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Weinreb SJ, Ampah SB, Okunowo O, Griffis H, Vetter VL. Longitudinal echocardiographic parameters before and after pacemaker placement in congenital complete heart block. Heart Rhythm 2024; 21:454-461. [PMID: 37981292 DOI: 10.1016/j.hrthm.2023.11.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 11/14/2023] [Accepted: 11/15/2023] [Indexed: 11/21/2023]
Abstract
BACKGROUND Congenital complete heart block (CCHB) is seen in 1:15,000-1:20,000 live births, with risk of left ventricular (LV) dysfunction or dilated cardiomyopathy in 7%-23% of subjects. OBJECTIVE The purpose of this study was to investigate serial changes in LV size and systolic function in paced CCHB subjects to examine the effect of time from pacemaker on echocardiographic parameters. METHODS Single-center retrospective cohort analysis of paced CCHB subjects was performed. Echocardiographic data were collected before and after pacemaker placement. Linear mixed effect regression of left ventricular end-diastolic dimension (LVEDD) z-score, left ventricular shortening fraction (LVSF), and left ventricular ejection fraction (LVEF) was performed, with slopes compared before and after pacemaker placement. RESULTS Of 114 CCHB subjects, 52 had echocardiographic data before and after pacemaker placement. Median age at CCHB diagnosis was 0.6 [interquartile range 0.0-3.5] years; age at pacemaker placement 3.4 [0.5-9.0] years; and pacing duration 10.8 [5.2-13.7] years. Estimated LVEDD z-score was 1.4 at pacemaker placement and decreased -0.08 per year (95% confidence interval [CI] -0.12 to -0.04; P = .002) to 0.2 (95% CI -0.3 to +0.3) 15 years postplacement. Estimated LVSF decreased -1.1% per year (95% CI -1.7% to -0.6%; P <.001) from 6 months prepacemaker placement to 34% (95% CI 32%-37%) 4 years postplacement. There was no significant change in LVSF between 4 and 15 years postplacement. Estimated LVEF did not change significantly after pacemaker placement, with estimated LVEF 59% (95% CI 55%-62%) 15 years postplacement. CONCLUSION In 52 paced CCHB subjects, estimated LVEDD z-score decreased significantly after pacemaker placement, and estimated LVSF and LVEF remained within normal limits at 15 years postpacemaker placement.
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Affiliation(s)
- Scott J Weinreb
- Division of Cardiology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.
| | - Steve B Ampah
- Data Science and Biostatistics Unit, Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Oluwatimilehin Okunowo
- Department of Computational and Quantitative Medicine, Division of Biostatistics, Beckman Research Institute of City of Hope, Duarte, California
| | - Heather Griffis
- Data Science and Biostatistics Unit, Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Victoria L Vetter
- Division of Cardiology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
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Rani V, Sharma R, Dalal JS, Saxena A, Lohchab SS, Dalal M. Newborns with congenital complete heart block: Advice for perinatal care providers. Trop Doct 2024; 54:167-171. [PMID: 38380895 DOI: 10.1177/00494755241231324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2024]
Abstract
Congenital complete heart block (CCHB) is a rare, but a potentially life-threatening manifestation of autoimmune diseases in neonates. Bradycardia in CCHB can be misdiagnosed as foetal distress in utero and thus precipitating a Caesarean section. We report a case series of three neonates with bradycardia without any electrolyte abnormalities and structurally normal hearts with favourable outcomes.
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Affiliation(s)
- Vijay Rani
- Resident, Department of Pediatrics, Pt. B. D. Sharma Post Graduate Institute of Medical Sciences, Rohtak, Haryana, India
| | - Renu Sharma
- Resident, Department of Pediatrics, Pt. B. D. Sharma Post Graduate Institute of Medical Sciences, Rohtak, Haryana, India
| | - Jagjit Singh Dalal
- Senior Professor and Head, Department of Neonatology, Pt. B. D. Sharma Post Graduate Institute of Medical Sciences, Rohtak, Haryana, India
| | - Anita Saxena
- Vice-Chancellor, Pt B D Sharma University of Health Sciences, Rohtak, Haryana, India
| | - Shamsher Singh Lohchab
- Senior Professor, Department of Cardiothoracic and Vascular Surgery, Pt. B. D. Sharma Post Graduate Institute of Medical Sciences, Rohtak, Haryana, India
| | - Monika Dalal
- Professor, Department of Obstetrics and Gynecology, Pt. B. D. Sharma Post Graduate Institute of Medical Sciences, Rohtak, Haryana, India
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Huang Y, Deng J, Liu J, Yang F, He Y. Autoimmune congenital heart block: a case report and review of the literature related to pathogenesis and pregnancy management. Arthritis Res Ther 2024; 26:8. [PMID: 38167489 PMCID: PMC10759413 DOI: 10.1186/s13075-023-03246-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 12/19/2023] [Indexed: 01/05/2024] Open
Abstract
Autoimmune congenital heart block (ACHB) is a passively acquired immune-mediated disease characterized by the presence of maternal antibodies against components of the Ro/SSA and La/SSB ribonucleoprotein complex that mainly affects the cardiac conducting system. ACHB occurs in 2% of women with positive anti-Ro/SSA and anti-La/SSB antibodies and causes a high risk of intrauterine fetal death, neonatal mortality, and long-term sequelae. In this review, we first describe a case of ACHB to provide preliminary knowledge. Then, we discuss the possible pathogenic mechanisms of ACHB; summarize the pregnancy management of patients with positive anti-Ro/SSA and anti-La/SSB antibodies and/or rheumatic diseases, the prevention of ACHB, and the treatment of ACHB fetuses; and propose routine screening of these antibodies for the general population. Careful follow-up, which consists of monitoring the fetal heart rate, is feasible and reassuring for pregnant women with positive anti-Ro/SSA and/or anti-La/SSB antibodies to lower the risk of ACHB in fetuses. Moreover, maternal administration of hydroxychloroquine may be useful in preventing ACHB in pregnant women with anti-Ro/SSA and/or anti-La/SSB antibodies.
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Affiliation(s)
- Ying Huang
- Department of Rheumatology and Immunology, The Third Affiliated Hospital, Southern Medical University, No. 183, Zhongshan Avenue West, Tianhe District, Guangzhou, 510630, China
- Institute of Clinical Immunology, Academy of Orthopedics, Guangdong Province, Guangzhou, China
| | - Jialin Deng
- Department of Rheumatology and Immunology, The Third Affiliated Hospital, Southern Medical University, No. 183, Zhongshan Avenue West, Tianhe District, Guangzhou, 510630, China
- Institute of Clinical Immunology, Academy of Orthopedics, Guangdong Province, Guangzhou, China
| | - Jinghua Liu
- Department of Pediatrics, The Third Affiliated Hospital, Southern Medical University, Guangzhou, China
| | - Fangyuan Yang
- Department of Rheumatology and Immunology, The Third Affiliated Hospital, Southern Medical University, No. 183, Zhongshan Avenue West, Tianhe District, Guangzhou, 510630, China.
- Institute of Clinical Immunology, Academy of Orthopedics, Guangdong Province, Guangzhou, China.
| | - Yi He
- Department of Rheumatology and Immunology, The Third Affiliated Hospital, Southern Medical University, No. 183, Zhongshan Avenue West, Tianhe District, Guangzhou, 510630, China.
- Institute of Clinical Immunology, Academy of Orthopedics, Guangdong Province, Guangzhou, China.
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González-Zambrano H, Orozco-Barocio G, Franco-Ramos MC. Prevalence of neonatal lupus in a small group of antibody-carrying mothers and frequency of complete atrioventricular block. Arch Cardiol Mex 2024; 94:33-38. [PMID: 38507328 DOI: 10.24875/acm.22000233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 05/10/2023] [Indexed: 03/22/2024] Open
Abstract
BACKGROUND Neonatal lupus (NL) is extremely rare and is caused by the transplacental passage of maternal IgG autoantibodies against Ro, La, and/or RNP proteins into the fetal circulation, which can cause congenital complete atrioventricular block (CCAB), permanent skin lesions, and liver involvement. OBJECTIVE To know the prevalence of NL in patients with CCAB and the clinical course in long-term follow-up. METHODS From January 1992 to December 2017, patients with CCAB were included. The presence of anti-SSA/Ro and anti-SSB/La antinuclear antibodies in maternal serum confirmed NL. RESULTS Eight patients were included with a follow-up of 10 ± 6 years; NL was concluded in 62.5%; two were male. One of them was diagnosed in utero, two at birth, and a pacemaker was implanted in them, one at 12 years of age and another at 15. The other two cases were diagnosed at 18 and 26 years of age, and permanent pacemakers were implanted 8 and 5 years later, respectively. In one case, a definitive pacemaker was not implanted in a newborn with only 1 year of follow-up. At delivery, 60% of the mothers were free of rheumatic disease, and altogether, they all had 19 children; none of them presented NL manifestations. CONCLUSIONS CCAB is rare and frequently associated with a maternal autoimmune disease, practically all of them will require a definitive pacemaker at some point in their lives.
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Affiliation(s)
- Héctor González-Zambrano
- Cardiology Service, Hospital General de Occidente, Ministry of Health
- National Institutes of Health, Ministry of Health
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Nair A, Sklansky M, Satou G, Papneja K. Perivascular Basal Echogenicity in the Fetal Heart: An Unconventional Marker of Maternal Autoimmune Antibodies. Pediatr Cardiol 2024; 45:196-199. [PMID: 37935867 DOI: 10.1007/s00246-023-03325-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 10/10/2023] [Indexed: 11/09/2023]
Abstract
Fetal congenital heart block is a widely recognized complication of pregnancies with anti Ro/La antibodies. Less common presentations, including dilated cardiomyopathy, myocarditis, valvular insufficiency, and endocardial fibroelastosis, have also been described in these fetuses. We present two cases where recognition of isolated basal echogenicity of the fetal heart, an unconventional manifestation of anti-SSA antibodies during pregnancy, led to a suspicion and ultimately diagnosis of antibody positivity in the mother. These cases highlight the importance of being aware of this rare manifestation of anti-SSA antibodies during pregnancy, as early recognition of antibody positivity may lead to improve fetal and maternal outcomes.
