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or in association with congenital heart defects&#44; in which cases the prognosis is worse&#46;<a class="elsevierStyleCrossRefs" href="#bib0510"><span class="elsevierStyleSup">3&#8211;6</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The most prevalent form of CAVB is autoimmune&#44; diagnosed in children of mothers diagnosed&#44; in most cases&#44; with systemic lupus erythematosus &#40;SLE&#41; or Sj&#246;gren syndrome &#40;SS&#41;&#46; However&#44; even when circulating maternal antibody levels are elevated&#44; only 2-5&#37; of pregnancies result in fetuses with CAVB&#46;<a class="elsevierStyleCrossRefs" href="#bib0510"><span class="elsevierStyleSup">3&#44;4&#44;10&#8211;12</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Clinically&#44; the condition can manifest with bradycardia&#44; with heart rates of less than 100 bpm&#44; pericardial effusion&#44; ventricular dilatation&#44; hyperechogenicity of the atrial walls due to fibrosis and reduced ventricular contractility&#44; alterations visible on the echocardiogram revealing a proinflammatory state and probable concomitant myocarditis&#44; endocardial fibroelastosis&#44; ascites and fetal hydrops&#46;<a class="elsevierStyleCrossRef" href="#bib0560"><span class="elsevierStyleSup">13</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">There is no effective prophylactic treatment&#44; although some drugs can improve the prognosis&#46; Permanent pacemaker implantation is virtually imperative&#44; since in most cases the block is complete and medically irreversible&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Etiology</span><p id="par0035" class="elsevierStylePara elsevierViewall">On the basis of its incidence and current knowledge of its pathophysiology&#44; CAVB can be immune-modulated or autoimmune&#44; and associated with congenital heart defects or idiopathic&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">In 56-90&#37; of cases it is autoimmune&#44; defined as such when the heart has no anatomical malformation that could explain the condition and the mother has a diagnosis of autoimmune disease and&#47;or is positive for autoantibodies&#46;<a class="elsevierStyleCrossRefs" href="#bib0515"><span class="elsevierStyleSup">4&#44;14&#44;15</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">The second most frequent cause is congenital heart malformations&#44; which are found in 14-42&#37; of cases&#46;<a class="elsevierStyleCrossRef" href="#bib0515"><span class="elsevierStyleSup">4</span></a> Defects in cardiac embryogenesis including congenital malformations of the anterior endocardium and the AV node are associated with loss of function and&#47;or anomalous location of these structures&#44; weak propagation of the electrical signal&#44; and a greater likelihood of CAVB&#46;<a class="elsevierStyleCrossRefs" href="#bib0510"><span class="elsevierStyleSup">3&#8211;5</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Transposition of the great vessels &#40;TGV&#41; 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cell receptor KIR2DL1&#44; and CAVB&#46; This epitope inhibits the action of NKs on macrophages and giant cells&#44; leading to inflammation and damage to cardiac tissue&#46;<a class="elsevierStyleCrossRef" href="#bib0600"><span class="elsevierStyleSup">21</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Maternal risk factors</span><p id="par0090" class="elsevierStylePara elsevierViewall">Advanced maternal age and the time of year of pregnancy&#44; when there are increased levels of anti-Ro&#47;SSA or anti-La&#47;SSB antibodies&#44; are believed to be the most important maternal risk factors&#46;<a class="elsevierStyleCrossRefs" href="#bib0515"><span class="elsevierStyleSup">4&#44;26</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">Other risk factors include maternal infections&#44; particularly respiratory infections and those occurring between the 18th and 24th week of pregnancy&#44; traumatic events during the same period including emotional stress due to the risk of fetal heart disease&#44; low vitamin D levels and hypothyroidism&#46; Conversely&#44; higher maternal vitamin D levels are protective&#44; associated with later need for pacemaker implantation&#46;<a class="elsevierStyleCrossRefs" href="#bib0515"><span class="elsevierStyleSup">4&#44;8&#44;18&#44;22&#8211;26</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Pathophysiology</span><p id="par0100" class="elsevierStylePara elsevierViewall">Positivity for maternal anti-Ro&#47;SSA or anti-La&#47;SSB antibodies is found in 60-95&#37; of cases&#44;<a class="elsevierStyleCrossRefs" href="#bib0510"><span class="elsevierStyleSup">3&#44;4&#44;10&#8211;12</span></a> in most of which SLE or SS has been diagnosed&#46;<a class="elsevierStyleCrossRefs" href="#bib0515"><span class="elsevierStyleSup">4&#44;25&#44;27&#44;28</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">However&#44; only 2-5&#37; of pregnancies in these women result in CAVB&#44;<a class="elsevierStyleCrossRefs" href="#bib0510"><span class="elsevierStyleSup">3&#44;4&#44;10&#8211;12&#44;29</span></a> rising to 12-25&#37; for subsequent pregnancies&#46; The results of several studies suggest that the increased risk in subsequent pregnancies may be overestimated&#44; since the selected groups consisted mainly of families with previous cases of neonatal lupus&#46; However&#44; the fact that women are older at the time of a subsequent birth may explain this increase&#46;<a class="elsevierStyleCrossRefs" href="#bib0510"><span class="elsevierStyleSup">3&#44;4</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">Damage to the conduction system usually occurs between the 16th and 24th weeks&#44; a period during which maternal antibodies most often cross the placenta via the trophoblast Fc&#947;Rn receptor&#46;<a class="elsevierStyleCrossRefs" href="#bib0515"><span class="elsevierStyleSup">4&#44;26&#44;29&#44;30</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">Maternal antibodies bind to L-type calcium channels in fetal cardiomyocytes&#44; particularly those in the AV node&#44; and reversibly inhibit these channels&#8217; current&#46; This results in inflammation&#44; calcification and fibrosis of the conduction tissue&#44; leading to irreversible damage&#44; even in structurally normal hearts&#46;<a class="elsevierStyleCrossRefs" href="#bib0510"><span class="elsevierStyleSup">3&#44;4&#44;14&#44;29&#44;31&#8211;36</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">In a case report analyzing an autopsy of cardiac tissue from a 19-week fetus with CAVB&#44; Friedman et al&#46; demonstrated extensive calcification and inflammatory infiltrate in the AV node and conduction tissue&#46;<a class="elsevierStyleCrossRef" href="#bib0680"><span class="elsevierStyleSup">37</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall">Apoptosis and inflammation trigger macrophages to secrete TGF-&#946;1 and TNF-&#945;&#44; inflammatory mediators that are permanently elevated in the conduction tissue of babies with heart disease on autopsy&#46;<a class="elsevierStyleCrossRefs" href="#bib0535"><span class="elsevierStyleSup">8&#44;36</span></a> The AV node and surrounding tissues are replaced by fibrotic tissue and areas of calcification that interrupt the electrical signal&#46;<a class="elsevierStyleCrossRefs" href="#bib0510"><span class="elsevierStyleSup">3&#44;32&#44;33&#44;38</span></a></p><p id="par0130" class="elsevierStylePara elsevierViewall">The polymorphism of codon 25 in the <span class="elsevierStyleItalic">TGFB1</span> gene has been associated with interindividual variability<a class="elsevierStyleCrossRef" href="#bib0615"><span class="elsevierStyleSup">24</span></a> and increased risk for developing CAVB&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">Another molecular mechanism is increased levels of interferon alpha &#40;INF-&#945;&#41;&#44; which were found in 78&#37; of cases in a recent study&#44; and increase the expression of class II MHC on CD14<span class="elsevierStyleSup">&#43;</span> monocytes&#46; While the former increase synthesis of SIGLEC1&#44; a proinflammatory protein&#44; the latter increases trafficking of maternal IgG across the placenta&#46;<a class="elsevierStyleCrossRef" href="#bib0555"><span class="elsevierStyleSup">12</span></a></p><p id="par0140" class="elsevierStylePara elsevierViewall">Analysis of umbilical cord blood showed that levels of C-reactive protein&#44; N-terminal pro-B-type natriuretic peptide &#40;NT-proBNP&#41;&#44; matrix metalloproteinases &#40;particularly type 2&#41;&#44; plasminogen and urokinase plasminogen activator are increased in cases of neonatal lupus with severe cardiac damage&#46; This is further evidence for the hypothesis that immune-mediated inflammation and fibrosis are associated with these alterations&#46;<a class="elsevierStyleCrossRef" href="#bib0535"><span class="elsevierStyleSup">8</span></a></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Clinical manifestations</span><p id="par0145" class="elsevierStylePara elsevierViewall">In utero&#44; the first manifestation is usually fetal bradycardia with a heart rate of less than 100 bpm&#46;<a class="elsevierStyleCrossRef" href="#bib0690"><span class="elsevierStyleSup">39</span></a> However&#44; the phenotype is variable&#44; depending on etiology&#44; age at presentation and ventricular function&#46;<a class="elsevierStyleCrossRef" href="#bib0695"><span class="elsevierStyleSup">40</span></a></p><p id="par0150" class="elsevierStylePara elsevierViewall">Differential diagnoses of fetal bradyarrhythmia include transient sinus bradycardia&#44; complete CAVB and partial CAVB&#46;<a class="elsevierStyleCrossRef" href="#bib0560"><span class="elsevierStyleSup">13</span></a> The heart block may be intermittent in the neonatal period but usually becomes permanent&#46;<a class="elsevierStyleCrossRefs" href="#bib0690"><span class="elsevierStyleSup">39&#44;41</span></a></p><p id="par0155" class="elsevierStylePara elsevierViewall">Fetal hydrops&#44; ventricular response of &#60;55 bpm&#44; prematurity and complex congenital defects are markers of poor prognosis and are associated with higher mortality&#46;<a class="elsevierStyleCrossRefs" href="#bib0500"><span class="elsevierStyleSup">1&#44;3&#44;5&#44;6&#44;28&#44;42</span></a></p><p id="par0160" class="elsevierStylePara elsevierViewall">Fetal hydrops is defined as the pathological accumulation of fluid in at least two fetal compartments&#44; which may include the pleural or pericardial spaces&#44; abdominal cavity&#44; integument&#44; or placenta&#46; It can result from a combination of increased hydrostatic pressure&#44; decreased oncotic pressure&#44; and in some cases&#44; lymphatic obstruction&#46; Approximately 15-25&#37; of fetuses with nonimmune hydrops have cardiac abnormalities&#46;<a class="elsevierStyleCrossRef" href="#bib0625"><span class="elsevierStyleSup">26</span></a></p><p id="par0165" class="elsevierStylePara elsevierViewall">Patients with autoimmune CAVB may present with other concomitant cardiac abnormalities&#44; endocardial fibroelastosis&#44; dilated cardiomyopathy &#40;DCM&#41; and&#47;or valve disease&#46; The incidence of the latter is 1&#46;6&#37;&#46;<a class="elsevierStyleCrossRefs" href="#bib0510"><span class="elsevierStyleSup">3&#44;4&#44;32</span></a></p><p id="par0170" class="elsevierStylePara