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Di Ludovico A, Rinaldi M, Mainieri F, Di Michele S, Girlando V, Ciarelli F, La Bella S, Chiarelli F, Attanasi M, Mauro A, Bizzi E, Brucato A, Breda L. Molecular Mechanisms of Fetal and Neonatal Lupus: A Narrative Review of an Autoimmune Disease Transferal across the Placenta. Int J Mol Sci 2024; 25:5224. [PMID: 38791261 PMCID: PMC11120786 DOI: 10.3390/ijms25105224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2024] [Revised: 05/01/2024] [Accepted: 05/08/2024] [Indexed: 05/26/2024] Open
Abstract
This study, conducted by searching keywords such as "maternal lupus", "neonatal lupus", and "congenital heart block" in databases including PubMed and Scopus, provides a detailed narrative review on fetal and neonatal lupus. Autoantibodies like anti-Ro/SSA and anti-La/SSB may cross the placenta and cause complications in neonates, such as congenital heart block (CHB). Management options involve hydroxychloroquine, which is able to counteract some of the adverse events, although the drug needs to be used carefully because of its impact on the QTc interval. Advanced pacing strategies for neonates with CHB, especially in severe forms like hydrops, are also assessed. This review emphasizes the need for interdisciplinary care by rheumatologists, obstetricians, and pediatricians in order to achieve the best maternal and neonatal health in lupus pregnancies. This multidisciplinary approach seeks to improve the outcomes and management of the disease, decreasing the burden on mothers and their infants.
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Affiliation(s)
- Armando Di Ludovico
- Paediatric Department, University of Chieti “G. D’Annunzio”, 66100 Chieti, Italy; (A.D.L.); (F.M.); (V.G.); (F.C.); (S.L.B.); (F.C.); (M.A.)
| | - Marta Rinaldi
- Paediatric Department, Buckinghamshire Healthcare NHS Trust, Aylesbury-Thames Valley Deanery, Aylesbury HP21 8AL, UK;
| | - Francesca Mainieri
- Paediatric Department, University of Chieti “G. D’Annunzio”, 66100 Chieti, Italy; (A.D.L.); (F.M.); (V.G.); (F.C.); (S.L.B.); (F.C.); (M.A.)
| | - Stefano Di Michele
- Department of Surgical Science, Division of Obstetrics and Gynecology, University of Cagliari, Cittadella Universitaria Blocco I, Asse didattico Medicina P2, Monserrato, 09042 Cagliari, Italy;
| | - Virginia Girlando
- Paediatric Department, University of Chieti “G. D’Annunzio”, 66100 Chieti, Italy; (A.D.L.); (F.M.); (V.G.); (F.C.); (S.L.B.); (F.C.); (M.A.)
| | - Francesca Ciarelli
- Paediatric Department, University of Chieti “G. D’Annunzio”, 66100 Chieti, Italy; (A.D.L.); (F.M.); (V.G.); (F.C.); (S.L.B.); (F.C.); (M.A.)
| | - Saverio La Bella
- Paediatric Department, University of Chieti “G. D’Annunzio”, 66100 Chieti, Italy; (A.D.L.); (F.M.); (V.G.); (F.C.); (S.L.B.); (F.C.); (M.A.)
| | - Francesco Chiarelli
- Paediatric Department, University of Chieti “G. D’Annunzio”, 66100 Chieti, Italy; (A.D.L.); (F.M.); (V.G.); (F.C.); (S.L.B.); (F.C.); (M.A.)
| | - Marina Attanasi
- Paediatric Department, University of Chieti “G. D’Annunzio”, 66100 Chieti, Italy; (A.D.L.); (F.M.); (V.G.); (F.C.); (S.L.B.); (F.C.); (M.A.)
| | - Angela Mauro
- Pediatric Rheumatology Unit, Department of Childhood and Developmental Medicine, Fatebenefratelli—Sacco Hospital, Piazzale Principessa Clotilde, 20121 Milan, Italy
| | - Emanuele Bizzi
- Division of Internal Medicine, ASST Fatebenefratelli Sacco, Fatebenefratelli Hospital, University of Milan, 20121 Milan, Italy; (E.B.); (A.B.)
| | - Antonio Brucato
- Division of Internal Medicine, ASST Fatebenefratelli Sacco, Fatebenefratelli Hospital, University of Milan, 20121 Milan, Italy; (E.B.); (A.B.)
- Department of Biomedical and Clinical Sciences “Sacco”, University of Milano, Ospedale Fatebenefratelli, 20121 Milan, Italy
| | - Luciana Breda
- Paediatric Department, University of Chieti “G. D’Annunzio”, 66100 Chieti, Italy; (A.D.L.); (F.M.); (V.G.); (F.C.); (S.L.B.); (F.C.); (M.A.)
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Dharmagadda A, Tambolkar S, Chavan S, Garlapati S. Late-Onset Dilated Cardiomyopathy in Auto Immune-Mediated Complete Congenital Heart Block: A Case Report. Cureus 2024; 16:e54222. [PMID: 38496172 PMCID: PMC10943330 DOI: 10.7759/cureus.54222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/14/2024] [Indexed: 03/19/2024] Open
Abstract
Complete congenital heart block (CHB), a rare and fatal bradyarrhythmia observed in children, carries significant mortality and morbidity. When congenital heart block occurs in isolation with a structurally normal heart, it prompts suspicion of an autoimmune etiology, wherein maternal antibodies are transmitted transplacentally, impacting the fetal conducting system. The manifestation of congenital complete atrioventricular block (CCAVB) can lead to complications such as dilated cardiomyopathies, arrhythmias, and fibroelastosis in certain cases. Notably, dilated cardiomyopathy is a significant prognostic factor in children diagnosed with congenital heart block. Pathological investigations have revealed the presence of antibodies, complements, and indicators of inflammation or fibrosis across the myocardium, emphasizing the shared molecular mechanisms between CCAVB and the development of dilated cardiomyopathy (DCM). This article presents the case of a one-year-old female child who presented with signs of dilated cardiomyopathy, later identified through retrospective evaluation as having autoimmune congenital heart block. The mother of the child was diagnosed with Sjogren's syndrome, characterized by positive anti-RO titers. Remarkably, the child remained asymptomatic for a year without the need for pacing intervention. The child's condition was successfully stabilized with appropriate treatment, and plans for pacemaker insertion will be considered once specific criteria are met. The onset of cardiomyopathy in a known case of CCAVB should serve as a crucial alert for prognostic considerations and the potential necessity for early-pacing intervention.
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Affiliation(s)
- Amulya Dharmagadda
- Pediatrics, Dr. D. Y. Patil Medical College, Hospital and Research Centre, Dr. D. Y. Patil Vidyapeeth (Deemed to be University), Pune, IND
| | - Sampada Tambolkar
- Pediatrics, Dr. D. Y. Patil Medical College, Hospital and Research Centre, Dr. D. Y. Patil Vidyapeeth (Deemed to be University), Pune, IND
| | - Sanjay Chavan
- Pediatrics, Dr. D. Y. Patil Medical College, Hospital and Research Centre, Dr. D. Y. Patil Vidyapeeth (Deemed to be University), Pune, IND
| | - Srinija Garlapati
- Pediatrics, Dr. D. Y. Patil Medical College, Hospital and Research Centre, Dr. D. Y. Patil Vidyapeeth (Deemed to be University), Pune, IND
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Cha JH, Hwang JK, Choi YJ, Na JY. The risk of pediatric cardiovascular diseases in offspring born to mothers with systemic lupus erythematosus: a nationwide study. Front Pediatr 2023; 11:1294823. [PMID: 38125818 PMCID: PMC10732165 DOI: 10.3389/fped.2023.1294823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 11/16/2023] [Indexed: 12/23/2023] Open
Abstract
Background Systemic lupus erythematosus (SLE), a common autoimmune disease predominantly affecting women, has been linked to various complications during pregnancy. The transfer of anti-Ro/SSA antibodies from SLE-affected mothers to their offspring can lead to neonatal lupus and cardiac issues. This study investigated the association between maternal SLE and the risk of pediatric cardiovascular disorders. Methods The study utilized South Korea's National Health Insurance Service (NHIS) database, covering 3,505,737 children born between 2007 and 2017 and tracked until 2020. Maternal SLE cases were identified using the World Health Organization's International Classification of Diseases Tenth revision (ICD-10) codes and linked with delivery records. Cardiologic disorders were categorized into congenital heart disease (CHD), arrhythmic disorders, and acquired heart disease. Propensity score matching with 1:4 ratios was applied to the set control group. Results Among 3,505,737 children, 0.7% (n = 23,330) were born to mothers with SLE. The incidence of preterm birth was significantly higher in the maternal SLE group (5.9% vs. 3.0%). Compared with the control group, children born to mothers with SLE exhibited a significantly elevated risk of overall CHDs (5.5%, adjusted odds ratio [aOR] 1.21; 95% confidence interval [CI] 1.14-1.29), including atrial septal defect (1.18; 1.09-1.28) and patent ductus arteriosus (1.15; 1.03-1.30). In addition, a notably higher risk was observed in arrhythmic disorders (complete atrioventricular block 7.20; 2.41-21.49) and acquired cardiac disorders, including cardiomyopathy (1.40; 1.17-1.68) and mucocutaneous lymph node syndrome (MCLS) (1.27; 1.15-1.43). Conclusions Maternal SLE is associated with congenital and acquired cardiac disorders in offspring, including structural, arrhythmic, and MCLS. This study highlights the need for continuous cardiovascular monitoring from the prenatal stage to preadolescence in these children due to multifactorial influences involving maternal autoantibodies, genetic predisposition, and environmental factors.
