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Bedei IA, Kniess D, Keil C, Wolter A, Schenk J, Sachs UJ, Axt-Fliedner R. Monitoring of Women with Anti-Ro/SSA and Anti-La/SSB Antibodies in Germany-Status Quo and Intensified Monitoring Concepts. J Clin Med 2024; 13:1142. [PMID: 38398455 PMCID: PMC10889801 DOI: 10.3390/jcm13041142] [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: 12/31/2023] [Revised: 02/10/2024] [Accepted: 02/14/2024] [Indexed: 02/25/2024] Open
Abstract
Background: The fetuses of pregnant women affected by anti-Ro/anti-La antibodies are at risk of developing complete atrioventricular heart block (CAVB) and other potentially life-threatening cardiac affections. CAVB can develop in less than 24 h. Treatment with anti-inflammatory drugs and immunoglobulins (IVIG) can restore the normal rhythm if applied in the transition period. Routine weekly echocardiography, as often recommended, will rarely detect emergent AVB. The surveillance of these pregnancies is controversial. Home-monitoring using a hand-held Doppler is a promising new approach. Methods: To obtain an overview of the current practice in Germany, we developed a web-based survey sent by the DEGUM (German Society of Ultrasound in Medicine) to ultrasound specialists. With the intention to evaluate practicability of home-monitoring, we instructed at-risk pregnant women to use a hand-held Doppler in the vulnerable period between 18 and 26 weeks at our university center. Results: There are trends but no clear consensus on surveillance, prophylaxis, and treatment of anti-Ro/La positive pregnant between specialists in Germany. Currently most experts do not offer home-monitoring but have a positive attitude towards its prospective use. Intensified fetal monitoring using a hand-held Doppler is feasible for pregnant women at risk and does not lead to frequent and unnecessary contact with the center. Conclusion: Evidence-based guidelines are needed to optimize the care of anti-Ro/La-positive pregnant women. Individual risk stratification could help pregnancy care of women at risk and is welcmed by most experts. Hand-held doppler monitoring is accepted by patients and prenatal medicine specialists as an option for intensified monitoring and can be included in an algorithm for surveillance.
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Affiliation(s)
- Ivonne Alexandra Bedei
- Department of Prenatal Diagnosis and Fetal Therapy, Justus-Liebig University Giessen, 35392 Giessen, Germany; (A.W.); (J.S.); (R.A.-F.)
| | - David Kniess
- Department of Prenatal Diagnosis and Fetal Therapy, Philipps-University Marburg, 35041 Marburg, Germany; (D.K.)
| | - Corinna Keil
- Department of Prenatal Diagnosis and Fetal Therapy, Philipps-University Marburg, 35041 Marburg, Germany; (D.K.)
| | - Aline Wolter
- Department of Prenatal Diagnosis and Fetal Therapy, Justus-Liebig University Giessen, 35392 Giessen, Germany; (A.W.); (J.S.); (R.A.-F.)
| | - Johanna Schenk
- Department of Prenatal Diagnosis and Fetal Therapy, Justus-Liebig University Giessen, 35392 Giessen, Germany; (A.W.); (J.S.); (R.A.-F.)
| | - Ulrich J. Sachs
- Institute for Clinical Immunology and Transfusion Medicine, Justus-Liebig University, 35392 Giessen, Germany;
- Center for Transfusion Medicine and Hemotherapy, University Hospital Giessen and Marburg, 35041 Marburg, Germany
- German Center for Fetomaternal Incompatibility (DZFI), University Hospital Giessen and Marburg, 35392 Giessen, Germany
| | - Roland Axt-Fliedner
- Department of Prenatal Diagnosis and Fetal Therapy, Justus-Liebig University Giessen, 35392 Giessen, Germany; (A.W.); (J.S.); (R.A.-F.)
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Padovani P, Singh Y, Pass RH, Vasile CM, Nield LE, Baruteau AE. E-Health: A Game Changer in Fetal and Neonatal Cardiology? J Clin Med 2023; 12:6865. [PMID: 37959330 PMCID: PMC10650296 DOI: 10.3390/jcm12216865] [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: 10/05/2023] [Revised: 10/20/2023] [Accepted: 10/26/2023] [Indexed: 11/15/2023] Open
Abstract
Technological advancements have greatly impacted the healthcare industry, including the integration of e-health in pediatric cardiology. The use of telemedicine, mobile health applications, and electronic health records have demonstrated a significant potential to improve patient outcomes, reduce healthcare costs, and enhance the quality of care. Telemedicine provides a useful tool for remote clinics, follow-up visits, and monitoring for infants with congenital heart disease, while mobile health applications enhance patient and parents' education, medication compliance, and in some instances, remote monitoring of vital signs. Despite the benefits of e-health, there are potential limitations and challenges, such as issues related to availability, cost-effectiveness, data privacy and security, and the potential ethical, legal, and social implications of e-health interventions. In this review, we aim to highlight the current application and perspectives of e-health in the field of fetal and neonatal cardiology, including expert parents' opinions.
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Affiliation(s)
- Paul Padovani
- CHU Nantes, Department of Pediatric Cardiology and Pediatric Cardiac Surgery, FHU PRECICARE, Nantes Université, 44000 Nantes, France;
- CHU Nantes, INSERM, CIC FEA 1413, Nantes Université, 44000 Nantes, France
| | - Yogen Singh
- Division of Neonatology, Department of Pediatrics, Loma Linda University School of Medicine, Loma Linda, CA 92354, USA
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Robert H. Pass
- Department of Pediatric Cardiology, Mount Sinai Kravis Children’s Hospital, New York, NY 10029, USA;
| | - Corina Maria Vasile
- Department of Pediatric and Adult Congenital Cardiology, University Hospital of Bordeaux, 33600 Bordeaux, France;
| | - Lynne E. Nield
- Division of Cardiology, Labatt Family Heart Centre, The Hospital for Sick Children, University of Toronto, Toronto, ON M5S 1A1, Canada
- Sunnybrook Health Sciences Centre, Toronto, ON M4N 3M5, Canada
| | - Alban-Elouen Baruteau
- CHU Nantes, Department of Pediatric Cardiology and Pediatric Cardiac Surgery, FHU PRECICARE, Nantes Université, 44000 Nantes, France;
- CHU Nantes, INSERM, CIC FEA 1413, Nantes Université, 44000 Nantes, France
- CHU Nantes, CNRS, INSERM, L’Institut du Thorax, Nantes Université, 44000 Nantes, France
- INRAE, UMR 1280, PhAN, Nantes Université, 44000 Nantes, France
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Ruican D, Petrescu AM, Istrate-Ofiţeru AM, Roșu GC, Zorilă GL, Dîră LM, Nagy RD, Mogoantă L, Pirici D, Iliescu DG. Confirmation of Heart Malformations in Fetuses in the First Trimester Using Three-Dimensional Histologic Autopsy. Obstet Gynecol 2023:00006250-990000000-00767. [PMID: 37141594 PMCID: PMC10184816 DOI: 10.1097/aog.0000000000005169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Accepted: 02/09/2023] [Indexed: 05/06/2023]
Abstract
BACKGROUND We aimed to evaluate the usefulness of three-dimensional (3D) reconstruction of histology slides to confirm congenital heart disease (CHD) detected by first-trimester fetal cardiac ultrasonography. Conventional autopsy is hindered by the small size of the first-trimester fetal heart, and current CHD confirmation studies employ the use of highly specialized and expensive methods. TECHNIQUE An extended first-trimester ultrasound examination protocol was used to diagnose fetal heart anomalies. Medical termination of pregnancies was followed by fetal heart extraction. The specimens were sliced, and the histology slides were stained and scanned. The resulting images were processed, and volume rendering was performed using 3D reconstruction software. The volumes were analyzed by a multidisciplinary team of maternal-fetal medicine subspecialists and pathologists and compared with ultrasound examination findings. EXPERIENCE Six fetuses with heart malformations were evaluated using histologic 3D imaging: two with hypoplastic left heart syndrome, two with atrioventricular septal defects, one with an isolated ventricular septal defect, and one with transposition of the great arteries. The technique allowed us to confirm ultrasound-detected anomalies and also identified additional malformations. CONCLUSION After pregnancy termination or loss, histologic 3D imaging can be used to confirm the presence of fetal cardiac malformations detected during first-trimester ultrasound examination. Additionally, this technique has the potential to refine the diagnosis for counseling regarding recurrence risk and retains the advantages of standard histology.
