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Bet BB, Eijsbroek FC, van Leeuwen E, Linskens IH, Knobbe I, Clur SA, Pajkrt E. Fetal premature atrial contractions: natural course, risk factors and adverse outcome. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2024; 63:650-657. [PMID: 38030959 DOI: 10.1002/uog.27546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 10/22/2023] [Accepted: 11/16/2023] [Indexed: 12/01/2023]
Abstract
OBJECTIVES Fetal premature atrial contractions (PAC) are usually benign but may be associated with congenital heart defect (CHD) and tachyarrhythmia, which in turn carry a risk of cardiac failure and fetal death. We aimed to explore the frequency of adverse outcome and to identify risk factors for tachyarrhythmia in pregnancies complicated by fetal PAC. METHODS This was a retrospective cohort study of fetuses diagnosed with PAC at two academic centers in Amsterdam, The Netherlands, between 2007 and 2022. Cases with a congenital anomaly and those with a prior diagnosis of CHD or other arrhythmias were excluded. M-mode and Doppler tracings were reanalyzed and the frequency of PAC was recorded. The incidence of the following adverse outcomes was examined: underlying CHD not identified at the 20-week fetal anomaly scan, tachyarrhythmia, other arrhythmia, administration of antiarrhythmic therapy and death. Risk factors for tachyarrhythmia were analyzed using odds ratios (OR). RESULTS In 24.1% of 1439 referred cases, PAC resolved before confirmation at the fetal medicine unit (FMU). Of the 939 included cases with confirmed PAC, the total incidence of adverse outcome was 6.8% (64/939). CHD was diagnosed in 14 (1.5% (95% CI, 0.9-2.5%)) cases, of which eight were diagnosed prenatally and six postnatally. Compared with baseline, the incidence of CHD was higher in the presence of fetal PAC (OR, 1.8 (95% CI, 1.0-3.3); P = 0.034). Tachyarrhythmia occurred prenatally and/or postnatally in 32 (3.4%) cases, of which eight (25.0%) showed signs of cardiac failure, and in 23 (71.9%) cases, antiarrhythmic therapy was required. No cases of tachyarrhythmia led to fetal or infant death. Risk factors for tachyarrhythmia were PAC with short runs of supraventricular tachycardia (OR, 98.7), blocked PAC (OR, 30.3), PAC in bigeminy (OR, 21.8), frequent PAC (one per 5-10 beats) (OR, 6.9), signs of cardiac failure (OR, 14.2) and the presence of a foramen ovale aneurysm (OR, 5.0). CONCLUSIONS PAC are generally benign and often resolve spontaneously. However, fetuses with an irregular heart rhythm should be referred for advanced ultrasonography, which should focus on classifying the type of PAC and risk of adverse outcome. When risk factors for tachyarrhythmia are identified, weekly fetal heart-rate monitoring is advised until resolution of the PAC. In the absence of risk factors, standard obstetric care may be sufficient, with additional instructions to report reduced fetal movements. Should tachyarrhythmia or cardiac failure develop, referral back to the FMU is indicated. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- B B Bet
- Department of Obstetrics and Gynecology, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Reproduction and Development, Amsterdam, The Netherlands
| | - F C Eijsbroek
- Department of Obstetrics and Gynecology, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
| | - E van Leeuwen
- Department of Obstetrics and Gynecology, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Reproduction and Development, Amsterdam, The Netherlands
| | - I H Linskens
- Amsterdam Reproduction and Development, Amsterdam, The Netherlands
- Department of Obstetrics and Gynecology, Amsterdam UMC location Vrije Universiteit, Amsterdam, The Netherlands
| | - I Knobbe
- Amsterdam Reproduction and Development, Amsterdam, The Netherlands
- Department of Pediatric Cardiology, Amsterdam UMC location Vrije Universiteit, Amsterdam, The Netherlands
| | - S A Clur
- Amsterdam Reproduction and Development, Amsterdam, The Netherlands
- Department of Pediatric Cardiology, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
- European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart - ERN GUARD-Heart
| | - E Pajkrt
- Department of Obstetrics and Gynecology, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Reproduction and Development, Amsterdam, The Netherlands
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2
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Yang X, Huang X, Wei C, Yu J, Yu X, Dong C, Chen J, Chen R, Wu X, Yu Z, Sun B, Wang J, Liu H, Han W, Sun B, Jiang Z, Ding J, Liu Z, Peng J, Ni D, Deng X, Liu L, Gou Z. An intelligent quantification system for fetal heart rhythm assessment: A multicenter prospective study. Heart Rhythm 2024; 21:600-609. [PMID: 38266752 DOI: 10.1016/j.hrthm.2024.01.024] [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: 10/25/2023] [Revised: 01/04/2024] [Accepted: 01/15/2024] [Indexed: 01/26/2024]
Abstract
BACKGROUND The motion relationship and time intervals of the pulsed-wave Doppler (PWD) spectrum are essential for diagnosing fetal arrhythmia. However, few technologies currently are available to automatically calculate fetal cardiac time intervals (CTIs). OBJECTIVE The purpose of this study was to develop a fetal heart rhythm intelligent quantification system (HR-IQS) for the automatic extraction of CTIs and establish the normal reference range for fetal CTIs. METHODS A total of 6498 PWD spectrums of 2630 fetuses over the junction between the left ventricular inflow and outflow tracts were recorded across 14 centers. E, A, and V waves were manually labeled by 3 experienced fetal cardiologists, with 17 CTIs extracted. Five-fold cross-validation was performed for training and testing of the deep learning model. Agreement between the manual and HR-IQS-based values was evaluated using the intraclass correlation coefficient and Spearman's rank correlation coefficient. The Jarque-Bera test was applied to evaluate the normality of CTIs' distributions, and the normal reference range of 17 CTIs was established with quantile regression. Arrhythmia subset was compared with the non-arrhythmia subset using the Mann-Whitney U test. RESULTS Significant positive correlation (P <.001) and moderate-to-excellent consistency (P <.001) between the manual and HR-IQS automated measurements of CTIs was found. The distribution of CTIs was non-normal (P <.001). The normal range (2.5th to 97.5th percentiles) was successfully established for the 17 CTIs. CONCLUSIONS Using our HR-IQS is feasible for the automated calculation of CTIs in practice and thus could provide a promising tool for the assessment of fetal rhythm and function.