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Affiliation(s)
- Anupama Nair
- Division of Fetal Cardiology, David Geffen School of Medicine, UCLA, Los Angeles, USA.
| | - Mark Sklansky
- Division of Fetal Cardiology, David Geffen School of Medicine, UCLA, Los Angeles, USA
| | - Gary Satou
- Division of Fetal Cardiology, David Geffen School of Medicine, UCLA, Los Angeles, USA
| | - Koyelle Papneja
- Division of Fetal Cardiology, David Geffen School of Medicine, UCLA, Los Angeles, USA
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李 宇, 闫 亚, 靳 家, 李 春, 裴 秋. [Clinical characteristics of fetal cardiac disease in patients with anti-SSA antibody positive]. Beijing Da Xue Xue Bao Yi Xue Ban 2023; 55:1053-1057. [PMID: 38101788 PMCID: PMC10723988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Indexed: 12/17/2023]
Abstract
OBJECTIVE To investigate the clinical manifestations and laboratory indicators of anti-Sjögren's-syndrome-related antigen A (SSA) antibody associated fetal cardiac disease. METHODS Pregnant women hospitalized at Peking University People's Hospital from January 2013 to July 2023 were included. Eleven patients with anti-SSA antibody positive were eventually diagnosed with fetal cardiac di-sease. And patients with anti-SSA antibody positive without fetal cardiac disease were selected as controls. Clinical manifestations, laboratory indications and drug usage were compared between the two groups. RESULTS Among these 11 patients, congenital heart block was confirmed in seven, which was the most common manifestations of fetal cardiac malformation. The proportion of the patients diagnosed with autoimmune disease before pregnancy in fetal cardiac malformation group was significantly lower than that in the control group (P=0.032), while most of the patients in the fetal cardiac malformation group received immune-related examinations for the first time because of this time's fetal cardiac diagnosis. While most of the patients in the control group received routine examinations because of autoimmune diseases diagnosed before pregnancy. During pregnancy, the white blood cell level [(9.29±2.58)×109/L vs. (7.10±1.90×109/L, t=3.052, P=0.004], erythrocyte sedimentation rate [(49.50 (48.00, 51.00) mm/h vs. 23.00 (15.00, 30.25) mm/h, Z=-2.251, P=0.024], IgA level [3.46 (2.30, 5.06) g/L vs. 2.13 (1.77, 2.77) g/L, Z=-2.181, P=0.029], and antinuclear antibody (ANA) titers [1∶320 (1∶160, 1∶320) vs. 1∶80 (1∶40, 1∶160), Z=-3.022, P=0.003] were significantly higher in fetal cardiac malformation group than in the control group. The proportion of positive anti-SSB antibody during pregnancy did not show a statistically significant difference between the two groups (37.5% vs. 7.7%, P=0.053). There was no significant difference in hydroxychloroquine dosage and initiation time between the two groups. The dosage of prednisone in the second and third trimesters was significantly higher in the cardiac malformation group than that in the control group, but there was no significant difference in the first trimester. CONCLUSION Fetal cardiac disease is rare in pregnant women with anti-SSA antibody. White blood cell, erythrocyte sedimentation rate, IgA, the titer of ANA positivity were higher in the fetal heart disease group during pregnancy. Since congenital heart block is difficult to reverse, its prevention and monitoring are more important than remedial treatment.
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Affiliation(s)
- 宇菲 李
- 北京大学人民医院风湿免疫科,北京 100044Department of Rheumatology and Immunology, Peking University People' s Hospital, Beijing 100044, China
| | - 亚妮 闫
- 北京大学人民医院妇产科,北京 100044Department of Obstetrics & Gynecology, Peking University People' s Hospital, Beijing 100044, China
| | - 家扬 靳
- 北京大学人民医院风湿免疫科,北京 100044Department of Rheumatology and Immunology, Peking University People' s Hospital, Beijing 100044, China
| | - 春 李
- 北京大学人民医院风湿免疫科,北京 100044Department of Rheumatology and Immunology, Peking University People' s Hospital, Beijing 100044, China
| | - 秋艳 裴
- 北京大学人民医院妇产科,北京 100044Department of Obstetrics & Gynecology, Peking University People' s Hospital, Beijing 100044, China
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7
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Flowers ME, Garber K, Temples HS. Identifying Congenital Heart Block in Primary Care. J Pediatr Health Care 2023; 37:478-483. [PMID: 37031100 DOI: 10.1016/j.pedhc.2023.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 03/02/2023] [Accepted: 03/07/2023] [Indexed: 04/10/2023]
Abstract
Congenital heart block is a rare disease characterized by electrical conduction abnormalities of the heart in patients with both structural and without structural abnormalities. The most common cause of congenital heart block is autoimmune related, but other potential causes exist. Treatment for congenital heart block is determined by the severity of the disease and presenting symptoms. Primary care providers are in the optimal position to support patients and families. Although common causes and treatments of congenital heart block are known, much research is still to be done on the cause, optimal treatments, and potential long-term side effects.
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8
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Hanumansetty K, Babu S, Koshy T, Dharan BS. The role of cardiac anaesthesiologists in placing a temporary transvenous endocardial lead in the operation room during pulse generator replacement in a child with congenital complete heart block. Ann Card Anaesth 2023; 26:362-363. [PMID: 37470547 PMCID: PMC10451133 DOI: 10.4103/aca.aca_173_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 02/21/2023] [Accepted: 02/25/2023] [Indexed: 07/21/2023] Open
Affiliation(s)
- Kartheek Hanumansetty
- Division of Cardiothoracic and Vascular Anesthesia, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
| | - Saravana Babu
- Division of Cardiothoracic and Vascular Anesthesia, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
| | - Thomas Koshy
- Division of Cardiothoracic and Vascular Anesthesia, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
| | - Baiju S. Dharan
- Department of Cardiothoracic and Vascular Surgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
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Lin MJ, Xiong DD, Wu L. [Detection and prevention of maternal autoantibody-related congenital heart block]. Zhonghua Xin Xue Guan Bing Za Zhi 2021; 49:1272-1276. [PMID: 34905911 DOI: 10.3760/cma.j.cn112148-20211028-00930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Affiliation(s)
- M J Lin
- Department of Cardiology, Peking University First Hospital, Beijing 100034, China
| | - D D Xiong
- Department of Pediatrics, Nationwide Children's Hospital, Toledo, Ohio 43608, United States
| | - L Wu
- Department of Cardiology, Peking University First Hospital, Beijing 100034, China
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10
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Strasburger JF, Wacker-Gussmann A. Congenital Heart Block in Subsequent Pregnancies of SSA/Ro-Positive Mothers: Cutting Recurrence in Half. J Am Coll Cardiol 2020; 76:303-305. [PMID: 32674793 PMCID: PMC7357977 DOI: 10.1016/j.jacc.2020.05.052] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Accepted: 05/27/2020] [Indexed: 11/04/2022]
Affiliation(s)
- Janette F Strasburger
- Department of Pediatrics, Division of Cardiology, Children's Wisconsin, Milwaukee, Wisconsin.
| | - Annette Wacker-Gussmann
- Department of Pediatric Cardiology and Congenital Heart Disease, German Heart Center, Munich, Germany
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Hoxha A, Mattia E, Zanetti A, Carrara G, Morel N, Costedoat-Chalumeau N, Brucato AL, Ruffatti A. Fluorinated steroids are not superior to any treatment to ameliorate the outcome of autoimmune mediated congenital heart block: a systematic review of the literature and meta-analysis. Clin Exp Rheumatol 2020; 38:783-791. [PMID: 32573408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Accepted: 10/28/2019] [Indexed: 06/11/2023]
Abstract
OBJECTIVES Fluorinated steroids are largely the therapeutic approach of autoimmune mediated congenital heart block (CHB). We performed a meta-analysis to assess the efficacy of fluorinated steroids for the treatment of CHB. METHODS Studies evaluating the efficacy of fluorinated steroids versus no treatment in CHB patients were identified in electronic databases. Random-effects model was used to pool odds ratio (OR) (with 95% CI) of live births as the primary outcome. ORs of CHB progression, pacemaker implantation and extranodal disease were the secondary outcome. Subgroup analysis according to CHB grade and study type was performed. RESULTS Data from nine studies involving 747 patients were analysed. The overall live birth rates were 86.8% and 86.7%, respectively, in the fluorinated steroids exposed foetuses and in the non-exposed ones. Fluorinated steroids did not ameliorate overall survival in CHB (OR 1.02; 95% CI: 0.65-1.61) with any significant statistical heterogeneity between studies (I2 0%, p=0.45). No significant differences for the progression of CHB, the pacing and the presence of extranodal disease were observed. Subgroup analysis revealed a significant protective role of fluorinated steroids for survival in 3rd degree CHB and for pacing in monocentric studies, OR 4.07; 95% CI: 1.10-15.08 and OR 0.15; 95% CI: 0.02-0.99, respectively. CONCLUSIONS This meta-analysis shows that fluorinated steroids are not superior to any treatment in patients with CHB in terms of live birth, prevention of progression of incomplete CHB, pacemaker implantation and extranodal disease. Thus, considering their side effects, their use in CHB patients should be discouraged.
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Affiliation(s)
- Ariela Hoxha
- Internal Medicine Unit, Department of Medicine, San Bortolo Hospital, Vicenza, and Rheumatology Unit, Department of Medicine-DIMED, University of Padova, Italy.
