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Mawad W, Hornberger L, Cuneo B, Raboisson MJ, Moon-Grady AJ, Lougheed J, Diab K, Parkman J, Silverman E, Jaeggi E. Outcome of Antibody-Mediated Fetal Heart Disease With Standardized Anti-Inflammatory Transplacental Treatment. J Am Heart Assoc 2022; 11:e023000. [PMID: 35001672 PMCID: PMC9238501 DOI: 10.1161/jaha.121.023000] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Background Transplacental fetal treatment of immune-mediated fetal heart disease, including third-degree atrioventricular block (AVB III) and endocardial fibroelastosis, is controversial. Methods and Results To study the impact of routine transplacental fetal treatment, we reviewed 130 consecutive cases, including 108 with AVB III and 22 with other diagnoses (first-degree/second-degree atrioventricular block [n=10]; isolated endocardial fibroelastosis [n=9]; atrial bradycardia [n=3]). Dexamethasone was started at a median of 22.4 gestational weeks. Additional treatment for AVB III included the use of a β-agonist (n=47) and intravenous immune globulin (n=34). Fetal, neonatal, and 1-year survival rates with AVB III were 95%, 93%, and 89%, respectively. Variables present at diagnosis that were associated with perinatal death included an atrial rate <90 beats per minute (odds ratio [OR], 258.4; 95% CI, 11.5-5798.9; P<0.001), endocardial fibroelastosis (OR, 28.9; 95% CI, 1.6-521.7; P<0.001), fetal hydrops (OR, 25.5; 95% CI, 4.4-145.3; P<0.001), ventricular dysfunction (OR, 7.6; 95% CI, 1.5-39.4; P=0.03), and a ventricular rate <45 beats per minute (OR, 12.9; 95% CI, 1.75-95.8; P=0.034). At a median follow-up of 5.9 years, 85 of 100 neonatal survivors were paced, and 1 required a heart transplant for dilated cardiomyopathy. Cotreatment with intravenous immune globulin was used in 16 of 22 fetuses with diagnoses other than AVB III. Neonatal and 1-year survival rates of this cohort were 100% and 95%, respectively. At a median age of 3.1 years, 5 of 21 children were paced, and all had normal ventricular function. Conclusions Our findings reveal a low risk of perinatal mortality and postnatal cardiomyopathy in fetuses that received transplacental dexamethasone±other treatment from the time of a new diagnosis of immune-mediated heart disease.
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Affiliation(s)
- Wadi Mawad
- The Hospital for Sick Children Toronto Ontario Canada
| | - Lisa Hornberger
- Stollery Children's Hospital University of Alberta Edmonton Alberta Canada
| | | | | | | | - Jane Lougheed
- Children's Hospital of Eastern Ontario Ottawa Ontario Canada
| | - Karim Diab
- Rush University Medical Center Chicago IL
| | - Julia Parkman
- Stollery Children's Hospital University of Alberta Edmonton Alberta Canada
| | | | - Edgar Jaeggi
- The Hospital for Sick Children Toronto Ontario Canada
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2
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Wang X, Liu XW, Han L, Li MT, Zhao JL, Sun L, Han JC, Zeng XF, Tian XP, Zhao Y, He YH. Cardiac manifestations in a Chinese cohort of fetuses from mothers with anti-Ro and anti-La antibodies. Front Pediatr 2022; 10:904138. [PMID: 35967560 PMCID: PMC9371606 DOI: 10.3389/fped.2022.904138] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Accepted: 07/11/2022] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVES To analyze the clinical characteristics, echocardiographic features, and prognosis of fetuses based on three groups of cardiac manifestations associated with maternal anti-Ro and anti-La antibodies in China. This study included three groups: the isolated-arrhythmia, isolated-endocardial fibroelastosis (EFE), and mixed groups. METHODS We prospectively evaluated 36 fetuses with cardiac manifestations due to maternal anti-Ro and anti-La antibodies from our center between 2016 and 2020 in China. Clinical and echocardiographic data were collected. RESULTS There were 13 patients (36%) in the isolated-arrhythmia group, eight (22%) in the isolated-EFE group, and 15 (42%) in the mixed group. All patients in the isolated-EFE group presented with mild EFE. Severe EFE was identified in four patients (27%) in the mixed group. Atrioventricular block (AVB) was more common in the isolated-arrhythmia group (13, 100%) than in the mixed group (6, 40%; p = 0.001). Moderate-severe mitral regurgitation (p = 0.006), dilated cardiomyopathy (DCM, p = 0.017), and low cardiovascular profile scores (p = 0.013) were more common in the mixed group than in the other two groups. Twenty-one mothers decided to terminate the pregnancy and 15 fetuses were