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Killen SAS, Strasburger JF. Diagnosis and Management of Fetal Arrhythmias in the Current Era. J Cardiovasc Dev Dis 2024; 11:163. [PMID: 38921663 PMCID: PMC11204159 DOI: 10.3390/jcdd11060163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Revised: 05/18/2024] [Accepted: 05/20/2024] [Indexed: 06/27/2024] Open
Abstract
Diagnosis and management of fetal arrhythmias have changed over the past 40-50 years since propranolol was first used to treat fetal tachycardia in 1975 and when first attempts were made at in utero pacing for complete heart block in 1986. Ongoing clinical trials, including the FAST therapy trial for fetal tachycardia and the STOP-BLOQ trial for anti-Ro-mediated fetal heart block, are working to improve diagnosis and management of fetal arrhythmias for both mother and fetus. We are also learning more about how "silent arrhythmias", like long QT syndrome and other inherited channelopathies, may be identified by recognizing "subtle" abnormalities in fetal heart rate, and while echocardiography yet remains the primary tool for diagnosing fetal arrhythmias, research efforts continue to advance the clinical envelope for fetal electrocardiography and fetal magnetocardiography. Pharmacologic management of fetal arrhythmias remains one of the most successful achievements of fetal intervention. Patience, vigilance, and multidisciplinary collaboration are key to successful diagnosis and treatment.
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Affiliation(s)
- Stacy A. S. Killen
- Thomas P. Graham Jr. Division of Pediatric Cardiology, Department of Pediatrics, Vanderbilt University Medical Center, Monroe Carell Jr. Children’s Hospital at Vanderbilt, 2200 Children’s Way, Suite 5230, Nashville, TN 37232, USA
| | - Janette F. Strasburger
- Division of Cardiology, Departments of Pediatrics and Biomedical Engineering, Children’s Wisconsin, Herma Heart Institute, Medical College of Wisconsin, Milwaukee, WI 53226, USA;
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Mlambo VC, Algaze CA, Mak K, Collins RT. Impact of Abnormal Potassium on Arrhythmia Risk During Pediatric Digoxin Therapy. Pediatr Cardiol 2024; 45:901-908. [PMID: 36403164 DOI: 10.1007/s00246-022-03051-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 11/09/2022] [Indexed: 11/21/2022]
Abstract
Digoxin is used in children with heart failure and tachyarrhythmia. Its use in patients with single ventricle anatomy has increased following evidence of improved interstage survival after the Norwood procedure. Digoxin has a narrow therapeutic window and may alter serum potassium balance, inducing arrhythmias. We hypothesized digoxin use in the setting of abnormal serum potassium levels is associated with arrhythmias. We reviewed all patients ≤ 18 years who received digoxin while admitted at our institution from 2014 to 2021. Admissions < 2 nights were excluded. We compared patients with a hemodynamically significant arrhythmia to those without. We performed adjusted mixed-effects logistic regression with arrhythmia as the outcome variable and potassium status as the predictor variable; adjusting for weight, route of digoxin administration, digoxin indication, serum creatinine, and number of interacting drugs prescribed. Abnormal potassium was defined as serum levels < 3.5 mmol/L or > 6.0 mmol/L. There were 268 encounters in 171 patients. Potassium levels were abnormal in 75.5% of patients who experienced an arrhythmia during digoxin administration, compared to 42.6% who did not (p < 0.001). Odds of arrhythmia was 138% higher in patients with abnormal potassium receiving digoxin (AOR = 2.38, 95% CI 1.07-5.29, p = 0.03). Receiving intravenous digoxin was also associated with a 7.35 odds of cardiac arrhythmia (AOR 7.35, p = 0.006, 95% CI 1.79-30.26). Odds of arrhythmia is increased during digoxin administration when pediatric patients have abnormal potassium levels. Vigilant attention to potassium levels is essential to prevent adverse outcomes during digoxin therapy.
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Affiliation(s)
- Vongai Christine Mlambo
- Division of Pediatric Cardiology, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Claudia A Algaze
- Division of Pediatric Cardiology, Stanford University School of Medicine, Palo Alto, CA, USA
- Lucile Packard Children's Hospital Stanford, Palo Alto, CA, USA
| | - Kwai Mak
- Lucile Packard Children's Hospital Stanford, Palo Alto, CA, USA
| | - R Thomas Collins
- Division of Pediatric Cardiology, Stanford University School of Medicine, Palo Alto, CA, USA.
- Lucile Packard Children's Hospital Stanford, Palo Alto, CA, USA.
- Division of Pediatric Cardiology, University of Kentucky College of Medicine, Lexington, KY, USA.
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Batra AS, Silka MJ, Borquez A, Cuneo B, Dechert B, Jaeggi E, Kannankeril PJ, Tabulov C, Tisdale JE, Wolfe D. Pharmacological Management of Cardiac Arrhythmias in the Fetal and Neonatal Periods: A Scientific Statement From the American Heart Association: Endorsed by the Pediatric & Congenital Electrophysiology Society (PACES). Circulation 2024; 149:e937-e952. [PMID: 38314551 DOI: 10.1161/cir.0000000000001206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2024]
Abstract
Disorders of the cardiac rhythm may occur in both the fetus and neonate. Because of the immature myocardium, the hemodynamic consequences of either bradyarrhythmias or tachyarrhythmias may be far more significant than in mature physiological states. Treatment options are limited in the fetus and neonate because of limited vascular access, patient size, and the significant risk/benefit ratio of any intervention. In addition, exposure of the fetus or neonate to either persistent arrhythmias or antiarrhythmic medications may have yet-to-be-determined long-term developmental consequences. This scientific statement discusses the mechanism of arrhythmias, pharmacological treatment options, and distinct aspects of pharmacokinetics for the fetus and neonate. From the available current data, subjects of apparent consistency/consensus are presented, as well as future directions for research in terms of aspects of care for which evidence has not been established.
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Agarwal A, Saha SC, Kaur A, Naganur S. Refractory supraventricular fetal tachycardia as a cause of non-immune hydrops: management conundrum. BMJ Case Rep 2023; 16:e255808. [PMID: 38154874 PMCID: PMC10759031 DOI: 10.1136/bcr-2023-255808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2023] Open
Abstract
Supraventricular tachyarrhythmia (SVT) is the most common form of fetal tachyarrhythmias. The presentation can vary from ill-defined, non-sustained episodes of tachyarrhythmia to frank non-immune hydrops. The standard of care is transplacental therapy by treating the mother with oral antiarrhythmic drugs, followed by direct fetal therapy in refractory cases. We report a case of primigravida in her late 20s, who presented at 28.1 weeks of gestation with fetal hydrops and SVT. She was initially managed with oral digoxin and flecainide, but due to worsening hydrops, risk of fetal demise and extreme prematurity, further management by direct fetal therapy was given in terms of intramuscular digoxin and intraperitoneal flecainide. Following which, the fetus had a favourable outcome. This case highlights the possible role of direct fetal therapy in refractory cases of SVT.
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Affiliation(s)
- Akanksha Agarwal
- Obstetrics and Gynaecology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Subash Chandra Saha
- Obstetrics and Gynaecology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Amanjot Kaur
- Obstetrics and Gynaecology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Sanjeev Naganur
- Cardiology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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Du R, Wang F, Dong Y, Chu W, Ma L, Gao J. Intrauterine management and outcomes of persistent fetal atrial flutter: A case report. Birth Defects Res 2023; 115:1570-1575. [PMID: 37491874 DOI: 10.1002/bdr2.2220] [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: 02/10/2023] [Revised: 06/14/2023] [Accepted: 06/16/2023] [Indexed: 07/27/2023]
Abstract
BACKGROUND Fetal atrial flutter (AF), accounting for 30% of all fetal tachyarrhythmias, predominantly (over 80%) manifests as a 2:1 atrioventricular conduction. Swift referral and timely intervention become imperative in instances of severe persistent arrhythmia. CASE PRESENTATION We discuss the case of a 32-year-old multiparous Chinese woman, at 30+2 weeks of gestation, wherein an ultrasonographic examination revealed persistent fetal AF (atrial rate ranging from 219 to 445 beats/min and ventricular rate from 219 to 228 beats/min, with a 2:1 or 1:1 down transmission) and minor ascites. Despite the maternal ingestion of digoxin and sotalol, the fetal heart rhythm remained uncorrected. Following this, at 32+3 weeks of gestation, an intramuscular injection of cedilanid, guided by ultrasound, was administered to the fetus. Postoperatively, the fetal ventricular rate demonstrated a decline after 6 days, and the ascites resolved. Subsequently, at 33+3 weeks, a cesarean section was necessitated due to maternal intolerance to the medication, resulting in the delivery of the infant. Remarkably, the infant's cardiac rhythm spontaneously converted to sinus rhythm within 5 min of birth. A follow-up conducted 1 year postpartum revealed no recurrence of AF. CONCLUSIONS This case illustrates that in the event of transplacental drug treatment failure, intrauterine therapeutic intervention should be considered. Moreover, it highlights the encouraging prognosis associated with fetal AF, as the cardiac rhythm spontaneously reverted to sinus rhythm postbirth in this instance.