| | - Elena Mattia
- Rheumatology Unit, Department of Medicine-DIMED, University of Padova, Italy
| | - Anna Zanetti
- Epidemiology Research Unit, Italian Society for Rheumatology, Milan, and Department of Statistics and Quantitative Methods, Division of Biostatistics, Epidemiology and Public Health, University of Milano-Bicocca, Milan, Italy
| | - Greta Carrara
- Epidemiology Research Unit, Italian Society for Rheumatology, Milan, Italy
| | - Nathalie Morel
- AP-HP, Hôpital Cochin, Centre de Référence Maladies Auto-Immunes et Systémiques Rares, Paris, and Université Paris Descartes-Sorbonne Paris Cité, Paris, France
| | - Nathalie Costedoat-Chalumeau
- AP-HP, Hôpital Cochin, Centre de Référence Maladies Auto-Immunes et Systémiques Rares, Paris; Université Paris Descartes-Sorbonne Paris Cité, and INSERM U 1153, Centre for Epidemiology and Statistics, Sorbonne Paris Cité (CRESS), France
| | - Antonio L Brucato
- Department of Biomedical and Clinical Sciences, University of Milan, Fatebenefratelli Hospital, Milan, Italy
| | - Amelia Ruffatti
- Rheumatology Unit, Department of Medicine-DIMED, University of Padova, Italy
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12
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Brito-Zerón P, Pasoto SG, Robles-Marhuenda A, Mandl T, Vissink A, Armagan B, Praprotnik S, Nocturne G, Sebastian A, Fernandes Moça Trevisani V, Retamozo S, Acar-Denizli N, Wiland P, Sisó-Almirall A, Bootsma H, Mariette X, Ramos-Casals M, Kostov B. Autoimmune congenital heart block and primary Sjögren's syndrome: characterisation and outcomes of 49 cases. Clin Exp Rheumatol 2020; 38 Suppl 126:95-102. [PMID: 33025893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 09/10/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVES To characterise autoimmune congenital heart block (CHB) associated with a maternal diagnosis of primary Sjögren's syndrome (pSS) confirmed either before, concomitant or after the first pregnancy complicated with CHB. METHODS The following inclusion criteria were applied: (i) Mothers with positive Ro/La autoantibodies detected previously or at the time of diagnosis of the first case of CHB; (ii) diagnosis of CHB confirmed by fetal echocardiography; (iii) AV block diagnosed in uterus, at birth or within the neonatal period (0-27 days after birth) (8); (iv) absence of anatomical cardiac abnormalities which might be causal of AV block; and (v) maternal fulfillment of the 2002 SS criteria before, during or after having a pregnancy complicated with CHB. RESULTS We identified 49 cases of autoimmune CHB in children born from 44 mothers who had a mean age at the time of pregnancy of 30.3 years (range 18 to 41). At the time of diagnosis of autoimmune CHB, all mothers had positive anti-Ro antibodies and 28/44 (64%) were positive for anti-La antibodies. Only 10 (22%) mothers with affected pregnancies had a diagnosis of primary SS at the time of diagnosis of the first pregnancy complicated by CHB (a mean of 4 years before, ranging from 1 to 10 years). In 6 (14%) mothers, primary SS was diagnosed during pregnancy or less than 12 months after the delivery/termination. In the remaining 28 (64%) mothers, pSS was confirmed 1-5 years after CHB diagnosis (n=19, 68%), 6-10 years after (n=2, 7%), or more than 10 years after the first case of CHB was diagnosed (n=7, 25%). CHB was diagnosed in uterus in all cases but two. AV block was initially incomplete in 11 fetuses and complete in 36 (no available data in 2 cases). Among the 35 (71%) surviving children with CHB, 5 (14%) developed other features of neonatal lupus. After the index pregnancy, 12 women had 20 subsequent pregnancies: five were complicated by a CHB (recurrence rate of CHB of 25%). The 4 women who had recurrent CHB were double-positive for anti-Ro and anti-La antibodies, and all had a confirmed pSS before having the first index case of CHB. CONCLUSIONS In pSS, autoimmune CHB could be one of the first "indirect" signs of the disease in women of childbearing-age, in whom the diagnosis is confirmed several years later. Some maternal characteristics could be related with recurrent CHB, such as having an already-confirmed diagnosis of pSS and carrying the two Ro/La autoantibodies.
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Affiliation(s)
- Pilar Brito-Zerón
- Autoimmune Diseases Unit, Department of Medicine, Hospital CIMA-Sanitas, Barcelona, and Laboratory of Autoimmune Diseases Josep Font, IDIBAPS-CELLEX, Barcelona, Spain
| | - Sandra G Pasoto
- Rheumatology Division, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | | | - Thomas Mandl
- Department of Rheumatology, Skane University Hospital Malmö, Lund University, Lund, Sweden
| | - Arjan Vissink
- Department of Oral and Maxillofacial Surgery, University of Groningen, University Medical Centre Groningen, The Netherlands
| | - Berkan Armagan
- Department of Internal Medicine, Hacettepe University, Faculty of Medicine, Ankara, Turkey
| | - Sonja Praprotnik
- Department of Rheumatology, University Medical Centre, Ljubljana, Slovenia
| | - Gaetane Nocturne
- Centre for Immunology of Viral Infections and Autoimmune Diseases, Assistance Publique - Hôpitaux de Paris, Hôpitaux Universitaires Paris-Sud, Le Kremlin-Bicêtre, Université Paris Sud, INSERM, Paris, France
| | - Agata Sebastian
- Department of Rheumatology and Internal Medicine, Wroclaw Medical University, Wroclaw, Poland
| | | | - Soledad Retamozo
- Instituto Modelo de Cardiología Privado SRL, Córdoba, and Instituto Universitario de Ciencias Biomédicas de Córdoba, Córdoba, Argentina
| | - Nihan Acar-Denizli
- Department of Statistics and Operations Research, Universitat Politècnica de Catalunya (UPC), Barcelona, Spain
| | - Piotr Wiland
- Department of Rheumatology and Internal Medicine, Wroclaw Medical University, Wroclaw, Poland
| | - Antoni Sisó-Almirall
- Primary Healthcare Transversal Research Group, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, and Primary Care Centre Les Corts, Consorci d'Atenció Primària de Salut Barcelona Esquerra (CAPSBE), Barcelona, Spain
| | - Hendrika Bootsma
- Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Centre Groningen, The Netherlands
| | - Xavier Mariette
- Centre for Immunology of Viral Infections and Autoimmune Diseases, Assistance Publique - Hôpitaux de Paris, Hôpitaux Universitaires Paris-Sud, Le Kremlin-Bicêtre, Université Paris Sud, INSERM, Paris, France
| | - Manuel Ramos-Casals
- Laboratory of Autoimmune Diseases Josep Font, IDIBAPS-CELLEX, Barcelona; Department of Medicine, University of Barcelona; and Department of Autoimmune Diseases, ICMiD, Hospital Clínic, Barcelona, Spain.
| | - Belchin Kostov
- Department of Statistics and Operations Research, Universitat Politècnica de Catalunya (UPC), Barcelona; Primary Healthcare Transversal Research Group, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona; and Primary Care Centre Les Corts, Consorci d'Atenció Primària de Salut Barcelona Esquerra (CAPSBE), Barcelona, Spain
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13
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Hamilton RM. Editorial commentary: Live better electrically? Optimizing the timing and application of pacing in congenital heart block. Trends Cardiovasc Med 2019; 30:287-288. [PMID: 31395307 DOI: 10.1016/j.tcm.2019.07.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Accepted: 07/25/2019] [Indexed: 01/13/2023]
Affiliation(s)
- Robert M Hamilton
- The Hospital for Sick Children, Pediatrics (Cardiology), 555 University Ave Rm 1725D, Toronto, Ontario M5G1X8, Canada.
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Amanullah M, Razzaq S, Siddiqui AH, Khan FW. Minimally invasive technique of placing a dual chamber permanent pacemaker in children. J PAK MED ASSOC 2019; 69:1119-1123. [PMID: 31431764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
OBJECTIVE To share the experience of a minimally invasive technique in the implantation of a dual chamber permanent pacemaker in paediatric population. METHODS The retrospective study was conducted at Aga Khan University Hospital, Karachi, and comprised data of patients aged up to 16 years who underwent epicardial dual chamber permanent pacemaker insertion via xiphisternal incision between April 2011 and August 2016. Demographic data included age, weight and gender of the patient. Indications for pacemaker insertion, electrocardiography findings, concomitant cardiac procedures and procedural complications were reviewed. Pacemaker thresholds and impedance at the time of implantation and throughout the course of follow-up were extracted from the clinical data. RESULTS Of the 10 patients, 5(50%) were males and 5(50%)were females. The overall mean age was 3.4}3.8 years (range: 1 month - 13 years). The mean weight at the time of operation was 11.4}6.8 kg (range: 4.3-27kg). Indications for permanent pacemaker insertion included postoperative advanced or complete atrioventricular block in 7(70%) and complete congenital heart block in 3(30%). There was no reported morbidity. CONCLUSIONS Dual chamber permanent pacemaker insertion via xiphisternal incision was found to be of benefit to the patients and the surgeons alike.
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Affiliation(s)
| | - Somia Razzaq
- Jinnah Sindh Medical University, Karachi,Pakistan
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15
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Sonesson SE, Ambrosi A, Wahren-Herlenius M. Benefits of fetal echocardiographic surveillance in pregnancies at risk of congenital heart block: single-center study of 212 anti-Ro52-positive pregnancies. Ultrasound Obstet Gynecol 2019; 54:87-95. [PMID: 30620419 DOI: 10.1002/uog.20214] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Revised: 11/15/2018] [Accepted: 11/16/2018] [Indexed: 06/09/2023]
Abstract
OBJECTIVES Assuming that autoimmune congenital heart block (CHB) is a progressive disease amenable to therapeutic modulation, we introduced a surveillance program for at-risk pregnancies with the dual aim of investigating if fetal atrioventricular block (AVB) could be detected and treated before becoming complete and irreversible, and to establish the incidence of AVB I, II and III in a large prospective cohort. METHODS This was a prospective study of 212 anti-Ro52 antibody-exposed pregnancies at risk of fetal AVB that were followed weekly between 18 and 24 weeks' gestation at our tertiary fetal cardiology center from 2000 to 2015. A 12-lead electrocardiogram (ECG) was recorded within 1 week after birth. Fetal Doppler atrioventricular (AV) intervals were converted to Z-scores using reference standard values derived from normal pregnancies. Each fetus was represented by the average value of the two recordings, obtained at two consecutive visits, which resulted in the longest AV interval. AV interval values were classified into normal AV conduction (Z-score ≤ 2.0) and three levels of delayed AV conduction: Z-score > 2.0 and ≤ 3.0, Z-score > 3.0 and ≤ 4.0, and Z-score > 4.0. RESULTS AVB II or III developed in 6/204 (2.9%) pregnancies without a CHB history and 1/8 (12.5%) of those with a CHB history. AV intervals > 2 and ≤ 3, > 3 and ≤ 4, and > 4 were detected in 16.0%, 7.5% and 2.8% of cases, respectively, and were related to the PR interval on 185 available ECGs. Three of the five cases with AVB III and one of two cases with 2:1 AVB II developed within 1 week of AV interval Z-score of 1.0, 1.9, 2.8 and 1.9, respectively. Transplacental treatment with betamethasone was associated with restoration of 1:1 AV conduction in the two fetuses with AVB II, with a better long-term result (normal ECG vs AVB I or II) observed in the case in which treatment was started within 1 week after AVB developed. Betamethasone treatment did not reverse AVB III, although a temporary effect on AV conduction was observed in 1/5 cases. Notably, the three cases in which treatment was started within 1 week after AVB III development responded with a higher ventricular rate than the other two cases and did not require pacemaker implantation until a later age (2-5 years vs 1.5-2 months). CONCLUSION Fetal AV interval is a poor predictor of CHB progression, but CHB surveillance still allows detection of fetuses with AVB II or III shortly after its development, allowing for timely treatment initiation and potentially better outcome. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- S-E Sonesson
- Department of Women's and Children's Health, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - A Ambrosi
- Department of Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - M Wahren-Herlenius
- Department of Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
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16
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Abstract
Linked Comment: Ultrasound Obstet Gynecol 2019; 54: 87-95.
