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Liu Y, Li W, Zhou K, Hu Z. Reverse complete heart block using transcutaneous pacing and repeated plasmapheresis in a neonate with lupus: a case report. Pediatr Rheumatol Online J 2023; 21:135. [PMID: 37946215 PMCID: PMC10636865 DOI: 10.1186/s12969-023-00920-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 10/30/2023] [Indexed: 11/12/2023] Open
Abstract
BACKGROUND It has been reported that the complete heart block (CHB) in neonatal lupus (NL) cannot be reversed. This study reported a case of NL-CHB that was reversed by transcutaneous pacing and repeated plasmapheresis. CASE PRESENTATION A 35+ 6-week male preterm baby was transferred to the neonatal intensive care unit of the Army Medical Center in May 2020 for slight cyanosis around the lips and nose. Two days after birth, a sudden decrease in heart rate was observed during electrocardiogram (EGG) monitoring. Physical examination revealed a bluish-purple discoloration around the lips and an irregular heartbeat. EGG showed the presence of isolated P (142 bpm) and QRS (78 bpm) waves, ventricular escape beats, and a diagnosis of NL-CHB. To reverse the condition, transcutaneous pacing and five sessions of plasmapheresis were performed. At a 1.5-year follow-up, the baby exhibited well-developed cardiac structure and normal neurodevelopment. CONCLUSIONS Transcutaneous pacing and repeated plasmapheresis might be possible to reverse CHB in NL.
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Affiliation(s)
- Yanfei Liu
- Department of Pediatrics & Neonatology, Army Medical Center, Army Medical University, Chongqing, 400042, China
| | - Wanwei Li
- Department of Pediatrics & Neonatology, Army Medical Center, Army Medical University, Chongqing, 400042, China
| | - Kun Zhou
- Department of Pediatrics & Neonatology, Army Medical Center, Army Medical University, Chongqing, 400042, China
| | - Zhangxue Hu
- Department of Pediatrics & Neonatology, Army Medical Center, Army Medical University, Chongqing, 400042, China.
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Flowers ME, Garber K, Temples HS. Identifying Congenital Heart Block in Primary Care. J Pediatr Health Care 2023; 37:478-483. [PMID: 37031100 DOI: 10.1016/j.pedhc.2023.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 03/02/2023] [Accepted: 03/07/2023] [Indexed: 04/10/2023]
Abstract
Congenital heart block is a rare disease characterized by electrical conduction abnormalities of the heart in patients with both structural and without structural abnormalities. The most common cause of congenital heart block is autoimmune related, but other potential causes exist. Treatment for congenital heart block is determined by the severity of the disease and presenting symptoms. Primary care providers are in the optimal position to support patients and families. Although common causes and treatments of congenital heart block are known, much research is still to be done on the cause, optimal treatments, and potential long-term side effects.
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3
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Abstract
Congenital complete heart block (CCHB) defines atrioventricular conduction abnormalities diagnosed in utero or within the first 27 days of life. Maternal autoimmune disease and congenital heart defects are most commonly responsible. Recent genetic discoveries have highlighted our understanding of the underlying mechanism. Hydroxychloroquine shows promise in preventing autoimmune CCHB. Patients may develop symptomatic bradycardia and cardiomyopathy. The presence of these and other specific findings warrants placement of a permanent pacemaker to relieve symptoms and prevent catastrophic events. The mechanisms, natural history, evaluation, and treatment of patients with or at risk for CCHB are reviewed.
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Affiliation(s)
- Leonard Steinberg
- Pediatric Cardiology, Children's Heart Center, Ascension St. Vincent, 8333 Naab Rd, Ste 320, Indianapolis, IN 46260, USA.
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4
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Dalili M, Ariannia A, Rezanejad E. Percutaneous extraction of a protruding atrial pacing lead in an 8-year-old child. J Cardiol Cases 2023; 28:32-35. [PMID: 37360832 PMCID: PMC10287992 DOI: 10.1016/j.jccase.2023.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2022] [Revised: 02/14/2023] [Accepted: 03/01/2023] [Indexed: 06/28/2023] Open
Abstract
An 8-year-old girl with a history of single-chamber epicardial pacemaker during infancy and cardiac resynchronization therapy with a His bundle pacing lead implantation six months earlier, presented with congenital complete heart block. At the follow-up visit, we found atrial pacing lead protrusion with probable insulation in the computed tomography scan. We have shown late pacemaker lead perforation management under fluoroscopic guidance in a pediatric patient. Learning objective A serious complication associated with cardiac implantable electronic devices is lead perforation. In the pediatric age group, limited data exist on this complication and its challenging management.We present a case of atrial pacing lead protrusion in an 8-year-old girl. The lead was extracted under fluoroscopic guidance without any complications.
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Affiliation(s)
- Mohammad Dalili
- Department of Pediatric Cardiology, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Ali Ariannia
- Department of Surgery, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Elham Rezanejad
- Department of Pediatric Cardiology, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
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Torpoco Rivera DM, Sriram C, Karpawich PP, Aggarwal S. Ventricular Functional Analysis in Congenital Complete Heart Block Using Speckle Tracking: Left Ventricular Epicardial Compared to Right Ventricular Septal Pacing. Pediatr Cardiol 2023. [PMID: 36625944 DOI: 10.1007/s00246-022-03093-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 12/28/2022] [Indexed: 01/11/2023]
Abstract
BACKGROUND Chronic right ventricular (RV) apical pacing in patients with congenital complete atrioventricular block (CCAVB) is associated with left ventricle (LV) dyssynchrony and dysfunction. Hence, alternative pacing sites are advocated. The aim of this study was to compare LV function using STE in selected patients with LV epicardial pacing (LVEp) vs. RV transvenous pacing (RVSp). METHODS This was a single-center, retrospective study in patients with CCAVB who underwent permanent pacemaker implant at age ≤ 18 years. Age- and gender-matched patients with a normal heart anatomy and function served as the control group. LV function was comprehensively assessed by conventional 2D Echocardiography and speckle-tracking echocardiography (STE). RESULTS We included 24 patients in the pacemaker group [27.6% male, mean age of 17.1 at last follow-up, follow-up duration of 8.7 years, RVSp (n = 9; 62.5%)] compared to 48 matched healthy controls. Shortening fraction (SF) and ejection fraction (EF) were normal and similar between cases and controls. However, STE detected abnormal LV function in the pacemaker group compared to controls. The former demonstrated lower/abnormal, Peak Longitudinal Strain myocardial (PLS Myo) [- 12.0 ± 3.3 vs. - 18.1 ± 1.9, p < 0.001] and Peak Longitudinal Strain endocardial (PLS endo) [- 16.1 ± 4.1 vs. 1.7 ± 1.7, p < 0.001]. STE parameters of LV function were significantly more abnormal in LVEp vs. RVSp subgroup as demonstrated by lower values for PLS Myo (- 10.1 ± 3.2 vs. - 13.1 ± 2.9, p = 0.03) and PLS Endo (- 13.8 ± 4.4 vs. - 17.5 ± 3.3, p = 0.03). CONCLUSION STE was more sensitive in detecting subtle differences in LV function relative to standard conventional 2D echocardiography (SF and EF) in selected patients with CCAVB and a permanent pacemaker. Furthermore, STE demonstrated that transvenous RV septal pacing was associated with better LV systolic function preservation than LV epicardial pacing for comparable post-implant intervals.
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Endo Y, Kawai Y, Yamagishi M. Histological finding of maternal antibody-associated congenital heart block accompanied by large atrial septal defect and severe cardiac dysfunction. Cardiol Young 2022; 32:2032-5. [PMID: 35351221 DOI: 10.1017/S1047951122001007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Cardiac dysfunction commonly occurs in congenital heart block associated with maternal anti-SSA antibodies, especially after pacemaker implantation. We report the case of a 4-year-old girl with antibody-associated congenital heart block and a large secundum atrial septal defect who presented with significant cardiac dysfunction 4 years after pacemaker implantation. Histological findings were useful for determining the course of treatment and perioperative risk of intracardiac repair.
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Pick J, Silka MJ, Bar-Cohen Y, Hill A, Shwayder M, Wood J, Pruetz JD. Third Trimester Fetal Heart Rates in Antibody-Mediated Complete Heart Block Predict Need for Neonatal Pacemaker Placement. Pediatr Cardiol 2022; 43:324-31. [PMID: 34514536 DOI: 10.1007/s00246-021-02723-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Accepted: 09/01/2021] [Indexed: 10/20/2022]
Abstract
Congenital complete heart block (CCHB) affects 1 in 20,000 newborns. This study evaluates fetal and neonatal risk factors predictive of neonatal pacemaker placement in antibody-mediated complete heart block. The Children's Hospital Los Angeles institutional fetal, pacemaker, and medical record databases were queried for confirmed SSA/SSB cases of CCHB between January 2004 and July 2019. Cases excluded were those with a diagnosis beyond the neonatal period, diagnosis of a channelopathy, or if maternal antibody status was unknown. We recorded the gestational age (GA), birth weight (BW), fetal heart rates (FHRs) of the last echocardiogram before delivery, specific neonatal ECG and echocardiogram findings, age at pacemaker placement, and mortality. Of 43 neonates identified with CCHB, 27 had confirmed maternal antibody exposure. Variables associated with neonatal pacemaker implantation were FHRs < 50 bpm (p = 0.005), neonatal heart rates < 52 bpm (p = 0.015), and neonatal left ventricular fractional shortening (FS) percentages < 34% (p = 0.03). On multivariate analysis, FHR remained significant (p = 0.03) and demonstrated an increased risk of neonatal pacemaker placement by an odds ratio of 12.5 (95% CI 1.3-116, p = 0.05). The median GA at which the FHR was obtained was 34 weeks (IQR 26-35 weeks). Neonatal pacemaker placement was highly associated with a FHR < 50 bpm, neonatal HR < 52 bpm, and neonatal FS < 34%. FHRs at 34 weeks GA (IQR 26-35 weeks) correlated well with postnatal heart rates and were predictive of neonatal pacemaker placement.
