysis was performed to examine the mean, standard deviation, significant difference, and correlation of the four methods. The detection rate of each method was also calculated. RESULTS There was no significant difference in the AV intervals between any of the four methods. There was also a positive correlation in the AV intervals of each of the four methods. The fetal heart rate and AV interval showed no correlation. The gestational age and AV interval also showed no correlation. The detection rate was highest for LV in/out (62.6%, 95% confidence interval: 56.5-68.4). CONCLUSION All four pulsed Doppler methods are useful for measuring AV intervals. The most practical method is LV in/out.
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Affiliation(s)
- Yayoi Matsubara
- Fujita Clinic, Shimanouchi Building 2F, 2-11-20 Shimanouchi, Chuo-ku, Osaka-shi, Osaka, 542-0082, Japan.
| | - Daisuke Fujita
- Department of Obstetrics and Gynecology, Osaka Medical and Pharmaceutical University, 2-7 Daigakucho, Takatsuki, Osaka, 569-8686, Japan
| | - Noboru Inamura
- Department of Pediatrics, Faculty of Medicine, Kindai University, 377-2 Ohno-Higashi, Osaka-Sayama, Osaka, 589-8511, Japan
| | - Tomio Fujita
- Fujita Clinic, Shimanouchi Building 2F, 2-11-20 Shimanouchi, Chuo-ku, Osaka-shi, Osaka, 542-0082, Japan
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Sunderji S, Peyvandi S, Jaeggi E, Szwast A, Ryan G, Tessier F, Siddiqui S, Cuneo B, Sheth S, Treadwell M, Frommelt M, Turan S, Copel J, Emery S, Rand L, Moon-Grady AJ. NAFTNet retrospective report on the treatment of anti-Ro/SSA mediated fetal heart block with dexamethasone. J Matern Fetal Neonatal Med 2022; 35:9263-9270. [PMID: 35014577 DOI: 10.1080/14767058.2022.2025536] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
BACKGROUND Complete atrioventricular block (CAVB) is a complication of maternal antibody positivity and treatment of fetal disease is controversial in terms of efficacy and safety. We hypothesized that dexamethasone treatment for fetal anti-Ro/SSA antibody-mediated cardiac disease leads to better pregnancy outcomes than expectant management. METHODS A retrospective multi-center cohort study of anti-Ro/SSA antibody positive pregnancies with fetal conduction disease reported by participating North American Fetal Therapy Network (NAFTNet) centers between January 2010 and December 2018. The primary outcomes included: fetal death, oligohydramnios, growth restriction, preterm delivery, and new maternal comorbidities. Secondary outcomes included: pacemaker prior to 28 days, transplantation, and neonatal death in maternal/fetal dyads treated with dexamethasone versus not. RESULTS In 127 anti-Ro/SSA positive pregnancies, 98 were treated with dexamethasone and 29 were not. Of those treated, 61/96 (63.5%) met the primary outcome including 45/91 (49.4%) premature deliveries; 20 mothers developed comorbidities during treatment (fetal death 5, 10 growth restriction, 14 oligohydramnios, two new/worsening gestational diabetes). In the untreated group, 15/25 (60%) met the primary outcome including 11/22 (50%) premature deliveries and four mothers developing comorbidities during their pregnancy (fetal death 3, one growth restriction, one new onset maternal hypertension). Regarding secondary outcomes, 37/96 (43%) treated fetuses required a pacemaker or died by 28 days, while untreated 13/25 (52%) required pacemaker placement, died prior to 28 days or required listing for transplantation. Excluding terminations, survival without transplant was 17 (68%) in untreated and 85 (89%) in treated patients (p<.01). CONCLUSIONS While the use of dexamethasone in anti-Ro/SSA positive pregnancies is associated with a high rate of poor pregnancy outcomes, there was an unexpected similarly high rate in untreated positive pregnancies. This suggests that the maternal disease itself is influencing pregnancy complications independent of dexamethasone. Our data, which show that treatment decreases neonatal morbidity and overall mortality without increasing overall pregnancy complications, warrant further study.
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Affiliation(s)
- Sherzana Sunderji
- Department of Pediatrics, University of California, Davis, Sacramento, CA, USA
| | - Shabnam Peyvandi
- Department of Pediatrics, University of California, San Francisco, San Francisco, CA, USA
| | | | - Anita Szwast
- The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Greg Ryan
- Mount Sinai Hospital, Toronto, Canada
| | - Francine Tessier
- Children's & Women's Health Centre of British Columbia, Vancouver, Canada
| | | | | | | | - Marjorie Treadwell
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA
| | | | - Shifa Turan
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD, USA
| | | | - Stephen Emery
- Department of Obstetrics, Gynecology, & Reproductive Sciences, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Larry Rand
- Department of Pediatrics, University of California, San Francisco, San Francisco, CA, USA
| | - Anita J Moon-Grady
- Department of Pediatrics, University of California, San Francisco, San Francisco, CA, USA
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de Carvalho HT, Chiquillo MPL, Tanaka SN, de Castro ACAV, Kummer L, Roscani MG. Accuracy of obstetric ultrasonography compared to fetal echocardiography in diagnosis of congenital heart disease at a secondary level hospital in Brazil: A pilot study. PROGRESS IN PEDIATRIC CARDIOLOGY 2021. [DOI: 10.1016/j.ppedcard.2021.101420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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8
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Soveral I, Crispi F, Guirado L, García-Otero L, Torres X, Bennasar M, Sepúlveda-Martínez Á, Nogué L, Gratacós E, Martínez JM, Bijnens B, Friedberg M, Gómez O. Fetal cardiac filling and ejection time fractions by pulsed-wave Doppler: reference ranges and potential clinical application. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2021; 58:83-91. [PMID: 32672395 DOI: 10.1002/uog.22152] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Revised: 06/10/2020] [Accepted: 07/01/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVES Fetal cardiac function can be evaluated using a variety of parameters. Among these, cardiac cycle time-related parameters, such as filling time fraction (FTF) and ejection time fraction (ETF), are promising but rarely studied. We aimed to report the feasibility and reproducibility of fetal FTF and ETF measurements using pulsed-wave Doppler, to provide reference ranges for fetal FTF and ETF, after evaluating their relationship with heart rate (HR), gestational age (GA) and estimated fetal weight (EFW), and to evaluate their potential clinical utility in selected fetal conditions. METHODS This study included a low-risk prospective cohort of singleton pregnancies and a high-risk population of fetuses with severe twin-twin transfusion syndrome (TTTS), aortic stenosis (AoS) or aortic coarctation (CoA), from 18 to 41 weeks' gestation. Left ventricular (LV) and right ventricular inflow and outflow pulsed-wave Doppler signals were analyzed, using valve clicks as landmarks. FTF was calculated as: (filling time/cycle time) × 100. ETF was calculated as: (ejection time/cycle time) × 100. Intraclass correlation coefficients (ICC) were used to evaluate the intra- and interobserver reproducibility of FTF and ETF measurements in low-risk fetuses. The relationships of FTF and ETF with HR, GA and EFW were evaluated using multivariate regression analysis. Reference ranges for FTF and ETF were then constructed using the low-risk population. Z-scores of FTF and ETF in the high-risk fetuses were calculated and analyzed. RESULTS In total, 602 low-risk singleton pregnancies and 54 high-risk fetuses (nine pairs of monochorionic twins with severe TTTS, 16 fetuses with AoS and 20 fetuses with CoA) were included. Adequate Doppler traces for FTF and ETF could be obtained in 95% of low-risk cases. Intraobserver reproducibility was good to excellent (ICC, 0.831-0.905) and interobserver reproducibility was good (ICC, 0.801-0.837) for measurements of all timing parameters analyzed. Multivariate analysis of FTF and ETF in relation to HR, GA and EFW in low-risk fetuses identified HR as the only variable predictive of FTF, while ETF was dependent on both HR and GA. FTF increased with decreasing HR in low-risk fetuses, while ETF showed the opposite behavior, decreasing with decreasing HR. Most recipient twins with severe TTTS showed reduced FTF and preserved ETF. AoS was associated with decreased FTF and increased ETF in the LV, with seemingly different patterns associated with univentricular vs biventricular postnatal outcome. The majority of fetuses with CoA had FTF and ETF within the normal range in both ventricles. CONCLUSIONS Measurement of FTF and ETF using pulsed-wave Doppler is feasible and reproducible in the fetus. The presented reference ranges account for associations of FTF with HR and of ETF with HR and GA. These time fractions are potentially useful for clinical monitoring of cardiac function in severe TTTS, AoS and other fetal conditions overloading the heart. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- I Soveral
- Fetal Medicine Research Center, BCNatal - Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Déu), Institut Clínic de Ginecologia, Obstetricia i Neonatologia, Universitat de Barcelona, Centre for Biomedical Research on Rare Diseases, Barcelona, Spain
- Department of Obstetrics and Gynecology, Hospital General de l'Hospitalet, Barcelona, Spain
| | - F Crispi
- Fetal Medicine Research Center, BCNatal - Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Déu), Institut Clínic de Ginecologia, Obstetricia i Neonatologia, Universitat de Barcelona, Centre for Biomedical Research on Rare Diseases, Barcelona, Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - L Guirado
- Fetal Medicine Research Center, BCNatal - Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Déu), Institut Clínic de Ginecologia, Obstetricia i Neonatologia, Universitat de Barcelona, Centre for Biomedical Research on Rare Diseases, Barcelona, Spain
| | - L García-Otero
- Fetal Medicine Research Center, BCNatal - Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Déu), Institut Clínic de Ginecologia, Obstetricia i Neonatologia, Universitat de Barcelona, Centre for Biomedical Research on Rare Diseases, Barcelona, Spain
| | - X Torres
- Fetal Medicine Research Center, BCNatal - Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Déu), Institut Clínic de Ginecologia, Obstetricia i Neonatologia, Universitat de Barcelona, Centre for Biomedical Research on Rare Diseases, Barcelona, Spain
| | - M Bennasar
- Fetal Medicine Research Center, BCNatal - Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Déu), Institut Clínic de Ginecologia, Obstetricia i Neonatologia, Universitat de Barcelona, Centre for Biomedical Research on Rare Diseases, Barcelona, Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Á Sepúlveda-Martínez
- Fetal Medicine Research Center, BCNatal - Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Déu), Institut Clínic de Ginecologia, Obstetricia i Neonatologia, Universitat de Barcelona, Centre for Biomedical Research on Rare Diseases, Barcelona, Spain
- Fetal Medicine Unit, Department of Obstetrics and Gynecology, Hospital Clínico de la Universidad de Chile, Santiago, Chile
| | - L Nogué
