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Joglar JA, Kapa S, Saarel EV, Dubin AM, Gorenek B, Hameed AB, Lara de Melo S, Leal MA, Mondésert B, Pacheco LD, Robinson MR, Sarkozy A, Silversides CK, Spears D, Srinivas SK, Strasburger JF, Tedrow UB, Wright JM, Zelop CM, Zentner D. 2023 HRS expert consensus statement on the management of arrhythmias during pregnancy. Heart Rhythm 2023; 20:e175-e264. [PMID: 37211147 DOI: 10.1016/j.hrthm.2023.05.017] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 05/12/2023] [Indexed: 05/23/2023]
Abstract
This international multidisciplinary expert consensus statement is intended to provide comprehensive guidance that can be referenced at the point of care to cardiac electrophysiologists, cardiologists, and other health care professionals, on the management of cardiac arrhythmias in pregnant patients and in fetuses. This document covers general concepts related to arrhythmias, including both brady- and tachyarrhythmias, in both the patient and the fetus during pregnancy. Recommendations are provided for optimal approaches to diagnosis and evaluation of arrhythmias; selection of invasive and noninvasive options for treatment of arrhythmias; and disease- and patient-specific considerations when risk stratifying, diagnosing, and treating arrhythmias in pregnant patients and fetuses. Gaps in knowledge and new directions for future research are also identified.
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Affiliation(s)
- José A Joglar
- The University of Texas Southwestern Medical Center, Dallas, Texas
| | | | - Elizabeth V Saarel
- St. Luke's Health System, Boise, Idaho, and Cleveland Clinic Lerner College of Medicine at Case Western Reserve University, Cleveland, Ohio
| | | | | | | | | | | | | | - Luis D Pacheco
- The University of Texas Medical Branch at Galveston, Galveston, Texas
| | | | - Andrea Sarkozy
- University Hospital of Antwerp, University of Antwerp, Antwerp, Belgium
| | | | - Danna Spears
- University Health Network, Toronto, Ontario, Canada
| | - Sindhu K Srinivas
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | | | | | | | - Carolyn M Zelop
- The Valley Health System, Ridgewood, New Jersey; New York University Grossman School of Medicine, New York, New York
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Prenatal Diagnosis of Right-Sided Congenital Ventricular Diverticulum (CVD) Assisted by Spatiotemporal Image Correlation (STIC) Acquisition and the Speckle-Tracking Technique to Assess Fetal Cardiac Function: A Case Report. Diagnostics (Basel) 2022; 12:diagnostics12102438. [PMID: 36292127 PMCID: PMC9600030 DOI: 10.3390/diagnostics12102438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2022] [Revised: 09/26/2022] [Accepted: 09/29/2022] [Indexed: 11/16/2022] Open
Abstract
Congenital ventricular diverticulum (CVD) is a cardiac malformation defined as an outpouching lesion of a ventricle with normal contractility and thickness, and the advancement of prenatal sonography has led to its prenatal diagnosis. In the prenatal period, CVD is reported in association with pericardial effusion, arrhythmia, and fetal hydrops or as an isolated condition. With the development of prenatal echocardiography, CVD can be diagnosed from the early stage of pregnancy, and prenatal procedures, such as pericardiocentesis, are also possible. Spatiotemporal image correlation (STIC) acquisition, a novel approach for the clinical evaluation of fetal hearts, provides easy-to-use techniques for acquiring data from fetal hearts and helping visualization with two-dimensional and three-dimensional (3D) cine sequences. Furthermore, the speckle-tracking technique enables a more comprehensive evaluation of the shape, continuity, and function of the fetal heart. These recent techniques have never been used for CVD diagnosis and evaluation. Here, we present a case of right-sided CVD, which is the first in which STIC acquisition and cardiac function assessment with the speckle-tracking technique were used to assist in the diagnosis and evaluation.
