The challenge of fetal dysrhythmias: Echocardiographic diagnosis and clinical management

Chair of Cardiology Second University of Naples, A.O. V. Monaldi, Italy.
Journal of Cardiovascular Medicine (Impact Factor: 1.51). 02/2008; 9(2):153-60. DOI: 10.2459/JCM.0b013e3281053bf1
Source: PubMed


The present study aimed to evaluate the management of fetal cardiac dysrhythmias based on prior identification of the underlying electrophysiological mechanism.
We studied 36 consecutive fetuses with cardiac dysrhythmia. Rhythm diagnosis was based on M-mode, pulsed wave Doppler and tissue Doppler imaging (TDI). Only fetuses with: (i) incessant tachycardia (> 12 h) and mean ventricular rate > 200 beats/min, (ii) signs of left ventricular dysfunction, or (iii) hydrops, were treated using oral maternal drug therapy.
The mean gestational age at diagnosis was 24.3 +/- 4.5 weeks. Twenty-one fetuses had tachycardia with a 1: 1 atrial-ventricular (AV) conduction. Based on ventricular-atrial interval, prenatal diagnosis was: permanent junctional reciprocating (n = 6), atrial ectopic (n = 6) or atrial-ventricular re-entry tachycardia (n = 9). One had atrial flutter, one ventricular tachycardia and four congenital AV block. Nine showed premature atrial or ventricular beats. Fifteen fetuses with incessant tachycardia, left ventricular dysfunction or hydrops were prenatally treated with maternal administration of digoxin, sotalol or flecainide. The total success rate (sinus rhythm or rate control) was 14/15 (93%). Seven fetuses were hydropics. Three of these died (one at 28 weeks of gestation, two in the first week of life). The prenatal diagnosis of dysrhythmia was confirmed at the birth in 31 of 35 live-born. No misdiagnosis was made using TDI. At 3 +/- 1.1-year follow-up, 33/35 children were alive and well.
Fetal echocardiography could clarify the electrophysiological mechanism of fetal cardiac dysrhythmias and guide the therapy.

Download full-text


Available from: Michele D'Alto
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: In unserer Pilotstudie ist erstmals die Anwendung eines High-end-Ultraschallsystems zur Erstellung qualitativ hochwertiger Kurvenprofile mittels Colour-TDI geprüft worden. Bei 20 Feten wurden im longitudinalen Vierkammerblick Untersuchungen zur Kontraktionsgeschwindigkeit in verschiedenen Phasen des Herzzyklus durchgeführt. Messungen wurden in beiden Ventrikeln und im Septum auf basaler, mittiger und apikaler Ebene vorgenommen. Velocity, Strain und Displacement sind in einer mit der Erwachsenenkardiologie vergleichbaren Qualität darstellbar. Im inter- und intraventrikulären Vergleich bestehen signifikante Unterschiede der Kontraktionsgeschwindigkeit und der Gewebeauslenkung, die physiologisch begründbar sind, während regionale Unterschiede der myokardialen Verformung nicht das geforderte Signifikanzniveau (p<0.05) erreichen. Die von uns aufgezeigten Unterschiede in der regionalen Funktion müssen bei Anwendung des Gewebedopplers in der Pränataldiagnostik stets Berücksichtigung finden.
    Preview · Article ·
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Though fetal arrhythmias account for a small proportion of referrals to a fetal cardiologist, they may be associated with significant morbidity and mortality. The present review outlines the current literature with regard to the diagnosis and, in brief, some management strategies in fetal arrhythmias. Advances in echocardiography have resulted in significant improvements in our ability to elucidate the mechanism of arrhythmia at the bedside. At the same time, magnetocardiography is broadening our understanding of mechanisms of arrhythmia especially as it pertains to ventricular arrhythmias and congenital heart block. It provides a unique window to study electrical properties of the fetal heart, unlike what has been available to date. Recent reports of bedside use of fetal ECG make it a promising new technology. Fetal magnetocardiography is also developing. The underlying mechanisms resulting in immune-mediated complete heart block in a small subset of 'at-risk' fetuses is under investigation. There have been great strides in noninvasive diagnosis of fetal arrhythmias. However, we still need to improve our knowledge of the electromechanical properties of the fetal heart as well as the mechanisms of arrhythmia to further improve outcomes. Multiinstitutional collaborative studies are needed to help answer some of the questions regarding patient, drug selection and management algorithms.
    Preview · Article · Nov 2008 · Current opinion in pediatrics
  • [Show abstract] [Hide abstract]
    ABSTRACT: To evaluate the diagnosis, clinical features, management and post-natal follow-up in consecutive fetuses identified with tachycardia. We reviewed consecutive fetuses with tachycardia identified in a single tertiary institution between January, 2001, and December, 2008. We considered several options for management, including no treatment but close surveillance, trans-placental antiarrhythmic therapy in fetuses presenting prior to 36 weeks of gestation, and delivery and treatment as a neonate for fetuses presenting after 36 weeks of gestation. Data was gathered by a review of prenatal and postnatal documentation. Among 29 fetuses with tachycardia, 21 had supraventricular tachycardia with 1 to 1 conduction, 4 had atrial flutter, 3 had atrial tachycardia, while the remaining fetus had ventricular tachycardia. Of the group, 8 fetuses (27.6%) were hydropic. Transplacental administration of antiarrhythmic drugs was used in just over half the fetuses, delivery and treatment as a neonate in one-quarter, and no intervention but close surveillance in one-sixth of the case. Twenty-six of 29 fetuses (89.7%) were born alive. Only patients with fetal hydrops suffered mortality, with 37.5% of this group dying, this being statistically significant, with the value of p equal to 0.03, when compared to non-hydropic fetuses. Only 3 patients (11.5%) were receiving antiarrhythmic prophylaxis beyond the first year of life. A significant proportion of fetal tachycardias recognized before 36 weeks of gestation can be treated successfully by transplacental administration of antiarrhythmic drugs. Fetuses presenting after 36 weeks of gestation can be effectively managed postnatally. The long-term prognosis for fetuses diagnosed with tachycardia is excellent, with the abnormal rhythm resolving spontaneously during the first year of life in most of them.
    No preview · Article · Sep 2009 · Cardiology in the Young
Show more