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Affiliation(s)
- Dan Ruican
- Department of Obstetrics and Gynecology, University Emergency County Hospital, and the Doctoral School, the Department of Histology, the Research Centre for Microscopic Morphology and Immunology, and the Department of Obstetrics and Gynecology, University of Medicine and Pharmacy of Craiova, Craiova, Romania
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Xie YY, Li QL, Li XL, Yang F. Pediatric acute heart failure caused by endocardial fibroelastosis mimicking dilated cardiomyopathy: A case report. World J Clin Cases 2023; 11:1771-1781. [PMID: 36970005 PMCID: PMC10037286 DOI: 10.12998/wjcc.v11.i8.1771] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 10/26/2022] [Accepted: 01/09/2023] [Indexed: 03/07/2023] Open
Abstract
BACKGROUND Endocardial fibroelastosis (EFE) is a diffuse endocardial collagen and elastin hyperplasia disease of unknown etiology, which may be accompanied by myocardial degenerative changes leading to acute or chronic heart failure. However, acute heart failure (AHF) without obvious associated triggers is rare. Prior to the report of endomyocardial biopsy, the diagnosis and treatment of EFE are highly susceptible to being confounded with other primary cardiomyopathies. Here, we report a case of pediatric AHF caused by EFE mimicking dilated cardiomyopathy (DCM), with the aim of providing a valuable reference for clinicians to early identify and diagnose EFE-induced AHF.
CASE SUMMARY A 13-mo-old female child was admitted to hospital with retching. Chest X-ray demonstrated enhanced texture in both lungs and an enlarged heart shadow. Color doppler echocardiography showed an enlarged left heart with ventricular wall hypokinesis and decreased left heart function. Abdominal color ultrasonography revealed a markedly enlarged liver. Pending the result of the endomyocardial biopsy report, the child was treated with a variety of resuscitative measures including nasal cannula for oxygen, intramuscular sedation with chlorpromazine and promethazine, cedilanid for cardiac contractility enhancement, and diuretic treatment with furosemide. Subsequently, the child’s endomyocardial biopsy report result was confirmed as EFE. After the above early interventions, the child’s condition gradually stabilized and improved. One week later, the child was discharged. During a 9-mo follow-up period, the child took intermittent low-dose oral digoxin with no signs of recurrence or exacerbation of the heart failure.
CONCLUSION Our report suggests that EFE-induced pediatric AHF may present in children over 1 year of age without any apparent precipitants, and that the associated clinical presentations are grossly similar to that of pediatric DCM. Nonetheless, it is still possible to be diagnosed effectively on the basis of the comprehensive analysis of auxiliary inspection findings before the result of the endomyocardial biopsy is reported.
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Affiliation(s)
- Yao-Ying Xie
- College of Clinical Medicine, Inner Mongolia Minzu University, Tongliao 028000, Inner Mongolia Autonomous Region, China
- Department of Pediatric Medical Center, Soochow University, Affiliated Hulunbuir Hospital, Hulunbuir 021000, Inner Mongolia Autonomous Region, China
| | - Qiu-Li Li
- College of Medicine, Shantou University, Shantou 515063, Guangdong Province, China
| | - Xin-Le Li
- College of Clinical Medicine, Inner Mongolia Minzu University, Tongliao 028000, Inner Mongolia Autonomous Region, China
| | - Fan Yang
- Department of Pediatric Medical Center, Soochow University, Affiliated Hulunbuir Hospital, Hulunbuir 021000, Inner Mongolia Autonomous Region, China
- School of Medicine, Shihezi University, Shihezi 832000, Xinjiang Uygur Autonomous Region, China
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5
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Xie YY, Li QL, Li XL, Yang F. Pediatric acute heart failure caused by endocardial fibroelastosis mimicking dilated cardiomyopathy: A case report. World J Clin Cases 2023; 11:1771-1781. [DOI: 10.12998/wjcc.v11.i8.1771 xie yy] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/30/2023] Open
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Wang X, Liu XW, Han L, Li MT, Zhao JL, Sun L, Han JC, Zeng XF, Tian XP, Zhao Y, He YH. Cardiac manifestations in a Chinese cohort of fetuses from mothers with anti-Ro and anti-La antibodies. Front Pediatr 2022; 10:904138. [PMID: 35967560 PMCID: PMC9371606 DOI: 10.3389/fped.2022.904138] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Accepted: 07/11/2022] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVES To analyze the clinical characteristics, echocardiographic features, and prognosis of fetuses based on three groups of cardiac manifestations associated with maternal anti-Ro and anti-La antibodies in China. This study included three groups: the isolated-arrhythmia, isolated-endocardial fibroelastosis (EFE), and mixed groups. METHODS We prospectively evaluated 36 fetuses with cardiac manifestations due to maternal anti-Ro and anti-La antibodies from our center between 2016 and 2020 in China. Clinical and echocardiographic data were collected. RESULTS There were 13 patients (36%) in the isolated-arrhythmia group, eight (22%) in the isolated-EFE group, and 15 (42%) in the mixed group. All patients in the isolated-EFE group presented with mild EFE. Severe EFE was identified in four patients (27%) in the mixed group. Atrioventricular block (AVB) was more common in the isolated-arrhythmia group (13, 100%) than in the mixed group (6, 40%; p = 0.001). Moderate-severe mitral regurgitation (p = 0.006), dilated cardiomyopathy (DCM, p = 0.017), and low cardiovascular profile scores (p = 0.013) were more common in the mixed group than in the other two groups. Twenty-one mothers decided to terminate the pregnancy and 15 fetuses were born with regular perinatal treatment. They all survived at 1 year of age. One patient in the isolated-arrhythmia group and two in the mixed group required a pacemaker due to third-degree AVB or atrioventricular junctional rhythm. Five patients in the isolated-EFE group and five in the mixed group had no DCM or heart failure and the location of mild EFE was significantly reduced. CONCLUSION Fetal cardiac manifestations due to maternal anti-Ro and anti-La antibodies can be divided into three groups, i.e., the isolated-arrhythmia, isolated-EFE, and mixed groups. AVB usually occurs in the isolated-arrhythmia group. Severe EFE, moderate-severe mitral regurgitation, and DCM mainly appear in the mixed group. Location of mild EFE significantly reduces after birth and the outcome of fetuses with mild EFE depends on the presence of arrhythmia and its subtypes.