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Affiliation(s)
- B F Cuneo
- Division of Cardiology, Department of Pediatrics, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, CO, USA
| | - J P Buyon
- Division of Rheumatology, Department of Internal Medicine, New York University Langone School of Medicine, NYU Langone Health, New York, NY, USA
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17
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Schneider AE, Wackel PL. Unconventional 2:1 Ventricular Pacing in a Neonate with Congenital Heart Block and Biventricular Noncompaction. Tex Heart Inst J 2019; 46:136-138. [PMID: 31236081 DOI: 10.14503/thij-17-6368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Congenital complete heart block with concomitant biventricular noncompaction cardiomyopathy has been reported once previously. Although not universal, when restrictive physiology is present, impaired diastolic filling may pose a distinct challenge to pacing during the neonatal period. We present the case of a neonate with congenital complete heart block and biventricular noncompaction that resulted in severe diastolic dysfunction and atrioventricular dyssynchrony. We intentionally used 2:1 ventricular pacing to provide atrioventricular synchrony with every paced beat, and this resulted in hemodynamic and clinical improvement. This unconventional pacing technique may be beneficial in other neonates who have complete heart block and diastolic dysfunction.
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18
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Jan SL, Lin MC, Chan SC. Spontaneous Return of Sinus Rhythm in a Child Born With Complete Heart Block. J Emerg Med 2019; 56:e81-e82. [PMID: 30922708 DOI: 10.1016/j.jemermed.2019.01.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2018] [Revised: 01/04/2019] [Accepted: 07/25/2019] [Indexed: 06/09/2023]
Affiliation(s)
- Sheng-Ling Jan
- Department of Pediatrics, Children's Medical Center, Taichung Veterans General Hospital, Taichung, Taiwan; Department of Pediatrics, School of Medicine, National Yang-Ming University, Taipei, Taiwan; Department of Pediatrics, School of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Ming-Chih Lin
- Department of Pediatrics, Children's Medical Center, Taichung Veterans General Hospital, Taichung, Taiwan; Department of Pediatrics, School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Sheng-Ching Chan
- Department of Nursing, Ta-Jen University, Pingtung County, Taiwan
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19
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Collée J, Malaise O, Emonts P, Seghaye MC, Van Linthout C. [Congenital heart block revealing a maternal systemic disease : pathophysiology and therapeutic approaches]. Rev Med Liege 2019; 74:95-99. [PMID: 30793563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Immunologic congenital atrioventricular block is due to the presence of anti-SSA and anti-SSB antibodies in maternal blood. This pathology is often diagnosed when the status is irreversible and is consequently associated with a high morbi-mortality. Close monitoring for high risk pregnancies can help to diagnose first and second degrees heart block and treatments can be offered when the block is still reversible. Fluorocorticoids, betamimetics and hydroxychloroquine use is not consensual. Studies are still in progress to prove their utility. We report the antenatal managing of a patient in which Goujerot-Sjögren disease was diagnosed after the revealing of an atrioventricular block in her fetus. After a brief physiopathological description, we present the current knowledge in preventive and curative treatments.
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Affiliation(s)
- J Collée
- Service de Gynécologie-Obstétrique, CHU Liège, Belgique
| | - O Malaise
- Service de Rhumatologie, CHU Liège, Belgique
| | - P Emonts
- Service de Gynécologie-Obstétrique, CHU Liège, Belgique
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20
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Mohan VK, Naik AK, Bharti N, Shende D. A Patient with Congenital Complete Heart Block Undergoing Multiple Exposures to General Anaesthesia. Anaesth Intensive Care 2019; 31:667-71. [PMID: 14719430 DOI: 10.1177/0310057x0303100611] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
We present a patient with congenital complete heart block who underwent multiple anaesthetic exposures for eye examination and bilateral cataract surgery. The diagnosis was made during the first general anaesthetic. Various complications encountered during the multiple exposures are discussed.
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Affiliation(s)
- V K Mohan
- Department of Anaesthesiology and Intensive Care, All India Institute of Medical Sciences, New Delhi-110029, India
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21
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Abstract
Fetal dysrhythmias are common abnormalities, usually manifesting as irregular rhythms. Although most irregularities are benign and caused by isolated atrial ectopics, in a few cases, rhythm irregularity may indicate partial atrioventricular block, which has different etiological and prognostic implications. We provide a flowchart for the initial management of irregular rhythm to help select cases requiring urgent specialist referral. Tachycardias and bradycardias are less frequent, can lead to hemodynamic compromise, and may require in utero therapy. Pharmacological treatment of tachycardia depends on the type (supraventricular tachycardia or atrial flutter) and presence of hydrops, with digoxin, flecainide, and sotalol being commonly used. An ongoing randomized trial may best inform about their efficacy. Bradycardia due to blocked bigeminy normally resolves spontaneously, but if it is due to established complete heart block, there is no effective treatment. Ongoing research suggests hydroxychloroquine may reduce the risk of autoimmune atrioventricular block. Sinus bradycardia (rate <3rd centile) may be a prenatal marker for long-QT syndrome.
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Affiliation(s)
- Julene S Carvalho
- Royal Brompton and Harefield NHS Foundation Trust, Sydney Street, London, SW3 6NP, UK; Fetal Medicine Unit, St George's University Hospital, Blackshaw Road, London, SW17 0QT, UK; Molecular and Clinical Sciences Research Institute, St George's, University of London, Cranmer Terrace, London, SW17 0RE, UK.
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22
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Abstract
RATIONALE Neonatal lupus erythematosus (NLE) is an infrequent disease caused by transplacental maternal autoantibodies. The most common effects of NLE include cutaneous involvement and congenital heart block (CHB), although it might involve multiple organs, such as the liver, lungs, blood, and nervous or digestive systems. Izmirly PM1 and Tonello et al recently reported cutaneous manifestations of neonatal lupus and risk of subsequent CHB. The most serious complication of NLE is complete atrioventricular (AV) block. PATIENT CONCERNS We experienced 2 cases of NLE that were diagnosed in the past year in our Neonatal Intensive Care Unit. These cases showed 2 different clinical spectrums (CHB, multisystemic effects). One case was a 32-week pregnant woman with combined liver damage and fever, and her fetus was premature due to bradycardia and pericardial effusion. The second case was a young pregnant woman who had systemic lupus erythematosus for 2 years and had been taking methylprednisolone and hydroxychloroquine for a long time since her illness. When prenatal testing at 28 weeks of pregnancy showed that the fetus had CHB, the mother began taking dexamethasone. DIAGNOSIS The first case was diagnosed as NLE with CHB after birth, while the second was diagnosed as NLE with CHB, ductus arteriosus, and atrial septal defect when she was born at 34 weeks. INTERVENTIONS Both of 2 cases were treated with steroids, intravenous immunoglobulin, and a diuretic. But the second case was treated with isoprenaline in addition to the above. OUTCOMES Both of the infants was followed up and found to be clinically normal. During the clinic follow-up of the first case, the 8-month-old infant was still asymptomatic with normal growth and development. Her heart rate fluctuated from 40 to 90 beats/minute. LESSONS Autoimmune CHB is a severe, potentially life-threatening disorder associated with passive transfer of maternal anti-Sjogren's syndrome A/Ro and anti-Sjogren's syndrome B/La autoantibodies. Mothers who are positive for these autoantibodies are recommended to have serial echocardiography and obstetric ultrasonography from the early second trimester. Newborns should be delivered at an early stage of gestation if there is evidence of pericardial effusion, ascites, increasing ventricular ectopy, reduced ventricular shortening fraction, or AV valve regurgitation. Aggressive medical management after birth should be coupled with pacemaker implantation in infants who do not respond to medical therapies alone.
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Affiliation(s)
- Xiaoxia Li
- Department of Neonatal Intensive Care Unit
| | - Xianmei Huang
- Department of Pediatrics, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
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23
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Clowse MEB, Eudy AM, Kiernan E, Williams MR, Bermas B, Chakravarty E, Sammaritano LR, Chambers CD, Buyon J. The prevention, screening and treatment of congenital heart block from neonatal lupus: a survey of provider practices. Rheumatology (Oxford) 2018; 57:v9-v17. [PMID: 30137589 PMCID: PMC6099126 DOI: 10.1093/rheumatology/key141] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Revised: 04/20/2018] [Indexed: 11/12/2022] Open
Abstract
Objective To survey an international sample of providers to determine their current practices for the prevention, screening, and treatment of congenital heart block (CHB) due to maternal Ro/SSA antibodies. Methods A survey was designed by the organizing committee of the 9th International Conference of Reproduction, Pregnancy and Rheumatic Diseases. It was sent to attendants of the conference and authors of recent publications or abstracts at ACR 2012, 2013 or 2014 on rheumatic diseases and pregnancy. Results In anti-Ro/SSA positive women, 80% of 49 respondents recommended screening by serial fetal echocardiogram (ECHO), with most starting at week 16 (59%) and stopping at week 28 (25%), although the time to stop varied widely. For women without a prior infant with neonatal lupus, respondents recommend every other week (44%) or weekly (28%) fetal ECHOs. For women with a prior infant with neonatal lupus, 80% recommend weekly fetal ECHOs. To prevent CHB, HCQ was recommended by 67% of respondents and most would start pre-pregnancy (62%). Respondents were asked about medications to treat varying degrees of CHB in a 20-week pregnant, anti-Ro and La positive SLE patient. For first degree, respondents recommended starting dexamethasone (53%) or HCQ (43%). For second degree, respondents recommended starting dexamethasone (88%). For third degree, respondents recommended starting dexamethasone (55%) or IVIg (33%), although 27% would not start treatment. Conclusion Despite the absence of official guidelines, many physicians with a focus on pregnancy and rheumatic disease have developed similar patterns in the screening, prevention and treatment of CHB.
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Affiliation(s)
- Megan E B Clowse
- Division of Rheumatology and Immunology, Duke University Medical Center, Durham, NC
| | - Amanda M Eudy
- Division of Rheumatology and Immunology, Duke University Medical Center, Durham, NC
| | - Elizabeth Kiernan
- Department of Pediatrics, Division of Dysmorphology and Teratology, University of California San Diego, San Diego, CA
| | - Matthew R Williams
- Pediatric Cardiology and Cardiovascular Surgery, Rady Children's Hospital, University of California San Diego, San Diego, CA
| | - Bonnie Bermas
- Division of Rheumatic Diseases, UT Southwestern, Dallas, TX
| | - Eliza Chakravarty
- Department of Arthritis and Clinical Immunology, Oklahoma Medical Research Foundation, Oklahoma City, OK
| | - Lisa R Sammaritano
- Division of Rheumatology, Hospital for Special Surgery, Weill Cornell Medicine, New York, NY
| | | | - Jill Buyon
- Division of Rheumatology, New York University School of Medicine, NY, USA
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24
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Tongprasert F, Sittiwangkul R, Lerthiranwong T, Tongsong T. Prenatal sonographic monitoring of progressive cardiac damages caused by anti-Ro antibodies: A case report. J Clin Ultrasound 2018; 46:347-350. [PMID: 29023775 DOI: 10.1002/jcu.22541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Revised: 08/07/2017] [Accepted: 08/16/2017] [Indexed: 06/07/2023]
Abstract
Maternal autoantibodies to Ro/SSA are often linked to congenital heart block and rarely associated with structural defects. We describe the case of a fetus with anti-Ro-mediated second-degree block at 19 weeks, which progressed to a complete block, fibroelastosis, atrioventricular valve insufficiency, and semilunar valve stenosis/insufficiency at 20, 22, 24, and 26 weeks, respectively, although the fetus received transplacental anti-arrhythmic drugs. The 2150-g fetus was vaginally delivered at 35 weeks. An external pacemaker was inserted immediately after birth and replaced with permanent pacemaker at the age of 3 months. The newborn has had a good outcome with well-controlled heart rate.
