Pediatric Cardiology

, Volume 25, Issue 3, pp 234–251 | Cite as

Cardiac Arrhythmias in the Human Fetus

  • C. S. KleinmanEmail author
  • R. A. Nehgme


Fetal cardiac arrhythmias have been recognized with increasing frequency during the past several years. Most fetal arrythmias are intermittent extrasystoles, often presenting as irregular pauses of rhythm. These are significant only when they occur with appropriate timing to initiate sustained tachycardia, mediated by anatomic bypass pathways. The most common important fetal arrhythmias are: 1) supraventricular tachycardias, and 2) severe bradyarrhythmias, associated with complete heart block. Symptomatic fetal tachycardias are usually supraventricular in origin, and may be associated with the developmet of hydrops fetalis. These patients may respond to antiarrhythmic drug therapy, administered via maternal ingestion or via direct fetal injection. Such therapy should be offered with careful fetal and maternal monitoring, and must be based on a logical, sequential analysis of the electrical mechanism underlying the arrhythmia, and an appreciation of the pharmacology and pharmacokinetics of the maternal, placental fetal system. Bradycardia from complete heart block may either be associated with complex congential heart malformations involving the atrioventricular junction of the heart, or may present in fetuses with normal cardiac structure, in mothers with autoimmune conditions associated with high titres of anti-SS-A or anti-SS-B antibody, which cross the placenta to cause immune-related inflammatory damage to the fetal atroventricular node. This paper reviews experience with the analysis of fetal caridac rhythm, a detailed discussion of the pathophysiology of arrhythmias and their effect on the fetal circulatory system, and offers a logical framework for the construction of treatment algorithms for fetuses at risk for circulatory compromise from fetal arrhythmias.


Fetal arrhythmias Cardiac arrhythmias Fetal physiology Hydrops fetalis Fetal therapy Fetal heart Fetal cardiology 


