Skip to main content Accessibility help

We use cookies to distinguish you from other users and to provide you with a better experience on our websites. Close this message to accept cookies or find out how to manage your cookie settings.

Close cookie message
×
Hostname: page-component-cd9895bd7-dzt6s Total loading time: 0 Render date: 2024-12-26T12:26:01.669Z Has data issue: false hasContentIssue false

Chapter 8.1 - Fetal dysrhythmias

The effects of antiarrhythmic therapy on the immature heart

from Section 2 - Fetal disease

Published online by Cambridge University Press:  05 February 2013

By
Edgar Jaeggi ,
Nico A. Blom  and
Tara Bharucha
Edited by
Mark D. Kilby ,
Anthony Johnson  and
Dick Oepkes
Mark D. Kilby
Affiliation:
Department of Fetal Medicine, University of Birmingham
Anthony Johnson
Affiliation:
Baylor College of Medicine, Texas
Dick Oepkes
Affiliation:
Department of Obstetrics, Leiden University Medical Center
Get access

Summary

Introduction

Supraventricular tachyarrhythmias (SVT) belong to the common cardiac causes of fetal hydrops and perinatal death [1, 2]. With cross-sectional echocardiography providing the non-invasive means to detect and monitor tachyarrhythmias in utero, the fetus has increasingly become the target of pharmacological treatment to prevent or treat heart failure. Survival in excess of 95% is now possible for fetal SVT when existing recommendations are implemented. These include the principles that the best treatment is one targeted specifically to the disease mechanism, and that the potential benefits of drug administration should outweigh the risks to the fetus and the co-treated mother. Hence, successful antiarrhythmic therapy necessitates a thorough knowledge of fetal-maternal physiology, arrhythmia mechanisms, treatment indications and limitations, pharmacokinetics, and effects of the elected drug. Antiarrhythmic agents affect the generation and/or propagation of the cardiac rhythm by their actions on one or several ion channel currents (channel blocker) and/or the autonomous nervous system (beta-blocker; digoxin; adenosine). The Singh Vaughan Williams (SVW) classification is often used to describe the specific drug actions. Class I agents (e.g. flecainide) block cardiac Na+ channels; class II agents are anti-sympathetic agents (beta-blocker); class III agents (sotalol; amiodarone) affect K+ efflux; and class IV agents (verapamil) inhibit calcium channels. Digoxin and adenosine have actions that were not included in the original SVW classification. The main focus of this chapter will be on five antiarrhythmic agents (digoxin; flecainide; sotalol; amiodarone; adenosine) which, due to their relative safety and efficacy, are considered the foundation of transplacental and/or direct pharmacological therapy of fetal SVT.

Keywords

sotalolfetal supraventricular tachyarrhythmiasdrug managementdigoxinfetal dysrhythmiasflecainidepharmacological therapyantiarrhythmic therapyadenosineamiodarone
Type
Chapter
Information
Fetal Therapy
Scientific Basis and Critical Appraisal of Clinical Benefits
 , pp. 78 - 86
Publisher: Cambridge University Press
Print publication year: 2012