- Fetal Medicine Research Center, BCNatal - Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Déu), Institut Clínic de Ginecologia, Obstetricia i Neonatologia, Universitat de Barcelona, Centre for Biomedical Research on Rare Diseases, Barcelona, Spain
| | - E Gratacós
- Fetal Medicine Research Center, BCNatal - Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Déu), Institut Clínic de Ginecologia, Obstetricia i Neonatologia, Universitat de Barcelona, Centre for Biomedical Research on Rare Diseases, Barcelona, Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - J M Martínez
- Fetal Medicine Research Center, BCNatal - Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Déu), Institut Clínic de Ginecologia, Obstetricia i Neonatologia, Universitat de Barcelona, Centre for Biomedical Research on Rare Diseases, Barcelona, Spain
| | - B Bijnens
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- ICREA, Barcelona, Spain
| | - M Friedberg
- The Labatt Family Heart Center, Division of Cardiology, Hospital for Sick Children and University of Toronto, Toronto, Canada
| | - O Gómez
- Fetal Medicine Research Center, BCNatal - Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Déu), Institut Clínic de Ginecologia, Obstetricia i Neonatologia, Universitat de Barcelona, Centre for Biomedical Research on Rare Diseases, Barcelona, Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
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Tang C, Yu H, Shao S, Hua Y, Chen M, Zhu Q, Li Y, Zhou K, Wang C. Case Report: Prenatal Diagnosis and Treatment of Fetal Autoimmune-Associated First-Degree Atrioventricular Block: First Report From China. Front Cardiovasc Med 2021; 8:683486. [PMID: 34235189 PMCID: PMC8255611 DOI: 10.3389/fcvm.2021.683486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Accepted: 06/01/2021] [Indexed: 11/16/2022] Open
Abstract
Background: The rapid progression from fetal first-degree atrioventricular block (AVB) to third-degree AVB had been reported. However, how to define fetal first-degree AVB with proper technique and the necessity of the treatment in utero for fetal autoimmune-associated first-degree AVB are still controversial. Purpose: To explore the diagnosis and the effect of treatment for fetal first-degree AVB. Cases Presentation: Four pregnant women with positive autoantibodies anti-SSA/Ro were admitted into our hospital with complaints of rapid prolonged atrioventricular (AV) intervals of their fetuses. Fetal AV intervals were re-measured by tissue Doppler imaging (TDI) from the onset of atrial contraction to ventricular systole (Aa-Sa), which were 170 ms (case 1-twin A), 160 ms (case 1-twin B), 163 ms (case 2) and 172 ms (case 3) and 170 ms (case 4), respectively. The histories of medication usage or infection during gestation were denied. Amniotic fluid genetic screenings and virological tests were negative in all cases. No structural cardiac disorders were found and the cardiovascular profile scores were 10 for each fetus. Oral dexamethasone (initial dose of 4.5 mg daily) and hydroxychloroquine (200 mg bid) plus weekly follow-up surveillance were suggested. The dosage of dexamethasone was adjusted according to the changes of the AV intervals and fetal development of biparietal diameters (BPD) and femur lengths (FL). All fetal AV intervals were controlled well. Maternal and fetal adverse effects were noted as diabetes in 1 mother and growth retardation in all fetuses. All fetuses were delivered via cesarean section at 35+4, 37, 38, and 37+1 gestational weeks, with 10 scores of Apgar score. Postnatally, positive anti-SSA/Ro was found in all neonates. However, there were no clinical or laboratory evidence of neonatal lupus syndrome. No abnormal signs were found on postnatal electrocardiogram and echocardiography for all neonates. With a follow-up of 8–53 months, there was no progression of disease and all infants demonstrated normal physical, mental, and motor development. Conclusion: Prenatal treatment for fetal autoimmune-associated first-degree AVB could be an alternative. Strict surveillance and timely adjustment of the treatment according to the conditions of the mother and the fetus are indicated. Further studies are necessary to prove our concept.
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Affiliation(s)
- Changqing Tang
- Department of Paediatric Cardiology, West China Second University Hospital, Sichuan University, Chengdu, China.,The Cardiac Development and Early Intervention Unit, West China Institute of Women and Children's Health, West China Second University Hospital, Sichuan University, Chengdu, China.,West China Medical School, Sichuan University, Chengdu, China
| | - Haiyan Yu
- The Cardiac Development and Early Intervention Unit, West China Institute of Women and Children's Health, West China Second University Hospital, Sichuan University, Chengdu, China.,Department of Obstetrics, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Shuran Shao
- Department of Paediatric Cardiology, West China Second University Hospital, Sichuan University, Chengdu, China.,The Cardiac Development and Early Intervention Unit, West China Institute of Women and Children's Health, West China Second University Hospital, Sichuan University, Chengdu, China.,West China Medical School, Sichuan University, Chengdu, China
| | - Yimin Hua
- Department of Paediatric Cardiology, West China Second University Hospital, Sichuan University, Chengdu, China.,The Cardiac Development and Early Intervention Unit, West China Institute of Women and Children's Health, West China Second University Hospital, Sichuan University, Chengdu, China.,Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, China.,Key Laboratory of Development and Diseases of Women and Children of Sichuan Province, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Maoli Chen
- The People's Hospital of Yaan, Yaan, China
| | - Qi Zhu
- Department of Ultrasonaography, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Yifei Li
- Department of Paediatric Cardiology, West China Second University Hospital, Sichuan University, Chengdu, China.,The Cardiac Development and Early Intervention Unit, West China Institute of Women and Children's Health, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Kaiyu Zhou
- Department of Paediatric Cardiology, West China Second University Hospital, Sichuan University, Chengdu, China.,The Cardiac Development and Early Intervention Unit, West China Institute of Women and Children's Health, West China Second University Hospital, Sichuan University, Chengdu, China.,Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, China.,Key Laboratory of Development and Diseases of Women and Children of Sichuan Province, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Chuan Wang
- Department of Paediatric Cardiology, West China Second University Hospital, Sichuan University, Chengdu, China.,The Cardiac Development and Early Intervention Unit, West China Institute of Women and Children's Health, West China Second University Hospital, Sichuan University, Chengdu, China
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10
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Sulas E, Ortu E, Urru M, Tumbarello R, Raffo L, Solinas G, Pani D. Impact of pulsed-wave-Doppler velocity-envelope tracing techniques on classification of complete fetal cardiac cycles. PLoS One 2021; 16:e0248114. [PMID: 33909636 PMCID: PMC8081200 DOI: 10.1371/journal.pone.0248114] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Accepted: 02/22/2021] [Indexed: 01/09/2023] Open
Abstract
Fetal echocardiography is an operator-dependent examination technique requiring a high level of expertise. Pulsed-wave Doppler (PWD) is often used as a reference for the mechanical activity of the heart, from which several quantitative parameters can be extracted. These aspects suggest the development of software tools that can reliably identify complete and clinically meaningful fetal cardiac cycles that can enable their automatic measurement. Several scientific works have addressed the tracing of the PWD velocity envelope. In this work, we assess the different steps involved in the signal processing chains that enable PWD envelope tracing. We apply a supervised classifier trained on envelopes traced by different signal processing chains for distinguishing complete and measurable PWD heartbeats from incomplete or malformed ones, which makes it possible to determine the impact of each of the different processing steps on the detection accuracy. In this study, we collected 43 images and labeled 174,319 PWD segments from 25 pregnant women volunteers. By considering seven envelope tracing techniques and the 23 different processing steps involved in their implementation, the results of our study reveal that, compared to the steps investigated in most other works, those that achieve binarisation and envelope extraction are significantly more important (p < 0.05). The best approaches among those studied enabled greater than 98% accuracy on our large manually annotated dataset.
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Affiliation(s)
- Eleonora Sulas
- Department of Electrical and Electronic Engineering, University of Cagliari, Cagliari, Italy
- * E-mail:
| | - Emanuele Ortu
- Department of Electrical and Electronic Engineering, University of Cagliari, Cagliari, Italy
| | - Monica Urru
- Division of Pediatric Cardiology, San Michele Hospital, Cagliari, Italy
| | | | - Luigi Raffo
- Department of Electrical and Electronic Engineering, University of Cagliari, Cagliari, Italy
| | - Giuliana Solinas
- Department of Biomedical Science, University of Sassari, Sassari, Italy
| | - Danilo Pani
- Department of Electrical and Electronic Engineering, University of Cagliari, Cagliari, Italy
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11
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Liao H, Tang C, Qiao L, Zhou K, Hua Y, Wang C, Li Y. Prenatal Management Strategy for Immune-Associated Congenital Heart Block in Fetuses. Front Cardiovasc Med 2021; 8:644122. [PMID: 33996939 PMCID: PMC8113399 DOI: 10.3389/fcvm.2021.644122] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Accepted: 03/30/2021] [Indexed: 12/13/2022] Open
Abstract
Fetal congenital heart block (CHB) is the most commonly observed type of fetal bradycardia, and is potentially life-threatening. More than 50% of cases of bradycardia are associated with maternal autoimmunity, and these are collectively termed immune-associated bradycardia. Several methods have been used to achieve reliable prenatal diagnoses of CHB. Emerging data and opinions on pathogenesis, prenatal diagnosis, fetal intervention, and the prognosis of fetal immune-associated CHB provide clues for generating a practical protocol for clinical management. The prognosis of fetal immune-associated bradycardia is based on the severity of heart blocks. Morbidity and mortality can occur in severe cases, thus hieratical management is essential in such cases. In this review, we mainly focus on optimal strategies pertaining to autoimmune antibodies related to CHB, although the approaches for managing autoimmune-mediated CHB are still controversial, particularly with regard to whether fetuses benefit from transplacental medication administration. To date there is still no accessible clinical strategy for autoimmune-mediated CHB. This review first discusses integrated prenatal management strategies for the condition. It then provides some advice for clinicians involved in management of fetal cardiovascular disorder.