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Sunderji S, Peyvandi S, Jaeggi E, Szwast A, Ryan G, Tessier F, Siddiqui S, Cuneo B, Sheth S, Treadwell M, Frommelt M, Turan S, Copel J, Emery S, Rand L, Moon-Grady AJ. NAFTNet retrospective report on the treatment of anti-Ro/SSA mediated fetal heart block with dexamethasone. J Matern Fetal Neonatal Med 2022; 35:9263-9270. [PMID: 35014577 DOI: 10.1080/14767058.2022.2025536] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
BACKGROUND Complete atrioventricular block (CAVB) is a complication of maternal antibody positivity and treatment of fetal disease is controversial in terms of efficacy and safety. We hypothesized that dexamethasone treatment for fetal anti-Ro/SSA antibody-mediated cardiac disease leads to better pregnancy outcomes than expectant management. METHODS A retrospective multi-center cohort study of anti-Ro/SSA antibody positive pregnancies with fetal conduction disease reported by participating North American Fetal Therapy Network (NAFTNet) centers between January 2010 and December 2018. The primary outcomes included: fetal death, oligohydramnios, growth restriction, preterm delivery, and new maternal comorbidities. Secondary outcomes included: pacemaker prior to 28 days, transplantation, and neonatal death in maternal/fetal dyads treated with dexamethasone versus not. RESULTS In 127 anti-Ro/SSA positive pregnancies, 98 were treated with dexamethasone and 29 were not. Of those treated, 61/96 (63.5%) met the primary outcome including 45/91 (49.4%) premature deliveries; 20 mothers developed comorbidities during treatment (fetal death 5, 10 growth restriction, 14 oligohydramnios, two new/worsening gestational diabetes). In the untreated group, 15/25 (60%) met the primary outcome including 11/22 (50%) premature deliveries and four mothers developing comorbidities during their pregnancy (fetal death 3, one growth restriction, one new onset maternal hypertension). Regarding secondary outcomes, 37/96 (43%) treated fetuses required a pacemaker or died by 28 days, while untreated 13/25 (52%) required pacemaker placement, died prior to 28 days or required listing for transplantation. Excluding terminations, survival without transplant was 17 (68%) in untreated and 85 (89%) in treated patients (p<.01). CONCLUSIONS While the use of dexamethasone in anti-Ro/SSA positive pregnancies is associated with a high rate of poor pregnancy outcomes, there was an unexpected similarly high rate in untreated positive pregnancies. This suggests that the maternal disease itself is influencing pregnancy complications independent of dexamethasone. Our data, which show that treatment decreases neonatal morbidity and overall mortality without increasing overall pregnancy complications, warrant further study.
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Affiliation(s)
- Sherzana Sunderji
- Department of Pediatrics, University of California, Davis, Sacramento, CA, USA
| | - Shabnam Peyvandi
- Department of Pediatrics, University of California, San Francisco, San Francisco, CA, USA
| | | | - Anita Szwast
- The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Greg Ryan
- Mount Sinai Hospital, Toronto, Canada
| | - Francine Tessier
- Children's & Women's Health Centre of British Columbia, Vancouver, Canada
| | | | | | | | - Marjorie Treadwell
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA
| | | | - Shifa Turan
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD, USA
| | | | - Stephen Emery
- Department of Obstetrics, Gynecology, & Reproductive Sciences, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Larry Rand
- Department of Pediatrics, University of California, San Francisco, San Francisco, CA, USA
| | - Anita J Moon-Grady
- Department of Pediatrics, University of California, San Francisco, San Francisco, CA, USA
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Hernstadt H, Regan W, Bhatt H, Rosenthal E, Meau-Petit V. Cohort study of congenital complete heart block among preterm neonates: a single-center experience over a 15-year period. Eur J Pediatr 2022; 181:1047-1054. [PMID: 34704129 PMCID: PMC8548064 DOI: 10.1007/s00431-021-04293-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 10/02/2021] [Accepted: 10/10/2021] [Indexed: 11/24/2022]
Abstract
Congenital complete heart block (CCHB) is a very rare condition, with high risk of mortality. Prematurity is associated with immaturity of the cardiovascular system. Morbidity related to CCHB and prematurity has never been described. We describe a tertiary perinatal center experience over a 15-year period on CCHB management and complications in preterm infants. This is a single-center observational cohort study. All neonates admitted to neonatal intensive care unit with a diagnosis of isolated CCHB between January 2006 and January 2021 were identified. All preterm neonates (< 37 weeks) were compared with a control cohort of term neonates (≥ 37 weeks). Antenatal data, complications of prematurity, medical, and surgical management of CCHB were recorded. Twenty-four neonates with isolated CCHB (16 preterm and 8 term) were born during the study period, including 5 very preterm (< 32 weeks) and 11 preterm (32 to 37 weeks). All very preterm were born via emergency caesarian section without antenatal steroid administration. They had multiple severe morbidities including chronic lung disease, necrotizing enterocolitis, grades 3-4 intraventricular hemorrhage, cystic periventricular leukomalacia, and longer periods of mechanical and non-invasive ventilatory support than preterm. Thirteen out of sixteen preterm infants had permanent pacemakers inserted, compared to 1/8 for term newborns. All babies born before 35-week gestation were either paced or died.Conclusion: Premature neonates with CCHB have high risk of mortality and morbidity especially if undiagnosed and born by unnecessary emergency caesarian section without antenatal steroids. Prematurity below 35 weeks may be associated with death or pacemaker insertion. This supports better antenatal screening to avoid induced prematurity. What is Known: • Congenital complete heart block is a very rare condition associated with high morbidity and mortality. • Antenatal risk factors for poor outcome include fetal hydrops, low ventricular rate (HR <55 beats per minute), and congenital heart defect. What is New: • Infants born <32 weeks with CCHB had no antenatal steroid administration, and sustained high burden of morbidity (chronic lung disease, intraventricular hemorrhage, and cystic periventricular leukomalacia). • Birth <35 weeks is strongly associated with requiring pacing prior to discharge or death.
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Affiliation(s)
- Hayley Hernstadt
- Department of Neonatology, Evelina London Children's Hospital, London, UK. .,Department of Paediatrics, Monash University, Melbourne, VIC, Australia.
| | - William Regan
- Department of Paediatric Cardiology, Evelina London Children’s Hospital, London, UK
| | - Hitarth Bhatt
- Department of Paediatric Cardiology, Evelina London Children’s Hospital, London, UK
| | - Eric Rosenthal
- Department of Paediatric Cardiology, Evelina London Children’s Hospital, London, UK
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Abstract
Congenital complete heart block (CCHB) defines atrioventricular conduction abnormalities diagnosed in utero or within the first 27 days of life. Maternal autoimmune disease and congenital heart defects are most commonly responsible. Recent genetic discoveries have highlighted our understanding of the underlying mechanism. Hydroxychloroquine shows promise in preventing autoimmune CCHB. Patients may develop symptomatic bradycardia and cardiomyopathy. The presence of these and other specific findings warrants placement of a permanent pacemaker to relieve symptoms and prevent catastrophic events. The mechanisms, natural history, evaluation, and treatment of patients with or at risk for CCHB are reviewed.
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11
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Chimoriya R, Awasthy N, Kumar G. Temporary pacemaker implantation through umbilical vein in a low birth weight neonate with congenital complete heart block. Cardiol Young 2021; 31:1687-9. [PMID: 33888171 DOI: 10.1017/S1047951121001220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Congenital heart block is a rare and lethal condition in paediatric population associated with maternal connective tissue disorders and rarely with structural cardiac disease like atrioventricular canal defects with or without left isomerism and congenitally corrected transposition of great arteries. Pacing in neonate if indicated is generally accomplished by epicardial pacing systems. However, in cases of significant bradycardia and haemodynamic instability, temporary pacemaker implantation via transvenous approach remains as a suitable option. Despite the advances in percutaneous catheter interventions, use of transvenous pacing in newborn is extremely challenging due to inadvertent risk of vessel injury, thrombus formation and mortality, and most of the time technical inability to place the lead within the right ventricular cavity. We report a case of congenital complete atrioventricular block in a premature male with birth weight of 1.51 kg who was managed with temporary pacemaker implantation through umbilical vein.
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Ng LY, Gallagher S, Walsh KP. Case series of late lead dislodgement of Medtronic SelectSecure 3830 pacing leads in growing paediatric patients. Eur Heart J Case Rep 2021; 5:ytaa545. [PMID: 33598620 PMCID: PMC7873804 DOI: 10.1093/ehjcr/ytaa545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Revised: 08/24/2020] [Accepted: 12/08/2020] [Indexed: 11/13/2022]
Abstract
Background The SelectSecure lumenless 3830 pacing lead is often considered to be the pacing lead of choice for transvenous pacing in children because of its small diameter, lead strength, and reliable long-term sensing and pacing characteristics. One of the potential long-term pitfalls of a sturdy pacing lead is relative retraction with growth in children resulting in late lead dislodgement. Case summary We report two cases of late SelectSecure 3830 lead dislodgement at 11.8 years (Case 1) and 8.8 years (Case 2), respectively, post the initial implantation. Case 1 was diagnosed with congenital complete heart block (CHB) at 9 months old when he presented with unconfirmed diphtheria infection. Case 2 was diagnosed with CHB at 14 weeks of age with positive maternal anti-Ro antibodies. Both patients underwent implantation of a transvenous permanent pacemaker implantation with Medtronic SelectSecure 3830 lead due to symptomatic bradycardia. Apart from a pulse generator change at 8.5 years (Case 1) and 7 years (Case 2), respectively, post-implant due to normal battery depletion, both patients are well in the interim. Discussion As part of the pacemaker follow-up for rapidly growing children, we recommend more frequent surveillance of lead ‘tautness’ by chest radiography especially in children with CHB with no underlying heart rhythm.