elsevierViewall">These alterations are among the manifestations of neonatal lupus syndrome &#40;NLS&#41;&#44; which is found in around 5&#37; of newborns of mothers with SLE and positivity for anti-Ro &#40;25-40&#37;&#41; and anti-La &#40;10-15&#37;&#41; antibodies&#46; The two most frequent forms of NLS are neonatal lupus erythematosus &#40;NLE&#41; and CAVB&#44; although hematological and hepatic manifestations have also been documented&#46;<a class="elsevierStyleCrossRef" href="#bib0710"><span class="elsevierStyleSup">43</span></a> Maternal antibodies usually cease to be detectable between the 6th and 8th month of postnatal life followed by regression of dermal&#44; hepatic and hematological manifestations&#44; but this regeneration does not occur in cardiac tissue&#46; Consequently&#44; most cases of established CAVB are complete and irreversible&#46;<a class="elsevierStyleCrossRef" href="#bib0630"><span class="elsevierStyleSup">27</span></a></p><p id="par0175" class="elsevierStylePara elsevierViewall">Data from the US Research Registry for Neonatal Lupus on neonatal outcomes in a group of pregnant women with SLE show that 49&#37; of newborns had NLS&#44; 30&#37; with cutaneous NLE&#44; 18&#37; CAVB and 1&#37; hematological&#47;hepatic NLE&#46;<a class="elsevierStyleCrossRef" href="#bib0710"><span class="elsevierStyleSup">43</span></a></p><p id="par0180" class="elsevierStylePara elsevierViewall">Comparison of late pediatric diagnoses with those made in utero or at birth shows that the former are less likely to have an autoimmune etiology<a class="elsevierStyleCrossRefs" href="#bib0515"><span class="elsevierStyleSup">4&#44;28</span></a> and have lower mortality and better prognosis&#46;<a class="elsevierStyleCrossRefs" href="#bib0510"><span class="elsevierStyleSup">3&#44;4&#44;8</span></a></p><p id="par0185" class="elsevierStylePara elsevierViewall">Overall mortality associated with CAVB ranges between 9&#37; and 25&#37;&#44; with 70&#37; of deaths occurring in utero&#46; Pacemaker implantation is required in the first year of life in 12-70&#37; of babies&#46;<a class="elsevierStyleCrossRefs" href="#bib0500"><span class="elsevierStyleSup">1&#44;3&#8211;5&#44;7&#44;8&#44;44</span></a></p><p id="par0190" class="elsevierStylePara elsevierViewall">Most births &#40;81&#37;&#41; are live&#44; 38&#37; of which are premature&#46; Vaginal birth should be the aim&#44; but due to the increased risk of preterm birth associated with maternal autoimmune disease&#44; cesarean delivery is preferred in around 75&#37; of cases&#46;<a class="elsevierStyleCrossRefs" href="#bib0515"><span class="elsevierStyleSup">4&#44;7&#44;43</span></a> Cesarean delivery is indicated whenever there is evidence of fetal distress or risk to the life of mother or fetus&#59; however&#44; it is associated with higher rates of infection and bleeding&#44; and should therefore only be performed for obstetric indications&#46;<a class="elsevierStyleCrossRef" href="#bib0710"><span class="elsevierStyleSup">43</span></a> The AV block diagnosed may be first or second degree&#44; but in around 80&#37; of cases it is third degree&#44; complete&#44; and irreversible&#46;<a class="elsevierStyleCrossRefs" href="#bib0515"><span class="elsevierStyleSup">4&#44;7</span></a></p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Diagnosis</span><p id="par0195" class="elsevierStylePara elsevierViewall">A thorough medical history&#44; particularly of the mother&#44; is essential to obtain an accurate and timely diagnosis&#46; In high-risk pregnancies&#44; fetal echocardiographic cardiac monitoring should begin in the 16th week and continue weekly until the 24th week&#44; and thereafter fortnightly until birth&#46;<a class="elsevierStyleCrossRefs" href="#bib0515"><span class="elsevierStyleSup">4&#44;25&#44;26</span></a></p><p id="par0200" class="elsevierStylePara elsevierViewall">Indicators of high risk include the presence of maternal SSA&#47;SSB antibodies&#44; a family history of congenital heart disease&#44; the presence of structural heart defects or rhythm disturbances on a routine obstetric echocardiogram&#44; and evidence of fetal hydrops&#46;<a class="elsevierStyleCrossRef" href="#bib0625"><span class="elsevierStyleSup">26</span></a></p><p id="par0205" class="elsevierStylePara elsevierViewall">Echocardiography remains the gold standard for diagnosis of CAVB&#44; with a diagnostic rate of 90&#37;&#44; although this is dependent on the experience and skill of the operator&#46;<a class="elsevierStyleCrossRef" href="#bib0625"><span class="elsevierStyleSup">26</span></a> Echocardiography is also the gold standard for anatomical and functional study of the fetal heart&#44; screening for abnormalities in anatomy&#44; rhythm and rate by assessing atrial and ventricular rates&#44; atrioventricular conduction&#44; and the presence of a ventricular contraction after every atrial contraction&#46;<a class="elsevierStyleCrossRefs" href="#bib0560"><span class="elsevierStyleSup">13&#44;26</span></a></p><p id="par0210" class="elsevierStylePara elsevierViewall">Other techniques for detecting arrhythmias and conduction defects have been proposed&#44; but&#44; although promising&#44; there is little agreement concerning their usefulness in clinical practice&#46; Cardiac magnetic resonance imaging is used to assess venous anatomy and associated extracardiac abnormalities&#44; Doppler echocardiography to determine rhythm and the PR interval&#44; fetal electrocardiography for fetal monitoring after rupture of membranes&#44; and magnetocardiography for more precise assessment of conduction and rhythm in fetuses with known conduction disorders &#40;class of recommendation IIa&#44; level of evidence B&#47;C&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0625"><span class="elsevierStyleSup">26&#44;28&#44;45</span></a></p><p id="par0215" class="elsevierStylePara elsevierViewall">Around 75&#37; of cases of CAVB are diagnosed between the 20th and 28th week of pregnancy&#46; Presentation tends to be earlier in cases of autoimmune CAVB&#46;<a class="elsevierStyleCrossRefs" href="#bib0510"><span class="elsevierStyleSup">3&#44;4&#44;6&#44;39</span></a></p><p id="par0220" class="elsevierStylePara elsevierViewall">In a study by Morel et al&#46;<a class="elsevierStyleCrossRef" href="#bib0725"><span class="elsevierStyleSup">46</span></a> of 187 neonates with CAVB over a median follow-up of seven years&#44; 94&#46;4&#37; of cases were diagnosed in utero&#46; Pacemakers were implanted in 80&#37; of cases&#59; 18&#46;8&#37; developed DCM&#44; a median of 8&#46;6 months after implantation&#46; Ten-year survival was 23&#37; for newborns diagnosed neonatally with DCM&#44; 54&#37; for those who developed late-onset DCM&#44; and 98&#46;6&#37; for those without DCM&#46; Fetal hydrops&#44; in-utero DCM and maternal treatment with hydroxychloroquine &#40;HCQ&#41; were risk factors for neonatal DCM&#44; while late-onset DCM was associated with in-utero mitral valve insufficiency and pacemaker implantation&#46;</p><p id="par0225" class="elsevierStylePara elsevierViewall">The same study reported high levels of IgG&#44; IgM&#44; CD43 T cells&#44; and other markers of myocarditis&#44; only in newborns with neonatal DCM&#46;<a class="elsevierStyleCrossRef" href="#bib0725"><span class="elsevierStyleSup">46</span></a></p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Treatment</span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Prenatal</span><p id="par0230" class="elsevierStylePara elsevierViewall">There is little agreement on the treatment for CAVB&#44; with various strategies having been proposed including steroids&#44; beta-adrenergic receptor agonists&#44; HCQ&#44; plasmapheresis&#44; and intravenous immunoglobulin &#40;IVIG&#41;&#46; The choice of therapy depends on the etiology of the AV block&#44; ventricular function&#44; and degree of heart failure&#46;<a class="elsevierStyleCrossRefs" href="#bib0625"><span class="elsevierStyleSup">26&#44;30&#44;47&#44;48</span></a></p><p id="par0235" class="elsevierStylePara elsevierViewall">Beta-adrenergic agonists&#44; preferably terbutaline&#44; increase fetal heart rate and are indicated when the rate is below 55 bpm&#46; However&#44; side effects include anxiety&#44; palpitations and headache and may not be tolerated by the mother&#46;<a class="elsevierStyleCrossRefs" href="#bib0510"><span class="elsevierStyleSup">3&#44;26&#44;30&#44;43&#44;49</span></a></p><p id="par0240" class="elsevierStylePara elsevierViewall">Plasmapheresis reduces the concentration of circulating maternal antibodies and hence damage to fetal cardiac tissue&#46;</p><p id="par0245" class="elsevierStylePara elsevierViewall">IVIG increases elimination and reduces placental transcytosis of maternal antibodies&#44; and modulates inhibitory signaling on macrophages&#44; reducing the inflammatory response and fibrosis&#46; It has not been shown to prevent CAVB but it may be indicated for treatment of cardiomyopathy at a dose of 400 mg&#47;kg&#47;day&#46;<a class="elsevierStyleCrossRefs" href="#bib0645"><span class="elsevierStyleSup">30&#44;48&#44;50</span></a></p><p id="par0250" class="elsevierStylePara elsevierViewall">HCQ inhibits Toll-like receptors and thereby reduces plasma INF-&#945; levels and the proinflammatory state in both mother and baby&#46; It is currently indicated for treating exacerbations of the mother&#39;s autoimmune disease during pregnancy and for prevention of NLS&#46;<a class="elsevierStyleCrossRefs" href="#bib0555"><span class="elsevierStyleSup">12&#44;13&#44;30&#44;37&#44;51&#8211;53</span></a> The Preventive Approach to Congenital Heart Block with Hydroxychloroquine &#40;PATCH&#41; prospective trial analyzed the effectiveness of this drug in preventing recurrence of cardiac manifestations of NLS in children of high-risk mothers&#46;<a class="elsevierStyleCrossRef" href="#bib0645"><span class="elsevierStyleSup">30</span></a></p><p id="par0255" class="elsevierStylePara elsevierViewall">Fluorinated steroids&#44; which are partially inactivated by placental 11beta-hydroxysteroid dehydrogenase and have satisfactory bioavailability in the fetus&#44; have been used&#44;<a class="elsevierStyleCrossRefs" href="#bib0520"><span class="elsevierStyleSup">5&#44;54&#44;55</span></a> mainly in immune-mediated CAVB &#40;class IIb&#44; level C&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0625"><span class="elsevierStyleSup">26</span></a> Some authors have proposed oral betamethasone or dexamethasone at doses of between 4 mg and 8 mg&#47;day for six weeks&#46;<a class="elsevierStyleCrossRefs" href="#bib0515"><span class="elsevierStyleSup">4&#44;56&#44;57</span></a> This regimen should be maintained until birth if AV block is reversed but should be discontinued when it is not&#44; when there is first- or second-degree block&#44; or if the fetus presents hydrops&#44; myocarditis or ascites&#44; even with complete block&#46;<a class="elsevierStyleCrossRefs" href="#bib0780"><span class="elsevierStyleSup">57&#44;58</span></a></p><p id="par0260" class="elsevierStylePara elsevierViewall">These drugs reduce the need for pacemaker implantation&#44; the degree of incomplete block&#44; and the risk of myocarditis&#46; They also inhibit the inflammatory cascade and suggest that there is a window of opportunity for treatment at the time when inflammation of the conduction system progresses to fibrosis&#46; They have not