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Affiliation(s)
- Fuanglada Tongprasert
- Department of Obstetrics and Gynecology, Faculty of Medicine, Chiang Mai University, Thailand
| | - Rekwan Sittiwangkul
- Department of Pediatrics, Faculty of Medicine, Chiang Mai University, Thailand
| | - Thitikarn Lerthiranwong
- Department of Obstetrics and Gynecology, Faculty of Medicine, Chiang Mai University, Thailand
| | - Theera Tongsong
- Department of Obstetrics and Gynecology, Faculty of Medicine, Chiang Mai University, Thailand
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25
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Friedman D, Lovig L, Halushka M, Clancy RM, Izmirly PM, Buyon JP. No histologic evidence of foetal cardiotoxicity following exposure to maternal hydroxychloroquine. Clin Exp Rheumatol 2017; 35:857-859. [PMID: 28598777 PMCID: PMC5657477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Accepted: 03/28/2017] [Indexed: 06/07/2023]
Abstract
It is currently recommended that hydroxychloroquine (HCQ) be maintained during pregnancy in patients with systemic lupus erythematosus. Recent data suggest that this Toll-like receptor inhibitor may also reduce the recurrence rate of anti-SSA/Ro associated congenital heart block (CHB). This case report describes a unique situation in which a CHB-afflicted, HCQ-exposed pregnancy was electively terminated. The heart did not reveal any characteristic features of cardiotoxicity, providing further evidence supporting the safety of foetal exposure to HCQ.
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Affiliation(s)
| | - Leif Lovig
- Paediatric Cardiology, Children's and Women's Physicians of Westchester LLP, Norwalk, CT, USA
| | - Marc Halushka
- Pathology, Johns Hopkins Medicine, Baltimore, MD, USA
| | - Robert M Clancy
- Medicine, Division of Rheumatology, New York University School of Medicine, New York, USA
| | - Peter M Izmirly
- Medicine, Division of Rheumatology, New York University School of Medicine, New York, USA
| | - Jill P Buyon
- Medicine, Division of Rheumatology, New York University School of Medicine, New York, NY, USA.
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26
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Mustafa F, Najam Y, Akbar MT, Ahmed TA. Discordant disease expression of neonatal lupus erythematosus in twins. J PAK MED ASSOC 2017; 67:939-941. [PMID: 28585599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Neonatal lupus erythematosus is an autoimmune disease resulting from the trans-placental passage of maternal anti-SSA/Ro, anti-SSB/La, and less frequently anti-RNP antibodies to the foetus. At the time of diagnosis 50% of mothers are asymptomatic. Neonatal manifestations of this multisystem disease may include congenital heart block, cutaneous lesions and haematological abnormalities. We present the case of congenital neonatal lupus erythematosus in non-identical twins, showing variability in clinical manifestation of this disease,despite receiving the same level of antibodies from the mother. This case adds to the growing body of evidence about the role of genetics and other feto-maternal contributing factors in addition to the presence of auto antibodies. It raises interesting questions about discordant disease expression in offspring's of the same mother.
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Affiliation(s)
- Faiza Mustafa
- Department of Paediatrics, Shifa International Hospital, Islamabad, Pakistan
| | - Yawar Najam
- Department of Paediatrics, Shifa International Hospital, Islamabad, Pakistan
| | | | - Tahir Aziz Ahmed
- Department of Immunology, Shifa International Hospital, Islamabad, Pakistan
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27
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Illana-Bravo CL, Méndez-Martínez S, Juan-Martínez ME. [Down syndrome and heart block secondary to neonatal lupus]. Rev Med Inst Mex Seguro Soc 2017; 55:128-132. [PMID: 28092260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
In Down syndrome, so far, has not been reported it's association with congenital heart block, this entity is rare and occurred in only 1% of mothers who have systemic lupus erythematosus, the presence of anti-Ro antibodies cross the placenta presenting neonatal lupus with skin lesions and congenital heart block, bradycardia, which is why we describe the following case. This is a new male end product of asymptomatic young mother, but serological birth with stigmata of Down syndrome, birth presents congenital bradycardia rare manifestation abnormalities, but common in children of mothers with lupus are initiated study protocol, realizing you including laboratory tests and immunological studies cabinet as electrocardiogram and echocardiogram, which gave tone to take the mother immunological studies, being positive antiRo. We concluded that the risk of heart block in a patient with Down syndrome is the same as for the general population.
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Affiliation(s)
- Carla Lucila Illana-Bravo
- Departamento de Cardiología Pediátrica, Hospital General Regional 36, Instituto Mexicano del Seguro Social, Puebla, Puebla, México.
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28
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Chaturvedi K, Prasad D, Ashwath R, Strainic JP, Snyder CS. Isolated Left Subclavian Artery, Complete Atrioventricular Block, and Tricuspid Atresia in a Neonate. Tex Heart Inst J 2016; 43:546-549. [PMID: 28100981 DOI: 10.14503/thij-15-5692] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Isolated left subclavian artery is one of the rarer aortic arch anomalies. It has been associated with other congenital heart diseases, typically tetralogy of Fallot, double-outlet right ventricle, and atrial and ventricular septal defects. Its significant clinical implications include a left-to-right shunt from the vertebrobasilar system, which causes pulmonary overcirculation and subclavian steal. We present an unusual case of a premature infant who was diagnosed prenatally with congenital complete atrioventricular block and tricuspid atresia and was found to have an isolated left subclavian artery postnatally. The patient underwent implantation of a permanent single-chamber epicardial pacing system. To our knowledge, this combination of lesions has not been reported-and in our case, it influenced our surgical planning.
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29
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Rouf S, Chowdhury AW. Congenital Complete Heart Block Presenting in Pregnancy: A Case Report. Mymensingh Med J 2016; 25:785-789. [PMID: 27941748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Congenital complete heart block presenting for the first time in pregnancy is a rare occurrence posing a therapeutic challenge. We present a case of unpaced preexisting congenital complete heart block in pregnancy diagnosed for the first time during routine prenatal care at her early weeks of gestation. Our patient was asymptomatic and haemodynamically stable and was managed conservatively with a multidisciplinary term approach. Intrauterine growth retardation (IUGR) was present and she was delivered by ceasarean section at term for foetal distress with IUGR. Prophylactic temporary pacing was done before surgery and was weaned off in the early postpartum period. When a multidisciplinary approach is used both maternal and neonatal outcome are favorable. We review the literature in an attempt to discuss the therapeutic policy for such patients.
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Affiliation(s)
- S Rouf
- Professor Salma Rouf, Professor, Department of Obstetrics & Gynaecology, Dhaka Medical College, Dhaka, Bangladesh
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30
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Abstract
Autoimmune diseases (AD) occur frequently in women during their childbearing years and may influence pregnancy outcome and neonatal health. Patients with systemic lupus erythematosus (SLE) can experience a disease flare-up during pregnancy with potential negative effects on the product of conceptus, especially if the disease is active. Recurrent pregnancy loss is now considered as a treatable clinical condition associated with the presence of circulating antiphospholipid antibodies (aPL). The neonatal lupus syndromes (NLS), caused by the transplacental passage of maternal IgG anti-Ro/SS-A and anti-La/SS-B antibodies to the fetus, carry significant morbidity and mortality in case of cardiac manifestations. Immunosuppressive agents are often administered during pregnancy in order to control maternal disease and to ensure a better pregnancy outcome. Nowadays, owing to our increasing knowledge of the disease pathophysiological mechanisms and the development of combined medical-obstetric clinics, pregnancy outcome in patients with AD has notably improved.
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Affiliation(s)
- A Tincani
- Rheumatology and Clinical Immunology, Brescia Hospital and University, Italy.
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Abstract
We compiled information on antibodies in Sjögren syndrome, focusing more on clinical manifestations associated with anti-Ro/SSA and anti-La/SSB antibodies and studies regarding novel antibodies. We reviewed previous as well as most recent studies with the subject heading Sjogren in combination with antibodies and congenital heart block (CHB). Almost half of asymptomatic mothers giving birth to children with CHB ultimately develop Sjögren. We discussed studies concerning the presence of antibodies predating clinical manifestations of disease. Studies in the future are required to ascertain the pathogenic mechanisms associated with these antibodies and the specific clinical manifestation related to new autoantibodies.
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Affiliation(s)
- Anum Fayyaz
- Arthritis & Clinical Immunology Program, Oklahoma Medical Research Foundation, 825 Northeast, 13th Street, Oklahoma City, OK 73104, USA; Department of Medicine, College of Medicine, 1000 N Lincoln Boulevard, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA; Medical and Research Services, US Department of Veterans Affairs Hospital, 921 NE 13th Street, Oklahoma City, OK 73104, USA
| | - Biji T Kurien
- Arthritis & Clinical Immunology Program, Oklahoma Medical Research Foundation, 825 Northeast, 13th Street, Oklahoma City, OK 73104, USA; Department of Medicine, College of Medicine, 1000 N Lincoln Boulevard, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA; Medical and Research Services, US Department of Veterans Affairs Hospital, 921 NE 13th Street, Oklahoma City, OK 73104, USA
| | - R Hal Scofield
- Arthritis & Clinical Immunology Program, Oklahoma Medical Research Foundation, 825 Northeast, 13th Street, Oklahoma City, OK 73104, USA; Department of Medicine, College of Medicine, 1000 N Lincoln Boulevard, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA; Medical and Research Services, US Department of Veterans Affairs Hospital, 921 NE 13th Street, Oklahoma City, OK 73104, USA.
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Affiliation(s)
- Graham Hughes
- Lupus Unit, The Rayne Institute, St Thomas' Hospital, London SE1 7EH, UK.