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Affiliation(s)
- Li Yen Ng
- Department of Paediatric Cardiology, Children's Health Ireland at Crumlin, Cooley Road, Crumlin, Dublin D12 N512, Ireland
| | - Sarah Gallagher
- Department of Paediatric Cardiology, Children's Health Ireland at Crumlin, Cooley Road, Crumlin, Dublin D12 N512, Ireland
| | - Kevin P Walsh
- Department of Paediatric Cardiology, Children's Health Ireland at Crumlin, Cooley Road, Crumlin, Dublin D12 N512, Ireland
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Suryawanshi H, Clancy R, Morozov P, Halushka MK, Buyon JP, Tuschl T. Cell atlas of the foetal human heart and implications for autoimmune-mediated congenital heart block. Cardiovasc Res 2021; 116:1446-1457. [PMID: 31589297 PMCID: PMC7314636 DOI: 10.1093/cvr/cvz257] [Citation(s) in RCA: 54] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Revised: 09/09/2019] [Accepted: 10/01/2019] [Indexed: 01/01/2023] Open
Abstract
Aims Investigating human heart development and applying this to deviations resulting in disease is incomplete without molecular characterization of the cell types required for normal functioning. We investigated foetal human heart single-cell transcriptomes from mid-gestational healthy and anti-SSA/Ro associated congenital heart block (CHB) samples. Methods and results Three healthy foetal human hearts (19th to 22nd week of gestation) and one foetal heart affected by autoimmune-associated CHB (21st week of gestation) were subjected to enzymatic dissociation using the Langendorff preparation to obtain single-cell suspensions followed by 10× Genomics- and Illumina-based single-cell RNA-sequencing (scRNA-seq). In addition to the myocytes, fibroblasts, immune cells, and other minor cell types, previously uncharacterized diverse sub-populations of endothelial cells were identified in the human heart. Differential gene expression analysis revealed increased and heterogeneous interferon responses in varied cell types of the CHB heart compared with the healthy controls. In addition, we also identified matrisome transcripts enriched in CHB stromal cells that potentially contribute to extracellular matrix deposition and subsequent fibrosis. Conclusion These data provide an information-rich resource to further our understanding of human heart development, which, as illustrated by comparison to a heart exposed to a maternal autoimmune environment, can be leveraged to provide insight into the pathogenesis of disease.
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Affiliation(s)
- Hemant Suryawanshi
- Laboratory of RNA Molecular Biology, The Rockefeller University, 1230 York Avenue, Box 186, New York, NY 10065, USA
| | - Robert Clancy
- Division of Rheumatology, Department of Medicine, New York University School of Medicine, New York, NY 10016, USA
| | - Pavel Morozov
- Laboratory of RNA Molecular Biology, The Rockefeller University, 1230 York Avenue, Box 186, New York, NY 10065, USA
| | - Marc K Halushka
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD, 21205, USA
| | - Jill P Buyon
- Division of Rheumatology, Department of Medicine, New York University School of Medicine, New York, NY 10016, USA
| | - Thomas Tuschl
- Laboratory of RNA Molecular Biology, The Rockefeller University, 1230 York Avenue, Box 186, New York, NY 10065, USA
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Milazzo R, Ligato E, Laoreti A, Ferri G, Basili L, Serati L, Brucato A, Cetin I. Home fetal heart rate monitoring in anti Ro/SSA positive pregnancies: Literature review and case report. Eur J Obstet Gynecol Reprod Biol 2021; 259:1-6. [PMID: 33556767 DOI: 10.1016/j.ejogrb.2021.01.031] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Accepted: 01/18/2021] [Indexed: 10/22/2022]
Abstract
Anti-Ro/SSA antibodies are associated with a risk of 1-2 % to develop complete atrioventricular block (AVB) in fetuses of positive mothers. Complete AVB is irreversible, but studies suggest that anti-inflammatory treatment during the transition period from a normal fetal heart rate (FHR) to an AVB might stop this progression and restore sinus rhythm. The most efficient method for diagnostic evaluation of this arrhythmia is the pulsed-Doppler fetal echocardiography. However, weekly or bi-weekly recommended fetal echocardiographic surveillance can rarely identify an AVB in time for treatment success, also because the transition from a normal rhythm to a third degree AVB is very fast. Daily FHR monitoring in a medical facility could increase the chances of identifying the AVB onset but is difficult to realize. For this reason, an alternative method of FHR monitoring, performed directly by mothers in their home context, has been recently proposed. We present a case report utilizing this approach and review the current evidence about this condition.
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Affiliation(s)
- Roberta Milazzo
- Department of Woman, Mother and Neonate, "V. Buzzi" Children Hospital, ASST Fatebenefratelli Sacco, Milan, Italy.
| | - Elisa Ligato
- Department of Woman, Mother and Neonate, "V. Buzzi" Children Hospital, ASST Fatebenefratelli Sacco, Milan, Italy
| | - Arianna Laoreti
- Department of Woman, Mother and Neonate, "V. Buzzi" Children Hospital, ASST Fatebenefratelli Sacco, Milan, Italy
| | - Giulia Ferri
- Department of Woman, Mother and Neonate, "V. Buzzi" Children Hospital, ASST Fatebenefratelli Sacco, Milan, Italy
| | - Ludovica Basili
- Department of Woman, Mother and Neonate, "V. Buzzi" Children Hospital, ASST Fatebenefratelli Sacco, Milan, Italy
| | - Lisa Serati
- Internal Medicine, Fatebenefratelli Hospital, Milan, Italy
| | | | - Irene Cetin
- Department of Woman, Mother and Neonate, "V. Buzzi" Children Hospital, ASST Fatebenefratelli Sacco, Milan, Italy; Department of Biomedical and Clinical Sciences "Luigi Sacco", University of Milan, Milan, Italy
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15
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Vermeulen AM, Zimmerman F, Nguyen HH. False Asystole Alarms Post-Temporary Pacemaker Placement Due to Pseudo-fusion. Pediatr Cardiol 2021; 42:215-218. [PMID: 33247766 DOI: 10.1007/s00246-020-02502-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Accepted: 11/17/2020] [Indexed: 11/25/2022]
Abstract
An infant with congenital heart block and hemodynamically significant bradycardia underwent therapeutic temporary pacing wires placement. Post-operatively, frequent "asystole" alarms were observed on telemetry causing distress to both the family and the nursing staff. Investigation of these alarms showed that pacemaker malfunction led to monitor pseudo-malfunction. The alarms were alleviated with mindful setting of the pacemaker and telemetry monitor parameters. This case highlights the challenges of pacemaker placement and monitoring of very small infants in the intensive care setting. Awareness of these challenges would help in troubleshooting pacemaker and telemetry monitor issues.
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Affiliation(s)
- Alyssa M Vermeulen
- Department of Pediatrics, Rush University Medical Center, Chicago, IL, 60612, USA
| | - Frank Zimmerman
- Department of Pediatrics, Rush University Medical Center, Chicago, IL, 60612, USA
| | - Hoang H Nguyen
- Department of Pediatrics, Rush University Medical Center, Chicago, IL, 60612, USA.
- Department of Pediatrics, UT Southwestern Medical Center, Dallas, TX, 75390, USA.
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Rudbeck-Resdal J, Christiansen MK, Johansen JB, Nielsen JC, Bundgaard H, Jensen HK. Aetiologies and temporal trends of atrioventricular block in young patients: a 20-year nationwide study. Europace 2020; 21:1710-1716. [PMID: 31424500 PMCID: PMC6826204 DOI: 10.1093/europace/euz206] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Accepted: 07/09/2019] [Indexed: 12/26/2022] Open
Abstract
Aims To describe aetiologies and temporal trends in young patients with atrioventricular block (AVB). Methods and results We identified all patients in Denmark, receiving their first pacemaker because of AVB before the age of 50 years between 1996 and 2015. Medical records were reviewed and clinical information and diagnostic work-up results were obtained to evaluate the aetiology. We used Poisson regression testing for temporal trends. One thousand and twenty-seven patients were identified, median age at time of implantation was 38 (interquartile range 25–45) years, 584 (56.9%) were male. The aetiologies were complications to cardiac surgery [n = 157 (15.3%)], congenital AVB [n = 93 (9.0%)], cardioinhibitory reflex [n = 52 (5.0%)], congenital heart disease [n = 43 (4.2%)], complication to radiofrequency ablation [n = 35 (3.4%)], cardiomyopathy [n = 31 (3.0%)], endocarditis [n = 18 (1.7%)], muscular dystrophy [n = 14 (1.4%)], ischaemic heart disease [n = 14 (1.4%)], sarcoidosis [n = 11 (1.1%)], borreliosis [n = 9 (0.9%)], hereditary [n = 6 (0.6%)], side-effect to antiarrhythmics [n = 6 (0.6%)], planned His-ablation [n = 5 (0.5%)], complication to alcohol septal ablation [n = 5 (0.5%)], and other known aetiologies [n = 11 (1.1%)]. The aetiology remained unknown in 517 (50.3%) cases. While the number of patients with unknown aetiology increased during the study period (P < 0.001), we observed no significant change in the number of patients with identified aetiology (P = 0.35). Conclusion In a nationwide cohort, the aetiology of AVB was identified in only half the patients younger than 50 years referred for first-time pacemaker implantation. The number of patients with unknown aetiology increased during the study period. These findings indicate need for better insight into aetiologies of AVB and improved diagnostic work-up guidelines.