been shown to have significant effects in cases of complete CAVB&#44; which is irreversible&#44;<a class="elsevierStyleCrossRefs" href="#bib0625"><span class="elsevierStyleSup">26&#44;44&#44;49&#44;60&#44;61</span></a> but if there is uncertainty as to the degree of block they can be used until this is confirmed&#46;<a class="elsevierStyleCrossRefs" href="#bib0545"><span class="elsevierStyleSup">10&#44;57&#44;59&#44;62</span></a></p><p id="par0265" class="elsevierStylePara elsevierViewall">The side effects of fluorinated steroids need to be taken into consideration&#44; bearing in mind the principle of &#8220;first&#44; do no harm&#8221;&#46; Adverse effects on the fetus can include miscarriage&#44; oligohydramnios&#44; delayed development&#44; growth retardation&#44; and adrenal insufficiency&#44; while diabetes&#44; hypertension and weight gain have been observed in mothers and must also be considered&#46;<a class="elsevierStyleCrossRefs" href="#bib0525"><span class="elsevierStyleSup">6&#44;44&#44;47&#44;57&#44;63&#44;64</span></a></p><p id="par0270" class="elsevierStylePara elsevierViewall">The main therapeutic options for medical therapy in utero are summarized in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0275" class="elsevierStylePara elsevierViewall">Percutaneous pacing techniques have been described&#44; but results are unsatisfactory and the risk of fetal death is high&#46; In most cases&#44; therefore&#44; the pregnancy runs its normal course and treatment only begins after birth&#46;<a class="elsevierStyleCrossRefs" href="#bib0625"><span class="elsevierStyleSup">26&#44;28&#44;65</span></a></p></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Postnatal</span><p id="par0280" class="elsevierStylePara elsevierViewall">After birth&#44; fetal bradycardia &#40;heart rate &#60;70 bpm&#41; can initially be controlled by drugs such as isoprenaline&#44; atropine&#44; epinephrine and&#47;or dopamine&#44; alone or in combination with transcutaneous pacing and&#47;or temporary cardiac pacing&#44; in order to prevent sudden death&#46;<a class="elsevierStyleCrossRefs" href="#bib0510"><span class="elsevierStyleSup">3&#44;27</span></a></p><p id="par0285" class="elsevierStylePara elsevierViewall">Temporary cardiac pacing is also indicated in cases of cardiogenic shock or fetal hydrops&#46; Temporary transesophageal pacing can also be used&#44; but the risk of esophageal stenosis is high&#46;<a class="elsevierStyleCrossRef" href="#bib0705"><span class="elsevierStyleSup">42</span></a></p><p id="par0290" class="elsevierStylePara elsevierViewall">Unfortunately CAVB is irreversible and hence a permanent pacemaker is necessary in 80&#37; of cases&#44;<a class="elsevierStyleCrossRef" href="#bib0690"><span class="elsevierStyleSup">39</span></a> which improves long-term survival and reduces presyncope and syncope&#44; even in asymptomatic cases&#46;<a class="elsevierStyleCrossRefs" href="#bib0510"><span class="elsevierStyleSup">3&#44;28&#44;48</span></a></p><p id="par0295" class="elsevierStylePara elsevierViewall">The latest indications for pacemaker implantation in children with CAVB are summarized in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0300" class="elsevierStylePara elsevierViewall">Pacemaker implantation is technically challenging&#44; and various complications have been reported due to both the size of the patients and their rapid growth&#44; and the presence of cardiac malformations&#46;<a class="elsevierStyleCrossRefs" href="#bib0525"><span class="elsevierStyleSup">6&#44;66</span></a> The task is further complicated by the small size of the vessels involved and the significant discrepancy between the size of the device and of the child&#39;s body&#46;<a class="elsevierStyleCrossRefs" href="#bib0825"><span class="elsevierStyleSup">66&#44;67</span></a></p><p id="par0305" class="elsevierStylePara elsevierViewall">Opinions differ concerning the best approach&#44; mode of stimulation&#44; and location of the pulse generator&#46;<a class="elsevierStyleCrossRef" href="#bib0510"><span class="elsevierStyleSup">3</span></a></p><p id="par0310" class="elsevierStylePara elsevierViewall">With regard to approach&#44; the current options are epicardial and endocardial &#40;transvenous&#41; pacing&#46; The most appropriate approach depends on body size&#44; age&#44; venous diameter&#44; and presence of congenital cardiac defects&#46;<a class="elsevierStyleCrossRef" href="#bib0830"><span class="elsevierStyleSup">67</span></a> Access can be via lateral thoracotomy&#44; sternotomy or a subxiphoid approach&#46;</p><p id="par0315" class="elsevierStylePara elsevierViewall">There is agreement that epicardial pacing is the first-line option in children weighing less than 15-20 kg and with structurally normal hearts<a class="elsevierStyleCrossRefs" href="#bib0510"><span class="elsevierStyleSup">3&#44;66&#8211;68</span></a> and when venous access to the heart is not feasible&#44; especially in a univentricular heart&#46;<a class="elsevierStyleCrossRef" href="#bib0575"><span class="elsevierStyleSup">16</span></a> However&#44; periodic reviews are needed to reduce the rate of complications&#46;<a class="elsevierStyleCrossRefs" href="#bib0840"><span class="elsevierStyleSup">69&#44;70</span></a></p><p id="par0320" class="elsevierStylePara elsevierViewall">Transvenous implantation of an endocardial pacemaker via tributaries of the superior vena cava or branches of the iliac veins is minimally invasive and has a low risk of malfunction&#44; although the risk of systemic thrombosis is higher and the rate of venous occlusion is 25&#37;&#46;<a class="elsevierStyleCrossRefs" href="#bib0845"><span class="elsevierStyleSup">70&#8211;72</span></a></p><p id="par0325" class="elsevierStylePara elsevierViewall">Intracardiac shunts increase the risk of systemic embolism and may need to be corrected before pacemaker implantation&#46;<a class="elsevierStyleCrossRef" href="#bib0575"><span class="elsevierStyleSup">16</span></a> According to Khairy et al&#46;&#44; endocardial pacing in patients with intracardiac shunts is associated with less frequent lead replacement compared to epicardial pacing&#44; but incurs a higher thromboembolic risk that is not reduced by anticoagulation&#46;<a class="elsevierStyleCrossRef" href="#bib0855"><span class="elsevierStyleSup">72</span></a></p><p id="par0330" class="elsevierStylePara elsevierViewall">Complications of a transvenous approach include lead dislodgement&#44; pocket hematoma or bleeding&#44; pneumothorax&#44; heart perforation&#44; cardiac tamponade&#44; and infection&#46;<a class="elsevierStyleCrossRef" href="#bib0575"><span class="elsevierStyleSup">16</span></a> The most common complication is infection&#44; which has an incidence of 1-8&#37; and is the most frequent indication for lead removal&#44; which in turn results in heart perforation in 1-2&#37; of cases and death in 0&#46;1-0&#46;4&#37;&#46;<a class="elsevierStyleCrossRefs" href="#bib0575"><span class="elsevierStyleSup">16&#44;73</span></a></p><p id="par0335" class="elsevierStylePara elsevierViewall">The small body size of the patients means that the chest wall is not a feasible location for the generator&#44; and so the abdominal wall is generally used&#46;<a class="elsevierStyleCrossRefs" href="#bib0510"><span class="elsevierStyleSup">3&#44;66</span></a> In children weighing less than 2&#46;5 kg&#44; the generator can be placed in the pleural cavity&#44; which affords better protection&#46;<a class="elsevierStyleCrossRef" href="#bib0865"><span class="elsevierStyleSup">74</span></a></p><p id="par0340" class="elsevierStylePara elsevierViewall">A recent study by Costa et al&#46; assessed the long-term results of epicardial pacemaker implantation with subxiphoid access&#46; They concluded that the technique is viable and had excellent results and system longevity&#44; reducing surgical trauma by placing the generator submuscularly in the preperitoneal space&#44; reducing cardiac fibrosis&#44; and diminishing the effect of the child&#39;s growth on the system by using a rectilinear trajectory&#46;<a class="elsevierStyleCrossRef" href="#bib0825"><span class="elsevierStyleSup">66</span></a></p><p id="par0345" class="elsevierStylePara elsevierViewall">In epicardial pacing&#44; ventricular lead placement improves mechanical synchrony and contraction efficiency&#46;<a class="elsevierStyleCrossRef" href="#bib0870"><span class="elsevierStyleSup">75</span></a> Apical pacing in the right ventricle is a common approach&#44; but left ventricular apical or lateral wall pacing result in better left ventricular function and are thus currently recommended&#46;<a class="elsevierStyleCrossRef" href="#bib0875"><span class="elsevierStyleSup">76</span></a></p><p id="par0350" class="elsevierStylePara elsevierViewall">Lead placement in the right ventricular lateral wall or outflow tract is associated with left ventricular dysfunction and dyssynchrony&#46;<a class="elsevierStyleCrossRef" href="#bib0870"><span class="elsevierStyleSup">75</span></a> Implantation in the posterior ventricle is also possible&#44; but increases the risk of cardiac and coronary compression and sudden death&#46;<a class="elsevierStyleCrossRefs" href="#bib0880"><span class="elsevierStyleSup">77&#8211;80</span></a></p><p id="par0355" class="elsevierStylePara elsevierViewall">The type of pacemaker to be used depends on the patient&#39;s body size&#44; level of activity and ventricular function&#46;<a class="elsevierStyleCrossRefs" href="#bib0900"><span class="elsevierStyleSup">81&#8211;83</span></a></p><p id="par0360" class="elsevierStylePara elsevierViewall">Some authors report that VVI pacing is more likely to lead to left ventricular dysfunction than DDD pacing&#46;<a class="elsevierStyleCrossRef" href="#bib0915"><span class="elsevierStyleSup">84</span></a> However&#44; multicenter studies have shown little difference between the two modes in terms of mortality&#44; cardiac function and quality of life&#46;<a class="elsevierStyleCrossRefs" href="#bib0920"><span class="elsevierStyleSup">85&#8211;87</span></a></p><p id="par0365" class="elsevierStylePara elsevierViewall">VVI pacemakers are often the first option in smaller children due to their smaller area&#46; When the child reaches a certain weight&#44; a second&#44; atrial lead can be added&#59; this change to a dual-chamber system improves quality of life and cardiac function&#44; smaller ventricular dimensions and lower natriuretic peptide levels&#46;<a class="elsevierStyleCrossRefs" href="#bib0900"><span class="elsevierStyleSup">81&#8211;83</span></a> However&#44; the risk-benefit ratio of further invasive surgery and the need for future reviews must be taken into account&#46;<a class="elsevierStyleCrossRefs" href="#bib0935"><span class="elsevierStyleSup">88&#44;89</span></a></p><p id="par0370" class="elsevierStylePara elsevierViewall">AV synchrony should be preserved&#44; since dyssynchronous and non-physiological activation induces pacemaker-induced cardiomyopathy in 7&#37; of patients with permanent pacing&#44; leading to pathological myocardial remodeling and ventricular dilatation&#46;<a class="elsevierStyleCrossRef" href="#bib0955"><span class="elsevierStyleSup">92</span></a></p><p id="par0375" class="elsevierStylePara elsevierViewall">Permanent His bundle pacing has fewer adverse effects on right ventricular function and cardiac function in general&#46;<a