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Wacker-Gussmann A, Strasburger JF, Wakai RT. Contribution of Fetal Magnetocardiography to Diagnosis, Risk Assessment, and Treatment of Fetal Arrhythmia. J Am Heart Assoc 2022; 11:e025224. [PMID: 35904205 PMCID: PMC9375504 DOI: 10.1161/jaha.121.025224] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Fetal echocardiography has been the mainstay of fetal arrhythmia diagnosis; however, fetal magnetocardiography (fMCG) has recently become clinically available. We sought to determine to what extent fMCG contributed to the precision and accuracy of fetal arrhythmia diagnosis and risk assessment, and in turn, how this altered pregnancy management. Methods and Results We reviewed fMCG tracings and medical records of 215 pregnancies referred to the Biomagnetism Laboratory, UW‐Madison, over the last 10 years, because of fetal arrhythmia or risk of arrhythmia. We compared referral diagnosis and treatment with fMCG diagnosis using a rating scale and restricted our review to the 144 subjects from the tachycardia, bradycardia/AV block, and familial long QT syndrome categories. Additional fMCG findings beyond those of the referring echocardiogram, or an alternative diagnosis were seen in 117/144 (81%), and 81 (56%) were critical changes. Eight (5.5%) had resolution of arrhythmia before fMCG. At least moderate changes in management were seen in 109/144 (76%) fetuses, of which 35/144 (24%) were major. The most diverse fMCG presentation was long QT syndrome, present in all 3 referral categories. Four of 5 stillbirths were seen with long QT syndrome. Nine fetuses showed torsades de pointes ventricular tachycardia, of which only 2 were recognized before fMCG. Conclusions FMCG has a significant impact on prenatal diagnosis and management of arrhythmias or familial arrhythmia risk, which cannot be fully met by existing technology. The combination of fMCG and fetal echocardiography in fetal care centers will be needed in the future to optimize care.
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Affiliation(s)
- Annette Wacker-Gussmann
- Department of Congential Heart Disease and Pediatric Cardiology German Heart Center Munich Germany
| | - Janette F Strasburger
- Departments of Pediatrics and Biomedical Engineering Children's Wisconsin and Herma Heart Institute Milwaukee WI
| | - Ronald T Wakai
- Department of Medical Physics University of Wisconsin-Madison Madison WI
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Morin C, Ponzio A, Guirgis M, Benzouid C, Beyler C, Rosenblatt J. Prenatal diagnosis of congenital ventricular aneurysm and diverticulum: prenatal features and perinatal management. Prenat Diagn 2022; 42:428-434. [PMID: 35238062 DOI: 10.1002/pd.6122] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 02/05/2022] [Accepted: 02/14/2022] [Indexed: 11/06/2022]
Abstract
Congenital ventricular diverticulum and aneurysm are rare cardiac developmental anomalies and their pathophysiology is still unclear. They present as an anomaly of the four chambers view, cardiomegaly, arrhythmia, pericardial effusion, or hydrops. They are usually isolated anomalies. Differential diagnosis between diverticulum and aneurysm is challenging during the prenatal period. Management policy is not uniform either conservative or repeated pericardial puncture. OBJECTIVE We wanted to describe prenatal features and post-natal outcomes of fetal cardiac out pouching. METHODS We retrospectively report 6 cases of ventricular diverticulum and aneurysm prenatally managed in our fetal medicine unit between 2010 and 2020. All cases were evaluated from the first or second trimester of pregnancy until postnatal follow-up (3 months to 3 years). RESULTS All 6 cases underwent a monthly ultrasound follow-up with spontaneous regression of pericardial effusion, and normal hemodynamics at birth No pericardial puncture was done and postnatal outcome was favorable in all cases. CONCLUSION Based on our experience and on cases previously published, prenatal counseling should be prudent regarding the final diagnosis. Referral and monthly prenatal ultrasound follow-up, birth in a tertiary center after multidisciplinary evaluation and cardiological evaluation at birth still seem mandatory. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Cecile Morin
- Fetal Medicine Unit, Hopital Universitaire Robert Debré, APHP, Paris, France
| | - Alice Ponzio
- Fetal Medicine Unit, Hopital Universitaire Robert Debré, APHP, Paris, France
| | - Maurice Guirgis
- Pediatric Cardiology Unit, Hopital Universitaire Robert Debré, APHP, Paris, France
| | - Cherine Benzouid
- Pediatric Cardiology Unit, Hopital Universitaire Robert Debré, APHP, Paris, France
| | - Constance Beyler
- Pediatric Cardiology Unit, Hopital Universitaire Robert Debré, APHP, Paris, France
| | - Jonathan Rosenblatt
- Fetal Medicine Unit, Hopital Universitaire Robert Debré, APHP, Paris, France
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Schoeneberg LA, Zakaria D, Bolin EH, Eble BK, Miquel-Verges F, Sandlin AT, Bornemeier RA. A Fetal Presentation of a Ruptured Right Ventricular Diverticulum. Pediatr Cardiol 2021; 42:978-980. [PMID: 33725147 DOI: 10.1007/s00246-021-02572-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Accepted: 02/25/2021] [Indexed: 11/26/2022]
Abstract
Ruptured diverticula and ventricular aneurysms are rare in the fetus, with a limited number of case reports published previously. Additional fetal complications secondary to these ventricular wall abnormalities can be seen. Interventional measures can be considered and attempted either in utero or postnatally to improve the chance of survival. We present a case of a ruptured diverticulum in a fetus and the clinical course.