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Affiliation(s)
- Xin Yang
- National-Regional Key Technology Engineering Laboratory for Medical Ultrasound, School of Biomedical Engineering, Health Science Center, Shenzhen University, Shenzhen, Guangdong, China
| | - Xiaoqiong Huang
- National-Regional Key Technology Engineering Laboratory for Medical Ultrasound, School of Biomedical Engineering, Health Science Center, Shenzhen University, Shenzhen, Guangdong, China
| | - Chenchen Wei
- Center for Cardiovascular Disease, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou, Jiangsu, China
| | - Junxuan Yu
- National-Regional Key Technology Engineering Laboratory for Medical Ultrasound, School of Biomedical Engineering, Health Science Center, Shenzhen University, Shenzhen, Guangdong, China; Shenzhen RayShape Medical Technology Co., Ltd, Shenzhen, Guangdong, China
| | - Xuejuan Yu
- Department of Ultrasonography, Suzhou Xiangcheng People's Hospital, Suzhou, Jiangsu, China
| | - Caixia Dong
- Department of Ultrasonography, Wulin Hospital, Hangzhou, Zhejiang, China
| | - Ju Chen
- Department of Ultrasonography, Taicang First People's Hospital, Suzhou, Jiangsu, China
| | - Ruifeng Chen
- Department of Ultrasound Diagnosis, The Affiliated Changsha Central Hospital, Hengyang Medical School, University of South China, Changsha, Hunan, China
| | - Xiafang Wu
- Department of Ultrasonography, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Linhai, Zhejiang, China
| | - Zhuan Yu
- Department of Ultrasonography, The Affiliated Hospital of Jiangsu University, Zhenjiang, Jiangsu, China
| | - Baojuan Sun
- Department of Ultrasonography, Huai'an Maternal and Child Health Hospital, Huai'an, Jiangsu, China
| | - Junli Wang
- Department of Ultrasonography, Wuhu No.2 People's Hospital, Wuhu, Anhui, China
| | - Hongmei Liu
- Department of Ultrasonography, Panzhou Emerging Hospital, Panzhou, Guizhou, China
| | - Wen Han
- Department of Ultrasonography, Suzhou Gaoxin District People's Hospital, Suzhou, Jiangsu, China
| | - Biyun Sun
- Department of Ultrasonography, The Affiliated Yijishan Hospital of Wannan Medical University, Wuhu, Anhui, China
| | - Zhiyong Jiang
- Department of Ultrasonography, The Huaren Hospital, Wuhu, Zhejiang, China
| | - Jie Ding
- Department of Ultrasonography, The Affiliated Suzhou Hospital of Nanjing University, Suzhou, Jiangsu, China
| | - Zhe Liu
- National-Regional Key Technology Engineering Laboratory for Medical Ultrasound, School of Biomedical Engineering, Health Science Center, Shenzhen University, Shenzhen, Guangdong, China; Shenzhen RayShape Medical Technology Co., Ltd, Shenzhen, Guangdong, China
| | - Jin Peng
- National-Regional Key Technology Engineering Laboratory for Medical Ultrasound, School of Biomedical Engineering, Health Science Center, Shenzhen University, Shenzhen, Guangdong, China; Shenzhen RayShape Medical Technology Co., Ltd, Shenzhen, Guangdong, China
| | - Dong Ni
- National-Regional Key Technology Engineering Laboratory for Medical Ultrasound, School of Biomedical Engineering, Health Science Center, Shenzhen University, Shenzhen, Guangdong, China
| | - Xuedong Deng
- Center for Medical Ultrasound, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou, Jiangsu, China
| | - Lian Liu
- National-Regional Key Technology Engineering Laboratory for Medical Ultrasound, School of Biomedical Engineering, Health Science Center, Shenzhen University, Shenzhen, Guangdong, China; Shenzhen RayShape Medical Technology Co., Ltd, Shenzhen, Guangdong, China.
| | - Zhongshan Gou
- Center for Cardiovascular Disease, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou, Jiangsu, China.
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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: 47] [Impact Index Per Article: 23.5] [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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Carvalho JS, Axt-Fliedner R, Chaoui R, Copel JA, Cuneo BF, Goff D, Gordin Kopylov L, Hecher K, Lee W, Moon-Grady AJ, Mousa HA, Munoz H, Paladini D, Prefumo F, Quarello E, Rychik J, Tutschek B, Wiechec M, Yagel S. ISUOG Practice Guidelines (updated): fetal cardiac screening. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2023; 61:788-803. [PMID: 37267096 DOI: 10.1002/uog.26224] [Citation(s) in RCA: 72] [Impact Index Per Article: 36.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 04/05/2023] [Indexed: 06/04/2023]
Affiliation(s)
- J S Carvalho
- Royal Brompton Hospital, Guy's & St Thomas' NHS Foundation Trust; and Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust and Cardiovascular Clinical Academic Group, Molecular and Clinical Sciences Research Institute, St George's, University of London, London, UK
| | - R Axt-Fliedner
- Division of Prenatal Medicine & Fetal Therapy, Department of Obstetrics & Gynecology, Justus-Liebig-University Giessen, University Hospital Giessen & Marburg, Giessen, Germany
| | - R Chaoui
- Center of Prenatal Diagnosis and Human Genetics, Berlin, Germany
| | - J A Copel
- Departments of Obstetrics, Gynecology & Reproductive Sciences, and Pediatrics, Yale School of Medicine, New Haven, CT, USA
| | - B F Cuneo
- Children's Hospital Colorado, The Heart Institute, Aurora, CO, USA
| | - D Goff
- Pediatrix Cardiology of Houston and Loma Linda University School of Medicine, Houston, TX, USA
| | - L Gordin Kopylov
- Obstetrical Unit, Shamir Medical Center (formerly Assaf Harofeh Medical Center), Zerifin, Israel; and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - K Hecher
- Department of Obstetrics and Fetal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - W Lee
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA
| | - A J Moon-Grady
- Clinical Pediatrics, UC San Francisco, San Francisco, CA, USA
| | - H A Mousa
- Fetal Medicine Unit, University of Leicester, Leicester, UK
| | - H Munoz
- Obstetrics and Gynecology, Universidad de Chile and Clinica Las Condes, Santiago, Chile
| | - D Paladini
- Fetal Medicine and Surgery Unit, IRCCS Istituto G. Gaslini, Genoa, Italy
| | - F Prefumo
- Obstetrics and Gynecology Unit, IRCCS Istituto G. Gaslini, Genoa, Italy
| | - E Quarello
- Image 2 Center, Obstetrics and Gynecologic Department, St Joseph Hospital, Marseille, France
| | - J Rychik
- Fetal Heart Program at Children's Hospital of Philadelphia, and Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA, USA
| | - B Tutschek
- Pränatal Zürich, Zürich, Switzerland; and Medical Faculty, Heinrich Heine University, Düsseldorf, Germany
| | - M Wiechec
- Department of Gynecology and Obstetrics, Jagiellonian University in Krakow, Krakow, Poland