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Affiliation(s)
- Hongyu Liao
- Key Laboratory of Birth Defects and Related Diseases of Women and Children of Ministry of Education (MOE), Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Changqing Tang
- Key Laboratory of Birth Defects and Related Diseases of Women and Children of Ministry of Education (MOE), Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Lina Qiao
- Key Laboratory of Birth Defects and Related Diseases of Women and Children of Ministry of Education (MOE), Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Kaiyu Zhou
- Key Laboratory of Birth Defects and Related Diseases of Women and Children of Ministry of Education (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 Ministry of Education (MOE), Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Chuan Wang
- Key Laboratory of Birth Defects and Related Diseases of Women and Children of Ministry of Education (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 Ministry of Education (MOE), Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China
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12
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Evaluation of cardiac function and systolic dyssynchrony of fetuses exposed to maternal autoimmune diseases using speckle tracking echocardiography. Clin Rheumatol 2021; 40:3807-3815. [PMID: 33813619 PMCID: PMC8357746 DOI: 10.1007/s10067-021-05723-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 03/23/2021] [Accepted: 03/29/2021] [Indexed: 10/29/2022]
Abstract
OBJECTIVES To compare cardiac function and systolic dyssynchrony of fetuses not exposed to and those exposed to maternal autoimmune antibodies using two-dimensional speckle tracking echocardiography (2DSTE). METHODS An observational study of 52 fetuses, 18 from mothers with autoimmune antibodies (anti-SSA/Ro60, anti-Ro52 or/and anti-SSB/La) and 34 from healthy mothers without antibodies, was conducted. Maternal baseline characteristics, fetoplacental Doppler parameters, and conventional echocardiographic data were prospectively collected. Systolic global and regional longitudinal strain of left and right ventricle (LV and RV) and the time to peak strain of regional myocardium were measured using 2DSTE. We also calculated the differences in time to peak strain between the LV free wall and RV free wall (two-chamber dyssynchrony, 2C-DYS) and the LV dyssynchrony between the septum and LV free wall (one-chamber dyssynchrony, 1C-DYS). RESULTS There were no significant differences in conventional systolic and diastolic functional parameters for the LV and RV. No effect modification was demonstrated in a myocardial deformation analysis. However, 1C-DYS was significantly more prolonged in the maternal autoimmune disease group (19.50 [8.00 to 29.25] vs. 28.50 [13.50 to 39.25], P = 0.042). CONCLUSIONS LV systolic mechanical dyssynchrony in fetuses of mothers with autoimmune antibodies suggests in-utero subclinical damage of the cardiac conduction system. Key points • The left ventricular systolic dyssynchrony was significantly more prolonged in the maternal autoimmune disease (AD) fetuses. • Subclinical damage to the left ventricular conduction system of the fetal heart in maternal AD was observed. • Systolic and diastolic functional of the left and right ventricle were preserved in fetuses exposed to maternal autoimmune disease.
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13
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Reference ranges and Z-scores of atrioventricular and ventriculoatrial time intervals in normal fetuses. Int J Cardiovasc Imaging 2021; 37:2419-2428. [PMID: 33723733 DOI: 10.1007/s10554-021-02217-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 03/03/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE To establish a reference range and compare differences among three methods, and then to construct Z-score reference ranges in normal fetuses from the three methods to provide an extra tool for fetal conduction time assessment. METHODS A total of 227 echocardiographic examinations were finally included. Fetal atrioventricular (AV) time and ventriculoatrial (VA) time intervals were measured by three methods: superior vena cava/ascending aorta (SVC/AAO), pulmonary artery/pulmonary vein (PA/PV) and tissue Doppler imaging (TDI). Regression analysis of the mean and standard deviation was performed to establish Z-scores. RESULTS With the three methods, positive correlations of intervals with gestational age (GA) and fetal heart rate (FHA) were observed, while intervals were negatively correlated with fetal heart rate (FHR). Correlations between VA/AV and GA, FHA and FHR were weak. The general trend of all intervals was towards an increase. In AV intervals, PA/PV revealed the longest mean AV time interval and SVC/AAO showed the shortest interval. In addition, PA/PV revealed the shortest VA interval. CONCLUSION This study presents not only the reference range of AV and VA intervals with the three methods but also the Z-score reference ranges for these indices against GA and FHA in normal fetuses. Each method has a different reference range, and appropriate application can facilitate diagnosis and treatment.
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14
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Saito M, Silverman E, Golding F, Guerra V, Hiraki L, Thakur V, Jaeggi E. Effects of Transplacental Dexamethasone Therapy on Fetal Immune-Mediated Complete Heart Block. Fetal Diagn Ther 2021; 48:183-188. [PMID: 33592603 DOI: 10.1159/000513202] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 11/08/2020] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Antibody-mediated complete atrioventricular block (CAVB) is considered irreversible. We sought to examine the effects of transplacental steroids on fetal AV conduction. METHODS Fifty-nine fetuses diagnosed with CAVB at our center from 1996 to 2018 were reviewed. Routine dexamethasone administration to birth was used to limit cardiac inflammatory damage. Restoration of fetal AV conduction was classified as "unexpected" treatment response. RESULTS CAVB resolved in 5/29 (17%) fetuses first treated ≤24-week gestation with 8 mg/day of dexamethasone, when compared with 0/30 (0%) when treatment was initiated later and/or at a starting dose of 4 mg/day (odds ratio 13.69; 95% confidence interval 0.72-260.13; p = 0.024). Treatment response was also associated with a faster ventricular rate at diagnosis (median [range]: 80 [60-97] beats per minute [bpm] vs. 58 [38-92] bpm; p = 0.0036). CAVB reappeared in all 5 responders either prenatally (n = 1) or postnatally before (n = 3) or after (n = 1) the first year of life. When compared with infants with treatment-resistant CAVB (median follow-up 10.3 years), responders (median follow-up 12.3 years) required postnatal pacing less frequent (2/5 [40%] vs. 45/49 [92%]; p = 0.013). CONCLUSIONS In a subgroup of CAVB fetuses, dexamethasone transiently restored AV conduction. This was associated with a lower rate of postnatal pacing when compared with nonresponders.
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Affiliation(s)
- Mika Saito
- Department of Pediatrics, Fetal Cardiac Program, Labatt Family Heart Centre, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Earl Silverman
- Division of Rheumatology, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Fraser Golding
- Department of Pediatrics, Fetal Cardiac Program, Labatt Family Heart Centre, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Vitor Guerra
- Department of Pediatrics, Fetal Cardiac Program, Labatt Family Heart Centre, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Linda Hiraki
- Division of Rheumatology, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Varsha Thakur
- Department of Pediatrics, Fetal Cardiac Program, Labatt Family Heart Centre, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Edgar Jaeggi
- Department of Pediatrics, Fetal Cardiac Program, Labatt Family Heart Centre, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada,
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15
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Sulas E, Urru M, Tumbarello R, Raffo L, Sameni R, Pani D. A non-invasive multimodal foetal ECG-Doppler dataset for antenatal cardiology research. Sci Data 2021; 8:30. [PMID: 33500414 PMCID: PMC7838287 DOI: 10.1038/s41597-021-00811-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Accepted: 12/18/2020] [Indexed: 12/29/2022] Open
Abstract
Non-invasive foetal electrocardiography (fECG) continues to be an open topic for research. The development of standard algorithms for the extraction of the fECG from the maternal electrophysiological interference is limited by the lack of publicly available reference datasets that could be used to benchmark different algorithms while providing a ground truth for foetal heart activity when an invasive scalp lead is unavailable. In this work, we present the Non-Invasive Multimodal Foetal ECG-Doppler Dataset for Antenatal Cardiology Research (NInFEA), the first open-access multimodal early-pregnancy dataset in the field that features simultaneous non-invasive electrophysiological recordings and foetal pulsed-wave Doppler (PWD). The dataset is mainly conceived for researchers working on fECG signal processing algorithms. The dataset includes 60 entries from 39 pregnant women, between the 21st and 27th week of gestation. Each dataset entry comprises 27 electrophysiological channels (2048 Hz, 22 bits), a maternal respiration signal, synchronised foetal trans-abdominal PWD and clinical annotations provided by expert clinicians during signal acquisition. MATLAB snippets for data processing are also provided.
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Affiliation(s)
- Eleonora Sulas
- University of Cagliari, Department of Electrical and Electronic Engineering, Cagliari, 09123, Italy
| | - Monica Urru
- Brotzu Hospital, Pediatric Cardiology and Congenital Heart Disease Unit, Cagliari, 09134, Italy
| | - Roberto Tumbarello
- Brotzu Hospital, Pediatric Cardiology and Congenital Heart Disease Unit, Cagliari, 09134, Italy
| | - Luigi Raffo
- University of Cagliari, Department of Electrical and Electronic Engineering, Cagliari, 09123, Italy
| | - Reza Sameni
- Department of Biomedical Informatics, Emory University School of Medicine, Atlanta, GA, 30322, US
| | - Danilo Pani
- University of Cagliari, Department of Electrical and Electronic Engineering, Cagliari, 09123, Italy.
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16
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Hansahiranwadee W. Diagnosis and Management of Fetal Autoimmune Atrioventricular Block. Int J Womens Health 2020; 12:633-639. [PMID: 32884363 PMCID: PMC7434531 DOI: 10.2147/ijwh.s257407] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 07/17/2020] [Indexed: 11/23/2022] Open
Abstract
Autoimmune congenital atrioventricular block (CAVB) has been extensively studied in recent decades. The American Heart Association published guidelines for monitoring pregnant women with anti-Ro/Sjögren’s syndrome antigen A (SSA) or anti-La/Sjögren’s syndrome antigen B (SSB) autoantibodies, which are considered to increase the risk of CAVB. Information about the natural history of the disease in utero has contributed to the detection of fetuses with CAVB in the treatable stage. Hydroxychloroquine (HCQ) may be used to prevent CAVB. The lack of large randomized control trials is a major drawback to fully confirm the benefits of fluorinated steroids such as dexamethasone. Although, when combined with a β-sympathomimetic agent, the outcome of administering a fluorinated steroid in complete CAVB is still controversial. Novel treatments targeting the immunological process might prevent the recurrence of CAVB in pregnant women with previously affected children.
