Recognition And Treatment Of Fetal And Neonatal Arrhythmias

Recognition and Treatment of
F t l and
Fetal
dN
Neonatal
t lA
Arrhythmias
h th i
Matthew Egan, MD
41st Regional Perinatal Symposium
p
12,, 2014
September
Fetal heart rates
N
Normall range 120 to
t 160 b
beats
t per
minute (bpm)
 Less
L
than
th
100 b
bpm is
i bradycardia
b d
di
 Great than 180 bpm is tachycardia
 Expect variation
y
1-3% of
 Fetal arrhythmias
pregnancies
Overview
R
Review
i
normall fetal
f t l heart
h
t rates
t and
d
electrocardiogram
 Irregular
I
l rhythms
h th
 Tachycardias
 Heart Block
Electrocardiogram
Normal ranges vary with age
Normal Electrocardiogram
0 1 d 1-3
0-1
1 3 d 3-7
37d 7
7-30
30 1-3
13
d
mo
3-6
3
6
mo
6-12
6
12
mo
Heart rate
94155
(122)
91158
(122)
90166
(128)
106182
(149)
120179
(149)
105185
(141)
108169
(131)
QRS axis
59189
(135)
64197
(134)
76191
(133)
70160
(109)
30115
(75)
7-105
(60)
6-98
(55)
R amplitude
V1
R amplitude
V6
5-26
(13)
5-27
(15)
3-25
(12)
3-12
(10)
3-19
(10)
3-20
(10)
2-20
(9)
0-10
((4))
0-12
((5))
1-12
((5))
3-16
((8))
5-21
((12))
6-22
((13))
6-23
((13))
Table adapted from Moss and Adams Heart Disease in infants, children and adolescents, 7th edition, page 257.
Irregular
g
rhythms:
y
Premature Atrial Contractions (PAC)
 Most common arrhythmia during fetal
and neonatal time period
 Can be conducted or blocked at AV
node
 Well tolerated and considered benign
 Less than 1% risk of progressing to
p
tachycardia
y
supraventricular
 Usually resolve spontaneously in first
few months of life
ECG of PAC
Blocked PAC
Fetal PAC
Heart rate 77 beats per minute in newborn infant
Premature Ventricular Contractions
(PVCs)
Fetal PAC
Doppler
 Premature beat with different QRS
morphology from baseline
 Rarely
y seen prenatally
p
y
 More concerning if polymorphic
 Terminology
 Couplet = two consecutive PVCs
 Bigeminy = alternating with sinus beat
 Trigeminy
g
y = every
y third beat is PVC
M-mode
 Typically benign with structurally normal
heart and usually no treatment required
Premature Ventricular Contractions
Tachycardias:
Sinus tachycardia
H
Heartt rates
t exceeding
di
upper limits
li it for
f
age, greater than 180 bpm in fetus
 1:1
1 1 atrial
t i l to
t ventricular
t i l conduction
d ti
 Gradual onset and cessation
 Secondary to other stimulus
 Fetus- hypoxia, maternal fever, infection
 Neonate- fever, dehydration, pain,
anemia, hyperthyroidism
Sinus tachycardia
Heart rate 180 bpm
Sinus tachycardia- Fetus
Supraventricular tachycardia
SVT Associated anomalies
 Most common tachycardia in fetus and
infants (1/250 to 1/1000)
 Rapid,
p , regular
g
tachycardia
y
 Abrupt onset and termination
 Atrioventricular (AV) re-entrant tachycardia
mostt common in
i infants
i f t
 AV nodal re-entrant tachycardia
predominates in older children
 90% spontaneously resolve in first year of
life
 Typically structurally normal heart
 9-32% have congenital heart disease
 Many defects described but most common
is Ebstein’s anomaly of the tricuspid valve
Re-entry mechanism
 Requires
R
i
2 pathways
h
around
d insulated
i
l
d core
 (AV valve annulus)
 Also hypertrophic
yp
p
cardiomyopathy,
y p
y,
rhabdomyomas
 Genetics – Typically sporadic
 Three
h
fold
f ld higher
hi h risk
i k iin WPW iin 1stt degree
d
relatives
 Non WPW 7% have first degree
g
relative with
SVT
Wolff-Parkinson-White (WPW)
Accessory Connection
P
Preexcitation
it ti
on b
baseline
li
ECG
 Connection allows for conduction
f
from
atrium
t i
to
t ventricle
t i l (antegrade)
( t
d )
and usually ventricle to atrium
(retrograde)
 May allow rapid transmission to
ventricle (i
(i.e.
e atrial fibrillation)
WPW ECG
Fetal SVT
Delta wave and short PR interval
Fetal SVT – M mode
Heart rate 250 bpm
Fetal SVT - Hydrops
Neonatal SVT EKG
SVT Management
Heart rate = 276 beats per minute
Acute management
Medical Therapy
 Vagal maneuvers
 Digoxin
 Ice to face, Valsalva, gag reflex
 Adenosine – rapid
p bolus,, then flush
 Short half life
 0.1 mg/kg (max 6 mg)
 Repeat 0.2
0 2 mg/kg (max 12 mg)
 Unstable, no IV access then cardioversion
 Sedation when possible
 0.5 to 1 J/kg, can repeat 2 J/kg
 If tachycardia recurs start anti-arrhythmic
therapy