| | - S Yagel
- Department of Obstetrics and Gynecology, Hadassah Medical Center, Mt. Scopus and the Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
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5
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Bet BB, De Vries JM, Limpens J, Van Wely M, Van Leeuwen E, Clur SA, Pajkrt E. Implications of fetal premature atrial contractions: systematic review. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2022; 60:721-730. [PMID: 35763619 PMCID: PMC10107702 DOI: 10.1002/uog.26017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 06/02/2022] [Accepted: 06/10/2022] [Indexed: 06/04/2023]
Abstract
OBJECTIVE Fetal heart-rate irregularities occur in 1-2% of pregnancies and are usually caused by premature atrial contractions (PAC). Although PAC are considered benign, they may be associated with cardiac defects and tachyarrhythmia. We aimed to determine the incidence of congenital heart defects (CHDs) and complications in fetuses with PAC. METHODS This was a systematic review and meta-analysis conducted in accordance with the PRISMA statement for reporting items for systematic reviews and meta-analyses. MEDLINE and EMBASE were searched from 1990 to June 2021 to identify studies on fetuses with PAC. The primary outcome was CHD; secondary outcomes were complications using the endpoints supraventricular tachyarrhythmia (SVT), cardiac failure and intrauterine fetal demise. Meta-analysis of proportions was performed, subdivided into high-risk and low-risk populations based on reason for referral. Pooled incidences with 95% CIs were calculated. RESULTS Of 2443 unique articles identified, 19 cohort studies including 2260 fetuses were included. The pooled incidence of CHD in fetuses with PAC was 2.8% (95% CI, 1.5-4.1%), when 0.6% is the incidence expected in the general population. The pooled incidence of CHD was 7.2% (95% CI, 3.5-10.9%) in the high-risk population and 0.9% (95% CI, 0.0-2.0%) in the low-risk population. SVT occurred in 1.4% (95% CI, 0.6-3.4%) of fetuses diagnosed with PAC. Cardiac failure was described in 16 fetuses (1.4% (95% CI, 0.5-3.5%)), of which eight were CHD-related. Intrauterine fetal demise occurred in four fetuses (0.9% (95% CI, 0.5-1.7%)) and was related to CHD in two cases. CONCLUSIONS Our findings suggest that the risk of CHD in fetuses with PAC is 4-5 times higher than that in the general population. CHD was present more frequently in the high-risk population. Consequently, an advanced ultrasound examination to diagnose PAC correctly and exclude CHD is recommended. Complications of PAC are rare but can result in fetal demise, thus weekly fetal heart-rate monitoring remains advisable to enable early detection of SVT and to prevent cardiac failure. © 2022 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- B. B. Bet
- Department of Obstetrics and Gynaecology, Amsterdam UMC locationUniversity of AmsterdamAmsterdamThe Netherlands
- Amsterdam Reproduction and DevelopmentAmsterdamThe Netherlands
| | - J. M. De Vries
- Department of Obstetrics and Gynaecology, Amsterdam UMC locationUniversity of AmsterdamAmsterdamThe Netherlands
- Amsterdam Reproduction and DevelopmentAmsterdamThe Netherlands
| | - J. Limpens
- Medical Library, Amsterdam UMC locationUniversity of AmsterdamAmsterdamThe Netherlands
| | - M. Van Wely
- Amsterdam Reproduction and DevelopmentAmsterdamThe Netherlands
- Centre for Reproductive Medicine, Amsterdam UMC locationUniversity of AmsterdamAmsterdamThe Netherlands
| | - E. Van Leeuwen
- Department of Obstetrics and Gynaecology, Amsterdam UMC locationUniversity of AmsterdamAmsterdamThe Netherlands
- Amsterdam Reproduction and DevelopmentAmsterdamThe Netherlands
| | - S. A. Clur
- Amsterdam Reproduction and DevelopmentAmsterdamThe Netherlands
- Department of Pediatric Cardiology, Amsterdam UMC locationUniversity of AmsterdamAmsterdamThe Netherlands
| | - E. Pajkrt
- Department of Obstetrics and Gynaecology, Amsterdam UMC locationUniversity of AmsterdamAmsterdamThe Netherlands
- Amsterdam Reproduction and DevelopmentAmsterdamThe Netherlands
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6
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Carvalho JS. Risk stratification for irregular fetal heart rhythm: practical approach to management. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2022; 60:717-720. [PMID: 36454638 DOI: 10.1002/uog.26109] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 10/27/2022] [Indexed: 06/17/2023]
Affiliation(s)
- J S Carvalho
- Brompton Centre for Fetal Cardiology, Royal Brompton Hospital, Guy's and St Thomas's NHS Foundation Trust, London, UK
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, London, UK
- Cardiovascular Clinical Academic Group, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
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7
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Nigam P, Weinberger S, Srivastava S, Lorber R. The evolution of fetal echocardiography before and during COVID-19. PROGRESS IN PEDIATRIC CARDIOLOGY 2020; 58:101259. [PMID: 32837145 PMCID: PMC7306716 DOI: 10.1016/j.ppedcard.2020.101259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 06/15/2020] [Accepted: 06/16/2020] [Indexed: 11/27/2022]
Abstract
The World Health Organization declared the novel coronavirus, or COVID-19, a pandemic in March 2020. Given the severity of COVID-19, appropriate use criteria have been implemented for fetal echocardiography. Screening low risk pregnancies for critical congenital heart disease has typically been a shared responsibility by pediatric cardiologists, obstetricians, and maternal fetal medicine (MFM). Currently, many of the fetal echocardiograms for low risk pregnancies for critical congenital heart disease have been deferred or cancelled with the emphasis on suspected abnormalities by MFMs and obstetricians. In this review, we discuss the literature that has been the basis of screening of low risk pregnancies by pediatric cardiologists. A new approach to more widespread usage of fetal tele-echocardiography may play a large part during COVID-19 and may continue after the pandemic. Appropriate use criteria for fetal echocardiography have been implemented during the COVID-19 pandemic. Pediatric cardiologists have deferred fetal echo for low risk pregnancies, emphasizing those with suspected abnormalities. Current fetal echo guidelines highlight maternal, familial, and fetal risk factors, and the associated incidence of CHD. Fetal tele-echocardiography and telehealth consultation may enhance the ability to provide care during and beyond COVID-19.