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Affiliation(s)
- Wirada Hansahiranwadee
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynaecology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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17
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Sulas E, Urru M, Tumbarello R, Raffo L, Pani D. Automatic detection of complete and measurable cardiac cycles in antenatal pulsed-wave Doppler signals. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2020; 190:105336. [PMID: 32007836 DOI: 10.1016/j.cmpb.2020.105336] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Revised: 12/21/2019] [Accepted: 01/09/2020] [Indexed: 06/10/2023]
Abstract
BACKGROUND AND OBJECTIVE Pulsed-wave Doppler (PWD) echocardiography is the primary tool for antenatal cardiological diagnosis. Based on it, different measurements and validated reference parameters can be extracted. The automatic detection of complete and measurable cardiac cycles would represent a useful tool for the quality assessment of the PWD trace and the automated analysis of long traces. METHODS This work proposes and compares three different algorithms for this purpose, based on the preliminary extraction of the PWD velocity spectrum envelopes: template matching, supervised classification over a reduced set of relevant waveshape features, and supervised classification over the whole waveshape potentially representing a cardiac cycle. A custom dataset comprising 43 fetal cardiac PWD traces (174,319 signal segments) acquired on an apical five-chamber window was developed and used for the assessment of the different algorithms. RESULTS The adoption of a supervised classifier trained with the samples representing the upper and lower envelopes of the PWD, with additional features extracted from the image, achieved significantly better results (p < 0.0001) than the other algorithms, with an average accuracy of 98% ± 1% when using an SVM classifier and a leave-one-subject-out cross-validation. Further, the robustness of the results with respect to the classifier model was proved. CONCLUSIONS The results reveal excellent detection performance, suggesting that the proposed approach can be adopted for the automatic analysis of long PWD traces or embedded in ultrasound machines as a first step for the extraction of measurements and reference clinical parameters.
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Affiliation(s)
- Eleonora Sulas
- Department of Electrical and Electronic Engineering, University of Cagliari, Italy.
| | - Monica Urru
- Division of Pediatric Cardiology, San Michele Hospital, Cagliari, Italy
| | | | - Luigi Raffo
- Department of Electrical and Electronic Engineering, University of Cagliari, Italy
| | - Danilo Pani
- Department of Electrical and Electronic Engineering, University of Cagliari, Italy
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18
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Cuneo BF, Bitant S, Strasburger JF, Kaizer AM, Wakai RT. Assessment of atrioventricular conduction by echocardiography and magnetocardiography in normal and anti-Ro/SSA-antibody-positive pregnancies. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2019; 54:625-633. [PMID: 30784137 PMCID: PMC6699937 DOI: 10.1002/uog.20245] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Revised: 02/04/2019] [Accepted: 02/11/2019] [Indexed: 06/09/2023]
Abstract
OBJECTIVES The objectives of this study were, first, to evaluate the association between fetal echocardiographic atrioventricular (AV) and magnetocardiographic (fMCG) PR intervals at different gestational ages (GAs) in normal and anti-Ro/SSA-antibody-positive pregnancies; second, to determine if PR interval could be predicted by AV interval; and third, to assess the neonatal outcome of fetuses with prolonged AV and PR intervals, with the goal of developing criteria for fetal first-degree AV block (AVB-I). METHODS This was a retrospective study of anti-Ro/SSA-antibody-positive pregnancies (cases) and controls that underwent fMCG and fetal echocardiography at the same recording session. Cardiac cycle length, GA and AV (by mitral inflow/aortic outflow Doppler) and PR (by fMCG) intervals were measured. We tested for significant differences between AV and PR intervals using generalized estimating equations to account for repeat measurements, and assessed whether PR interval could be predicted reliably by AV interval. After delivery, infants with fetal AV or PR interval Z-score ≥ 3 underwent 12-lead electrocardiography. RESULTS Thirty-nine controls and 31 cases underwent 46 and 36 simultaneous fMCG and echocardiographic examinations, respectively; 101 controls and nine cases underwent fMCG only. AV and PR intervals increased with GA (P < 0.05 for both). Overall, AV and PR intervals were significantly different from each other (P < 0.001); this difference was not significant when compared between cases and controls (P = 0.222). PR interval could not be predicted accurately from AV interval and GA alone. Three of four cases with AV and PR interval Z-scores > + 3 had postnatal AVB-I despite treatment. The fourth fetus, which had predominately second-degree AVB and rare periods of AVB-I, progressed to third-degree AVB despite treatment with dexamethasone. CONCLUSIONS The diagnostic threshold for AVB-I, defined by AV interval Z-score, is GA dependent. Based on the observed data, an AV interval Z-score threshold of 3 (AV interval, 151-167 ms) may be appropriate. Echocardiographic AV interval was not predictive of fMCG-PR interval. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- B F Cuneo
- Division of Cardiology, Department of Pediatrics, Children's Hospital Colorado and the University of Colorado School of Medicine, Aurora, CO, USA
- The Colorado Fetal Care Center, Children's Hospital Colorado and the University of Colorado School of Medicine, Aurora, CO, USA
| | - S Bitant
- Department of Medical Physics, The University of Wisconsin, Madison, WI, USA
| | - J F Strasburger
- Division of Cardiology, Department of Pediatrics, Children's Hospital of Wisconsin, Medical College of Wisconsin, Milwaukee, WI, USA
| | - A M Kaizer
- Department of Biostatistics and Informatics, University of Colorado, Aurora, CO, USA
| | - R T Wakai
- Department of Medical Physics, The University of Wisconsin, Madison, WI, USA
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19
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Doshi AN, Mass P, Cleary KR, Moak JP, Funamoto K, Kimura Y, Khandoker AH, Krishnan A. Feasibility of Non-invasive Fetal Electrocardiographic Interval Measurement in the Outpatient Clinical Setting. Pediatr Cardiol 2019; 40:1175-1182. [PMID: 31172229 DOI: 10.1007/s00246-019-02128-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2019] [Accepted: 05/30/2019] [Indexed: 12/29/2022]
Abstract
Non-invasive fetal electrocardiography (ECG) is a promising method for evaluating fetal cardiac electrical activity. Despite advances in fetal ECG technology, its ability to provide reliable, interpretable results in a typical outpatient fetal cardiology setting remains unclear. We sought to determine the feasibility of measuring standard ECG intervals in an outpatient fetal cardiology practice using an abdominal fetal ECG device that employs blind source separation with reference, an innovative signal-processing technique for fetal ECG extraction. Women scheduled for clinically indicated outpatient fetal echocardiogram underwent 10 min of fetal ECG acquisition from the maternal abdomen using specialized gel electrodes. A bedside laptop computer performed fetal ECG extraction, allowing real-time visualization of fetal and maternal ECG signals. Offline post-processing of 1 min of recorded data yielded fetal P-wave duration, PR interval, QRS duration, RR interval, QT interval, and QTc. Fifty-five fetuses were studied with gestational age 18-37 weeks, including 13 with abnormal fetal echocardiogram findings and three sets of twins. Interpretable results were obtained in 91% of fetuses, including 85% during the vernix period and 100% of twin fetuses. PR interval and RR interval of 18-24 week gestation fetuses were significantly shorter than those with gestational age 25-31 and 32-37 weeks. Of the six fetuses with abnormal rhythms on fetal echocardiogram, fetal ECG tracing was interpretable in five and matched the rhythm noted on fetal echocardiogram. Abdominal fetal ECG acquisition is feasible for arrhythmia detection and ECG interval calculation in a routine clinical setting.
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Affiliation(s)
- Ashish N Doshi
- Division of Cardiology, Children's National Health System, 111 Michigan Ave NW, Washington, DC, 20010, USA. .,Institute for Computational Medicine, Johns Hopkins University, 3400 N Charles St, Hackerman Hall Room 208, Baltimore, MD, 21218, USA.
| | - Paige Mass
- Sheikh Zayed Institute for Pediatric Surgical Innovation, Children's National Health System, 111 Michigan Ave NW, Washington, DC, 20010, USA
| | - Kevin R Cleary
- Sheikh Zayed Institute for Pediatric Surgical Innovation, Children's National Health System, 111 Michigan Ave NW, Washington, DC, 20010, USA
| | - Jeffrey P Moak
- Division of Cardiology, Children's National Health System, 111 Michigan Ave NW, Washington, DC, 20010, USA
| | - Kiyoe Funamoto
- Advanced Interdisciplinary Biomedical Engineering, Tohoku University School of Medicine, 2-1 Seiryo-machi, Aoba-ku, Sendai-shi, Miyagi, 980-8575, Japan
| | - Yoshitaka Kimura
- Advanced Interdisciplinary Biomedical Engineering, Tohoku University School of Medicine, 2-1 Seiryo-machi, Aoba-ku, Sendai-shi, Miyagi, 980-8575, Japan
| | - Ahsan H Khandoker
- Department of Biomedical Engineering, Khalifa University of Science and Technology, PO Box 127788, Abu Dhabi, United Arab Emirates
| | - Anita Krishnan
- Division of Cardiology, Children's National Health System, 111 Michigan Ave NW, Washington, DC, 20010, USA
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Gyenes DL, McBrien AH, Bohun CM, Serrano-Lomelin J, Alvarez SGV, Howley LW, Savard W, Jain V, Motan T, Atallah J, Hornberger LK. Evolution of the Fetal Atrioventricular Interval from 6 to 40 Weeks of Gestation. Am J Cardiol 2019; 123:1709-1714. [PMID: 30871745 DOI: 10.1016/j.amjcard.2019.02.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Revised: 02/06/2019] [Accepted: 02/13/2019] [Indexed: 11/17/2022]
Abstract
Doppler-based methods of estimating the atrioventricular interval are commonly used as a surrogate for the electrical PR in fetuses at risk of conduction abnormalities; however, to date, normal values for the fetal atrioventricular interval and an understanding of the evolution of its components in the late first trimester are lacking. We sought to investigate changes in the fetal atrioventricular interval from the first trimester to 40 weeks gestational age, and to explore functional and electrophysiological events that potentially impact its evolution. We prospectively examined healthy pregnancies by fetal echocardiography from 6 to 40 weeks' gestational age. The atrioventricular interval, heart rate, isovolumic contraction time, and A-wave duration were measured from simultaneous ventricular inflow-outflow Doppler tracings. Regression analysis was used to examine relations with gestational age, and linear relations with heart rate were assessed by Pearson's correlation coefficient. Data were collected in 305 fetuses from 279 pregnancies. Atrioventricular interval demonstrated an inverse relation with heart rate (r = -0.45, p <0.0001), dramatically decreasing before 10 weeks and slowly increasing thereafter. Between 6 and 9 weeks, isovolumic contraction time acutely decreased approaching 0, thereafter minimally increasing to term. In contrast, from 6 weeks, the A-wave duration linearly increased through gestation, and negatively correlated with heart rate (r = -0.62, p <0.0001). In conclusion, we have established normal measures of the atrioventricular interval from 6 to 40 weeks' gestational age. Before 10 weeks, a prolonged atrioventricular interval in healthy fetuses largely reflects the lengthened isovolumic contraction time which is likely influenced by the evolution of ventricular function and afterload.