born with regular perinatal treatment. They all survived at 1 year of age. One patient in the isolated-arrhythmia group and two in the mixed group required a pacemaker due to third-degree AVB or atrioventricular junctional rhythm. Five patients in the isolated-EFE group and five in the mixed group had no DCM or heart failure and the location of mild EFE was significantly reduced. CONCLUSION Fetal cardiac manifestations due to maternal anti-Ro and anti-La antibodies can be divided into three groups, i.e., the isolated-arrhythmia, isolated-EFE, and mixed groups. AVB usually occurs in the isolated-arrhythmia group. Severe EFE, moderate-severe mitral regurgitation, and DCM mainly appear in the mixed group. Location of mild EFE significantly reduces after birth and the outcome of fetuses with mild EFE depends on the presence of arrhythmia and its subtypes.
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Affiliation(s)
- Xin Wang
- Echocardiography Medical Center, Maternal-Fetal Medicine Center in Fetal Heart Disease, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Xiao-Wei Liu
- Echocardiography Medical Center, Maternal-Fetal Medicine Center in Fetal Heart Disease, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Ling Han
- Department of Pediatric Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Meng-Tao Li
- Department of Rheumatology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, National Clinical Research Center for Dermatologic and Immunologic Diseases, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Jiu-Liang Zhao
- Department of Rheumatology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, National Clinical Research Center for Dermatologic and Immunologic Diseases, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Lin Sun
- Echocardiography Medical Center, Maternal-Fetal Medicine Center in Fetal Heart Disease, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Jian-Cheng Han
- Echocardiography Medical Center, Maternal-Fetal Medicine Center in Fetal Heart Disease, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Xiao-Feng Zeng
- Department of Rheumatology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, National Clinical Research Center for Dermatologic and Immunologic Diseases, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Xin-Ping Tian
- Department of Rheumatology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, National Clinical Research Center for Dermatologic and Immunologic Diseases, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Ying Zhao
- Echocardiography Medical Center, Maternal-Fetal Medicine Center in Fetal Heart Disease, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Yi-Hua He
- Echocardiography Medical Center, Maternal-Fetal Medicine Center in Fetal Heart Disease, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
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3
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Liao H, Tang C, Qiao L, Zhou K, Hua Y, Wang C, Li Y. Prenatal Management Strategy for Immune-Associated Congenital Heart Block in Fetuses. Front Cardiovasc Med 2021; 8:644122. [PMID: 33996939 PMCID: PMC8113399 DOI: 10.3389/fcvm.2021.644122] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Accepted: 03/30/2021] [Indexed: 12/13/2022] Open
Abstract
Fetal congenital heart block (CHB) is the most commonly observed type of fetal bradycardia, and is potentially life-threatening. More than 50% of cases of bradycardia are associated with maternal autoimmunity, and these are collectively termed immune-associated bradycardia. Several methods have been used to achieve reliable prenatal diagnoses of CHB. Emerging data and opinions on pathogenesis, prenatal diagnosis, fetal intervention, and the prognosis of fetal immune-associated CHB provide clues for generating a practical protocol for clinical management. The prognosis of fetal immune-associated bradycardia is based on the severity of heart blocks. Morbidity and mortality can occur in severe cases, thus hieratical management is essential in such cases. In this review, we mainly focus on optimal strategies pertaining to autoimmune antibodies related to CHB, although the approaches for managing autoimmune-mediated CHB are still controversial, particularly with regard to whether fetuses benefit from transplacental medication administration. To date there is still no accessible clinical strategy for autoimmune-mediated CHB. This review first discusses integrated prenatal management strategies for the condition. It then provides some advice for clinicians involved in management of fetal cardiovascular disorder.
