Antenatal Therapy for Fetal Supraventricular Tachyarrhythmias

Miyoshi, Takekazu; Maeno, Yasuki; Hamasaki, Toshimitsu; Inamura, Noboru; Yasukochi, Satoshi; Kawataki, Motoyoshi; Horigome, Hitoshi; Yoda, Hitoshi; Taketazu, Mio; Nii, Masaki; Hagiwara, Akiko; Kato, Hitoshi; Shimizu, Wataru; Shiraishi, Isao; Sakaguchi, Heima; Ueda, Keiko; Katsuragi, Shinji; Yamamoto, Haruko; Sago, Haruhiko; Ikeda, Tomoaki

doi:10.1016/j.jacc.2019.06.024

Cited by 48 publications

(74 citation statements)

References 26 publications

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“…Fetuses with sustained SVT are typically managed with either transplacental antiarrhythmic drug (AAD) therapy or expedited delivery depending on the gestational age and degree of fetal compromise. Successful termination of fetal SVT using transplacental AAD therapy has previously been described 8‐14 . These works have been limited by small patient sample size, and thus, we sought to add to this fund of knowledge by contributing our own institutional experience managing fetuses with sustained SVT.…”

Section: Introductionmentioning

confidence: 99%

Low mortality in fetal supraventricular tachycardia: Outcomes in a 30‐year single‐institution experience

O’Leary

Alexander

Bezzerides

et al. 2020

Cardiovasc electrophysiol

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Objectives: To describe a single institutional experience managing fetuses with supraventricular tachycardia (SVT) and to identify associations between patient characteristics and fetal and postnatal outcomes.Background: Sustained fetal SVT is associated with significant morbidity and mortality if untreated, yet the optimal management strategy remains unclear.Methods: Retrospective cohort study including fetuses diagnosed with sustained SVT (>50% of the diagnostic echocardiogram) between 1985 and 2018. Fetuses with congenital heart disease were excluded.Results: Sustained SVT was diagnosed in 65 fetuses at a median gestational age of 30 weeks (range, 14-37). Atrioventricular re-entrant tachycardia and atrial flutter were the most common diagnoses, seen in 41 and 16 cases, respectively. Moderate/ severe ventricular dysfunction was present in 20 fetuses, and hydrops fetalis was present in 13. Of the 57 fetuses initiated on transplacental drug therapy, 47 received digoxin first-line, yet 39 of 57 (68%) required advanced therapy with sotalol, flecainide, or amiodarone. Rate or rhythm control was achieved in 47 of 57 treated fetuses. There were no cases of intrauterine fetal demise. Later gestational age at fetal diagnosis (odds ratio [OR], 1.1, 95% confidence interval [CI], 1.01-1.2, P = .02) and moderate/severe fetal ventricular dysfunction (OR, 6.1, 95% CI, 1.7-21.6, P = .005) were associated with postnatal SVT. Two postnatal deaths occurred. Conclusions: Fetuses with structurally normal hearts and sustained SVT can be effectively managed with transplacental drug therapy with minimal risk of intrauterine fetal demise. Treatment requires multiple antiarrhythmic agents in over half of cases. Later gestational age at fetal diagnosis and the presence of depressed fetal ventricular function, but not hydrops, predict postnatal arrhythmia burden. K E Y W O R D S atrial flutter, fetal tachycardia, supraventricular tachycardia, therapy SUPPORTING INFORMATION Additional supporting information may be found online in the Supporting Information section. How to cite this article: O'Leary ET, Alexander ME, Bezzerides VJ, et al. Low mortality in fetal supraventricular tachycardia: Outcomes in a 30-year single-institution experience.

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Section: Introductionmentioning

confidence: 99%

Low mortality in fetal supraventricular tachycardia: Outcomes in a 30‐year single‐institution experience

O’Leary

Alexander

Bezzerides

et al. 2020

Cardiovasc electrophysiol

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“… 10 More recently, a prospective study showed a higher rate of cardioversion, up to 93% for fetuses presenting flutter without hydrops. 13 Its management can be challenging, especially when associated with ventricular dysfunction and severe hydrops. In our population, however, cardioversion was achieved in 14 of 17 (82%) of all flutter cases (including hydropic fetuses), which is similar to the overall rate of cardioversion in our population.…”

Section: Discussionmentioning

confidence: 99%

“…The rationale for transplacental antiarrhythmic treatment (TPT) is to restore sinus rhythm to prevent hydrops and intrauterine death, and potentially allow for vaginal delivery when stable sinus rhythm has been obtained. 8 , 9 Although the overall efficacy of medical transplacental therapies is undisputed, failures and recurrences occur, 10 , 11 , 12 , 13 accounting for a large proportion of the perinatal morbidity and mortality of the condition. The objective of this study is to analyze the perinatal outcomes of fetal tachyarrhythmias after in utero treatment.…”