  1. 1.
    Anandakumar, C, Biswas, A, Chew, SS,  et al. 1996Direct fetal therapy for hydrops secondary to congenital atrioventricular heart block.Obstet Gynecol87835837PubMedGoogle Scholar
  2. 2.
    Anderson, PAW 1996The heart and development.Sem Perinatolo20482509Google Scholar
  3. 3.
    Assad, RS, Jatene, MB, Moreira, LF,  et al. 1994Fetal heart block: a new experimental model to assess fetal pacing.Pacing Clin Electrophysiol1712561263PubMedGoogle Scholar
  4. 4.
    Better, DJ, Kaufman, S, Allan, LD 1996The normal pattern of pulmonary venous flow on pulsed Doppler examination of the human fetus.J Am Soc Echocardiogr9281285PubMedGoogle Scholar
  5. 5.
    Carpenter, RJ, Strasburger, JF, Garson Jr, A,  et al. 1986Fetal ventricular pacing for hydrops secondary to complete atrioventricular block.J Am Coll Cardiol814341436PubMedGoogle Scholar
  6. 6.
    Copel, JA, Buyon, JP, Kleinman, CS 1995Successful in utero therapy of fetal heart block.Am J Obstet Gynecol17313841390CrossRefPubMedGoogle Scholar
  7. 7.
    Copel, JA, Liang, RI, Demasio, K, Ozeren, S, Kleinman, CS 2000The clinical significance of the irregular fetal heart rhythm.Am J Obstet Gynecol182813817PubMedGoogle Scholar
  8. 8.
    DeWolff, D, deSchepper, J, Verhaaren, H,  et al. 1988Congenital hypothyroid goiter and amiodarone.Acta Paediatr Scand77616618PubMedGoogle Scholar
  9. 9.
    Evans, MI, Pryde, PG, Reichler, A,  et al. 1993Fetal drug therapy.Western J Med159325332Google Scholar
  10. 10.
    Friedman, WF 1993The intrinsic physiologic properties of the developing heart.Friedman, WFLesch, MSonnenblick, EH eds. Neonatal Heart Disease.Grune & StrattonNew York87111Google Scholar
  11. 11.
    Garson, A 1987Medicolegal problems in the management of cardiac arrhythmias in children.Pediatrics798488PubMedGoogle Scholar
  12. 12.
    Gillette, PC 1980The mechanisms of supraventricular tachycardia in children.Circulation54133139Google Scholar
  13. 13.
    Gladstone, GR, Hordof, A, Gersony, WM 1975Propranolol administration during pregnancy: effects on the fetus.J Pediatr86962964PubMedGoogle Scholar
  14. 14.
    Hansmann, M, Gembruch, U, Bald, RK,  et al. 1991Fetal tachyarrhythmias: transplacental and direct treatment of the fetus. A report of 60 cases.Ultrasound Obstet Gynecol1162167CrossRefPubMedGoogle Scholar
  15. 15.
    Harris, JP, Alexson, CG, Manning, JA, Thompson, HO 1993Medical therapy for the hydropic fetus with congenital complete atrioventricular block.Am J Perinatol10217219PubMedGoogle Scholar
  16. 16.
    Horsfall, AC, Li, JM, Maini, RN 1996Placental and fetal cardiac laminin are targets for cross-reacting autoantibodies from mothers of children with congenital heart block.J Autoimmun9561568CrossRefPubMedGoogle Scholar
  17. 17.
    Kikuchi, Y, Shiraisi, H, Igarashi, H,  et al. 1995Cardiac pacing in fetal lambs: Intrauterine transvenous cardiac pacing for fetal complete heart block.Pacing Clin Electrophysiol18417423PubMedGoogle Scholar
  18. 18.
    Kleinman, CS, Copel, JA 1992Fetal cardiovascular physiology and therapy.Fetal Diagn Ther7147157PubMedGoogle Scholar
  19. 19.
    Kleinman, CS, Copel, JA, Nehgme, RA 2001The fetus with cardiac arrhythmia.Harrison, MREvans, MIAdzick, NSHolzgreve, W eds. The Unborn Patient: The Art and Science of Fetal Therapy.SaundersPhiladelphia417441Google Scholar
  20. 20.
    Kleinman, CS, Donnerstein, RL, DeVore, GR,  et al. 1982Fetal echocardiography for evaluation of in utero congestive heart failure: a technique for study of nonimmune fetal hydrops.N Engl J Med306568575PubMedGoogle Scholar
  21. 21.
    Kleinman, CS, Donnerstein, RL, Jaffe, CC,  et al. 1983Fetal echocardiography. A tool for evaluation of in utero cardiac arrhythmias and monitoring of in utero therapy: analysis of 71 patients.Am J Cardiol51237243PubMedGoogle Scholar
  22. 22.
    Kleinman, CS, Dubin, AM, Nehgme, RA 1999Left atrial tachycardia in the human fetus: identifying the fetus at greatest risk for developing nonimmune hydrops fetalis.Proceedings of the Second World Congress of Pediatric Cardiology and Cardiac Surgery.FuturaArmonk, NYGoogle Scholar
  23. 23.
    Kleinman, CS, Hobbins, JC, Jaffe, CC,  et al. 1980Echocardiographic studies of the human fetus: prenatal diagnosis of congenital heart disease and cardiac dysrhythmias.Pediatrics6510591067PubMedGoogle Scholar
  24. 24.
    Kleinman, CS, Nehgme, RA, Copel, JA 1988Fetal cardiac arrhythmias: diagnosis and therapy.Creasy, RKResnik, R eds. Maternal Fetal Medicine, 4th edn.SaundersPhiladelphia301318Google Scholar
  25. 25.
    Kolke, T, Minakami, H, Shiraishi, H, Sato, I 1997Fetal ventricular rate in case of congenital complete heart block is increased by ritodrine. Case report.J Perinat Med25216218PubMedGoogle Scholar
  26. 26.
    Krapp, M, Gembruch, U, Baumann, P 1997Venous blood flow pattern suggesting tachycardia-induced “cardiomyopathy” in the fetus.Ultrasound Obstet Gynecol103240CrossRefPubMedGoogle Scholar
  27. 27.