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Affiliation(s)
- Priya Nigam
- Nemours Cardiac Center, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, United States of America
| | - Sharon Weinberger
- Nemours Cardiac Center, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, United States of America
| | - Shubhika Srivastava
- Nemours Cardiac Center, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, United States of America
| | - Richard Lorber
- Nemours Cardiac Center, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, United States of America
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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: 0.8] [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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9
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Abstract
Fetal arrhythmias are common, and they may resolve spontaneously in majority of the cases. Sustained fetal arrhythmias associated with major structural heart disorders, hydrops fetalis, and fetal heart failure warrant intrauterine pharmaceutical conversion of heart rhythm or early pacemaker implant in order to avoid fetal demise. Fetal atrial flutter (AF) and supraventricular tachycardia (SVT) resemble in terms of the effects of intrauterine therapies. Digoxin is more suitable for rhythm conversion of fetal AF and SVT in fetuses free of hydrops fetalis, while sotalol shows better effects for those with hydrops fetalis. In fetal cases of atrioventricular blocks, an etiological treatment for the maternal antibody exposure by steroids could be an alternative remedy. In this article, the clinical diagnosis and treatment of fetal arrhythmias are presented, and advantages and disadvantages of antiarrhythmic agents for fetal arrhythmias are compared.
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Affiliation(s)
- Shi-Min Yuan
- Department of Cardiothoracic Surgery, The First Hospital of Putian, Teaching Hospital, Fujian Medical University, Putian, Fujian Province, China
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10
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Abstract
Fetal cardiac abnormalities are some of the commonest congenital disorders seen in prenatal life. They can be anatomical or functional and can develop de novo or as a consequence of either maternal or fetal disease. Untreated, morbidity and mortality rates are high for hypoplastic left heart disorders and for some fetal tachy and bradyarrhythmias. Optimum management strategies are often not clear because of the lack of knowledge about the precise natural history of some of these conditions. Prenatal therapy ranges from invasive fetal cardiac intervention to maternal administration of drugs for transplacental transfer to the fetus. This comprehensive review covers many fetal cardiac disorders and various prenatal therapeutic options that are available.
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Affiliation(s)
- Sailesh Kumar
- a Mater Research Institute / University of Queensland , Brisbane , Australia.,b Mater Centre for Maternal Fetal Medicine , Mater Mothers' Hospital , Brisbane , Australia.,c Faculty of Medicine , the University of Queensland , Brisbane , Australia
| | - Jade Lodge
- b Mater Centre for Maternal Fetal Medicine , Mater Mothers' Hospital , Brisbane , Australia
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11
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Gordon GH, Thomas J, Trampe B, Iruretagoyena JI. Foetal premature atrial contractions during the second and third trimester are not associated with foetal breathing. J OBSTET GYNAECOL 2017; 37:742-745. [PMID: 28502200 DOI: 10.1080/01443615.2017.1306693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Foetal premature atrial contractions (PACs) are the most commonly encountered and also the most benign foetal arrhythmia. A retrospective cohort study was conducted with the objective to assess whether the presence of foetal breathing was associated with the presence of foetal PACs. A further objective was to evaluate whether this association would affect neonatal outcomes at a high volume referral centre. The diagnosis of PACs was based on the observation of a premature atrial contraction followed by a ventricular contraction on ultrasound myocardial M-mode. Trained ultrasonographers documented in the ultrasound report whether or not foetal breathing was present with PACs. 91 exams were identified, which included 75 individual pregnancies. Six women were identified who had foetal PACs associated with foetal breathing on ultrasound evaluation. Foetuses with PACs did not differ between the associated breathing and no-associated breathing groups with respect to maternal age, parity, mode of delivery, gestational age at delivery or birthweight. This study reaffirms that isolated PACs are a benign finding. Furthermore, it adds to the pool of literature on foetal PACs in that it is not associated with abnormal pregnancy outcomes regardless of the presence or absence of foetal breathing. Impact statement • What is already known on this subjectSince foetal breathing can effect Doppler ultrasound assessment of the foetal cardiovascular system, it is reasonable to consider that it may impact conditions such as foetal arrhythmias. • What the results of this study addFoetal breathing does not impact on the presence of premature atrial contractions. • What the implications are of these findings for clinical practice and/or further researchFoetal breathing is not associated with the finding of foetal premature atrial contractions.
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Affiliation(s)
- Geoffrey H Gordon
- a Department of OB/GYN, Division Maternal-Fetal Medicine , University of Wisconsin School of Medicine and Public Health
| | - Joelle Thomas
- b Department of Obstetrics & Gynecology , University of Wisconsin School of Medicine and Public Health , Madison , WI , USA
| | - Barbara Trampe
- b Department of Obstetrics & Gynecology , University of Wisconsin School of Medicine and Public Health , Madison , WI , USA
| | - J I Iruretagoyena
- a Department of OB/GYN, Division Maternal-Fetal Medicine , University of Wisconsin School of Medicine and Public Health
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Sonesson SE, Acharya G. Hemodynamics in fetal arrhythmia. Acta Obstet Gynecol Scand 2015; 95:697-709. [PMID: 26660845 DOI: 10.1111/aogs.12837] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2015] [Accepted: 12/03/2015] [Indexed: 10/22/2022]
Abstract
Fetal arrhythmias are among the few conditions that can be managed in utero. However, accurate diagnosis is essential for appropriate management. Ultrasound-based imaging methods can be used to study fetal heart structure and function noninvasively and help to understand fetal cardiovascular pathophysiology, and they remain the mainstay of evaluating fetuses with arrhythmias in clinical settings. Hemodynamic evaluation using Doppler echocardiography allows the elucidation of the electrophysiological mechanism and helps to make an accurate diagnosis. It can also be used as a tool to understand fetal cardiac pathophysiology, for assessing fetal condition and monitoring the effect of antiarrhythmic treatment. This narrative review describes Doppler techniques that are useful for evaluating fetal cardiac rhythms to refine diagnosis and provides an overview of hemodynamic changes observed in different types of fetal arrhythmia.