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Affiliation(s)
- Dora L Gyenes
- Fetal and Neonatal Cardiology Program, Division of Cardiology, Department of Pediatrics, Stollery Children's Hospital, Edmonton, Alberta, Canada; Women's and Children's Health Research Institute and Cardiovascular Research Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Angela H McBrien
- Fetal and Neonatal Cardiology Program, Division of Cardiology, Department of Pediatrics, Stollery Children's Hospital, Edmonton, Alberta, Canada; Women's and Children's Health Research Institute and Cardiovascular Research Institute, University of Alberta, Edmonton, Alberta, Canada
| | - C Monique Bohun
- Department of Pediatrics/Cardiology, The University of New Mexico, Albuquerque, New Mexico
| | - Jesus Serrano-Lomelin
- Women's and Children's Health Research Institute and Cardiovascular Research Institute, University of Alberta, Edmonton, Alberta, Canada; School of Public Health, University of Alberta, Edmonton, Alberta, Canada
| | | | - Lisa W Howley
- The Heart Institute, Children's Hospital Colorado/University of Colorado, Aurora, Colorado
| | - Winnie Savard
- Fetal and Neonatal Cardiology Program, Division of Cardiology, Department of Pediatrics, Stollery Children's Hospital, Edmonton, Alberta, Canada; Women's and Children's Health Research Institute and Cardiovascular Research Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Venu Jain
- Women's and Children's Health Research Institute and Cardiovascular Research Institute, University of Alberta, Edmonton, Alberta, Canada; Department of Obstetrics and Gynecology, University of Alberta, Edmonton, Alberta, Canada
| | - Tarek Motan
- Department of Obstetrics and Gynecology, University of Alberta, Edmonton, Alberta, Canada
| | - Joseph Atallah
- Fetal and Neonatal Cardiology Program, Division of Cardiology, Department of Pediatrics, Stollery Children's Hospital, Edmonton, Alberta, Canada
| | - Lisa K Hornberger
- Fetal and Neonatal Cardiology Program, Division of Cardiology, Department of Pediatrics, Stollery Children's Hospital, Edmonton, Alberta, Canada; Women's and Children's Health Research Institute and Cardiovascular Research Institute, University of Alberta, Edmonton, Alberta, Canada; Department of Obstetrics and Gynecology, University of Alberta, Edmonton, Alberta, Canada.
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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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Alvarez SGV, Khoo NS, Colen T, McBrien A, Eckersley L, Brooks P, Savard W, Hornberger LK. The Incremental Benefit of Color Tissue Doppler in Fetal Arrhythmia Assessment. J Am Soc Echocardiogr 2018; 32:145-156. [PMID: 30340890 DOI: 10.1016/j.echo.2018.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Accurate fetal arrhythmia (FA) diagnosis is key for effective management. Currently, FA assessment relies on standard echocardiography-based techniques (M mode and spectral Doppler), which require adequate fetal position and cursor alignment to define temporal relationships of mechanical events. Few data exist on the application of color Doppler tissue imaging (c-DTI) in FA assessment. The aim of this study was to examine the feasibility and clinical applicability of c-DTI in FA assessment in comparison with standard techniques. METHODS Pregnancies with diagnosed FA were prospectively recruited to undergo c-DTI following fetal echocardiography. Multiple-cycle four-chamber clips in any orientation were recorded (mean frame rate, 180 ± 16 frames/sec). With offline analysis, sample volumes were placed on atrial (A) and ventricular (V) free walls for simultaneous recordings. Atrial and ventricular rates, intervals (for atrial-ventricular conduction and tachyarrhythmia mechanism), and relationships were assessed to decipher FA mechanism. FA diagnosis by c-DTI, conventional echocardiographic techniques, and postnatal electrocardiography and/or Holter monitoring were compared. RESULTS FA was assessed by c-DTI in 45 pregnancies at 15 to 39 weeks, including 16 with atrial and/or ventricular ectopic beats; 18 with supraventricular tachyarrhythmias, including ectopic atrial tachycardia in 11, atrioventricular reentrant tachycardia in four, atrial flutter in two, and intermittent atrial flutter and junctional ectopic rhythm in one; three with ventricular tachycardias; and eight with bradycardias or atrioventricular conduction pathology, including five with complete atrioventricular block (AVB), one with first-degree AVB evolving into complete AVB, one with second-degree AVB, and one with sinus bradycardia. After training, FA diagnosis by c-DTI could be made irrespective of fetal orientation within 10 to 15 min. FA diagnosis by c-DTI concurred with standard techniques in 41 cases (91%), with additional findings identified by c-DTI in 10. c-DTI led to new FA diagnoses in four cases (9%) not definable by standard techniques. FA diagnosis by c-DTI was confirmed in all 20 with persistent arrhythmias after birth, including three with new diagnoses defined by c-DTI. c-DTI was particularly helpful in deciphering SVT mechanism (long vs short ventricular-atrial interval) in all 18 cases, whereas standard techniques permitted definition in only half. CONCLUSIONS c-DTI with offline analysis permits rapid and accurate definition of FA mechanism, providing new information in nearly one-third of affected pregnancies.
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Affiliation(s)
- Silvia G V Alvarez
- Fetal and Neonatal Cardiology Program, Department of Pediatrics, Division of Cardiology, Women's & Children's Health Research Institute, University of Alberta, Stollery Children's Hospital, Edmonton, Alberta, Canada; Instituto Dante Pazzanese de Cardiologia, São Paulo, Brazil
| | - Nee S Khoo
- Fetal and Neonatal Cardiology Program, Department of Pediatrics, Division of Cardiology, Women's & Children's Health Research Institute, University of Alberta, Stollery Children's Hospital, Edmonton, Alberta, Canada
| | - Timothy Colen
- Fetal and Neonatal Cardiology Program, Department of Pediatrics, Division of Cardiology, Women's & Children's Health Research Institute, University of Alberta, Stollery Children's Hospital, Edmonton, Alberta, Canada
| | - Angela McBrien
- Fetal and Neonatal Cardiology Program, Department of Pediatrics, Division of Cardiology, Women's & Children's Health Research Institute, University of Alberta, Stollery Children's Hospital, Edmonton, Alberta, Canada
| | - Luke Eckersley
- Fetal and Neonatal Cardiology Program, Department of Pediatrics, Division of Cardiology, Women's & Children's Health Research Institute, University of Alberta, Stollery Children's Hospital, Edmonton, Alberta, Canada
| | - Paul Brooks
- Fetal and Neonatal Cardiology Program, Department of Pediatrics, Division of Cardiology, Women's & Children's Health Research Institute, University of Alberta, Stollery Children's Hospital, Edmonton, Alberta, Canada; Western Health, Melbourne, Australia
| | - Winnie Savard
- Fetal and Neonatal Cardiology Program, Department of Pediatrics, Division of Cardiology, Women's & Children's Health Research Institute, University of Alberta, Stollery Children's Hospital, Edmonton, Alberta, Canada
| | - Lisa K Hornberger
- Fetal and Neonatal Cardiology Program, Department of Pediatrics, Division of Cardiology, Women's & Children's Health Research Institute, University of Alberta, Stollery Children's Hospital, Edmonton, Alberta, Canada.
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Cuneo BF, Sonesson SE, Levasseur S, Moon-Grady AJ, Krishnan A, Donofrio MT, Raboisson MJ, Hornberger LK, Van Eerden P, Sinkovskaya E, Abuhamad A, Arya B, Szwast A, Gardiner H, Jacobs K, Freire G, Howley L, Lam A, Kaizer AM, Benson DW, Jaeggi E. Home Monitoring for Fetal Heart Rhythm During Anti-Ro Pregnancies. J Am Coll Cardiol 2018; 72:1940-1951. [DOI: 10.1016/j.jacc.2018.07.076] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Revised: 07/06/2018] [Accepted: 07/09/2018] [Indexed: 10/28/2022]
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The transverse four-chamber view for the assessment of atrial tissue deformation in the fetus. PLoS One 2018; 13:e0199581. [PMID: 29965971 PMCID: PMC6028085 DOI: 10.1371/journal.pone.0199581] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Accepted: 05/09/2018] [Indexed: 01/30/2023] Open
Abstract
AIMS To determine if atrial tissue deformation (peak strain, PS) and time to peak strain (TTPS) can be assessed in the fetus, with identification of best echocardiographic plane. MATERIALS AND METHODS Pulsed-wave tissue Doppler study of a longitudinal and a transverse four-chamber view (FCV) in each of 20 healthy fetuses. Determination of PS and TTPS in regions of interest (ROI), viz., lateral walls of the right and left atria (RA, LA); comparison of values depending on section plane, with results-based discussion of the physiology of fetal atrial deformation and of possible clinical uses. RESULTS PS and TTPS could be determined on transverse FCV in 91% of subjects and in 61% on longitudinal FCV. Transverse PS and TTPS were significantly higher than longitudinal (p = 0.0001). Transverse PS was significantly higher in RA than in LA (26.9% vs. 17.3%, p = 0.034), and transverse TTPS was significantly shorter in RA than in LA (p = 0.034). CONCLUSION Atrial radial PS and TTPS determinations are possible in the fetus. The transverse FCV is best suited for these. The highest PS values and shortest TTPS values are found in ROI representing the RA. Our findings may contribute to detailed intrauterine assessment of atrial and ventricular myocardial function.
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Abstract
This article reviews important features for improving the diagnosis of fetal arrhythmias by ultrasound in prenatal cardiac screening and echocardiography. Transient fetal arrhythmias are more common than persistent fetal arrhythmias. However, persistent severe bradycardia and sustained tachycardia may cause fetal hydrops, preterm delivery, and higher perinatal morbidity and mortality. Hence, the diagnosis of these arrhythmias during the routine obstetric ultrasound, before the progression to hydrops, is crucial and represents a challenge that involves a team of specialists and subspecialists on fetal ultrasonography. The images in this review highlight normal cardiac rhythms as well as pathologic cases consistent with premature atrial and ventricular contractions, heart block, supraventricular tachycardia (VT), atrial flutter, and VT. In this review, the details of a variety of arrhythmias in fetuses were provided by M-mode and Doppler ultrasound/echocardiography with high-quality imaging, enhancing diagnostic accuracy. Moreover, an update on the intrauterine management and treatment of many arrhythmias is provided, focusing on improving outcomes to enable planned delivery and perinatal management.
