Diagnosis and Treatment of Fetal Tachyarrhythmias

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US Cardiology, 2006;3(2):1-5

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Fetal tachyarrhythmias occur in approximately 0.4-0.6% of all fetuses.1-3 Normal fetal heart rates range from 120-160 beats per minute (bpm), with rates greater than 180bpm indicative of tachycardia.4-7 Usually, fetal arrhythmias are isolated findings; however, 5% of fetuses will also have congenital heart disease,8,9 such as EbsteinÔÇÖs anomaly, atrioventricular canal, hypoplastic left heart syndrome, or intracardiac tumors. While most arrhythmias are intermittent, more persistent arrhythmias may lead to fetal heart failure, or non-immune hydrops fetalis;4,10 progression to hydrops may be seen in up to 40% of cases with sustained tachycardia.11 Hydrops is seen with ventricular rates greater than 230bpm lasting for over 12 hours.2,5,12 Early echocardiographic evidence of hemodynamic compromise includes biatrial enlargement and atrioventricular valvar regurgitation; later findings include cardiomegaly and decreased systolic function. The diagnosis of hydrops is made by echocardiographic findings of ascites, pericardial effusion, pleural effusions, and subcutaneous edema. The prognosis for hydrops associated with fetal arrhythmia is poor with mortality as high as 50-98%,4,13 compared with 0-4% in cases without evidence of significant failure.6

The primary goal of fetal therapy is the prevention or resolution of hydrops.14,15 This may be achieved by: conversion to sinus rhythm; or ventricular rate control.8,12,16 The use of fetal echocardiography, M-mode and pulse-wave Doppler has lead to improved diagnosis of fetal arrhythmias, and remains the cornerstone of diagnosis.1,6 Fetal magnetocardiography, a non-invasive method for diagnosing complex fetal arrhythmias, is available at limited centers.1,8

Initial medical therapy is delivered transplacentally by administering medication to the mother orally or intravenously. Since there are reports of serious maternal adverse events, it is recommended that the mother remain hospitalized and monitored during initiation of therapy.4,15,17 If transplacental therapy fails, there are other modalities (i.e. direct fetal therapies) for therapy including intramuscular, intra-amniotic, intra-peritoneal, intra-umbilical, and intra-cardiac fetal injections.14 There is a greater mortality for fetuses who undergo these procedures;16 it is unclear if the increased mortality is due to the procedure or the severity of the underlying condition.14

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