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Affiliation(s)
- Sven-Erik Sonesson
- Pediatric Cardiology Unit, Department of Women's and Children's Health, Karolinska Institute, Stockholm, Sweden
| | - Ganesh Acharya
- Women's Health and Perinatology Research Group, Department of Clinical Medicine, Faculty of Health Sciences, UiT - The Arctic University of Norway, Tromsø, Norway.,Department of Obstetrics and Gynecology, University Hospital of Northern Norway, Tromsø, Norway.,Department of Clinical Sciences, Intervention and Technology, Karolinska Institute, Stockholm, Sweden
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Sedmera D, Kockova R, Vostarek F, Raddatz E. Arrhythmias in the developing heart. Acta Physiol (Oxf) 2015; 213:303-20. [PMID: 25363044 DOI: 10.1111/apha.12418] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2014] [Revised: 09/08/2014] [Accepted: 10/23/2014] [Indexed: 01/10/2023]
Abstract
Prevalence of cardiac arrhythmias increases gradually with age; however, specific rhythm disturbances can appear even prior to birth and markedly affect foetal development. Relatively little is known about these disorders, chiefly because of their relative rarity and difficulty in diagnosis. In this review, we cover the most common forms found in human pathology, specifically congenital heart block, pre-excitation, extrasystoles and long QT syndrome. In addition, we cover pertinent literature data from prenatal animal models, providing a glimpse into pathogenesis of arrhythmias and possible strategies for treatment.
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Affiliation(s)
- D. Sedmera
- Institute of Anatomy; First Faculty of Medicine; Charles University; Prague Czech Republic
- Institute of Physiology; Academy of Sciences of the Czech Republic; Prague Czech Republic
| | - R. Kockova
- Institute of Physiology; Academy of Sciences of the Czech Republic; Prague Czech Republic
- Department of Cardiology; Institute of Clinical and Experimental Medicine; Prague Czech Republic
| | - F. Vostarek
- Institute of Physiology; Academy of Sciences of the Czech Republic; Prague Czech Republic
| | - E. Raddatz
- Department of Physiology; Faculty of Biology and Medicine; University of Lausanne; Lausanne Switzerland
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Carvalho JS. Primary bradycardia: keys and pitfalls in diagnosis. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2014; 44:125-130. [PMID: 25088508 DOI: 10.1002/uog.13451] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Affiliation(s)
- J S Carvalho
- Brompton Centre for Fetal Cardiology, Royal Brompton Hospital, Sydney Street, London, SW3 6NP, UK; Fetal Medicine Unit, St George's Hospital, St George's University of London, London, SW17 0QT, UK.
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Donofrio MT, Moon-Grady AJ, Hornberger LK, Copel JA, Sklansky MS, Abuhamad A, Cuneo BF, Huhta JC, Jonas RA, Krishnan A, Lacey S, Lee W, Michelfelder EC, Rempel GR, Silverman NH, Spray TL, Strasburger JF, Tworetzky W, Rychik J. Diagnosis and treatment of fetal cardiac disease: a scientific statement from the American Heart Association. Circulation 2014; 129:2183-242. [PMID: 24763516 DOI: 10.1161/01.cir.0000437597.44550.5d] [Citation(s) in RCA: 798] [Impact Index Per Article: 72.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND The goal of this statement is to review available literature and to put forth a scientific statement on the current practice of fetal cardiac medicine, including the diagnosis and management of fetal cardiovascular disease. METHODS AND RESULTS A writing group appointed by the American Heart Association reviewed the available literature pertaining to topics relevant to fetal cardiac medicine, including the diagnosis of congenital heart disease and arrhythmias, assessment of cardiac function and the cardiovascular system, and available treatment options. The American College of Cardiology/American Heart Association classification of recommendations and level of evidence for practice guidelines were applied to the current practice of fetal cardiac medicine. Recommendations relating to the specifics of fetal diagnosis, including the timing of referral for study, indications for referral, and experience suggested for performance and interpretation of studies, are presented. The components of a fetal echocardiogram are described in detail, including descriptions of the assessment of cardiac anatomy, cardiac function, and rhythm. Complementary modalities for fetal cardiac assessment are reviewed, including the use of advanced ultrasound techniques, fetal magnetic resonance imaging, and fetal magnetocardiography and electrocardiography for rhythm assessment. Models for parental counseling and a discussion of parental stress and depression assessments are reviewed. Available fetal therapies, including medical management for arrhythmias or heart failure and closed or open intervention for diseases affecting the cardiovascular system such as twin-twin transfusion syndrome, lung masses, and vascular tumors, are highlighted. Catheter-based intervention strategies to prevent the progression of disease in utero are also discussed. Recommendations for delivery planning strategies for fetuses with congenital heart disease including models based on classification of disease severity and delivery room treatment will be highlighted. Outcome assessment is reviewed to show the benefit of prenatal diagnosis and management as they affect outcome for babies with congenital heart disease. CONCLUSIONS Fetal cardiac medicine has evolved considerably over the past 2 decades, predominantly in response to advances in imaging technology and innovations in therapies. The diagnosis of cardiac disease in the fetus is mostly made with ultrasound; however, new technologies, including 3- and 4-dimensional echocardiography, magnetic resonance imaging, and fetal electrocardiography and magnetocardiography, are available. Medical and interventional treatments for select diseases and strategies for delivery room care enable stabilization of high-risk fetuses and contribute to improved outcomes. This statement highlights what is currently known and recommended on the basis of evidence and experience in the rapidly advancing and highly specialized field of fetal cardiac care.