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Affiliation(s)
- Laura A Schoeneberg
- Department of Pediatrics (Cardiology), University of Arkansas for Medical Sciences and Arkansas Children's Hospital, 1 Children's Way, Slot 512-3, Little Rock, AR, 72202, USA.
| | - Dala Zakaria
- Department of Pediatrics (Cardiology), University of Arkansas for Medical Sciences and Arkansas Children's Hospital, 1 Children's Way, Slot 512-3, Little Rock, AR, 72202, USA
| | - Elijah H Bolin
- Department of Pediatrics (Cardiology), University of Arkansas for Medical Sciences and Arkansas Children's Hospital, 1 Children's Way, Slot 512-3, Little Rock, AR, 72202, USA
| | - Brian K Eble
- Department of Pediatrics (Cardiology), University of Arkansas for Medical Sciences and Arkansas Children's Hospital, 1 Children's Way, Slot 512-3, Little Rock, AR, 72202, USA
| | - Franscesca Miquel-Verges
- Department of Pediatrics (Neonatology), University of Arkansas for Medical Sciences and Arkansas Children's Hospital, 1 Children's Way, Slot 512-3, Little Rock, AR, 72202, USA
| | - Adam T Sandlin
- Department of Obstetrics and Gynecology, University of Arkansas for Medical Sciences, 1 Children's Way, Slot 512-3, Little Rock, AR, 72202, USA
| | - Renee A Bornemeier
- Department of Pediatrics (Cardiology), University of Arkansas for Medical Sciences and Arkansas Children's Hospital, 1 Children's Way, Slot 512-3, Little Rock, AR, 72202, USA
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Shuplock JM, Kavanaugh-McHugh A, Parra D. Prenatally Diagnosed Congenital Ventricular Outpouchings: An Institutional Experience and Review of the Literature. Pediatr Cardiol 2020; 41:272-281. [PMID: 31728571 DOI: 10.1007/s00246-019-02252-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Accepted: 11/05/2019] [Indexed: 10/25/2022]
Abstract
Congenital ventricular outpouchings (CVOs) are rare congenital heart defects with limited data regarding prognosis and outcomes. We aimed to describe the characteristics, outcomes and factors associated with morbidity and mortality of prenatally diagnosed CVOs using our institutional experience and a review of published cases. A total of 86 cases of prenatally diagnosed CVOs were identified, including 3 from our institution and 83 cases identified from a review of the literature. Fetal and postnatal outcomes were analyzed for each case. Pericardial effusions (44%) and ventricular dysfunction (17%) were the most common associated findings. Excluding cases that resulted in pregnancy termination, mortality was 17%, with the majority (11/13) occurring in the prenatal period. Factors associated with mortality included an outpouching located on the left ventricle, a diagnosis of hydrops fetalis, the presence of a pericardial effusion, and an earlier gestational age at diagnosis. Of those that survived to delivery, 57% remained asymptomatic without the need for intervention, and the outpouching regressed or resolved in an additional 15%. Prenatally diagnosed congenital ventricular outpouchings are a dynamic form of congenital heart disease with a high fetal mortality rate. The outcomes associated with the outpouchings appear to be the most variable in the prenatal period and the first year after birth. Serial prenatal and postnatal evaluations should be performed to evaluate for a change in the characteristics of the outpouching.