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Affiliation(s)
- Xin Wang
- Echocardiography Medical Center, Maternal-Fetal Medicine Center in Fetal Heart Disease, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Xiao-Wei Liu
- Echocardiography Medical Center, Maternal-Fetal Medicine Center in Fetal Heart Disease, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Ling Han
- Department of Pediatric Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Meng-Tao Li
- Department of Rheumatology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, National Clinical Research Center for Dermatologic and Immunologic Diseases, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Jiu-Liang Zhao
- Department of Rheumatology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, National Clinical Research Center for Dermatologic and Immunologic Diseases, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Lin Sun
- Echocardiography Medical Center, Maternal-Fetal Medicine Center in Fetal Heart Disease, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Jian-Cheng Han
- Echocardiography Medical Center, Maternal-Fetal Medicine Center in Fetal Heart Disease, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Xiao-Feng Zeng
- Department of Rheumatology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, National Clinical Research Center for Dermatologic and Immunologic Diseases, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Xin-Ping Tian
- Department of Rheumatology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, National Clinical Research Center for Dermatologic and Immunologic Diseases, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Ying Zhao
- Echocardiography Medical Center, Maternal-Fetal Medicine Center in Fetal Heart Disease, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Yi-Hua He
- Echocardiography Medical Center, Maternal-Fetal Medicine Center in Fetal Heart Disease, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
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Tamhane T, Baliga P, Chidambarathanu S, Suresh I, Seshadri S. Echogenic Fetal Heart Without Conduction Defect in Maternal Autoimmune Disease: A Lesser Known Association. JOURNAL OF FETAL MEDICINE 2021. [DOI: 10.1007/s40556-021-00299-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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8
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Pedra SRFF, Zielinsky P, Binotto CN, Martins CN, Fonseca ESVBD, Guimarães ICB, Corrêa IVDS, Pedrosa KLM, Lopes LM, Nicoloso LHS, Barberato MFA, Zamith MM. Brazilian Fetal Cardiology Guidelines - 2019. Arq Bras Cardiol 2019; 112:600-648. [PMID: 31188968 PMCID: PMC6555576 DOI: 10.5935/abc.20190075] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Affiliation(s)
- Simone R F Fontes Pedra
- Instituto Dante Pazzanese de Cardiologia, São Paulo, SP - Brazil.,Hospital do Coração (HCor), São Paulo, SP - Brazil
| | - Paulo Zielinsky
- Instituto de Cardiologia do Rio Grande do Sul, Porto Alegre, RS - Brazil
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Cuneo BF, Sonesson SE, Levasseur S, Moon-Grady AJ, Krishnan A, Donofrio MT, Raboisson MJ, Hornberger LK, Van Eerden P, Sinkovskaya E, Abuhamad A, Arya B, Szwast A, Gardiner H, Jacobs K, Freire G, Howley L, Lam A, Kaizer AM, Benson DW, Jaeggi E. Home Monitoring for Fetal Heart Rhythm During Anti-Ro Pregnancies. J Am Coll Cardiol 2018; 72:1940-1951. [DOI: 10.1016/j.jacc.2018.07.076] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Revised: 07/06/2018] [Accepted: 07/09/2018] [Indexed: 10/28/2022]
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10
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Heart sounds at home: feasibility of an ambulatory fetal heart rhythm surveillance program for anti-SSA-positive pregnancies. J Perinatol 2017; 37:226-230. [PMID: 27977016 DOI: 10.1038/jp.2016.220] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Revised: 10/12/2016] [Accepted: 10/14/2016] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Fetuses exposed to anti-SSA (Sjögren's) antibodies are at risk of developing irreversible complete atrioventricular block (CAVB), resulting in death or permanent cardiac pacing. Anti-inflammatory treatment during the transition period from normal heart rhythm (fetal heart rhythm (FHR)) to CAVB (emergent CAVB) can restore sinus rhythm, but detection of emergent CAVB is challenging, because it can develop in ⩽24 h. We tested the feasibility of a new technique that relies on home FHR monitoring by the mother, to surveil for emergent CAVB. STUDY DESIGN We recruited anti-SSA-positive mothers at 16 to 18 weeks gestation (baseline) from 8 centers and instructed them to monitor FHR two times a day until 26 weeks, using a Doppler device at home. FHR was also surveilled by weekly or every other week fetal echo. If FHR was irregular, the mother underwent additional fetal echo. We compared maternal stress/anxiety before and after monitoring. Postnatally, infants underwent a 12-lead electrocardiogram. RESULTS Among 133 recruited, 125 (94%) enrolled. Among those enrolled, 96% completed the study. Reasons for withdrawal (n=5) were as follows: termination of pregnancy, monitoring too time consuming or moved away. During home monitoring, 9 (7.5%) mothers detected irregular FHR diagnosed by fetal echo as normal (false positive, n=2) or benign atrial arrhythmia (n=7). No CAVB was undetected or developed after monitoring. Questionnaire analysis indicated mothers felt comforted by the experience and would monitor again in future pregnancies. CONCLUSION These data suggest ambulatory FHR surveillance of anti-SSA-positive pregnancies is feasible, has a low false positive rate and is empowering to mothers.
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11
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Kan N, Silverman ED, Kingdom J, Dutil N, Laskin C, Jaeggi E. Serial echocardiography for immune-mediated heart disease in the fetus: results of a risk-based prospective surveillance strategy. Prenat Diagn 2017; 37:375-382. [DOI: 10.1002/pd.5021] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2016] [Revised: 01/28/2017] [Accepted: 02/03/2017] [Indexed: 11/08/2022]
Affiliation(s)
- Nobuhiko Kan
- Fetal Cardiac Program, Labatt Family Heart Centre, Hospital for Sick Children; University of Toronto; Toronto Canada
| | - Earl D. Silverman
- Department of Immunology; Hospital for Sick Children, University of Toronto; Toronto Canada
| | - John Kingdom
- Department of Obstetrics and Gynecology; Mount Sinai Hospital, University of Toronto; Toronto Canada
| | - Nathalie Dutil
- Fetal Cardiac Program, Labatt Family Heart Centre, Hospital for Sick Children; University of Toronto; Toronto Canada
| | - Carl Laskin
- Department of Medicine; Mount Sinai Hospital, University of Toronto; Toronto Canada
| | - Edgar Jaeggi
- Fetal Cardiac Program, Labatt Family Heart Centre, Hospital for Sick Children; University of Toronto; Toronto Canada
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12
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Abstract
Cardiac arrhythmias are an important aspect of fetal and neonatal medicine. Premature complexes of atrial or ventricular origin are the main cause of an irregular heart rhythm. The finding is typically unrelated to an identifiable cause and no treatment is required. Tachyarrhythmia most commonly relates to supraventricular reentrant tachycardia, atrial flutter, and sinus tachycardia. Several antiarrhythmic agents are available for the perinatal treatment of tachyarrhythmias. Enduring bradycardia may result from sinus node dysfunction, complete heart block and nonconducted atrial bigeminy as the main arrhythmia mechanisms. The management and outcome of bradycardia depend on the underlying mechanism.
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MESH Headings
- Anti-Arrhythmia Agents/therapeutic use
- Arrhythmias, Cardiac/diagnosis
- Arrhythmias, Cardiac/drug therapy
- Atrial Flutter/diagnosis
- Atrial Flutter/drug therapy
- Atrial Premature Complexes/diagnosis
- Atrial Premature Complexes/drug therapy
- Bradycardia/diagnosis
- Bradycardia/drug therapy
- Electrocardiography
- Fetal Diseases/diagnosis
- Fetal Diseases/drug therapy
- Heart Block/diagnosis
- Heart Block/drug therapy
- Humans
- Infant, Newborn
- Infant, Newborn, Diseases/diagnosis
- Infant, Newborn, Diseases/drug therapy
- Sick Sinus Syndrome/diagnosis
- Sick Sinus Syndrome/drug therapy
- Tachycardia, Sinus/diagnosis
- Tachycardia, Sinus/drug therapy
- Tachycardia, Supraventricular/diagnosis
- Tachycardia, Supraventricular/drug therapy
- Ventricular Premature Complexes/diagnosis
- Ventricular Premature Complexes/drug therapy
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Affiliation(s)
- Edgar Jaeggi
- Labatt Family Heart Centre, Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, Ontario M5G 1X8, Canada.
| | - Annika Öhman
- Labatt Family Heart Centre, Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, Ontario M5G 1X8, Canada
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Clark ES, Pepper VK, Best CA, Onwuka EA, Yi T, Tara S, Cianciolo R, Baker P, Shinoka T, Breuer CK. A mouse model of endocardial fibroelastosis. Cardiovasc Pathol 2015; 24:388-94. [PMID: 26363814 DOI: 10.1016/j.carpath.2015.08.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2015] [Revised: 07/08/2015] [Accepted: 08/07/2015] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Endocardial fibroelastosis (EFE) is a pathologic condition of abnormal deposition of collagen and elastin within the endocardium of the heart. It is seen in conjunction with a variety of diseases including hypoplastic left heart syndrome and viral endocarditis. While an experimental model using heterotopic heart transplant in rats has been described, we sought to fully describe a mouse model that can be used to further elucidate the potential mechanisms of and treatments for EFE. MATERIALS AND METHODS The hearts of 2-day-old C57BL/6 mice were transplanted into the abdomen of 7-week-old C57BL/6 mice. At 2 weeks, the hearts were harvested and histologic analysis was performed using hematoxylin and eosin, Masson's trichrome, Russell-Movat's pentachrome, Picrosirius red, Hart's, Verhoeff-Van Gieson, and Weigert's Resorcin-Fuchsin stains. Additionally, one heart was analyzed using transmission electron microscopy (TEM). RESULTS Specimens demonstrated abnormal accumulation of both collagen and elastin within the endocardium with occasional expansion into the myocardium. Heterogeneity in extracellular matrix deposition was noted in the histologic specimens. In addition, TEM demonstrated the presence of excess collagen within the endocardium. CONCLUSIONS The heterotopic transplantation of an immature heart into a mouse results in changes consistent with EFE. This model is appropriate to investigate the etiology and treatment of EFE.
