Sinus rhythm, ectopic beats and tachycardia Do ectopics matter? The FAST-TT protocol for fetal tachycardia London 23 January 2020 Prof Julene S Carvalho Head of Brompton Centre for Fetal Cardiology Consultant Fetal and Paediatric Cardiologist Professor of Practice, Fetal Cardiology Molecular & Clinical Sciences Research Institute, SGUL Normal and abnormal rhythm Learning objectives Normal and abnormal rhythm Learning objectives • To assess the normal cardiac rhythm Normal and abnormal rhythm Learning objectives • To assess the normal cardiac rhythm • To diagnose & manage irregular rhythm Normal and abnormal rhythm Learning objectives • To assess the normal cardiac rhythm • To diagnose & manage irregular rhythm • To diagnose & manage tachycardia Abnormal rhythm Learning objectives • To assess the normal cardiac rhythm Rhythm Sinus rhythm • regular • 1 atrial : 1 ventricular activity • constant AV timing (PR interval) Sinus rhythm Sinus rhythm Sinus rhythm Sinus rhythm ‘Eye-balling’ ‘Eye-balling’ Rhythm Study of rhythm (sinus or arrhythmia) • Based on simultaneous recording of atrial and ventricular activity Fetal arrhythmias Diagnostic modalities in the fetus Simultaneous recording Ultrasound • M-mode • Pulsed wave Doppler • Tissue Doppler Fetal magnetocardiography Fetal electrocardiography Fetal arrhythmias Diagnostic modalities in the fetus Simultaneous recording Ultrasound • M-mode • Pulsed wave Doppler • Tissue Doppler Sinus rhythm M-mode echocardiography LV V RA A Sinus rhythm Pulmonary vessels Carvalho et al. Heart 2007;93:1448-53 (Epub 2006 Dec 12) Simultaneous pulmonary artery and vein Methods • At the level of the 4-chamber view • Colour flow mapping: artery and vein • Inner 2/3 of lung parenchyma • Sample volume over artery and vein • Low velocity • (Absence of fetal breathing movement) Carvalho et al. Heart 2007;93:1448-53 (Epub 2006 Dec 12) Simultaneous pulmonary artery and vein Methods • At the level of the 4-chamber view • Colour flow mapping: artery and vein • Inner 2/3 of lung parenchyma • Sample volume over artery and vein • Low velocity • (Absence of fetal breathing movement) Carvalho et al. Heart 2007;93:1448-53 (Epub 2006 Dec 12) Simultaneous pulmonary artery and vein Doppler V = ventricular systole A = atrial systole Pulmonary artery-vein AV interval 180 160 140 120 100 Adjusted AV interval (ms) AV Adjusted 80 X axis labels - editable shape and text placeholder 14 18 22 26 30 34 38 Gestational age aAV = AV - 0.173 x (VV - 417) Sinus rhythm LV inflow / outflow Api and Carvalho, 2008 Sinus rhythm LV inflow / outflow Api and Carvalho, 2008 Abnormal rhythm Learning objectives • To assess the normal cardiac rhythm • To diagnose & manage irregular rhythm Abnormal rhythm Learning objectives • To diagnose & manage irregular rhythm In antenatal clinic, … no video clip… no echo … In antenatal clinic, … no video clip… no echo … Irregular Skipped Missing Ectopic beats beats beats In antenatal clinic, … no video clip… no echo … Irregular Skipped Missing Ectopic beats beats beats In antenatal clinic, … no video clip… no echo … Irregular Skipped Missing Ectopic beats beats beats 95-98% are fine In antenatal clinic, … no video clip… no echo … Irregular Skipped Missing Ectopic beats beats beats 95-98% 2-5% are fine are not fine! In antenatal clinic, … no video clip… no echo … Irregular Skipped Missing Ectopic beats beats beats 95-98% 2-5% are fine are not fine! Significant Structural arrhythmia congenital heart disease Irregular rhythm Irregular rhythm Skipped, missing or ectopic beats Carvalho, Fetal therapy 2013 Irregular rhythm Irregular rhythm Irregular rhythm Atrial ectopics Most common cause of irregular rhythm Benign in the vast majority of cases Small risk of tachycardia Atrial ectopics A A A V V V FHR = 140bpm Atrial ectopics A A A V V V FHR = 140bpm A A Atrial ectopics A A A V V V FHR = 140bpm AE A A Atrial ectopics A A A V V V FHR = 140bpm AE SVT A A HR = 202 bpm Atrial ectopics Intermittent SVT triggered by ectopic A A A V V V FHR = 140bpm AE SVT A A HR = 202 bpm Atrial ectopics Intermittent SVT triggered by ectopic A A A Not benign! V V V FHR = 140bpm AE SVT A A HR = 202 bpm Atrial ectopics Intermittent SVT triggered by ectopic A A A Not benign! How to risk-stratify? V V V FHR = 140bpm AE SVT A A HR = 202 bpm Could be intermittent tachycardia If > 180bpm = tachycardia If < 110 bpm = bradycardia If < 110 bpm = bradycardia If 110-120 bpm If < 110 bpm = bradycardia If 110-120 bpm If < 110 bpm Could be= bradycardia ectopics (risk of tachycardia) OR heart block Fetal tachycardia • can lead to heart failure / fetal hydrops • treatment depends on mechanism of tachycardia fetal status gestational age maternal choice Fetal tachycardia • treatment depends on mechanism of tachycardia fetal status gestational