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Affiliation(s)
- Hongyu Liao
- Key Laboratory of Birth Defects and Related Diseases of Women and Children of Ministry of Education (MOE), Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Changqing Tang
- Key Laboratory of Birth Defects and Related Diseases of Women and Children of Ministry of Education (MOE), Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Lina Qiao
- Key Laboratory of Birth Defects and Related Diseases of Women and Children of Ministry of Education (MOE), Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Kaiyu Zhou
- Key Laboratory of Birth Defects and Related Diseases of Women and Children of Ministry of Education (MOE), Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Yimin Hua
- Key Laboratory of Birth Defects and Related Diseases of Women and Children of Ministry of Education (MOE), Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Chuan Wang
- Key Laboratory of Birth Defects and Related Diseases of Women and Children of Ministry of Education (MOE), Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Yifei Li
- Key Laboratory of Birth Defects and Related Diseases of Women and Children of Ministry of Education (MOE), Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China
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4
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Gravenhorst VD, Schneider HE, Müller MJ, Krause U, Felke B, Paul T. [Fetal ECG and arrhythmias]. Herzschrittmacherther Elektrophysiol 2021; 32:152-157. [PMID: 33825056 DOI: 10.1007/s00399-021-00758-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 03/18/2021] [Indexed: 11/26/2022]
Abstract
The normal fetal heart rate ranges between 110 und 180 beats per minute (bpm). Intrauterine arrhythmias are not an uncommon finding. Fetal echocardiography (ECG) allows for correct diagnosis of the arrhythmia, which is prerequisite for decision making and treatment. Most fetal rhythm disturbances are the result of premature atrial contractions and are of little clinical significance. Intrauterine bradycardias (heart rate < 110 bpm) result from sinus node dysfunction, complete AV block and nonconducted atrial bigeminy. Isolated complete heart block related to maternal anti-SSA/Ro or SSB/La auto-antibodies is irreversible in almost all fetuses. Anti-inflammatory therapy and chronotropic medication may improve outcome. Newborn babies often require pacemaker implantation to augment cardiac output. Intrauterine tachycardias (heart rate > 180 bpm) are most commonly related to supraventricular tachycardia and atrial flutter. Specific antiarrhythmic medication is available to stop the arrhythmia and to prevent hemodynamic deterioration.
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Affiliation(s)
- Verena D Gravenhorst
- Klinik für Kinder- und Jugendmedizin, Pädiatrische Kardiologie, Intensivmedizin und Pneumologie, Kinderherzklinik/Überregionales EMAH-Zentrum, Universitätsmedizin Göttingen, Robert-Koch-Str. 40, 37075, Göttingen, Deutschland.
| | - Heike E Schneider
- Klinik für Kinder- und Jugendmedizin, Pädiatrische Kardiologie, Intensivmedizin und Pneumologie, Kinderherzklinik/Überregionales EMAH-Zentrum, Universitätsmedizin Göttingen, Robert-Koch-Str. 40, 37075, Göttingen, Deutschland
| | - Matthias J Müller
- Klinik für Kinder- und Jugendmedizin, Pädiatrische Kardiologie, Intensivmedizin und Pneumologie, Kinderherzklinik/Überregionales EMAH-Zentrum, Universitätsmedizin Göttingen, Robert-Koch-Str. 40, 37075, Göttingen, Deutschland
| | - Ulrich Krause
- Klinik für Kinder- und Jugendmedizin, Pädiatrische Kardiologie, Intensivmedizin und Pneumologie, Kinderherzklinik/Überregionales EMAH-Zentrum, Universitätsmedizin Göttingen, Robert-Koch-Str. 40, 37075, Göttingen, Deutschland
| | - Barbara Felke
- Klinik für Gynäkologie und Geburtshilfe, Universitätsmedizin Göttingen, Göttingen, Deutschland
| | - Thomas Paul
- Klinik für Kinder- und Jugendmedizin, Pädiatrische Kardiologie, Intensivmedizin und Pneumologie, Kinderherzklinik/Überregionales EMAH-Zentrum, Universitätsmedizin Göttingen, Robert-Koch-Str. 40, 37075, Göttingen, Deutschland
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5