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Affiliation(s)
- Elizabeth S Clark
- Tissue Engineering Program, The Research Institute at Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA; Department of Veterinary Biosciences, College of Veterinary Medicine, The Ohio State University, 1900 Coffey Road, Columbus, OH 43210, USA
| | - Victoria K Pepper
- Tissue Engineering Program, The Research Institute at Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA; Department of Pediatric Surgery, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205-2664, USA
| | - Cameron A Best
- Tissue Engineering Program, The Research Institute at Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA
| | - Ekene A Onwuka
- Tissue Engineering Program, The Research Institute at Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA; Department of Surgery, The Ohio State University, 395 W. 12th Avenue - Suite 670, Columbus, OH 43210, USA
| | - Tai Yi
- Tissue Engineering Program, The Research Institute at Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA
| | - Shuhei Tara
- Tissue Engineering Program, The Research Institute at Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA
| | - Rachel Cianciolo
- Department of Veterinary Biosciences, College of Veterinary Medicine, The Ohio State University, 1900 Coffey Road, Columbus, OH 43210, USA
| | - Peter Baker
- Tissue Engineering Program, The Research Institute at Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA; Department of Pathology, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205-2664, USA
| | - Toshiharu Shinoka
- Tissue Engineering Program, The Research Institute at Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA; Department of Cardiovascular Surgery, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205-2664, USA
| | - Christopher K Breuer
- Tissue Engineering Program, The Research Institute at Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA; Department of Pediatric Surgery, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205-2664, USA.
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Natarajan S, Szwast A, Tian Z, McCann M, Soffer D, Rychik J. Right ventricular mechanics in the fetus with hypoplastic left heart syndrome. J Am Soc Echocardiogr 2013; 26:515-20. [PMID: 23473605 DOI: 10.1016/j.echo.2013.02.001] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2012] [Indexed: 12/16/2022]
Abstract
BACKGROUND Right ventricular mechanics influence outcomes in patients with hypoplastic left heart syndrome (HLHS). The aim of this study was to determine whether differences in right ventricular performance have their origins in fetal life and if the architectural character of the hypoplastic left ventricle affects right ventricular mechanics. METHODS The first complete fetal echocardiograms after 17 weeks' gestation were reviewed in 84 fetuses with HLHS and in 115 gestational age-matched normal controls. Inflow, outflow, and myocardial tissue Doppler velocities were measured. E/A and E/e' ratios and right ventricular myocardial performance index were calculated. RESULTS In fetuses with HLHS, there were lower tricuspid E/A ratios (mean, 0.6 ± 0.1 vs 0.7 ± 0.1; P < .001), higher E/e' ratios (mean, 8.1 ± 2.6 vs 7.0 ± 1.3; P = .006), and higher right ventricular myocardial performance indices (mean, 0.47 ± 0.14 vs 0.40 ± 0.10; P < .001) compared with controls. Among fetuses with HLHS grouped according to left ventricular architecture, those with left ventricular endocardial fibroelastosis had the most striking differences in right ventricular mechanics. CONCLUSIONS Right ventricular mechanics are different from normal in fetuses with HLHS and are influenced by the presence of left ventricular endocardial fibroelastosis. These differences precede the imposition of undue loading conditions as a consequence of surgical palliation and may offer clues to the development of later right ventricular failure.
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Affiliation(s)
- Shobha Natarajan
- Fetal Heart Program, Cardiac Center at The Children's Hospital of Philadelphia, Department of Pediatrics, University of Pennsylvania School of Medicine, Philadelphia, PA, USA.
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15
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Medrano-Lopez C, Fouron JC. Fetal cardiology, the frontier of pediatric cardiovascular medicine. Rev Esp Cardiol 2012; 65:700-4. [PMID: 22699048 DOI: 10.1016/j.recesp.2012.03.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2012] [Accepted: 03/08/2012] [Indexed: 10/28/2022]
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16
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Killen SAS, Buyon JP, Friedman DM. Discordant spectrum of cardiac manifestations of neonatal lupus in twins. Lupus 2011; 21:559-62. [PMID: 22140143 DOI: 10.1177/0961203311430512] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Congenital complete heart block associated with transplacental passage of maternal autoantibodies reactive with SSA/Ro and SSB/La is a rare disease with significant fetal, neonatal, and childhood morbidity and mortality. We present the case of dichorionic, diamniotic twins (female twin A and male twin B) exposed to maternal Ro and La autoantibodies with different disease expression. Twin A (female) had Mobitz type I second degree atrioventricular (AV) block (Wenckebach); twin B (male) had normal sinus rhythm. Both twins had structurally normal hearts but demonstrated echocardiographic evidence of endocardial fibroelastosis (EFE). Following maternal dexamethasone 4 mg once daily, twin A reverted to sinus rhythm in utero; twin B remained in sinus rhythm throughout pregnancy. Echocardiograms after delivery demonstrated resolution of EFE in both fetuses, and EKGs confirmed sinus rhythm. However, at five months of age, Holter monitor demonstrated first degree AV block and intermittent Wenckebach in twin A. Twin B remains in sinus rhythm. This case is one of only three in the literature that describes Mobitz type I second degree atrioventricular block presenting in fetuses exposed to maternal SSA and SSB autoantibodies and is the first case that we have seen reported in twins. Importantly, this case also adds to the growing body of literature describing EFE as a presentation of neonatal lupus with or without conduction system abnormalities, emphasizes the spectrum of cardiac conduction abnormalities in neonatal lupus syndrome, and raises interesting questions about discordant disease expression in twins.
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Affiliation(s)
- S A S Killen
- Department of Pediatrics, Vanderbilt University School of Medicine and the Monroe Carell Jr Children's Hospital at Vanderbilt, USA.
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Eliasson H, Sonesson SE, Sharland G, Granath F, Simpson JM, Carvalho JS, Jicinska H, Tomek V, Dangel J, Zielinsky P, Respondek-Liberska M, Freund MW, Mellander M, Bartrons J, Gardiner HM. Isolated Atrioventricular Block in the Fetus. Circulation 2011; 124:1919-26. [PMID: 21986286 DOI: 10.1161/circulationaha.111.041970] [Citation(s) in RCA: 151] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
Isolated complete atrioventricular block in the fetus is a rare but potentially lethal condition in which the effect of steroid treatment on outcome is unclear. The objective of this work was to study risk factors associated with death and the influence of steroid treatment on outcome.
Methods and Results—
We studied 175 fetuses diagnosed with second- or third-degree atrioventricular block (2000–2007) retrospectively in a multinational, multicenter setting. In 80% of 162 pregnancies with documented antibody status, atrioventricular block was associated with maternal anti-Ro/SSA antibodies. Sixty-seven cases (38%) were treated with fluorinated corticosteroids for a median of 10 weeks (1–21 weeks). Ninety-one percent were alive at birth, and survival in the neonatal period was 93%, similar in steroid-treated and untreated fetuses, regardless of degree of block and/or presence of anti-Ro/SSA. Variables associated with death were gestational age <20 weeks, ventricular rate ≤50 bpm, fetal hydrops, and impaired left ventricular function at diagnosis. The presence of ≥1 of these variables was associated with a 10-fold increase in mortality before birth and a 6-fold increase in the neonatal period independently of treatment. Except for a lower gestational age at diagnosis in treated than untreated (23.4±2.9 versus 24.9±4.9 weeks;
P
=0.02), risk factors were distributed equally between treatment groups. Two-thirds of survivors had a pacemaker by 1 year of age; 8 children developed cardiomyopathy.