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Affiliation(s)
- Johnni Rudbeck-Resdal
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens, Boulevard 99, Aarhus N, Denmark.,Department of Clinical Medicine, Health, Aarhus University, Palle Juul-Jensens Boulevard 82, Aarhus N, Denmark
| | - Morten K Christiansen
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens, Boulevard 99, Aarhus N, Denmark
| | - Jens B Johansen
- Department of Cardiology, Danish Pacemaker and ICD Registry, Odense University Hospital, J. B. Winsløws Vej 4, Odense, Denmark
| | - Jens C Nielsen
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens, Boulevard 99, Aarhus N, Denmark.,Department of Clinical Medicine, Health, Aarhus University, Palle Juul-Jensens Boulevard 82, Aarhus N, Denmark
| | - Henning Bundgaard
- Unit for Inherited Cardiovascular Diseases, The Heart Centre, Department of Cardiology B2142, National University Hospital, University of Copenhagen, Blegdamsvej 9, Copenhagen, Denmark
| | - Henrik K Jensen
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens, Boulevard 99, Aarhus N, Denmark.,Department of Clinical Medicine, Health, Aarhus University, Palle Juul-Jensens Boulevard 82, Aarhus N, Denmark
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17
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Gupta S, Cho K, Papagiannis J, Tisma-Dupanovic S, Borsa J. A novel technique for extraction of a leadless pacemaker that embolized to the pulmonary artery in a young patient: A case report. HeartRhythm Case Rep 2020; 6:724-728. [PMID: 33101941 PMCID: PMC7573366 DOI: 10.1016/j.hrcr.2020.07.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Affiliation(s)
- Sanjaya Gupta
- Division of Cardiology, Saint Luke’s Mid-America Heart Institute, Kansas City, Missouri
- Address reprint requests and correspondence: Dr Sanjaya Gupta, Saint Luke’s Mid-America Heart Institute, 9th Floor – Cardiovascular Research, 4400 Wornall Rd, Kansas City, MO 64111.
| | - Ken Cho
- Department of Radiology, Saint Luke’s Hospital of Kansas City, Kansas City, Missouri
| | - John Papagiannis
- Division of Cardiology, Saint Luke’s Mid-America Heart Institute, Kansas City, Missouri
- Division of Cardiology, Children’s Mercy Hospital, Kansas City, Missouri
| | - Svjetlana Tisma-Dupanovic
- Division of Cardiology, Saint Luke’s Mid-America Heart Institute, Kansas City, Missouri
- Division of Cardiology, Children’s Mercy Hospital, Kansas City, Missouri
| | - John Borsa
- Department of Radiology, Saint Luke’s Hospital of Kansas City, Kansas City, Missouri
- Department of Radiology, University of Missouri Kansas City, Kansas City, Missouri
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18
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Wainwright B, Bhan R, Trad C, Cohen R, Saxena A, Buyon J, Izmirly P. Autoimmune-mediated congenital heart block. Best Pract Res Clin Obstet Gynaecol 2019; 64:41-51. [PMID: 31685414 DOI: 10.1016/j.bpobgyn.2019.09.001] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Accepted: 09/09/2019] [Indexed: 12/17/2022]
Abstract
Autoimmune-mediated congenital heart block (CHB) is a severe manifestation of neonatal lupus in which conduction tissues of the fetal heart are damaged. This occurs due to passive transference of maternal anti-SSA/Ro and anti-SSB/La autoantibodies and subsequent inflammation and fibrosis of the atrioventricular (AV) node. Notably, the disease manifests after the fetal heart has structurally developed, ruling out other anatomical abnormalities that could otherwise contribute to the block of conduction. Complete AV block is irreversible and the most common manifestation of CHB, although other cardiac complications such as endocardial fibroelastosis (EFE), dilated cardiomyopathy, and valvular insufficiency have been observed. In this review, we detail the classification, prevalence, pathogenesis, and clinical management recommendations for autoimmune CHB.
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Affiliation(s)
| | - Rohit Bhan
- NYU School of Medicine, New York, NY, USA
| | | | | | | | - Jill Buyon
- NYU School of Medicine, New York, NY, USA
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19
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Manolis AA, Manolis TA, Melita H, Manolis AS. Congenital heart block: Pace earlier (Childhood) than later (Adulthood). Trends Cardiovasc Med 2020; 30:275-86. [PMID: 31262557 DOI: 10.1016/j.tcm.2019.06.006] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2019] [Revised: 06/16/2019] [Accepted: 06/17/2019] [Indexed: 12/22/2022]
Abstract
Congenital complete heart block (CCHB) occurs in 2-5% of pregnancies with positive anti-Ro/SSA and/or anti-La/SSB antibodies, and has a recurrence rate of 12-25% in a subsequent pregnancy. After trans-placental passage, these autoantibodies attack and destroy the atrioventricular (AV) node in susceptible fetuses with the highest-risk period observed between 16 and 28 weeks' gestational age. Many mothers are asymptomatic carriers, while <1/3 have a preexisting diagnosis of a rheumatic disease. The mortality of CCHB is predominant in utero and in the first months of life, reaching 15-30%. The diagnosis of CCHB can be confirmed by fetal echocardiography before birth and by electrocardiography after birth. Whether early in-utero detection and treatment might prevent or reverse this condition remains controversial. In addition to autoantibody-associated CCHB, there is also an isolated (absent structural heart disease) nonimmune early- or late-onset heart block detected later in childhood that may be associated with specific genetic markers or other pathogenic mechanisms. In isolated immune or non-immune CCHB, cardiac pacemakers are implanted in symptomatic patients, however, data on the natural history of CCHB in the adult life indicate that all patients, even if asymptomatic, should receive a pacemaker when first diagnosed. However, important issues have emerged in these patients wherein life-long conventional right ventricular apical pacing may produce left ventricular dysfunction (pacing-induced cardiomyopathy) necessitating a priori alternate site pacing or subsequent upgrading to biventricular pacing. All these issues are herein reviewed and two algorithms are proposed for diagnosis and management of CCHB in the fetus and in the older individual.
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20
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Kurath-Koller S, Schweintzger S, Grangl G, Burmas A, Gamillscheg A, Koestenberger M. First clinical experience with the Kora pacemaker system in congenital complete heart block in newborn infants. BMC Pediatr 2019; 19:124. [PMID: 31018851 PMCID: PMC6480703 DOI: 10.1186/s12887-019-1494-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Accepted: 04/08/2019] [Indexed: 11/30/2022] Open
Abstract
Background To report first clinical experience on three cases of congenital complete heart block and the use of a pacemaker system with a maximum lower rate interval of 95 beats per minute. Methods We retrospectively analyzed three patients treated with a pacemaker system with a maximum lower rate interval of 95 beats per minute suffering from congenital complete heart block. We report a follow up period of 2.9 years, focusing on the patients’ growth, development, and adverse events, as well as pacemaker function. Results In all three patients pacemaker function was impeccable, including minute ventilation sensor rate adaption. All patients showed limited growths as expected, adequate development, good feeding tolerability and circadiane heart rate adaption. One patient experienced skin traction and revision. All patients showed high aortic velocity time integral values after birth. Conclusion The use of a pacemaker system with a maximum lower rate interval of 95 beats per minute in infants suffering from congenital complete heart block and showing high aortic VTI values seems to be feasible and to result in limited growths but adequate development. Electronic supplementary material The online version of this article (10.1186/s12887-019-1494-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Stefan Kurath-Koller
- Division of Pediatric Cardiology, Department of Pediatrics, Medical University Graz, Auenbruggerplatz 34/2, A-8036, Graz, Austria.
| | - Sabrina Schweintzger
- Division of Pediatric Cardiology, Department of Pediatrics, Medical University Graz, Auenbruggerplatz 34/2, A-8036, Graz, Austria
| | - Gernot Grangl
- Division of Pediatric Cardiology, Department of Pediatrics, Medical University Graz, Auenbruggerplatz 34/2, A-8036, Graz, Austria
| | - Ante Burmas
- Division of Pediatric Cardiology, Department of Pediatrics, Medical University Graz, Auenbruggerplatz 34/2, A-8036, Graz, Austria
| | - Andreas Gamillscheg
- Division of Pediatric Cardiology, Department of Pediatrics, Medical University Graz, Auenbruggerplatz 34/2, A-8036, Graz, Austria
| | - Martin Koestenberger
- Division of Pediatric Cardiology, Department of Pediatrics, Medical University Graz, Auenbruggerplatz 34/2, A-8036, Graz, Austria
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21
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Demarchi J, Papasidero SB, Klajn D, Alba P, Babini AM, Durigan V, Gobbi C, Raiti L. Primary Sjögren's syndrome and pregnancy: A report of 18 cases. ACTA ACUST UNITED AC 2017; 15:109-112. [PMID: 28844688 DOI: 10.1016/j.reuma.2017.07.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Revised: 07/06/2017] [Accepted: 07/14/2017] [Indexed: 11/30/2022]
Abstract
Primary Sjögren's syndrome (pSS) is a condition that predominantly affects women. Reports of pregnancy outcome in these patients are limited and contradictory. OBJECTIVE To describe pregnancy characteristics and outcomes and newborn morbidity in women with pSS. MATERIAL AND METHODS We included women with pSS who became pregnant after the onset of the symptoms of the disease. Clinical and serological characteristics, risk factors and previous maternal comorbidities are described. For each pregnancy in a woman with pSS, we recorded pregnancy course and outcome and newborn condition. RESULTS We assessed 11 patients with 18 pregnancies after the onset of pSS symptoms. All of them presented FAN +; 10 anti-Ro / SSA + and 7 anti-La / SSB +. The mean age in years at the onset of symptoms was 24.9 (SD 6.9) and at the time of pregnancy was 30.3 (SD 5.4). Thirteen pregnancies happened before the diagnosis, reporting only one miscarriage. Two preterm births, 1 case of oligohydramnios, 2 of premature membrane rupture and 2 low birthweight babies were reported after the onset of pSS symptoms. There was 1 newborn with congenital atrioventricular block and another with neonatal cutaneous lupus. All the women with pregnancy complications (n=6) had anti-Ro/SSA antibodies. CONCLUSIONS Almost half of the pregnancies assessed in women with pSS were associated with complications not attributable to factors other than the disease.