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Affiliation(s)
| | - Luciane Alves Rocha
- Department of Obstetrics, Paulista School of Medicine, Federal University of São Paulo (EPM-UNIFESP), São Paulo, Brazil
| | | | - Edward Araujo Júnior
- Department of Obstetrics, Paulista School of Medicine, Federal University of São Paulo (EPM-UNIFESP), São Paulo, Brazil
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Anuwutnavin S, Kolakarnprasert K, Chanprapaph P, Sklansky M, Mongkolchat N. Measurement of fetal atrioventricular time intervals: A comparison of 3 spectral Doppler techniques. Prenat Diagn 2018; 38:459-466. [PMID: 29633288 DOI: 10.1002/pd.5261] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2018] [Revised: 03/29/2018] [Accepted: 03/29/2018] [Indexed: 11/05/2022]
Abstract
OBJECTIVE To establish nomograms for fetal atrioventricular (AV) time intervals assessed by 3 different pulsed-wave Doppler techniques: left ventricular inflow and outflow tracts (LV in/out), superior vena cava and ascending aorta (SVC/AA), and pulmonary artery and pulmonary vein (PA/PV). METHODS A cross-sectional study was performed in 311 normal fetuses divided into 5 groups between 16 and 38 weeks. Pulsed-wave Doppler-derived AV intervals were measured by interrogation of flow in LV in/out, SVC/AA, and PA/PV. Linear regression analyses were performed to examine correlations with gestational age (GA) and fetal heart rate (FHR). Intraclass correlation coefficients for reproducibility of each method were compared. RESULTS Pulmonary artery and pulmonary vein revealed the longest mean AV time intervals (P < .001). The AV intervals in all methods were positively correlated with GA (R2 = 0.20-0.36; P < .001) and negatively correlated with FHR (R2 = 0.09-0.19; P < .001). The SCV/AA time intervals demonstrated the weakest influence of FHR. For LV in/out, SVC/AA, and PA/PV, intraobserver and interobserver reliability coefficients showed excellent agreements (all intraclass correlation coefficients ≥ 0.80). CONCLUSION All pulsed-wave Doppler-derived AV time intervals increased with advancing GA and decreased with increasing FHR. Fetal AV interval measurements can be obtained in a clinically viable fashion with excellent reproducibility.
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Affiliation(s)
- Sanitra Anuwutnavin
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | | | - Pharuhas Chanprapaph
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Mark Sklansky
- Division of Pediatric Cardiology, Department of Pediatrics, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Nadda Mongkolchat
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
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Toward noninvasive monitoring of ongoing electrical activity of human uterus and fetal heart and brain. Clin Neurophysiol 2017; 128:2470-2481. [PMID: 29100065 PMCID: PMC5697525 DOI: 10.1016/j.clinph.2017.08.026] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2017] [Revised: 08/01/2017] [Accepted: 08/12/2017] [Indexed: 11/23/2022]
Abstract
Evaluated a fetal-maternal scanner for monitoring electrical maternal and fetal organ activity. The simulated scanner can monitor the uterine and fetal heart and brain activity online. Biomagnetic monitors similar to this instrument should be useful in clinical neurophysiology.
Objective To evaluate whether a full-coverage fetal-maternal scanner can noninvasively monitor ongoing electrophysiological activity of maternal and fetal organs. Methods A simulation study was carried out for a scanner with an array of magnetic field sensors placed all around the torso from the chest to the hip within a horizontal magnetic shielding enclosure. The magnetic fields from internal organs and an external noise source were computed for a pregnant woman with a 35-week old fetus. Signal processing methods were used to reject the external and internal interferences, to visualize uterine activity, and to detect activity of fetal heart and brain. Results External interference was reduced by a factor of 1000, sufficient for detecting signals from internal organs when combined with passive and active shielding. The scanner rejects internal interferences better than partial-coverage arrays. It can be used to estimate currents around the uterus. It clearly detects spontaneous activity from the fetal heart and brain without averaging and weaker evoked brain activity at all fetal head positions after averaging. Conclusion The simulated device will be able to monitor the ongoing activity of the fetal and maternal organs. Significance This type of scanner may become a novel tool in fetal medicine.
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Bokiniec R, Własienko P, Borszewska-Kornacka M, Szymkiewicz-Dangel J. Evaluation of left ventricular function in preterm infants with bronchopulmonary dysplasia using various echocardiographic techniques. Echocardiography 2017; 34:567-576. [DOI: 10.1111/echo.13488] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- Renata Bokiniec
- Neonatal and Intensive Care Department; Medical University of Warsaw; Warsaw Poland
| | - Paweł Własienko
- Perinatal Cardiology Unit; Medical University of Warsaw; Warsaw Poland
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Kan N, Silverman ED, Kingdom J, Dutil N, Laskin C, Jaeggi E. Serial echocardiography for immune-mediated heart disease in the fetus: results of a risk-based prospective surveillance strategy. Prenat Diagn 2017; 37:375-382. [DOI: 10.1002/pd.5021] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2016] [Revised: 01/28/2017] [Accepted: 02/03/2017] [Indexed: 11/08/2022]
Affiliation(s)
- Nobuhiko Kan
- Fetal Cardiac Program, Labatt Family Heart Centre, Hospital for Sick Children; University of Toronto; Toronto Canada
| | - Earl D. Silverman
- Department of Immunology; Hospital for Sick Children, University of Toronto; Toronto Canada
| | - John Kingdom
- Department of Obstetrics and Gynecology; Mount Sinai Hospital, University of Toronto; Toronto Canada
| | - Nathalie Dutil
- Fetal Cardiac Program, Labatt Family Heart Centre, Hospital for Sick Children; University of Toronto; Toronto Canada
| | - Carl Laskin
- Department of Medicine; Mount Sinai Hospital, University of Toronto; Toronto Canada
| | - Edgar Jaeggi
- Fetal Cardiac Program, Labatt Family Heart Centre, Hospital for Sick Children; University of Toronto; Toronto Canada
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Bokiniec R, Własienko P, Borszewska-Kornacka M, Szymkiewicz-Dangel J. Echocardiographic evaluation of right ventricular function in preterm infants with bronchopulmonary dysplasia. Echocardiography 2017; 34:577-586. [PMID: 28229480 DOI: 10.1111/echo.13489] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
AIM To evaluate right ventricular function in preterm infants with and without bronchopulmonary dysplasia. METHODS Eighty-nine preterm infants (<32 weeks) were divided into three groups: (1) no-bronchopulmonary dysplasia (n=32); (2) mild-bronchopulmonary dysplasia (n=35); (3) severe-bronchopulmonary dysplasia (n=15). Right ventricular echocardiographic parameters included the following: (1) pulsed-wave Doppler through the tricuspid valve (E/A ratio), pulmonary artery acceleration time, right ventricular ejection time, right ventricular velocity-time integral; (2) tissue Doppler measurements of myocardial velocities and atrioventricular conduction times; (3) pulsed-wave Doppler and tissue Doppler evaluation of myocardial performance index and E/E' ratio; and (4) M-mode detection of right ventricular end-diastolic wall diameter. RESULTS The severe-bronchopulmonary dysplasia group had higher mean right ventricular myocardial performance index (on the 28th day of life by pulsed-wave Doppler) than the no-bronchopulmonary dysplasia (P=.014) or mild-bronchopulmonary dysplasia (P=.031) groups; no differences were found between no-bronchopulmonary dysplasia and mild-bronchopulmonary dysplasia groups (P=.919). A reduction in right ventricular myocardial performance index at later time points was observed in all three groups (P<.05). We found no differences between preterm infants with differing bronchopulmonary dysplasia severity in other right ventricular echocardiographic parameters. CONCLUSION Right ventricular myocardial performance index measured by pulsed-wave Doppler indicates impaired right ventricular function in preterm infants with severe bronchopulmonary dysplasia.
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Affiliation(s)
- Renata Bokiniec
- Neonatal and Intensive Care Department, Medical University of Warsaw, Warsaw, Poland
| | - Paweł Własienko
- Perinatal Cardiology Unit, Medical University of Warsaw, Warsaw, Poland
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Cardiac time intervals derived by magnetocardiography in fetuses exposed to pregnancy hypertension syndromes. J Perinatol 2016; 36:643-8. [PMID: 27031323 DOI: 10.1038/jp.2016.58] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2015] [Revised: 02/18/2016] [Accepted: 03/03/2016] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To test the hypothesis that fetuses exposed to maternal preeclampsia or chronic hypertension have deranged development of cardiac time intervals. STUDY DESIGN Pregnancies were divided into three groups: Intrauterine Growth Restricted (IUGR), Hypertensive, and Normal. Each group's mean fetal cardiac time intervals (P, PR, QRS and RR) derived by magnetocardiography were calculated using an analysis of covariance model's regression-adjusted estimates for a gestational age of 35 weeks. RESULTS We reviewed 141 recordings from 21 IUGR, 46 Hypertensive and 74 Normal patients. The IUGR, Hypertensive and Normal groups, respectively, had adjusted mean intervals in milliseconds of 66.4, 66.8 and 76.2 for P (P=0.001), 95.9, 101.6 and 109.6 for PR (P=0.002), 77.2, 78.7 and 78.7 for QRS (P=0.81) and 429.8, 429.2 and 428.5 for RR (P=0.97). CONCLUSION P and PR intervals are abbreviated in normotrophic fetuses exposed to maternal hypertension, suggesting shortened atrioventricular conduction times.