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Popescu MR, Dudu A, Jurcut C, Ciobanu AM, Zagrean AM, Panaitescu AM. A Broader Perspective on Anti-Ro Antibodies and Their Fetal Consequences-A Case Report and Literature Review. Diagnostics (Basel) 2020; 10:E478. [PMID: 32674462 PMCID: PMC7399931 DOI: 10.3390/diagnostics10070478] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Revised: 07/11/2020] [Accepted: 07/12/2020] [Indexed: 12/20/2022] Open
Abstract
The presence of maternal Anti-Ro/Anti-La antibodies causes a passively acquired autoimmunity that may be associated with serious fetal complications. The classic example is the autoimmune-mediated congenital heart block (CHB) which is due in most cases to the transplacental passage of Anti-Ro/Anti-La antibodies. The exact mechanisms through which these pathologic events arise are linked to disturbances in calcium channels function, impairment of calcium homeostasis and ultimately apoptosis, inflammation and fibrosis. CHB still represents a challenging diagnosis and a source of debate regarding the best management. As the third-degree block is usually irreversible, the best strategy is risk awareness and prevention. Although CHB is a rare occurrence, it affects one in 20,000 live births, with a high overall mortality rate (up to 20%, with 70% of in utero deaths). There is also concern over the lifelong consequences, as most babies need a pacemaker. This review aims to offer, apart from the data needed for a better understanding of the issue at hand, a broader perspective of the specialists directly involved in managing this pathology: the rheumatologist, the maternal-fetal specialist and the cardiologist. To better illustrate the theoretical facts presented, we also include a representative clinical case.
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Affiliation(s)
- Mihaela Roxana Popescu
- Cardiology Department, Elias University Hospital, “Carol Davila” University of Medicine and Pharmacy, 011461 Bucharest, Romania
| | - Andreea Dudu
- Internal Medicine Department, “Dr Carol Davila” Central Emergency University Military Hospital, 010825 Bucharest, Romania; (A.D.); (C.J.)
| | - Ciprian Jurcut
- Internal Medicine Department, “Dr Carol Davila” Central Emergency University Military Hospital, 010825 Bucharest, Romania; (A.D.); (C.J.)
| | - Anca Marina Ciobanu
- Department of Obstetrics and Gynecology, Filantropia Clinical Hospital, “Carol Davila” University of Medicine and Pharmacy, 011171 Bucharest, Romania; (A.M.C.); (A.M.P.)
| | - Ana-Maria Zagrean
- Division of Physiology and Neuroscience, Department of Functional Sciences, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania;
| | - Anca Maria Panaitescu
- Department of Obstetrics and Gynecology, Filantropia Clinical Hospital, “Carol Davila” University of Medicine and Pharmacy, 011171 Bucharest, Romania; (A.M.C.); (A.M.P.)
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6
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Yuan SM. Fetal arrhythmias: Surveillance and management. Hellenic J Cardiol 2018; 60:72-81. [PMID: 30576831 DOI: 10.1016/j.hjc.2018.12.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Revised: 12/04/2018] [Accepted: 12/11/2018] [Indexed: 10/27/2022] Open
Abstract
Fetal arrhythmias warrant sophisticated surveillance and management, especially for the high-risk pregnancies. Clinically, fetal arrhythmias can be categorized into 3 types: premature contractions, tachyarrhythmias, and bradyarrhythmias. Fetal arrhythmias include electrocardiography, cardiotocography, echocardiography and magnetocardiography. Oxygen saturation monitoring can be an effective way of fetal surveillance for congenital complete AV block or SVT during labor. Genetic surveillance of fetal arrhythmias may facilitate the understanding of the mechanisms of the arrhythmias and provide theoretical basis for diagnosis and treatment. For fetal benign arrhythmias, usually no treatment but a close follow-up is need, while persistant fetal arrhythmias with congestive heart dysfunction or hydrops fetalis, intrauterine or postnatal treatments are required. The prognoses of fetal arrhythmias depend on the type and severity of fetal arrhythmias and the associated fetal conditions. Responses of fetal arrhythmias to individual treatments and clinical schemes are heterogeneous, and the prognoses are poor particularly under such circumstances.