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Affiliation(s)
- Julia Demarchi
- Servicio de Reumatología, Hospital General de Agudos Dr. Enrique Tornú, Ciudad Autónoma de Buenos Aires, Argentina.
| | - Silvia B Papasidero
- Servicio de Reumatología, Hospital General de Agudos Dr. Enrique Tornú, Ciudad Autónoma de Buenos Aires, Argentina
| | - Diana Klajn
- Servicio de Reumatología, Hospital General de Agudos Dr. Enrique Tornú, Ciudad Autónoma de Buenos Aires, Argentina
| | - Paula Alba
- Hospital Córdoba, Hospital Materno Neonatal Córdoba, Cátedra de Medicina I UHMN 3 UNC, Córdoba, Argentina
| | | | - Virginia Durigan
- Hospital Bernardino Rivadavia, Ciudad Autónoma de Buenos Aires, Argentina
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22
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Tonello M, Hoxha A, Mattia E, Zambon A, Visentin S, Cerutti A, Ghirardello A, Milanesi O, Ruffatti A. Low titer, isolated anti Ro/SSA 60 kd antibodies is correlated with positive pregnancy outcomes in women at risk of congenital heart block. Clin Rheumatol 2017; 36:1155-1160. [PMID: 28204891 DOI: 10.1007/s10067-017-3572-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Revised: 02/03/2017] [Accepted: 02/04/2017] [Indexed: 11/30/2022]
Abstract
Congenital heart block (CHB) is an autoantibody mediated disorder presumably caused by placental transmission of maternal autoantibodies to Ro/SSA 52 kd, p200, Ro/SSA 60 kd, La/SSB ribonucleoproteins. This study investigated the clinical significance of isolated anti-Ro/SSA 52 kd, anti-p200, anti-Ro/SSA 60 kd, and anti-La/SSB antibodies in positive pregnant patients. One hundred sixty-three pregnant women positive to anti-Ro/SSA 52 kd and/or anti-Ro/SSA 60 kd and/or anti-La/SSB antibodies were prospectively enrolled in the study. Anti-Ro52, anti-Ro60, anti-p200, and anti-La antibodies were assayed using home-made ELISA assays. Isolated antibody positivity was found in 25 women (15.3%), while multiple antibody positivity in 138 (84.7%). Twenty-four developed CHB, and the 139 had a favorable pregnancy outcome. The prevalence of isolated anti-Ro/SSA 60 kd antibodies was significantly higher (p < 0.046) as the prevalence of lower mean antibody titers (p < 0.0001) in the later group. Confirmation of these results by large-scale studies could lead clinicians to recommend less stringent fetal echocardiography monitoring in women with isolated anti-Ro/SSA 60 kd antibodies.
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Affiliation(s)
- Marta Tonello
- Rheumatology Unit, Department of Medicine, University of Padua, Padua, Italy
| | - Ariela Hoxha
- Rheumatology Unit, Department of Medicine, University of Padua, Padua, Italy
| | - Elena Mattia
- Rheumatology Unit, Department of Medicine, University of Padua, Padua, Italy
| | - Alessandra Zambon
- Gynaecology and Obstetrics Unit, Department of Women's and Children's Health, University of Padua, Padua, Italy
| | - Silvia Visentin
- Gynaecology and Obstetrics Unit, Department of Women's and Children's Health, University of Padua, Padua, Italy
| | - Alessia Cerutti
- Paediatric Cardiology Unit, Department of Women's and Children's Health, University of Padua, Padua, Italy
| | - Anna Ghirardello
- Rheumatology Unit, Department of Medicine, University of Padua, Padua, Italy
| | - Ornella Milanesi
- Paediatric Cardiology Unit, Department of Women's and Children's Health, University of Padua, Padua, Italy
| | - Amelia Ruffatti
- Rheumatology Unit, Department of Medicine, University of Padua, Padua, Italy.
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23
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Affiliation(s)
- Jason Payne
- Cardiology Department, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Monica Lo
- Cardiology Department, University of Arkansas for Medical Sciences, Little Rock, Arkansas.,Arkansas Heart Hospital, Little Rock, Arkansas
| | - Hakan Paydak
- Cardiology Department, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Waddah Maskoun
- Cardiology Department, University of Arkansas for Medical Sciences, Little Rock, Arkansas
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24
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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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Abstract
We compiled information on antibodies in Sjögren syndrome, focusing more on clinical manifestations associated with anti-Ro/SSA and anti-La/SSB antibodies and studies regarding novel antibodies. We reviewed previous as well as most recent studies with the subject heading Sjogren in combination with antibodies and congenital heart block (CHB). Almost half of asymptomatic mothers giving birth to children with CHB ultimately develop Sjögren. We discussed studies concerning the presence of antibodies predating clinical manifestations of disease. Studies in the future are required to ascertain the pathogenic mechanisms associated with these antibodies and the specific clinical manifestation related to new autoantibodies.
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Affiliation(s)
- Anum Fayyaz
- Arthritis & Clinical Immunology Program, Oklahoma Medical Research Foundation, 825 Northeast, 13th Street, Oklahoma City, OK 73104, USA; Department of Medicine, College of Medicine, 1000 N Lincoln Boulevard, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA; Medical and Research Services, US Department of Veterans Affairs Hospital, 921 NE 13th Street, Oklahoma City, OK 73104, USA
| | - Biji T Kurien
- Arthritis & Clinical Immunology Program, Oklahoma Medical Research Foundation, 825 Northeast, 13th Street, Oklahoma City, OK 73104, USA; Department of Medicine, College of Medicine, 1000 N Lincoln Boulevard, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA; Medical and Research Services, US Department of Veterans Affairs Hospital, 921 NE 13th Street, Oklahoma City, OK 73104, USA
| | - R Hal Scofield
- Arthritis & Clinical Immunology Program, Oklahoma Medical Research Foundation, 825 Northeast, 13th Street, Oklahoma City, OK 73104, USA; Department of Medicine, College of Medicine, 1000 N Lincoln Boulevard, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA; Medical and Research Services, US Department of Veterans Affairs Hospital, 921 NE 13th Street, Oklahoma City, OK 73104, USA.
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26
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Kim NE, Lee JH, Chung IS, Lee JY. Anesthetic management of patient with Sjogren's syndrome who underwent cesarean section: a case report. Korean J Anesthesiol 2016; 69:283-6. [PMID: 27274376 PMCID: PMC4891543 DOI: 10.4097/kjae.2016.69.3.283] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2015] [Revised: 02/23/2015] [Accepted: 03/16/2015] [Indexed: 11/29/2022] Open
Abstract
Sjogren's syndrome is one of the most common autoimmune disorders and has a female predominance. Maternal circulating autoantibodies such as anti-Ro/SSA and anti-La/SSB antibodies can cause congenital heart block of fetus, and in severe case, emergency pacemaker implantation may be needed for neonate. Therefore, it is very important to understand maternal and fetal condition and pay attention to the status of the neonate during delivery. In this paper, we present a case of patient with Sjogren's syndrome who underwent cesarean section under spinal anesthesia.
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Affiliation(s)
- Na Eun Kim
- Department of Anesthesiology and Pain Medicine, Seoul Medical Center, Seoul, Korea
| | - Jae Hyuk Lee
- Department of Anesthesiology and Pain Medicine, Seoul Medical Center, Seoul, Korea
| | - In Sun Chung
- Department of Anesthesiology and Pain Medicine, Seoul Medical Center, Seoul, Korea
| | - Jun Yong Lee
- Department of Anesthesiology and Pain Medicine, Seoul Medical Center, Seoul, Korea
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27
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Doti PI, Escoda O, Cesar-Díaz S, Palasti S, Teixidó I, Sarquella-Brugada G, Gómez O, Martínez JM, Espinosa G. Congenital heart block related to maternal autoantibodies: descriptive analysis of a series of 18 cases from a single center. Clin Rheumatol 2016; 35:351-6. [PMID: 26791874 DOI: 10.1007/s10067-016-3174-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Revised: 01/07/2016] [Accepted: 01/08/2016] [Indexed: 10/22/2022]
Abstract
The objective of this study was to describe the clinical and immunological characteristics of maternal autoimmune-mediated fetal congenital heart block (CHB) in a cohort of pregnant women from an autoimmune disease pregnancy clinic. This is a retrospective observational study of all women presenting with CHB in our autoimmune disease pregnancy clinic from January 1997 to December 2014. In addition, perinatal outcome is also described. Fourteen patients accounting for 18 fetuses with CHB were identified. The median age was 32.5 years (range, 22-40). Seven (50 %) patients had Sjögren's syndrome, and the remaining seven were asymptomatic carriers of autoantibodies. All patients had anti-Ro/SSA antibodies, and 11/13 (85 %) had anti-La/SSB antibodies. The median gestational age at the time of CHB was 22 weeks (range 18-28). Complete third degree CHB was detected in 12 (67 %). Seven cases of CHB were treated with dexamethasone, two with ritodrine, and one with the association of dexamethasone, ritodrine, and terbutaline. In 9 (50 %) cases that presented with, or developed, very poor prognosis factors, such as a ventricular rate below 50-55 bpm and/or the presence of fetal hydrops, parents opted for the termination of pregnancy, after dedicated counseling. Finally, there were nine newborns (seven males [78 %]) with median age at delivery of 37 weeks (range, 32-39). A definitive epicardial pacemaker was placed in six newborns, four of them within 2 weeks of life. CHB is a severe complication related to maternal anti-Ro/SSA and anti-La/SSB antibodies. Our results confirm previous data showing that therapy is ineffective, and most of the surviving patients will require neonatal pacemaker.