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Affiliation(s)
- Runxuan Du
- Department of Reproduction and Genetics, Hebei General Hospital, Shijiazhuang, China
| | - Fangna Wang
- Department of Reproduction and Genetics, Hebei General Hospital, Shijiazhuang, China
| | - Yuewen Dong
- Department of Reproduction and Genetics, Hebei General Hospital, Shijiazhuang, China
| | - Wei Chu
- Department of Reproduction and Genetics, Hebei General Hospital, Shijiazhuang, China
| | - Lishuang Ma
- Department of Reproduction and Genetics, Hebei General Hospital, Shijiazhuang, China
| | - Jian Gao
- Department of Reproduction and Genetics, Hebei General Hospital, Shijiazhuang, China
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Holmes S, Hornberger LK, Jaeggi E, Howley L, Moon-Grady AJ, Uzun O, Kaizer A, Gilicze O, Cuneo BF. Treatment, not delivery, of the late preterm and term fetus with supraventricular arrhythmia. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2023; 62:552-557. [PMID: 37128167 DOI: 10.1002/uog.26239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 03/31/2023] [Accepted: 04/18/2023] [Indexed: 05/03/2023]
Abstract
OBJECTIVE While in-utero treatment of sustained fetal supraventricular arrhythmia (SVA) is standard practice in the previable and preterm fetus, data are limited on best practice for late preterm (34 + 0 to 36 + 6 weeks), early term (37 + 0 to 38 + 6 weeks) and term (> 39 weeks) fetuses with SVA. We reviewed the delivery and postnatal outcomes of fetuses at ≥ 35 weeks of gestation undergoing treatment rather than immediate delivery. METHODS This was a retrospective case series of fetuses presenting at ≥ 35 weeks of gestation with sustained SVA and treated transplacentally at six institutions between 2012 and 2022. Data were collected on gestational age at presentation and delivery, SVA diagnosis (short ventriculoatrial (VA) tachycardia, long VA tachycardia or atrial flutter), type of antiarrhythmic medication used, interval between treatment and conversion to sinus rhythm and postnatal SVA recurrence. RESULTS Overall, 37 fetuses presented at a median gestational age of 35.7 (range, 35.0-39.7) weeks with short VA tachycardia (n = 20), long VA tachycardia (n = 7) or atrial flutter (n = 10). Four (11%) fetuses were hydropic. In-utero treatment led to restoration of sinus rhythm in 35 (95%) fetuses at a median of 2 (range, 1-17) days; this included three of the four fetuses with hydrops. Antiarrhythmic medications included flecainide (n = 11), digoxin (n = 7), sotalol (n = 11) and dual therapy (n = 8). Neonates were liveborn at 36-41 weeks via spontaneous vaginal delivery (23/37 (62%)) or Cesarean delivery (14/37 (38%)). Cesarean delivery was indicated for fetal SVA in two fetuses, atrial ectopy or sinus bradycardia in three fetuses and obstetric reasons in nine fetuses that were in sinus rhythm at the time of delivery. Twenty-one (57%) cases were treated for recurrent SVA after birth. CONCLUSION In-utero treatment of the near term and term (≥ 35-week) SVA fetus is highly successful even in the presence of hydrops, with the majority of cases delivered vaginally closer to term, thereby avoiding unnecessary Cesarean section. © 2023 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- S Holmes
- The Heart Institute, Children's Hospital Colorado, University of Colorado, Aurora, CO, USA
| | - L K Hornberger
- Division of Cardiology, Department of Pediatrics, Stollery Children's Hospital, University of Alberta, Edmonton, AB, Canada
| | - E Jaeggi
- Division of Cardiology, Department of Pediatrics, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - L Howley
- Children's Hospital Minnesota, Minneapolis, MN, USA
| | - A J Moon-Grady
- University of California San Francisco, San Francisco, CA, USA
| | - O Uzun
- School of Medicine and University Hospital of Wales, Cardiff, UK
| | - A Kaizer
- Department of Biostatistics and Informatics, University of Colorado, Aurora, CO, USA
| | - O Gilicze
- University of California San Francisco, San Francisco, CA, USA
| | - B F Cuneo
- The Heart Institute, Children's Hospital Colorado, University of Colorado, Aurora, CO, USA
- Colorado Fetal Care Center, Children's Hospital Colorado, University of Colorado, Aurora, CO, USA
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Joglar JA, Kapa S, Saarel EV, Dubin AM, Gorenek B, Hameed AB, Lara de Melo S, Leal MA, Mondésert B, Pacheco LD, Robinson MR, Sarkozy A, Silversides CK, Spears D, Srinivas SK, Strasburger JF, Tedrow UB, Wright JM, Zelop CM, Zentner D. 2023 HRS expert consensus statement on the management of arrhythmias during pregnancy. Heart Rhythm 2023; 20:e175-e264. [PMID: 37211147 DOI: 10.1016/j.hrthm.2023.05.017] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 05/12/2023] [Indexed: 05/23/2023]
Abstract
This international multidisciplinary expert consensus statement is intended to provide comprehensive guidance that can be referenced at the point of care to cardiac electrophysiologists, cardiologists, and other health care professionals, on the management of cardiac arrhythmias in pregnant patients and in fetuses. This document covers general concepts related to arrhythmias, including both brady- and tachyarrhythmias, in both the patient and the fetus during pregnancy. Recommendations are provided for optimal approaches to diagnosis and evaluation of arrhythmias; selection of invasive and noninvasive options for treatment of arrhythmias; and disease- and patient-specific considerations when risk stratifying, diagnosing, and treating arrhythmias in pregnant patients and fetuses. Gaps in knowledge and new directions for future research are also identified.
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Affiliation(s)
- José A Joglar
- The University of Texas Southwestern Medical Center, Dallas, Texas
| | | | - Elizabeth V Saarel
- St. Luke's Health System, Boise, Idaho, and Cleveland Clinic Lerner College of Medicine at Case Western Reserve University, Cleveland, Ohio
| | | | | | | | | | | | | | - Luis D Pacheco
- The University of Texas Medical Branch at Galveston, Galveston, Texas
| | | | - Andrea Sarkozy
- University Hospital of Antwerp, University of Antwerp, Antwerp, Belgium
| | | | - Danna Spears
- University Health Network, Toronto, Ontario, Canada
| | - Sindhu K Srinivas
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | | | | | | | - Carolyn M Zelop
- The Valley Health System, Ridgewood, New Jersey; New York University Grossman School of Medicine, New York, New York
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Kazma JM, Van Den Anker J, Ahmadzia HK. Pharmacoethics and pregnancy: Overcoming the therapeutic orphan stigma. Br J Clin Pharmacol 2023; 89:483-490. [PMID: 34904271 DOI: 10.1111/bcp.15173] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 11/07/2021] [Accepted: 11/24/2021] [Indexed: 01/18/2023] Open
Abstract
There is paucity of evidence to support clinical decision making and counselling related to medication use in pregnancy. Despite multiple efforts from legislative bodies and advocacy groups, the inclusion of pregnant women in clinical drug trials assessing efficacy and safety remains scarce. Pregnancy can be complicated by multiple comorbidities that require pharmacological intervention; these interventions primarily target the pregnant woman but also sometimes have secondary effects for the foetus. The US Food and Drug Administration has issued multiple guidance documents on incorporating pregnant women in clinical trials to aid pharmaceutical companies in designing a protocol to ensure safety and adherence to ethical standards. Advances in paediatric pharmacology studies provide lessons for researchers on the best practice of designing clinical trials with inclusion of patients from special populations. In this review, we present the status of pregnant women in clinical trials, highlighting the ethical stigma and possible future directives.
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Affiliation(s)
- Jamil M Kazma
- Department of Obstetrics & Gynecology, The George Washington University School of Medicine and Health Sciences, Washington D.C., USA
| | - John Van Den Anker
- Division of Clinical Pharmacology, Children's National Hospital, Washington D.C., USA.,Division of Pediatric Pharmacology and Pharmacometrics, University Children's Hospital Basel, University of Basel, Switzerland
| | - Homa K Ahmadzia
- Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, The George Washington University School of Medicine and Health Sciences, Washington D.C., USA
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Transplacental Therapeutic Drug Monitoring in Pregnant Women with Fetal Tachyarrhythmia Using HPLC-MS/MS. Int J Mol Sci 2023; 24:ijms24031848. [PMID: 36768172 PMCID: PMC9916042 DOI: 10.3390/ijms24031848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 01/11/2023] [Accepted: 01/13/2023] [Indexed: 01/19/2023] Open
Abstract
Fetal arrhythmia develops in 0.1-5% of pregnancies and may cause fetal heart failure and fetal hydrops, thus increasing fetal, neonatal, and infant mortality. The timely initiation of transplacental antiarrhythmic therapy (ART) promotes the conversion of fetal tachycardia to sinus rhythm and the regression of the concomitant non-immune fetal hydrops. The optimal treatment regimen search for the fetus with tachyarrhythmia is still of high value. Polymorphisms of these genes determines the individual features of the drug pharmacokinetics. The aim of this study was to study the pharmacokinetics of transplacental anti-arrhythmic drugs in the fetal therapy of arrhythmias using HPLC-MS/MS, as well as to assess the effect of the multidrug-resistance gene ABCB1 3435C > T polymorphism on the efficacy and maternal/fetal complications of digoxin treatment. The predisposition to a decrease in the bioavailability of the digoxin in patients with a homozygous variant of the CC polymorphism showed a probable association with the development of ART side effects. A pronounced decrease in heart rate in women with the 3435TT allele of the ABCB1 gene was found. The homozygous TT variant in the fetus showed a probable association with an earlier response to ART and rhythm disruptions on the digoxin dosage reduction. high-performance liquid chromatography with tandem mass spectrometry (HPLC-MS/MS) methods for digoxin and sotalol therapeutic drug monitoring in blood plasma, amniotic fluid, and urine were developed. The digoxin and sotalol concentrations were determined in the plasma blood, urine, and amniotic fluid of 30 pregnant women at four time points (from the beginning of the transplacental antiarrhythmic therapy to delivery) and the plasma cord blood of 30 newborns. A high degree of correlation between the level of digoxin and sotalol in maternal and cord blood was found. The ratio of digoxin and sotalol in cord blood to maternal blood was 0.35 (0.27 and 0.46) and 1.0 (0.97 and 1.07), accordingly. The digoxin concentration in the blood of the fetus at the moment of the first rhythm recovery episode, 0.58 (0.46, 0.8) ng/mL, was below the therapeutic interval. This confirms the almost complete transplacental transfer of sotalol and the significant limitation in the case of digoxin. Previously, ABCB1/P-glycoprotein had been shown to limit fetal exposure to drugs. Further studies (including multicenter ones) to clarify the genetic features of the transplacental pharmacokinetics of antiarrhythmic drugs are needed.
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Miyoshi T, Maeno Y, Matsuda T, Ito Y, Inamura N, Kim KS, Shiraishi I, Kurosaki K, Ikeda T, Sago H. Neurodevelopmental outcome after antenatal therapy for fetal supraventricular tachyarrhythmia: 3-year follow-up of multicenter trial. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2023; 61:49-58. [PMID: 36350016 DOI: 10.1002/uog.26113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Revised: 09/30/2022] [Accepted: 10/20/2022] [Indexed: 05/27/2023]
Abstract
OBJECTIVES Although many studies have supported the efficacy of transplacental treatment for fetal supraventricular tachyarrhythmia, the long-term neurodevelopmental outcome after antenatal antiarrhythmic treatment is not well understood. The aim of this study was to investigate the prognosis and neurodevelopmental outcome at 36 months of corrected age and the incidence of tachyarrhythmia after birth, following protocol-defined antenatal therapy for fetal supraventricular tachyarrhythmia. METHODS This was a 3-year follow-up study of a multicenter trial that evaluated the efficacy and safety of protocol-defined transplacental treatment for fetal supraventricular tachycardia (SVT) and atrial flutter (AFL). The primary endpoints were mortality and neurodevelopmental impairment (NDI) at 36 months of corrected age. NDI was defined as any of the following outcomes: cerebral palsy, bilateral blindness, bilateral deafness or neurodevelopmental delay. Neurodevelopmental delay was evaluated using appropriate developmental quotient scales, mainly the Kyoto Scale of Psychological Development, or examination by pediatric neurologists. The detection rate of tachyarrhythmia at birth and at 18 and 36 months of corrected age was also evaluated as the secondary endpoint. In addition, the association of NDI at 36 months with perinatal and postnatal factors was analyzed. RESULTS Of 50 patients enrolled in the original trial, one withdrew consent and in two there was fetal death, leaving 47 patients available for enrollment in this follow-up study. Of these, 45 cases were available for analysis after two infants were lost to follow-up. The mortality rate was 2.2% (1/45) during a median follow-up of 3.2 (range, 2.1-9.4) years. The infant died at the age of 2.1 years. Another infant had missing neurodevelopmental assessment data. In the remaining 43 infants, at 36 months of corrected age, NDI was detected in 9.3% (4/43) overall and in two of three (66.7%) cases with fetal hydrops with subcutaneous edema. Cerebral palsy was noted in two infants with severe subcutaneous edema or ascites at an early gestational age. Neurodevelopmental delay was found in two infants with severe congenital abnormalities (one with tuberous sclerosis and the other with heterotaxy syndrome). Tachyarrhythmia was present in 31.9% (15/47) cases in the neonatal period and decreased to 8.9% (4/45) and 4.5% (2/44) at 18 and 36 months of corrected age, respectively. The median ventricular rate at diagnosis was significantly higher in infants with NDI compared to those without (265 vs 229 bpm; P = 0.003). In infants with NDI, compared to those without, fetal hydrops with subcutaneous edema at diagnosis was more common (50.0% vs 2.6%; P = 0.019) and the duration of fetal effusion was longer (median, 10.5 vs 0 days; P = 0.013). Postnatal arrhythmia and physical development abnormalities were not associated with NDI. CONCLUSIONS This multicenter 3-year follow-up study is the first to demonstrate the long-term mortality and morbidity of infants born following protocol-defined transplacental treatment for fetal SVT and AFL. NDI was associated with the presence of fetal hydrops with subcutaneous edema at diagnosis and longer duration of fetal effusion. Neurodevelopmental delay was detected only in infants with severe congenital abnormalities. Therefore, in infants that have undergone antenatal treatment for fetal tachyarrhythmia and in which there are no comorbidities, the risk of NDI is low. However, in those with fetal hydrops with subcutaneous edema and/or associated severe congenital abnormalities, the risk for long-term neurologic morbidity might be considered somewhat increased. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- T Miyoshi
- Department of Regenerative Medicine and Tissue Engineering, National Cerebral and Cardiovascular Center, Suita, Japan
- Clinical Research Center, National Center for Child Health and Development, Tokyo, Japan
| | - Y Maeno
- Department of Pediatrics and Child Health, Kurume University School of Medicine, Kurume, Japan
| | - T Matsuda
- Department of Pediatrics, Yonaha Okanoue Hospital, Kuwana, Japan
| | - Y Ito
- Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - N Inamura
- Department of Pediatric Cardiology, Osaka Women's and Children's Hospital, Izumi, Japan
| | - K-S Kim
- Department of Cardiology, Kanagawa Children's Medical Center, Yokohama, Japan
| | - I Shiraishi
- Department of Pediatric Cardiology, NCVC, Suita, Japan
| | - K Kurosaki
- Department of Pediatric Cardiology, NCVC, Suita, Japan
| | - T Ikeda
- Department of Obstetrics and Gynecology, Mie University, Tsu, Japan
| | - H Sago
- Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
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11
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Haxel CS, Johnson JN, Hintz S, Renno MS, Ruano R, Zyblewski SC, Glickstein J, Donofrio MT. Care of the Fetus With Congenital Cardiovascular Disease: From Diagnosis to Delivery. Pediatrics 2022; 150:189887. [PMID: 36317976 DOI: 10.1542/peds.2022-056415c] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/29/2022] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND The majority of congenital cardiovascular disease including structural cardiac defects, abnormalities in cardiac function, and rhythm disturbances can be identified prenatally using screening obstetrical ultrasound with referral for fetal echocardiogram when indicated. METHODS Diagnosis of congenital heart disease in the fetus should prompt assessment for extracardiac abnormalities and associated genetic abnormalities once maternal consent is obtained. Pediatric cardiologists, in conjunction with maternal-fetal medicine, neonatology, and cardiothoracic surgery subspecialists, should counsel families about the details of the congenital heart defect as well as prenatal and postnatal management. RESULTS Prenatal diagnosis often leads to increased maternal depression and anxiety; however, it decreases morbidity and mortality for many congenital heart defects by allowing clinicians the opportunity to optimize prenatal care and plan delivery based on the specific lesion. Changes in prenatal care can include more frequent assessments through the remainder of the pregnancy, maternal medication administration, or, in selected cases, in utero cardiac catheter intervention or surgical procedures to optimize postnatal outcomes. Delivery planning may include changing the location, timing or mode of delivery to ensure that the neonate is delivered in the most appropriate hospital setting with the required level of hospital staff for immediate postnatal stabilization. CONCLUSIONS Based on the specific congenital heart defect, prenatal echocardiogram assessment in late gestation can often aid in predicting the severity of postnatal instability and guide the medical or interventional level of care needed for immediate postnatal intervention to optimize the transition to postnatal circulation.