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Affiliation(s)
- Jong Ho Cha
- Department of Pediatrics, Hanyang University Hospital, Seoul, Republic of Korea
| | - Jae Kyoon Hwang
- Department of Pediatrics, Hanyang University Guri Hospital, Guri, Republic of Korea
| | - Young-Jin Choi
- Department of Pediatrics, Hanyang University Guri Hospital, Guri, Republic of Korea
- Department of Pediatrics, Hanyang University College of Medicine, Seoul, Republic of Korea
| | - Jae Yoon Na
- Department of Pediatrics, Hanyang University Hospital, Seoul, Republic of Korea
- Department of Pediatrics, Hanyang University College of Medicine, Seoul, Republic of Korea
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Makadia L, Izmirly P, Buyon JP, Phoon CKL. Autoimmune Congenital Complete Heart Block: How Late Can It Occur? AJP Rep 2023; 13:e29-e34. [PMID: 37168107 PMCID: PMC10166639 DOI: 10.1055/s-0043-1768708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 03/14/2023] [Indexed: 05/13/2023] Open
Abstract
Objective Maternal anti-Ro (SSA) and/or anti-La (SSB) antibodies are a risk factor for congenital complete heart block (CHB). Because detailed analysis of the incidence of CHB after 24 weeks of gestational age (GA) is lacking, we aimed to ascertain the risk of "later-onset" CHB among offspring of SSA/SSB-positive mothers in the published literature. Study Design Using search terms "neonatal lupus heart block" and "autoimmune congenital heart block" on PubMed and Ovid, we gathered prospective studies of SSA/SSB-positive mothers with fetal echo surveillance starting from before CHB diagnosis and retrospective cases of fetal CHB diagnosis after 24 weeks of GA (if there was prior normal heart rate) or after birth. Results Ten prospective studies included 1,248 SSA/SSB-positive pregnancies with 24 cases of CHB diagnosed during pregnancy (1.9%). Among these, three (12.5%) were after 24 weeks-at weeks 25, 26, and 28. Our retrospective studies revealed 50 patients with CHB diagnosis in late fetal life and neonatal period and 34 in the nonneonatal childhood period. An additional four cases were diagnosed after age 18 years. Conclusion Later-onset autoimmune CHB in offspring of SSA/SSB-positive mothers does occur. Our analysis suggests that prenatal surveillance should continue beyond 24 weeks of GA but is limited by inconsistent published surveillance data.
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Affiliation(s)
- Luv Makadia
- Division of Pediatric Cardiology, Department of Pediatrics, Hassenfeld Children's Hospital at NYU Langone and NYU Grossman School of Medicine, New York, New York
| | - Peter Izmirly
- Division of Rheumatology, Department of Medicine, NYU Langone Health and NYU Grossman School of Medicine, New York, New York
| | - Jill P. Buyon
- Division of Rheumatology, Department of Medicine, NYU Langone Health and NYU Grossman School of Medicine, New York, New York
| | - Colin K. L. Phoon
- Division of Pediatric Cardiology, Department of Pediatrics, Hassenfeld Children's Hospital at NYU Langone and NYU Grossman School of Medicine, New York, New York
- Address for correspondence Colin K. L. Phoon, MPhil, MD Division of Pediatric Cardiology, Department of Pediatrics, Hassenfeld Children's Hospital at NYU Langone and NYU Grossman School of Medicine150-160 East 32nd Street, New York, NY 10016
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Sheng X, Song X, Xiong Y, Ren T, Chang X, Wu J, Cao J, Cheng T, Wang M. Maternal and infant outcomes of pregnancy associated with anti-SSA/RO antibodies: a systematic review and meta-analysis. Pediatr Rheumatol Online J 2023; 21:22. [PMID: 36870970 PMCID: PMC9985242 DOI: 10.1186/s12969-023-00803-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Accepted: 02/26/2023] [Indexed: 03/06/2023] Open
Abstract
OBJECTIVE The relationship between anti-SSA/RO antibodies and pregnancy has been reported previously, and we aim to visualize the rates of maternal and infant outcomes with anti-SSA/RO. METHODS We systematically searched records from Pubmed, Cochrane, Embase, and Web of Science databases, pooled incidence rates of adverse outcomes of pregnancy, and 95% confidence intervals (CIs) were performed with RStudio. RESULTS A total of 890 records comprising 1675 patients and 1920 pregnancies were searched from the electronic databases. For maternal outcomes, the pooled estimate rates were 4% for termination of pregnancy, 5% for spontaneous abortion, 26% for preterm labor, and 50% for cesarean operation. While for fetal outcomes, the pooled estimate rates were 4% for perinatal death, 3% for intrauterine growth retardation, 6% for endocardial fibroelastosis, 6% for dilated cardiomyopathy, 7% for congenital heart block, 12% for congenital heart block recurrence, 19% for cutaneous neonatal lupus erythematosus, 12% for hepatobiliary disease and 16% for hematological manifestations. A subgroup analysis of congenital heart block prevalence was performed, diagnostic method and study region were found to affect heterogeneity to some extent. CONCLUSION Cumulative analysis of data from real-world studies confirmed adverse pregnancy outcomes of women with anti-SSA/RO, serves as a reference and a guide for the diagnosis and subsequent treatment of these women, thereby enhancing maternal and infant health. Additional studies with real-world cohorts are required to validate these results.
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Affiliation(s)
- Xiangrui Sheng
- Department of Rheumatology, The First Affiliated Hospital of Soochow University, No.188 Shizi St, Suzhou, 215006, Jiangsu, China
| | - Xiaohui Song
- Department of Rheumatology, The First Affiliated Hospital of Soochow University, No.188 Shizi St, Suzhou, 215006, Jiangsu, China
| | - Yue Xiong
- Department of Rheumatology, The First Affiliated Hospital of Soochow University, No.188 Shizi St, Suzhou, 215006, Jiangsu, China
| | - Tian Ren
- Department of Rheumatology, The First Affiliated Hospital of Soochow University, No.188 Shizi St, Suzhou, 215006, Jiangsu, China
| | - Xin Chang
- Department of Rheumatology, The First Affiliated Hospital of Soochow University, No.188 Shizi St, Suzhou, 215006, Jiangsu, China
| | - Jian Wu
- Department of Rheumatology, The First Affiliated Hospital of Soochow University, No.188 Shizi St, Suzhou, 215006, Jiangsu, China
| | - Jing Cao
- Department of Rheumatology, The First Affiliated Hospital of Soochow University, No.188 Shizi St, Suzhou, 215006, Jiangsu, China.
| | - Tao Cheng
- Department of Rheumatology, The First Affiliated Hospital of Soochow University, No.188 Shizi St, Suzhou, 215006, Jiangsu, China.
| | - Mingjun Wang
- Department of Rheumatology, The First Affiliated Hospital of Soochow University, No.188 Shizi St, Suzhou, 215006, Jiangsu, China.
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Non-invasive diagnosis of fetal arrhythmia based on multi-domain feature and hierarchical extreme learning machine. Biomed Signal Process Control 2023. [DOI: 10.1016/j.bspc.2022.104191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Russell MD, Dey M, Flint J, Davie P, Allen A, Crossley A, Frishman M, Gayed M, Hodson K, Khamashta M, Moore L, Panchal S, Piper M, Reid C, Saxby K, Schreiber K, Senvar N, Tosounidou S, van de Venne M, Warburton L, Williams D, Yee CS, Gordon C, Giles I, Roddy E, Armon K, Astell L, Cotton C, Davidson A, Fordham S, Jones C, Joyce C, Kuttikat A, McLaren Z, Merrison K, Mewar D, Mootoo A, Williams E. British Society for Rheumatology guideline on prescribing drugs in pregnancy and breastfeeding: immunomodulatory anti-rheumatic drugs and corticosteroids. Rheumatology (Oxford) 2022; 62:e48-e88. [PMID: 36318966 PMCID: PMC10070073 DOI: 10.1093/rheumatology/keac551] [Citation(s) in RCA: 35] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 09/15/2022] [Indexed: 11/07/2022] Open
Affiliation(s)
- Mark D Russell
- Centre for Rheumatic Diseases, King's College London, London, UK
| | - Mrinalini Dey
- Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
| | - Julia Flint
- Department of Rheumatology, Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust, Shropshire, UK
| | - Philippa Davie
- Centre for Rheumatic Diseases, King's College London, London, UK
| | - Alexander Allen
- Clinical Affairs, British Society for Rheumatology, London, UK
| | | | - Margreta Frishman
- Rheumatology, North Middlesex University Hospital NHS Trust, London, UK
| | - Mary Gayed
- Rheumatology, Sandwell and West Birmingham Hospitals, Birmingham, UK
| | | | - Munther Khamashta
- Lupus Research Unit, Division of Women's Health, King's College London, London, UK
| | - Louise Moore
- Rheumatic and Musculoskeletal Disease Unit, Our Lady's Hospice and Care Service, Dublin, Ireland
| | - Sonia Panchal
- Department of Rheumatology, South Warwickshire NHS Foundation Trust, Warwickshire, UK
| | - Madeleine Piper
- Royal National Hospital for Rheumatic Diseases, Royal United Hospital, Bath, UK
| | | | - Katherine Saxby
- Pharmacy, University College London Hospitals NHS Foundation Trust, London, UK
| | - Karen Schreiber
- Thrombosis and Haemostasis, Guy's and St Thomas' NHS Foundation Trust, London, UK.,Department of Rheumatology, Danish Hospital for Rheumatic Diseases, Sonderborg, Denmark.,Department of Regional Health Research (IRS), University of Southern Denmark, Odense, Denmark
| | - Naz Senvar
- Obstetrics and Gynaecology, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Sofia Tosounidou
- Lupus UK Centre of Excellence, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
| | | | | | - David Williams
- Obstetrics, University College London Hospitals NHS Foundation Trust, London, UK
| | - Chee-Seng Yee
- Department of Rheumatology, Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust, Doncaster, UK
| | - Caroline Gordon
- Rheumatology Research Group, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | - Ian Giles
- Centre for Rheumatology, Division of Medicine, University College London, London, UK
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Su LN, Wu MY, Cui YX, Lee CY, Song JX, Chen H. Unusual course of congenital complete heart block in an adult: A case report. World J Clin Cases 2022; 10:6602-6608. [PMID: 35979314 PMCID: PMC9294914 DOI: 10.12998/wjcc.v10.i19.6602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 01/20/2022] [Accepted: 05/14/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Congenital complete heart block (CCHB) with normal cardiac structure and negativity for anti-Ro/La antibody is rare. Additionally, CCHB is much less frequently diagnosed in adults, and its natural history in adults is less well known.