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28
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Tsuboi H, Sumida T, Noma H, Yamagishi K, Anami A, Fukushima K, Horigome H, Maeno Y, Kishimoto M, Takasaki Y, Nakayama M, Waguri M, Sago H, Murashima A. Maternal predictive factors for fetal congenital heart block in pregnant mothers positive for anti-SS-A antibodies. Mod Rheumatol 2015; 26:569-75. [PMID: 26457409 DOI: 10.3109/14397595.2015.1106661] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
OBJECTIVE To determine the maternal predictive factors for fetal congenital heart block (CHB) in pregnancy in mothers positive for anti-SS-A antibodies. METHODS The Research Team for Surveillance of Autoantibody-Exposed Fetuses and Treatment of Neonatal Lupus Erythematosus, the Research Program of the Japan Ministry of Health, Labor and Welfare, performed a national survey on pregnancy of mothers positive for anti-SS-A antibodies. We analyzed 635 pregnant mothers who tested positive for anti-SS-A antibodies before conception but had no previous history of fetal CHB. We performed univariate and multivariate analysis (models 1, 2, and 3 using different set of independent variables) investigated the relation between risk of fetal CHB and maternal clinical features. RESULTS Of the 635 pregnant mothers, fetal CHB was detected in 16. Univariate analysis showed that fetal CHB associated with use of corticosteroids before conception (OR 3.72, p = 0.04), and negatively with use of corticosteroids (equivalent doses of prednisolone (PSL), at ≥10 mg/day) after conception before 16-week gestation (OR 0.17, p = 0.03). In multivariate analysis, model 1 identified the use of corticosteroids before conception (OR 4.28, p = 0.04) and high titer of anti-SS-A antibodies (OR 3.58, p = 0.02) as independent and significant risk factors, and model 3 identified use of corticosteroids (equivalent doses of PSL, at ≥10 mg/day) after conception before 16-week gestation as independent protective factor against the development of fetal CHB (OR 0.16, p = 0.03). Other maternal clinical features did not influence the development of fetal CHB. CONCLUSION The results identified high titers of anti-SS-A antibodies and use of corticosteroids before conception as independent risk factors, and use of corticosteroids (equivalent doses of PSL, at ≥10 mg/day) after conception before 16-week gestation as an independent protective factor for fetal CHB.
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Affiliation(s)
- Hiroto Tsuboi
- a Department of Internal Medicine , Faculty of Medicine, University of Tsukuba , Ibaraki , Japan .,m The Research Team for Surveillance of Autoantibody-Exposed Fetuses and Treatment of Neonatal Lupus Erythematosus, the Research Program of the Japan Ministry of Health, Labor and Welfare (MHLW) (H22-Jisedai-Ippan-007) , Tokyo , Japan
| | - Takayuki Sumida
- a Department of Internal Medicine , Faculty of Medicine, University of Tsukuba , Ibaraki , Japan .,m The Research Team for Surveillance of Autoantibody-Exposed Fetuses and Treatment of Neonatal Lupus Erythematosus, the Research Program of the Japan Ministry of Health, Labor and Welfare (MHLW) (H22-Jisedai-Ippan-007) , Tokyo , Japan
| | - Hisashi Noma
- b Department of Data Science , The Institute of Statistical Mathematics , Tokyo , Japan .,m The Research Team for Surveillance of Autoantibody-Exposed Fetuses and Treatment of Neonatal Lupus Erythematosus, the Research Program of the Japan Ministry of Health, Labor and Welfare (MHLW) (H22-Jisedai-Ippan-007) , Tokyo , Japan
| | - Kazumasa Yamagishi
- c Department of Public Health Medicine , Faculty of Medicine, University of Tsukuba , Ibaraki , Japan .,m The Research Team for Surveillance of Autoantibody-Exposed Fetuses and Treatment of Neonatal Lupus Erythematosus, the Research Program of the Japan Ministry of Health, Labor and Welfare (MHLW) (H22-Jisedai-Ippan-007) , Tokyo , Japan
| | - Ai Anami
- d Department of Obstetrics and Gynecology , Kyushu University Hospital , Fukuoka , Japan .,m The Research Team for Surveillance of Autoantibody-Exposed Fetuses and Treatment of Neonatal Lupus Erythematosus, the Research Program of the Japan Ministry of Health, Labor and Welfare (MHLW) (H22-Jisedai-Ippan-007) , Tokyo , Japan
| | - Kotaro Fukushima
- d Department of Obstetrics and Gynecology , Kyushu University Hospital , Fukuoka , Japan .,m The Research Team for Surveillance of Autoantibody-Exposed Fetuses and Treatment of Neonatal Lupus Erythematosus, the Research Program of the Japan Ministry of Health, Labor and Welfare (MHLW) (H22-Jisedai-Ippan-007) , Tokyo , Japan
| | - Hitoshi Horigome
- e Department of Child Health , Faculty of Medicine, University of Tsukuba , Ibaraki , Japan .,m The Research Team for Surveillance of Autoantibody-Exposed Fetuses and Treatment of Neonatal Lupus Erythematosus, the Research Program of the Japan Ministry of Health, Labor and Welfare (MHLW) (H22-Jisedai-Ippan-007) , Tokyo , Japan
| | - Yasuki Maeno
- f The Department of Pediatrics and Child Health , Kurume University School of Medicine , Fukuoka , Japan .,m The Research Team for Surveillance of Autoantibody-Exposed Fetuses and Treatment of Neonatal Lupus Erythematosus, the Research Program of the Japan Ministry of Health, Labor and Welfare (MHLW) (H22-Jisedai-Ippan-007) , Tokyo , Japan
| | - Mitsumasa Kishimoto
- g Immuno-Rheumatology Center, St Luke's International Hospital , Tokyo , Japan .,m The Research Team for Surveillance of Autoantibody-Exposed Fetuses and Treatment of Neonatal Lupus Erythematosus, the Research Program of the Japan Ministry of Health, Labor and Welfare (MHLW) (H22-Jisedai-Ippan-007) , Tokyo , Japan
| | - Yoshinari Takasaki
- h Department of Rheumatology , School of Medicine, Juntendo University , Tokyo , Japan .,m The Research Team for Surveillance of Autoantibody-Exposed Fetuses and Treatment of Neonatal Lupus Erythematosus, the Research Program of the Japan Ministry of Health, Labor and Welfare (MHLW) (H22-Jisedai-Ippan-007) , Tokyo , Japan
| | - Masahiro Nakayama
- i Department of Laboratory Medicine , Osaka Medical Center and Research Institute for Maternal and Child Health , Osaka , Japan .,m The Research Team for Surveillance of Autoantibody-Exposed Fetuses and Treatment of Neonatal Lupus Erythematosus, the Research Program of the Japan Ministry of Health, Labor and Welfare (MHLW) (H22-Jisedai-Ippan-007) , Tokyo , Japan
| | - Masako Waguri
- j Department of Maternal Medicine , Osaka Medical Center and Research Institute for Maternal and Child Health , Osaka , Japan .,m The Research Team for Surveillance of Autoantibody-Exposed Fetuses and Treatment of Neonatal Lupus Erythematosus, the Research Program of the Japan Ministry of Health, Labor and Welfare (MHLW) (H22-Jisedai-Ippan-007) , Tokyo , Japan
| | - Haruhiko Sago
- k Center of Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development , Tokyo , Japan .,m The Research Team for Surveillance of Autoantibody-Exposed Fetuses and Treatment of Neonatal Lupus Erythematosus, the Research Program of the Japan Ministry of Health, Labor and Welfare (MHLW) (H22-Jisedai-Ippan-007) , Tokyo , Japan
| | - Atsuko Murashima
- l Department of Maternal Medicine , National Center for Child Health and Development , Tokyo , Japan , and.,m The Research Team for Surveillance of Autoantibody-Exposed Fetuses and Treatment of Neonatal Lupus Erythematosus, the Research Program of the Japan Ministry of Health, Labor and Welfare (MHLW) (H22-Jisedai-Ippan-007) , Tokyo , Japan
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Tingström J, Hjelmstedt A, Welin Henriksson E, Sonesson SE, Wahren-Herlenius M. Ro/SSA autoantibody-positive pregnancy: reactions to serial fetal Doppler echocardiographic surveillance. Lupus 2015; 24:1540-5. [PMID: 26113358 DOI: 10.1177/0961203315593171] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2015] [Accepted: 06/02/2015] [Indexed: 11/16/2022]
Abstract
OBJECTIVE The risk for congenital heart block (CHB) associated with maternal Ro/SSA autoantibodies is low, but the possibility of treating early stages of disease has seen the introduction of Doppler echocardiographic surveillance programs with serial examinations during the CHB susceptibility weeks of pregnancy. The aim of the present study was to understand how Ro/SSA autoantibody-positive women having undergone Doppler echocardiographic surveillance programs and giving birth to children without CHB experienced their pregnancy and frequent ultrasound examinations. METHODS A validated questionnaire based on data from an interview-study was distributed to Ro/SSA-positive women supervised with Doppler examinations during their pregnancy (n = 100). RESULTS The response rate was 79%. The majority of the women (61%) reported that the increased number of ultrasound examinations influenced their pregnancy, but in a positive way, with qualified information and additional support from health care personnel in conjunction with the examinations. Further, the visits to the clinic provided opportunities to see the ultrasound picture of the expected infant. However, one-third of the women also reported stress in relation to the examinations. CONCLUSIONS Fetal echocardiographic surveillance holds many and predominantly positive effects for Ro/SSA-positive women during pregnancy in addition to the medical advantages.
