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(Circulation. 2004;109:375-379.)
© 2004 American Heart Association, Inc.

Clinical Investigation and Reports

Amiodarone Therapy for Drug-Refractory Fetal Tachycardia

Janette F. Strasburger, MD; Bettina F. Cuneo, MD; Maaike M. Michon, MD; Nina L. Gotteiner, MD; Barbara J. Deal, MD; Scott N. McGregor, DO; Martijn A. Oudijk, MD; Erik J. Meijboom, MD; Leonard Feinkind, MD; Michael Hussey, MD; Barbara V. Parilla, MD

From the Division of Cardiology, Department of Pediatrics, Children’s Hospital of Wisconsin, Milwaukee (J.F.S.); Children’s Memorial Hospital, Chicago, Ill (N.L.G., B.J.D.); The Heart Institute for Children, Oak Lawn, Ill (B.F.C.); the Departments of Maternal-Fetal Medicine, Evanston Hospital, Evanston, Ill (S.N.M., B.V.P.); Christ Hospital, Oak Lawn, Ill (L.F.); Rush-Presbyterian St-Luke’s Hospital, Prentice Woman’s Hospital (M.H.), Chicago, Ill (B.V.P.); and University Medical Center, Utrecht, the Netherlands (M.M.M., M.A.O., E.J.M.).

Correspondence to Janette F. Strasburger, MD, Children’s Hospital of Wisconsin, Division of Cardiology, MS-713, 9000 W Wisconsin Ave, Milwaukee, WI 53201. E-mail jstrasbu{at}mcw.edu

Received February 26, 2003; de novo received July 31, 2003; revision received October 15, 2003; accepted October 19, 2003.

Background— Fetal tachycardia complicated by ventricular dysfunction and hydrops fetalis carries a significant risk of morbidity and mortality. Transplacental digoxin is effective therapy in a small percentage, but there is no consensus with regard to antiarrhythmic treatment if digoxin fails. This study evaluates the safety, efficacy, and outcome of amiodarone therapy for digoxin-refractory fetal tachycardia with heart failure.

Methods and Results— Fetuses with incessant tachycardia and either hydrops fetalis (n=24) or ventricular dysfunction (n=2) for whom digoxin monotherapy and secondary antiarrhythmic agents (n=13) were not effective were treated transplacentally with a loading dose of oral amiodarone for 2 to 7 days, followed by daily maintenance therapy for <1 to 15 weeks. Digoxin therapy was continued throughout gestation. Newborns were studied by transesophageal pacing or ECG monitoring to determine the mechanism of tachycardia. Three fetuses were delivered urgently in tachycardia during amiodarone loading, and 3 required additional antiarrhythmic agents for sustained cardioversion. Amiodarone or amiodarone combinations converted 14 of 15 (93%) with reentrant supraventricular tachycardia, 2 of 2 with ventricular or junctional ectopic tachycardia, and 3 of 9 (33%) with atrial flutter. Amiodarone-related adverse effects were transient in 5 infants and 8 mothers. Mean gestational age at delivery was 37 weeks, with 100% survival.

Conclusions— Orally administered amiodarone is safe and effective treatment for drug-refractory fetal tachycardia, specifically reentrant supraventricular tachycardia, junctional ectopic, or ventricular tachycardia, even when accompanied by hydrops fetalis or ventricular dysfunction.

Key Words: tachycardia • atrial flutter • antiarrhythmia agents • fetus • amiodarone

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