CASE SUMMARY A 23-year-old woman was admitted to our hospital for frequent syncopal episodes. She had bradycardia at the age of 1 year but had never had impaired exercise capacity or a syncopal episode before admission. The possible diagnosis of acquired complete atrioventricular block was carefully ruled out, and then the diagnosis of CCHB was made. According to existing guidelines, permanent pacemaker implantation was recommended, but the patient declined. With regular follow-up for 28 years, the patient had an unusually good outcome without any invasive intervention or medicine. She had an uneventful pregnancy and led a normally active life without any symptoms of low cardiac output or syncopal recurrence.
CONCLUSION This case implies that CCHB in adulthood may have good clinical outcomes and does not always require permanent pacemaker implantation.
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Affiliation(s)
- Li-Na Su
- Department of Cardiology, Peking University People’s Hospital, Beijing 100044, China
| | - Man-Yan Wu
- Department of Cardiology, Peking University People’s Hospital, Beijing 100044, China
| | - Yu-Xia Cui
- Department of Cardiology, Peking University People’s Hospital, Beijing 100044, China
| | - Chong-You Lee
- Department of Cardiology, Peking University People’s Hospital, Beijing 100044, China
| | - Jun-Xian Song
- Department of Cardiology, Peking University People’s Hospital, Beijing 100044, China
| | - Hong Chen
- Department of Cardiology, Peking University People’s Hospital, Beijing 100044, China
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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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Third Trimester Fetal Heart Rates in Antibody-Mediated Complete Heart Block Predict Need for Neonatal Pacemaker Placement. Pediatr Cardiol 2022; 43:324-331. [PMID: 34514536 DOI: 10.1007/s00246-021-02723-w] [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: 04/24/2021] [Accepted: 09/01/2021] [Indexed: 10/20/2022]
Abstract
Congenital complete heart block (CCHB) affects 1 in 20,000 newborns. This study evaluates fetal and neonatal risk factors predictive of neonatal pacemaker placement in antibody-mediated complete heart block. The Children's Hospital Los Angeles institutional fetal, pacemaker, and medical record databases were queried for confirmed SSA/SSB cases of CCHB between January 2004 and July 2019. Cases excluded were those with a diagnosis beyond the neonatal period, diagnosis of a channelopathy, or if maternal antibody status was unknown. We recorded the gestational age (GA), birth weight (BW), fetal heart rates (FHRs) of the last echocardiogram before delivery, specific neonatal ECG and echocardiogram findings, age at pacemaker placement, and mortality. Of 43 neonates identified with CCHB, 27 had confirmed maternal antibody exposure. Variables associated with neonatal pacemaker implantation were FHRs < 50 bpm (p = 0.005), neonatal heart rates < 52 bpm (p = 0.015), and neonatal left ventricular fractional shortening (FS) percentages < 34% (p = 0.03). On multivariate analysis, FHR remained significant (p = 0.03) and demonstrated an increased risk of neonatal pacemaker placement by an odds ratio of 12.5 (95% CI 1.3-116, p = 0.05). The median GA at which the FHR was obtained was 34 weeks (IQR 26-35 weeks). Neonatal pacemaker placement was highly associated with a FHR < 50 bpm, neonatal HR < 52 bpm, and neonatal FS < 34%. FHRs at 34 weeks GA (IQR 26-35 weeks) correlated well with postnatal heart rates and were predictive of neonatal pacemaker placement.
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Grotra R, Pansari V, Jain A, Gupta A. Neonatal lupus erythematosus with congenital complete heart block in an asymptomatic mother. INDIAN JOURNAL OF RHEUMATOLOGY 2022. [DOI: 10.4103/injr.injr_92_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
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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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13
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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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14
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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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15
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Milazzo R, Ligato E, Laoreti A, Ferri G, Basili L, Serati L, Brucato A, Cetin I. Home fetal heart rate monitoring in anti Ro/SSA positive pregnancies: Literature review and case report. Eur J Obstet Gynecol Reprod Biol 2021; 259:1-6. [PMID: 33556767 DOI: 10.1016/j.ejogrb.2021.01.031] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Accepted: 01/18/2021] [Indexed: 10/22/2022]
Abstract
Anti-Ro/SSA antibodies are associated with a risk of 1-2 % to develop complete atrioventricular block (AVB) in fetuses of positive mothers. Complete AVB is irreversible, but studies suggest that anti-inflammatory treatment during the transition period from a normal fetal heart rate (FHR) to an AVB might stop this progression and restore sinus rhythm. The most efficient method for diagnostic evaluation of this arrhythmia is the pulsed-Doppler fetal echocardiography. However, weekly or bi-weekly recommended fetal echocardiographic surveillance can rarely identify an AVB in time for treatment success, also because the transition from a normal rhythm to a third degree AVB is very fast. Daily FHR monitoring in a medical facility could increase the chances of identifying the AVB onset but is difficult to realize. For this reason, an alternative method of FHR monitoring, performed directly by mothers in their home context, has been recently proposed. We present a case report utilizing this approach and review the current evidence about this condition.
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Affiliation(s)
- Roberta Milazzo
- Department of Woman, Mother and Neonate, "V. Buzzi" Children Hospital, ASST Fatebenefratelli Sacco, Milan, Italy.
| | - Elisa Ligato
- Department of Woman, Mother and Neonate, "V. Buzzi" Children Hospital, ASST Fatebenefratelli Sacco, Milan, Italy
| | - Arianna Laoreti
- Department of Woman, Mother and Neonate, "V. Buzzi" Children Hospital, ASST Fatebenefratelli Sacco, Milan, Italy
| | - Giulia Ferri
- Department of Woman, Mother and Neonate, "V. Buzzi" Children Hospital, ASST Fatebenefratelli Sacco, Milan, Italy
| | - Ludovica Basili
- Department of Woman, Mother and Neonate, "V. Buzzi" Children Hospital, ASST Fatebenefratelli Sacco, Milan, Italy
| | - Lisa Serati
- Internal Medicine, Fatebenefratelli Hospital, Milan, Italy
| | | | - Irene Cetin
- Department of Woman, Mother and Neonate, "V. Buzzi" Children Hospital, ASST Fatebenefratelli Sacco, Milan, Italy; Department of Biomedical and Clinical Sciences "Luigi Sacco", University of Milan, Milan, Italy
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16
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Satış H, Bilici Salman R, Avanoğlu Güler A, Karadeniz H, Yıldız Ş, Kayahan N. Comorbidity and long-term outcome in patients with congenital heart block and their siblings exposed to Ro/SSA autoantibodies in utero. Ann Rheum Dis 2020; 79:e94. [PMID: 31088791 DOI: 10.1136/annrheumdis-2019-215542] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Revised: 05/04/2019] [Accepted: 05/06/2019] [Indexed: 11/04/2022]
Affiliation(s)
- Hasan Satış
- Rheumatology Deparment, Gazi University, Ankara, Turkey
| | | | | | | | - Şeyma Yıldız
- Internal Medicine Deparment, Gazi University, Ankara, Turkey
| | - Neslihan Kayahan
- Department of Internal Medicine, Gülhane Egitim ve Arastirma Hastanesi, Ankara, Turkey
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17
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Popescu MR, Dudu A, Jurcut C, Ciobanu AM, Zagrean AM, Panaitescu AM. A Broader Perspective on Anti-Ro Antibodies and Their Fetal Consequences-A Case Report and Literature Review. Diagnostics (Basel) 2020; 10:E478. [PMID: 32674462 PMCID: PMC7399931 DOI: 10.3390/diagnostics10070478] [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: 05/31/2020] [Revised: 07/11/2020] [Accepted: 07/12/2020] [Indexed: 12/20/2022] Open
Abstract
The presence of maternal Anti-Ro/Anti-La antibodies causes a passively acquired autoimmunity that may be associated with serious fetal complications. The classic example is the autoimmune-mediated congenital heart block (CHB) which is due in most cases to the transplacental passage of Anti-Ro/Anti-La antibodies. The exact mechanisms through which these pathologic events arise are linked to disturbances in calcium channels function, impairment of calcium homeostasis and ultimately apoptosis, inflammation and fibrosis. CHB still represents a challenging diagnosis and a source of debate regarding the best management. As the third-degree block is usually irreversible, the best strategy is risk awareness and prevention. Although CHB is a rare occurrence, it affects one in 20,000 live births, with a high overall mortality rate (up to 20%, with 70% of in utero deaths). There is also concern over the lifelong consequences, as most babies need a pacemaker. This review aims to offer, apart from the data needed for a better understanding of the issue at hand, a broader perspective of the specialists directly involved in managing this pathology: the rheumatologist, the maternal-fetal specialist and the cardiologist. To better illustrate the theoretical facts presented, we also include a representative clinical case.
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Affiliation(s)
- Mihaela Roxana Popescu
- Cardiology Department, Elias University Hospital, “Carol Davila” University of Medicine and Pharmacy, 011461 Bucharest, Romania
| | - Andreea Dudu
- Internal Medicine Department, “Dr Carol Davila” Central Emergency University Military Hospital, 010825 Bucharest, Romania; (A.D.); (C.J.)
| | - Ciprian Jurcut
- Internal Medicine Department, “Dr Carol Davila” Central Emergency University Military Hospital, 010825 Bucharest, Romania; (A.D.); (C.J.)
| | - Anca Marina Ciobanu
- Department of Obstetrics and Gynecology, Filantropia Clinical Hospital, “Carol Davila” University of Medicine and Pharmacy, 011171 Bucharest, Romania; (A.M.C.); (A.M.P.)
| | - Ana-Maria Zagrean
- Division of Physiology and Neuroscience, Department of Functional Sciences, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania;
| | - Anca Maria Panaitescu
- Department of Obstetrics and Gynecology, Filantropia Clinical Hospital, “Carol Davila” University of Medicine and Pharmacy, 011171 Bucharest, Romania; (A.M.C.); (A.M.P.)