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Affiliation(s)
- Shi-Min Yuan
- Department of Cardiothoracic Surgery, The First Hospital of Putian, Teaching Hospital, Fujian Medical University, Putian, Fujian Province, People's Republic of China.
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7
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An unusual course of anti-Ro antibody-mediated fetal complete heart block. Cardiol Young 2018; 28:171-174. [PMID: 29110745 DOI: 10.1017/s1047951117001937] [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: 11/07/2022]
Abstract
Fetal hydrops is a serious complication of immune-mediated congenital complete atrioventricular block. We present the case of a fetus with severe hydrops and profound bradycardia and an unusual favourable outcome. This case enhances the importance of considering the contribution of ventricular ectopic beats to the cardiac output when counselling and predicting outcome of complete heart block.
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8
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Lazzerini PE, Capecchi PL, Laghi-Pasini F, Boutjdir M. Autoimmune channelopathies as a novel mechanism in cardiac arrhythmias. Nat Rev Cardiol 2017; 14:521-535. [PMID: 28470179 DOI: 10.1038/nrcardio.2017.61] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Cardiac arrhythmias confer a considerable burden of morbidity and mortality in industrialized countries. Although coronary artery disease and heart failure are the prevalent causes of cardiac arrest, in 5-15% of patients, structural abnormalities at autopsy are absent. In a proportion of these patients, mutations in genes encoding cardiac ion channels are documented (inherited channelopathies), but, to date, the molecular autopsy is negative in nearly 70% of patients. Emerging evidence indicates that autoimmunity is involved in the pathogenesis of cardiac arrhythmias. In particular, several arrhythmogenic autoantibodies targeting specific calcium, potassium, or sodium channels in the heart have been identified. Experimental and clinical studies demonstrate that these autoantibodies can promote conduction disturbances and life-threatening tachyarrhythmias by inducing substantial electrophysiological changes. In this Review, we propose the term 'autoimmune cardiac channelopathies' to define this novel pathogenic mechanism of cardiac arrhythmias, which could be more frequent and clinically relevant than previously appreciated. Indeed, pathogenic autoantibodies against ion channels are detectable not only in patients with manifest autoimmune disease, but also in apparently healthy individuals, which suggests a causal role in some cases of unexplained arrhythmias and cardiac arrest. Considering this possibility and performing specific testing in patients with 'idiopathic' rhythm disturbances could create novel treatment opportunities.
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Affiliation(s)
- Pietro Enea Lazzerini
- Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Viale Bracci 16, Siena, 53100, Italy
| | - Pier Leopoldo Capecchi
- Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Viale Bracci 16, Siena, 53100, Italy
| | - Franco Laghi-Pasini
- Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Viale Bracci 16, Siena, 53100, Italy
| | - Mohamed Boutjdir
- VA New York Harbor Healthcare System, 800 Poly Place, Brooklyn, New York 11209, USA.,SUNY Downstate Medical Center, 450 Clarkson Avenue, Brooklyn, New York 11203, USA.,NYU School of Medicine, 550 1st Avenue, New York, New York 10016, USA
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9
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Brito-Zerón P, Izmirly PM, Ramos-Casals M, Buyon JP, Khamashta MA. Autoimmune congenital heart block: complex and unusual situations. Lupus 2016; 25:116-28. [PMID: 26762645 DOI: 10.1177/0961203315624024] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Autoimmune congenital heart block (ACHB) is an immune-mediated cardiac disease included among the manifestations collectively referred to as neonatal lupus. The placental transference of maternal Ro/La autoantibodies may damage the conduction tissues during fetal development leading to blocking of signal conduction at the atrioventricular (AV) node in an otherwise structurally normal heart. Irreversible complete AV block is the main cardiac manifestation of ACHB, but some babies may develop endocardial fibroelastosis, valvular insufficiency, and/or frank cardiomyopathies with significantly reduced cardiac function requiring transplant. The severity of ACHB is illustrated by a global mortality rate of 20% and pacemaker rates of at least 64%, often within the first year of life. This review analyses the main complex and/or unusual clinical situations associated with ACHB, including unusual maternal immunological profiles, infrequent maternal autoimmune diseases, cardiac damage unrelated to AV block, fetal invasive management, late complications after birth, risk of congenital heart block (CHB) in ovodonation and in vitro fertilization techniques, the role of maternal features other than autoimmunity, the influence of the birth order or the risk of CHB in twins and triplets.