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Carvalho JS, Allan LD, Chaoui R, Copel JA, DeVore GR, Hecher K, Lee W, Munoz H, Paladini D, Tutschek B, Yagel S. ISUOG Practice Guidelines (updated): sonographic screening examination of the fetal heart. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2013; 41:348-359. [PMID: 23460196 DOI: 10.1002/uog.12403] [Citation(s) in RCA: 469] [Impact Index Per Article: 39.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
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Arythmies cardiaques fœtales : diagnostic et prise en charge. ARCHIVES OF CARDIOVASCULAR DISEASES SUPPLEMENTS 2012. [DOI: 10.1016/s1878-6480(12)70824-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Blocked atrial bi/trigeminy in utero evolving in supraventricular tachycardia after birth. Case Rep Obstet Gynecol 2012; 2012:406497. [PMID: 22844624 PMCID: PMC3403126 DOI: 10.1155/2012/406497] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2012] [Accepted: 06/20/2012] [Indexed: 12/02/2022] Open
Abstract
Transient episodes of fetal bradycardia (heart rate less than 110 bpm) are usually benign and typically result from increased vagal stimulation in the fetus. Causes of sustained fetal bradycardia include sinus bradycardia, blocked atrial bigeminy/trigeminy, high-degree atrioventricular block, and long QT syndrome. We present the case of a 34-year-old Caucasian patient referred to our department for “blocked atrial bigeminy with pseudobradycardia” detected elsewhere at 33 weeks of gestation. A fetal echocardiography showed during all the examination a blocked atrial trigeminy with a mean fetal heart rate of 100 bpm. After birth three subsequent ECGs until day 3 showed no evidence of atrial extrasystoles, confirming the well-known frequent regression of this kind of fetal benign arrhythmia, but on day 11 recurrence of supraventricular trigeminy and development of episodes of paroxystic supraventricular tachycardia were observed. On the basis of this observation, we recommend that fetuses with complex atrial ectopic beats should be closely monitored before and after birth for evidence of new arrhythmias.
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Carvalho JS. Best practice guidelines: fetal cardiology. Early Hum Dev 2012; 88:259-60. [PMID: 22445210 DOI: 10.1016/j.earlhumdev.2012.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2012] [Accepted: 02/22/2012] [Indexed: 10/28/2022]
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Femitha P, Joy R, Bharathi B, Adhisivam B, Gane BD, Vishnu Bhat B, Balachander J. Atrial flutter in a newborn. Interv Med Appl Sci 2011. [DOI: 10.1556/imas.3.2011.2.7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
Fetal and neonatal arrhythmias present as diagnostic and therapeutic challenges to obstetricians and neonatologists. We present a case of antenatally detected atrial flutter in which the infant presented with congestive cardiac failure at birth and a short review of tachyarrhythmias in the perinatal period.
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Affiliation(s)
- P. Femitha
- 1 Department of Pediatrics, JIPMER, Puducherry, India
| | - Rojo Joy
- 1 Department of Pediatrics, JIPMER, Puducherry, India
| | - B. Bharathi
- 1 Department of Pediatrics, JIPMER, Puducherry, India
| | - B. Adhisivam
- 1 Department of Pediatrics, JIPMER, Puducherry, India
| | - B. D. Gane
- 1 Department of Pediatrics, JIPMER, Puducherry, India
| | - B. Vishnu Bhat
- 1 Department of Pediatrics, JIPMER, Puducherry, India
- 3 Department of Pediatrics, JIPMER, Puducherry, 605006, India
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Saemundsson Y, Johansson C, Wenling S, Gudmundsson S. Hepatic venous Doppler in the evaluation of fetal extrasystoles. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2011; 37:179-183. [PMID: 20503235 DOI: 10.1002/uog.7684] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 04/29/2010] [Indexed: 05/29/2023]
Abstract
OBJECTIVES To evaluate the use of fetal hepatic venous Doppler in the diagnosis of fetal extrasystoles, to estimate the prevalence and persistence of extra atrial and ventricular heart beats throughout pregnancy, labor and delivery, and to estimate the frequency of coexisting congenital heart disease. METHODS This was a retrospective study of 256 singleton pregnancies attending our hospital as outpatients due to fetal extrasystoles. Hepatic venous Doppler and detailed fetal echocardiography were performed. Information on fetal heart rate patterns during labor and neonatal conditions was collected. Congenital heart malformations and the frequency and persistence of fetal extrasystoles were noted. RESULTS On venous Doppler examination, 228 (89%) of the fetuses showed signs of supraventricular extrasystoles (SVES) and 28 (11%) had ventricular extrasystoles (VES). One fetus with SVES developed atrial flutter during pregnancy and another case developed supraventricular tachycardia postnatally. SVES persisted until labor and delivery in 28 (12.3%) fetuses and VES persisted in six (21.4%). In 31 of 34 (91.2%) fetuses with extrasystoles during labor and delivery, the conduction pattern normalized within 3 days. Five neonates were referred for evaluation by a pediatric cardiologist. Two cases had congenital heart disease. Extrasystoles persisted until labor and delivery more frequently in male fetuses (P < 0.0001). CONCLUSION Hepatic venous Doppler can differentiate between SVES and VES. Despite being the more uncommon of the two, VES persists throughout pregnancy more often. Our results strongly support the suggestion that extrasystoles are a benign finding, with very few cases developing tachycardia or having a coexisting congenital heart malformation.
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Affiliation(s)
- Y Saemundsson
- Department of Obstetrics and Gynecology, Malmö University Hospital, Malmö, Sweden
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Abstract
The human fetal heart develops arrhythmias and conduction disturbances in response to ischemia, inflammation, electrolyte disturbances, altered load states, structural defects, inherited genetic conditions, and many other causes. Yet sinus rhythm is present without altered rate or rhythm in some of the most serious electrophysiological diseases, which makes detection of diseases of the fetal conduction system challenging in the absence of magnetocardiographic or electrocardiographic recording techniques. Life-threatening changes in QRS or QT intervals can be completely unrecognized if heart rate is the only feature to be altered. For many fetal arrhythmias, echocardiography alone can assess important clinical parameters for diagnosis. Appropriate treatment of the fetus requires awareness of arrhythmia characteristics, mechanisms, and potential associations. Criteria to define fetal bradycardia specific to gestational age are now available and may allow detection of ion channelopathies, which are associated with fetal and neonatal bradycardia. Ectopic beats, once thought to be entirely benign, are now recognized to have important pathologic associations. Fetal tachyarrhythmias can now be defined precisely for mechanism-specific therapy and for subsequent monitoring of response. This article reviews the current and future diagnostic techniques and pharmacologic treatments for fetal arrhythmia.