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Affiliation(s)
- Caitlin S Haxel
- The University of Vermont Children's Hospital, Burlington, Vermont
| | | | - Susan Hintz
- Stanford University, Lucille Salter Packard Children's Hospital, Palo Alto, California
| | - Markus S Renno
- University Arkansas for Medical Sciences, Little Rock, Arkansas
| | | | | | - Julie Glickstein
- Columbia University Vagelos School of Medicine, Morgan Stanley Children's Hospital, New York, New York
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12
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Favourable outcome for hydrops or cardiac failure associated with fetal tachyarrhythmia: a 20-year review. Cardiol Young 2022; 32:1077-1084. [PMID: 34551832 DOI: 10.1017/s104795112100367x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Prognosis of fetuses with hydrops and tachyarrhythmia has been portrayed as poor in most published reports. This might lead to biased counselling, unnecessary caesarean section, preterm delivery, and even termination of pregnancy. AIMS To evaluate contemporary fetal and postnatal outcomes of hydropic fetuses with fetal tachyarrhythmia when it is treated effectively and monitored systematically. METHODS This is a retrospective review of a single centre experience at the University Hospital of Wales over a 20-year period. All fetuses received high doses of flecainide and digoxin combination treatment. Tachycardia response rate, time to arrhythmia and hydrops resolution, fetal and postnatal morbidity, and mortality rates were analysed. RESULTS Twenty fetuses were diagnosed with hydrops fetalis and received treatment. The mechanism of fetal tachyarrhythmia was supraventricular tachycardia in thirteen and atrial flutter in eight cases. Among the 20 fetuses treated, the overall tachycardia response rate was 90% (18/20) with the restoration of sinus rhythm in 85% (17/20) of the cases. The median time to restore sinus rhythm or to rate control of the arrhythmia was 1.5 days (range 12 hours to 13 days). Hydrops resolved in 17 of the 20 fetuses, with a median time of 12 days (range 3-21 days). Four fetuses went into spontaneous preterm birth and one fetus was delivered early due to worsening hydrops. No significant neurological morbidity was observed in surviving neonates and infants on clinical examination. There was one postnatal death due to respiratory complications of prematurity in the non-responsive supraventricular tachycardia case. CONCLUSIONS High-dose flecainide and digoxin combination offers effective treatment strategy in fetuses with hydrops and tachyarrhythmia with favourable outcomes. This study may guide more realistic counselling for pregnancies complicated by tachyarrhythmia and hydrops.
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13
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Qin J, Deng Z, Tang C, Zhang Y, Hu R, Li J, Hua Y, Li Y. Efficacy and Safety of Various First-Line Therapeutic Strategies for Fetal Tachycardias: A Network Meta-Analysis and Systematic Review. Front Pharmacol 2022; 13:935455. [PMID: 35770083 PMCID: PMC9235149 DOI: 10.3389/fphar.2022.935455] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 05/24/2022] [Indexed: 11/26/2022] Open
Abstract
Background: Fetal arrhythmias are common cardiac abnormalities associated with high mortality due to ventricular dysfunction and heart failure, particularly when accompanied by hydrops. Although several types of common fetal tachycardias have been relatively identified medications, such as digoxin, flecainide, and sotalol, there is no first-line drug treatment protocol established for the treatment of various types of fetal tachycardias. Methods: We conducted a network meta-analysis using a Bayesian hierarchical framework to obtain a model for integrating both direct and indirect evidence. All tachycardia types (Total group), supraventricular tachycardia (SVT subgroup), atrial flutter (AF subgroup), hydrops subgroup, and non-hydrops subgroup fetuses were analyzed, and five first-line regimens were ranked according to treatment outcomes: digoxin monotherapy (D), flecainide monotherapy (F), sotalol monotherapy (S), digoxin plus flecainide combination therapy (DF), and digoxin plus sotalol combination therapy (DS). Effectiveness and safety were determined according to the cardioversion rate and intrauterine death rate. Results: The pooled data indicated that DF combination therapy was always superior to D monotherapy, regardless of the tachycardia type or the presence of hydrops: Total, 2.44 (95% CrI: 1.59, 3.52); SVT, 2.77 (95% CrI: 1.59, 4.07); AF, 67.85 (95% CrI: 14.25, 168.68); hydrops, 6.03 (95% CrI: 2.54, 10.68); and non-hydrops, 5.06 (95% CrI: 1.87, 9.88). DF and F had a similar effect on control of fetal tachycardias. No significant differences were observed when comparing S, DS with D therapies across the subgroup analyses for the SVT, hydrops, and non-hydrops groups. No significant differences in mortality risks were among the various treatment regimens for the total group. And no significant differences were found in rates of intrauterine death rates at the same cardioversion amount. Conclusion The flecainide monotherapy and combination of digoxin and flecainide should be considered the most superior therapeutic strategies for fetal tachycardia. Systematic Review Registration: (https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=288997), identifier (288997).
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Affiliation(s)
- Jiangwei Qin
- Key Laboratory of Birth Defects and Related Diseases of Women and Children of MOE, Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Zhengrong Deng
- Key Laboratory of Birth Defects and Related Diseases of Women and Children of MOE, Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Changqing Tang
- Department of Pediatric Cardiology, Children’s Hospital of Soochow University, Suzhou, China
| | - Yunfan Zhang
- Key Laboratory of Birth Defects and Related Diseases of Women and Children of MOE, Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Ruolan Hu
- Key Laboratory of Birth Defects and Related Diseases of Women and Children of MOE, Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Jiawen Li
- Key Laboratory of Birth Defects and Related Diseases of Women and Children of MOE, Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Yimin Hua
- Key Laboratory of Birth Defects and Related Diseases of Women and Children of MOE, Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Yifei Li
- Key Laboratory of Birth Defects and Related Diseases of Women and Children of MOE, Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China
- *Correspondence: Yifei Li,
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14
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Fetal Intervention for Refractory Supraventricular Tachycardia Complicated by Hydrops Fetalis. Case Rep Obstet Gynecol 2022; 2022:5148250. [PMID: 35313721 PMCID: PMC8934222 DOI: 10.1155/2022/5148250] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Revised: 02/22/2022] [Accepted: 03/04/2022] [Indexed: 11/17/2022] Open
Abstract
Introduction. Few reports have shown promising treatments for refractory fetal tachycardia. Data are limited regarding optimal treatment, route of treatment, and medication dosages. Over 90% of cases of fetal tachycardia can be attributed to supraventricular tachycardia (SVT). The first-line treatment of fetal SVT is transplacental digoxin. Case Presentation. We present the management of a patient with fetal tachyarrhythmia diagnosed at 24 weeks and offer a unique approach for treatment. Fetal intramuscular injection of 72.3 mcg of digoxin allowed for resolution of SVT and sustained normal sinus rhythm. Further assessment in the third trimester showed persistent hydrops in the setting of mirror (Ballantyne's) syndrome resulting in delivery. Discussion/Conclusion. Our observations suggest that a one-time injection of digoxin allows for complete resolution of SVT. Utilizing an invasive approach for management of SVT that is resistant to traditional treatment modalities appears to both be therapeutic and decrease maternal adverse effects associated with more toxic effects of other transplacental medications.
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15
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Gozar L, Gabor-Miklosi D, Toganel R, Fagarasan A, Gozar H, Toma D, Cerghit-Paler A. Fetal Tachyarrhythmia Management from Digoxin to Amiodarone-A Review. J Clin Med 2022; 11:jcm11030804. [PMID: 35160256 PMCID: PMC8836967 DOI: 10.3390/jcm11030804] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 01/26/2022] [Accepted: 01/31/2022] [Indexed: 11/21/2022] Open
Abstract
Sustained fetal tachycardias are rare but represent a high risk of mortality and morbidity. Consensus has yet to be found regarding their optimal management. The aim of this narrative review is to summarize the data available in the current literature regarding the efficacy and safety of medications used in the management of intrauterine tachyarrhythmias and to provide possible treatment protocols. In this review, we would like to emphasize the importance of a thorough evaluation of both the fetus and the mother, prior to transplacental antiarrhythmic drug initiation. Factors such as the hemodynamic status of the fetus, possible mechanisms of fetal arrhythmia, and concomitant maternal conditions are of primordial importance. As a possible treatment protocol, we would like to recommend the following: due to the risk of sustained supraventricular tachycardia (SVT), fetuses with frequent premature atrial beats should be evaluated more frequently by echocardiography. A careful hemodynamic evaluation of a fetus with tachycardia is primordial in forestalling the appearance of hydrops. In the case of atrial flutter (AFL), sotalol therapy could represent a first choice, whereas when dealing with SVT patients, flecainide should be considered, especially for hydropic patients. These data require consolidation through larger scale, non-randomized studies and should be handled with caution.