class="elsevierStyleCrossRefs" href="#bib0945"><span class="elsevierStyleSup">90&#44;91</span></a> Although technically demanding&#44; especially in pediatric patients&#44; it may become an alternative option in the near future&#46;<a class="elsevierStyleCrossRefs" href="#bib0955"><span class="elsevierStyleSup">92&#8211;94</span></a></p><p id="par0380" class="elsevierStylePara elsevierViewall">Recommendations for pacemaker implantation in pediatric patients with CAVB are summarized in <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0385" class="elsevierStylePara elsevierViewall">The first case reported in Portugal of pediatric cardiac resynchronization in a case of cardiomyopathy induced by right ventricular pacing due to CAVB showed improved ejection fraction&#44; reduced left ventricular end-diastolic diameter and significantly reduced mitral regurgitation&#44; as well as improvement in New York Heart Association function class from III-IV to I&#46;<a class="elsevierStyleCrossRef" href="#bib0970"><span class="elsevierStyleSup">95</span></a></p><p id="par0390" class="elsevierStylePara elsevierViewall">Fujioka et al&#46; successfully applied a staged therapeutic approach to a premature low-birth-weight infant&#46; Following diagnosis of CAVB and myocarditis in the 27th week of pregnancy&#44; with a fetal atrial rate of 152 bpm and ventricular rate of 48 bpm&#44; 4 mg&#47;day of dexamethasone was administered&#46; Cesarean delivery took place at 29 weeks and two days due to fetal distress&#44; and temporary right ventricular pacing &#40;120 bpm&#41; was begun&#46; A second lead was subsequently implanted in the ventricular apex and prednisolone &#40;1 mg&#47;kg&#47;day for two weeks&#41; and IGIV &#40;1 g&#47;day for three days&#41; were administered&#46; Permanent pacemaker implantation &#40;VVI mode at 120 bpm&#41; was performed on day 64&#46;<a class="elsevierStyleCrossRef" href="#bib0975"><span class="elsevierStyleSup">96</span></a></p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Future prospects</span><p id="par0395" class="elsevierStylePara elsevierViewall">Gene therapy for biological pacing&#44; using an adenovirus as vector in cardiomyocytes&#44; is a promising research field in constant development&#46;<a class="elsevierStyleCrossRef" href="#bib0510"><span class="elsevierStyleSup">3</span></a></p><p id="par0400" class="elsevierStylePara elsevierViewall">Antagonism of molecular pathways&#44; particularly of MMP-2&#44; is based on discoveries that link these pathways with increased inflammation and fibrosis&#46;<a class="elsevierStyleCrossRef" href="#bib0535"><span class="elsevierStyleSup">8</span></a></p><p id="par0405" class="elsevierStylePara elsevierViewall">Measurement of molecules including NT-proBNP can be used as a short-term diagnostic aid when no alterations are observed on imaging studies&#46;<a class="elsevierStyleCrossRef" href="#bib0535"><span class="elsevierStyleSup">8</span></a></p><p id="par0410" class="elsevierStylePara elsevierViewall">A study of 38 patients showed that permanent His bundle pacing preserves left ventricular function and cardiac synchrony as compared with right ventricular septal pacing&#46;<a class="elsevierStyleCrossRef" href="#bib0955"><span class="elsevierStyleSup">92</span></a></p><p id="par0415" class="elsevierStylePara elsevierViewall">Micropacemakers are an alternative under development to treat progressive CAVB associated with hydrops and may be applied in future projects&#46;<a class="elsevierStyleCrossRef" href="#bib0980"><span class="elsevierStyleSup">97</span></a></p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Conclusions</span><p id="par0420" class="elsevierStylePara elsevierViewall">Although rare&#44; CAVB is an important and treatable cause of pediatric mortality&#46; Its etiology is predominantly autoimmune&#44; mothers of affected fetuses usually being diagnosed with SLE or SS&#46;</p><p id="par0425" class="elsevierStylePara elsevierViewall">Various genetic polymorphisms and inflammatory markers are associated with the condition&#44; which is caused by fibrosis and calcification of the AV node and conduction tissue&#46;</p><p id="par0430" class="elsevierStylePara elsevierViewall">Maternal risk is higher in cases of autoimmune disease&#44; hypothyroidism or infection during pregnancy&#44; which may explain why only 2-5&#37; of pregnancies in which autoimmune disease is the only risk factor result in CAVB&#46;</p><p id="par0435" class="elsevierStylePara elsevierViewall">Fetal echocardiography remains the diagnostic gold standard&#46;</p><p id="par0440" class="elsevierStylePara elsevierViewall">Regarding therapy&#44; effective antagonism of the inflammatory cascade is of value to prevent the genesis and evolution of AV block&#46;</p><p id="par0445" class="elsevierStylePara elsevierViewall">In most cases&#44; monitoring of the pregnancy until birth is all that is recommended&#46; Postnatally&#44; pacemaker implantation is necessary in the majority of affected infants&#46;</p><p id="par0450" class="elsevierStylePara elsevierViewall">New techniques aimed at reducing morbidity and mortality have been proposed and continue to be studied&#46; Some have been applied in clinical practice with satisfactory results&#44; but most have only been analyzed in small samples or isolated cases&#44; so there is still hesitancy and uncertainty concerning the use of these therapies&#46;</p><p id="par0455" class="elsevierStylePara elsevierViewall">Further studies are therefore required to optimize both diagnosis and treatment&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conflicts of interest</span><p id="par0460" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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          "titulo" => "Palavras-chave"
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          "titulo" => "Introduction"
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          "identificador" => "sec0010"
          "titulo" => "Etiology"
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        6 => array:2 [
          "identificador" => "sec0015"
          "titulo" => "Genetic alterations"
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          "identificador" => "sec0020"
          "titulo" => "Maternal risk factors"
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        8 => array:2 [
          "identificador" => "sec0025"
          "titulo" => "Pathophysiology"
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        9 => array:2 [
          "identificador" => "sec0030"
          "titulo" => "Clinical manifestations"
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        10 => array:2 [
          "identificador" => "sec0035"
          "titulo" => "Diagnosis"
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          "identificador" => "sec0040"
          "titulo" => "Treatment"
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            0 => array:2 [
              "identificador" => "sec0045"
              "titulo" => "Prenatal"
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          "identificador" => "sec0050"
          "titulo" => "Postnatal"
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        13 => array:2 [
          "identificador" => "sec0055"
          "titulo" => "Future prospects"
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          "identificador" => "sec0060"
          "titulo" => "Conclusions"
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          "identificador" => "sec0065"
          "titulo" => "Conflicts of interest"
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          "titulo" => "References"
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    "fechaRecibido" => "2018-02-28"
    "fechaAceptado" => "2019-09-23"
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          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec1504608"
          "palabras" => array:5 [
            0 => "Congenital atrioventricular block"
            1 => "Neonatal lupus"
            2 => "Pacemaker"
            3 => "Pathophysiology"
            4 => "Prenatal diagnosis"
          ]
        ]
      ]
      "pt" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palavras-chave"
          "identificador" => "xpalclavsec1504607"
          "palabras" => array:5 [
            0 => "Bloqueio auriculoventricular cong&#233;nito"
            1 => "L&#250;pus neonatal"
            2 => "<span class="elsevierStyleItalic">Pacemaker</span>"
            3 => "Fisiopatologia"
            4 => "Diagn&#243;stico pr&#233;-natal"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Congenital atrioventricular block &#40;CAVB&#41;&#44; classified as such when diagnosed in utero&#44; at birth or during the first month of life&#44; is a rare condition with an estimated incidence between 1&#47;15 000 and 1&#47;22 000 live births&#46; It is now accepted that the pathophysiology of this condition is predominantly associated with an immunologically mediated response to the conduction system&#44; which occurs due to transplacental passage of maternal autoantibodies from mothers diagnosed&#44; in most cases&#44; with systemic lupus erythematosus or Sj&#246;gren syndrome&#46; Fetal echocardiography continues to be the diagnostic gold standard&#44; however there are other techniques with good results and advantages&#46; Regarding therapeutics&#44; both pharmacological measures and cardiac stimulation techniques have been developed to increase the safety of procedures&#44; decrease associated mortality and morbidity&#44; and provide a better quality of life for patients&#44; although there are disagreements in deciding the best therapeutic plan&#46; This review aims to summarize and elucidate the best diagnostic approach as well as the best therapeutic strategies&#46; A search was performed in the PubMed and Science Direct databases of articles published and accepted for publication&#46; The following search terms were used&#58; &#8220;Congenital atrioventricular block&#8221;&#44; &#8220;Neonatal lupus&#8221;&#44; &#8220;Pacemaker&#8221;&#44; &#8220;Pathophysiology&#8221;&#44; &#8220;Electrophysiology&#8221;&#44; and &#8220;Prenatal diagnosis&#8221;&#46; Articles in Portuguese and English were selected&#46; No time constraints were used&#46; Repeated articles were excluded from the two databases&#46;</p></span>"
      ]
      "pt" => array:2 [