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Affiliation(s)
- P Brito-Zerón
- Josep Font Laboratory of Autoimmune Diseases, Department of Autoimmune Diseases, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
| | - P M Izmirly
- Division of Rheumatology, Department of Medicine, New York University School of Medicine, New York, USA
| | - M Ramos-Casals
- Josep Font Laboratory of Autoimmune Diseases, Department of Autoimmune Diseases, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
| | - J P Buyon
- Division of Rheumatology, Department of Medicine, New York University School of Medicine, New York, USA
| | - M A Khamashta
- Graham Hughes Lupus Research Laboratory, The Rayne Institute, Division of Women's Health, Kings College London St Thomas Hospital, United Kingdom
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10
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Abstract
Cardiac arrhythmias are an important aspect of fetal and neonatal medicine. Premature complexes of atrial or ventricular origin are the main cause of an irregular heart rhythm. The finding is typically unrelated to an identifiable cause and no treatment is required. Tachyarrhythmia most commonly relates to supraventricular reentrant tachycardia, atrial flutter, and sinus tachycardia. Several antiarrhythmic agents are available for the perinatal treatment of tachyarrhythmias. Enduring bradycardia may result from sinus node dysfunction, complete heart block and nonconducted atrial bigeminy as the main arrhythmia mechanisms. The management and outcome of bradycardia depend on the underlying mechanism.
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MESH Headings
- Anti-Arrhythmia Agents/therapeutic use
- Arrhythmias, Cardiac/diagnosis
- Arrhythmias, Cardiac/drug therapy
- Atrial Flutter/diagnosis
- Atrial Flutter/drug therapy
- Atrial Premature Complexes/diagnosis
- Atrial Premature Complexes/drug therapy
- Bradycardia/diagnosis
- Bradycardia/drug therapy
- Electrocardiography
- Fetal Diseases/diagnosis
- Fetal Diseases/drug therapy
- Heart Block/diagnosis
- Heart Block/drug therapy
- Humans
- Infant, Newborn
- Infant, Newborn, Diseases/diagnosis
- Infant, Newborn, Diseases/drug therapy
- Sick Sinus Syndrome/diagnosis
- Sick Sinus Syndrome/drug therapy
- Tachycardia, Sinus/diagnosis
- Tachycardia, Sinus/drug therapy
- Tachycardia, Supraventricular/diagnosis
- Tachycardia, Supraventricular/drug therapy
- Ventricular Premature Complexes/diagnosis
- Ventricular Premature Complexes/drug therapy
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Affiliation(s)
- Edgar Jaeggi
- Labatt Family Heart Centre, Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, Ontario M5G 1X8, Canada.
| | - Annika Öhman
- Labatt Family Heart Centre, Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, Ontario M5G 1X8, Canada
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11
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Sonesson SE, Acharya G. Hemodynamics in fetal arrhythmia. Acta Obstet Gynecol Scand 2015; 95:697-709. [PMID: 26660845 DOI: 10.1111/aogs.12837] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2015] [Accepted: 12/03/2015] [Indexed: 10/22/2022]
Abstract
Fetal arrhythmias are among the few conditions that can be managed in utero. However, accurate diagnosis is essential for appropriate management. Ultrasound-based imaging methods can be used to study fetal heart structure and function noninvasively and help to understand fetal cardiovascular pathophysiology, and they remain the mainstay of evaluating fetuses with arrhythmias in clinical settings. Hemodynamic evaluation using Doppler echocardiography allows the elucidation of the electrophysiological mechanism and helps to make an accurate diagnosis. It can also be used as a tool to understand fetal cardiac pathophysiology, for assessing fetal condition and monitoring the effect of antiarrhythmic treatment. This narrative review describes Doppler techniques that are useful for evaluating fetal cardiac rhythms to refine diagnosis and provides an overview of hemodynamic changes observed in different types of fetal arrhythmia.