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Affiliation(s)
- Liliana Gozar
- Department of Pediatrics, “George Emil Palade” University of Medicine, Pharmacy, Science, and Technology of Târgu-Mureș, 540139 Târgu-Mureș, Romania; (L.G.); (R.T.); (A.F.); (D.T.); (A.C.-P.)
- Pediatric Cardiology, Emergency Institute of Cardiovascular Diseases and Transplantation, 540139 Târgu-Mureș, Romania
| | - Dorottya Gabor-Miklosi
- Pediatric Cardiology, Emergency Institute of Cardiovascular Diseases and Transplantation, 540139 Târgu-Mureș, Romania
- Correspondence: ; Tel.: +40-740-371-322
| | - Rodica Toganel
- Department of Pediatrics, “George Emil Palade” University of Medicine, Pharmacy, Science, and Technology of Târgu-Mureș, 540139 Târgu-Mureș, Romania; (L.G.); (R.T.); (A.F.); (D.T.); (A.C.-P.)
- Pediatric Cardiology, Emergency Institute of Cardiovascular Diseases and Transplantation, 540139 Târgu-Mureș, Romania
| | - Amalia Fagarasan
- Department of Pediatrics, “George Emil Palade” University of Medicine, Pharmacy, Science, and Technology of Târgu-Mureș, 540139 Târgu-Mureș, Romania; (L.G.); (R.T.); (A.F.); (D.T.); (A.C.-P.)
- Pediatric Cardiology, Emergency Institute of Cardiovascular Diseases and Transplantation, 540139 Târgu-Mureș, Romania
| | - Horea Gozar
- Department of Pediatric Surgery, “George Emil Palade” University of Medicine, Pharmacy, Science, and Technology of Târgu-Mureș, 540139 Târgu-Mureș, Romania;
| | - Daniela Toma
- Department of Pediatrics, “George Emil Palade” University of Medicine, Pharmacy, Science, and Technology of Târgu-Mureș, 540139 Târgu-Mureș, Romania; (L.G.); (R.T.); (A.F.); (D.T.); (A.C.-P.)
- Pediatric Cardiology, Emergency Institute of Cardiovascular Diseases and Transplantation, 540139 Târgu-Mureș, Romania
| | - Andreea Cerghit-Paler
- Department of Pediatrics, “George Emil Palade” University of Medicine, Pharmacy, Science, and Technology of Târgu-Mureș, 540139 Târgu-Mureș, Romania; (L.G.); (R.T.); (A.F.); (D.T.); (A.C.-P.)
- Pediatric Cardiology, Emergency Institute of Cardiovascular Diseases and Transplantation, 540139 Târgu-Mureș, Romania
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16
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Jeong SI, Won H, Song I, Oh J. Therapeutic drug monitoring on the use of transplacental digoxin in fetal tachyarrhythmia: a case report. Transl Clin Pharmacol 2022; 30:83-86. [PMID: 35800665 PMCID: PMC9253450 DOI: 10.12793/tcp.2022.30.e11] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 06/17/2022] [Accepted: 06/17/2022] [Indexed: 11/19/2022] Open
Affiliation(s)
- Sae Im Jeong
- Department of Clinical Pharmacology and Therapeutics, Seoul National University College of Medicine and Hospital, Seoul 03080, Korea
| | - Heejae Won
- Department of Clinical Pharmacology and Therapeutics, Seoul National University College of Medicine and Hospital, Seoul 03080, Korea
| | - Ildae Song
- Department of Pharmaceutical Science and Technology, Kyungsung University, Busan 48434, Korea
| | - Jaeseong Oh
- Department of Clinical Pharmacology and Therapeutics, Seoul National University College of Medicine and Hospital, Seoul 03080, Korea
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17
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Demirci O, Tosun Ö, Bolat G. Prenatal Diagnosis and Management of Fetal Supraventricular Tachyarrhythmia and Postnatal outcomes. J Gynecol Obstet Hum Reprod 2022; 51:102323. [DOI: 10.1016/j.jogoh.2022.102323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 01/02/2022] [Accepted: 01/17/2022] [Indexed: 10/19/2022]
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18
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Purkayastha S, Weinreich M, Fontes J, Lau JF, Wolfe DS, Bortnick AE. Fetal Supraventricular Tachycardia: What the Adult Cardiologist Needs to Know. Cardiol Rev 2022; 30:31-37. [PMID: 33165088 PMCID: PMC8715790 DOI: 10.1097/crd.0000000000000370] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Fetal supraventricular tachycardia management is challenging, with consequences for both the fetus and the mother. If left untreated, fetal hydrops may ensue, at which point delivery and treatment of the arrhythmia is preferred. However, if the fetus is not at term nor near-term, significant doses of antiarrhythmics may be needed to achieve adequate transplacental bioavailability. Although digoxin has classically been the mainstay of treatment, the use of flecainide or sotalol as monotherapy or in combination with digoxin is being studied. Interdisciplinary team management and shared decision-making between the physician and patient are key to achieving successful outcomes. Adult cardiologists, particularly inpatient consultation services or through burgeoning cardio-obstetrics programs, may, in some practice settings, be asked to evaluate or comanage pregnant women with fetal arrhythmia.
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Affiliation(s)
- Sutopa Purkayastha
- Department of Medicine, Maternal Fetal Medicine-Cardiology Joint Program at Montefiore Health System and Albert Einstein College of Medicine, Bronx, NY
| | - Michael Weinreich
- Department of Medicine, Maternal Fetal Medicine-Cardiology Joint Program at Montefiore Health System and Albert Einstein College of Medicine, Bronx, NY
| | - Joao Fontes
- Department of Medicine, Maternal Fetal Medicine-Cardiology Joint Program at Montefiore Health System and Albert Einstein College of Medicine, Bronx, NY
| | - Joe F. Lau
- Department of Cardiology, Long Island Jewish Medical Center, Northwell Health, New Hyde Park, NY
| | - Diana S. Wolfe
- Division of Geriatrics, Maternal Fetal Medicine-Cardiology Joint Program at Montefiore Health System and Albert Einstein College of Medicine, Bronx, NY
- Department of Obstetrics and Gynecology, Montefiore Medical Center, and Albert Einstein College of Medicine, Bronx, NY
| | - Anna E. Bortnick
- Department of Medicine, Maternal Fetal Medicine-Cardiology Joint Program at Montefiore Health System and Albert Einstein College of Medicine, Bronx, NY
- Division of Cardiology, Maternal Fetal Medicine-Cardiology Joint Program at Montefiore Health System and Albert Einstein College of Medicine, Bronx, NY
- Division of Geriatrics, Maternal Fetal Medicine-Cardiology Joint Program at Montefiore Health System and Albert Einstein College of Medicine, Bronx, NY
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19
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Broom E, Thomas JT, Petersen S, Gooi A, Ward C, Gardener G, Kostner K, Lee-Tannock A, Kumar S. Management of Fetal Supraventricular Tachycardia: Case Series from a Tertiary Perinatal Cardiac Center. Fetal Diagn Ther 2021; 48:794-800. [PMID: 34753148 DOI: 10.1159/000519911] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Accepted: 08/16/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Fetal supraventricular tachycardia is a relatively uncommon cardiac rhythm abnormality which is often associated with adverse perinatal outcomes if untreated. Although there are several treatment modalities and protocols in use globally, there is no consensus as to the most effective antiarrhythmic to manage this condition. AIM This study aimed to evaluate perinatal outcomes following prenatal maternal therapy for fetal supraventricular tachycardia. MATERIALS AND METHODS This was a 20-year retrospective cohort study. Institutional records were reviewed for antenatal therapy choice and maternal and fetal outcomes. RESULTS Sixty-nine cases met diagnostic criteria for fetal SVT, of which 56 (81%) received maternal antiarrhythmic therapy. Digoxin was the most common, but least effective, first-line therapy in 28 patients, achieving successful rate reversion in 35.7%. Thirty-one patients (55%) required second-line therapy, and this was most successful with digoxin and flecainide polytherapy achieving rate reversion in 17 of 18 cases (94.5%) at a median of 3 days (1.5-7). Hydrops was present in 23 (33%) cases at initial presentation, 16 of which achieved rate reversion. There was minimal difference in treatment efficacy comparing single- or multiple-agent treatment in the setting of hydrops (50% vs. 42.8%). Side effects occurred in 14/56 treated patients (25%) but were severe in only 8 (14.3%) women, most commonly with digoxin and flecainide polytherapy (6 of 8 cases). There were 3 (4%) fetal deaths amongst the study cohort. CONCLUSIONS Digoxin and flecainide polytherapy were well tolerated and successfully achieved rhythm and rate control in fetuses with prenatally diagnosed supraventricular tachycardia. The presence of hydrops was a poor prognostic feature.
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Affiliation(s)
- Elisha Broom
- Mater Centre for Maternal Fetal Medicine, Mater Mother's Hospital, South Brisbane, Queensland, Australia
| | - Joseph T Thomas
- Mater Centre for Maternal Fetal Medicine, Mater Mother's Hospital, South Brisbane, Queensland, Australia.,Mater Research Institute-University of Queensland, Aubigny Place, Raymond Terrace, South Brisbane, Queensland, Australia
| | - Scott Petersen
- Mater Centre for Maternal Fetal Medicine, Mater Mother's Hospital, South Brisbane, Queensland, Australia.,Mater Research Institute-University of Queensland, Aubigny Place, Raymond Terrace, South Brisbane, Queensland, Australia
| | - Alex Gooi
- Qld Paediatric Cardiac Service, Queensland Children's Hospital, South Brisbane, Queensland, Australia
| | - Cameron Ward
- Qld Paediatric Cardiac Service, Queensland Children's Hospital, South Brisbane, Queensland, Australia
| | - Glenn Gardener
- Mater Centre for Maternal Fetal Medicine, Mater Mother's Hospital, South Brisbane, Queensland, Australia.,Mater Research Institute-University of Queensland, Aubigny Place, Raymond Terrace, South Brisbane, Queensland, Australia
| | - Karam Kostner
- Department of Adult Cardiology, Mater Health Services, South Brisbane, Queensland, Australia
| | - Alison Lee-Tannock
- Mater Centre for Maternal Fetal Medicine, Mater Mother's Hospital, South Brisbane, Queensland, Australia
| | - Sailesh Kumar
- Mater Centre for Maternal Fetal Medicine, Mater Mother's Hospital, South Brisbane, Queensland, Australia.,Mater Research Institute-University of Queensland, Aubigny Place, Raymond Terrace, South Brisbane, Queensland, Australia.,Department of Obstetrics and Gynaecology, Faculty of Medicine, The University of Queensland, Herston, Queensland, Australia
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20
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Jouannic JM, Guilbaud L, Maurice P, Maisonneuve E, de Saint Denis T, du Peuty C, Zerah M. [The ethics of fetal myelomeningocele surgery]. ACTA ACUST UNITED AC 2021; 50:189-193. [PMID: 34656790 DOI: 10.1016/j.gofs.2021.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Indexed: 10/20/2022]
Abstract
Fetal myelomeningocele surgery was introduced in France in 2014. Developments in prenatal diagnosis of neural tube defects have accompanied the development of prenatal diagnosis. This fetal surgery represents one of the three possible care paths for pregnant women faced with this prenatal diagnosis. The ethical issues of this fetal surgery are discussed and in particular regarding prenatal counselling and patient autonomy of choice.