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

Naheed, ZJ, Strasburger, JF, Deal, BJ, Benson, DW Jr, Gidding, SS. Fetal tachycardia: mechanisms and predictors of hydrops fetalis. J Am Coll Cardiol 1996;27(7):1736–40.Google Scholar
Simpson, JM, Milburn, A, Yates, RW, Maxwell, DJ, Sharland, GK. Outcome of intermittent tachyarrhythmias in the fetus. Pediatr Cardiol 1997;18(2):78–82.Google Scholar
Artman, M, Coetzee, W. Developmental regulation of cardiac ion channels. In: Zipes, D, Jalife, J, eds. Cardiac Electrophysiology From Cell to Bedside. Philadelphia, PA, Saunders Elsevier. 2009; 157–68.
Creazzo, T. Functional developmental biology of the myocardium. In: Loewy Kirby, M, ed. Cardiac Development. New York, NY, Oxford University Press. 2007; 53–68.
Friedman, WF. The intrinsic physiologic properties of the developing heart. Prog Cardiovasc Dis 1972;15(1):87–111.Google Scholar
Romero, T, Covell, J, Friedman, WF. A comparison of pressure-volume relations of the fetal, newborn, and adult heart. Am J Physiol 1972;222(5):1285–90.Google Scholar
Schmidt, MR, Kristiansen, SB, White, P, et al. Glucose-insulin infusion improves cardiac function during fetal tachycardia. J Am Coll Cardiol 2004;43(3):445–52.Google Scholar
Vanoli, E, Cerati, D, Pedretti, RF. Autonomic control of heart rate: pharmacological and nonpharmacological modulation. Basic Res Cardiol 1998;93 Suppl 1:133–42.Google Scholar
Brace, RA. Effects of outflow pressure on fetal lymph flow. Am J Obstet Gynecol 1989;160(2):494–7.Google Scholar
Rudolph, A. The fetal circulation and postnatal adaptation. In: Rudolph, A, ed. Congenital Heart Disease of the Heart. Armonk, NY: Future Publishing Company. 2001; 3–44
Schmidt, KG, Ulmer, HE, Silverman, NH, Kleinman, CS, Copel, JA. Perinatal outcome of fetal complete atrioventricular block: a multicenter experience. J Am Coll Cardiol 1991;17(6):1360–6.Google Scholar
Simpson, JM, Sharland, GK. Fetal tachycardias: management and outcome of 127 consecutive cases. Heart 1998;79(6):576–81.Google Scholar
Jaeggi, E, Carvalho, J, De Groot, E, et al. Comparison of transplacental treatment of fetal supraventricular tachyarrhythmias with digoxin, flecainide and sotalol: results of a non-randomized multicenter study. Circulation 2011; 124(16):1747–54.Google Scholar
Jaeggi, E, Fouron, JC, Fournier, A, et al. Ventriculo-atrial time interval measured on M mode echocardiography: a determining element in diagnosis, treatment, and prognosis of fetal supraventricular tachycardia. Heart 1998;79(6):582–7.Google Scholar
Miller, JM, Zipes, DP. Therapy for cardiac arrhythmias. In: Bonow, RO, Mann, DL, Zipes, DP, Libby, P, Braunwald, E, eds. Braunwald;s Heart Disease. A Textbook of Cardiovascular disease, 9th edn. Philadelphia, PA, Elsevier Saunders. 2012; 715.
Parkash, R, Green, MS, Kerr, CR, et al. The association of left atrial size and occurrence of atrial fibrillation: a prospective cohort study from the Canadian Registry of Atrial Fibrillation. Am Heart J 2004;148(4):649–54.Google Scholar
Hansmann, M, Gembruch, U, Bald, R, Manz, M, Redel, DA. Fetal tachyarrhythmias: transplacental and direct treatment of the fetus-a report of 60 cases. Ultrasound Obstet Gynecol 1991;1(3):162–8.Google Scholar
Jaeggi, E, Fouron, JC, Drblik, SP. Fetal atrial flutter: diagnosis, clinical features, treatment, and outcome. J Pediatr 1998;132(2):335–9.Google Scholar
van Engelen, AD, Weijtens, O, Brenner, JI, et al. Management outcome and follow-up of fetal tachycardia. J Am Coll Cardiol 1994;24(5):1371–5.Google Scholar
Newburger, JW, Keane, JF. Intrauterine supraventricular tachycardia. J Pediatr 1979;95(5 Pt 1):780–6.Google Scholar
Ebenroth, ES, Cordes, TM, Darragh, RK. Second-line treatment of fetal supraventricular tachycardia using flecainide acetate. Pediatr Cardiol 2001;22(6):483–7.Google Scholar
Frohn-Mulder, IM, Stewart, PA, Witsenburg, M, et al. The efficacy of flecainide versus digoxin in the management of fetal supraventricular tachycardia. Prenat Diagn 1995;15(13):1297–302.Google Scholar
Kleinman, CS, Copel, JA, Weinstein, EM, Santulli, TV Jr, Hobbins, JC. Treatment of fetal supraventricular tachyarrhythmias. J Clin Ultrasound 1985;13(4):265–73.Google Scholar
Krapp, M, Baschat, AA, Gembruch, U, Geipel, A, Germer, U. Flecainide in the intrauterine treatment of fetal supraventricular tachycardia. Ultrasound Obstet Gynecol 2002;19(2):158–64.Google Scholar
Fouron, JC, Fournier, A, Proulx, F, et al. Management of fetal tachyarrhythmia based on superior vena cava/aorta Doppler flow recordings. Heart 2003;89(10):1211–16.Google Scholar
Jaeggi, E, Tulzer, G. Pharmacological and interventional fetal cardiovascular treatment. In: Anderson, R, Baker, E, Penny, D, et al. eds. Paediatric Cardiology, 3rd edn. Philadelphia, PA, Churchill Livingstone Elsevier. 2010; 199–218.
Parilla, BV, Strasburger, JF, Socol, ML. Fetal supraventricular tachycardia complicated by hydrops fetalis: a role for direct fetal intramuscular therapy. Am J Perinatol 1996;13(8):483–6.Google Scholar