    Mahony, L 1996Calcium homeostasis and control of contractility in the developing heart.Sem Perinatol20510519Google Scholar
  28. 28.
    Michaelsson, M, Engle, MA 1972Congenital complete heart block: an international study of the natural history.Cardiovascular Clin485101Google Scholar
  29. 29.
    Morganroth, J 1987Risk factors for the development of proarrhythmic events.Am J Cardiol5932E37ECrossRefPubMedGoogle Scholar
  30. 30.
    Mrotsuki, J, Okamura, K, Watanabe, T,  et al. 1995Production of complete heart block and in utero cardiac pacing in fetal lambs.J Obstet Gynaecol21223239Google Scholar
  31. 31.
    Naheed, ZJ, Strasburger, JF, Deal, BJ,  et al. 1996Fetal tachycardia: mechanisms and predictors of hydrops fetalis.J Am Coll Cardiol2717361740CrossRefPubMedGoogle Scholar
  32. 32.
    Nimrod, C, Davies, D, Harder, J,  et al. 1987Ultrasound evaluation of tachycardia-induced hydrops in the fetal lamb.Am J Obstet Gynecol57655661Google Scholar
  33. 33.
    Physician’s Desk Reference (2003) Medical Economics, Montvale, NJGoogle Scholar
  34. 34.
    Rasheed, A, Simpson, J, Rosenthal, E 2003Neonatal EGG changes caused by supratherapeutic flecainide following treatment for fetal supraventricular tachycardia.Heart89470CrossRefGoogle Scholar
  35. 35.
    Reed, KL, Appleton, CP, Anderson, CF,  et al. 1990Doppler studies of vena cava flows in human fetuses. Insights into normal and abnormal cardiac physiology.Circulation81498505PubMedGoogle Scholar
  36. 36.
    Roden, DM 1994Risks and benefits of antiarrhythmic therapy.N Engl J Med305785791CrossRefGoogle Scholar
  37. 37.
    Rogers, MC, Willerson, JT, Goldblatt, A, Smith, TW 1972Serum digoxin concentrations in the human fetus, neonate and infant.N Engl J Med28710101014PubMedGoogle Scholar
  38. 38.
    Rudolph, AM 2001Congenital Diseases of the Heart, 2nd edn.FuturaArmonk, NYGoogle Scholar
  39. 39.
    Rudolph, AM, Heymann, MA 1976Cardiac output in the fetal lamb: the effect of spontaneous and induced changes of heart rate on the right and left ventricular output.Am J Obstet Gynecol124183189PubMedGoogle Scholar
  40. 40.
    Schmidt, KG, Ulmer, HE, Silverman, NH,  et al. 1991Perinatal outcome of fetal congenital complete atrioventricular block: a multicenter experience.J Am Coll Cardiol1713601366PubMedGoogle Scholar
  41. 41.
    Silverman, NH, Kleinman, CS, Rudolph, AM,  et al. 1985Fetal atrioventricular valve insufficiency associated with nonimmune hydrops. A two-dimensional echocardiography and pulsed Doppler ultrasound study.Circulation72825831PubMedGoogle Scholar
  42. 42.
    Simpson, JM, Milburn, A, Yates, RW,  et al. 1997Outcome of intermittent tachyarrhythmias in the fetus.Pediatr Cardiol187882CrossRefPubMedGoogle Scholar
  43. 43.
    Simpson, LL, Marx, GR, D’Alton, ME 1997Supraventricular tachycardia in the fetus: conservative management in the absence of hemodynamic compromise.J Ultrasound Med16459464PubMedGoogle Scholar
  44. 44.
    Van Leeuwen, P, Schussler, .,  et al. 1995Magnetocardiography for assessment of fetal heart actions.Geburtshilfe Frauenheilkd55642646PubMedGoogle Scholar
  45. 45.
    Walkinshaw, SA, Welch, CR, McCormack, J,  et al. 1994In utero pacing for congenital hart block.Fetal Diagn Ther9183185PubMedGoogle Scholar
  46. 46.
    Walsh, EP 2001Clinical approach to diagnosis and acute management of tachycardias in children.Walsh, EPSaul, JPTriedman, JK eds. Cardiac Arrhythmias in Children and Young Adults with Congenital Heart Disease.Lippincott Williams & WilkinsPhiladelphia95113Google Scholar
  47. 47.
    Ward, RM 1995Pharmacological treatment of the fetus: clinical pharmacokinetic considerations.Clin Pharmacokinet28343350PubMedGoogle Scholar
  48. 48.
    Welner, CP, Thompson, MIB 1988Direct treatment of fetal supraventricular tachycardia after failed transplacental therapy.Am J Obstet Gynecol158570573PubMedGoogle Scholar
  49. 49.
    Wellens, JHH, Durrer, D 1973Effect of digitalis on atrioventricular conduction and circus movement tachycardia in patients with the Wolff–Parkinson–White syndrome.Circulation4712291236PubMedGoogle Scholar
  50. 50.
    Younis, JS, Granat, M 1987Insufficient transplacental digoxin transfer in severe hydrops fetalis.Am J Obstet Gynecol15712681269PubMedGoogle Scholar
  51. 51.
    Rein, AJ, O’Donnell, C, Geva, T, Nir, A, Pereles, Z, Hashimoto, Li, XK, Sahn, DJ (2002) Use of tissue velocity imaging in the diagnosis of fetal cardiac arrhythmias. Circulation 106: 1827–1833CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag 2004

Authors and Affiliations

  1. 1.Professor of Clinical Pediatrics in Obstetrics & Gynecology, Columbia University College of Physicians and SurgeonsWeill Medical College of Cornell University, Director of Pediatric Cardiac Imaging, New York — Presbyterian HospitalNew York, NYUSA
  2. 2.Assistant Professor of Pediatrics, Jefferson Medical College, Acting Chief, Pediatric CardiologyNemours Cardiac Center, A.I. duPont Hospital for ChildrenWilmington, DEUSA

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