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Affiliation(s)
- J-M Jouannic
- Service de médecine fœtale, Sorbonne Université, AP-HP Sorbonne Université, Hôpital Armand-Trousseau, 26, avenue du Docteur-Arnold-Netter, 75012 Paris, France; Centre de référence Maladies Rares C-MAVEM, Hôpital Armand Trousseau, AP-HP Sorbonne Université, 26, avenue du Docteur-Arnold-Netter, 75012 Paris, France.
| | - L Guilbaud
- Service de médecine fœtale, Sorbonne Université, AP-HP Sorbonne Université, Hôpital Armand-Trousseau, 26, avenue du Docteur-Arnold-Netter, 75012 Paris, France; Centre de référence Maladies Rares C-MAVEM, Hôpital Armand Trousseau, AP-HP Sorbonne Université, 26, avenue du Docteur-Arnold-Netter, 75012 Paris, France
| | - P Maurice
- Service de médecine fœtale, Sorbonne Université, AP-HP Sorbonne Université, Hôpital Armand-Trousseau, 26, avenue du Docteur-Arnold-Netter, 75012 Paris, France; Centre de référence Maladies Rares C-MAVEM, Hôpital Armand Trousseau, AP-HP Sorbonne Université, 26, avenue du Docteur-Arnold-Netter, 75012 Paris, France
| | - E Maisonneuve
- Service de médecine fœtale, Sorbonne Université, AP-HP Sorbonne Université, Hôpital Armand-Trousseau, 26, avenue du Docteur-Arnold-Netter, 75012 Paris, France; Centre de référence Maladies Rares C-MAVEM, Hôpital Armand Trousseau, AP-HP Sorbonne Université, 26, avenue du Docteur-Arnold-Netter, 75012 Paris, France
| | - T de Saint Denis
- Centre de référence Maladies Rares C-MAVEM, Hôpital Armand Trousseau, AP-HP Sorbonne Université, 26, avenue du Docteur-Arnold-Netter, 75012 Paris, France; Service de neurochirurgie pédiatrique, Hôpital Necker, Université de Paris, 149, rue du Sèvres, 75015 Paris, France
| | - C du Peuty
- Service de médecine fœtale, Sorbonne Université, AP-HP Sorbonne Université, Hôpital Armand-Trousseau, 26, avenue du Docteur-Arnold-Netter, 75012 Paris, France
| | - M Zerah
- Centre de référence Maladies Rares C-MAVEM, Hôpital Armand Trousseau, AP-HP Sorbonne Université, 26, avenue du Docteur-Arnold-Netter, 75012 Paris, France; Service de neurochirurgie pédiatrique, Hôpital Necker, Université de Paris, 149, rue du Sèvres, 75015 Paris, France
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21
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Treatment of Fetal Arrhythmias. J Clin Med 2021; 10:jcm10112510. [PMID: 34204066 PMCID: PMC8201238 DOI: 10.3390/jcm10112510] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Revised: 06/01/2021] [Accepted: 06/01/2021] [Indexed: 11/16/2022] Open
Abstract
Fetal arrhythmias are mostly benign and transient. However, some of them are associated with structural defects or can cause heart failure, fetal hydrops, and can lead to intrauterine death. The analysis of fetal heart rhythm is based on ultrasound (M-mode and Doppler echocardiography). Irregular rhythm due to atrial ectopic beats is the most common type of fetal arrhythmia and is generally benign. Tachyarrhythmias are diagnosed when the fetal heart rate is persistently above 180 beats per minute (bpm). The most common fetal tachyarrhythmias are paroxysmal supraventricular tachycardia and atrial flutter. Most fetal tachycardias can be terminated or controlled by transplacental or direct administration of anti-arrhythmic drugs. Fetal bradycardia is diagnosed when the fetal heart rate is slower than 110 bpm. Persistent bradycardia outside labor or in the absence of placental pathology is mostly due to atrioventricular (AV) block. Approximately half of fetal heart blocks are in cases with structural heart defects, and AV block in cases with structurally normal heart is often caused by maternal anti-Ro/SSA antibodies. The efficacy of prenatal treatment for fetal AV block is limited. Our review aims to provide a practical guide for the diagnosis and management of common fetal arrythmias, from the joint perspective of the fetal medicine specialist and the cardiologist.
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22
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Battistuz E, Travan L, Bua J, Trappan A, Galdo F, Bobbo M, Barbi E, Risso FM. Newborn with hydrops fetalis and a severe supraventricular arrhythmia. Arch Dis Child Educ Pract Ed 2021; 106:103-104. [PMID: 31434639 DOI: 10.1136/archdischild-2019-317410] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Accepted: 07/21/2019] [Indexed: 11/04/2022]
Affiliation(s)
| | - Laura Travan
- IRCCS materno infantile Burlo Garofolo, Trieste, Italy
| | - Jenny Bua
- IRCCS materno infantile Burlo Garofolo, Trieste, Italy
| | | | | | - Marco Bobbo
- IRCCS materno infantile Burlo Garofolo, Trieste, Italy
| | - Egidio Barbi
- University of Trieste, Trieste, Italy.,IRCCS materno infantile Burlo Garofolo, Trieste, Italy
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23
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Takatsuka H, Wakabayashi K, Yamazaki S, Tanaka H, Omoto A, Suzuki T, Shozu M, Ishii I. Transition of maternal serum concentration of digoxin and flecainide in the third trimester-A case report of fetal supraventricular tachycardia with hydrops. Clin Case Rep 2021; 9:e03992. [PMID: 34026129 PMCID: PMC8117821 DOI: 10.1002/ccr3.3992] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Revised: 12/30/2020] [Accepted: 02/13/2021] [Indexed: 11/25/2022] Open
Abstract
When transplacental therapy is conducted, the maternal serum concentrations of digoxin and flecainide may fluctuate throughout third trimester. Therefore, TDM may be effective in improving the efficacy and safety of treatment.
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Affiliation(s)
| | | | | | - Hirokazu Tanaka
- Department of Obstetrics and Gynecology International University of Health and Welfare Narita Hospital Chiba Japan
| | - Akiko Omoto
- Department of Maternal-Fetal Medicine Chiba University Hospital Chiba Japan
| | - Takaaki Suzuki
- Division of Pharmacy Chiba University Hospital Chiba Japan.,Graduate School of Pharmaceutical Sciences Chiba University Chiba Japan
| | - Makio Shozu
- Department of Reproductive Medicine Graduate School of Medicine Chiba University Chiba Japan
| | - Itsuko Ishii
- Division of Pharmacy Chiba University Hospital Chiba Japan.,Graduate School of Pharmaceutical Sciences Chiba University Chiba Japan
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24
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Eckardt L. [Cardiac arrhythmias in pregnancy : Epidemiology, clinical characteristics, and treatment options]. Herzschrittmacherther Elektrophysiol 2021; 32:137-144. [PMID: 33740101 DOI: 10.1007/s00399-021-00752-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Accepted: 03/15/2021] [Indexed: 12/12/2022]
Abstract
Symptomatic arrhythmias rarely occur during pregnancy and are predominantly benign. However, the increasing average age of women who are pregnant, especially in Western European countries, has contributed to a significant increase in arrhythmias in pregnant women in recent years. Previous or existing heart diseases can increase the occurrence of arrhythmias. In most cases pregnancy is safe and without consequences for the child and/or mother. Further cardiological work-up (including ECG and echocardiography, and possibly cardiac MRI) should always be performed. The indication for treatment should be made in close cooperation between obstetricians and cardiologists considering symptoms, hemodynamics and prognosis. In the absence of larger studies on efficacy and side effects of antiarrhythmic drugs, these should be administered very cautiously, under strict indication and whenever possible by avoiding the first trimester. Cardiologists with special expertise in arrhythmias should always be consulted, especially in the case of complex and relevant rhythm disturbances.
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Affiliation(s)
- Lars Eckardt
- Klinik für Kardiologie II - Rhythmologie, Universitätsklinikum Münster, Albert-Schweitzer-Campus1, Gebäude A1, 48149, Münster, Deutschland.
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Bartin R, Maltret A, Nicloux M, Ville Y, Bonnet D, Stirnemann J. Outcomes of sustained fetal tachyarrhythmias after transplacental treatment. Heart Rhythm O2 2021; 2:160-167. [PMID: 34113918 PMCID: PMC8183966 DOI: 10.1016/j.hroo.2021.02.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Background Fetal tachyarrhythmia is a condition that may lead to cardiac dysfunction, hydrops, and death. Despite a transplacental treatment, failure to obtain or maintain sinus rhythm may occur. Objective We aimed to analyze the perinatal outcomes of sustained fetal tachyarrhythmias after in utero treatment. Methods We performed a retrospective evaluation of 69 cases with sustained fetal tachyarrhythmia. We compared the perinatal and long-term outcomes of prenatally converted and drug-resistant fetuses. Tachyarrhythmia subtypes were also evaluated. Results Conversion to sinus rhythm was obtained in 74% of cases; 26% of cases were drug-resistant and delivered arrhythmic. Three perinatal deaths occurred in both groups (6.7% vs 17%, P = .34). Neonates delivered arrhythmic were more frequently admitted to neonatal intensive care units (75% vs 31%, P < .01), and their hospital stay was longer (20.9 vs 6.64 days, P < .001). Multiple neonatal recurrences (81% vs 11%, P < .001), temporary hemodynamic dysfunction or heart failure (50% vs 6.7%, P < .001), and postnatal use of a combination treatment (44% vs 13%, P = .028) were also more frequent in this population. Beyond the neonatal period, rates of recurrences within the first 16 months were higher in drug-resistant fetuses (HR = 16.14, CI 95% [4.485; 193.8], P < .001). In this population, postnatal electrocardiogram revealed an overrepresentation of rare mechanisms, especially permanent junctional reciprocating tachycardia (PJRT) (31%). Conclusion Prenatal conversion to stable sinus rhythm is a major determinant of perinatal and long-term outcomes in fetal tachyarrhythmias. The underlying electrophysiological mechanisms have a major role in predicting these differential outcomes with an overrepresentation of PJRT in the drug-resistant population.
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Affiliation(s)
- Raphael Bartin
- Obstetric and Maternal Fetal Medicine and EA7328.,Hôpital universitaire Necker-Enfants malades, AP-HP
| | - Alice Maltret
- M3C-Necker, Pediatric and Congenital Cardiology Unit.,Hôpital universitaire Necker-Enfants malades, AP-HP
| | - Muriel Nicloux
- Neonatology and Neonatal Intensive Care Unit.,Hôpital universitaire Necker-Enfants malades, AP-HP
| | - Yves Ville
- Obstetric and Maternal Fetal Medicine and EA7328.,Hôpital universitaire Necker-Enfants malades, AP-HP.,Université de Paris, Paris, France
| | - Damien Bonnet
- M3C-Necker, Pediatric and Congenital Cardiology Unit.,Hôpital universitaire Necker-Enfants malades, AP-HP.,Université de Paris, Paris, France
| | - Julien Stirnemann
- Obstetric and Maternal Fetal Medicine and EA7328.,Hôpital universitaire Necker-Enfants malades, AP-HP.,Université de Paris, Paris, France
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26
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Chen T, Yang Y, Shi K, Pan Y, Wei S, Yang Z, Yang X. Multiple antiarrhythmic transplacental treatments for fetal supraventricular tachyarrhythmia: A protocol for systematic review and meta analysis. Medicine (Baltimore) 2020; 99:e23534. [PMID: 33327301 PMCID: PMC7738056 DOI: 10.1097/md.0000000000023534] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Revised: 10/30/2020] [Accepted: 11/06/2020] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Fetal supraventricular tachyarrhythmia is a common reason for referral to fetal cardiology. Multiple antiarrhythmic transplacental medications can be used to treat these diseases. Debates remain regarding the standardized therapy. METHODS PubMed, EMBASE, Cochrane Library, Web of Science, Google Scholar, and ClinicalTrials.gov will be searched from inception to September 2020. A handsearching for gray literature, including unpublished conference articles, will be performed. The randomized control trials, case-control, and cohort studies will be accepted, no matter what the languages they were reported. We will first focus on the effectiveness of the therapy on fetal cardiac rhythm and/or heart rate. Then we will do further analysis of preterm delivery, fetal hydrops, intrauterine fetal demise, and maternal side effects. The Cochrane Risk of Bias Tool and the Newcastle-Ottawa scale will be used to assess the risk of bias of the randomized controlled trials, case-control, and cohort studies, respectively. Two independent reviewers will carry out literature identification, data collection, and study quality assessment. Discrepancies will be resolved by a third reviewer. Statistical analysis will be conducted using the STATA 13.0 software. RESULT The results will provide helpful information about the effect of multiple antiarrhythmic transplacental therapies in pregnancies with supraventricular tachycardia or atrial flutter, and demonstrate which therapy is more effective. CONCLUSION The conclusion drawn from this systematic review will benefit the patients with fetal supraventricular tachyarrhythmia.