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Affiliation(s)
- Jacqueline M Shuplock
- Thomas P. Graham Jr. Division of Pediatric Cardiology, Monroe Carell Jr. Children's Hospital at Vanderbilt, 2200 Children's Way, Suite 5230, Nashville, TN, 37232, USA.
| | - Ann Kavanaugh-McHugh
- Thomas P. Graham Jr. Division of Pediatric Cardiology, Monroe Carell Jr. Children's Hospital at Vanderbilt, 2200 Children's Way, Suite 5230, Nashville, TN, 37232, USA
| | - David Parra
- Thomas P. Graham Jr. Division of Pediatric Cardiology, Monroe Carell Jr. Children's Hospital at Vanderbilt, 2200 Children's Way, Suite 5230, Nashville, TN, 37232, USA
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Li X, An J, Wang S, Lu W, Liu Z, Wu Y, Jiao F. A Large Isolated Congenital Left Circumflex Artery-to-Right Atrial Fistula in a 9-Year-Old Child. Front Pediatr 2020; 8:51. [PMID: 32154196 PMCID: PMC7044179 DOI: 10.3389/fped.2020.00051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2019] [Accepted: 02/03/2020] [Indexed: 11/15/2022] Open
Abstract
Isolated congenital coronary artery fistula (ICCAF) is an exceedingly rare anomaly in which there is a direct abnormal connection between a coronary artery and other cardiac chambers or any of great vessels. The left circumflex artery (LCX) is the least common source of ICCAF. Here we reported a rare case of large ICCAF originated from the LCX in a 9-year-old boy. He presented fatigability, murmurs and NYHA class II. Echocardiography and cardiac CT revealed that an aneurysmal dilatation of the LCX along with the dilated coronary sinus entered into the right atrium (RA) through the great cardiac vein. However, it showed that the dilated LCX directly drained into the RA by coronary angiography, which was confirmed by the surgery. During the surgical procedure, the LCX fistula was identified in a 3*3 cm bulbous structure, the aneurysmal dilation of RA tissue. The end of fistula was located in the lower-middle interatrial septum, which was near the coronary sinus and above the opening of inferior vena cava (IVC). Transcardiac chamber closure with cardiopulmonary bypass (CPB) was successfully performed for the correction of the fistula. It indicated that preoperative angiography is essential to define the details of large ICCAF with aneurysmal dilation. Moreover, transcardiac chamber closure with CPB is the optimal procedure for the treatment of large ICCAF, while interventional catheterization is not feasible due to the presence of aneurysmal dilation of the LCX. The description of this rare case might have great value for the diagnosis and treatment of large ICCAF originated from the LCX.
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Affiliation(s)
- Xin Li
- Department of Pediatrics, TEDA International Cardiovascular Hospital, TEDA, Tianjin, China.,Department of Pediatric Cardiac Surgery, TEDA International Cardiovascular Hospital, TEDA, Tianjin, China
| | - Jun An
- Department of Biochemistry and Molecular Biology, College of Life Sciences, Nankai University, Tianjin, China
| | - Shuai Wang
- Shandong Collaborative Innovation Center for Diagnosis, Treatment and Behavioral Interventions of Mental Disorders, Institute of Mental Health, Jining Medical University, Jining, China.,Shandong Key Laboratory of Behavioral Medicine, School of Mental Health, Jining Medical University, Jining, China
| | - Wanli Lu
- Department of Pediatric Cardiac Surgery, TEDA International Cardiovascular Hospital, TEDA, Tianjin, China
| | - Zhigang Liu
- Department of Pediatric Cardiac Surgery, TEDA International Cardiovascular Hospital, TEDA, Tianjin, China.,Department of Great Blood Vessel and Cardiac Surgery, TEDA International Cardiovascular Hospital, TEDA, Tianjin, China
| | - Yili Wu
- Shandong Collaborative Innovation Center for Diagnosis, Treatment and Behavioral Interventions of Mental Disorders, Institute of Mental Health, Jining Medical University, Jining, China.,Shandong Key Laboratory of Behavioral Medicine, School of Mental Health, Jining Medical University, Jining, China.,Collaborative Innovation Center for Birth Defect Research and Transformation of Shandong Province, Jining Medical University, Jining, China
| | - Fengjuan Jiao
- Shandong Collaborative Innovation Center for Diagnosis, Treatment and Behavioral Interventions of Mental Disorders, Institute of Mental Health, Jining Medical University, Jining, China.,Shandong Key Laboratory of Behavioral Medicine, School of Mental Health, Jining Medical University, Jining, China
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Wacker-Gussmann A, Plankl C, Sewald M, Schneider KTM, Oberhoffer R, Lobmaier SM. Fetal cardiac time intervals in healthy pregnancies - an observational study by fetal ECG (Monica Healthcare System). J Perinat Med 2018; 46:587-592. [PMID: 28453441 DOI: 10.1515/jpm-2017-0003] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2017] [Accepted: 03/06/2017] [Indexed: 11/15/2022]
Abstract