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Fetal colour tissue Doppler imaging (cTDI): biventricular reference ranges for the time segments of the cardiac cycle in second and third trimesters of gestation. Arch Gynecol Obstet 2016; 294:917-924. [PMID: 27016345 DOI: 10.1007/s00404-016-4076-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2015] [Accepted: 03/14/2016] [Indexed: 10/22/2022]
Abstract
PURPOSE To construct biventricular reference ranges for isovolumic time intervals (isovolumic contraction time, ICT; isovolumic relaxation time, IRT) and ejection time (ET) for colour tissue Doppler imaging (cTDI) between 15 and 37 weeks' in healthy fetuses. METHODS This was a prospective multicentre cross-sectional study involving 160 singleton pregnancies between 15 and 37 weeks of gestation, using cTDI. ICT, ET, IRT and myocardial performance index (MPI) were analysed offline using a small region of interest (ROI) within the basal part of the right and left ventricular wall immediately distal to the annulus. Regression analysis was used to determine gestational age-adjusted reference ranges and to construct nomograms for cTDI parameters. RESULTS Right and left ventricular ICT (p = 0.004 and p < 0.001) and ET (p = 0.011 and p = 0.050) increased, whereas IRT (p = 0.862 and p = 0.067) and MPI (p = 0.476 and p = 0.777) remained constant with gestational age. CONCLUSIONS This is the first study to evaluate fetal isovolumic time intervals in the second and third trimesters of gestation using cTDI. Normal data for fetal isovolumic time intervals and biventricular MPI by colour tissue Doppler imaging are provided. The reference ranges may be useful in research or clinical studies and can be used in fetuses with compromised cardiac function.
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Abstract
Cardiac arrhythmias are an important aspect of fetal and neonatal medicine. Premature complexes of atrial or ventricular origin are the main cause of an irregular heart rhythm. The finding is typically unrelated to an identifiable cause and no treatment is required. Tachyarrhythmia most commonly relates to supraventricular reentrant tachycardia, atrial flutter, and sinus tachycardia. Several antiarrhythmic agents are available for the perinatal treatment of tachyarrhythmias. Enduring bradycardia may result from sinus node dysfunction, complete heart block and nonconducted atrial bigeminy as the main arrhythmia mechanisms. The management and outcome of bradycardia depend on the underlying mechanism.
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MESH Headings
- Anti-Arrhythmia Agents/therapeutic use
- Arrhythmias, Cardiac/diagnosis
- Arrhythmias, Cardiac/drug therapy
- Atrial Flutter/diagnosis
- Atrial Flutter/drug therapy
- Atrial Premature Complexes/diagnosis
- Atrial Premature Complexes/drug therapy
- Bradycardia/diagnosis
- Bradycardia/drug therapy
- Electrocardiography
- Fetal Diseases/diagnosis
- Fetal Diseases/drug therapy
- Heart Block/diagnosis
- Heart Block/drug therapy
- Humans
- Infant, Newborn
- Infant, Newborn, Diseases/diagnosis
- Infant, Newborn, Diseases/drug therapy
- Sick Sinus Syndrome/diagnosis
- Sick Sinus Syndrome/drug therapy
- Tachycardia, Sinus/diagnosis
- Tachycardia, Sinus/drug therapy
- Tachycardia, Supraventricular/diagnosis
- Tachycardia, Supraventricular/drug therapy
- Ventricular Premature Complexes/diagnosis
- Ventricular Premature Complexes/drug therapy
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Affiliation(s)
- Edgar Jaeggi
- Labatt Family Heart Centre, Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, Ontario M5G 1X8, Canada.
| | - Annika Öhman
- Labatt Family Heart Centre, Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, Ontario M5G 1X8, Canada
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Marzbanrad F, Kimura Y, Funamoto K, Oshio S, Endo M, Sato N, Palaniswami M, Khandoker AH. Model-Based Estimation of Aortic and Mitral Valves Opening and Closing Timings in Developing Human Fetuses. IEEE J Biomed Health Inform 2016; 20:240-8. [DOI: 10.1109/jbhi.2014.2363452] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Sterling RA, Carlin A. Prevention of recurrent congenital heart block in a SSA/SSB positive mother using high dose maternal IVIG from 16-week gestation. Prenat Diagn 2015; 35:1148-50. [PMID: 26179183 DOI: 10.1002/pd.4651] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2015] [Revised: 04/25/2015] [Accepted: 07/06/2015] [Indexed: 11/10/2022]
Affiliation(s)
- Ruth-Ann Sterling
- Maternal and Fetal Medicine Department, John Hunter Hospital, Newcastle, Australia
| | - Andrew Carlin
- Maternal and Fetal Medicine Department, John Hunter Hospital, Newcastle, Australia
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Mahajan A, Henry A, Meriki N, Hernandez-Andrade E, Crispi F, Wu L, Welsh AW. The (Pulsed-Wave) Doppler Fetal Myocardial Performance Index: Technical Challenges, Clinical Applications and Future Research. Fetal Diagn Ther 2015; 38:1-13. [DOI: 10.1159/000363181] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2014] [Accepted: 04/24/2014] [Indexed: 11/19/2022]
Abstract
Functional cardiovascular assessment is becoming an increasingly important tool in the study of fetal pathology. The myocardial performance index (MPI) is a parameter measuring global myocardial function. Since its introduction, several studies have proposed methods to improve its reproducibility and have constructed normative reference ranges. Fetal heart evaluation using the MPI is technically challenging, requiring specific training and expertise, and a consensus has yet to be reached on the method of delineating the time periods used to calculate the index. Despite these limitations, it has been shown to be a useful and highly sensitive parameter of dysfunction in a number of fetal pathologies. Further research is warranted into the effect of pathology on MPI, parameters of unilateral cardiac strain that utilise MPI, and automation of the MPI to encourage incorporation of the MPI as a useful tool in clinical practice.
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Sedmera D, Kockova R, Vostarek F, Raddatz E. Arrhythmias in the developing heart. Acta Physiol (Oxf) 2015; 213:303-20. [PMID: 25363044 DOI: 10.1111/apha.12418] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2014] [Revised: 09/08/2014] [Accepted: 10/23/2014] [Indexed: 01/10/2023]
Abstract
Prevalence of cardiac arrhythmias increases gradually with age; however, specific rhythm disturbances can appear even prior to birth and markedly affect foetal development. Relatively little is known about these disorders, chiefly because of their relative rarity and difficulty in diagnosis. In this review, we cover the most common forms found in human pathology, specifically congenital heart block, pre-excitation, extrasystoles and long QT syndrome. In addition, we cover pertinent literature data from prenatal animal models, providing a glimpse into pathogenesis of arrhythmias and possible strategies for treatment.
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Affiliation(s)
- D. Sedmera
- Institute of Anatomy; First Faculty of Medicine; Charles University; Prague Czech Republic
- Institute of Physiology; Academy of Sciences of the Czech Republic; Prague Czech Republic
| | - R. Kockova
- Institute of Physiology; Academy of Sciences of the Czech Republic; Prague Czech Republic
- Department of Cardiology; Institute of Clinical and Experimental Medicine; Prague Czech Republic
| | - F. Vostarek
- Institute of Physiology; Academy of Sciences of the Czech Republic; Prague Czech Republic
| | - E. Raddatz
- Department of Physiology; Faculty of Biology and Medicine; University of Lausanne; Lausanne Switzerland
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Abstract
AIMS Detection and careful stratification of fetal heart rate (FHR) is extremely important in all pregnancies. The most lethal cardiac rhythm disturbances occur during apparently normal pregnancies where FHR and rhythm are regular and within normal or low-normal ranges. These hidden depolarization and repolarization abnormalities, associated with genetic ion channelopathies cannot be detected by echocardiography, and may be responsible for up to 10% of unexplained fetal demise, prompting a need for newer and better fetal diagnostic techniques. Other manifest fetal arrhythmias such as premature beats, tachycardia, and bradycardia are commonly recognized. METHODS Heart rhythm diagnosis in obstetrical practice is usually made by M-mode and pulsed Doppler fetal echocardiography, but not all fetal cardiac time intervals are captured by echocardiographic methods. RESULTS AND CONCLUSIONS This article reviews different types of fetal arrhythmias, their presentation and treatment strategies, and gives an overview of the present and future diagnostic techniques.
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Affiliation(s)
| | - Janette F. Strasburger
- Division of Cardiology, Department of Pediatrics, Children’s Hospital of Wisconsin-Milwaukee and Fox Valley, Milwaukee, Wisconsin
| | - Bettina F. Cuneo
- Department of Pediatrics, Children’s Hospital Colorado, The Heart Institute, The University of Colorado School of Medicine, Denver, Colorado
| | - Ronald T. Wakai
- Department of Medical Physics, University of Wisconsin, Madison, Wisconsin
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Hunter LE, Simpson JM. Atrioventricular block during fetal life. J Saudi Heart Assoc 2014; 27:164-78. [PMID: 26136631 PMCID: PMC4481419 DOI: 10.1016/j.jsha.2014.07.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2014] [Revised: 06/27/2014] [Accepted: 07/05/2014] [Indexed: 12/21/2022] Open
Abstract
Congenital complete atrioventricular (AV) block occurs in approximately 1 in 20,000 live births and is known to result in significant mortality and morbidity both during fetal life and postnatally. Complete AV block can occur as a result of an immune or a non-immune mediated process. Immune mediated AV block is a multifactorial disease, but is associated with the trans-placental passage of maternal autoantibodies (anti-Ro/SSA and/or anti-La/SSB). These autoantibodies attach to and subsequently damage the cardiomyocytes and conduction tissue in susceptible fetuses. In this report, we examine the evidence in reference to means of assessment, pathophysiology, and potential prenatal therapy of atrioventricular block.
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Affiliation(s)
- Lindsey E. Hunter
- Fetal Cardiology Unit, Department of Congenital Heart Disease, Evelina London Children’s Hospital, London, UK
| | - John M. Simpson
- Fetal Cardiology Unit, Department of Congenital Heart Disease, Evelina London Children’s Hospital, London, UK
- Corresponding author. Tel.: +44 20 7188 2308; fax: +44 20 7188 2307.