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Affiliation(s)
| | | | - Kun Shi
- Department of Pediatric Cardiology
| | | | | | - Zexuan Yang
- Department of Ultrasound, Chengdu Women's and Children’ s Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
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27
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Eckardt L, Schmitz R. Rhythmusstörungen in der Schwangerschaft. AKTUELLE KARDIOLOGIE 2020. [DOI: 10.1055/a-1283-5661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
ZusammenfassungSymptomatische Rhythmusstörungen treten während einer Schwangerschaft selten auf und sind überwiegend gutartig. Sie stellen dennoch eine besondere klinische Herausforderung dar, wobei sich diagnostische und therapeutische Möglichkeiten in Zusammenhang mit gleichzeitig älterem Durchschnittsalter bei Schwangerschaften in den vergangenen Jahren deutlich verbessert haben. In der Regel ist eine Schwangerschaft trotz Auftreten von Rhythmusstörungen sicher und ohne Folgen für das Kind. Vorbekannte oder vorhandene Herzerkrankungen können das Auftreten von Rhythmusstörungen begünstigen. Es sollte immer eine weiterführende kardiologische Diagnostik (u. a. EKG und Echokardiografie) erfolgen. Die Indikation zur Therapie sollte in enger Absprache zwischen Geburtsmediziner und Kardiologen/Rhythmologen erfolgen und dabei Symptomatik, Hämodynamik und Prognose berücksichtigen. Bei fehlenden größeren Studien zu Wirksamkeit und Nebenwirkungen von Antiarrhythmika sollten diese nur sehr
zurückhaltend, unter strenger Indikation und am ehesten unter Umgehung des 1. Trimenons verabreicht werden. Insbesondere bei komplexen und prognostisch relevanten Rhythmusstörungen sollten immer Kardiologen mit besonderer rhythmologischer Erfahrung hinzugezogen werden.
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Affiliation(s)
- Lars Eckardt
- Klinik für Kardiologie II – Rhythmologie, Universitätsklinikum Münster, Deutschland
| | - Ralf Schmitz
- Klinik für Frauenheilkunde und Geburtshilfe, Universitätsklinikum Münster, Deutschland
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Maternal effects induced by oral digoxin during treatment of fetal tachyarrhythmia: Case series and literature review. Eur J Obstet Gynecol Reprod Biol 2020; 256:354-357. [PMID: 33276280 DOI: 10.1016/j.ejogrb.2020.11.055] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Revised: 11/14/2020] [Accepted: 11/19/2020] [Indexed: 11/22/2022]
Abstract
OBJECTIVES The aim of this study is to evaluate the prevalence of maternal complications derived from digoxin treatment and its relationship with digoxinemia, as well as its occurrence in relation to the different treatment doses and therapeutic schemes used. STUDY DESIGN This is a retrospective observational study of women who received digoxin for the treatment of fetal tachyarrhythmia over a 10-year period at the University Hospital Virgen del Rocío (Seville). Data corresponding to the digoxin dose, its duration, serum digoxin levels and electrocardiographic parameters during follow-up were collected. Maternal side effects were reported, and its relationship to the treatment dose as well as digoxinemia. The study is accompanied by a narrative review of related literature. RESULTS There were 10 cases eligible. During treatment, as least one symptom or sign was present in 30 % of cases, being in all cases digestive symptoms. In all those cases, the digoxin level was higher than established as therapeutic threshold (2 ng/mL), and all reversed within a maximum of 48 h after the dose decrease. Digoxinemia overdosing (> 2 ng/mL) was observed in 6 women (60 %), one of which reached the toxicity range (> 3 ng/mL). In all cases, normal range was achieved decreasing the dose of digoxin 0.25 mg every 24 h. No patient developed side effects with digoxinemia below 2 ng/mL. No electrocardiographic abnormalities appeared during treatment. CONCLUSION Digoxin is a safe treatment for management of fetal tachyarrhythmias. Side effects appear frequently when serum digoxin level is over 2 ng/mL, but they are usually mild and self-limited. However, it remains advisable to monitor electrocardiographic changes and digoxinemia through the whole therapy to prevent serious complications related to digoxin toxicity.
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29
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Manolis TA, Manolis AA, Apostolopoulos EJ, Papatheou D, Melita H, Manolis AS. Cardiac arrhythmias in pregnant women: need for mother and offspring protection. Curr Med Res Opin 2020; 36:1225-1243. [PMID: 32347120 DOI: 10.1080/03007995.2020.1762555] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Cardiac arrhythmias are the most common cardiac complication reported in pregnant women with and without structural heart disease (SHD); they are more frequent among women with SHD, such as cardiomyopathy and congenital heart disease (CHD). While older studies had indicated supraventricular tachycardia as the most common tachyarrhythmia in pregnancy, more recent data indicate an increase in the frequency of arrhythmias, with atrial fibrillation (AF) emerging as the most frequent arrhythmia in pregnancy, attributed to an increase in maternal age, cardiovascular risk factors and CHD in pregnancy. Importantly, the presence of any tachyarrhythmia during pregnancy may be associated with adverse maternal and fetal outcomes, including death. Thus, both the mother and the offspring need to be protected from such consequences. The use of antiarrhythmic drugs (AADs) depends on clinical presentation and on the presence of underlying SHD, which requires caution as it promotes pro-arrhythmia. In hemodynamically compromised women, electrical cardioversion is successful and safe to both mother and fetus. Use of beta-blockers appears quite safe; however, caution is advised when using other AADs, while no AAD should be used, if at all possible, during the first trimester when organogenesis takes place. Regarding the anticoagulation regimen in patients with AF, warfarin should be substituted with heparin during the first trimester, while direct oral anticoagulants are not indicated given the lack of data in pregnancy. Finally, for refractory arrhythmias, ablation and/or device implantation can be performed with current techniques in pregnant women, when needed, using minimal exposure to radiation. All these issues and relevant current guidelines are herein reviewed.
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30
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Vedel C, Vejlstrup N, Jensen LN, Ekelund CK, Nørgaard LN, Harmsen L, Petersen OB, Jaeggi E, Gembruch U, Sundberg K. Refractory Fetal Supraventricular Tachycardia with Hydrops Successfully Converted by Intraperitoneal Flecainide in the Fetus: A Case Report. Fetal Diagn Ther 2020; 47:717-720. [PMID: 32570238 DOI: 10.1159/000508811] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Accepted: 05/19/2020] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Supraventricular tachycardia is the most common fetal tachyarrhythmia and if persistent often associated with fetal hydrops which can cause intrauterine and neonatal death. CASE PRESENTATION We present a case of early second trimester supraventricular tachycardia in a hydropic fetus, initially refractory to transplacental treatment. CONCLUSION The supraventricular tachycardia was successfully treated when supplemented with intraperitoneal flecainide in the fetus.
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Affiliation(s)
- Cathrine Vedel
- Center of Fetal Medicine and Pregnancy, Department of Obstetrics, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark, .,Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark,
| | - Niels Vejlstrup
- Department of Cardiology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Lisa Neerup Jensen
- Center of Fetal Medicine and Pregnancy, Department of Obstetrics, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Charlotte Kvist Ekelund
- Center of Fetal Medicine and Pregnancy, Department of Obstetrics, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark.,Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Lone Nikoline Nørgaard
- Center of Fetal Medicine and Pregnancy, Department of Obstetrics, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Lotte Harmsen
- Center of Fetal Medicine and Pregnancy, Department of Obstetrics, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Olav Bjørn Petersen
- Center of Fetal Medicine and Pregnancy, Department of Obstetrics, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark.,Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Edgar Jaeggi
- Division of Cardiology, Department of Pediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Ulrich Gembruch
- Department of Obstetrics and Prenatal Medicine, University of Bonn, Bonn, Germany
| | - Karin Sundberg
- Center of Fetal Medicine and Pregnancy, Department of Obstetrics, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
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Maciuleviciute A, Semenaite M, Gintautas V, Maciuleviciene R, Puodziukynas A, Savukyne E. Resolution of Fetal Hydrops Dependent on Sustained Fetal Supraventricular Tachycardia after Digoxin Therapy. ACTA ACUST UNITED AC 2020; 56:medicina56050223. [PMID: 32392830 PMCID: PMC7279374 DOI: 10.3390/medicina56050223] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Revised: 05/04/2020] [Accepted: 05/05/2020] [Indexed: 11/28/2022]
Abstract
We present a special case of fetal supraventricular tachycardia detected at 34 weeks gestation. Fetal hydrops was noted on ultrasound upon admission. Normal fetal heart rate was maintained for three weeks by maternal administration of digoxin. A live infant was delivered via caesarian section at 37 weeks gestation. This clinical case demonstrated that pharmacological treatment can be effective and helps to prolong pregnancy safely.
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Affiliation(s)
- Aureja Maciuleviciute
- Department of Obstetrics and Gynecology, Lithuanian University of Health Sciences, LT-50161 Kaunas, Lithuania; (M.S.); (V.G.); (R.M.); (E.S.)
- Correspondence: ; Tel.: +370-615-995-51
| | - Migle Semenaite
- Department of Obstetrics and Gynecology, Lithuanian University of Health Sciences, LT-50161 Kaunas, Lithuania; (M.S.); (V.G.); (R.M.); (E.S.)
| | - Vladas Gintautas
- Department of Obstetrics and Gynecology, Lithuanian University of Health Sciences, LT-50161 Kaunas, Lithuania; (M.S.); (V.G.); (R.M.); (E.S.)
| | - Regina Maciuleviciene
- Department of Obstetrics and Gynecology, Lithuanian University of Health Sciences, LT-50161 Kaunas, Lithuania; (M.S.); (V.G.); (R.M.); (E.S.)
| | - Aras Puodziukynas
- Department of Cardiology, Lithuanian University of Health Sciences, LT-50161 Kaunas, Lithuania;
| | - Egle Savukyne
- Department of Obstetrics and Gynecology, Lithuanian University of Health Sciences, LT-50161 Kaunas, Lithuania; (M.S.); (V.G.); (R.M.); (E.S.)