        "titulo" => "Resumo"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">O bloqueio auriculoventricular cong&#233;nito &#40;BAVC&#41;&#44; assim classificado quando diagnosticado <span class="elsevierStyleItalic">in utero</span>&#44; ao nascimento ou durante o primeiro m&#234;s de vida&#44; &#233; uma patologia rara com uma incid&#234;ncia estimada que varia entre 1&#47;15&#46;000 e 1&#47;22&#46;000 nados vivos&#46; &#201; atualmente aceite que a fisiopatologia inerente a esta condi&#231;&#227;o est&#225; predominantemente associada a uma resposta imunologicamente mediada contra o sistema de condu&#231;&#227;o que ocorre devido &#224; passagem transplacent&#225;ria de autoanticorpos maternos de m&#227;es diagnosticadas&#44; na maioria dos casos&#44; com l&#250;pus eritematoso sist&#233;mico &#40;LES&#41; ou s&#237;ndrome de Sj&#246;gren &#40;SS&#41;&#46; A ecocardiografia fetal continua a ser o <span class="elsevierStyleItalic">gold-standard</span> diagn&#243;stico&#44; contudo existem outras t&#233;cnicas com bons resultados e vantagens relativamente &#224; primeira&#46; No que concerne &#224; terap&#234;utica&#44; tanto as estrat&#233;gias farmacol&#243;gicas quanto as t&#233;cnicas de estimula&#231;&#227;o card&#237;aca t&#234;m evolu&#237;do no sentido de aumentar a seguran&#231;a dos procedimentos&#44; diminuir a mortalidade e morbilidade associadas e promover uma maior qualidade de vida dos doentes&#44; continuando&#44; apesar disso&#44; a existir diverg&#234;ncias no momento de decidir qual o melhor plano terap&#234;utico&#46; Deste modo&#44; esta revis&#227;o tem como objetivo o resumo e a clarifica&#231;&#227;o da melhor abordagem diagn&#243;stica&#44; bem como das melhores estrat&#233;gias terap&#234;uticas&#46; Foi feita uma pesquisa nas bases de dados Pubmed e Science Direct de artigos publicados e aceites para publica&#231;&#227;o&#46; Foram utilizadas as seguintes express&#245;es de pesquisa&#58; &#8220;Congenital atrioventricular block&#8221;&#44; &#8220;Neonatal lupus&#8221;&#44; &#8220;Pacemaker&#8221;&#44; &#8220;Pathophysiology&#8221;&#44; &#8220;Electrophysiology&#8221;&#44; &#8220;Prenatal diagnosis&#8221;&#46; Foram selecionados artigos escritos em portugu&#234;s e ingl&#234;s&#46; N&#227;o foram utilizadas restri&#231;&#245;es temporais&#46; Foram exclu&#237;dos artigos repetidos nas duas bases de dados&#46;</p></span>"
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          "leyenda" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">bpm&#58; beats per minute&#59; CR&#58; class of recommendation&#59; IVIG&#58; intravenous immunoglobulin&#59; LE&#58; level of evidence&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Cause&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Treatment&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">CR&#47;LE&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " rowspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Autoimmune</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Observation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">I&#47;A&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Structurally normal heart&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Dexamethazone&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">IIb&#47;B&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1st- or 2nd-degree block with evidence of inflammation &#40;pericardial effusion&#44; ventricular dilatation&#44; hyperechogenicity of the atrial walls or reduced biventricular contractility&#41;Prophylactic&#44; to reduce mortality and cardiomyopathy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">IVIG&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">IIb&#47;B&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Not recommended for prophylaxis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Beta-adrenergic agonists&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">IIa&#47;C&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Heart rate &#60;55 bpm&#44; fetal hydrops&#44; congenital malformations or cardiac dysfunction&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " rowspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Cardiac malformations</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Observation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">I&#47;A&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Beta-adrenergic agonists&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">IIa&#47;C&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Heart rate &#60;55 bpm&#44; fetal hydrops&#44; congenital malformations or cardiac dysfunction&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Idiopathic&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Observation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">I&#47;A&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab2888128.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Treatment of congenital atrioventricular block in utero &#40;adapted from <a class="elsevierStyleCrossRef" href="#bib0625"><span class="elsevierStyleSup">26</span></a>&#41;&#46;</p>"
        ]
      ]
      1 => array:8 [
        "identificador" => "tbl0010"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at2"
            "detalle" => "Table "
            "rol" => "short"
          ]
        ]
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">bpm&#58; beats per minute&#59; CAVB&#58; congenital atrioventricular block&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">ESC guidelines<a class="elsevierStyleCrossRef" href="#bib0985"><span class="elsevierStyleSup">98</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">ACCF&#47;AHA&#47;HRS guidelines<a class="elsevierStyleCrossRef" href="#bib0990"><span class="elsevierStyleSup">99</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">ESC pediatric guidelines<a class="elsevierStyleCrossRef" href="#bib0575"><span class="elsevierStyleSup">16</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2nd- or 3rd-degree CAVB&#44; symptomatic&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Class I&#44; level C&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Class I&#44; level C&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Class I&#44; level C&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2nd- or 3rd-degree CAVB&#44; asymptomatic with ventricular dysfunction&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Class I&#44; level C&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Class I&#44; level B&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Class I&#44; level C&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2nd- or 3rd-degree CAVB&#44; asymptomatic with prolonged QT interval&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Class I&#44; level C&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">-&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Class I&#44; level C&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2nd- or 3rd-degree CAVB&#44; asymptomatic with complex ventricular ectopy or wide QRS escape rhythm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Class I&#44; level C&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Class I&#44; level B&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Class I&#44; level B&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2nd- or 3rd-degree CAVB&#44; asymptomatic with abrupt ventricular pauses &#62;2-3 basic cycle length&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Class I&#44; level C&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Class IIa&#44; level B&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Class I&#44; level B&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3rd-degree CAVB&#44; asymptomatic &#43; ventricular rate &#60;55 bpm or with congenital heart disease &#43; ventricular rate &#60;70 bpm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">-&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Class I&#44; level C&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Class I&#44; level C&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2nd- or 3rd-degree CAVB&#44; asymptomatic &#43; ventricular rate &#60;50 bpm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Class I&#44; level C&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">-&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">-&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2nd- or 3rd-degree postoperative CAVB&#44; permanent 7 days after the intervention or with no expectation of resolution&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Class I&#44; level B&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Class I&#44; level B&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Class I&#44; level B&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Transient postoperative 3rd-degree CAVB&#44; with residual bifascicular block&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Class IIa&#44; level C&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Class IIb&#44; level C&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Class IIb&#44; level C&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2nd- or 3rd-degree CAVB &#43; neuromuscular disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">-&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">-&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Class I&#44; level B&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab2888129.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Indications for permanent pacemaker implantation in children with congenital atrioventricular block &#40;adapted from <a class="elsevierStyleCrossRefs" href="#bib0575"><span class="elsevierStyleSup">16&#44;98&#44;99</span></a>&#41;&#46;</p>"
        ]
      ]
      2 => array:8 [
        "identificador" => "tbl0015"
        "etiqueta" => "Table 3"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at3"
            "detalle" => "Table "
            "rol" => "short"
          ]
        ]
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">LV&#58; left ventricular&#59; RV&#58; right ventricular&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Patient size&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Access&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Pacing mode&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Ventricular lead placement&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " rowspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;10 kg</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Epicardial&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">VVIR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">LV apex&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Endocardial &#40;when epicardial access fails&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">DDD&#40;R&#41; &#40;in case of a specific hemodynamic indication&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">RV septum&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " rowspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10-20 kg</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">VVIR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">LV apex&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Endocardial&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">DDD&#40;R&#41; &#40;in case of a specific hemodynamic indication&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">RV septum&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " rowspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#62;20 kg</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">Endocardial&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">DDD&#40;R&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">RV septum&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Epicardial &#40;e&#46;g&#46; concomitant with other cardiac surgery&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">VVIR&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">LV apex or free wall&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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Review Article
Congenital atrioventricular heart block: From diagnosis to treatment
Bloqueio auriculoventricular congénito: do diagnóstico ao tratamento
Clara Melim
Autor para correspondência
claramelim@live.com.pt

Corresponding author.