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18
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Sonesson SE, Ambrosi A, Wahren-Herlenius M. Benefits of fetal echocardiographic surveillance in pregnancies at risk of congenital heart block: single-center study of 212 anti-Ro52-positive pregnancies. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2019; 54:87-95. [PMID: 30620419 DOI: 10.1002/uog.20214] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Revised: 11/15/2018] [Accepted: 11/16/2018] [Indexed: 06/09/2023]
Abstract
OBJECTIVES Assuming that autoimmune congenital heart block (CHB) is a progressive disease amenable to therapeutic modulation, we introduced a surveillance program for at-risk pregnancies with the dual aim of investigating if fetal atrioventricular block (AVB) could be detected and treated before becoming complete and irreversible, and to establish the incidence of AVB I, II and III in a large prospective cohort. METHODS This was a prospective study of 212 anti-Ro52 antibody-exposed pregnancies at risk of fetal AVB that were followed weekly between 18 and 24 weeks' gestation at our tertiary fetal cardiology center from 2000 to 2015. A 12-lead electrocardiogram (ECG) was recorded within 1 week after birth. Fetal Doppler atrioventricular (AV) intervals were converted to Z-scores using reference standard values derived from normal pregnancies. Each fetus was represented by the average value of the two recordings, obtained at two consecutive visits, which resulted in the longest AV interval. AV interval values were classified into normal AV conduction (Z-score ≤ 2.0) and three levels of delayed AV conduction: Z-score > 2.0 and ≤ 3.0, Z-score > 3.0 and ≤ 4.0, and Z-score > 4.0. RESULTS AVB II or III developed in 6/204 (2.9%) pregnancies without a CHB history and 1/8 (12.5%) of those with a CHB history. AV intervals > 2 and ≤ 3, > 3 and ≤ 4, and > 4 were detected in 16.0%, 7.5% and 2.8% of cases, respectively, and were related to the PR interval on 185 available ECGs. Three of the five cases with AVB III and one of two cases with 2:1 AVB II developed within 1 week of AV interval Z-score of 1.0, 1.9, 2.8 and 1.9, respectively. Transplacental treatment with betamethasone was associated with restoration of 1:1 AV conduction in the two fetuses with AVB II, with a better long-term result (normal ECG vs AVB I or II) observed in the case in which treatment was started within 1 week after AVB developed. Betamethasone treatment did not reverse AVB III, although a temporary effect on AV conduction was observed in 1/5 cases. Notably, the three cases in which treatment was started within 1 week after AVB III development responded with a higher ventricular rate than the other two cases and did not require pacemaker implantation until a later age (2-5 years vs 1.5-2 months). CONCLUSION Fetal AV interval is a poor predictor of CHB progression, but CHB surveillance still allows detection of fetuses with AVB II or III shortly after its development, allowing for timely treatment initiation and potentially better outcome. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- S-E Sonesson
- Department of Women's and Children's Health, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - A Ambrosi
- Department of Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - M Wahren-Herlenius
- Department of Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
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19
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Pedra SRFF, Zielinsky P, Binotto CN, Martins CN, Fonseca ESVBD, Guimarães ICB, Corrêa IVDS, Pedrosa KLM, Lopes LM, Nicoloso LHS, Barberato MFA, Zamith MM. Brazilian Fetal Cardiology Guidelines - 2019. Arq Bras Cardiol 2019; 112:600-648. [PMID: 31188968 PMCID: PMC6555576 DOI: 10.5935/abc.20190075] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Affiliation(s)
- Simone R F Fontes Pedra
- Instituto Dante Pazzanese de Cardiologia, São Paulo, SP - Brazil.,Hospital do Coração (HCor), São Paulo, SP - Brazil
| | - Paulo Zielinsky
- Instituto de Cardiologia do Rio Grande do Sul, Porto Alegre, RS - Brazil
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20
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Lethal immunoglobulins: Autoantibodies and sudden cardiac death. Autoimmun Rev 2019; 18:415-425. [DOI: 10.1016/j.autrev.2018.12.005] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Accepted: 12/13/2018] [Indexed: 02/08/2023]
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21
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Pruetz JD, Miller JC, Loeb GE, Silka MJ, Bar-Cohen Y, Chmait RH. Prenatal diagnosis and management of congenital complete heart block. Birth Defects Res 2019; 111:380-388. [PMID: 30821931 DOI: 10.1002/bdr2.1459] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Accepted: 01/04/2019] [Indexed: 01/03/2023]
Abstract
Congenital complete heart block (CCHB) is a life-threatening medical condition in the unborn fetus with insufficiently validated prenatal interventions. Maternal administration of medications aimed at decreasing the immune response in the fetus and beta-agonists intended to increase fetal cardiac output have shown only marginal benefits. Anti-inflammatory therapies cannot reverse CCHB, but may decrease myocarditis and improve heart function. Advances in prenatal diagnosis and use of strict surveillance protocols for delivery timing have demonstrated small improvements in morbidity and mortality. Ambulatory surveillance programs and wearable fetal heart rate monitors may afford early identification of evolving fetal heart block allowing for emergent treatment. There is also preliminary data suggesting a roll for prevention of CCHB with hydroxychloroquine, but the efficacy and safety is still being studied. To date, intrauterine fetal pacing has not been successful due to the high-risk invasive placement techniques and potential problems with lead dislodgement. The development of a fully implantable micropacemaker via a minimally invasive approach has the potential to pace fetal patients with CCHB and thus delay delivery and allow fetal hydrops to resolve. The challenge remains to establish accepted prenatal interventions capable of successfully managing CCHB in utero until postnatal pacemaker placement is successfully achieved.
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Affiliation(s)
- Jay D Pruetz
- Department of Pediatrics/Division of Pediatric Cardiology, Children's Hospital Los Angeles, Los Angeles, California.,Keck School of Medicine of USC, Los Angeles, California
| | - Jennifer C Miller
- Department of Pediatrics/Division of Pediatric Cardiology, Children's Hospital Los Angeles, Los Angeles, California.,Keck School of Medicine of USC, Los Angeles, California
| | - Gerald E Loeb
- Department of Biomedical Engineering, University of Southern California (USC), Los Angeles, California
| | - Michael J Silka
- Department of Pediatrics/Division of Pediatric Cardiology, Children's Hospital Los Angeles, Los Angeles, California.,Keck School of Medicine of USC, Los Angeles, California
| | - Yaniv Bar-Cohen
- Department of Pediatrics/Division of Pediatric Cardiology, Children's Hospital Los Angeles, Los Angeles, California.,Keck School of Medicine of USC, Los Angeles, California
| | - Ramen H Chmait
- Department of Obstetrics and Gynecology/Division of Maternal Fetal Medicine, Keck School of Medicine of USC, Los Angeles, California
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22
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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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23
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Clowse MEB, Eudy AM, Kiernan E, Williams MR, Bermas B, Chakravarty E, Sammaritano LR, Chambers CD, Buyon J. The prevention, screening and treatment of congenital heart block from neonatal lupus: a survey of provider practices. Rheumatology (Oxford) 2018; 57:v9-v17. [PMID: 30137589 PMCID: PMC6099126 DOI: 10.1093/rheumatology/key141] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Revised: 04/20/2018] [Indexed: 11/12/2022] Open
Abstract
Objective To survey an international sample of providers to determine their current practices for the prevention, screening, and treatment of congenital heart block (CHB) due to maternal Ro/SSA antibodies. Methods A survey was designed by the organizing committee of the 9th International Conference of Reproduction, Pregnancy and Rheumatic Diseases. It was sent to attendants of the conference and authors of recent publications or abstracts at ACR 2012, 2013 or 2014 on rheumatic diseases and pregnancy. Results In anti-Ro/SSA positive women, 80% of 49 respondents recommended screening by serial fetal echocardiogram (ECHO), with most starting at week 16 (59%) and stopping at week 28 (25%), although the time to stop varied widely. For women without a prior infant with neonatal lupus, respondents recommend every other week (44%) or weekly (28%) fetal ECHOs. For women with a prior infant with neonatal lupus, 80% recommend weekly fetal ECHOs. To prevent CHB, HCQ was recommended by 67% of respondents and most would start pre-pregnancy (62%). Respondents were asked about medications to treat varying degrees of CHB in a 20-week pregnant, anti-Ro and La positive SLE patient. For first degree, respondents recommended starting dexamethasone (53%) or HCQ (43%). For second degree, respondents recommended starting dexamethasone (88%). For third degree, respondents recommended starting dexamethasone (55%) or IVIg (33%), although 27% would not start treatment. Conclusion Despite the absence of official guidelines, many physicians with a focus on pregnancy and rheumatic disease have developed similar patterns in the screening, prevention and treatment of CHB.
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Affiliation(s)
- Megan E B Clowse
- Division of Rheumatology and Immunology, Duke University Medical Center, Durham, NC
| | - Amanda M Eudy
- Division of Rheumatology and Immunology, Duke University Medical Center, Durham, NC
| | - Elizabeth Kiernan
- Department of Pediatrics, Division of Dysmorphology and Teratology, University of California San Diego, San Diego, CA
| | - Matthew R Williams
- Pediatric Cardiology and Cardiovascular Surgery, Rady Children's Hospital, University of California San Diego, San Diego, CA
| | - Bonnie Bermas
- Division of Rheumatic Diseases, UT Southwestern, Dallas, TX
| | - Eliza Chakravarty
- Department of Arthritis and Clinical Immunology, Oklahoma Medical Research Foundation, Oklahoma City, OK
| | - Lisa R Sammaritano
- Division of Rheumatology, Hospital for Special Surgery, Weill Cornell Medicine, New York, NY
| | | | - Jill Buyon
- Division of Rheumatology, New York University School of Medicine, NY, USA
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Kállay K, Zakariás D, Csordás K, Benyó G, Kassa C, Sinkó J, Stréhn A, Horváth O, Vásárhelyi B, Kriván G. Antithymocyte Globuline Therapy and Bradycardia in Children. Pathol Oncol Res 2018. [PMID: 29524166 DOI: 10.1007/s12253-018-0403-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
In antithymocyte globulin (ATG) treated patients occasionally bradycardia has been noticed. Therefore, we retrospectively analyzed the occurrence of bradycardia in ATG-treated children. Using medical records between 2007 and 2012 we identified children undergoing a combined therapy with ATG and glucocorticoids (ATG group, n = 22). The incidence of bradycardia was compared to that registered in children treated with glucocorticoids alone (glucocorticoid alone group, n = 21). Heart rates (HR) were registered before and on days 0-3, 4-7 and 8-14 after the ATG or steroid administration. The rate of bradycardic episodes was higher during ATG therapy than in the steroid alone group, while severe bradycardia occurred only in the ATG group (97 versus 32, p = 0.0037, and 13 versus 0, p = 0.0029, respectively). There was an interaction between the time and treatment group on HR (p = 0.046). Heart rates in ATG and steroid alone groups differed significantly on day 0-3 and day 4-7 (p = 0.046, p = 0.006, respectively). Within the ATG group HR was lower on days 4-7 compared to the days before and the days 8-14 values (p < 0.001, 95%CI: 0.020-0.074). These findings indicate that transient asymptomatic bradycardia is probably more common with ATG therapy than previously reported. HR should be closely monitored during and after ATG therapy.