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32
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O'Leary ET, Alexander ME, Bezzerides VJ, Drogosz M, Economy KE, Friedman KG, Pickard SS, Tworetzky W, Mah DY. Low mortality in fetal supraventricular tachycardia: Outcomes in a 30-year single-institution experience. J Cardiovasc Electrophysiol 2020; 31:1105-1113. [PMID: 32100356 DOI: 10.1111/jce.14406] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Revised: 01/31/2020] [Accepted: 02/17/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To describe a single institutional experience managing fetuses with supraventricular tachycardia (SVT) and to identify associations between patient characteristics and fetal and postnatal outcomes. BACKGROUND Sustained fetal SVT is associated with significant morbidity and mortality if untreated, yet the optimal management strategy remains unclear. METHODS Retrospective cohort study including fetuses diagnosed with sustained SVT (>50% of the diagnostic echocardiogram) between 1985 and 2018. Fetuses with congenital heart disease were excluded. RESULTS Sustained SVT was diagnosed in 65 fetuses at a median gestational age of 30 weeks (range, 14-37). Atrioventricular re-entrant tachycardia and atrial flutter were the most common diagnoses, seen in 41 and 16 cases, respectively. Moderate/severe ventricular dysfunction was present in 20 fetuses, and hydrops fetalis was present in 13. Of the 57 fetuses initiated on transplacental drug therapy, 47 received digoxin first-line, yet 39 of 57 (68%) required advanced therapy with sotalol, flecainide, or amiodarone. Rate or rhythm control was achieved in 47 of 57 treated fetuses. There were no cases of intrauterine fetal demise. Later gestational age at fetal diagnosis (odds ratio [OR], 1.1, 95% confidence interval [CI], 1.01-1.2, P = .02) and moderate/severe fetal ventricular dysfunction (OR, 6.1, 95% CI, 1.7-21.6, P = .005) were associated with postnatal SVT. Two postnatal deaths occurred. CONCLUSIONS Fetuses with structurally normal hearts and sustained SVT can be effectively managed with transplacental drug therapy with minimal risk of intrauterine fetal demise. Treatment requires multiple antiarrhythmic agents in over half of cases. Later gestational age at fetal diagnosis and the presence of depressed fetal ventricular function, but not hydrops, predict postnatal arrhythmia burden.
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Affiliation(s)
- Edward T O'Leary
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Mark E Alexander
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Vassilios J Bezzerides
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Monika Drogosz
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Katherine E Economy
- Harvard Medical School, Boston, Massachusetts.,Department of Maternal-Fetal Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Kevin G Friedman
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Sarah S Pickard
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Wayne Tworetzky
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Douglas Y Mah
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
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Jelin AC, Sobreira N, Wohler E, Solomon B, Sparks T, Sagaser KG, Forster KR, Miller J, Witmer PD, Hamosh A, Valle D, Blakemore K. The utility of exome sequencing for fetal pleural effusions. Prenat Diagn 2020; 40:590-595. [PMID: 31994743 DOI: 10.1002/pd.5650] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Revised: 01/06/2020] [Accepted: 01/07/2020] [Indexed: 01/23/2023]
Abstract
OBJECTIVE We sought to evaluate the performance of exome sequencing (ES) in determining an underlying genetic etiology for cases of fetal pleural effusions. STUDY DESIGN We examined a prospective cohort series of fetal pleural effusions visualized sonographically between 1 April 2016 and 31 August 2017. Fetal pleural effusions attributed to twin sharing, anemia, or structural anomalies were excluded, as were all cases with a genetic diagnosis established by karyotype or chromosomal microarray analysis. The remaining cases with pleural effusions of unclear etiology were offered ES. ES was performed by clinical sequencing and/or sequencing under the Baylor-Hopkins Center for Mendelian Genomics' (BHCMG) research platform. All cases were evaluated for novel genes or phenotypic expansion of disease-causing genes. RESULTS ES was performed on six probands affected by pleural effusions. A pathogenic variant was identified in one case (16.7%). Four additional cases had variants of uncertain significance (VUS) in candidate genes of pathological interest. Neither clinical nor candidate genes were evident in the final case. CONCLUSION ES should be considered in the evaluation of prenatally detected idiopathic pleural effusions when other diagnostic workup for a genetic etiology has failed.
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Affiliation(s)
- Angie C Jelin
- Department of Gynecology and Obstetrics, Division of Maternal Fetal Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA.,McKusick-Nathans Institute of Genetic Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Nara Sobreira
- McKusick-Nathans Institute of Genetic Medicine, Johns Hopkins University, Baltimore, MD, USA.,Baylor-Hopkins Center for Mendelian Genomics, Baltimore, MD, USA
| | - Elizabeth Wohler
- McKusick-Nathans Institute of Genetic Medicine, Johns Hopkins University, Baltimore, MD, USA.,Baylor-Hopkins Center for Mendelian Genomics, Baltimore, MD, USA
| | | | - Teresa Sparks
- Department of Obstetrics, Gynecology & Reproductive Sciences, Division of Maternal Fetal Medicine, University of California, San Francisco, CA, USA
| | - Katelynn G Sagaser
- Department of Gynecology and Obstetrics, Division of Maternal Fetal Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Katherine R Forster
- Department of Gynecology and Obstetrics, Center for Fetal Therapy, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Jena Miller
- Department of Gynecology and Obstetrics, Center for Fetal Therapy, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - P Dane Witmer
- McKusick-Nathans Institute of Genetic Medicine, Johns Hopkins University, Baltimore, MD, USA.,Baylor-Hopkins Center for Mendelian Genomics, Baltimore, MD, USA
| | - Ada Hamosh
- McKusick-Nathans Institute of Genetic Medicine, Johns Hopkins University, Baltimore, MD, USA.,Baylor-Hopkins Center for Mendelian Genomics, Baltimore, MD, USA
| | - David Valle
- McKusick-Nathans Institute of Genetic Medicine, Johns Hopkins University, Baltimore, MD, USA.,Baylor-Hopkins Center for Mendelian Genomics, Baltimore, MD, USA
| | - Karin Blakemore
- Department of Gynecology and Obstetrics, Division of Maternal Fetal Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA.,McKusick-Nathans Institute of Genetic Medicine, Johns Hopkins University, Baltimore, MD, USA
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34
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Yuan SM, Xu ZY. Fetal arrhythmias: prenatal evaluation and intrauterine therapeutics. Ital J Pediatr 2020; 46:21. [PMID: 32050988 PMCID: PMC7017517 DOI: 10.1186/s13052-020-0785-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Accepted: 02/03/2020] [Indexed: 11/24/2022] Open
Abstract
Introduction Fetal arrhythmias are a common phenomenon with rather complicated etiologies. Debates remain regarding prenatal diagnosis and treatment of fetal arrhythmias. Methods The literature reporting on prenatal diagnosis and treatment of fetal arrhythmias published in the recent two decades were retrieved, collected and analyzed. Results Both fetal magnetocardiogram and electrocardiogram provide information of cardiac time intervals, including the QRS and QT durations. M-mode ultrasound detects the AV and VA intervals, fetal heart rate, and AV conduction. By using Doppler ultrasound, simultaneous recording of the atrial and ventricular waves can be obtained. Benign fetal arrhythmias, including premature contractions and sinus tachycardia, do not need any treatment before and after birth. Sustained fetal arrhythmias that predispose to the occurrence of hydrops fetalis, cardiac dysfunction or eventual fetal demise require active treatments. Intrauterine therapy of fetal tachyarrhythmias has been carried out by the transplacental route. If maternal transplacental treatment fails, intraumbilical, intraperitoneal, or direct fetal intramuscular injection of antiarrhythmic agents can be attempted. Conclusions The outcomes of intrauterine therapy of fetal tachyarrhythmias depend on the types or etiology of fetal arrhythmias and fetal conditions. Most are curable to a transplacental treatment by the first-line antiarrhythmic agents. Fetal cardiac pacings are effective methods to restore sinus rhythm in drug-resistant or hemodynamically compromised cases. Immediate postnatal pacemaker implantation is warranted in refractory cases.
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Affiliation(s)
- Shi-Min Yuan
- Department of Cardiothoracic Surgery, The First Hospital of Putian, Teaching Hospital, Fujian Medical University, 389 Longdejing Street, Chengxiang District, Putian, 351100, Fujian Province, People's Republic of China
| | - Zhi-Yang Xu
- Department of Cardiothoracic Surgery, The First Hospital of Putian, Teaching Hospital, Fujian Medical University, 389 Longdejing Street, Chengxiang District, Putian, 351100, Fujian Province, People's Republic of China.
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35
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Refaat M, El Dick J, Sabra M, Bitar F, Tayeh C, Abutaqa M, Arabi M. Sotalol as an effective adjunct therapy in the management of supraventricular tachycardia induced fetal hydrops fetalis. J Neonatal Perinatal Med 2020; 13:267-273. [PMID: 31707376 DOI: 10.3233/npm-190268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Sustained fetal supraventricular tachycardia (SVT) complicated by hydrops fetalis carries a significant risk of morbidity and mortality. While there is no clear consensus on first- and second-line therapy options for the management of fetal SVT with or without hydrops fetalis, there exists significant nonrandomized experience with a number of antiarrhythmic agents that has founded the basis for management. Furthermore, recently published meta-analyses and ongoing multicenter prospective studies have aimed to bridge the gap in the literature. We report two cases of sustained fetal SVT with severe secondary hydrops fetalis managed successfully with flecainide-sotalol combination therapy in one case and sotalol-digoxin combination therapy in the second and review the literature for the management of fetal SVT.
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Affiliation(s)
- Marwan Refaat
- Department of Internal Medicine, American University of Beirut Medical Center, Division of Cardiology, Beirut, Lebanon
| | - Joud El Dick
- Department of Internal Medicine, American University of Beirut Medical Center, Division of Cardiology, Beirut, Lebanon
| | - Mohammad Sabra
- Department of Internal Medicine, American University of Beirut Medical Center, Division of Cardiology, Beirut, Lebanon
| | - Fadi Bitar
- Department of Pediatrics and Adolescent Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Christelle Tayeh
- Department of Pediatrics and Adolescent Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Mohamad Abutaqa
- Department of Pediatrics and Adolescent Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Mariam Arabi
- Department of Pediatrics and Adolescent Medicine, American University of Beirut Medical Center, Beirut, Lebanon
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36
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López Ramón Y Cajal C, Couceiro Naveira E, Piñón Mosquera A, Gómez Mosquera A. Treatment of fetal supraventricular tachycardia by intra-amniotic administration of digoxin. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2019; 54:698-699. [PMID: 30801817 DOI: 10.1002/uog.20250] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 01/29/2019] [Accepted: 02/15/2019] [Indexed: 06/09/2023]
Affiliation(s)
- C López Ramón Y Cajal
- University Hospital Alvaro Cunqueiro, Estrada Clara Campoamor, Vigo, Pontevedra, Spain
| | - E Couceiro Naveira
- Complejo Hospitalario Universitario de Vigo, Obstetrics & Gynecology, Vigo, Pontevedra, Spain
| | - A Piñón Mosquera
- Complejo Hospitalario Universitario de Vigo, Obstetrics & Gynecology, Vigo, Pontevedra, Spain
| | - A Gómez Mosquera
- Complejo Hospitalario Universitario de Vigo, Obstetrics & Gynecology, Vigo, Pontevedra, Spain
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Gesuete V, Fantasia I, Lo Bello L, Rizzante E, D'Agata Mottolese B, Stampalija T. Is antiarrhythmic therapy safe in twin pregnancies? Acta Paediatr 2019; 108:1580-1583. [PMID: 31116481 DOI: 10.1111/apa.14870] [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: 11/19/2018] [Revised: 04/14/2019] [Accepted: 05/20/2019] [Indexed: 11/28/2022]
Abstract
AIM The optimal treatment for foetal supraventricular tachycardia (SVT) in twin pregnancies is unclear because of the possible impact on the second twin. This review compared a foetus we treated with antiarrhythmic drugs with the previous case studies. METHODS Our case was a dichorionic diamniotic twin pregnancy, where one twin developed foetal hydrops secondary to SVT at 22 weeks of gestation. We searched PubMed to look for previous cases of SVT in twin pregnancies. RESULTS Treatment with transplacental antiarrhythmic therapy from 22 to 36 weeks of gestation successfully resolved the SVT in our affected twin without any impact on the healthy twin or mother. We only found seven similar cases of SVT in twin pregnancies from 1999 to 2017. Although there was no consensus on the treatment that should be provided, none of the studies reported side effects in the twins or the mothers. CONCLUSION Despite a lack of data on SVT in twin pregnancies, our case, and the previous cases we identified, allowed us to conclude that transplacental antiarrhythmic treatment can successfully achieve cardioversion in the affected twin. It can do this without side effects for the healthy foetus or the mother, even if the treatment lasts for a long period of time.