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Affiliation(s)
- Sven-Erik Sonesson
- Pediatric Cardiology Unit, Department of Women's and Children's Health, Karolinska Institute, Stockholm, Sweden
| | - Ganesh Acharya
- Women's Health and Perinatology Research Group, Department of Clinical Medicine, Faculty of Health Sciences, UiT - The Arctic University of Norway, Tromsø, Norway.,Department of Obstetrics and Gynecology, University Hospital of Northern Norway, Tromsø, Norway.,Department of Clinical Sciences, Intervention and Technology, Karolinska Institute, Stockholm, Sweden
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12
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Brooks P. Fetal manifestations of maternal anti-Ro and La antibodies - more than complete heart block. Australas J Ultrasound Med 2015; 18:124-128. [PMID: 28191254 PMCID: PMC5024963 DOI: 10.1002/j.2205-0140.2015.tb00212.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Complete heart block (CHB) is a potentially fatal condition occurring in approximately 1:10000 fetuses. Whilst it is well recognised that maternal anti-Ro and La antibodies are associated with fetal CHB, there are multiple other manifestations of fetal exposure to these autoantibodies which are not widely appreciated and rarely diagnosed. The importance of identifying affected fetuses lies in the significantly increased risk of recurrence in future pregnancies, and the potential for treatments which may modify this risk. This paper presents several cases to highlight the varying fetal presentations of maternal anti-Ro and La antibodies.
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Affiliation(s)
- Paul Brooks
- Melbourne Paediatric CardiologyFitzroy; Royal Children's HospitalParkville; Western Health Sunshine HospitalSunshine MelbourneAustralia
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13
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Abstract
Autoimmune congenital heart block (CHB) is an immune-mediated acquired disease that is associated with the placental transference of maternal antibodies specific for Ro and La autoantigens. The disease develops in a fetal heart without anatomical abnormalities that could otherwise explain the block, and which is usually diagnosed in utero, but also at birth or within the neonatal period. Autoantibody-mediated damage of fetal conduction tissues causes inflammation and fibrosis and leads to blockage of signal conduction at the atrioventricular (AV) node. Irreversible complete AV block is the principal cardiac manifestation of CHB, although some babies might develop other severe cardiac complications, such as endocardial fibroelastosis or valvular insufficiency, even in the absence of cardiac block. In this Review, we discuss the epidemiology, classification and management of women whose pregnancies are affected by autoimmune CHB, with a particular focus on the autoantibodies associated with autoimmune CHB and how we should test for these antibodies and diagnose this disease. Without confirmed effective preventive or therapeutic strategies and further research on the aetiopathogenic mechanisms, autoimmune CHB will remain a severe life-threatening disorder.
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Krishnan A, Arya B, Moak JP, Donofrio MT. Outcomes of fetal echocardiographic surveillance in anti-SSA exposed fetuses at a large fetal cardiology center. Prenat Diagn 2014; 34:1207-12. [PMID: 24989941 DOI: 10.1002/pd.4454] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2013] [Revised: 05/15/2014] [Accepted: 06/28/2014] [Indexed: 11/11/2022]
Abstract
BACKGROUND Echocardiography screening in anti-SSA antibody exposed fetuses is controversial. OBJECTIVE The aim of this study is to evaluate utility of fetal echocardiography in anti-SSA exposure. METHODS Echocardiograms performed over 9 years for maternal anti-SSA exposure were reviewed for atrioventricular (AV) block, cardiomyopathy, arrhythmias, effusion, valve abnormalities, or other abnormalities identified by the echocardiographer. Fetuses with AV block referred to our institution and subsequently found to be anti-SSA exposed were also identified. RESULTS Six hundred thirty six echocardiograms were performed on 140 fetuses (Cohort 1) of 134 women screened for maternal anti-SSA +/- anti-SSB antibodies. No fetuses developed second or third-degree AV block or cardiomyopathy (odds ratio 0.1, CI 0.0051 to 1.9410, p = 0.13). Dexamethasone was administered to three fetuses for sinus bradycardia, echogenicity near AV node, and ventricular systolic dysfunction with valve regurgitation; all normalized. Screening echocardiograms identified: sinus bradycardia (n = 1), PR prolongation (n = 5), premature atrial contractions (n = 3), valve regurgitation (n = 24), echogenic myocardium (n = 4), and pericardial effusion (n = 1). Isolated tricuspid regurgitation and first-degree AV block did not progress. Nine cases of SSA-mediated AV block (Cohort 2) were referred after heart block developed. CONCLUSIONS Serial fetal echocardiography in anti-SSA exposed fetuses did not detect AV block. In rare cases, dexamethasone treatment may have affected disease course.
