Comparison of Transplacental Treatment of Fetal Supraventricular Tachyarrhythmias With Digoxin, Flecainide, and Sotalol Results of a Nonrandomized Multicenter Study

Background-Fetal tachyarrhythmia may result in low cardiac output and death. Consequently, antiarrhythmic treatment is offered in most affected pregnancies. We compared 3 drugs commonly used to control supraventricular tachycardia (SVT) and atrial flutter (AF). Methods and Results-We reviewed 159 consecutive referrals with fetal SVT (n = 114) and AF (n = 45). Of these, 75 fetuses with SVT and 36 with AF were treated nonrandomly with transplacental flecainide (n = 35), sotalol (n = 52), or digoxin (n = 24) as a first-line agent. Prenatal treatment failure was associated with an incessant versus intermittent arrhythmia pattern (n = 85; hazard ratio [HR] = 3.1; P < 0.001) and, for SVT, with fetal hydrops (n = 28; HR = 1.8; P = 0.04). Atrial flutter had a lower rate of conversion to sinus rhythm before delivery than SVT (HR = 2.0; P = 0.005). Cardioversion at 5 and 10 days occurred in 50% and 63% of treated SVT cases, respectively, but in only 25% and 41% of treated AF cases. Sotalol was associated with higher rates of prenatal AF termination than digoxin (HR = 5.4; P = 0.05) or flecainide (HR = 7.4; P = 0.03). If incessant AF/SVT persisted to day 5 (n = 45), median ventricular rates declined more with flecainide (-22%) and digoxin (-13%) than with sotalol (-5%; P = 0.001). Flecainide (HR = 2.1; P = 0.02) and digoxin (HR = 2.9; P = 0.01) were also associated with a higher rate of conversion of fetal SVT to a normal rhythm over time. No serious drug-related adverse events were observed, but arrhythmia-related mortality was 5%. Conclusion-Flecainide and digoxin were superior to sotalol in converting SVT to a normal rhythm and in slowing both AF and SVT to better-tolerated ventricular rates and therefore might be considered first to treat significant fetal tachyarrhythmia. (Circulation. 2011;124:1747-1754.)