age maternal choice Fetal tachycardia - Mechanisms • SVT with 1:1 conduction short VA interval AVRT = AV reentry tachycardia long VA interval sinus tachycardia AET = atrial ectopic tachycardia PJRT = permanent junctional reciprocating tachycardia • Atrial flutter often with 2:1 AV conduction variable AV conduction • Ventricular tachycardia Fetal tachycardia - Mechanisms • SVT with 1:1 conduction short VA interval AVRT = AV reentry tachycardia long VA interval sinus tachycardia AET = atrial ectopic tachycardia PJRT = permanent junctional reciprocating tachycardia SVT with 1:1 AV conduction Api and Carvalho 2008 Short VA tachycardia (re-entry), VA < AV interval Api and Carvalho 2008 Long VA tachycardia (SR, AET or PJRT), VA > AV interval Heart rate = 192 ppm VA interval = 169ms; AV interval = 143ms VA AV Fetal tachycardia - Mechanisms • SVT with 1:1 conduction short VA interval AVRT = AV reentrant tachycardia long VA interval sinus tachycardia AET = atrial ectopic tachycardia PJRT = persistent junctional reciprocating tachycardia • Atrial flutter often with 2:1 AV conduction variable AV conduction • Ventricular tachycardia Fetal tachycardia - Mechanisms • Atrial flutter often with 2:1 AV conduction variable AV conduction Atrial flutter with 2:1 conduction Carvalho et al. Heart 2007;93:1448-53 (Epub 2006 Dec 12) Atrial flutter Api and Carvalho 2008 Fetal tachycardia - Mechanisms • SVT with 1:1 conduction short VA interval AVRT = AV reentrant tachycardia long VA interval sinus tachycardia AET = atrial ectopic tachycardia PJRT = persistent junctional reciprocating tachycardia • Atrial flutter often with 2:1 AV conduction variable AV conduction • Ventricular tachycardia Fetal tachycardia - Mechanisms • Ventricular tachycardia Ventricular tachycardia Atrial rate = 109 bpm Ventricular rate = 193bpm Left ventricle Right atrium Fetal tachycardia • treatment depends on mechanism of tachycardia: SVT or Atrial flutter fetal status gestational age maternal choice Fetal tachycardia • treatment depends on mechanism of tachycardia: SVT or Atrial flutter fetal status gestational age maternal choice FAST Therapy Trial United Kingdom Study Protocols (Version 2.2: 12-Oct-2017) RCT Protocol and Procedures 1 Slide Version Date: 02-Nov-2017 FAST Therapy Trial United Kingdom Study Protocols (Version 2.2: 12-Oct-2017) RCT Protocol and Procedures 1 Slide Version Date: 02-Nov-2017 FAST Therapy Trial United Kingdom Study Protocols (Version 2.2: 12-Oct-2017) RCT Protocol and Procedures 1 Slide Version Date: 02-Nov-2017 FAST Therapy Trial United Kingdom Study Protocols (Version 2.2: 12-Oct-2017) RCT Protocol and Procedures 1 Slide Version Date: 02-Nov-2017 Flecainide • Admit to hospital • Maternal ECG • Blood: electrolytes, liver and renal function • 100mg 8/8h orally • blood level around day 3, if available • Adjust dose accordingly • blood level 1-2 weeks thereafter • Good transplacental transfer • Well tolerated; side effects are uncommon Digoxin • Admit to hospital • Maternal ECG • Blood: electrolytes, liver and renal function • Loading dose: 2 mg orally or IV 12/12h OR if hydropic, 8/8h • blood level after loading • thereafter, adjust maintenance dose accordingly • Poor transplacental transfer in hydrops • Well tolerated; side effects are uncommon *** Direct therapy: intramuscular injection = 88mcg / estimated fetal weight (Parilla et al 1996) Sotalol • Admit to hospital • Maternal ECG • Blood: electrolytes, liver and renal function • 240 mg (initial dose) orally, max 480mg 80mg 8/8h OR 120mg 12/12h • 320mg (initial dose) orally, if hydropic 160mg 12/12h • Good transplacental transfer • Prolongs QT interval Amiodarone • Admit to hospital • Maternal ECG • Blood: electrolytes, liver and renal function Oral • 1800 - 2400mg/day over 2-5 days (load) • 400-800mg/day (maintenance) Cuneo & Strasburger 2000 Combined • Oral 1200mg for 5-7 days (load) 600-800mg/day afterwards • Direct in umbilical vein: 2.5mg/Kg estimated dry weight, over 30min Gembruch Heart block or blocked ectopics? - diagnosis & management Distinguishing physiological from pathological block London 23 January 2020 Prof Julene S Carvalho Head of Brompton Centre for Fetal Cardiology Consultant Fetal and Paediatric Cardiologist Professor of Practice, Fetal Cardiology Molecular & Clinical Sciences Research Institute, SGUL Fetal arrhythmias • Ectopic or premature beats atrial ventricular • Tachycardias supraventricular (sinus, re-entry, AET, PJRT) atrial flutter ventricular • Bradycardias Sinus (1:1 AV relationship) Bigeminy / trigeminy (with blocked ectopics) Heart block Fetal arrhythmias • Bradycardias Sinus (1:1 AV relationship) Bigeminy / trigeminy (with blocked ectopics) Heart block Bradycardia: FHR baseline is less than 110 beats per minuteBr Bradycardia: FHR baseline is less