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Affiliation(s)
- Anita Krishnan
- Department of Cardiology, Children's National Heart Institute, Children's National Medical Center, 111 Michigan Ave, NW, Washington, DC, 20010, USA
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15
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Strandberg LS, Cui X, Rath A, Liu J, Silverman ED, Liu X, Siragam V, Ackerley C, Su BB, Yan JY, Capecchi M, Biavati L, Accorroni A, Yuen W, Quattrone F, Lung K, Jaeggi ET, Backx PH, Deber CM, Hamilton RM. Congenital heart block maternal sera autoantibodies target an extracellular epitope on the α1G T-type calcium channel in human fetal hearts. PLoS One 2013; 8:e72668. [PMID: 24039792 PMCID: PMC3767782 DOI: 10.1371/journal.pone.0072668] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2012] [Accepted: 07/17/2013] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Congenital heart block (CHB) is a transplacentally acquired autoimmune disease associated with anti-Ro/SSA and anti-La/SSB maternal autoantibodies and is characterized primarily by atrioventricular (AV) block of the fetal heart. This study aims to investigate whether the T-type calcium channel subunit α1G may be a fetal target of maternal sera autoantibodies in CHB. METHODOLOGY/PRINCIPAL FINDINGS We demonstrate differential mRNA expression of the T-type calcium channel CACNA1G (α1G gene) in the AV junction of human fetal hearts compared to the apex (18-22.6 weeks gestation). Using human fetal hearts (20-22 wks gestation), our immunoprecipitation (IP), Western blot analysis and immunofluorescence (IF) staining results, taken together, demonstrate accessibility of the α1G epitope on the surfaces of cardiomyocytes as well as reactivity of maternal serum from CHB affected pregnancies to the α1G protein. By ELISA we demonstrated maternal sera reactivity to α1G was significantly higher in CHB maternal sera compared to controls, and reactivity was epitope mapped to a peptide designated as p305 (corresponding to aa305-319 of the extracellular loop linking transmembrane segments S5-S6 in α1G repeat I). Maternal sera from CHB affected pregnancies also reacted more weakly to the homologous region (7/15 amino acids conserved) of the α1H channel. Electrophysiology experiments with single-cell patch-clamp also demonstrated effects of CHB maternal sera on T-type current in mouse sinoatrial node (SAN) cells. CONCLUSIONS/SIGNIFICANCE Taken together, these results indicate that CHB maternal sera antibodies readily target an extracellular epitope of α1G T-type calcium channels in human fetal cardiomyocytes. CHB maternal sera also show reactivity for α1H suggesting that autoantibodies can target multiple fetal targets.
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Affiliation(s)
- Linn S. Strandberg
- Department of Physiology and Experimental Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Xuezhi Cui
- Department of Physiology and Experimental Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Arianna Rath
- Division of Molecular Structure and Function, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Jie Liu
- Departments of Physiology and Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Earl D. Silverman
- Department of Physiology and Experimental Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Xiaoru Liu
- Department of Physiology and Experimental Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Vinayakumar Siragam
- Department of Physiology and Experimental Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Cameron Ackerley
- Department of Physiology and Experimental Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Brenda Bin Su
- Department of Physiology and Experimental Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Jane Yuqing Yan
- Department of Physiology and Experimental Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
| | | | | | | | - William Yuen
- Department of Physiology and Experimental Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
| | | | - Kalvin Lung
- Department of Physiology and Experimental Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Edgar T. Jaeggi
- Department of Physiology and Experimental Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Peter H. Backx
- Departments of Physiology and Medicine, University of Toronto, Toronto, Ontario, Canada
- Division of Cardiology, University Health Network, Toronto, Ontario, Canada
| | - Charles M. Deber
- Division of Molecular Structure and Function, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Biochemistry, University of Toronto, Toronto, Ontario, Canada
| | - Robert M. Hamilton
- Department of Physiology and Experimental Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
- * E-mail:
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