BACKGROUND Fetal electrocardiogram (fECG) can detect QRS signals in fetuses from as early as 17 weeks' gestation; however, the technique is limited by the minute size of the fetal signal relative to noise ratio. The aim of this study was to evaluate precise fetal cardiac time intervals (fCTIs) with the help of a newly developed fetal ECG device (Monica Healthcare System). METHODS In a prospective manner we included 15-18 healthy fetuses per gestational week from 32 weeks onwards. The small and wearable Monica AN24 monitoring system uses standard ECG electrodes placed on the maternal abdomen to monitor fECG, maternal ECG and uterine electromyogram (EMG). Fetal CTIs were estimated on 1000 averaged fetal heart beats. Detection was deemed successful if there was a global signal loss of less than 30% and an analysis loss of the Monica AN24 signal separation analysis of less than 50%. Fetal CTIs were determined visually by three independent measurements. RESULTS A total of 149 fECGs were performed. After applying the requirements 117 fECGs remained for CTI analysis. While the onset and termination of P-wave and QRS-complex could be easily identified in most ECG patterns (97% for P-wave, PQ and PR interval and 100% for QRS-complex), the T-wave was detectable in only 41% of the datasets. The CTI results were comparable to other available methods such as fetal magnetocardiography (fMCG). CONCLUSIONS Although limited and preclinical in its use, fECG (Monica Healthcare System) could be an additional useful tool to detect precise fCTIs from 32 weeks' gestational age onwards.
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Affiliation(s)
- Annette Wacker-Gussmann
- Institute of Preventive Pediatrics, Faculty of Sport and Health Sciences and German Heart Center, Pediatric Cardiology, Munich, Germany
| | - Cordula Plankl
- Department of Gynecology and Obstetrics, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Maria Sewald
- Department of Gynecology and Obstetrics, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Karl-Theo Maria Schneider
- Department of Gynecology and Obstetrics, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Renate Oberhoffer
- Institute of Preventive Pediatrics, Faculty of Sport and Health Sciences and German Heart Center, Department of Pediatric Cardiology and Congenital Heart Defects, Munich, Germany
| | - Silvia M Lobmaier
- Department of Gynecology and Obstetrics, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
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Prenatally Diagnosed Isolated Coronary Arterial Fistula Leading to Severe Complications at Birth. Case Rep Cardiol 2018; 2018:2509502. [PMID: 29780642 PMCID: PMC5892279 DOI: 10.1155/2018/2509502] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Accepted: 02/04/2018] [Indexed: 11/30/2022] Open
Abstract
Prenatal diagnosis of a huge coronary artery fistula between the left coronary artery and the right ventricle was made by Doppler echocardiography at 22 weeks of gestation. Progression of the dilated fistula was monitored throughout pregnancy. The size of the fistula increased enormously up to 11 mm. Death occurred at birth. Monitoring of these fetuses is essential as severe complications can occur during pregnancy or at birth.
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Fetal Right Ventricular Diverticulum Detected by Prenatal Ultrasound Screening. Case Rep Obstet Gynecol 2016; 2016:6382920. [PMID: 27818814 PMCID: PMC5080481 DOI: 10.1155/2016/6382920] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Revised: 09/20/2016] [Accepted: 09/21/2016] [Indexed: 12/02/2022] Open
Abstract
Prenatal ultrasound screening has allowed for the detection of in utero cardiac abnormalities. Specifically, distinction is possible between ventricular diverticula and aneurysms, which is important because each condition has a different clinical outcome. We report the case of a 35-year-old, gravida 1, para 1 woman, with no significant past medical history, who underwent routine prenatal ultrasound screening at 32 weeks' gestation. A four-chamber ultrasound of the fetal heart combined with M-mode echocardiography showed abnormal dilatation of the right ventricular chamber measuring 2.2 cm × 1.0 cm but with normal contractility. Delivery was performed at full term by cesarean section, and a right ventricular diverticulum was confirmed by postnatal cardiac computed tomography. The baby developed normally with no cardiac sequelae during followup. This case demonstrates the importance of making a correct diagnosis of ventricular diverticula by prenatal ultrasound when abnormal dilatation of the fetal ventricle is identified during routine screening. Because evaluating the wall contractility by M-mode ultrasound leads to evaluating whether it has the myocardium, we conclude that M-mode echocardiography is effective for the purpose of prenatal cardiac diagnosis and can distinguish between ventricular aneurysms and functioning ventricular diverticula.