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Abstract
The neonatal lupus syndromes (NLS), while quite rare, carry significant mortality and morbidity in cases of cardiac manifestations. Although anti-SSA/Ro-SSB/La antibodies are detected in .85% of mothers whose fetuses are identified with congenital heart block (CHB) in a structurally normal heart, when clinicians applied this testing to their pregnant patients, the risk for a woman with the candidate antibodies to have a child with CHB was at or below 1 in 50. While the precise pathogenic mechanism of antibody-mediated injury remains unknown, it is clear that the antibodies alone are insufficient to cause disease and fetal factors are likely contributory. In vivo and in vitro evidence supports a pathologic cascade involving apoptosis of cardiocytes, surface translocation of Ro and La antigens, binding of maternal autoantibodies, secretion of profibrosing factors (e.g., TGFb) from the scavenging macrophages and modulation of cardiac fibroblasts to a myofibroflast scarring phenotype. The spectrum of cardiac abnormalities continues to expand, with varying degrees of block identified in utero and reports of late onset cardiomyopathy (some of which display endocardial fibroelastosis). Moreover, there is now clear documentation that incomplete blocks (including those improving in utero with dexamethasone) can progress postnatally, despite the clearance of the maternal antibodies from the neonatal circulation. Better echocardiographic measurements which identify first degree block in utero may be the optimal means of approaching pregnant women at risk. Prophylactic therapies, including treatment with intravenous immunoglobulin, await larger trials. In order to achieve advances at both the bench and bedside, national research registries established in the US and Canada are critical.
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Affiliation(s)
- J P Buyon
- Department of Medicine, Division of Rheumatology, New York University School of Medicine, New York, NY, USA.
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Motta M, Tincani A, Lojacono A, Faden D, Gorla R, Airò P, Neri F, Gasparoni A, Ciardelli L, de Silvestri A, Marconi M, Chirico G. Neonatal outcome in patients with rheumatic disease. Lupus 2016; 13:718-23. [PMID: 15485111 DOI: 10.1191/0961203403lu2002oa] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Rheumatic autoimmune diseases have a higher prevalence in women, particularly during their childbearing age. Due to improved management, an increasing number of patients plan and carry out one or more pregnancies. Therefore, a growing interest is being paid to the possible consequences of maternal disease and associated treatment on the fetus and newborn infant. If maternal disease is characterized by the presence of IgG isotype autoantibodies, these can cross the placenta with possible antibody-mediated damage to the fetus. This is typically the case of the so called neonatal lupus erythematosus (NLE); a similar mechanism has been shown in infants of patients with immune thrombocytopenic purpura (ITP) and, less frequently, in those from mothers with antiphospholipid syndrome (APS). Indeed, this last condition is often responsible for placental, rather than neonatal, pathology. In addition, immunosuppressive and other drugs administered to the mothers during pregnancy and lactation might affect the fetal and neonatal immune system development. Finally, mothers disease and/or treatment could be related to neuropsychological alteration reported in some of their children.
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Affiliation(s)
- M Motta
- Neonatology and Neonatal Intensive Care, Spedali Civili, Brescia, Italy.
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Gargouri L, Safi F, Maalej B, Mallek S, Turki F, Majdoub I, Akrout M, Abid D, Kamoun S, Mahfoudh A. Neonatal lupus erythematosus with congenital heart block in twins. Tunis Med 2016; 94:401-404. [PMID: 28051234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Background - Neonatal lupus erythematosus is an uncommon acquired autoimmune disease caused by transplacental passage of maternal antibodies SSA/Ro, SSB/La or U1 ribonucleoproteins. The most common clinical manifestations are skin rash, cardiac lesions, thrombocytopenia, anemia and hepatosplenomegaly. Complete congenital heart block is usually irreversible needing a pacemaker implantation in two-thirds of cases. Cases report - We report neonatal lupus erythematosus with complete congenital heart block in twins. Newborns were delivered by caesarean section at week 38 of gestation with a heart rate regular at 70 beats per minute. Both twins and mother were positive for antinuclear, anti-SSA, and anti-SSB antibodies. Twins received single-chamber pacemaker implants at day 12 of life. The evolution was immediately favorable with a heart rate around 110 beats per minute. The follow-up was 2 years. The twins are currently asymptomatic. Conclusion - Complete congenital heart block is the most serious manifestation of the neonatal lupus erythematosus associated with significant morbidity and mortality.
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Ruffatti A, Cerutti A, Favaro M, Del Ross T, Calligaro A, Hoxha A, Marson P, Leoni L, Milanesi O. Plasmapheresis, intravenous immunoglobulins and bethametasone - a combined protocol to treat autoimmune congenital heart block: a prospective cohort study. Clin Exp Rheumatol 2016; 34:706-713. [PMID: 27385463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2015] [Accepted: 02/08/2016] [Indexed: 06/06/2023]
Abstract
OBJECTIVES At the moment there are no standard guidelines for the treatment of autoimmune congenital heart block (CHB). We set out to carry out a prospective cohort study to evaluate the benefits, limits, and safety of a combined therapy protocol to treat antibody-related CHB. METHODS Twelve consecutive pregnant patients positive to anti-SSA/Ro ± anti-SSB/La antibodies in whom CHB was detected were prospectively evaluated from 2009 to 2014. The treatment protocol consisted of: weekly plasmapheresis, fortnightly intravenous immunoglobulins (IVIG), and daily 4 mg betamethasone from CHB detection until delivery; IVIG was administered to the neonates soon after birth. RESULTS At the time CHB was detected, six of the foetuses presented atrioventricular blocks of 2(nd) degree type and six of 3(rd) degree type. Two of the foetuses with a 2(nd) degree block reverted to a 1st degree block and one to a normal atrioventricular conduction. The condition was stable throughout the pregnancy in the other three cases of 2(nd) degree block. All six 3(rd) degree blocks were stable during pregnancy and confirmed at birth. After a mean of 37.6 months ± 19.6 SD post-birth, the infants with 1st, normal sinus rhythm, and 2(nd) degree blocks at birth were all found to be stable. During the follow-up (29 months ± 19.8 SD), pacemakers were implanted in three of the six infants with 3(rd) degree blocks. CONCLUSIONS This combined therapy seems to be effective and safe in treating 2(nd) degree CHB, while its efficacy in treating 3rd degree CHB remains to be established.
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Affiliation(s)
- Amelia Ruffatti
- Rheumatology Unit, Department of Medicine, University of Padua, Italy.
| | - Alessia Cerutti
- Paediatric Cardiology Unit, Department of Women's and Children's Health, University of Padua, Italy
| | - Maria Favaro
- Rheumatology Unit, Department of Medicine, University of Padua, Italy
| | - Teresa Del Ross
- Rheumatology Unit, Department of Medicine, University of Padua, Italy
| | - Antonia Calligaro
- Rheumatology Unit, Department of Medicine, University of Padua, Italy
| | - Ariela Hoxha
- Rheumatology Unit, Department of Medicine, University of Padua, Italy
| | - Piero Marson
- Apheresis Unit, Blood Transfusion Service, University Hospital of Padua, Italy
| | - Loira Leoni
- Cardiology Unit, Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Italy
| | - Ornella Milanesi
- Paediatric Cardiology Unit, Department of Women's and Children's Health, University of Padua, Italy
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Altit G, Sarquella-Brugada G, Dahdah N, Dallaire F, Carceller AM, Abadir S, Fournier A. Effect of dual-chamber pacemaker implantation on aortic dilatation in patients with congenital heart block. Am J Cardiol 2014; 114:1573-7. [PMID: 25248809 DOI: 10.1016/j.amjcard.2014.08.022] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2014] [Revised: 08/15/2014] [Accepted: 08/15/2014] [Indexed: 11/29/2022]
Abstract
Ascending aortic dilatation (AoD) in patients with structurally normal hearts and congenital heart block (CHB) has been previously described. The cause and management of AoD are yet to be determined. The aim of this study was to test the hypothesis that AoD in children with CHB regresses after the implantation of cardiac dual-chamber pacemakers (PMs). The secondary hypothesis was an association between the presence of maternal antibodies (SS-A or SS-B) and the degree of aortic dilatation. Clinical data with echocardiographic correlates of patients with CHB followed at a single institution were retrospectively reviewed. Comparison of the target structures diameter was based on 3 different z-score equations, with AoD defined as a z score >2. Inclusion criteria were CHB diagnosis by 12-lead electrocardiography or Holter recording and benefit from a permanent dual-chamber PM. Excluded were patients with incomplete echocardiographic measurements, those with major structural heart defects, and those with syndromes or diseases known to be associated with AoD. There were 17 patients, diagnosed at a median age of 6 months (interquartile range 0 to 47.8). Maternal antibodies were positive in 6 patients and negative in 11. All patients underwent PM implantation at a median age of 4.5 years (interquartile range 1.4 to 7.9). AoD (z score >2.0 according to 3 different equations) was present in 35% to 59% of patients. There was a significant reduction of mean ascending aortic z score in patients with AoD from 4.66 to 3.67 (p = 0.06), from 4.82 to 2.95 (p = 0.002), and from 6.07 to 3.39 (p = 0.006) according to the various z-score equations. Most patients with positive serology had AoD, without reaching statistical significance. In conclusion, AoD is associated with CHB, more likely in infants exposed to maternal antibodies. AoD decreases after the implantation of a PM. This is probably related to the regularization of stroke volume.
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Affiliation(s)
- Gabriel Altit
- Department of Pediatrics, Université de Montréal, Faculté de Médecine, Montréal, Québec, Canada
| | - Georgia Sarquella-Brugada
- Division of Pediatric Cardiology, CHU Sainte-Justine, Université de Montréal, Faculté de Médecine, Montréal, Québec, Canada; Division of Pediatric Cardiology, Centre de Genètica Cardiovascular, Universitat de Girona, Girona, Spain
| | - Nagib Dahdah
- Division of Pediatric Cardiology, CHU Sainte-Justine, Université de Montréal, Faculté de Médecine, Montréal, Québec, Canada
| | - Frédéric Dallaire
- Division of Pediatric Cardiology, University Hospital of Sherbrooke, Université de Sherbrooke, Sherbrooke, Québec, Canada
| | - Ana Maria Carceller
- Department of Pediatrics, Université de Montréal, Faculté de Médecine, Montréal, Québec, Canada
| | - Sylvia Abadir
- Division of Pediatric Cardiology, CHU Sainte-Justine, Université de Montréal, Faculté de Médecine, Montréal, Québec, Canada
| | - Anne Fournier
- Division of Pediatric Cardiology, CHU Sainte-Justine, Université de Montréal, Faculté de Médecine, Montréal, Québec, Canada.