, Joana Pimenta, José Carlos Areias
Serviço de Cardiologia Pediátrica do Centro Hospitalar de São João, Departamento de Ginecologia Obstetrícia e Pediatria da FMUP, Porto, Portugal
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or in association with congenital heart defects&#44; in which cases the prognosis is worse&#46;<a class="elsevierStyleCrossRefs" href="#bib0510"><span class="elsevierStyleSup">3&#8211;6</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The most prevalent form of CAVB is autoimmune&#44; diagnosed in children of mothers diagnosed&#44; in most cases&#44; with systemic lupus erythematosus &#40;SLE&#41; or Sj&#246;gren syndrome &#40;SS&#41;&#46; However&#44; even when circulating maternal antibody levels are elevated&#44; only 2-5&#37; of pregnancies result in fetuses with CAVB&#46;<a class="elsevierStyleCrossRefs" href="#bib0510"><span class="elsevierStyleSup">3&#44;4&#44;10&#8211;12</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Clinically&#44; the condition can manifest with bradycardia&#44; with heart rates of less than 100 bpm&#44; pericardial effusion&#44; ventricular dilatation&#44; hyperechogenicity of the atrial walls due to fibrosis and reduced ventricular contractility&#44; alterations visible on the echocardiogram revealing a proinflammatory state and probable concomitant myocarditis&#44; endocardial fibroelastosis&#44; ascites and fetal hydrops&#46;<a class="elsevierStyleCrossRef" href="#bib0560"><span class="elsevierStyleSup">13</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">There is no effective prophylactic treatment&#44; although some drugs can improve the prognosis&#46; Permanent pacemaker implantation is virtually imperative&#44; since in most cases the block is complete and medically irreversible&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Etiology</span><p id="par0035" class="elsevierStylePara elsevierViewall">On the basis of its incidence and current knowledge of its pathophysiology&#44; CAVB can be immune-modulated or autoimmune&#44; and associated with congenital heart defects or idiopathic&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">In 56-90&#37; of cases it is autoimmune&#44; defined as such when the heart has no anatomical malformation that could explain the condition and the mother has a diagnosis of autoimmune disease and&#47;or is positive for autoantibodies&#46;<a class="elsevierStyleCrossRefs" href="#bib0515"><span class="elsevierStyleSup">4&#44;14&#44;15</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">The second most frequent cause is congenital heart malformations&#44; which are found in 14-42&#37; of cases&#46;<a class="elsevierStyleCrossRef" href="#bib0515"><span class="elsevierStyleSup">4</span></a> Defects in cardiac embryogenesis including congenital malformations of the anterior endocardium and the AV node are associated with loss of function and&#47;or anomalous location of these structures&#44; weak propagation of the electrical signal&#44; and a greater likelihood of CAVB&#46;<a class="elsevierStyleCrossRefs" href="#bib0510"><span class="elsevierStyleSup">3&#8211;5</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Transposition of the great vessels &#40;TGV&#41; 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in which cardiac conduction disorders were demonstrated in both parents and children&#44; the authors hypothesized that an inherited genetic alteration causes isolated&#44; non-immune and idiopathic CAVB&#46;<a class="elsevierStyleCrossRef" href="#bib0585"><span class="elsevierStyleSup">18</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">Various mutations have been associated with increased risk for development of CAVB&#44; in <span class="elsevierStyleItalic">SCN5A</span>&#44; <span class="elsevierStyleItalic">SCN1B</span>&#44; <span class="elsevierStyleItalic">SCN10A</span>&#44; <span class="elsevierStyleItalic">TRPM4</span>&#44; <span class="elsevierStyleItalic">KCNK17</span>&#44; <span class="elsevierStyleItalic">KCNJ2</span>&#44; <span class="elsevierStyleItalic">HCN4</span>&#44; <span class="elsevierStyleItalic">LMNA</span>&#44; <span class="elsevierStyleItalic">ANKB</span>&#44; <span class="elsevierStyleItalic">NKX2</span>-5 and <span class="elsevierStyleItalic">TBX5</span>&#44; among other genes&#46;<a class="elsevierStyleCrossRefs" href="#bib0505"><span class="elsevierStyleSup">2&#44;7&#44;19&#44;20</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">The gene that is generally agreed to be most closely associated with the pathogenesis of CAVB is <span class="elsevierStyleItalic">SCN5A</span>&#44; which is responsible for phase 0 of the cardiac action potential&#46; Alterations in the alpha subunit of the sodium channel Na<span class="elsevierStyleInf">V</span>1&#46;5 are associated with a 70&#37; reduction in the density of these channels&#44; and hence a decrease in the I<span class="elsevierStyleInf">Na</span> current generated&#46;<a class="elsevierStyleCrossRef" href="#bib0530"><span class="elsevierStyleSup">7</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">Mutations in the <span class="elsevierStyleItalic">SCN5A</span> gene are also the third most frequently associated with long QT syndrome&#44; particularly type 3&#44; caused by gain-of-function mutations in the sodium channel&#46; Mutations in this gene are also associated with 20-30&#37; of cases of Brugada syndrome&#44; in this case with loss-of-function mutations in the sodium channel&#44; classified as type 1 Brugada&#46;<a class="elsevierStyleCrossRef" href="#bib0575"><span class="elsevierStyleSup">16</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">The concomitant presence of manifestations of more than one of the above syndromes can lead to cardiac sodium channelopathy overlap syndrome&#44; which is associated with higher risk of alterations in the conduction system&#46;<a class="elsevierStyleCrossRef" href="#bib0510"><span class="elsevierStyleSup">3</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">Ainsworth et al&#46; identified a link between an allele of the HLA-C Asn80Lys polymorphism&#44; which codes for the C2 epitope&#44; a high-affinity ligand for the inhibitory natural killer &#40;NK&#41; cell receptor KIR2DL1&#44; and CAVB&#46; This epitope inhibits the action of NKs on macrophages and giant cells&#44; leading to inflammation and damage to cardiac tissue&#46;<a class="elsevierStyleCrossRef" href="#bib0600"><span class="elsevierStyleSup">21</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Maternal risk factors</span><p id="par0090" class="elsevierStylePara elsevierViewall">Advanced maternal age and the time of year of pregnancy&#44; when there are increased levels of anti-Ro&#47;SSA or anti-La&#47;SSB antibodies&#44; are believed to be the most important maternal risk factors&#46;<a class="elsevierStyleCrossRefs" href="#bib0515"><span class="elsevierStyleSup">4&#44;26</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">Other risk factors include maternal infections&#44; particularly respiratory infections and those occurring between the 18th and 24th week of pregnancy&#44; traumatic events during the same period including emotional stress due to the risk of fetal heart disease&#44; low vitamin D levels and hypothyroidism&#46; Conversely&#44; higher maternal vitamin D levels are protective&#44; associated with later need for pacemaker implantation&#46;<a class="elsevierStyleCrossRefs" href="#bib0515"><span class="elsevierStyleSup">4&#44;8&#44;18&#44;22&#8211;26</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Pathophysiology</span><p id="par0100" class="elsevierStylePara elsevierViewall">Positivity for maternal anti-Ro&#47;SSA or anti-La&#47;SSB antibodies is found in 60-95&#37; of cases&#44;<a class="elsevierStyleCrossRefs" href="#bib0510"><span class="elsevierStyleSup">3&#44;4&#44;10&#8211;12</span></a> in most of which SLE or SS has been diagnosed&#46;<a class="elsevierStyleCrossRefs" href="#bib0515"><span class="elsevierStyleSup">4&#44;25&#44;27&#44;28</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">However&#44; only 2-5&#37; of pregnancies in these women result in CAVB&#44;<a class="elsevierStyleCrossRefs" href="#bib0510"><span class="elsevierStyleSup">3&#44;4&#44;10&#8211;12&#44;29</span></a> rising to 12-25&#37; for subsequent pregnancies&#46; The results of several studies suggest that the increased risk in subsequent pregnancies may be overestimated&#44; since the selected groups consisted mainly of families with previous cases of neonatal lupus&#46; However&#44; the fact that women are older at the time of a subsequent birth may explain this increase&#46;<a class="elsevierStyleCrossRefs" href="#bib0510"><span class="elsevierStyleSup">3&#44;4</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">Damage to the conduction system usually occurs between the 16th and 24th weeks&#44; a period during which maternal antibodies most often cross the placenta via the trophoblast Fc&#947;Rn receptor&#46;<a class="elsevierStyleCrossRefs" href="#bib0515"><span class="elsevierStyleSup">4&#44;26&#44;29&#44;30</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">Maternal antibodies bind to L-type calcium channels in fetal cardiomyocytes&#44; particularly those in the AV node&#44; and reversibly inhibit these channels&#8217; current&#46; This results in inflammation&#44; calcification and fibrosis of the conduction tissue&#44; leading to irreversible damage&#44; even