Conclusions—
Risk factors associated with a poor outcome were gestation <20 weeks, ventricular rate ≤50 bpm, hydrops, and impaired left ventricular function. No significant effect of treatment with fluorinated corticosteroids was seen.
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Affiliation(s)
- Håkan Eliasson
- Pediatric Cardiology Q1:03, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden.
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18
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Jaeggi ET, Silverman ED, Laskin C, Kingdom J, Golding F, Weber R. Prolongation of the Atrioventricular Conduction in Fetuses Exposed to Maternal Anti-Ro/SSA and Anti-La/SSB Antibodies Did Not Predict Progressive Heart Block. J Am Coll Cardiol 2011; 57:1487-92. [DOI: 10.1016/j.jacc.2010.12.014] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2010] [Revised: 11/15/2010] [Accepted: 12/13/2010] [Indexed: 10/18/2022]
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19
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Eliasson H, Wahren-Herlenius M, Sonesson SE. Mechanisms in fetal bradyarrhythmia: 65 cases in a single center analyzed by Doppler flow echocardiographic techniques. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2011; 37:172-178. [PMID: 21264981 DOI: 10.1002/uog.8866] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
OBJECTIVE Fetal bradyarrhythmias have various underlying mechanisms. As blocked atrial bigeminy (BB) generally resolves spontaneously, but incomplete atrioventricular block (AVB) might respond to steroid treatment, correct diagnosis is of major importance. Our objectives were to assess the underlying mechanisms in fetal bradyarrhythmia and the accuracy of Doppler techniques in differentiating between them. METHODS Seventy-eight patients referred to our tertiary center between 1990 and 2007 for evaluation of fetal bradycardia were analyzed retrospectively. Besides Doppler recordings from the mitral valve/aorta, superior vena cava/aorta and pulmonary vein/peripheral pulmonary artery, we used recordings from the pulmonary trunk and ductus venosus. We calculated the ratio of the time interval between conducted and consecutive blocked atrial contractions divided by the interval between two conducted atrial beats (a(cb) /a(cc) ), to analyze more meticulously the atrial rhythm in BB and second-degree AVB. RESULTS Fetal bradycardia ( ≤ 110 bpm) was confirmed in 65 of the 78 referred cases. Twenty-five had AVB (of which 20 were complete AVB), 29 had BB (of which 23 were intermittent) and 11 had sinus bradycardia. The bradyarrhythmic mechanism was identified correctly in all but one fetus with an atrial ectopic rhythm. Heart rates < 65 bpm were not seen in fetuses diagnosed with BB and rates < 60 bpm were seen only in cases with complete AVB, but heart rate did not distinguish between BB and AVB in the 60-75 bpm range. The a(cb) /a(cc) ratio clearly differentiated between fetsues with BB and those with second-degree AVB, including during midgestation, when it was difficult to distinguish these fetuses. CONCLUSIONS Using Doppler flow recordings, the mechanism causing fetal bradycardia can be clarified. In most cases this can be accomplished by visual validation only, and meticulous measurements are needed mainly to distinguish midterm fetuses with BB from those with second-degree AVB.
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Affiliation(s)
- H Eliasson
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
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20
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Guettrot-Imbert G, Cohen L, Fermont L, Villain E, Francès C, Thiebaugeorges O, Foliguet B, Leroux G, Cacoub P, Amoura Z, Piette JC, Costedoat-Chalumeau N. A new presentation of neonatal lupus: 5 cases of isolated mild endocardial fibroelastosis associated with maternal Anti-SSA/Ro and Anti-SSB/La antibodies. J Rheumatol 2010; 38:378-86. [PMID: 21078712 DOI: 10.3899/jrheum.100317] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Maternal anti-SSA/Ro or anti-SSB/La antibodies are associated with neonatal lupus erythematosus syndrome (NLES), especially congenital heart block (CHB), which may be associated with severe endocardial fibroelastosis (EFE) and dilated cardiomyopathy (DCM). A few reports have described severe EFE without CHB associated with anti-SSA/Ro antibodies, with a poor prognosis. EFE has also been observed in biopsies of DCM that had been considered idiopathic. These points, considered in association with 5 unusual cases of mild EFE, led us to consider the relationship between underrecognized cases of isolated autoantibody-associated EFE and DCM that had been considered idiopathic. METHODS We analyzed 5 cases of EFE diagnosed in utero (n = 4) or after birth (n = 1). In 3 cases, maternal antibody status was discovered because of the EFE diagnosis. RESULTS Endomyocardial hyperechogenicity predominated in the left atrium (n = 3) and mitral annulus (n = 3). No left-heart dysfunction was observed. Two mothers were treated with betamethasone. One mother chose to have a therapeutic abortion, and EFE was confirmed at autopsy. Electrocardiograms at birth (n = 4) did not show CHB. Other manifestations of NLES were present in all cases. One child had right ventricular hypoplasia and underwent a partial cavopulmonary anastomosis. At last followup (4-7 yrs), the other 3 children had normal heart function, and echocardiography showed a normal heart (n = 2) or mild persistent EFE (n = 1). CONCLUSION Middle-term prognosis of isolated autoantibody-associated EFE may be better than previously reported, although the longterm prognosis remains unknown. We hypothesize that a fetal insult can lead to DCM.
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Affiliation(s)
- Gaëlle Guettrot-Imbert
- AP-HP, Service de Médecine Interne, Centre de Référence National pour le Lupus Systémique et le Syndrome des Antiphospholipides, Centre Hospitalier Universitaire Pitié-Salpêtrière, 47-83 Boulevard de l'Hôpital, 75651 Paris Cedex 13, France
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21
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Abstract
Foetal echocardiographic ultrasound techniques still remain the dominating modality for diagnosing foetal atrioventricular block (AVB). Foetal electrocardiography might become a valuable tool to measure time intervals, but magnetocardiography is unlikely to get a place in clinical practice. Assuming that AVB is a gradually progressing and preventable disease, starting during a critical period in mid-gestation with a less abnormal atrioventricular conduction before progressing to a complete irreversible AVB (CAVB), echocardiographic methods to detect first-degree AVB have been developed. The time intervals obtained with these techniques are all based on the identification of mechanical or hemodynamic events as markers of atrial (A) and ventricular (V) depolarizations and will accordingly include both electrical and mechanical components. Prospective observational studies have demonstrated a transient prolongation of AV time intervals in anti-Ro/SSA antibody-exposed foetuses, but it has not succeeded to identify a degree of AV time prolongation predicting irreversible cardiac damage and progression to CAVB. Causes of sustained bradycardia include CAVB, 2:1 AVB, sinus bradycardia and blocked atrial bigeminy (BAB). Using foetal echocardiographic techniques and a systematic approach, a correct diagnosis can be made in almost every case. Sinus bradycardia and CAVB are usually easy to diagnose, but BAB has a tendency to be sustained and shows a high degree of resemblance with 2:1 AVB when diagnosed during mid-gestational. As BAB resolves without treatment and 2:1 AVB may respond to treatment with fluorinated steroids, a correct diagnosis becomes an issue of major importance to avoid unnecessary treatment of harmless and spontaneously reversing conditions.
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Affiliation(s)
- S-E Sonesson
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden.