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Affiliation(s)
- Krisztián Kállay
- Pediatric Hematology and Stem Cell Transplantation Unit, United St. István and St. László Hospital, Albert Flórián street 5-7, Budapest, H-1097, Hungary.
| | - Dávid Zakariás
- Pediatric Hematology and Stem Cell Transplantation Unit, United St. István and St. László Hospital, Albert Flórián street 5-7, Budapest, H-1097, Hungary
| | - Katalin Csordás
- Pediatric Hematology and Stem Cell Transplantation Unit, United St. István and St. László Hospital, Albert Flórián street 5-7, Budapest, H-1097, Hungary
| | - Gábor Benyó
- Pediatric Hematology and Stem Cell Transplantation Unit, United St. István and St. László Hospital, Albert Flórián street 5-7, Budapest, H-1097, Hungary
| | - Csaba Kassa
- Pediatric Hematology and Stem Cell Transplantation Unit, United St. István and St. László Hospital, Albert Flórián street 5-7, Budapest, H-1097, Hungary
| | - János Sinkó
- Pediatric Hematology and Stem Cell Transplantation Unit, United St. István and St. László Hospital, Albert Flórián street 5-7, Budapest, H-1097, Hungary
| | - Anita Stréhn
- Pediatric Hematology and Stem Cell Transplantation Unit, United St. István and St. László Hospital, Albert Flórián street 5-7, Budapest, H-1097, Hungary
| | - Orsolya Horváth
- Pediatric Hematology and Stem Cell Transplantation Unit, United St. István and St. László Hospital, Albert Flórián street 5-7, Budapest, H-1097, Hungary
| | - Barna Vásárhelyi
- Department of Laboratory Medicine, Semmelweis University, Budapest, Hungary
| | - Gergely Kriván
- Pediatric Hematology and Stem Cell Transplantation Unit, United St. István and St. László Hospital, Albert Flórián street 5-7, Budapest, H-1097, Hungary
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Esparza Martín N, Esparza Martín M, García Cantón C. Kidney disease in pregnant patients. Med Clin (Barc) 2017; 149:406-411. [PMID: 28754337 DOI: 10.1016/j.medcli.2017.06.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Revised: 06/13/2017] [Accepted: 06/15/2017] [Indexed: 11/25/2022]
Affiliation(s)
- Noemí Esparza Martín
- Servicio de Nefrología, Complejo Hospitalario Universitario Materno Infantil de Gran Canaria, Las Palmas, España.
| | - Miriam Esparza Martín
- Servicio de Obstetricia y Ginecología, Complejo Hospitalario Universitario Materno Infantil de Gran Canaria, Las Palmas, España
| | - César García Cantón
- Servicio de Nefrología, Complejo Hospitalario Universitario Materno Infantil de Gran Canaria, Las Palmas, España
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Rezazadeh S, Duff HJ. Genetic Determinants of Hereditary Bradyarrhythmias: A Contemporary Review of a Diverse Group of Disorders. Can J Cardiol 2017; 33:758-767. [PMID: 28545623 DOI: 10.1016/j.cjca.2017.03.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2017] [Revised: 03/03/2017] [Accepted: 03/10/2017] [Indexed: 11/25/2022] Open
Abstract
Bradyarrhythmia is a common clinical presentation. Although the majority of cases are acquired, genetic screening of families with bradyarrhythmia has led to the discovery of a growing number of causative hereditary mutations. These mutations can interfere with any of the steps required for the occurrence of each cardiac cycle, including generation of an action potential in the sinoatrial node, successful exit of the action potential from the node, propagation of the action potential throughout the atria until the depolarization waves reach the atrioventricular node, and finally transmission of the action potential to the ventricles through the His-Purkinje system. As expected, channelopathies are the predominant culprit for hereditary bradyarrhythmias, because they play a crucial role in action potential generation and propagation. Interestingly, there are an increasing number of genes that encode for various regulatory or structural cellular components that have been linked to hereditary bradyarrhythmias. Furthermore, population-based genetic screening has revealed that age-related conduction defects may in fact be caused by genetic predispositions rather than the simple process of aging. With recent advances in genetic testing and the creation of animal models, not only have we discovered new culprit genes but it has also has become evident that there are still significant gaps in our knowledge of cardiac pathophysiology. In this review, we discuss the clinical presentations of known hereditary bradyarrhythmias and their associated conditions in addition to detailing our current molecular understanding of the mechanisms by which they are manifested.
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Affiliation(s)
- Saman Rezazadeh
- Department of Cardiac Sciences and Libin Cardiovascular Institute of Alberta, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Henry J Duff
- Department of Cardiac Sciences and Libin Cardiovascular Institute of Alberta, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.
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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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28
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Brito-Zerón P, Izmirly PM, Ramos-Casals M, Buyon JP, Khamashta MA. Autoimmune congenital heart block: complex and unusual situations. Lupus 2016; 25:116-28. [PMID: 26762645 DOI: 10.1177/0961203315624024] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Autoimmune congenital heart block (ACHB) is an immune-mediated cardiac disease included among the manifestations collectively referred to as neonatal lupus. The placental transference of maternal Ro/La autoantibodies may damage the conduction tissues during fetal development leading to blocking of signal conduction at the atrioventricular (AV) node in an otherwise structurally normal heart. Irreversible complete AV block is the main cardiac manifestation of ACHB, but some babies may develop endocardial fibroelastosis, valvular insufficiency, and/or frank cardiomyopathies with significantly reduced cardiac function requiring transplant. The severity of ACHB is illustrated by a global mortality rate of 20% and pacemaker rates of at least 64%, often within the first year of life. This review analyses the main complex and/or unusual clinical situations associated with ACHB, including unusual maternal immunological profiles, infrequent maternal autoimmune diseases, cardiac damage unrelated to AV block, fetal invasive management, late complications after birth, risk of congenital heart block (CHB) in ovodonation and in vitro fertilization techniques, the role of maternal features other than autoimmunity, the influence of the birth order or the risk of CHB in twins and triplets.
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Affiliation(s)
- P Brito-Zerón
- Josep Font Laboratory of Autoimmune Diseases, Department of Autoimmune Diseases, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
| | - P M Izmirly
- Division of Rheumatology, Department of Medicine, New York University School of Medicine, New York, USA
| | - M Ramos-Casals
- Josep Font Laboratory of Autoimmune Diseases, Department of Autoimmune Diseases, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
| | - J P Buyon
- Division of Rheumatology, Department of Medicine, New York University School of Medicine, New York, USA
| | - M A Khamashta
- Graham Hughes Lupus Research Laboratory, The Rayne Institute, Division of Women's Health, Kings College London St Thomas Hospital, United Kingdom
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Pallangyo P, Mawenya I, Nicholaus P, Mayala H, Kalombola A, Sharau G, Majani N, Janabi M. Isolated congenital complete heart block in a five-year-old seronegative girl born to a woman seropositive for human immunodeficiency virus: a case report. J Med Case Rep 2016; 10:288. [PMID: 27756424 PMCID: PMC5070073 DOI: 10.1186/s13256-016-1082-5] [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: 08/15/2016] [Accepted: 09/29/2016] [Indexed: 11/24/2022] Open
Abstract
Background Congenital complete heart block is a life-threatening condition which is highly associated with autoimmune and connective tissue disorders. Presence of maternal autoantibodies for associated conditions increases the risk of delivering a child with congenital complete heart block, however, less than a half of all women with such antibodies are symptomatic even after delivery. Mortality rate is highest during the neonatal period (45 %) and about two-thirds of all cases will require permanent pacing at some point in their lives. Case presentation We report a case of isolated complete heart block in a 5-year-old HIV-free girl of African descent born to an HIV-infected woman with no prior history of autoimmune disorders. She was referred to us with chief complaints of recurrent syncopal attacks and effort intolerance since birth. A physical examination was unremarkable except for her being small for her age (body mass index 16.3 kg/m2) and bradycardia. Her vital signs were within acceptable range with the exception of her pulse rate, which ranged between 22 and 34 beats/minute. An echocardiogram revealed a sinus bradycardia, otherwise a structurally normal heart. An electrocardiogram showed atrioventricular dissociation in keeping with third-degree atrioventricular block. The child underwent a permanent epicardial pacemaker insertion and has been symptom-free following pacing. Conclusions Despite its infrequency and life-threatening potential, patients with congenital complete heart block have an excellent survival rate with timely diagnosis and intervention. An incidental detection of bradycardia in a fetus during routine obstetrical ultrasound examination should increase the index of suspicion for congenital complete heart block and warrant a screening for associated maternal autoantibodies.