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Scarsi M, Radice A, Pregnolato F, Ramoni V, Grava C, Bianchi L, Gerosa M, Mosca M, Ghirardello A, Tani C, Motta M, Quinzanini M, Tincani A, Ruffatti A, Migliorini P, Doria A, Meroni PL, Brucato A. Anti-Ro/SSA-p200 antibodies in the prediction of congenital heart block. An Italian multicentre cross-sectional study on behalf of the 'Forum Interdisciplinare per la Ricerca nelle Malattie Autoimmuni (FIRMA) Group'. Clin Exp Rheumatol 2014; 32:848-854. [PMID: 25327946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2013] [Accepted: 01/09/2014] [Indexed: 06/04/2023]
Abstract
OBJECTIVES To verify the association between the presence of specific anti-52 Ro/SSA-p200 antibodies and congenital heart block (CHB). METHODS 207 pregnant Italian women carrying anti-Ro/SSA Ab were retrospectively evaluated. Anti-p200 Ab were investigated in the mothers' sera by ELISA (Euro-Diagnostica,Wieslab SS-A p200). RESULTS CHB occurred in 42 children (34 complete CHB), whereas 165 were not affected. All CHB cases were previously identified with an ELISA screening for anti-Ro/SSA 60 kD Ab. Anti-p200 Ab were more frequently positive (81.0% vs. 59.1%, p=0.013) and at a higher titer in CHB mothers (Absorbance ratio: 2.030 (0.208-4.052) vs. 0.925 (0.200-3.816); p=0.017). This association was maintained even when the 42 mothers of children with CHB were compared with a control group matched for age and diagnosis (80.9% vs. 50.0%; p=0.006). The presence of anti-p200 Ab provided an odds ratio (OR) for CHB of 2.98 (CI: 1.30-6.83), which was higher than that of other variables, such as maternal disease and other antibody specificities. CHB risk significantly decreased in the absence of this fine specificity (OR:0.34, CI: 0.15-0.77). However, while the negative predictive value related to anti-Ro/SSA 60 kD Ab ELISA was 100%, almost 20% of mothers negative for anti-p200 Ab delivered babies with CHB. CONCLUSIONS Anti-p200 antibodies seem to be associated with CHB with a higher probability than anti-Ro/SSA Ab, and therefore may be an additional test to identify mothers at higher risk to deliver affected children. An ELISA screening for anti-Ro/SSA 60 kD Ab is nevertheless mandatory given the probability of developing CHB also in the absence of anti-p200 Ab.
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Affiliation(s)
- Mirko Scarsi
- Rheumatology and Clinical Immunology Unit, Spedali Civili and University of Brescia, Italy.
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Rai V, Shariffuddin II, Chan YK, Muniandy RK, Wong KK, Singh S. Peri-operative management of hysterostomy in a parturient with complete heart block, placenta accreta and intrauterine death. BMC Anesthesiol 2014; 14:49. [PMID: 25002831 PMCID: PMC4083103 DOI: 10.1186/1471-2253-14-49] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2014] [Accepted: 06/25/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Complete heart block in pregnancy has serious implications particularly during the period of delivery. This is more so if the delivery is an operative one as the presence of heart block may produce haemodynamic instability in the intra operative period. We report a unique case of a pregnant mother with complete heart block undergoing hysterostomy, complicated by placenta accreta and intrauterine death. CASE PRESENTATION A 37 year old Malaysian Chinese parturient was admitted at 25 weeks gestation following a scan which suggested intrauterine death and placenta accreta. She was diagnosed to have congenital complete heart block after her first delivery eight years previously but a pacemaker was never inserted. These medical conditions make her extremely likely to experience massive bleeding and haemodynamic instability. Among the measures taken to optimise her pre-operatively were the insertion of a temporary intravenous pacemaker and embolization of the uterine arteries to minimize peri-operative blood loss. She successfully underwent surgery under general anesthesia, which was relatively uneventful and was discharged well on the fourth post-operative day. CONCLUSION Congenital heart block in pregnancies in the presence of potential massive bleeding is best managed by a team, with meticulous pre-operative optimization. Suggested strategies would include insertion of a temporary pacemaker and embolization of the uterine arteries to reduce the risk of the patient getting into life threatening situations.
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Affiliation(s)
- Vineya Rai
- Department of Anaesthesiology, Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur, Malaysia
| | - Ina I Shariffuddin
- Department of Anaesthesiology, Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur, Malaysia
| | - Yoo K Chan
- Department of Anaesthesiology, Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur, Malaysia
| | - Rajesh K Muniandy
- Department of Medicine Based, School of Medicine, Universiti Malaysia Sabah, Kota Kinabalu, Sabah, Malaysia
| | - Kang K Wong
- Department of Anaesthesiology, Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur, Malaysia
| | - Sukcharanjit Singh
- Department of Anaesthesiology, Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur, Malaysia
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Singalavanija S, Limpongsanurak W, Aoongern S. Neonatal lupus erythematosus: a 20-year retrospective study. J Med Assoc Thai 2014; 97 Suppl 6:S74-S82. [PMID: 25391176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
OBJECTIVE To study clinical manifestations, investigations, treatment and outcomes of neonatal lupus erythematosus (NLE) patients and their mothers. MATERIAL AND METHOD A retrospective descriptive study was performed to review the neonatal lupus erythematosus patients and their mothers at Queen Sirikit National Institute of Child Health during January 1993 to December 2013. The diagnostic criteria required the presence of clinical symptoms plus positive anti-Ro/SSA or anti-La/SSB or both. RESULTS There were 34 cases, 12 males and 22 females. Age of onset of clinical manifestations was from birth to 60 days with median age of 21 days. Cutaneous, hepatobiliary, hematological and cardiac abnormalities were found in 88.2%, 61.2%, 50%, 14.7%, respectively. Cutaneous lesions included erythematous rash (70%), annular lesions (75.8%), petechiae (26.6%), raccoon eyes (26.6%), and telangiectasia (20%). Among those with hepatic involvement (n = 18), transaminitis was the most common finding (100%) followed by hepatosplenomegaly (38.8%) and cholestasis (22.2%). Seventeen cases (50%) had hematological problems including anemia (29.4%) and anemia with thrombocytopenia (20.6%). The most severe complication, complete heart block was found in 14.7% (n = 5). Anti-Ro/SSA and anti-La/SSB were positive in 91.1% and 58.8% of cases, respectively. All four babies with complete heart block were treated with pacemaker. Systemic corticosteroids were given to eleven babies due to severe skin lesions and hepatic involvement. There was no mortality during the study. Most neonatal lupus erythematosus mothers (24 cases, 74.2%) were asymptomatic. Ten mothers (25.8%) were diagnosed as autoimmune diseases (systemic lupus erythematosus in 6 cases and other autoimmune diseases in 4 cases). However, 7 of 24 asymptomatic mothers developed SLE within 3 years after delivery. CONCLUSION NLE should be suspected among neonates or young infants presenting with congenital heart block or skin rash with multi-system involvement despite a lack of concurrent maternal autoimmune diseases. Anti-Ro/SSA and/or anti-La/SSB are the most useful laboratory diagnosis. Most NLE patients without congenital heart block have relatively good prognosis.
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Miyano A, Nakayama M, Waguri M, Nakanishi I. [Comparison of tests for SS-A/Ro, Ro52 and Ro60 in predicting congenital heart block]. Rinsho Byori 2014; 62:324-331. [PMID: 25022061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Neonatal lupus erythematosus (NLE) is a rare syndrome caused by the transplacental passage of maternal autoantibodies. Anti SS-A antibodies of a mother with Sjögren syndrome are associated with congenital heart block (CHB) in the newborns with NLE. The purpose of this study was to investigate the utility of maternal antibody titers for SS-A, Ro52 and Ro60 in mothers of newborns with CHB. The study involved a total of 304 cases, 25 from mothers of newborns with CHB, 104 from mothers of newborns without and 175 from mothers suspected to have connective tissue diseases. All sera were tested with the EliA SS-A, EliA Ro52, EliA Ro60, MESACUP Ro52 and MESACUP Ro60. The concordance rate of Ro52 assays was 93.4%, whereas Ro60 assays showed a lower concordance rate (74.7%). The areas under the curve (AUC) of the EliA assays were higher than those of the MESACUP assays. The optimal cut-off values for EliA SS-A/Ro and EliA Ro60 as derived from the ROC analysis were 2027 U/mL and 2446 U/mL, respectively. The sensitivity and specificity for EliA SS-A using optimal cut-off values were 96.0% and 92.3%, respectively. A titer of 90% positive predictive value for EliA SS-A was reached at a cut-off of 9897.1 U/mL, corresponding to sensitivity and specificity values of 36.0% and 100%, respectively. In conclusion, the optimal cut-off value for EliA SS-A is likely to be useful for application in clinical practice for the EliA SS-A measurements in mothers to evaluate the risk of NLE for their newborns.
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Zhou L, Vest AN, Chmait RH, Bar-Cohen Y, Pruetz J, Silka M, Zheng K, Peck R, Loeb GE. A percutaneously implantable fetal pacemaker. Annu Int Conf IEEE Eng Med Biol Soc 2014; 2014:4459-4463. [PMID: 25570982 PMCID: PMC4346192 DOI: 10.1109/embc.2014.6944614] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
A miniaturized, self-contained pacemaker that could be implanted with a minimally invasive technique would dramatically improve the survival rate for fetuses that develop hydrops fetalis as a result of congenital heart block. We are currently validating a device that we developed to address this bradyarrhythmia. Preclinical studies in a fetal sheep model are underway to demonstrate that the device can be implanted via a minimally invasive approach, can mechanically withstand the harsh bodily environment, can induce effective contractions of the heart muscle with an adequate safety factor, and can successfully operate for the required device lifetime of three months using the previously-developed closed loop transcutaneous recharging system.