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22
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Hutter D, Silverman ED, Jaeggi ET. The benefits of transplacental treatment of isolated congenital complete heart block associated with maternal anti-Ro/SSA antibodies: a review. Scand J Immunol 2010; 72:235-41. [PMID: 20696021 DOI: 10.1111/j.1365-3083.2010.02440.x] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Isolated congenital complete atrio-ventricular block (CAVB) is associated with the transplacental passage of maternal autoantibodies directed to foetal Ro/SSA ribonucleoproteins. Their interactions most likely trigger the inflammation of the atrio-ventricular node and the myocardium in susceptible foetuses. The inflamed tissues may then heal with fibrosis that may cause heart block, endocardial fibroelastosis, and dilated cardiomyopathy. CAVB, the most common cardiac complication, typically develops between 18 and 24 gestational weeks. Untreated, the condition carries a significant mortality risk as the foetus needs to overcome the sudden drop in ventricular rate, the loss of normal atrial systolic contribution to ventricular filling, and perhaps concomitant myocardial inflammation and fibrosis. The rationale to treat a foetus at the stage of CAVB is primarily to mitigate myocardial inflammation and to augment foetal cardiac output. Maternal dexamethasone administration has been shown to improve incomplete foetal AV block, myocardial dysfunction, and cavity effusions. Beta-sympathomimetics may be useful to increase the foetal heart rate and myocardial contractility. Published data from our institution suggest an improved survival >90% if maternal high-dose dexamethasone was initiated at the time of CAVB detection and maintained during the pregnancy and if a beta-adrenergic drug was added at foetal heart rates below 55 beats/min. Despite the improvement in outcome, there is an ongoing debate about treatment-related risks. In this review, we will appraise the natural history of untreated CAVB, discuss currently available management options, and examine the results and risks of in-utero treatment of antibody-mediated CAVB.
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Affiliation(s)
- D Hutter
- Division of Cardiology, The Hospital for Sick Children, Toronto, Ontario, Canada
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23
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Mivelaz Y, Raboisson MJ, Abadir S, Sarquella-Brugada G, Fournier A, Fouron JC. Ultrasonographic diagnosis of delayed atrioventricular conduction during fetal life: a reliability study. Am J Obstet Gynecol 2010; 203:174.e1-7. [PMID: 20435283 DOI: 10.1016/j.ajog.2010.02.024] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2009] [Revised: 10/30/2009] [Accepted: 02/10/2010] [Indexed: 11/29/2022]
Abstract
OBJECTIVE The objective of the study was to evaluate the reliability of the 2 most commonly used ultrasonographic approaches for monitoring fetal atrioventricular conduction time (AVCT): (1) superior vena cava/ascending aorta (SVC/AA), and (2) left ventricular inflow/outflow tract (LVI/O) Doppler recordings. STUDY DESIGN Echographic studies from fetuses followed up for first-degree atrioventricular block (AVB-1) between 1998 and 2008 were reviewed. The ability to identify atrial contractions in the same fetuses by the SVC/AA and LVI/O approaches was analyzed. RESULTS Sixty-six studies of 13 fetuses with AVB-1 were available. Atrial contractions were visible in all SVC/AA studies. With the LVI/O approach, atrial contractions could not be identified in 26 studies (39%). AVCT delay was significantly greater in the nonidentifiable compared with the identifiable atrial contraction group (P < .001). Differences in heart rate and gestational age were not significant. CONCLUSION The LVI/O is unsuitable for prenatal screening of conduction system anomalies.
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Affiliation(s)
- Yvan Mivelaz
- Cardiology Division, Fetal Cardiology Unit, Department of Pediatrics, Centre Hospitalier Universitaire Sainte-Justine, University of Montreal, Montreal, QC, Canada
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24
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Abstract
Endocardial fibroelastosis is not a disease but a reaction of the endocardium. I review the history of the term with emphasis on the gradual understanding of the many causes of this reaction. I include a comprehensive list of diseases or other cardiac stresses that authors have reported in association, and I try to explain the mechanism of the reaction. Although endocardial fibroelastosis is rare today, I issue a warning of a possible epidemic recrudescence of some of the associated diseases. My hope is for nosologic purity, therefore that outworn but surviving concepts will be firmly rejected.
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25
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Bergman G, Eliasson H, Bremme K, Wahren-Herlenius M, Sonesson SE. Anti-Ro52/SSA antibody-exposed fetuses with prolonged atrioventricular time intervals show signs of decreased cardiac performance. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2009; 34:543-549. [PMID: 19795521 DOI: 10.1002/uog.7343] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
OBJECTIVE To investigate if anti-Ro/SSA antibody-exposed fetuses with prolonged atrioventricular (AV) time intervals also have prolongation of the isovolumetric contraction time (ICT). METHODS Seventy-eight anti-Ro/SSA (including 70 anti-Ro52) antibody-exposed fetuses at risk for congenital heart block (CHB) were followed weekly, between 18 and 24 weeks of gestation, with two Doppler echocardiographic methods designed to detect signs of first-degree AV block. One of these AV time measurements, using hemodynamic events from the mitral valve and aortic outflow as indirect markers of atrial and ventricular depolarization (MV-Ao), was also used to calculate a time interval representing an early phase of systolic cardiac performance, i.e. the ICT. Two hundred and eighty-four women with normal pregnancies served as controls for AV time intervals and another 106 were used to establish an ICT reference range. RESULTS Strong positive relationships were found between ICT and MV-Ao time intervals (r = 0.91, P < 0.001), as well as between ICT and time intervals obtained from the superior vena cava and aorta (r = 0.85, P < 0.001). The ICT was estimated to contribute more than 50% of the total AV time prolongation. Abnormal AV time and ICT intervals were only seen in anti-Ro52 positive pregnancies. CONCLUSIONS The ICT is an important contributor to prolongation of AV time intervals. This observation suggests that anti-Ro52/SSA antibody-exposed fetal hearts have not only disturbed electrical conduction but also decreased mechanical performance. Moreover, our findings have implications for the interpretation of AV time intervals used for surveillance of fetuses at risk for developing CHB.
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Affiliation(s)
- G Bergman
- Department of Woman and Child Health, Karolinska Institutet, Stockholm, Sweden
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26
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The underestimated potential of Doppler ultrasound to assess fetal arrhythmia: First report of a prenatal, transient, atypical atrioventricular block. Heart Rhythm 2009; 6:1226-8. [DOI: 10.1016/j.hrthm.2009.03.049] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2009] [Accepted: 03/25/2009] [Indexed: 11/20/2022]
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27
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Papakonstantinou K, Hasiakos D, Kondi-Paphiti A, Vitoratos N. Congenital heart block in neonatal lupus erythematosus. J OBSTET GYNAECOL 2009; 29:153-4. [PMID: 19274557 DOI: 10.1080/01443610802644277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- K Papakonstantinou
- 2nd Department of Obstetrics and Gynecology, University of Athens, School of Medicine, Aretaieion Hospital, Athens, Greece.
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28
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Positive maternal anti-SSA/SSB antibody-related fetal right ventricular endocardial fibroelastosis without atrioventricular block, reversal of endocardial fibroelastosis. Prenat Diagn 2008; 29:177-8. [DOI: 10.1002/pd.2073] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Adams LL, Gungor S, Salim M, Harman CR, Baschat AA. Regression of fetal heart block and myocardial echogenicity with steroid therapy in maternal Sjögren's syndrome. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2008; 32:839-840. [PMID: 18839397 DOI: 10.1002/uog.6213] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
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30
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Strandberg L, Winqvist O, Sonesson SE, Mohseni S, Salomonsson S, Bremme K, Buyon JP, Julkunen H, Wahren-Herlenius M. Antibodies to amino acid 200-239 (p200) of Ro52 as serological markers for the risk of developing congenital heart block. Clin Exp Immunol 2008; 154:30-7. [PMID: 18727629 DOI: 10.1111/j.1365-2249.2008.03732.x] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Maternal autoantibodies to the p200-epitope of Ro52 have been suggested to correlate with development of congenital heart block. The aim of the present study was to evaluate the clinical relevance and predictive value of p200-antibodies in high-risk pregnancies. Sera from 515 Finnish, Swedish and American women were included in the study. Sera originated from 202 mothers with an infant affected by second- or third-degree atrioventricular block (AVB), 177 mothers with rheumatic disease having infants with normal heart rate and female blood donors (n = 136). A novel serological assay for Ro52 p200-antibodies with intra- and inter-assay variability of 3% and 3.8% respectively was developed. Mothers of children affected by AVB II-III had significantly higher p200-antibody levels than mothers with rheumatic disease having children with normal heart rate (P < 0.001). In the Swedish cohort, a distinction between foetuses with normal conduction, AVB I, AVB II and III was possible. A significant difference in anti-p200 levels between AVB I and AVB II-III groups compared with foetuses with normal conduction (P < 0.05 and P < 0.01) was observed. Using p200-antibodies as a second step analysis in Ro52-positive pregnancies increased the positive predictive value for foetal cardiac involvement (AVB I, II or III) from 0.39 (0.27-0.51) to 0.53 (0.37-0.68). In conclusion, Ro52 p200-antibodies may occur in women with unaffected children, but levels are significantly higher in mothers of children with congenital heart block and are suggested as a relevant marker in evaluating the risk for foetal AV block.
