First‐Line Antiarrhythmic Transplacental Treatment for Fetal Tachyarrhythmia: A Systematic Review and Meta‐Analysis

Alsaied, Tarek; Baskar, Shankar; Fares, Maan; Alahdab, Fares; Czosek, Richard J.; Murad, M. Hassan; Prokop, Larry J.; Divanović, Allison

doi:10.1161/jaha.117.007164

Cited by 67 publications

(86 citation statements)

References 28 publications

(96 reference statements)

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“…Hydrops and fetal ventricular dysfunction were commonly found at diagnosis in our cohort, affecting 20% and 31% of fetuses, respectively. This degree of fetal circulatory distress was similar to that reported in systematic reviews of fetal tachyarrhythmias, where hydrops was present in 17% to 41% of fetuses 6,16 . In the cohort published by Jaeggi et al, 8 hydrops was diagnosed in 6 of 45 (13%) and 35 of 114 (31%) of fetuses with AFL and AVRT, respectively.…”

Section: Discussionsupporting

confidence: 84%

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: Discussionsupporting

confidence: 84%

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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“…The treatment of choices for fetal tachyarrhythmias[43,44] Both M-mode and Doppler echocardiography can help diagnose sinus bradycardia. The prolonged episodes of sinus bradycardia can be caused by fetal distress as a result of fetal hypoxia and acidosis, long QT syndrome, and congenital sinus node dysfunction…”

mentioning

confidence: 99%

Fetal arrhythmias: prenatal evaluation and intrauterine therapeutics

Yuan

2020

Ital J Pediatr

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Introduction: Fetal arrhythmias are a common phenomenon with rather complicated etiologies. Debates remain regarding prenatal diagnosis and treatment of fetal arrhythmias. Methods:The literature reporting on prenatal diagnosis and treatment of fetal arrhythmias published in the recent two decades were retrieved, collected and analyzed. Results: Both fetal magnetocardiogram and electrocardiogram provide information of cardiac time intervals, including the QRS and QT durations. M-mode ultrasound detects the AV and VA intervals, fetal heart rate, and AV conduction. By using Doppler ultrasound, simultaneous recording of the atrial and ventricular waves can be obtained. Benign fetal arrhythmias, including premature contractions and sinus tachycardia, do not need any treatment before and after birth. Sustained fetal arrhythmias that predispose to the occurrence of hydrops fetalis, cardiac dysfunction or eventual fetal demise require active treatments. Intrauterine therapy of fetal tachyarrhythmias has been carried out by the transplacental route. If maternal transplacental treatment fails, intraumbilical, intraperitoneal, or direct fetal intramuscular injection of antiarrhythmic agents can be attempted. Conclusions: The outcomes of intrauterine therapy of fetal tachyarrhythmias depend on the types or etiology of fetal arrhythmias and fetal conditions. Most are curable to a transplacental treatment by the first-line antiarrhythmic agents. Fetal cardiac pacings are effective methods to restore sinus rhythm in drug-resistant or hemodynamically compromised cases. Immediate postnatal pacemaker implantation is warranted in refractory cases.

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“…Both drugs decrease the speed of impulse propagation throughout the entire conduction axis, but with different mechanisms: digoxin acts on the atrioventricular node, while flecainide acts on the His–Purkinje tissue. Apparently, there are no differences in the rate of foetal demise or toxicity between the two drugs . The higher efficacy of flecainide in hydropic foetuses has been attributable to its lipophilic compound, which makes it easier to cross the hydropic placenta.…”

Section: Discussionmentioning

confidence: 99%

Is antiarrhythmic therapy safe in twin pregnancies?

et al. 2019

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Aim The optimal treatment for foetal supraventricular tachycardia (SVT) in twin pregnancies is unclear because of the possible impact on the second twin. This review compared a foetus we treated with antiarrhythmic drugs with the previous case studies. Methods Our case was a dichorionic diamniotic twin pregnancy, where one twin developed foetal hydrops secondary to SVT at 22 weeks of gestation. We searched PubMed to look for previous cases of SVT in twin pregnancies. Results Treatment with transplacental antiarrhythmic therapy from 22 to 36 weeks of gestation successfully resolved the SVT in our affected twin without any impact on the healthy twin or mother. We only found seven similar cases of SVT in twin pregnancies from 1999 to 2017. Although there was no consensus on the treatment that should be provided, none of the studies reported side effects in the twins or the mothers. Conclusion Despite a lack of data on SVT in twin pregnancies, our case, and the previous cases we identified, allowed us to conclude that transplacental antiarrhythmic treatment can successfully achieve cardioversion in the affected twin. It can do this without side effects for the healthy foetus or the mother, even if the treatment lasts for a long period of time.

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First‐Line Antiarrhythmic Transplacental Treatment for Fetal Tachyarrhythmia: A Systematic Review and Meta‐Analysis

Cited by 67 publications

References 28 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

Fetal arrhythmias: prenatal evaluation and intrauterine therapeutics

Is antiarrhythmic therapy safe in twin pregnancies?

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