The Incremental Benefit of Color Tissue Doppler in Fetal Arrhythmia Assessment.

BACKGROUND: Accurate fetal arrhythmia (FA) diagnosis is key for effective management. Currently, FA assessment relies on standard echocardiography-based techniques (M mode and spectral Doppler), which require adequate fetal position and cursor alignment to define temporal relationships of mechanical events. Few data exist on the application of color Doppler tissue imaging (c-DTI) in FA assessment. The aim of this study was to examine the feasibility and clinical applicability of c-DTI in FA assessment in comparison with standard techniques. METHODS: Pregnancies with diagnosed FA were prospectively recruited to undergo c-DTI following fetal echocardiography. Multiple-cycle four-chamber clips in any orientation were recorded (mean frame rate, 180 ± 16 frames/sec). With offline analysis, sample volumes were placed on atrial (A) and ventricular (V) free walls for simultaneous recordings. Atrial and ventricular rates, intervals (for atrial-ventricular conduction and tachyarrhythmia mechanism), and relationships were assessed to decipher FA mechanism. FA diagnosis by c-DTI, conventional echocardiographic techniques, and postnatal electrocardiography and/or Holter monitoring were compared. RESULTS: FA was assessed by c-DTI in 45 pregnancies at 15 to 39 weeks, including 16 with atrial and/or ventricular ectopic beats; 18 with supraventricular tachyarrhythmias, including ectopic atrial tachycardia in 11, atrioventricular reentrant tachycardia in four, atrial flutter in two, and intermittent atrial flutter and junctional ectopic rhythm in one; three with ventricular tachycardias; and eight with bradycardias or atrioventricular conduction pathology, including five with complete atrioventricular block (AVB), one with first-degree AVB evolving into complete AVB, one with second-degree AVB, and one with sinus bradycardia. After training, FA diagnosis by c-DTI could be made irrespective of fetal orientation within 10 to 15 min. FA diagnosis by c-DTI concurred with standard techniques in 41 cases (91%), with additional findings identified by c-DTI in 10. c-DTI led to new FA diagnoses in four cases (9%) not definable by standard techniques. FA diagnosis by c-DTI was confirmed in all 20 with persistent arrhythmias after birth, including three with new diagnoses defined by c-DTI. c-DTI was particularly helpful in deciphering SVT mechanism (long vs short ventricular-atrial interval) in all 18 cases, whereas standard techniques permitted definition in only half. CONCLUSIONS: c-DTI with offline analysis permits rapid and accurate definition of FA mechanism, providing new information in nearly one-third of affected pregnancies.

[Diagnostic and frequency of fetal heart disease by echocardiography in pregnancies with high-risk factors]. / Diagnóstico y frecuencia de cardiopatía fetal mediante ecocardiografía en embarazos con factores de alto riesgo.

BACKGROUND: Fetal heart diseases are increasingly frequent. These are part of birth defects and, therefore, appear in early phases of the gestation. Diagnosis or early detection of functional and structural abnormalities of the heart allows to the obstetrician and the pediatric cardiologist to plan, in a timely manner, the treatment and prenatal and postnatal monitoring with the purpose of preventing complications. OBJECTIVE: To determine the types and frequencies of heart diseases in pregnancies with high-risk factors. PATIENTS AND METHOD: It was analized an observational, descriptive and retrospective series of cases. From January 2003 to June 2006, fetal echocardiograms were made in women with pregnancies longer than 15 weeks and with high-risk factors. At childbirth was made a cardiovascular evaluation. Analysis was carried out through descriptive statistics. RESULTS: maternal age average was of 27.3 +/- 6.8 years; gestational age was of 31 +/- 5 weeks. In total, there were carried out 275 fetal echocardiograms (FE) in 208 patients; in 56 of them, was made one fetal ecocardiogram, two in 37 and three in 15. Risk factors of reference to the specialized medical unit were: abnormalities detected through obstetrical ultrasound (35.1%), tachycardia-bradycardia-arrhythmia (29.8%), probable chromosomic anomalies (13.9%), oligohydramnios or polyhydramnios (4.8%), familiar antecedents of congenital heart diseases (3.8%), others (12.6%). Heart disease was diagnosed by fetal echocardiogram in 55 patient (26.4%): unique ventricle (n = 5), hypoplastic right ventricle (n = 3), hypoplastic left ventricle (n = 4), congenital complete heart block (n = 1), Ebstein and dysplasia of the mitral and tricuspid valves (n = 12), tumor (n = 5), ectopia cordis (n = 2), auriculoventricular channel (= 1), supraventricular tachycardia (n = 4), supraventricular extrasystole (n = 3) and other. Diagnosis was confirmed at childbirth in 99.5% of the cases. The treatment was initiated in uterus for arrhythmia and cardiac insufficiency in 19 patients. The patients with high-risk cardiopathy (at birth) were evaluated at beginning through specialized cardiological treatment and then they were transferred to the service of pediatric cardiology. CONCLUSIONS: Frequency of fetal heart diseases in patients with high-risk factors is of 25.4%. In these patients, the fetal echocardiogram (prenatal and postnatal) allows planning the optimal cardiological and obstetric treatment as well as to inform to the relatives.

Neonatal cholestasis associated with fetal arrhythmia.

We evaluated the consequence of different types of fetal arrhythmia in the development of neonatal cholestasis. The charts of 38 children born at St. Justine Hospital between 1993 and 2001 with sustained and hemodynamically significant fetal arrhythmias were studied: 19 with supraventricular tachycardia, 14 with atrial flutter, and 5 with atrio-ventricular (AV) block. Six of these 38 children presented with cholestasis. The average duration of arrhythmia was 15.7 days in the noncholestatic group, compared with 40.3 days in the cholestatic group ( P <.05). The three infants with supraventricular tachycardia who developed cholestasis survived and resolved their cholestasis, whereas 2 of 3 infants with AV block died. No infant with atrial flutter developed cholestasis. We conclude that newborns who developed tachyarrhythmia during their fetal life can show transient neonatal cholestasis. In patients with AV block, severe and irreversible liver failure could be observed. In addition, extensive collapse of the stroma and the absence of hepatocytes (foie vide) also were observed in a patient with anti-Ro antibodies.