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Affiliation(s)
- L Strandberg
- Rheumatology Unit, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
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31
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Skog A, Wahren-Herlenius M, Sundström B, Bremme K, Sonesson SE. Outcome and growth of infants fetally exposed to heart block-associated maternal anti-Ro52/SSA autoantibodies. Pediatrics 2008; 121:e803-9. [PMID: 18381509 DOI: 10.1542/peds.2007-1659] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE The purpose of this work was to analyze outcome with focus on growth in infants fetally exposed to heart block-associated maternal anti-Ro52/SSA autoantibodies and identify maternal factors other than the autoantibodies increasing the risk of fetal heart block. PATIENTS AND METHODS Thirty-two pregnancies in 30 anti-Ro52-positive mothers were included. Seven fetuses developed second-degree or third-degree atrioventricular block, 8 developed first-degree atrioventricular block, and 17 had normal atrioventricular conduction, as diagnosed by using Doppler echocardiography. Three of 6 surviving fetuses with second-degree or third-degree atrioventricular block received treatment with fluorinated steroids. Two fetuses with second-degree atrioventricular block converted to first-degree atrioventricular block without any signs of progression during the study period. Maternal and longitudinal infant data were collected from planned neonatal follow-up and childhood health records from birth to 12 months of age in 31 survivors. RESULTS Women giving birth to infants with prenatal second-degree or third-degree atrioventricular block were older and with higher parity than those with first-degree atrioventricular block or normal atrioventricular conduction. Second-degree or third-degree atrioventricular block pregnancies were <40 completed weeks, whereas pregnancies with first-degree atrioventricular block or normal atrioventricular conduction had a normal duration. Fetuses with second-degree or third-degree atrioventricular block were retarded by -0.98 +/- 0.77 SD in weight at birth and did not show any catch-up during infancy. In contrast, fetuses with first-degree atrioventricular block or normal atrioventricular conduction had a weight reduction of -0.51 +/- 1.01 SD with a catch-up during the first months after birth. CONCLUSIONS This report documents that newborns with autoantibody-mediated second-degree or third-degree atrioventricular block are retarded in growth, with no catch-up during infancy, whereas fetuses with first-degree atrioventricular block or normal atrioventricular conduction have a normal growth soon after birth. Increased maternal age and/or parity seem to carry an increased risk for fetal heart block.
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Affiliation(s)
- Amanda Skog
- Rheumatology Unit, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
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32
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Skinner JR, Sharland G. Detection and management of life threatening arrhythmias in the perinatal period. Early Hum Dev 2008; 84:161-72. [PMID: 18358642 DOI: 10.1016/j.earlhumdev.2008.01.010] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2008] [Accepted: 01/15/2008] [Indexed: 11/20/2022]
Abstract
The management of tachyarrhythmias and bradyarrythmias in the fetus requires a team approach with careful monitoring of fetal well-being as well as care in establishing a precise diagnosis with use of m-mode and Doppler echocardiography to determine the atrial and ventricular rate. A persistent fetal heart rate less than 80 beats per minute (bpm) suggests complete atrioventricular block. A persistent fetal heart rate over 180 bpm suggests pathological tachycardia, most of which are a supraventricular tachycardia mediated via an accessory pathway. However, around 20% are due to atrial flutter, and this review highlights why medical management should be different for these cases, and for those with hydrops or cardiac failure. It also illustrates which fetus or infant may be at particular risk, and illustrates key features in their management before and after birth.
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Affiliation(s)
- Jonathan R Skinner
- Green Lane Paediatric and Congenital Cardiac Services, Starship Hospital, Grafton, Auckland, New Zealand.
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33
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Abstract
The final common pathway to death in all of us is an arrhythmia, yet we still know far too little about the contribution of conduction abnormalities and arrhythmias to the compromised states of the human fetus. At no other time in the human life cycle is the human being at more risk of unexplained and unexpected death than during the prenatal period. The risk of sudden death from 20-40 weeks gestation is 6-12 deaths/1000 fetuses/year. This is equal to, and in some ethnic groups HIGHER than, the risk of death in the adult population with known coronary artery disease over the same time frame (6-12 deaths/1000 patients/year). Because only a small percentage of the United States population is pregnant each year, because fetal demise is not often acknowledged through public displays such as funerals, and finally because fetal death is culturally accepted to a much greater extent than it should be, this critically important area of women's healthcare has not had the technological advances that have been seen in adult cardiac intensive care and other areas of medicine. Fetal cardiac deaths may be preventable and the diseases that lead to these deaths are often treatable, especially if the sophistication of our modern ICU's could somehow be translated to the prenatal monitoring arena. This review article will outline recent advances in evaluating fetal electrophysiology, helping the perinatologist to better understand the nuances of fetal arrhythmias.
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Affiliation(s)
- Janette F Strasburger
- Children's Hospital of Wisconsin - Fox Valley, 200 Theda Clark Medical Plaza, Suite 480, Neenah, WI 54956-2884, USA.
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34
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Abstract
Knowledge about cardiac arrhythmias has significantly improved in the last 20 years, and the improvements in diagnosis and in therapy have also had important effects on the management of pediatric arrhythmias. In this paper, the most important developments in the field of management of pediatric arrhythmias (fetal arrhythmias, genetics, pharmacological strategies, radiofrequency ablation, new technologies) as well as the remaining problems (risk stratification of some arrhythmic forms as for example Wolff-Parkinson-White and ventricular arrhythmias) will be discussed.
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Affiliation(s)
- Gabriele Vignati
- Pediatric Cardiology, Niguarda Hospital, Piazza Ospedale Maggiore, Milan, Italy.
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Wahren-Herlenius M, Sonesson SE. Specificity and effector mechanisms of autoantibodies in congenital heart block. Curr Opin Immunol 2006; 18:690-6. [PMID: 17011766 DOI: 10.1016/j.coi.2006.09.012] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2006] [Accepted: 09/19/2006] [Indexed: 11/25/2022]
Abstract
Complete congenital atrio-ventricular (AV) heart block develops in 2-5% of fetuses of Ro/SSA and La/SSB autoantibody-positive pregnant women. During pregnancy, the Ro/SSA and La/SSB antibodies are transported across the placenta and affect the fetus. Emerging data suggest that this happens by a two-stage process. In the first step, maternal autoantibodies bind fetal cardiomyocytes, dysregulate calcium homestasis and induce apoptosis in affected cells. This step might clinically correspond to a first-degree heart block, and be reversible. La/SSB antibodies can bind apoptotic cardiomyocytes and thus increase Ig deposition in the heart. The tissue damage could, as a second step, lead to spread of inflammation in genetically pre-disposed fetuses, progressing to fibrosis and calcification of the AV-node and subsequent complete congenital heart block. Early intrauterine treatment of an incomplete AV-block with fluorinated steroids has been shown to prevent progression of the heart block, making it clinically important to find specific markers to identify the high-risk pregnancies.
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Affiliation(s)
- Marie Wahren-Herlenius
- Rheumatology Unit, Department of Medicine, Karolinska Institutet, SE-171 76 Stockholm, Sweden.