Mechanism: inhibits Na-K ATPase
Slows down AV node conduction
Positive inotropic effects
First line for SVT,, especially
p
y in infants
Contraindicated in WPW
 Studies suggest it can increase conductivity
in accessory pathway or increase risk
sudden death
Medical Therapy
Medical Therapy- Second line
 Beta
B t blocker
bl k
 Flecainide – Na channel blocker
 Inhibition of sinus node, AV node
conduction
 Esmolol- IV form with short half life
 Propranolol- non selective beta 1 and
beta 2 adrenergic receptor blocker
 Atenolol- selective beta 1 blocker
Treatment- Fetal SVT
 Risk of proarrhythmia, widens QRS
 Sotalol – K channel blocking and beta
blocker effects
 Can lead to QTc prolongation, proarrhythmia
 Amiodarone – K channel blocking +
multiple other actions, potent
 L
Long half
h lf life
lif
 Photosensitivity, thyroid dysfunction, pulmonary
fibrosis,, elevation of liver enzymes
y
Fetal strip of SVT conversion
 Intermittent SVT less than 50% of
time – observation
 Sustained tachycardia
 Digoxin
 Digoxin + Flecainide
 Sotalol +/- Digoxin
 We initiate therapy
py as inpatient,
p
,
monitor maternal telemetry after
initial electrocardiogram
Sudden decrease in heart rate with increased
variability post conversion
Fetal SVT with hydrops resolution
after anti-arrhythmic therapy
Atrial Flutter
 Regular
Regular, rapid narrow complex
tachycardia
 As much as 30% fetal tachycardia
 Atrial rates 300 to 500 bpm
prenatally, typically 240 to 360 in
neonates
 Usually
y 2:1 or 3:1 AV conduction
 Adenosine can be diagnostic if flutter
waves difficult to see
Fetal Atrial Flutter
Fetal Atrial Flutter
Fetal Atrial Flutter
Fetal atrial flutter 1:1
Atrial Flutter EKG- 2:1 block
Treatment fetal atrial flutter
 If near term, consider delivery
 First line therapy- Digoxin or Sotalol
 Second line - Amiodarone
** This article provides treatment and dosing recommendations for
fetal arrhythmias
Treatment neonatal atrial flutter
AV Block
 Synchronized DC cardioversion
 Ab
Abnormall conduction
d ti
from
f
atria
t i to
t
ventricles
 1st degreed
PR prolonged
l
d
 2nd degree
 0.5 to 1 Joule/kg
 Antiarrhythmic medication
medication, such as
digoxin, can be given
 Controversial need for maintenance
therapy after cardioversion due to low
recurrence risk
 Typically will continue digoxin for 6-9
months
Complete AV Block
 Type I (Wenkebach)- progressive PR
prolongation
 Type
T
II – abrupt
b
t ffailure
il
off conduction
d ti
 3rd degree (Complete) AV dissociation
Congenital heart block
 40% associated with maternal autoimmune disease
(Lupus, Sjogren)
 Anti-Ro and Anti-La antibodies
 Cross react with fetal conduction system
 ~50% associated with complex congenital heart
disease
 Heterotaxy common (Polysplenia or left isomerism)
 May be asymptomatic or associated with heart failure,
such as hydrops
 Worse outcome
 Hydrops, structurally heart disease, ventricular rate
less than 55
Fetal heart block
Fetal heart block
Congenital heart block
Treatment
Congenital heart block
Treatment
 Observation for structurally normal
heart, normal function
 Immune associated variant
S
Sympathomimetics
th
i
ti (terbutaline)
(t b t li )
when ventricular rates less than 55
bpm
 Steroids (dexamethasone) have been
effective in some studies at preventing
progression to complete block
 Consider IVIG
 Both have
ha e side effects
 Not effective in those with structural
heart disease
 Fetal
F
l pacing
i
not been
b
effective
ff
i
Class 1 Indications for pacemaker
placement
Thank you
 Congenital
C
it l 3rd degree
d
bl
block
k
 Sonographers:
 with ventricular dysfunction or wide
complex escape
 With rate less than 50 bpm and a
structurally normal heart
 With rate less than 70 bpm with
congenital heart defect
 Maureen, Margaret and Sue
 Colleagues at Pediatric Cardiology
 Dr
Dr. Atallah,
Atallah Dr
Dr. Smith
Smith, Dr.
Dr Kveselis
Kveselis, Dr.
Dr
Byrum
 Neonatology and Perinatology
Services
Resources








Allen et al. Moss and Adams’
Adams Heart Disease in Infants, Children,
and Adolescents. 8th Edition; 2013, 441-472.
Donofrio M et al. Diagnosis and Treatment of Fetal Cardiac
Disease. Circulation 2014.
Gregoratos
g
G et al. ACC/AHA Guidelines for Implantation of
Cardiac
d
Pacemakers
k
and
d Antiarrhythmia
h h
Devices (Committee
(
on
Pacemaker implantation) Circulation. 1998; 97:1325-1335.
Killen S and Fish F. Fetal and Neonatal Arrhythmias. Neoreviews
2008:9:e242-e252.
Lai et al
al. Echocardiography in Pediatric and Congenital Heart
Disease from Fetus to Adult. 2009.
Lopes, L et al. Perinatal Outcome of Fetal AV Block. Circulation.
2008;118.
Skinner J and Sharland G.
G Detection and management of life
threatening arrhythmias in the perinatal period. Early Human
Development. 2008; 84, 161-172.
Zaidi A and Ro P. Treatment of Fetal and Neonatal Arrhythmias.
Touch briefings
g 2008;; 27-29.