in structurally normal hearts&#46;<a class="elsevierStyleCrossRefs" href="#bib0510"><span class="elsevierStyleSup">3&#44;4&#44;14&#44;29&#44;31&#8211;36</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">In a case report analyzing an autopsy of cardiac tissue from a 19-week fetus with CAVB&#44; Friedman et al&#46; demonstrated extensive calcification and inflammatory infiltrate in the AV node and conduction tissue&#46;<a class="elsevierStyleCrossRef" href="#bib0680"><span class="elsevierStyleSup">37</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall">Apoptosis and inflammation trigger macrophages to secrete TGF-&#946;1 and TNF-&#945;&#44; inflammatory mediators that are permanently elevated in the conduction tissue of babies with heart disease on autopsy&#46;<a class="elsevierStyleCrossRefs" href="#bib0535"><span class="elsevierStyleSup">8&#44;36</span></a> The AV node and surrounding tissues are replaced by fibrotic tissue and areas of calcification that interrupt the electrical signal&#46;<a class="elsevierStyleCrossRefs" href="#bib0510"><span class="elsevierStyleSup">3&#44;32&#44;33&#44;38</span></a></p><p id="par0130" class="elsevierStylePara elsevierViewall">The polymorphism of codon 25 in the <span class="elsevierStyleItalic">TGFB1</span> gene has been associated with interindividual variability<a class="elsevierStyleCrossRef" href="#bib0615"><span class="elsevierStyleSup">24</span></a> and increased risk for developing CAVB&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">Another molecular mechanism is increased levels of interferon alpha &#40;INF-&#945;&#41;&#44; which were found in 78&#37; of cases in a recent study&#44; and increase the expression of class II MHC on CD14<span class="elsevierStyleSup">&#43;</span> monocytes&#46; While the former increase synthesis of SIGLEC1&#44; a proinflammatory protein&#44; the latter increases trafficking of maternal IgG across the placenta&#46;<a class="elsevierStyleCrossRef" href="#bib0555"><span class="elsevierStyleSup">12</span></a></p><p id="par0140" class="elsevierStylePara elsevierViewall">Analysis of umbilical cord blood showed that levels of C-reactive protein&#44; N-terminal pro-B-type natriuretic peptide &#40;NT-proBNP&#41;&#44; matrix metalloproteinases &#40;particularly type 2&#41;&#44; plasminogen and urokinase plasminogen activator are increased in cases of neonatal lupus with severe cardiac damage&#46; This is further evidence for the hypothesis that immune-mediated inflammation and fibrosis are associated with these alterations&#46;<a class="elsevierStyleCrossRef" href="#bib0535"><span class="elsevierStyleSup">8</span></a></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Clinical manifestations</span><p id="par0145" class="elsevierStylePara elsevierViewall">In utero&#44; the first manifestation is usually fetal bradycardia with a heart rate of less than 100 bpm&#46;<a class="elsevierStyleCrossRef" href="#bib0690"><span class="elsevierStyleSup">39</span></a> However&#44; the phenotype is variable&#44; depending on etiology&#44; age at presentation and ventricular function&#46;<a class="elsevierStyleCrossRef" href="#bib0695"><span class="elsevierStyleSup">40</span></a></p><p id="par0150" class="elsevierStylePara elsevierViewall">Differential diagnoses of fetal bradyarrhythmia include transient sinus bradycardia&#44; complete CAVB and partial CAVB&#46;<a class="elsevierStyleCrossRef" href="#bib0560"><span class="elsevierStyleSup">13</span></a> The heart block may be intermittent in the neonatal period but usually becomes permanent&#46;<a class="elsevierStyleCrossRefs" href="#bib0690"><span class="elsevierStyleSup">39&#44;41</span></a></p><p id="par0155" class="elsevierStylePara elsevierViewall">Fetal hydrops&#44; ventricular response of &#60;55 bpm&#44; prematurity and complex congenital defects are markers of poor prognosis and are associated with higher mortality&#46;<a class="elsevierStyleCrossRefs" href="#bib0500"><span class="elsevierStyleSup">1&#44;3&#44;5&#44;6&#44;28&#44;42</span></a></p><p id="par0160" class="elsevierStylePara elsevierViewall">Fetal hydrops is defined as the pathological accumulation of fluid in at least two fetal compartments&#44; which may include the pleural or pericardial spaces&#44; abdominal cavity&#44; integument&#44; or placenta&#46; It can result from a combination of increased hydrostatic pressure&#44; decreased oncotic pressure&#44; and in some cases&#44; lymphatic obstruction&#46; Approximately 15-25&#37; of fetuses with nonimmune hydrops have cardiac abnormalities&#46;<a class="elsevierStyleCrossRef" href="#bib0625"><span class="elsevierStyleSup">26</span></a></p><p id="par0165" class="elsevierStylePara elsevierViewall">Patients with autoimmune CAVB may present with other concomitant cardiac abnormalities&#44; endocardial fibroelastosis&#44; dilated cardiomyopathy &#40;DCM&#41; and&#47;or valve disease&#46; The incidence of the latter is 1&#46;6&#37;&#46;<a class="elsevierStyleCrossRefs" href="#bib0510"><span class="elsevierStyleSup">3&#44;4&#44;32</span></a></p><p id="par0170" class="elsevierStylePara elsevierViewall">These alterations are among the manifestations of neonatal lupus syndrome &#40;NLS&#41;&#44; which is found in around 5&#37; of newborns of mothers with SLE and positivity for anti-Ro &#40;25-40&#37;&#41; and anti-La &#40;10-15&#37;&#41; antibodies&#46; The two most frequent forms of NLS are neonatal lupus erythematosus &#40;NLE&#41; and CAVB&#44; although hematological and hepatic manifestations have also been documented&#46;<a class="elsevierStyleCrossRef" href="#bib0710"><span class="elsevierStyleSup">43</span></a> Maternal antibodies usually cease to be detectable between the 6th and 8th month of postnatal life followed by regression of dermal&#44; hepatic and hematological manifestations&#44; but this regeneration does not occur in cardiac tissue&#46; Consequently&#44; most cases of established CAVB are complete and irreversible&#46;<a class="elsevierStyleCrossRef" href="#bib0630"><span class="elsevierStyleSup">27</span></a></p><p id="par0175" class="elsevierStylePara elsevierViewall">Data from the US Research Registry for Neonatal Lupus on neonatal outcomes in a group of pregnant women with SLE show that 49&#37; of newborns had NLS&#44; 30&#37; with cutaneous NLE&#44; 18&#37; CAVB and 1&#37; hematological&#47;hepatic NLE&#46;<a class="elsevierStyleCrossRef" href="#bib0710"><span class="elsevierStyleSup">43</span></a></p><p id="par0180" class="elsevierStylePara elsevierViewall">Comparison of late pediatric diagnoses with those made in utero or at birth shows that the former are less likely to have an autoimmune etiology<a class="elsevierStyleCrossRefs" href="#bib0515"><span class="elsevierStyleSup">4&#44;28</span></a> and have lower mortality and better prognosis&#46;<a class="elsevierStyleCrossRefs" href="#bib0510"><span class="elsevierStyleSup">3&#44;4&#44;8</span></a></p><p id="par0185" class="elsevierStylePara elsevierViewall">Overall mortality associated with CAVB ranges between 9&#37; and 25&#37;&#44; with 70&#37; of deaths occurring in utero&#46; Pacemaker implantation is required in the first year of life in 12-70&#37; of babies&#46;<a class="elsevierStyleCrossRefs" href="#bib0500"><span class="elsevierStyleSup">1&#44;3&#8211;5&#44;7&#44;8&#44;44</span></a></p><p id="par0190" class="elsevierStylePara elsevierViewall">Most births &#40;81&#37;&#41; are live&#44; 38&#37; of which are premature&#46; Vaginal birth should be the aim&#44; but due to the increased risk of preterm birth associated with maternal autoimmune disease&#44; cesarean delivery is preferred in around 75&#37; of cases&#46;<a class="elsevierStyleCrossRefs" href="#bib0515"><span class="elsevierStyleSup">4&#44;7&#44;43</span></a> Cesarean delivery is indicated whenever there is evidence of fetal distress or risk to the life of mother or fetus&#59; however&#44; it is associated with higher rates of infection and bleeding&#44; and should therefore only be performed for obstetric indications&#46;<a class="elsevierStyleCrossRef" href="#bib0710"><span class="elsevierStyleSup">43</span></a> The AV block diagnosed may be first or second degree&#44; but in around 80&#37; of cases it is third degree&#44; complete&#44; and irreversible&#46;<a class="elsevierStyleCrossRefs" href="#bib0515"><span class="elsevierStyleSup">4&#44;7</span></a></p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Diagnosis</span><p id="par0195" class="elsevierStylePara elsevierViewall">A thorough medical history&#44; particularly of the mother&#44; is essential to obtain an accurate and timely diagnosis&#46; In high-risk pregnancies&#44; fetal echocardiographic cardiac monitoring should begin in the 16th week and continue weekly until the 24th week&#44; and thereafter fortnightly until birth&#46;<a class="elsevierStyleCrossRefs" href="#bib0515"><span class="elsevierStyleSup">4&#44;25&#44;26</span></a></p><p id="par0200" class="elsevierStylePara elsevierViewall">Indicators of high risk include the presence of maternal SSA&#47;SSB antibodies&#44; a family history of congenital heart disease&#44; the presence of structural heart defects or rhythm disturbances on a routine obstetric echocardiogram&#44; and evidence of fetal hydrops&#46;<a class="elsevierStyleCrossRef" href="#bib0625"><span class="elsevierStyleSup">26</span></a></p><p id="par0205" class="elsevierStylePara elsevierViewall">Echocardiography remains the gold standard for diagnosis of