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Affiliation(s)
- Pedro Pallangyo
- Department of Cardiovascular Medicine, The Jakaya Kikwete Cardiac Institute, P.O Box 65141, Dar es Salaam, Tanzania.
| | - Isaac Mawenya
- Department of Cardiovascular Medicine, The Jakaya Kikwete Cardiac Institute, P.O Box 65141, Dar es Salaam, Tanzania
| | - Paulina Nicholaus
- Department of Cardiovascular Medicine, The Jakaya Kikwete Cardiac Institute, P.O Box 65141, Dar es Salaam, Tanzania
| | - Henry Mayala
- Department of Cardiovascular Medicine, The Jakaya Kikwete Cardiac Institute, P.O Box 65141, Dar es Salaam, Tanzania
| | - Amida Kalombola
- Department of Pediatric and Child Health, Muhimbili National Hospital, P.O Box 65000, Dar es Salaam, Tanzania
| | - Godwin Sharau
- Department of Pediatric Cardiology, The Jakaya Kikwete Cardiac Institute, P.O Box 65141, Dar es Salaam, Tanzania
| | - Naiz Majani
- Department of Pediatric Cardiology, The Jakaya Kikwete Cardiac Institute, P.O Box 65141, Dar es Salaam, Tanzania
| | - Mohamed Janabi
- Department of Cardiovascular Medicine, The Jakaya Kikwete Cardiac Institute, P.O Box 65141, Dar es Salaam, Tanzania
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30
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Baruteau AE, Pass RH, Thambo JB, Behaghel A, Le Pennec S, Perdreau E, Combes N, Liberman L, McLeod CJ. Congenital and childhood atrioventricular blocks: pathophysiology and contemporary management. Eur J Pediatr 2016; 175:1235-1248. [PMID: 27351174 PMCID: PMC5005411 DOI: 10.1007/s00431-016-2748-0] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2016] [Revised: 06/13/2016] [Accepted: 06/16/2016] [Indexed: 02/07/2023]
Abstract
UNLABELLED Atrioventricular block is classified as congenital if diagnosed in utero, at birth, or within the first month of life. The pathophysiological process is believed to be due to immune-mediated injury of the conduction system, which occurs as a result of transplacental passage of maternal anti-SSA/Ro-SSB/La antibodies. Childhood atrioventricular block is therefore diagnosed between the first month and the 18th year of life. Genetic variants in multiple genes have been described to date in the pathogenesis of inherited progressive cardiac conduction disorders. Indications and techniques of cardiac pacing have also evolved to allow safe permanent cardiac pacing in almost all patients, including those with structural heart abnormalities. CONCLUSION Early diagnosis and appropriate management are critical in many cases in order to prevent sudden death, and this review critically assesses our current understanding of the pathogenetic mechanisms, clinical course, and optimal management of congenital and childhood AV block. WHAT IS KNOWN • Prevalence of congenital heart block of 1 per 15,000 to 20,000 live births. AV block is defined as congenital if diagnosed in utero, at birth, or within the first month of life, whereas childhood AV block is diagnosed between the first month and the 18th year of life. As a result of several different etiologies, congenital and childhood atrioventricular block may occur in an entirely structurally normal heart or in association with concomitant congenital heart disease. Cardiac pacing is indicated in symptomatic patients and has several prophylactic indications in asymptomatic patients to prevent sudden death. • Autoimmune, congenital AV block is associated with a high neonatal mortality rate and development of dilated cardiomyopathy in 5 to 30 % cases. What is New: • Several genes including SCN5A have been implicated in autosomal dominant forms of familial progressive cardiac conduction disorders. • Leadless pacemaker technology and gene therapy for biological pacing are promising research fields. In utero percutaneous pacing appears to be at high risk and needs further development before it can be adopted into routine clinical practice. Cardiac resynchronization therapy is of proven value in case of pacing-induced cardiomyopathy.
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Affiliation(s)
- Alban-Elouen Baruteau
- Cardiovascular and Cell Sciences Research Center, St George’s University of London, London, UK
- LIRYC Institute, CHU Bordeaux, Department of Pediatric Cardiology, Bordeaux-II University, Bordeaux, France
- Service de Cardiologie Pédiatrique, Hôpital du Haut Lévèque, Institut Hospitalo-Universitaire LIRYC (Electrophysiology and Heart Modeling Institute), 5 avenue de Magellan, 33600 Pessac, France
| | - Robert H. Pass
- Division of Pediatric Electrophysiology, Albert Einstein College of Medicine, Montefiore Children’s Hospital, Bronx, NY USA
| | - Jean-Benoit Thambo
- LIRYC Institute, CHU Bordeaux, Department of Pediatric Cardiology, Bordeaux-II University, Bordeaux, France
| | - Albin Behaghel
- CHU Rennes, Department of Cardiology, LTSI, INSERM 1099, Rennes-1 University, Rennes, France
| | - Solène Le Pennec
- CHU Rennes, Department of Cardiology, LTSI, INSERM 1099, Rennes-1 University, Rennes, France
| | - Elodie Perdreau
- LIRYC Institute, CHU Bordeaux, Department of Pediatric Cardiology, Bordeaux-II University, Bordeaux, France
| | - Nicolas Combes
- Department of Cardiology, Clinique Pasteur, Toulouse, France
| | - Leonardo Liberman
- Morgan Stanley Children’s Hospital, Division of Pediatric Cardiology, New York Presbyterian Hospital, Columbia University Medical Center, New York, NY USA
| | - Christopher J. McLeod
- Mayo Clinic, Division of Cardiovascular Diseases, Mayo Clinic College of Medicine, Rochester, MN USA
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Yamamoto Y, Aoki S. Systemic lupus erythematosus: strategies to improve pregnancy outcomes. Int J Womens Health 2016; 8:265-72. [PMID: 27468250 PMCID: PMC4944915 DOI: 10.2147/ijwh.s90157] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Systemic lupus erythematosus (SLE) is a chronic autoimmune inflammatory disease with a high prevalence in females of childbearing age. Thus, reproduction in SLE patients is a major concern for clinicians. In the past, SLE patients were advised to defer pregnancy because of poor pregnancy outcomes and fear of SLE flares during pregnancy. Investigations to date show that maternal and fetal risks are higher in females with SLE than in the general population. However, with appropriate management of the disease, sufferers may have a relatively uncomplicated pregnancy course. Factors such as appropriate preconception counseling and medication adjustment, strict disease control prior to pregnancy, intensive surveillance during and after pregnancy by both the obstetrician and rheumatologist, and appropriate interventions when necessary play a key role. This review describes the strategies to improve pregnancy outcomes in SLE patients at different time points in the reproduction cycle (preconception, during pregnancy, and postpartum period) and also details the neonatal concerns.
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Affiliation(s)
- Yuriko Yamamoto
- Perinatal Center for Maternity and Neonate, Yokohama City University Medical Center, Yokohama, Kanagawa Prefecture, Japan
| | - Shigeru Aoki
- Perinatal Center for Maternity and Neonate, Yokohama City University Medical Center, Yokohama, Kanagawa Prefecture, Japan
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Sonesson SE, Acharya G. Hemodynamics in fetal arrhythmia. Acta Obstet Gynecol Scand 2015; 95:697-709. [PMID: 26660845 DOI: 10.1111/aogs.12837] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2015] [Accepted: 12/03/2015] [Indexed: 10/22/2022]
Abstract
Fetal arrhythmias are among the few conditions that can be managed in utero. However, accurate diagnosis is essential for appropriate management. Ultrasound-based imaging methods can be used to study fetal heart structure and function noninvasively and help to understand fetal cardiovascular pathophysiology, and they remain the mainstay of evaluating fetuses with arrhythmias in clinical settings. Hemodynamic evaluation using Doppler echocardiography allows the elucidation of the electrophysiological mechanism and helps to make an accurate diagnosis. It can also be used as a tool to understand fetal cardiac pathophysiology, for assessing fetal condition and monitoring the effect of antiarrhythmic treatment. This narrative review describes Doppler techniques that are useful for evaluating fetal cardiac rhythms to refine diagnosis and provides an overview of hemodynamic changes observed in different types of fetal arrhythmia.
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Affiliation(s)
- Sven-Erik Sonesson
- Pediatric Cardiology Unit, Department of Women's and Children's Health, Karolinska Institute, Stockholm, Sweden
| | - Ganesh Acharya
- Women's Health and Perinatology Research Group, Department of Clinical Medicine, Faculty of Health Sciences, UiT - The Arctic University of Norway, Tromsø, Norway.,Department of Obstetrics and Gynecology, University Hospital of Northern Norway, Tromsø, Norway.,Department of Clinical Sciences, Intervention and Technology, Karolinska Institute, Stockholm, Sweden
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Tingström J, Hjelmstedt A, Welin Henriksson E, Ambrosi A, Sonesson SE, Wahren-Herlenius M. Anti-Ro/SSA autoantibody-positive women’s experience of information given on the risk of congenital heart block. Lupus 2015; 25:536-42. [DOI: 10.1177/0961203315620760] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2015] [Accepted: 11/02/2015] [Indexed: 11/17/2022]
Abstract
Objective Congenital heart block (CHB) may develop in fetuses of women with anti-Ro/SSA autoantibodies, and carries substantial morbidity and mortality. The aim was to evaluate how information on CHB is imparted and identify areas of improvement. Methods A questionnaire was distributed to anti-Ro/SSA antibody-positive women who had either participated in a surveillance programme but whose expected child did not develop CHB ( n = 100, denoted Doppler-Assessed Pregnancies (DAP) group) or given birth to a child with CHB ( n = 88, denoted CHB-Affected Pregnancies (CAP) group). Results The response rate was 83% (157/188). Most women received the information on CHB when they were already pregnant (DAP group 60%, CAP group 83%). However, a majority of them would have wanted the information before pregnancy (DAP group 52%, CAP group 56%), and most stated that it would not have influenced their decision to have a child (DAP group 77%, CAP group 58%). The ability to both understand the information and to perceive the information as sufficient were significantly higher when someone trained in paediatric cardiology gave the information. Conclusions Our findings indicate that information on CHB should be given to women before pregnancy. The data further highlight the importance of having specific knowledge for giving relevant and understandable, yet sufficient information.