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Strandberg LS, Cui X, Rath A, Liu J, Silverman ED, Liu X, Siragam V, Ackerley C, Su BB, Yan JY, Capecchi M, Biavati L, Accorroni A, Yuen W, Quattrone F, Lung K, Jaeggi ET, Backx PH, Deber CM, Hamilton RM. Congenital heart block maternal sera autoantibodies target an extracellular epitope on the α1G T-type calcium channel in human fetal hearts. PLoS One 2013; 8:e72668. [PMID: 24039792 PMCID: PMC3767782 DOI: 10.1371/journal.pone.0072668] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2012] [Accepted: 07/17/2013] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Congenital heart block (CHB) is a transplacentally acquired autoimmune disease associated with anti-Ro/SSA and anti-La/SSB maternal autoantibodies and is characterized primarily by atrioventricular (AV) block of the fetal heart. This study aims to investigate whether the T-type calcium channel subunit α1G may be a fetal target of maternal sera autoantibodies in CHB. METHODOLOGY/PRINCIPAL FINDINGS We demonstrate differential mRNA expression of the T-type calcium channel CACNA1G (α1G gene) in the AV junction of human fetal hearts compared to the apex (18-22.6 weeks gestation). Using human fetal hearts (20-22 wks gestation), our immunoprecipitation (IP), Western blot analysis and immunofluorescence (IF) staining results, taken together, demonstrate accessibility of the α1G epitope on the surfaces of cardiomyocytes as well as reactivity of maternal serum from CHB affected pregnancies to the α1G protein. By ELISA we demonstrated maternal sera reactivity to α1G was significantly higher in CHB maternal sera compared to controls, and reactivity was epitope mapped to a peptide designated as p305 (corresponding to aa305-319 of the extracellular loop linking transmembrane segments S5-S6 in α1G repeat I). Maternal sera from CHB affected pregnancies also reacted more weakly to the homologous region (7/15 amino acids conserved) of the α1H channel. Electrophysiology experiments with single-cell patch-clamp also demonstrated effects of CHB maternal sera on T-type current in mouse sinoatrial node (SAN) cells. CONCLUSIONS/SIGNIFICANCE Taken together, these results indicate that CHB maternal sera antibodies readily target an extracellular epitope of α1G T-type calcium channels in human fetal cardiomyocytes. CHB maternal sera also show reactivity for α1H suggesting that autoantibodies can target multiple fetal targets.
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Affiliation(s)
- Linn S. Strandberg
- Department of Physiology and Experimental Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Xuezhi Cui
- Department of Physiology and Experimental Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Arianna Rath
- Division of Molecular Structure and Function, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Jie Liu
- Departments of Physiology and Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Earl D. Silverman
- Department of Physiology and Experimental Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Xiaoru Liu
- Department of Physiology and Experimental Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Vinayakumar Siragam
- Department of Physiology and Experimental Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Cameron Ackerley
- Department of Physiology and Experimental Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Brenda Bin Su
- Department of Physiology and Experimental Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Jane Yuqing Yan
- Department of Physiology and Experimental Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
| | | | | | | | - William Yuen
- Department of Physiology and Experimental Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
| | | | - Kalvin Lung
- Department of Physiology and Experimental Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Edgar T. Jaeggi
- Department of Physiology and Experimental Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Peter H. Backx
- Departments of Physiology and Medicine, University of Toronto, Toronto, Ontario, Canada
- Division of Cardiology, University Health Network, Toronto, Ontario, Canada
| | - Charles M. Deber
- Division of Molecular Structure and Function, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Biochemistry, University of Toronto, Toronto, Ontario, Canada
| | - Robert M. Hamilton
- Department of Physiology and Experimental Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
- * E-mail:
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Abstract
Maternal immune responses during pregnancy are critical in programming the future health of a newborn. The maternal immune system is required to accommodate fetal immune tolerance as well as to provide a protective defence against infections for the immunocompromised mother and her baby during gestation and lactation. Natural immunity and antibody production by maternal B cells play a significant role in providing such immunoprotection. However, aberrations in the B cell compartment as a consequence of maternal autoimmunity can pose serious risks to both the mother and her baby. Despite their potential implication in shaping pregnancy outcomes, the role of B cells in human pregnancy has been poorly studied. This review focuses on the role of B cells and the implications of B cell depletion therapy in pregnancy. It highlights the evidence of an association between aberrant B cell compartment and obstetric conditions. It also alludes to the potential mechanisms that amplify these B cell aberrances and thereby contribute to exacerbation of some maternal autoimmune conditions and poor neonatal outcomes. Clinical and experimental evidence suggests strongly that maternal autoantibodies contribute directly to the pathologies of obstetric and neonatal conditions that have significant implications for the lifelong health of a newborn. The evidence for clinical benefit and safety of B cell depletion therapies in pregnancy is reviewed, and an argument is mounted for further clinical evaluation of B cell-targeted therapies in high-risk pregnancy, with an emphasis on improving neonatal outcomes and prevention of neonatal conditions such as congenital heart block and fetal/neonatal alloimmune thrombocytopenia.
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Affiliation(s)
- T G Nguyen
- Perinatal Research, Kolling Institute of Medical Research, North Shore Hospital, Sydney, Australia.
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46
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Barrios Prieto E, Martínez Ceccopieri DA, Panduro Barón JG, Fajardo Dueñas S. [Anti-Ro/SSA antibodies in congenital heart block]. Ginecol Obstet Mex 2012; 80:417-420. [PMID: 22826970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
Describe a case of a female patient having anti-Ro/SSA antibodies without any other risk factor or collagen disease. In her first pregnancy a congenital heart block and hydrops in the fetus were diagnosed, and these caused stillbirth. In a second pregnancy an in utero treatment resulted in the succesful delivery of a normal child.
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47
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Blank AC, Hakim S, Strengers JL, Tanke RB, van Veen TA, Vos MA, Takken T. Exercise capacity in children with isolated congenital complete atrioventricular block: does pacing make a difference? Pediatr Cardiol 2012; 33:576-85. [PMID: 22331055 PMCID: PMC3311981 DOI: 10.1007/s00246-012-0176-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2011] [Accepted: 11/09/2011] [Indexed: 12/17/2022]
Abstract
The management of patients with isolated congenital complete atrioventricular block (CCAVB) has changed during the last decades. The current policy is to pace the majority of patients based on a variety of criteria, among which is limited exercise capacity. Data regarding exercise capacity in this population stems from previous publications reporting small case series of unpaced patients. Therefore, we have investigated the exercise capacity of a group of contemporary children with CCAVB. Sixteen children (mean age 11.5 ± 4; seven boys, nine girls) with CCAVB were tested. In 13 patients, a median number of three pacemakers were implanted, whereas in three patients no pacemaker was given. All patients had an echocardiogram and completed a cardiopulmonary cycle exercise test. Exercise parameters were determined and compared with reference values obtained from healthy Dutch peers. The peak oxygen uptake/body mass was reduced to 34.4 ± 9.5 ml kg(-1) min(-1) (79 ± 24% of predicted) and the ventilatory threshold was reduced to 52 ± 17% of peak oxygen uptake (78 ± 21% of predicted), whereas the peak work load/body mass was 2.8 ± 0.6 W/kg (91 ± 24% of predicted), which was similar to controls. Importantly, 25% of the paced patients showed upper rate restriction by the pacemaker. In conclusion, children with CCAVB show a reduced peak oxygen uptake and ventilatory threshold, whereas they show normal peak work rates. This indicates that they generate more energy during exercise from anaerobic energy sources. Paced children with CCAVB do not perform better than unpaced children.
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Affiliation(s)
- A Christian Blank
- Department of Pediatric Cardiology, Wilhelmina Children's Hospital, University Medical Center, P.O. Box 85090, 3508 AB Utrecht, The Netherlands.
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48
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Abstract
Ro/SSA and La/SSB comprise a linked set of autoantigens that are clinically important members of the extractable nuclear antigen family and key translational biomarkers for lupus and primary Sjögren's syndrome. Autoantibodies directed against the Ro60 and La polypeptide components of the Ro/La ribonucleoprotein complex, and the structurally unrelated Ro52 protein, mediate tissue damage in the neonatal lupus syndrome, a model of passively acquired autoimmunity in humans in which the most serious manifestation is congenital heart block (CHB). Recent studies have concentrated on two distinct pathogenic mechanisms by which maternal anti-Ro/La autoantibodies can cause CHB: by forming immune complexes with apoptotic cells in developing fetal heart; and/or by acting as functional autoantibodies that cross-react with and inhibit calcium channels. Although the precise role of the individual autoantibodies is yet to be settled, maternal anti-Ro60 and anti-Ro52 remain the most likely culprits. This article will discuss the molecular pathways that culminate in the development of CHB, including the recent discovery of β2 glycoprotein I as a protective factor, and present a proteomic approach based on direct mass spectrometric sequencing, which may give a more representative snapshot of the idiotype repertoire of these autoantibodies than genomic-based technologies.
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Affiliation(s)
- Rhianna Lindop
- Department of Immunology, Flinders Medical Centre and Flinders University, Bedford Park, South Australia, Australia
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49
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Chockalingam P, Jaeggi ET, Rammeloo LA, Haak MC, Adama van Scheltema PN, Breur JMPJ, Bartelings MM, Clur SAB, Blom NA. Persistent fetal sinus bradycardia associated with maternal anti-SSA/Ro and anti-SSB/La antibodies. J Rheumatol 2011; 38:2682-5. [PMID: 22089457 DOI: 10.3899/jrheum.110720] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
Abstract
OBJECTIVE To study the clinical course and outcome of fetal sinus bradycardia (SB) due to maternal antibody-induced sinus node dysfunction. METHODS We reviewed the maternal, prenatal, and postnatal findings of fetuses with SB associated with elevated maternal anti-SSA/Ro and anti-SSB/La antibodies. RESULTS Of the 6 cases diagnosed prenatally, 3 had isolated SB persisting after birth and had a good prognosis. Three fetuses with SB and severe myocardial involvement (congenital complete heart block and/or endocardial fibroelastosis) succumbed in utero in spite of treatment. Postmortem histopathology in 1 fetus showed inflammatory destruction of the sinus and atrioventricular nodes. SB was detected incidentally in a 7-year-old girl. She had intermittent heart block with progressive sinus arrest requiring permanent pacemaker. CONCLUSION Fetal SB associated with maternal autoantibodies may persist in childhood, with a good prognosis in the absence of widespread cardiac involvement.
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Affiliation(s)
- Priya Chockalingam
- Department of Pediatric Cardiology, Academic Medical Centre, Amsterdam, The Netherlands
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50
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Narayan HK, Fifer W, Carroll S, Kern J, Silver E, Williams IA. Hypoplastic left heart syndrome with restrictive atrial septum and advanced heart block documented with a novel fetal electrocardiographic monitor. Ultrasound Obstet Gynecol 2011; 38:472-474. [PMID: 21374749 PMCID: PMC3612972 DOI: 10.1002/uog.8982] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 02/21/2011] [Indexed: 05/30/2023]
Abstract
Hypoplastic left ventricle with congenital heart block has been reported previously in a fetus with concurrent left atrial isomerism and levo-transposition of the great arteries. We present the unusual case of an infant diagnosed in utero with hypoplastic left heart syndrome, a restrictive atrial septum and advanced heart block but with D-looping of the ventricles and no atrial isomerism. In addition, fetal heart rhythm was documented with the assistance of a new fetal electrocardiographic monitor.
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Affiliation(s)
- H K Narayan
- Department of Pediatrics, Division of Pediatric Cardiology, Columbia University Medical Center, New York, NY 10032, USA
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