Prospective Evaluation of High Titer Autoantibodies and Fetal Home Monitoring in the Detection of Atrioventricular Block Among Anti-SSA/Ro Pregnancies

OBJECTIVE

This prospective study of pregnant patients, Surveillance To Prevent AV Block Likely to Occur Quickly (STOP BLOQ), addresses the impact of anti-SSA/Ro titers and utility of ambulatory monitoring in the detection of fetal second-degree atrioventricular block (AVB).

METHODS

Women with anti-SSA/Ro autoantibodies by commercial testing were stratified into high and low anti-52-kD and/or 60-kD SSA/Ro titers applying at-risk thresholds defined by previous evaluation of AVB pregnancies. The high-titer group performed fetal heart rate and rhythm monitoring (FHRM) thrice daily and weekly/biweekly echocardiography from 17-26 weeks. Abnormal FHRM prompted urgent echocardiography to identify AVB.

RESULTS

Anti-52-kD and/or 60-kD SSA/Ro met thresholds for monitoring in 261 of 413 participants (63%); for those, AVB frequency was 3.8%. No cases occurred with low titers. The incidence of AVB increased with higher levels, reaching 7.7% for those in the top quartile for anti-60-kD SSA/Ro, which increased to 27.3% in those with a previous child who had AVB. Based on levels from 15 participants with paired samples from both an AVB and a non-AVB pregnancy, healthy pregnancies were not explained by decreased titers. FHRM was considered abnormal in 45 of 30,920 recordings, 10 confirmed AVB by urgent echocardiogram, 7 being second-degree AVB, all <12 hours from normal FHRM and within another 0.75 to 4 hours to echocardiogram. The one participant with second/third-degree and two participants with third-degree AVB were diagnosed by urgent echocardiogram >17 to 72 hours from an FHRM. Surveillance echocardiograms detected no AVB when the preceding interval FHRM recordings were normal.

CONCLUSION

High-titer antibodies are associated with an increased incidence of AVB. Anti-SSA/Ro titers remain stable over time and do not explain the discordant recurrence rates, suggesting that other factors are required. Fetal heart rate and rhythm (FHRM) with results confirmed by a pediatric cardiologist reliably detects conduction abnormalities, which may reduce the need for serial echocardiograms.

Cardiac involvement in a pediatric patient with COVID-19: Looking beyond the nonspecific global cardiac injury

We report a case of a 17-year-old healthy male presenting with multisystem hyperinflammatory shock temporally associated with COVID-19. Cardiac involvement was suspected based on evidence of significant cardiac injury (elevated cardiac biomarkers, electrocardiographic and echocardiographic abnormalities). Cardiac magnetic resonance imaging was performed demonstrating global biventricular systolic dysfunction, as well as a small area of T2 hyperintensity and mid-wall late gadolinium enhancement. This case discusses the varied cardiac involvement in pediatric patients with COVID-19 infection and highlights that cardiac injury is not just limited to hyperinflammatory syndrome related global dysfunction but a more focal myocarditis can also be seen.

Endocarditic sinus of valsalva fistulae to right ventricular outflow tract in adult ventricular septal defects

Surgical repair of congenital ventricular septal defects (VSDs) in adults is quite rare. Most congenital VSDs are repaired in children. Of those adult patients diagnosed as having VSDs, many are not repaired due to irreversible pulmonary vascular disease. Repair in a patient with a VSD and fistula is even more uncommon. From a review of the literature, we found no other case reports with our unique combination of echocardiographic and surgical findings: a supracristal VSD, right and left sinus of Valsalva fistulas into the right ventricular outflow tract, and a pulmonary artery to pulmonary vein fistula in the context of an aseptic endocarditis lesion. We review the important aspects of anesthetic management in an adult with an intracardiac shunt. An adult patient with unrepaired congenital VSD may develop multiple fistulas as a consequence of endocarditis. This patient refused surgery until the progressive dyspnea was worsened by the endocarditis and the fistulas. At the time of surgery, his ventricular ejection fraction measured 47%, the ventricular chambers were enlarged, and the pulmonary to systemic flow ratio measured 2:1. He did well clinically after the VSD and fistulae repair.

The ocular dose of ultraviolet radiation to outdoor workers

Ocular ultraviolet radiation (UVR) exposure was assessed in three occupational groups: fisherman, landscape workers and construction workers. The ratio of ocular exposure to ambient exposure was determined by placing UV-sensitive film (295-320 nm) between the eyes of the subjects and in a nearby open field. The mean ocular exposures varied between 2 and 17% of the ambient exposure on a horizontal surface, depending on whether subjects wore hats, the job performed and the time of year. Wearing a brimmed hat significantly reduced ocular exposure in all groups of subjects. Subjects working over more reflective surfaces had significantly higher ocular exposure. A seasonal effect on the ocular ambient exposure ratio (OAER) was also observed. These results are consistent with measurements of OAER in mannikin and measurements of surface reflectivity in this and previous studies. The results provide parameters which can be used in modeling ocular UVR exposure in epidemiological and clinical studies.