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Affiliation(s)
- J Tingström
- Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - A Hjelmstedt
- Department of Women’s and Children’s Health, Karolinska Institutet, Stockholm, Sweden
| | - E Welin Henriksson
- Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden
| | - A Ambrosi
- Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - S-E Sonesson
- Department of Women’s and Children’s Health, Karolinska Institutet, Stockholm, Sweden
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Ruffatti A, Favaro M, Brucato A, Ramoni V, Facchinetti M, Tonello M, Del Ross T, Calligaro A, Hoxha A, Grava C, De Silvestro G. Apheresis in high risk antiphospholipid syndrome pregnancy and autoimmune congenital heart block. Transfus Apher Sci 2015; 53:269-78. [DOI: 10.1016/j.transci.2015.11.006] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Tanriverdi S, Ulger Z, Siyah Bilgin B, Kultursay N, Yalaz M, Atay Y, Koroglu OA. Treatment of Congenital Complete Atrioventricular Heart Block With Permanent Epicardial Pacemaker in Neonatal Lupus Syndrome. IRANIAN RED CRESCENT MEDICAL JOURNAL 2015; 17:e16200. [PMID: 26473068 PMCID: PMC4601204 DOI: 10.5812/ircmj.16200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/17/2013] [Revised: 12/11/2014] [Accepted: 02/22/2015] [Indexed: 11/16/2022]
Abstract
Introduction: Neonatal lupus syndrome (NLS) is a passively acquired autoimmune condition due to the transplacental passage of maternal anti-Ro/SSA and anti-La/SSB antibodies in mothers with systemic lupus erythematosus (SLE), and congenital complete heart block (CHB) is its most serious manifestation. Skin and hepatic involvement may occur in later infancy. Case Presentation: A term infant with fetal bradycardia, detected at the 23rd gestational age, was diagnosed with CHB due to NLS and was successfully treated with a permanent epicardial pacemaker. The patient was reported here due to rarity of the procedure in neonatal period. Conclusions: Mothers with SLE should be screened and closely followed up during pregnancy for the development of fetal atrioventricular (AV) block.
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Affiliation(s)
- Sema Tanriverdi
- Department of Pediatrics, Ege University, Faculty of Medicine, Division of Neonatology, Izmir, Turkey
- Corresponding Author: Sema Tanriverdi, Department of Pediatrics, Ege University, Faculty of Medicine, Division of Neonatology, Izmir, Turkey. Tel: +90-2323901306, Fax: +90-2323901011, E-mail:
| | - Zulal Ulger
- Department of Pediatrics, Ege University, Faculty of Medicine, Division of Pediatric Cardiology, Izmir, Turkey
| | - Betul Siyah Bilgin
- Department of Pediatrics, Ege University, Faculty of Medicine, Division of Neonatology, Izmir, Turkey
| | - Nilgun Kultursay
- Department of Pediatrics, Ege University, Faculty of Medicine, Division of Neonatology, Izmir, Turkey
| | - Mehmet Yalaz
- Department of Pediatrics, Ege University, Faculty of Medicine, Division of Neonatology, Izmir, Turkey
| | - Yuksel Atay
- Department of Cardiovascular Surgey, Ege University, Faculty of Medicine, Izmir, Turkey
| | - Ozge Altun Koroglu
- Department of Pediatrics, Ege University, Faculty of Medicine, Division of Neonatology, Izmir, Turkey
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36
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Understanding and Managing Pregnancy in Patients with Lupus. Autoimmune Dis 2015; 2015:943490. [PMID: 26246905 PMCID: PMC4515284 DOI: 10.1155/2015/943490] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2015] [Accepted: 05/31/2015] [Indexed: 12/16/2022] Open
Abstract
Systemic lupus erythematosus (SLE) is a chronic, multisystemic autoimmune disease that occurs predominantly in women of fertile age. The association of SLE and pregnancy, mainly with active disease and especially with nephritis, has poorer pregnancy outcomes, with increased frequency of preeclampsia, fetal loss, prematurity, growth restriction, and newborns small for gestational age. Therefore, SLE pregnancies are considered high risk condition, should be monitored frequently during pregnancy and delivery should occur in a controlled setting. Pregnancy induces dramatic immune and neuroendocrine changes in the maternal body in order to protect the fetus from immunologic attack and these modifications can be affected by SLE. The risk of flares depends on the level of maternal disease activity in the 6–12 months before conception and is higher in women with repeated flares before conception, in those who discontinue useful medications and in women with active glomerulonephritis at conception. It is a challenge to differentiate lupus nephritis from preeclampsia and, in this context, the angiogenic and antiangiogenic cytokines are promising. Prenatal care of pregnant patients with SLE requires close collaboration between rheumatologist and obstetrician. Planning pregnancy is essential to increase the probability of successful pregnancies.
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Tingström J, Hjelmstedt A, Welin Henriksson E, Sonesson SE, Wahren-Herlenius M. Ro/SSA autoantibody-positive pregnancy: reactions to serial fetal Doppler echocardiographic surveillance. Lupus 2015; 24:1540-5. [PMID: 26113358 DOI: 10.1177/0961203315593171] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2015] [Accepted: 06/02/2015] [Indexed: 11/16/2022]
Abstract
OBJECTIVE The risk for congenital heart block (CHB) associated with maternal Ro/SSA autoantibodies is low, but the possibility of treating early stages of disease has seen the introduction of Doppler echocardiographic surveillance programs with serial examinations during the CHB susceptibility weeks of pregnancy. The aim of the present study was to understand how Ro/SSA autoantibody-positive women having undergone Doppler echocardiographic surveillance programs and giving birth to children without CHB experienced their pregnancy and frequent ultrasound examinations. METHODS A validated questionnaire based on data from an interview-study was distributed to Ro/SSA-positive women supervised with Doppler examinations during their pregnancy (n = 100). RESULTS The response rate was 79%. The majority of the women (61%) reported that the increased number of ultrasound examinations influenced their pregnancy, but in a positive way, with qualified information and additional support from health care personnel in conjunction with the examinations. Further, the visits to the clinic provided opportunities to see the ultrasound picture of the expected infant. However, one-third of the women also reported stress in relation to the examinations. CONCLUSIONS Fetal echocardiographic surveillance holds many and predominantly positive effects for Ro/SSA-positive women during pregnancy in addition to the medical advantages.
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Affiliation(s)
- J Tingström
- Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - A Hjelmstedt
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - E Welin Henriksson
- Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden
| | - S-E Sonesson
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
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Abstract
Autoimmune congenital heart block (CHB) is an immune-mediated acquired disease that is associated with the placental transference of maternal antibodies specific for Ro and La autoantigens. The disease develops in a fetal heart without anatomical abnormalities that could otherwise explain the block, and which is usually diagnosed in utero, but also at birth or within the neonatal period. Autoantibody-mediated damage of fetal conduction tissues causes inflammation and fibrosis and leads to blockage of signal conduction at the atrioventricular (AV) node. Irreversible complete AV block is the principal cardiac manifestation of CHB, although some babies might develop other severe cardiac complications, such as endocardial fibroelastosis or valvular insufficiency, even in the absence of cardiac block. In this Review, we discuss the epidemiology, classification and management of women whose pregnancies are affected by autoimmune CHB, with a particular focus on the autoantibodies associated with autoimmune CHB and how we should test for these antibodies and diagnose this disease. Without confirmed effective preventive or therapeutic strategies and further research on the aetiopathogenic mechanisms, autoimmune CHB will remain a severe life-threatening disorder.
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Abstract
PURPOSE OF REVIEW The purpose of this study is to encourage discussion of reproduction issues in all patients of fertile age in order to prevent unplanned and ill-timed pregnancies in patients with rheumatoid arthritis (RA). RECENT FINDINGS Counselling patients who desire children requires consideration of relevant reproductive health issues, including fertility, interaction of pregnancy and RA, and management during pregnancy and lactation. RA patients have no disease-related restrictions in regard to contraception, but need to be counselled on safe birth control particularly during treatment with potentially teratogenic drugs. In spite of mostly beneficial effects of pregnancy on RA, active disease and aggressive drug treatment can impair pregnancy outcomes. Options for drug therapy, though limited, may help to maintain low disease activity during pregnancy and lactation. SUMMARY Careful preconception counselling and risk assessment is important in RA women, with a particular focus on preventing unplanned pregnancy by information on contraception. Antibody status and all medications need to be reviewed before pregnancy. Maintaining low disease activity before and during pregnancy is crucial for good outcomes. Preconceptional counselling shared with all health professionals engaged in the care of a patient helps to ensure healthy pregnancy outcomes for mother and child.
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Santos-Pardo I, Villuendas R, Salvador-Corres I, Martínez-Morillo M, Olivé A, Bayes-Genis A. Anti-Ro/SSA antibodies and cardiac rhythm disturbances: Present and future perspectives. Int J Cardiol 2014; 184:244-250. [PMID: 25725306 DOI: 10.1016/j.ijcard.2014.11.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2014] [Revised: 10/06/2014] [Accepted: 11/01/2014] [Indexed: 12/17/2022]
Abstract
Several case reports, small case series, and original research papers have recently suggested that the action of certain auto-antibodies related to connective tissue diseases may be responsible for significant cardiac rhythm disturbances in adults. The relationship between anti-Ro/SSA antibodies and congenital complete atrioventricular block is well recognized in the fetal heart. Herein we review the emerging evidences of the link to increased levels of anti-Ro/SSA antibodies with rhythm disorders of unknown origin in the adult. Confirmation of this distinct etiology may eventually be the basis for new therapies.