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Affiliation(s)
- J Tingström
- Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - A Hjelmstedt
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - E Welin Henriksson
- Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden
| | - S-E Sonesson
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
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Morel N, Georgin-Lavialle S, Levesque K, Guettrot-Imbert G, Le Guern V, Le Bidois J, Bessières B, Brouzes C, Le Mercier D, Villain E, Maltret A, Costedoat-Chalumeau N. [Neonatal lupus syndrome: Literature review]. Rev Med Interne 2015; 36:159-66. [PMID: 25240481 DOI: 10.1016/j.revmed.2014.07.013] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2014] [Accepted: 07/31/2014] [Indexed: 11/22/2022]
Abstract
Neonatal lupus syndrome is associated with transplacental passage of maternal anti-SSA/Ro and anti-SSB/La antibodies. Children display cutaneous, hematological, liver or cardiac features. Cardiac manifestations include congenital heart block (CHB); endocardial fibroelastosis and dilated cardiomyopathy. The prevalence of CHB in newborns of anti-Ro/SSA positive women with known connective tissue disease is between 1 and 2% and the risk of recurrence is around 19%. Skin and systemic lesions are transient, whereas CHB is definitive and associated with significant morbidity and a mortality of 18%. A pacemaker must be implanted in 2/3 of cases. Myocarditis may be associated or appear secondly. Mothers of children with CHB are usually asymptomatic or display Sjogren's syndrome or undifferentiated connective tissue disease. In anti-Ro/SSA positive pregnant women, fetal echocardiography should be performed at least every 2 weeks from the 16th to 24th week gestation. An electrocardiogram should be performed for all newborn babies. The benefit of fluorinated corticosteroid therapy for CHB detected in utero remains unclear. Maternal use of hydroxychloroquine may be associated with a decreased recurrent CHB risk in a subsequent offspring. A prospective study is actually ongoing to confirm these findings.
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Abstract
The heart is one of the most frequently affected organs in SLE. Any part of the heart can be affected, including the pericardium, myocardium, coronary arteries, valves, and the conduction system. In addition to pericarditis and myocarditis, a high incidence of CAD has become increasingly recognized as a cause of mortality, especially in older adult patients and those with long-standing SLE. Many unanswered questions remain in terms of understanding the pathogenesis of cardiac manifestations of SLE. It is not currently possible to predict the patients who are at greatest risk for the various types of cardiac involvement. However, with the rapid advancement of basic science and translational research approaches, it is now becoming easier to identify specific mutations associated with SLE. A better understanding of these genetic factors may eventually allow clinicians to categorize and predict the patients who are at risk for specific cardiac manifestations of SLE.
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Massie C, Hudson M, Tatibouet S, Steele R, Huynh T, Fritzler MJ, Baron M, Pineau CA. Absence of an association between anti-Ro antibodies and prolonged QTc interval in systemic sclerosis: a multicenter study of 689 patients. Semin Arthritis Rheum 2014; 44:338-44. [PMID: 25128430 DOI: 10.1016/j.semarthrit.2014.07.001] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2014] [Revised: 06/05/2014] [Accepted: 07/09/2014] [Indexed: 01/19/2023]
Abstract
OBJECTIVE To examine the association between anti-Ro antibodies, namely anti-Ro60/SS-A and anti-Ro52/TRIM21, together and separately, and a prolonged QT interval corrected for heart rate (QTc) in systemic sclerosis (SSc) patients. METHODS A total of 689 SSc patients enrolled in a multicenter cohort study underwent a 12-lead resting EKG at baseline. The QTc interval was measured, and a QTc ≥ 440ms was considered prolonged. Detailed clinical data and sera of these patients were collected and positivity for anti-Ro60/SS-A and anti-Ro52/TRIM21 antibodies was determined using an addressable laser bead immunoassay (ALBIA). RESULTS QTc prolongation was common in this SSc cohort (25%). In a univariate analysis, Ro antibodies, together or separately, were not associated with prolongation of the QTc interval [mean difference in QTc in anti-Ro antibody positive versus negative subjects was -2.2ms (p = 0.5748), in anti-Ro60/SS-A antibody positive versus negative subjects was 1.3ms (p = 0.8616), and in anti-Ro52/TRIM21 antibody positive versus negative subjects was -3.3ms (p = 0.4106)]. In a multivariate logistic regression analysis adjusting for possible confounders, there was no association between prolonged QTc and anti-Ro antibodies [odds ratio (OR) = 0.74, 95% confidence interval (CI): 0.45, 1.22], anti-Ro60/SS-A antibodies (OR = 1.57, 95% CI: 0.72, 3.41), and anti-Ro52/TRIM21 antibodies (OR = 0.76, 95% CI: 0.46, 1.26). However, in both univariate and multivariate analyses, QTc prolongation was associated with longer disease duration, greater disease severity, and the presence of anti-RNA polymerase III antibodies. CONCLUSIONS QTc prolongation is common in SSc, although anti-Ro antibodies do not seem to be associated with it as is the case in systemic lupus erythematosus. The reasons for this difference as well as the cause of abnormalities in cardiac repolarization in SSc will require additional studies.
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Affiliation(s)
- Charles Massie
- Department of Medicine, McGill University, Montréal, Quebec, Canada
| | - Marie Hudson
- Department of Medicine, McGill University, Montréal, Quebec, Canada; Division of Rheumatology, Jewish General Hospital, Room A-725, 3755 Côte Sainte-Catherine Rd, Montréal, Quebec, Canada H3T 1E2; Lady Davis Institute, Jewish General Hospital, Montréal, Quebec, Canada.
| | - Solène Tatibouet
- Lady Davis Institute, Jewish General Hospital, Montréal, Quebec, Canada
| | - Russell Steele
- Lady Davis Institute, Jewish General Hospital, Montréal, Quebec, Canada; Department of Mathematics, McGill University, Montréal, Quebec, Canada
| | - Thao Huynh
- Department of Medicine, McGill University, Montréal, Quebec, Canada; Division of Cardiology, McGill University Health Center, Montreal, Quebec, Canada
| | - Marvin J Fritzler
- Faculty of Medicine, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Murray Baron
- Department of Medicine, McGill University, Montréal, Quebec, Canada; Division of Rheumatology, Jewish General Hospital, Room A-725, 3755 Côte Sainte-Catherine Rd, Montréal, Quebec, Canada H3T 1E2
| | - Christian A Pineau
- Department of Medicine, McGill University, Montréal, Quebec, Canada; Division of Rheumatology, McGill University Health Center, Montreal, Quebec, Canada
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Pervolaraki E, Hodgson S, Holden AV, Benson AP. Towards computational modelling of the human foetal electrocardiogram: normal sinus rhythm and congenital heart block. Europace 2014; 16:758-65. [PMID: 24798966 DOI: 10.1093/europace/eut377] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
AIMS We aim to engineer a computational model of propagation during normal sinus rhythm in the foetal human heart, by modifying models for adult cardiac tissue to match foetal electrocardiogram (fECG) characteristics. The model will be partially validated by fECG data, and applied to explore possible mechanisms of arrhythmogenesis in the foetal heart. METHODS AND RESULTS Foetal electrocardiograms have been recorded during pregnancy, with P- and T-waves, and the QRS complex, identified by averaging and signal processing. Intervals of the fECG are extracted and used to modify currently available human adult cardiomyocyte models. RR intervals inform models of the pacemaking cells by constraining their rate, the QT interval and its rate dependence constrain models of ventricular cells, and the width of the P-wave, the QR and PR intervals constrain propagation times, conduction velocities, and intercellular coupling. These cell models are coupled into a one-dimensional (1D) model of propagation during normal sinus rhythm in the human foetal heart. We constructed a modular, heterogeneous 1D model for propagation in the foetal heart, and predicted the effects of reduction in L-type Ca(++) current. These include bradycardia and atrioventricular conduction blocks. These may account quantitatively for congenital heart block produced by positive IgG antibodies. CONCLUSION The fECG can be interpreted mechanistically and quantitatively by using a simple computational model for propagation. After further validation, by clinical recordings of the fECG and the electrophysiological experiments on foetal cardiac cells and tissues, the model may be used to predict the effects of maternally administered pharmaceuticals on the fECG.
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Saini AG, Sankhyan N, Bhattad S, Vyas S, Saikia B, Singhi P. CNS vasculitis and stroke in neonatal lupus erythematosus: a case report and review of literature. Eur J Paediatr Neurol 2014; 18:444-8. [PMID: 24508360 DOI: 10.1016/j.ejpn.2014.01.007] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2013] [Revised: 01/12/2014] [Accepted: 01/19/2014] [Indexed: 11/15/2022]
Abstract
Neonatal lupus erythematosus refers to the clinical spectrum of cardiac, cutaneous and other systemic abnormalities in neonates born to mothers with autoantibodies against Ro/SSA and La/SSB antigens. Isolated central nervous system involvement is very rare and has been described as transient vasculopathy only. We describe a 2-months-old girl who presented with acute ischemic stroke secondary to central nervous system vasculitis without any cardiac, cutaneous or hematological manifestations. The mother was pauci-symptomatic with raised anti-Ro autoantibody titers; the baby was positive for autoantibodies against Ro-antigen. Angiography confirmed vasculitis in cerebral vasculature. Our case highlights that neonatal lupus erythematosus can present with isolated nervous system manifestations and the vascular damage can be permanent in the form of vasculitis. Early recognition will help pediatricians identify such possible permanent complications in newborns with neonatal lupus erythematosus. A review of previously reported central nervous system manifestations of neonatal lupus is also presented.
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Affiliation(s)
- Arushi G Saini
- Department of Pediatrics, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh 160012, India
| | - Naveen Sankhyan
- Department of Pediatrics, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh 160012, India
| | - Sagar Bhattad
- Department of Pediatrics, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh 160012, India
| | - Sameer Vyas
- Department of Radiodiagnosis, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh 160012, India
| | - Biman Saikia
- Department of Immunopathology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh 160012, India
| | - Pratibha Singhi
- Department of Pediatrics, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh 160012, India.