Section: Introductionmentioning

confidence: 99%

Outcomes of sustained fetal tachyarrhythmias after transplacental treatment

et al. 2021

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Background Fetal tachyarrhythmia is a condition that may lead to cardiac dysfunction, hydrops, and death. Despite a transplacental treatment, failure to obtain or maintain sinus rhythm may occur. Objective We aimed to analyze the perinatal outcomes of sustained fetal tachyarrhythmias after in utero treatment. Methods We performed a retrospective evaluation of 69 cases with sustained fetal tachyarrhythmia. We compared the perinatal and long-term outcomes of prenatally converted and drug-resistant fetuses. Tachyarrhythmia subtypes were also evaluated. Results Conversion to sinus rhythm was obtained in 74% of cases; 26% of cases were drug-resistant and delivered arrhythmic. Three perinatal deaths occurred in both groups (6.7% vs 17%, P = .34). Neonates delivered arrhythmic were more frequently admitted to neonatal intensive care units (75% vs 31%, P < .01), and their hospital stay was longer (20.9 vs 6.64 days, P < .001). Multiple neonatal recurrences (81% vs 11%, P < .001), temporary hemodynamic dysfunction or heart failure (50% vs 6.7%, P < .001), and postnatal use of a combination treatment (44% vs 13%, P = .028) were also more frequent in this population. Beyond the neonatal period, rates of recurrences within the first 16 months were higher in drug-resistant fetuses (HR = 16.14, CI 95% [4.485; 193.8], P < .001). In this population, postnatal electrocardiogram revealed an overrepresentation of rare mechanisms, especially permanent junctional reciprocating tachycardia (PJRT) (31%). Conclusion Prenatal conversion to stable sinus rhythm is a major determinant of perinatal and long-term outcomes in fetal tachyarrhythmias. The underlying electrophysiological mechanisms have a major role in predicting these differential outcomes with an overrepresentation of PJRT in the drug-resistant population.

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“…The practice of fetal medicine centers varies widely in respect to the drug chosen as initial treatment for fetal SVT. All of the following drugs: digoxin, flecainide, sotalol, and amiodarone have been used as first-line transplacental therapy in SVT [ 1 , 9 , 10 , 12 , 13 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 ]. The effectiveness of transplacental treatment is dependent on pharmacokinetics, its capacity to cross the placenta, and fetal bioavailability [ 1 , 5 ].…”

Section: Tachyarrhythmiasmentioning

confidence: 99%

“…For a longtime, digoxin has been used as first line therapy for fetal SVT, but none of the recent studies and meta-analyses supports this idea [ 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 ]. Nonetheless, digoxin has some practical advantages if treatment is considered for moderate fetal disease [ 1 , 3 ].…”

Section: Tachyarrhythmiasmentioning

confidence: 99%

Treatment of Fetal Arrhythmias

Veduță

Panaitescu

Ciobanu

et al. 2021

JCM

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Fetal arrhythmias are mostly benign and transient. However, some of them are associated with structural defects or can cause heart failure, fetal hydrops, and can lead to intrauterine death. The analysis of fetal heart rhythm is based on ultrasound (M-mode and Doppler echocardiography). Irregular rhythm due to atrial ectopic beats is the most common type of fetal arrhythmia and is generally benign. Tachyarrhythmias are diagnosed when the fetal heart rate is persistently above 180 beats per minute (bpm). The most common fetal tachyarrhythmias are paroxysmal supraventricular tachycardia and atrial flutter. Most fetal tachycardias can be terminated or controlled by transplacental or direct administration of anti-arrhythmic drugs. Fetal bradycardia is diagnosed when the fetal heart rate is slower than 110 bpm. Persistent bradycardia outside labor or in the absence of placental pathology is mostly due to atrioventricular (AV) block. Approximately half of fetal heart blocks are in cases with structural heart defects, and AV block in cases with structurally normal heart is often caused by maternal anti-Ro/SSA antibodies. The efficacy of prenatal treatment for fetal AV block is limited. Our review aims to provide a practical guide for the diagnosis and management of common fetal arrythmias, from the joint perspective of the fetal medicine specialist and the cardiologist.

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Antenatal Therapy for Fetal Supraventricular Tachyarrhythmias

Cited by 48 publications

References 26 publications

Low mortality in fetal supraventricular tachycardia: Outcomes in a 30‐year single‐institution experience

Low mortality in fetal supraventricular tachycardia: Outcomes in a 30‐year single‐institution experience

Outcomes of sustained fetal tachyarrhythmias after transplacental treatment

Treatment of Fetal Arrhythmias

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