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Starikov RS, Bsat FA, Knee AB, Tsirka AE, Paris Y, Markenson GR. Utility of fetal echocardiography after normal cardiac imaging findings on detailed fetal anatomic ultrasonography. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2009; 28:603-608. [PMID: 19389899 DOI: 10.7863/jum.2009.28.5.603] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
OBJECTIVE The purpose of this study was to assess the utility of fetal echocardiography (FE) after normal fetal cardiac imaging findings during detailed fetal anatomic ultrasonography (FAU). METHODS We conducted a retrospective cohort review of obstetric ultrasonographic studies from November 2001 through July 2005. We identified women with a singleton gestation with increased risk for congenital heart disease who received FAU performed by a maternal-fetal medicine specialist at 16 to 20 weeks' gestation with subsequent FE. These records were compared with newborn outcomes. RESULTS Of 789 pregnancies that had FAU and FE, 481 had satisfactory cardiac imaging. Of those, only 1 fetus had abnormal FE findings. After delivery, 4 of the 480 neonates with normal FAU and FE findings had a diagnosis of a heart defect. CONCLUSIONS Fetal echocardiography does not substantially increase the detection rate of major cardiac anomalies after normal findings on detailed FAU performed by a maternal-fetal medicine specialist.
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Affiliation(s)
- Roman S Starikov
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Baystate Medical Center, Tufts University School of Medicine, Springfield, MA 01199-0001, USA.
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Karadayi K, Managuli R, Kim Y. Three-Dimensional Ultrasound: From Acquisition to Visualization and From Algorithms to Systems. IEEE Rev Biomed Eng 2009. [DOI: 10.1109/rbme.2009.2034132] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Abstract
Fetal cardiac dysrhythmias are potentially life-threatening conditions. However, intermittent extrasystoles, which are frequently encountered in clinical practice, do not require treatment. Sustained forms of brady- and tachyarrhythmias might require fetal intervention. Fetal echocardiography is essential not only to establish the diagnosis but also to monitor fetal response to therapy. In the last decade, improvements in ultrasound methodology and new diagnostic tools have contributed to better diagnostic accuracy and to a greater understanding of the electrophysiological mechanisms involved in fetal cardiac dysrhythmias. The most common form of supraventricular tachycardia - that caused by an atrioventricular re-entry circuit - should be differentiated from other forms of tachyarrhythmias, such as atrial flutter and atrial ectopic tachycardia. Ventricular tachycardia is rare in the fetus. Sustained tachycardias, intermittent or not, might be associated with the development of congestive heart failure and hydrops fetalis. Prompt treatment with either anti-arrhythmic drugs or delivery must be considered. Persistent fetal bradycardias associated with complete heart block are also potentially dangerous, whereas bradyarrhythmia due to blocked ectopy is well tolerated in pregnancy. Heart block can be associated with maternal anti-Ro/La autoantibodies or develop in fetuses with left atrial isomerism or with malformations involving the atrioventricular junction. The treatment of fetuses with immune-mediated heart block remains debatable. The use of antenatal steroid therapy is not widely accepted and there is concern over the risks and benefits of its use in the fetus. Direct fetal cardiac pacing has rarely been attempted.
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Brucks U, Duval J, Roberson D, Cuneo BF, Husayni T. Fetal Bifid Left Ventricular Diverticulum Presenting With Ventricular Ectopy. JOURNAL OF DIAGNOSTIC MEDICAL SONOGRAPHY 2008. [DOI: 10.1177/8756479308317003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
We report the diagnosis and outcome of a fetus with an unusual left ventricular wall defect. A 34-week fetus presented for echocardiographic evaluation because of an irregular cardiac rhythm. Fetal echocardiography revealed frequent ventricular ectopy and an “accessory” ventricular chamber diagnosed as a left ventricular diverticulum (LVD). The ectopy resolved in utero but recurred after delivery. Angiography revealed a “bifid” LVD. Inderal therapy suppressed the ventricular ectopy. The association between ventricular ectopy and LVD is unusual, but the prognosis of LVD even with arrhythmia is excellent.
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Affiliation(s)
| | - Jude Duval
- Heart Institute for Children, Oak Lawn, IL
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Cardiac screening examination of the fetus: guidelines for performing the 'basic' and 'extended basic' cardiac scan. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2006; 27:107-113. [PMID: 16374757 DOI: 10.1002/uog.2677] [Citation(s) in RCA: 112] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
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Vergani P, Mariani E, Ciriello E, Locatelli A, Strobelt N, Galli M, Ghidini A. Fetal arrhythmias: natural history and management. ULTRASOUND IN MEDICINE & BIOLOGY 2005; 31:1-6. [PMID: 15653224 DOI: 10.1016/j.ultrasmedbio.2004.10.001] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/29/2004] [Revised: 09/28/2004] [Accepted: 10/05/2004] [Indexed: 05/24/2023]
Abstract
The aim was to delineate the significance and natural history of fetal arrhythmias and provide information about their management. A cohort of 114 infants with fetal arrhythmias detected during prenatal ultrasound (US) screening were studied. All subjects underwent echocardiography and were treated as clinically indicated. Postnatal outcome was obtained in 100% of infants until 1 year of age. The incidence of fetal arrhythmias was 0.3%. Among the 87 fetuses with atrial extrasystoles, 2.3% developed supraventricular tachycardia (SVT) in utero. Of the 10 SVT cases, only five required antiarrhythmic therapy in utero with digoxin and propafenone, which successfully restored sinus rhythm in 100% of fetuses, both nonhydropic and hydropic. Sinus bradycardia was associated with structural anomalies in 5 of 6 patients and only 2 of 4 fetuses with atrioventricular block survived. It is concluded that prognosis is good for most fetal tachyarrhythmias, whereas it is less favorable for bradyarrhythmias.
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Affiliation(s)
- Patrizia Vergani
- Department of Obstetrics and Gynecology, University of Milano-Bicocca, Monza, Italy.