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Wacker-Gussmann A, Wakai RT, Strasburger JF. Importance of Fetal Arrhythmias to the Neonatologist and Pediatrician. Neoreviews 2016; 17:e568-e578. [PMID: 28042286 PMCID: PMC5193162 DOI: 10.1542/neo.17-10-e568] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Sudden, unexplained death during the perinatal period remains a major, longstanding challenge. Recent advances in diagnostic techniques and genetic testing has provided evidence that a significant fraction of these deaths may result from lethal cardiac arrhythmias. In this paper, we review current methods of diagnosing arrhythmia in the fetus and strategies for management of life-threatening arrhythmia throughout the perinatal period, including transitional care at the time of delivery.
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Affiliation(s)
- Annette Wacker-Gussmann
- Institute of Preventive Pediatrics, Faculty of Sport and Health Sciences, and German Heart Center, Department of Pediatric Cardiology and Congenital Heart Defects, Munich, Germany
| | - Ronald T Wakai
- Department of Medical Physics, University of Wisconsin-Madison, Madison, Wisconsin 53706, USA
| | - Janette F Strasburger
- Department of Pediatrics, Division of Cardiology, Children's Hospital of Wisconsin- Milwaukee and Fox Valley, 9000 W Wisconsin Avenue, Milwaukee, Wisconsin 53226, USA
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12
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Cuneo BF, Strasburger JF, Wakai RT. The natural history of fetal long QT syndrome. J Electrocardiol 2016; 49:807-813. [PMID: 27539165 DOI: 10.1016/j.jelectrocard.2016.07.023] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2016] [Indexed: 01/13/2023]
Abstract
INTRODUCTION Fetal magnetocardiography (fMCG), the magnetic analog of ECG, has provided invaluable insight into the mechanisms of fetal arrhythmias. In the past 15years, we have evaluated over 300 fetuses with arrhythmia by fMCG. We review the unique characteristics and natural history of the long QT syndrome (LQTS) rhythms. METHODS We reviewed the fMCGs of subjects referred with suspected LQTS based on either a positive family history or echo diagnosis of the LQTS rhythms (sinus bradycardia, ventricular tachycardia, or 2:1 AV conduction) to the Biomagnetism laboratory in the Department of Medical Physics, UW-Madison. We recorded fMCGs using a 37-channel (Magnes, 4D Neuroimaging, Inc., San Diego, CA) superconducting quantum interference device (SQUID) biomagnetometer, housed in a magnetically-shielded room for 1200-6000s. Signal processing was used to remove maternal interference. Cardiac intervals (R-R, p, QRS, QT) were measured and compared to published normals. We correlated fetal heart rate (FHR) patterns and effects of fetal movement on FHR and rhythm using actocardiography. RESULTS Thirty-nine fetuses were studied at a mean of 28 (19-38) weeks of gestation. All had structurally normal hearts. One was on amiodarone for suspected supraventricular tachycardia and hydrops. Five had serial fMCGs. Isolated sinus bradycardia with a QTc >490ms was found in 35: 33 had a KCNQ1 mutation There was one false positive and one false negative LQTS diagnosis. Four fetuses had torsades de pointes (TdP) and 3 had periods of 2:1 conduction and either KCNH2 or SCN5A mutations. TdP was rarely initiated with a preceding long-short pattern and did not degenerate into ventricular fibrillation. One fetus with TdP died in utero, 2 with fetal TdP had postnatal cardiac arrest. CONCLUSION Fetal LQTS is diagnosed by an fMCG QTc >490ms with an 89% sensitivity and specificity. TdP are seen with uncharacterized, KCNH2 or SCN5A R1623q mutations. Fetal TdP occurs when QTc ≥620ms. Identifying fetal LQTS and defining its rhythms by fMCG risk stratifies postnatal management.
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Affiliation(s)
- Bettina F Cuneo
- Children's Hospital Colorado, Department of Pediatrics, Heart Institute, University of Colorado School of Medicine, Aurora, CO.
| | - Janette F Strasburger
- Children's Hospital of Wisconsin Department of Pediatrics, Section of Cardiology, the Medical College of Wisconsin, Milwaukee, WI
| | - Ronald T Wakai
- The Biomagnetism Laboratory, Department of Medical Physics, University of Wisconsin, Madison, WI
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