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Bergman G, Skog A, Tingström J, Ottosson V, Hoxha A, Ambrosi A, Salomonsson S, Wahren-Herlenius M. Late development of complete atrioventricular block may be immune mediated and congenital in origin. Acta Paediatr 2014; 103:275-81. [PMID: 24164657 DOI: 10.1111/apa.12483] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2013] [Revised: 07/30/2013] [Accepted: 10/21/2013] [Indexed: 11/29/2022]
Abstract
AIM To investigate the correlation between maternal autoantibodies and age at diagnosis of isolated complete atrioventricular (AV) block (CAVB) and to study signs of late progression of foetal immune-mediated insults in cases of postnatally diagnosed CAVB. METHODS Patients with CAVB (n = 190) identified in a population-based manner were included. Maternal autoantibody profile was correlated with age at CAVB diagnosis. A structured review of medical records was performed if a late CAVB diagnosis (>27 days post-partum) was associated with a sero-positive mother. RESULTS Maternal Ro/La autoantibodies were observed in 88% of cases with a congenital diagnosis. Thirteen cases with a sero-positive mother and late CAVB diagnosis were found (age-range: 4 months-43 years). In two cases, CAVB was diagnosed in conjunction with infections, one case had a family history of cardiomyopathy and two cases had nontypical clinical presentations, indicating alternative pathogenetic mechanisms. In the remaining eight cases, no likely factors inducing CAVB, other than maternal autoantibodies, could be identified. CONCLUSION Our observations support the hypothesis that late progression to CAVB can be the result of an immune-mediated pathogenetic mechanism during foetal life. An autoantibody-associated diagnosis after the neonatal period is therefore possible, and testing of maternal serology at the time of diagnosis is recommended.
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Affiliation(s)
- Gunnar Bergman
- Department of Women‘s and Children‘s Health; Karolinska Institutet; Stockholm Sweden
| | - Amanda Skog
- Department of Medicine; Karolinska Institutet; Stockholm Sweden
| | | | - Vijole Ottosson
- Department of Medicine; Karolinska Institutet; Stockholm Sweden
| | - Ariela Hoxha
- Department of Medicine; Karolinska Institutet; Stockholm Sweden
| | - Aurelie Ambrosi
- Department of Medicine; Karolinska Institutet; Stockholm Sweden
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Ambrosi A, Sonesson SE, Wahren-Herlenius M. Molecular mechanisms of congenital heart block. Exp Cell Res 2014; 325:2-9. [PMID: 24434353 DOI: 10.1016/j.yexcr.2014.01.003] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2013] [Revised: 01/02/2014] [Accepted: 01/06/2014] [Indexed: 01/30/2023]
Abstract
Autoantibody-associated congenital heart block (CHB) is a passively acquired autoimmune condition associated with maternal anti-Ro/SSA antibodies and primarily affecting electric signal conduction at the atrioventricular node in the fetal heart. CHB occurs in 1-2% of anti-Ro/SSA antibody-positive pregancies and has a recurrence rate of 12-20% in a subsequent pregnancy. Despite the long-recognized association between maternal anti-Ro/SSA autoantibodies and CHB, the molecular mechanisms underlying CHB pathogenesis are not fully understood, but several targets for the maternal autoantibodies in the fetal heart have been suggested. Recent studies also indicate that fetal susceptibility genes determine whether an autoantibody-exposed fetus will develop CHB or not, and begin to identify such genes. In this article, we review the different lines of investigation undertaken to elucidate the molecular pathways involved in CHB development and reflect on the hypotheses put forward to explain CHB pathogenesis as well as on the questions left unanswered and that should guide future studies.
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Affiliation(s)
- Aurélie Ambrosi
- Unit of Experimental Rheumatology, Department of Medicine, Karolinska Institutet, 171 76 Stockholm, Sweden.
| | - Sven-Erik Sonesson
- Department of Women and Child Health, Karolinska Institutet, 171 76 Stockholm, Sweden.
| | - Marie Wahren-Herlenius
- Unit of Experimental Rheumatology, Department of Medicine, Karolinska Institutet, 171 76 Stockholm, Sweden.
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Dey M, Jose T, Shrivastava A, Wadhwa RD, Agarwal R, Nair V. Complete congenital foetal heart block: a case report. Facts Views Vis Obgyn 2014; 6:39-42. [PMID: 25009724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Congenital heart block (CHB) is the most severe manifestation of neonatal lupus which can develop into a lethal atrioventricular (AV) block. Complete congenital foetal heart block related to maternal anti-Ro/SSA autoanti-bodies typically develops between 20 and 24 weeks of gestation. CHB with a structurally normal heart is frequently associated with maternal autoantibodies to Ro/SSA and La/SSB. We are presenting a case of foetal complete CHB with high maternal Ro/SSA and La/SSB titre with favourable outcome.
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Porcel Chacón R, Tapia Ceballos L, Díaz Cabrera R, Gutiérrez Perandones MT. Neonatal lupus erythematosis: a five-year case review. ACTA ACUST UNITED AC 2013; 10:170-3. [PMID: 24296269 DOI: 10.1016/j.reuma.2013.10.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2013] [Revised: 10/08/2013] [Accepted: 10/09/2013] [Indexed: 10/26/2022]
Abstract
Neonatal lupus erythematosus is an infrequent disease seen in newborns. It is caused by transplacental maternal autoantibody passage. Cutaneous involvement and congenital heart block (CHB) are the most common affections, although it may involve multiple organs like the liver, lungs, blood, nervous or digestive systems. This article present a review of the four cases diagnosed in the past five years in a Neonatal Unit, which shows the different clinical spectrum which can develop around this disease (CHB, multisystemic affection and two cutaneous cases), different autoantibodies (specially anti-SSA) with an early negativization during the first year of life and the possibility of future collagen vascular disease as occurred in one case.
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Cavallasca JA, Costa CA, Maliandi MDR, Musuruana JL. Hot topics in lupus pregnancy. World J Rheumatol 2013; 3:32-39. [DOI: 10.5499/wjr.v3.i3.32] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2013] [Revised: 08/30/2013] [Accepted: 11/03/2013] [Indexed: 02/06/2023] Open
Abstract
Systemic lupus erythematosus (SLE) typically affects women in their childbearing age, who have the same fertility rates as the healthy population. The effect of pregnancy on the disease and the effect of SLE on pregnancy and the fetus are highly important issues for the attending physician. Whether lupus flares are more frequent during pregnancy remains controversial. Among the possible effects of SLE on pregnancy are a greater number of abortions, fetal loss, pre-term deliveries and perinatal mortality. The newborn may be affected by the onset of neonatal lupus erythematosus (neonatal LE), either as a skin or blood disease, or by the presence of congenital heart block. The frequent association between SLE and antiphospholipid syndrome represents another risk situation for the mother and the product of conception. Multiples drugs used in SLE patients should be evaluated. Those with teratogenic potential should be withdrawn before pregnancy, and when necessary, appropriate medications should be indicated to treat the mother without compromising the safety of the baby. In conclusion, pregnancies in lupus patients represent a challenge for the physician and must be closely followed up and treated if necessary, during all trimesters and in the puerperium period, to improve outcome.
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Iozza I, Cianci S, Di Natale A, Garofalo G, Giacobbe AM, Giorgio E, De Oronzo MA, Politi S. Update on systemic lupus erythematosus pregnancy. J Prenat Med 2010; 4:67-73. [PMID: 22439065 PMCID: PMC3279186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Women with Systemic Lupus Erythematosus (SLE) still face significant risks when embarking on a pregnancy. Improvements in the field of pathophysiology, in diagnosis and a greater number of therapeutic options in the treatment of SLE, have made the medical community regard these patients with less trepidation. Despite these advances, however, the risk of significant morbidity to both the mother and the fetus still exists. THE INTERACTION OF LUPUS AND PREGNANCY IS VERY COMPLEX: the consensus is that pregnancy can worsen the lupus disease process, even if this is not predictable, and pregnancy can mimic the clinical manifestations of lupus, particularly preeclampsia/eclampsia. More specifically, pregnancy is associated in 50 to 60% of cases with a clinical flare manifesting as renalor hematological symptoms. Severe flares are uncommon (10%) and the risk of maternal death is now2 to 3%. The risk of the fetus remains high, however with increased risk of spontaneous fetal wastage and premature births, by 4.8 and 6.8 times, respectively. It is well documented that antiphospholipid syndrome and antiphospholipid antibodies are strongly associated with fetal wastage. Low-dose aspirin orheparin improves fetal outcome in these cases.Timing a pregnancy to coincide with a period of disease quiescence for at least 6 months strongly increases the chances for a healthy and uneventful pregnancy for both mother and baby. Close surveillance, with monitoring of blood pressure, proteinuria and placental blood flow by doppler studies helps the early diagnosis and treatment of complications such as preeclampsia andfoetal distress. Women with SLE frequently need treatment throughout pregnancy based on hydroxychloroquine, lowdose steroids and azathioprine. This update, based on previous available literature, should inform rheumatologists, obstetricians and neonatologists who guide patients in their reproductive decisions.
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Affiliation(s)
- Irene Iozza
- Santo Bambino Hospital, Department of Microbiological and Gynecological Sciences, University of Catania, Italy
| | - Stefano Cianci
- Santo Bambino Hospital, Department of Microbiological and Gynecological Sciences, University of Catania, Italy
| | - Angela Di Natale
- Policlinico Universitario “G. Martino”, Department of Obstetrics and Gynecology, University of Messina, Italy
| | - Giovanna Garofalo
- Policlinico Universitario “G. Martino”, Department of Obstetrics and Gynecology, University of Messina, Italy
| | - Anna Maria Giacobbe
- Policlinico Universitario “G. Martino”, Department of Obstetrics and Gynecology, University of Messina, Italy
| | - Elsa Giorgio
- Policlinico Universitario “G. Martino”, Department of Obstetrics and Gynecology, University of Messina, Italy
| | | | - Salvatore Politi
- Santo Bambino Hospital, Department of Microbiological and Gynecological Sciences, University of Catania, Italy
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