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Affiliation(s)
- Irene Santos-Pardo
- Cardiology Service, Hospital Universitari Germans Trias i Pujol, Universitat Autònoma de Barcelona (UAB), Spain
| | - Roger Villuendas
- Cardiology Service, Hospital Universitari Germans Trias i Pujol, Universitat Autònoma de Barcelona (UAB), Spain
| | - Iñaki Salvador-Corres
- Immunology Service, Hospital Universitari Germans Trias i Pujol, Universitat Autònoma de Barcelona (UAB), FOCIS-CE, Spain
| | - Melania Martínez-Morillo
- Rheumatology Service, Hospital Universitari Germans Trias i Pujol, Universitat Autònoma de Barcelona (UAB), Spain
| | - Alejandro Olivé
- Rheumatology Service, Hospital Universitari Germans Trias i Pujol, Universitat Autònoma de Barcelona (UAB), Spain; Department of Medicine, Universitat Autònoma de Barcelona (UAB), Spain
| | - Antoni Bayes-Genis
- Cardiology Service, Hospital Universitari Germans Trias i Pujol, Universitat Autònoma de Barcelona (UAB), Spain; Department of Medicine, Universitat Autònoma de Barcelona (UAB), Spain
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Perin F, Rodríguez Vázquez del Rey M, Deiros Bronte L, Ferrer Menduiña Q, Rueda Nuñez F, Zabala Arguelles J, García de la Calzada D, Teodoro Marin S, Centeno Malfaz F, Galindo Izquierdo A. Foetal bradycardia: A retrospective study in 9 Spanish centres. An Pediatr (Barc) 2014. [DOI: 10.1016/j.anpede.2013.12.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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42
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Congenital heart block: current thoughts on management, morphologic spectrum, and role of intervention. Cardiol Young 2014; 24 Suppl 2:41-6. [PMID: 25247254 DOI: 10.1017/s1047951114001358] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Abstract
Neonatal lupus syndrome is associated with transplacental passage of maternal anti-SSA/Ro and anti-SSB/La antibodies. Children display cutaneous, hematological, liver or cardiac features. Cardiac manifestations include congenital heart block (CHB); endocardial fibroelastosis and dilated cardiomyopathy. The prevalence of CHB in newborns of anti-Ro/SSA positive women with known connective tissue disease is between 1 and 2% and the risk of recurrence is around 19%. Skin and systemic lesions are transient, whereas CHB is definitive and associated with significant morbidity and a mortality of 18%. A pacemaker must be implanted in 2/3 of cases. Myocarditis may be associated or appear secondly. Mothers of children with CHB are usually asymptomatic or display Sjogren's syndrome or undifferentiated connective tissue disease. In anti-Ro/SSA positive pregnant women, fetal echocardiography should be performed at least every 2 weeks from the 16th to 24th week gestation. An electrocardiogram should be performed for all newborn babies. The benefit of fluorinated corticosteroid therapy for CHB detected in utero remains unclear. Maternal use of hydroxychloroquine may be associated with a decreased recurrent CHB risk in a subsequent offspring. A prospective study is actually ongoing to confirm these findings.
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Sonesson SE, Eliasson H, Conner P, Wahren-Herlenius M. Doppler echocardiographic isovolumetric time intervals in diagnosis of fetal blocked atrial bigeminy and 2:1 atrioventricular block. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2014; 44:171-175. [PMID: 24585694 DOI: 10.1002/uog.13344] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/14/2013] [Revised: 01/17/2014] [Accepted: 02/14/2014] [Indexed: 06/03/2023]
Abstract
OBJECTIVE To distinguish between blocked atrial bigeminy (BB) and incomplete atrioventricular block with 2:1 conduction (2:1 AVB) can be very difficult, especially in the mid-term fetus. Making a correct diagnosis has important clinical implications, as their prognosis and management differ markedly. Our objective was to investigate whether analysis of isovolumetric time intervals could improve Doppler echocardiography in differentiating these conditions. METHODS Sixteen fetuses with sustained BB or isolated 2:1 AVB, diagnosed at our tertiary center from 2002 to 2012, were reviewed retrospectively. Doppler recordings of left ventricular in- and outflow, including mitral and aortic valve movements, were used to measure isovolumetric contraction (ICT) and relaxation (IRT) time intervals. ICT reference values obtained from 104 normal pregnancies were used for comparison. RESULTS Ten fetuses had BB and six 2:1 AVB. Five of the AVB cases were anti-Ro antibody positive and one had long QT syndrome (LQTS). ICT was systematically shorter in BB than in antibody-mediated 2:1 AVB. Nine of 10 cases with BB had an ICT below -2 SD and the five with antibody-mediated 2:1 AVB had values at or above +2 SD. All 15 fetuses with either BB or antibody-mediated AVB had an IRT of < 70 ms, as opposed to a markedly prolonged IRT (105 ms) in the LQTS case. CONCLUSION Measurement of ICT can improve the differential diagnosis between BB and antibody-mediated 2:1 AVB. Fetuses with BB or antibody-mediated AVB are unlikely to have IRT measurements exceeding 70 ms and, when this is observed, LQTS should be considered a more likely diagnosis.
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Affiliation(s)
- S-E Sonesson
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
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Abstract
Exposure to maternal anti-Ro (SS-A) and anti-La (SS-B) antibodies is a well-described risk factor for the development of fetal atrioventricular (AV) block. The role of maternal fluorinated steroids in the treatment and prevention of antibody-mediated fetal AV block is controversial. Fetal atrial flutter has rarely been described in association with maternal antibodies. This report describes a case of fetal exposure to maternal anti-Ro antibodies with associated second-degree AV block and atrial flutter. Interestingly, the reported patient had 2:1 AV conduction during both normal atrial rates (consistent with AV node conduction disease) and episodes of flutter (consistent with physiologic AV node functionality). The fetus was treated with transplacental digoxin and dexamethasone, which resolved both rhythm disturbances. The case report is followed by a brief discussion of AV block and atrial flutter associated with maternal antibody exposure.
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46
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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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Atrioventricular conduction delay in the second trimester measured by fetal magnetocardiography. J Immunol Res 2014; 2014:753953. [PMID: 24741622 PMCID: PMC3987975 DOI: 10.1155/2014/753953] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2013] [Revised: 12/22/2013] [Accepted: 12/24/2013] [Indexed: 11/26/2022] Open
Abstract
Introduction. Fetal AV block in SSA/Ro pregnancies is generally not seen before 18-week gestation and onset is rare after 28-week gestation. If complete AV block appears, it is believed to be irreversible. The purpose of the study was to evaluate precise electrophysiological AV conduction from 18-week gestation onwards. Patients and Methods. 21 fetuses of pregnant women with collagen vascular diseases were included in the study group and 59 healthy fetuses served as controls. In addition to fetal echocardiography, fetal magnetocardiography (fMCG) was used to investigate precise electrophysiological fetal cardiac time intervals (fCTIs). Results. The PR segment (isoelectric segment between the end of the P wave and the start of the QRS complex) was significantly prolonged (P < 0.036 2nd trimester, P < 0.023 3rd trimester) in both trimesters within the study group. In fetuses less than 23-week gestational age, a nearly complete separation was found, where a PR segment of 60 ms or greater completely excluded control fetuses. All other fCTIs did not differ significantly. None of the fetuses progressed to a more advanced heart block. Conclusion. Slight antibody effects in pregnancy, leading to PR segment prolongation, can already be seen from 18-week gestation onwards by fMCG. Serial fetal Doppler echocardiography and additional fMCG can be useful methods to measure early and precise AV conduction time, to achieve best surveillance for these high-risk pregnancies.
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48
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[Fetal bradycardia: a retrospective study in 9 Spanish centers]. An Pediatr (Barc) 2014; 81:275-82. [PMID: 24548871 DOI: 10.1016/j.anpedi.2013.12.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2013] [Revised: 12/09/2013] [Accepted: 12/26/2013] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE The aim of this study is to review the current management and outcomes of fetal bradycardia in 9 Spanish centers. METHODS Retrospective multicenter study: analysis of all fetuses with bradycardia diagnosed between January 2008 and September 2010. Underlying mechanisms of fetal bradyarrhythmias were studied with echocardiography. RESULTS A total of 37 cases were registered: 3 sinus bradycardia, 15 blocked atrial bigeminy, and 19 high grade atrioventricular blocks. Sinus bradycardia: 3 cases (100%) were associated with serious diseases. Blocked atrial bigeminy had an excellent outcome, except for one case with post-natal tachyarrhythmia. Of the atrioventricular blocks, 16% were related to congenital heart defects with isomerism, 63% related to the presence of maternal SSA/Ro antibodies, and 21% had unclear etiology. Overall mortality was 20% (37%, if terminations of pregnancy are taken into account). Risk factors for mortality were congenital heart disease, hydrops and/or ventricular dysfunction. Management strategies differed among centers. Steroids were administrated in 73% of immune-mediated atrioventricular blocks, including the only immune-mediated IInd grade block. More than half (58%) of atrioventricular blocks had a pacemaker implanted in a follow-up of 18 months. CONCLUSIONS Sustained fetal bradycardia requires a comprehensive study in all cases, including those with sinus bradycardia. Blocked atrial bigeminy has a good prognosis, but tachyarrhythmias may develop. Heart block has significant mortality and morbidity rates, and its management is still highly controversial.
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Abstract
Systemic lupus erythematosus (SLE) is an auto-immune disease, primarily affecting young females. Pregnancy in a woman with SLE remains a high-risk situation with higher maternal and foetal mortality and morbidity. Although live births are achieved in majority of the pregnancies, active disease and major organ involvement can negatively affect the outcomes. A higher risk of foetal loss, pre-term birth, intra-uterine growth restriction (IUGR) and neonatal lupus syndromes (NLSs) are major foetal issues. Mothers are faced with disease flares, pre-eclampsia and other complications. Disease flares during SLE pregnancy pose the unique issue of recognition and differentiation between physiologic changes and disease state. Similarly, pre-eclampsia and lupus nephritis may lead to diagnostic confusion. Treatment choices during pregnancy are limited to a few safe drugs, further restricting the options. Refractory pregnancy loss associated with anti-phospholipid antibodies (aPLs) and complete heart block associated with anti-Ro antibodies remain unresolved issues. A multidisciplinary approach, with close monitoring, is essential for optimal outcomes.
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Affiliation(s)
- Aisha Lateef
- Division of Rheumatology, University Medicine Cluster, National University Health System, 1E, Kent Ridge, Singapore 119074, Singapore.
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50
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Costedoat-Chalumeau N, Izmirly P, Clancy R, Saxena A, Wahren-Herlenius M, Silverman E, Brucato A, Boutjdir M, Khamashta M, Llanos C, Pisoni CN, Friedman DM, Phoon CKL, Buyon JP. Letter to the Editor in response to the article "Preventing congenital neonatal heart block in offspring of mothers with anti-SSA/Ro and SSB/La antibodies: a review of published literature and registered clinical trials." by Gleicher N, Elkayam U, Autoimmun Rev. 2013 Sep;12(11):1039-45. Autoimmun Rev 2013; 13:70-2. [PMID: 24008147 DOI: 10.1016/j.autrev.2013.08.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2013] [Accepted: 08/02/2013] [Indexed: 12/29/2022]
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