Persistent junctional reciprocating tachycardia in the fetus

Abstract

Background: Persistent junctional reciprocating tachycardia (PJRT) tends to be a persistent arrhythmia and requires aggressive therapeutic management. Diagnosis and management of this infrequentlyoccurring tachycardia in the fetus at an early stage is of importance for the prevention of congestive heart failure (CHF).Methods: A retrospective study of four fetuses with supraventriculartachycardia (SVT) of the PJRT type was performed.Results: All had sustained SVT (mean of 228 beats/min) at a mean gestational age of 34 + 5 weeks, with CHF present in two. Three fetuses hadprenatal characteristics of PJRT on M-mode echocardiography with a ventriculoatrial (VA)/atrioventricular ratio of > 1 on M-mode echocardiography suggesting a slow conducting accessory pathway. All fourfetuses had postnatal confirmation of the diagnosis. Transplacental treatment with flecainide was effective in one patient; sotalol as a single drug or in combination with digoxin was partially effectivein the remaining three. Two developed sinus rhythm, with short intermittent periods of tachycardia and decreasing signs of CHF; one case showed a minimal decrease in heart rate. Oral propranolol therapyconverted two patients postnatally; in the remaining two patients radiofrequency ablation was performed at the age of 5 months and 6 years.Conclusions: The characteristics of our prenatal PJRTcases included a sustained heart rate not exceeding 240 beats/min with a long VA interval, the presence of CHF and therapy resistance. Transplacental treatment should be initiated, possibly with a combinationof sotalol and digoxin in non-hydropic cases, or flecainide, especially in case of fetal hydrops. Pharmacological therapy is to be preferred postnatally, but radiofrequency ablation seems to be indicatedin therapy-resistant cases with CHF, even in the first months of life.