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Donofrio MT, Moon-Grady AJ, Hornberger LK, Copel JA, Sklansky MS, Abuhamad A, Cuneo BF, Huhta JC, Jonas RA, Krishnan A, Lacey S, Lee W, Michelfelder EC, Rempel GR, Silverman NH, Spray TL, Strasburger JF, Tworetzky W, Rychik J. Diagnosis and treatment of fetal cardiac disease: a scientific statement from the American Heart Association. Circulation 2014; 129:2183-242. [PMID: 24763516 DOI: 10.1161/01.cir.0000437597.44550.5d] [Citation(s) in RCA: 707] [Impact Index Per Article: 70.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND The goal of this statement is to review available literature and to put forth a scientific statement on the current practice of fetal cardiac medicine, including the diagnosis and management of fetal cardiovascular disease. METHODS AND RESULTS A writing group appointed by the American Heart Association reviewed the available literature pertaining to topics relevant to fetal cardiac medicine, including the diagnosis of congenital heart disease and arrhythmias, assessment of cardiac function and the cardiovascular system, and available treatment options. The American College of Cardiology/American Heart Association classification of recommendations and level of evidence for practice guidelines were applied to the current practice of fetal cardiac medicine. Recommendations relating to the specifics of fetal diagnosis, including the timing of referral for study, indications for referral, and experience suggested for performance and interpretation of studies, are presented. The components of a fetal echocardiogram are described in detail, including descriptions of the assessment of cardiac anatomy, cardiac function, and rhythm. Complementary modalities for fetal cardiac assessment are reviewed, including the use of advanced ultrasound techniques, fetal magnetic resonance imaging, and fetal magnetocardiography and electrocardiography for rhythm assessment. Models for parental counseling and a discussion of parental stress and depression assessments are reviewed. Available fetal therapies, including medical management for arrhythmias or heart failure and closed or open intervention for diseases affecting the cardiovascular system such as twin-twin transfusion syndrome, lung masses, and vascular tumors, are highlighted. Catheter-based intervention strategies to prevent the progression of disease in utero are also discussed. Recommendations for delivery planning strategies for fetuses with congenital heart disease including models based on classification of disease severity and delivery room treatment will be highlighted. Outcome assessment is reviewed to show the benefit of prenatal diagnosis and management as they affect outcome for babies with congenital heart disease. CONCLUSIONS Fetal cardiac medicine has evolved considerably over the past 2 decades, predominantly in response to advances in imaging technology and innovations in therapies. The diagnosis of cardiac disease in the fetus is mostly made with ultrasound; however, new technologies, including 3- and 4-dimensional echocardiography, magnetic resonance imaging, and fetal electrocardiography and magnetocardiography, are available. Medical and interventional treatments for select diseases and strategies for delivery room care enable stabilization of high-risk fetuses and contribute to improved outcomes. This statement highlights what is currently known and recommended on the basis of evidence and experience in the rapidly advancing and highly specialized field of fetal cardiac care.
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Abstract
BACKGROUND Fetal echocardiography plays a critical role in the diagnosis and management of structural, functional and rhythm-related fetal cardiovascular disease. OBJECTIVES/METHODS This article reviews the history of fetal echocardiography and the prenatal diagnosis of fetal cardiovascular disease as well as the evolution of the field of fetal cardiology. The clinical application of fetal echocardiography, including indications for referral, timing of referral and considerations in the diagnosis and serial assessment of fetal cardiovascular disease, is presented. CONCLUSIONS Newer directions in the field of fetal cardiology, including first trimester diagnoses and fetal intervention, will continue to expand its role in the evaluation and treatment of affected pregnancies in the future; however, equally as important are efforts to continue to improve prenatal detection rates.
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Affiliation(s)
- Lisa K Hornberger
- Professor of Pediatrics University of Alberta William C McKenzie Health Centre, Director of the Fetal & Neonatal Cardiology Program, Division of Cardiology, Department of Pediatrics & Obstetrics, 4C2.23, 8440 112th Street, Edmonton, Alberta T6G2B7, Canada +1 780 407 3952 ; +1 780 407 3954 ;
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Medrano-Lopez C, Fouron JC. Fetal cardiology, the frontier of pediatric cardiovascular medicine. Rev Esp Cardiol 2012; 65:700-4. [PMID: 22699048 DOI: 10.1016/j.recesp.2012.03.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2012] [Accepted: 03/08/2012] [Indexed: 10/28/2022]
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Bergman G, Eliasson H, Mohlkert LA, Wahren-Herlenius M, Sonesson SE. Progression to first-degree heart block in preschool children exposed in utero to maternal anti-SSA/Ro52 autoantibodies. Acta Paediatr 2012; 101:488-93. [PMID: 22175870 DOI: 10.1111/j.1651-2227.2011.02563.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
AIMS To study the children exposed in utero to maternal anti-SSA/Ro52 antibodies in terms of impaired atrioventricular (AV) conduction or disturbed myocardial performance, and to investigate the ability of prenatal Doppler to predict conduction abnormalities during childhood. METHODS Fifty-seven children exposed in utero to anti-SSA/Ro52 antibodies were grouped in accordance with (A) prolonged AV time intervals in utero by Doppler or (B) normal findings and examined by ECG, 24-hour ECG and echocardiography. RESULTS PR interval on ECG was longer in group A (n = 16) compared with that of group B (n = 41), 140 ± 24 ms vs. 121 ± 13 ms (p < 0.01). Six cases of 1°Atrioventricular block (AVB) developed in group A, giving an estimated prevalence of 10.5%, (95% confidence interval; 4.4-22.2%), progressing from normal sinus rhythm at 1 month of age. Prenatal Doppler predicted development of 1°AVB at follow-up with a sensitivity of 100%, Positive predictive value (PPV) 37.5%, LR+ 5.1, and Negative predictive value (NPV) 100%. Children in group A had a slightly higher myocardial performance index in flow and tissue Doppler imaging recordings. CONCLUSIONS Ten per cent of children exposed in utero to anti-SSA/Ro52, with a normal ECG at birth or 1 month of age, progressed to 1°AVB during preschool years. Cases at risk can be identified by prenatal Doppler echocardiography.
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Affiliation(s)
- Gunnar Bergman
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
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Phoon CKL, Kim MY, Buyon JP, Friedman DM. Finding the "PR-fect" solution: what is the best tool to measure fetal cardiac PR intervals for the detection and possible treatment of early conduction disease? CONGENIT HEART DIS 2012; 7:349-60. [PMID: 22494551 DOI: 10.1111/j.1747-0803.2012.00652.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
In the absence of structural heart disease, the great majority of cases with complete congenital heart block will be associated with the maternal autoantibodies directed to components of the SSA/Ro-SSB/La ribonucleoprotein complex. Usually presenting in fetal life before 26 weeks' gestation, once third-degree (complete) heart block develops, it is irreversible. Therefore, investigators over the past several years have attempted to predict which fetuses will be at risk for advanced conduction abnormalities by identifying a biomarker for less severe or incomplete disease, in this case, PR interval prolongation or first-degree atrioventricular block. In this state-of-the-art review, we critically analyze the various approaches to defining PR interval prolongation in the fetus, and then analyze several clinical trials that have attempted to address the question of whether complete heart block can be predicted and/or prevented. We find that, first and foremost, definitions of first-degree atrioventricular block vary but that the techniques themselves are all similarly valid and reliable. Nevertheless, the task of predicting those fetuses at risk, and who are therefore candidates for treatment, remains challenging. Of concern, despite anecdotal evidence, there is currently no conclusive proof that a prolonged PR interval predicts complete heart block.
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Affiliation(s)
- Colin K L Phoon
- Division of Pediatric Cardiology, Department of Pediatrics, New York University School of Medicine, New York, NY, USA.
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Crispi F, Sepulveda-Swatson E, Cruz-Lemini M, Rojas-Benavente J, Garcia-Posada R, Dominguez JM, Sitges M, Bijnens B, Gratacós E. Feasibility and Reproducibility of a Standard Protocol for 2D Speckle Tracking and Tissue Doppler-Based Strain and Strain Rate Analysis of the Fetal Heart. Fetal Diagn Ther 2012; 32:96-108. [DOI: 10.1159/000337329] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2011] [Accepted: 02/09/2012] [Indexed: 11/19/2022]
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47
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Comas M, Crispi F. Assessment of Fetal Cardiac Function Using Tissue Doppler Techniques. Fetal Diagn Ther 2012; 32:30-8. [DOI: 10.1159/000335028] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2011] [Accepted: 11/02/2011] [Indexed: 11/19/2022]
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Kato Y, Takahashi-Igari M, Inaba T, Sumazaki R, Horigome H. Comparison of PR Intervals Determined by Fetal Magnetocardiography and Pulsed Doppler Echocardiography. Fetal Diagn Ther 2012; 32:109-15. [DOI: 10.1159/000331399] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2011] [Accepted: 08/02/2011] [Indexed: 11/19/2022]
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Tutschek B, Schmidt KG. Pulsed-wave tissue Doppler echocardiography for the analysis of fetal cardiac arrhythmias. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2011; 38:406-412. [PMID: 21656866 DOI: 10.1002/uog.9070] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
OBJECTIVES Rhythm analysis of the fetal heart is hampered by the inability to routinely obtain electrocardiographic recordings of the fetus. Doppler studies of fetal cardiac tissue movements, assessing cardiac movements both qualitatively and quantitatively, have recently been described. We used a conventional high-resolution ultrasound system to obtain rhythm data from pulsed-wave tissue Doppler signals of the fetal heart in normal cardiac rhythm and in a variety of fetal cardiac arrhythmias. METHODS Fifty-five fetuses with normal (sinus) rhythm, 45 fetuses with rhythm disturbances and two neonates (one with arrhythmia and one with normal sinus rhythm) were studied. Using a conventional high-resolution ultrasound system equipped for fetal studies, but without specific tissue Doppler hardware or software, we performed pulsed-wave tissue Doppler echocardiography (PW-TDE) of atrioventricular valve ring excursions to study the atrial and ventricular mechanical actions. In the neonates, electrocardiograms were also recorded. RESULTS PW-TDE in normal fetuses shows a typical pattern of tissue motion parallel to the long axis of the heart and in the opposite direction to the blood flow, both in systole and diastole. This pattern is easily obtained from the tricuspid valve annulus in normal sinus rhythm and shows characteristic changes in various fetal arrhythmias. CONCLUSION PW-TDE of atrioventricular valve annulus movement patterns may prove to be a valuable additional tool for assessing fetal cardiac arrhythmias.
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Affiliation(s)
- B Tutschek
- Department of Obstetrics and Gynecology, Bern University Hospital, Bern, Switzerland; Medical Faculty, Heinrich Heine University, Düsseldorf, Germany.
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Jaeggi ET, Silverman ED, Laskin C, Kingdom J, Golding F, Weber R. Prolongation of the Atrioventricular Conduction in Fetuses Exposed to Maternal Anti-Ro/SSA and Anti-La/SSB Antibodies Did Not Predict Progressive Heart Block. J Am Coll Cardiol 2011; 57:1487-92. [DOI: 10.1016/j.jacc.2010.12.014] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2010] [Revised: 11/15/2010] [Accepted: 12/13/2010] [Indexed: 10/18/2022]
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