Weiner, CP, Thompson, MI. Direct treatment of fetal supraventricular tachycardia after failed transplacental therapy. Am J Obstet Gynecol 1988;158(3 Pt 1):570–3.Google Scholar
Bourget, P, Pons, JC, Delouis, C, Fermont, L, Frydman, R. Flecainide distribution, transplacental passage, and accumulation in the amniotic fluid during the third trimester of pregnancy. Ann Pharmacother 1994;28(9):1031–4.Google Scholar
Allan, LD, Chita, SK, Sharland, GK, Maxwell, D, Priestley, K. Flecainide in the treatment of fetal tachycardias. Br Heart J 1991;65(1):46–8.Google Scholar
Jouannic, JM, Delahaye, S, Fermont, L, et al. Fetal supraventricular tachycardia: a role for amiodarone as second-line therapy? Prenat Diagn 2003;23(2):152–6.Google Scholar
Hopson, JR, Buxton, AE, Rinkenberger, RL, et al. Safety and utility of flecainide acetate in the routine care of patients with supraventricular tachyarrhythmias: results of a multicenter trial. The Flecainide Supraventricular Tachycardia Study Group. Am J Cardiol 1996;77(3):72A–82A.Google Scholar
Hohnloser, SH, Woosley, RL. Sotalol. N Engl J Med 1994;331(1):31–8.Google Scholar
Peralta, AO, John, RM, Gaasch, WH, et al. The class III antiarrhythmic effect of sotalol exerts a reverse use-dependent positive inotropic effect in the intact canine heart. J Am Coll Cardiol 2000;36(4):1404–10.Google Scholar
Oudijk, MA, Ruskamp, JM, Ververs, FF, et al. Treatment of fetal tachycardia with sotalol: transplacental pharmacokinetics and pharmacodynamics. J Am Coll Cardiol 2003;42(4):765–70.Google Scholar
Oudijk, MA, Michon, MM, Kleinman, CS, et al. Sotalol in the treatment of fetal dysrhythmias. Circulation 2000;101(23):2721–6.Google Scholar
Oudijk, MA, Ruskamp, JM, Ververs, FF, et al. Treatment of fetal tachycardia with sotalol: transplacental pharmacokinetics and pharmacodynamics. J Am Coll Cardiol 2003;42(4):765–70.Google Scholar
Sonesson, SE, Fouron, JC, Wesslen-Eriksson, E, Jaeggi, E, Winberg, P. Foetal supraventricular tachycardia treated with sotalol. Acta Paediatr 1998;87(5):584–7.Google Scholar
Strasburger, JF, Cuneo, BF, Michon, MM, et al. Amiodarone therapy for drug-refractory fetal tachycardia. Circulation 2004;109(3):375–9.Google Scholar
Arnoux, P, Seyral, P, Llurens, M, et al. Amiodarone and digoxin for refractory fetal tachycardia. Am J Cardiol 1987;59(1):166–7.Google Scholar
Gembruch, U, Manz, M, Bald, R, et al. Repeated intravascular treatment with amiodarone in a fetus with refractory supraventricular tachycardia and hydrops fetalis. Am Heart J 1989;118(6):1335–8.Google Scholar
Pezard, PG, Boussion, F, Sentilhes, L, et al. Fetal tachycardia: a role for amiodarone as first- or second-line therapy? Arch Cardiovasc Dis 2008;101(10):619–27.Google Scholar
Bartalena, L, Bogazzi, F, Braverman, LE, Martino, E. Effects of amiodarone administration during pregnancy on neonatal thyroid function and subsequent neurodevelopment. J Endocrinol Invest 2001;24(2):116–30.Google Scholar
Magee, LA, Nulman, I, Rovet, JF, Koren, G. Neurodevelopment after in utero amiodarone exposure. Neurotoxicol Teratol 1999;21(3):261–5.Google Scholar
Vanbesien, J, Casteels, A, Bougatef, A, et al. Transient fetal hypothyroidism due to direct fetal administration of amiodarone for drug resistant fetal tachycardia. Am J Perinatol 2001;18(2):113–16.Google Scholar
Kohl, T, Tercanli, S, Kececioglu, D, Holzgreve, W. Direct fetal administration of adenosine for the termination of incessant supraventricular tachycardia. Obstet Gynecol 1995;85(5 Pt 2):873–4.Google Scholar
Dangel, JH, Roszkowski, T, Bieganowska, K, Kubicka, K, Ganowicz, J. Adenosine triphosphate for cardioversion of supraventricular tachycardia in two hydropic fetuses. Fetal Diagn Ther 2000;15(6):326–30.Google Scholar
Blanch, G, Walkinshaw, SA, Walsh, K. Cardioversion of fetal tachyarrhythmia with adenosine. Lancet 1994;344(8937):1646.Google Scholar

Save book to Kindle

To save this book to your Kindle, first ensure [email protected] is added to your Approved Personal Document E-mail List under your Personal Document Settings on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part of your Kindle email address below. Find out more about saving to your Kindle.

Note you can select to save to either the @free.kindle.com or @kindle.com variations. ‘@free.kindle.com’ emails are free but can only be saved to your device when it is connected to wi-fi. ‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.

Find out more about the Kindle Personal Document Service.

Available formats
×

Save book to Dropbox

To save content items to your account, please confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account. Find out more about saving content to Dropbox.

Available formats
×

Save book to Google Drive

To save content items to your account, please confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account. Find out more about saving content to Google Drive.

Available formats
×