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Brisinda D, Comani S, Meloni AM, Alleva G, Mantini D, Fenici R. Multichannel mapping of fetal magnetocardiogram in an unshielded hospital setting. Prenat Diagn 2005; 25:376-82. [PMID: 15906428 DOI: 10.1002/pd.1160] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVES To evaluate the feasibility of unshielded in-hospital multichannel mapping of fetal magnetocardiogram (FMCG), with a 36-channel system for standard adult magnetocardiographic (MCG) recordings, and its reliability according to the recommended standards for FMCG. METHODS FMCG was ambulatory mapped with a 36-channel MCG system, in six normal pregnancies at different gestational ages. MCG analysis included adaptive digital filtering of 50 Hz, signal averaging, reconstruction of magnetic field distribution (MFD) and source localization. Fixed Point Independent Component Analysis algorithm (FastICA) was used to reconstruct the FMCG, separating them from maternal contamination and noise. RESULTS The quality of FMCG recorded after the 32nd gestational week and reconstructed with FastICA was close to FMCG obtained in shielded rooms, and good enough to measure cardiac intervals and heart rate variability parameters. In two cases, reconstruction of the MFD during the QRS allowed three-dimensional localization of ventricular sources. CONCLUSIONS A first demonstration has been given that multichannel mapping of FMCG can be performed in unshielded clinical environments, with resolution good enough for contactless assessment of fetal cardiac electrophysiology. FastICA processing on unshielded FMCG, recorded after the 32nd week, provided beat-to-beat analysis and heart rate variability assessment. Further work is needed to improve signal reconstruction in early pregnancy.
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Affiliation(s)
- Donatella Brisinda
- Clinical Physiology-Biomagnetism Center, Catholic University, Rome, Italy
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Abstract
Fetal cardiac arrhythmias have been recognized with increasing frequency during the past several years. Most fetal arrythmias are intermittent extrasystoles, often presenting as irregular pauses of rhythm. These are significant only when they occur with appropriate timing to initiate sustained tachycardia, mediated by anatomic bypass pathways. The most common important fetal arrhythmias are: 1) supraventricular tachycardias, and 2) severe bradyarrhythmias, associated with complete heart block. Symptomatic fetal tachycardias are usually supraventricular in origin, and may be associated with the developmet of hydrops fetalis. These patients may respond to antiarrhythmic drug therapy, administered via maternal ingestion or via direct fetal injection. Such therapy should be offered with careful fetal and maternal monitoring, and must be based on a logical, sequential analysis of the electrical mechanism underlying the arrhythmia, and an appreciation of the pharmacology and pharmacokinetics of the maternal, placental fetal system. Bradycardia from complete heart block may either be associated with complex congential heart malformations involving the atrioventricular junction of the heart, or may present in fetuses with normal cardiac structure, in mothers with autoimmune conditions associated with high titres of anti-SS-A or anti-SS-B antibody, which cross the placenta to cause immune-related inflammatory damage to the fetal atroventricular node. This paper reviews experience with the analysis of fetal caridac rhythm, a detailed discussion of the pathophysiology of arrhythmias and their effect on the fetal circulatory system, and offers a logical framework for the construction of treatment algorithms for fetuses at risk for circulatory compromise from fetal arrhythmias.
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Affiliation(s)
- C S Kleinman
- Clinical Pediatrics in Obstetrics & Gynecology, Columbia University College of Physicians and Surgeons, New York, NY, USA.
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Wakai RT, Strasburger JF, Li Z, Deal BJ, Gotteiner NL. Magnetocardiographic rhythm patterns at initiation and termination of fetal supraventricular tachycardia. Circulation 2003; 107:307-12. [PMID: 12538433 DOI: 10.1161/01.cir.0000043801.92580.79] [Citation(s) in RCA: 107] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Using fetal magnetocardiography (fMCG), we characterize for the first time the electrophysiological patterns of initiation and termination of reentrant fetal supraventricular tachycardia (SVT), the most common form of life-threatening fetal arrhythmia. METHODS AND RESULTS In contrast to the expectation that reentrant SVT is initiated by spontaneous premature atrial contractions (PACs) and is terminated by spontaneous block, 5 distinct patterns of initiation and 4 patterns of termination were documented, with the most common patterns of initiation involving reentrant PACs. Waveform morphology and timing, including QRS and ventriculoatrial interval, were assessed. This enabled detection of such phenomena as Wolff-Parkinson-White syndrome, QRS aberrancy, and multiple reentrant pathways that were crucial for defining the rhythm patterns. In addition, fMCG actocardiography revealed an unexpectedly strong association between fetal trunk movement and the initiation and termination of SVT, suggesting that autonomic influences play a key role. CONCLUSIONS This study demonstrates that the patterns of initiation and termination of fetal SVT are more diverse than is generally believed and that the most common patterns of initiation involve reentrant PACs. The ability to discern such patterns can help elucidate the underlying mechanisms and guide antiarrhythmic drug therapy. fMCG provides a noninvasive means of analyzing complex tachyarrhythmia in utero, with efficacy approaching that of postnatal electrocardiographic rhythm monitoring.
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Affiliation(s)
- R T Wakai
- Department of Medical Physics, University of Wisconsin-Madison, USA.
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Wong SF, Chau KT, Ho LC. Fetal bradycardia in the first trimester: an unusual presentation of atrial extrasystoles. Prenat Diagn 2002; 22:976-8. [PMID: 12424759 DOI: 10.1002/pd.450] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
We report a fetus with fetal bradycardia at 13 weeks of gestation secondary to atrial extrasystoles. The fetus subsequently developed paroxysmal supraventricular tachycardia and hydrops fetalis. The cardiac arrhythmia recovered spontaneously without any medical intervention. This case illustrates that atrial ectopic beats can present in the first trimester with fetal bradycardia. Rapidly evolving hydrops fetalis secondary to supraventricular tachycardia can develop, warranting close monitoring with weekly heart rate assessment. Fetal bradycardia secondary to atrial extrasystole should be differentiated from first trimester sinus bradycardia and those associated with major structural cardiac abnormality, which have a high fetal loss rate.
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Affiliation(s)
- S F Wong
- Department of Obstetrics and Gynaecology, Princess Margaret Hospital, Hong Kong.
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Abebe-Campino G, Offer D, Stahl B, Merlob P. Cardiac arrhythmia in a newborn infant associated with fluoxetine use during pregnancy. Ann Pharmacother 2002; 36:533-4. [PMID: 11895072 DOI: 10.1345/aph.10255] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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