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36
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Abstract
PURPOSE OF REVIEW The present review summarizes the prenatal and postnatal outcome of cardiac anomalies and sustained arrhythmias diagnosed during fetal life. RECENT FINDINGS The outcome of sustained fetal arrhythmias has improved with greater experience using Sotalol for atrial flutter, and digoxin and amiodarone for 1: 1 reciprocating tachycardia. The outcome of fetal conduction system disease secondary to maternal Sjögren's antibodies has noticeably improved with transplacental dexamethasone. The postnatal prognosis for atrioventricular block associated with left atrial isomerism, however, remains very bleak. Assessing the effect of prenatal diagnosis on the outcome of structural defects remains difficult because of the high number of extracardiac anomalies and chromosome defects in this group. Preoperative survival is improved, but postoperative mortality has not improved. One clear advantage of prenatal diagnosis is the selection of fetuses that may benefit from in-utero intervention to limit the progression of their disease or lessen its severity at birth. SUMMARY For the most part, postoperative mortality of structural cardiac defects is not significantly improved by prenatal diagnosis. In-utero management of tachyarrhythmias and conduction system disease has improved postnatal outcome, except for the fetus with atrioventricular block and left atrial isomerism.
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Affiliation(s)
- Bettina F Cuneo
- The Heart Institute for Children, Department of Pediatrics, Rush Medical College, and Hope Children's Hospital, 440 W. 95th Street, Oak Lawn, IL 60453, USA.
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Jayaprasad N, Johnson F, Venugopal K. Congenital complete heart block and maternal connective tissue disease. Int J Cardiol 2006; 112:153-8. [PMID: 16815568 DOI: 10.1016/j.ijcard.2005.11.115] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2005] [Revised: 11/12/2005] [Accepted: 11/27/2005] [Indexed: 11/24/2022]
Abstract
Congenital complete heart block can be isolated or can occur in association with other structural heart diseases. Isolated congenital complete heart block (CCHB) is due to transplacental transfer of autoantibodies from mothers with connective tissue disease. Congenital heart block is usually complete, but incomplete blocks, sinus bradycardia and QTc prolongation are also reported. Anti SS A and Anti SS B antibodies transferred from mothers have inflammatory and arrhythmogenic effects in the fetal conduction system. Cardiac manifestations reported include dilated cardiomyopathy, endocardial fibroelastosis and mitral insufficiency. Low ventricular rate, QT prolongation and arrhythmias on monitoring are high risk features. CCHB has a mortality of 30%, and 60% of infants require pacemaker therapy. Fetal echocardiography is useful in early diagnosis. Prophylactic steroid therapy is controversial. Beta adrenergic agonists were tried in mothers with fetuses having congenital heart block to increase fetal heart rate. Early pacemaker therapy is indicated in patients with symptomatic bradycardia and ventricular dysfunction. The indications for pacing in congenital heart block continue to evolve with advances in techniques and most of these children will ultimately require permanent pacemakers by adulthood.
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Affiliation(s)
- N Jayaprasad
- Department of Cardiology, Medical College, Calicut, Kerala State, 673008, India.
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Nii M, Hamilton RM, Fenwick L, Kingdom JCP, Roman KS, Jaeggi ET. Assessment of fetal atrioventricular time intervals by tissue Doppler and pulse Doppler echocardiography: normal values and correlation with fetal electrocardiography. Heart 2006; 92:1831-7. [PMID: 16775085 PMCID: PMC1861294 DOI: 10.1136/hrt.2006.093070] [Citation(s) in RCA: 74] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE To establish gestational age-specific reference values of normal fetal atrioventricular (AV) time interval by spectral tissue Doppler imaging (TDI) and pulse-wave Doppler (PD) methods, and to assess their correlation with signal-averaged fetal PR intervals (ECG). DESIGN Cohort study. SETTING Tertiary centre for fetal cardiology. PATIENTS AND MEASURES: 131 pregnant women between 14 and 42 weeks' gestation underwent 196 fetal echocardiograms and 158 fetal ECG studies. TDI-derived AV intervals were measured as the intervals from atrial contraction (Aa) to isovolumic contraction (IV) and from Aa to ventricular systole (Sa) at the right ventricular free wall. PD-derived AV intervals were measured from simultaneous left ventricular inflow/outflow (in/out) and superior vena cava/aorta (V/AO) recordings. RESULTS Measurements were possible by ECG in 61%, by TDI in 100%, by in/out in 100% and by V/AO in 97% of examinations. Aa-IV correlated significantly better with PR intervals (y = 0.67x + 38.29, R(2) = 0.15, p < 0.0001, mean bias 8.0 ms) than did in/out (R(2) = 0.10, p = 0.002, bias 18.7 ms) and V/AO (R(2) = 0.06, p = 0.02, bias 12.4 ms). Gestational age and AV intervals were positively correlated with all imaging modalities (R(2) = 0.19-0.31, p < 0.0001). CONCLUSION This study showed the feasibility of fetal AV interval measurements by TDI, and established gestational age-specific reference data. TDI-derived Aa-IV intervals track ECG PR intervals more closely than PD-derived AV intervals and thus should be used as the ultrasound method of choice in assessing fetal AV conduction.
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Affiliation(s)
- M Nii
- Division of Cardiology, The Hospital for Sick Children, Toronto, Ontario, Canada
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Costedoat-Chalumeau N, Amoura Z, Villain E, Cohen L, Fermont L, Le Thi Huong D, Vauthier D, Georgin-Lavialle S, Wechsler B, Dommergues M, Piette JC. Prise en charge obstétricale des patientes à risque de « lupus néonatal ». ACTA ACUST UNITED AC 2006; 35:146-56. [PMID: 16575360 DOI: 10.1016/s0368-2315(06)76388-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Fetuses and infants of women with anti-SSA/Ro and anti-SSB/La antibodies are at risk of neonatal lupus syndrome, featuring skin lesions, hematological and hepatic disorders, and congenital heart block (CHB) in the absence of severe cardiac malformation. The prevalence of CHB in newborns of anti-SSA/Ro positive women with known connective tissue disease is 1 to 2% and the risk of recurrence ranges from 10 to 17%. CHB is definitive and is associated with significant morbidity (pacemaker must be implanted in 2/3 of cases) and mortality (16 to 19%). Myocardial involvement may either be associated or appear subsequently. Other manifestations are discussed. For anti-SSA/Ro positive pregnant women, echocardiograms should be performed every 2 weeks from 16 to 24 weeks of gestation, and every week in case of past history of CHB. Electrocardiogram should be performed in the first days of life for all children to detect incomplete CHB. Therapy for CHB detected in utero is based on fluorinated steroids, especially betamethasone. Its efficiency is variable.
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MESH Headings
- Antibodies, Antinuclear/blood
- Antibodies, Antinuclear/immunology
- Autoimmune Diseases/complications
- Female
- Heart Defects, Congenital/immunology
- Hematologic Diseases/immunology
- Humans
- Infant, Newborn
- Infant, Newborn, Diseases/immunology
- Infant, Newborn, Diseases/mortality
- Infant, Newborn, Diseases/prevention & control
- Liver Diseases/immunology
- Lupus Erythematosus, Systemic/immunology
- Lupus Erythematosus, Systemic/mortality
- Lupus Erythematosus, Systemic/prevention & control
- Male
- Pregnancy
- Pregnancy Complications/immunology
- Skin Diseases/immunology
- Syndrome
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Affiliation(s)
- N Costedoat-Chalumeau
- Service de Médecine Interne, CHU Pitié-Salpêtrière, 47-83, boulevard de l'Hôpital, 75651 Paris Cedex 13.
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40
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Abstract
Life-threatening fetal arrhythmias are rare and warrant sophisticated specialty prenatal care, often provided by maternal-fetal medicine obstetricians, and pediatric and adult cardiologists. This medical field is in quick transition, and new methods of diagnosis and treatment of the fetus with arrhythmias are emerging. In this article, the mechanisms of arrhythmias are presented in light of recent progress in the new field of fetal electrophysiology. Treatments are reviewed with recommendations based on the small number of series of fetal tachycardia and fetal atrioventricular (AV) block drug treatment strategies published to date. Finally, a summary of areas of potential future research is provided.
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Affiliation(s)
- Janette F Strasburger
- Medical College of Wisconsin, and Children's Hospital of Wisconsin, 9000 West Wisconsin Avenue, MS 713, Milwaukee, WI 53201, USA.
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