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Affiliation(s)
- Valentina Gesuete
- Cardiology Service Institute for Maternal and Child Health IRCCS Burlo Garofolo Trieste Italy
| | - Ilaria Fantasia
- Unit of Fetal Medicine and Prenatal Diagnosis Institute for Maternal and Child Health IRCCS Burlo Garofolo Trieste Italy
| | - Leila Lo Bello
- Unit of Fetal Medicine and Prenatal Diagnosis Institute for Maternal and Child Health IRCCS Burlo Garofolo Trieste Italy
| | - Elisa Rizzante
- Unit of Fetal Medicine and Prenatal Diagnosis Institute for Maternal and Child Health IRCCS Burlo Garofolo Trieste Italy
- Department Of Medical Surgical and Health Science University of Trieste Trieste Italy
| | | | - Tamara Stampalija
- Unit of Fetal Medicine and Prenatal Diagnosis Institute for Maternal and Child Health IRCCS Burlo Garofolo Trieste Italy
- Department Of Medical Surgical and Health Science University of Trieste Trieste Italy
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Miyoshi T, Hosoda H, Kurosaki KI, Shiraishi I, Nakai M, Nishimura K, Miyazato M, Kangawa K, Yoshimatsu J, Minamino N. Plasma natriuretic peptide levels reflect the status of the heart failure in fetuses with arrhythmia. J Matern Fetal Neonatal Med 2019; 34:1883-1889. [PMID: 31414622 DOI: 10.1080/14767058.2019.1651271] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVES To evaluate the significance of natriuretic peptide (NP) levels in fetal arrhythmia. STUDY DESIGN Cardiovascular profile (CVP) scores and umbilical vein (UV) NP levels at birth were compared by different fetal arrhythmia statuses. RESULTS Fetal tachyarrhythmia (n = 22), bradyarrhythmia (n = 12), extrasystole (n = 12) and controls (n = 127) were enrolled in this study. Fetal antiarrhythmic therapy was performed in fetuses with tachyarrhythmia (n = 18) and bradyarrhythmia (n = 5). Fetal arrhythmias were divided into three groups: group A (arrhythmia controlled at birth, n = 17), Group B (arrhythmia uncontrolled at birth, n = 9) and Group C (fetal therapy not indicated, n = 20). Group B had significantly lower CVP scores and higher NP levels than the other two groups and controls (p < .01). Groups A and C had significantly lower CVP scores than controls, but NP levels in Groups A and C showed no differences compared with controls. CONCLUSIONS UV NP concentrations reflect the severity of fetal arrhythmia and responses to fetal therapy.
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Affiliation(s)
- Takekazu Miyoshi
- Department of Perinatology and Gynecology, National Cerebral and Cardiovascular Center, Suita, Japan.,Department of Regenerative Medicine and Tissue Engineering, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Hiroshi Hosoda
- Department of Regenerative Medicine and Tissue Engineering, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Ken-Ichi Kurosaki
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Isao Shiraishi
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Michikazu Nakai
- Department of Statistics and Data Analysis, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Kunihiro Nishimura
- Department of Statistics and Data Analysis, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Mikiya Miyazato
- Department of Biochemistry, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Kenji Kangawa
- Department of Biochemistry, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Jun Yoshimatsu
- Department of Perinatology and Gynecology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Naoto Minamino
- Omics Research Center, National Cerebral and Cardiovascular Center, Suita, Japan
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Abstract
Pregnancy is a period of increased cardiovascular risk in a woman's life. In the setting of an inherited arrhythmia syndrome (IAS), cardiologists and obstetricians may be unfamiliar with cardiovascular optimization and risk stratification in pregnancy. Historically, there were little data addressing the safety of pregnancy in these rare disorders. Recent advances suggest that no type of IAS represents an absolute contraindication to pregnancy. However, it is imperative that obstetric and cardiovascular clinicians understand the major forms of IAS and how they affect the risks and course of pregnancy. This includes any disease-specific proarrhythmic triggers unique to pregnancy, such as the postpartum period in long QT syndrome (especially type 2), which poses the greatest risk of arrhythmias, and the adrenergic nature of labor and delivery, which is relevant to catecholaminergic polymorphic ventricular tachycardia. Fortunately, several effective antiarrhythmic options exist that pose little fetal risk. IAS-specific optimization of implantable cardioverter-defibrillator algorithms, drug therapy, and a maternal cardiac plan addressing the antepartum, labor, and delivery and postpartum periods reduces the risk. Where evidence does not exist, there are plausible mechanistic considerations to guide clinicians. To achieve optimal outcomes, early involvement of an expert pregnancy heart team comprising obstetrics, genetics, cardiology, and anesthesiology team members and a shared decision-making approach to IAS issues in pregnancy are needed.
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Georgiopoulos G, Tsiachris D, Kordalis A, Kontogiannis C, Spartalis M, Pietri P, Magkas N, Stefanadis C. Pharmacotherapeutic strategies for atrial fibrillation in pregnancy. Expert Opin Pharmacother 2019; 20:1625-1636. [PMID: 31136204 DOI: 10.1080/14656566.2019.1621290] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Georgios Georgiopoulos
- Department of Cardiology, Athens Medical Center, Athens, Greece
- Department of Clinical Therapeutics, Alexandra Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | | | | | - Christos Kontogiannis
- Department of Clinical Therapeutics, Alexandra Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Michael Spartalis
- Division of Cardiology, Onassis Cardiac Surgery Center, Athens, Greece
| | | | - Nikolaos Magkas
- 1stDepartment of Cardiology, Hippocration Hospital, National and Kapodistrian University of Athens, Athens, Greece
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Tanaka N, Fujii T, Mikami N, Uchinami Y, Saito H, Morimoto Y. Anesthetic management for cesarean section in a patient receiving transplacental treatment of fetal tachyarrhythmia: a case report. JA Clin Rep 2019; 5:31. [PMID: 32026053 PMCID: PMC6967271 DOI: 10.1186/s40981-019-0251-0] [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: 02/11/2019] [Accepted: 04/24/2019] [Indexed: 11/10/2022] Open
Abstract
Background Although rare, long-lasting fetal tachyarrhythmia often leads to fetal heart failure and hydrops. Some mothers receive transplacental treatment of fetal tachyarrhythmia (TTFT), which can potentially worsen maternal hypotension and bradycardia. Moreover, the use of rescue cardiovascular agents intraoperatively can worsen fetal tachycardia. However, reports of the anesthetic management of patients receiving TTFT are rare. Case presentation A 31-year-old woman who was receiving digoxin and sotalol for TTFT underwent planned elective cesarean section. The fetus had hypoplastic left heart syndrome, hydrops, and tachycardia. We used combined spinal-epidural anesthesia with a reduced dose of local anesthetic. We also employed a non-invasive continuous hemodynamic monitoring system. The mother’s systolic blood pressure remained at ≥ 90% of the baseline value; intraoperative administration of rescue cardiovascular agents was not required. Conclusions We successfully anesthetized a woman for cesarean section, who was receiving TTFT for fetal tachyarrhythmia, using combined spinal-epidural anesthesia and non-invasive continuous hemodynamic monitoring.
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Affiliation(s)
- Nobuhiro Tanaka
- Department of Anesthesiology and Critical Care Medicine, Hokkaido University Graduate School of Medicine, Kita-15, Nishi-7, Kita-ku, Sapporo, 060-8638, Japan.
| | - Tomoaki Fujii
- Department of Anesthesiology and Critical Care Medicine, Hokkaido University Graduate School of Medicine, Kita-15, Nishi-7, Kita-ku, Sapporo, 060-8638, Japan
| | - Niina Mikami
- Department of Anesthesiology and Critical Care Medicine, Hokkaido University Graduate School of Medicine, Kita-15, Nishi-7, Kita-ku, Sapporo, 060-8638, Japan
| | - Yuka Uchinami
- Department of Anesthesiology and Critical Care Medicine, Hokkaido University Graduate School of Medicine, Kita-15, Nishi-7, Kita-ku, Sapporo, 060-8638, Japan
| | - Hitoshi Saito
- Department of Anesthesiology and Critical Care Medicine, Hokkaido University Graduate School of Medicine, Kita-15, Nishi-7, Kita-ku, Sapporo, 060-8638, Japan
| | - Yuji Morimoto
- Department of Anesthesiology and Critical Care Medicine, Hokkaido University Graduate School of Medicine, Kita-15, Nishi-7, Kita-ku, Sapporo, 060-8638, Japan
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Minisha F, Deniz M, AlObaidly S, Kamal R. Extended multi-drug maternal therapy for refractory supraventricular tachycardia in premature hydrops fetalis. CASE REPORTS IN PERINATAL MEDICINE 2019. [DOI: 10.1515/crpm-2018-0034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Abstract
Background
Fetal supraventricular tachycardia (SVT) is a reversible cause of fetal hydrops, with better outcomes if detected early and reverted in utero. Modern imaging allows accurate diagnosis and maternal anti-arrhythmic therapy can be practiced ensuring in utero cardioversion.
Case presentation
We present a case of preterm fetal hydrops due to SVT successfully reverted in utero by multidrug maternal therapy. The mother presented to our tertiary care hospital at 32 weeks’ gestation with a fetal heart rate of 229 beats/min with evidence of mild fetal pericardial effusion and ascites. Under strict maternal monitoring, the treatment was started with parenteral digoxin. Flecainide, sotalol and amiodarone were introduced sequentially based on the response until cardioversion was achieved at 35 weeks with no maternal side effects. She labored spontaneously and delivered a 2.6 kg baby boy 4 days after the successful cardioversion. The baby was discharged home on day 7 on oral amiodarone with outpatient follow-up. Digoxin monotherapy failed in our case, possibly due to evidence of hydrops and a sequential multi-drug therapy was required for an extended duration of up to 2 weeks to achieve cardioversion successfully.
Conclusions
Our report suggests that multi-drug therapy is more successful in cases of SVT with fetal hydrops, titrated according to fetal response and maternal tolerance, although a prolonged period of therapy might be required to achieve the desired clinical effect.
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Affiliation(s)
- Fathima Minisha
- Women’s Wellness and Research Centre, Hamad Medical Corporation , Department of Obstetrics and Gynecology , PO Box 3050, Doha , Qatar
| | - Melissa Deniz
- Women’s Wellness and Research Centre, Hamad Medical Corporation , Department of Obstetrics and Gynecology , PO Box 3050, Doha , Qatar
| | - Sawsan AlObaidly
- Women’s Wellness and Research Centre, Hamad Medical Corporation , Department of Obstetrics and Gynecology , PO Box 3050, Doha , Qatar
| | - Reema Kamal
- Department of Pediatrics , Hamad Medical Corporation , Doha , Qatar
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