CAVB&#44; with a diagnostic rate of 90&#37;&#44; although this is dependent on the experience and skill of the operator&#46;<a class="elsevierStyleCrossRef" href="#bib0625"><span class="elsevierStyleSup">26</span></a> Echocardiography is also the gold standard for anatomical and functional study of the fetal heart&#44; screening for abnormalities in anatomy&#44; rhythm and rate by assessing atrial and ventricular rates&#44; atrioventricular conduction&#44; and the presence of a ventricular contraction after every atrial contraction&#46;<a class="elsevierStyleCrossRefs" href="#bib0560"><span class="elsevierStyleSup">13&#44;26</span></a></p><p id="par0210" class="elsevierStylePara elsevierViewall">Other techniques for detecting arrhythmias and conduction defects have been proposed&#44; but&#44; although promising&#44; there is little agreement concerning their usefulness in clinical practice&#46; Cardiac magnetic resonance imaging is used to assess venous anatomy and associated extracardiac abnormalities&#44; Doppler echocardiography to determine rhythm and the PR interval&#44; fetal electrocardiography for fetal monitoring after rupture of membranes&#44; and magnetocardiography for more precise assessment of conduction and rhythm in fetuses with known conduction disorders &#40;class of recommendation IIa&#44; level of evidence B&#47;C&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0625"><span class="elsevierStyleSup">26&#44;28&#44;45</span></a></p><p id="par0215" class="elsevierStylePara elsevierViewall">Around 75&#37; of cases of CAVB are diagnosed between the 20th and 28th week of pregnancy&#46; Presentation tends to be earlier in cases of autoimmune CAVB&#46;<a class="elsevierStyleCrossRefs" href="#bib0510"><span class="elsevierStyleSup">3&#44;4&#44;6&#44;39</span></a></p><p id="par0220" class="elsevierStylePara elsevierViewall">In a study by Morel et al&#46;<a class="elsevierStyleCrossRef" href="#bib0725"><span class="elsevierStyleSup">46</span></a> of 187 neonates with CAVB over a median follow-up of seven years&#44; 94&#46;4&#37; of cases were diagnosed in utero&#46; Pacemakers were implanted in 80&#37; of cases&#59; 18&#46;8&#37; developed DCM&#44; a median of 8&#46;6 months after implantation&#46; Ten-year survival was 23&#37; for newborns diagnosed neonatally with DCM&#44; 54&#37; for those who developed late-onset DCM&#44; and 98&#46;6&#37; for those without DCM&#46; Fetal hydrops&#44; in-utero DCM and maternal treatment with hydroxychloroquine &#40;HCQ&#41; were risk factors for neonatal DCM&#44; while late-onset DCM was associated with in-utero mitral valve insufficiency and pacemaker implantation&#46;</p><p id="par0225" class="elsevierStylePara elsevierViewall">The same study reported high levels of IgG&#44; IgM&#44; CD43 T cells&#44; and other markers of myocarditis&#44; only in newborns with neonatal DCM&#46;<a class="elsevierStyleCrossRef" href="#bib0725"><span class="elsevierStyleSup">46</span></a></p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Treatment</span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Prenatal</span><p id="par0230" class="elsevierStylePara elsevierViewall">There is little agreement on the treatment for CAVB&#44; with various strategies having been proposed including steroids&#44; beta-adrenergic receptor agonists&#44; HCQ&#44; plasmapheresis&#44; and intravenous immunoglobulin &#40;IVIG&#41;&#46; The choice of therapy depends on the etiology of the AV block&#44; ventricular function&#44; and degree of heart failure&#46;<a class="elsevierStyleCrossRefs" href="#bib0625"><span class="elsevierStyleSup">26&#44;30&#44;47&#44;48</span></a></p><p id="par0235" class="elsevierStylePara elsevierViewall">Beta-adrenergic agonists&#44; preferably terbutaline&#44; increase fetal heart rate and are indicated when the rate is below 55 bpm&#46; However&#44; side effects include anxiety&#44; palpitations and headache and may not be tolerated by the mother&#46;<a class="elsevierStyleCrossRefs" href="#bib0510"><span class="elsevierStyleSup">3&#44;26&#44;30&#44;43&#44;49</span></a></p><p id="par0240" class="elsevierStylePara elsevierViewall">Plasmapheresis reduces the concentration of circulating maternal antibodies and hence damage to fetal cardiac tissue&#46;</p><p id="par0245" class="elsevierStylePara elsevierViewall">IVIG increases elimination and reduces placental transcytosis of maternal antibodies&#44; and modulates inhibitory signaling on macrophages&#44; reducing the inflammatory response and fibrosis&#46; It has not been shown to prevent CAVB but it may be indicated for treatment of cardiomyopathy at a dose of 400 mg&#47;kg&#47;day&#46;<a class="elsevierStyleCrossRefs" href="#bib0645"><span class="elsevierStyleSup">30&#44;48&#44;50</span></a></p><p id="par0250" class="elsevierStylePara elsevierViewall">HCQ inhibits Toll-like receptors and thereby reduces plasma INF-&#945; levels and the proinflammatory state in both mother and baby&#46; It is currently indicated for treating exacerbations of the mother&#39;s autoimmune disease during pregnancy and for prevention of NLS&#46;<a class="elsevierStyleCrossRefs" href="#bib0555"><span class="elsevierStyleSup">12&#44;13&#44;30&#44;37&#44;51&#8211;53</span></a> The Preventive Approach to Congenital Heart Block with Hydroxychloroquine &#40;PATCH&#41; prospective trial analyzed the effectiveness of this drug in preventing recurrence of cardiac manifestations of NLS in children of high-risk mothers&#46;<a class="elsevierStyleCrossRef" href="#bib0645"><span class="elsevierStyleSup">30</span></a></p><p id="par0255" class="elsevierStylePara elsevierViewall">Fluorinated steroids&#44; which are partially inactivated by placental 11beta-hydroxysteroid dehydrogenase and have satisfactory bioavailability in the fetus&#44; have been used&#44;<a class="elsevierStyleCrossRefs" href="#bib0520"><span class="elsevierStyleSup">5&#44;54&#44;55</span></a> mainly in immune-mediated CAVB &#40;class IIb&#44; level C&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0625"><span class="elsevierStyleSup">26</span></a> Some authors have proposed oral betamethasone or dexamethasone at doses of between 4 mg and 8 mg&#47;day for six weeks&#46;<a class="elsevierStyleCrossRefs" href="#bib0515"><span class="elsevierStyleSup">4&#44;56&#44;57</span></a> This regimen should be maintained until birth if AV block is reversed but should be discontinued when it is not&#44; when there is first- or second-degree block&#44; or if the fetus presents hydrops&#44; myocarditis or ascites&#44; even with complete block&#46;<a class="elsevierStyleCrossRefs" href="#bib0780"><span class="elsevierStyleSup">57&#44;58</span></a></p><p id="par0260" class="elsevierStylePara elsevierViewall">These drugs reduce the need for pacemaker implantation&#44; the degree of incomplete block&#44; and the risk of myocarditis&#46; They also inhibit the inflammatory cascade and suggest that there is a window of opportunity for treatment at the time when inflammation of the conduction system progresses to fibrosis&#46; They have not been shown to have significant effects in cases of complete CAVB&#44; which is irreversible&#44;<a class="elsevierStyleCrossRefs" href="#bib0625"><span class="elsevierStyleSup">26&#44;44&#44;49&#44;60&#44;61</span></a> but if there is uncertainty as to the degree of block they can be used until this is confirmed&#46;<a class="elsevierStyleCrossRefs" href="#bib0545"><span class="elsevierStyleSup">10&#44;57&#44;59&#44;62</span></a></p><p id="par0265" class="elsevierStylePara elsevierViewall">The side effects of fluorinated steroids need to be taken into consideration&#44; bearing in mind the principle of &#8220;first&#44; do no harm&#8221;&#46; Adverse effects on the fetus can include miscarriage&#44; oligohydramnios&#44; delayed development&#44; growth retardation&#44; and adrenal insufficiency&#44; while diabetes&#44; hypertension and weight gain have been observed in mothers and must also be considered&#46;<a class="elsevierStyleCrossRefs" href="#bib0525"><span class="elsevierStyleSup">6&#44;44&#44;47&#44;57&#44;63&#44;64</span></a></p><p id="par0270" class="elsevierStylePara elsevierViewall">The main therapeutic options for medical therapy in utero are summarized in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0275" class="elsevierStylePara elsevierViewall">Percutaneous pacing techniques have been described&#44; but results are unsatisfactory and the risk of fetal death is high&#46; In most cases&#44; therefore&#44; the pregnancy runs its normal course and treatment only begins after birth&#46;<a class="elsevierStyleCrossRefs" href="#bib0625"><span class="elsevierStyleSup">26&#44;28&#44;65</span></a></p></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Postnatal</span><p id="par0280" class="elsevierStylePara elsevierViewall">After birth&#44; fetal bradycardia &#40;heart rate &#60;70 bpm&#41; can initially be controlled by drugs such as isoprenaline&#44; atropine&#44; epinephrine and&#47;or dopamine&#44; alone or in combination with transcutaneous pacing and&#47;or temporary cardiac pacing&#44; in order to prevent sudden death&#46;<a class="elsevierStyleCrossRefs" href="#bib0510"><span class="elsevierStyleSup">3&#44;27</span></a></p><p id="par0285" class="elsevierStylePara elsevierViewall">Temporary cardiac pacing is also indicated in cases of cardiogenic shock or fetal hydrops&#46; Temporary transesophageal pacing can also be used&#44; but the risk of esophageal stenosis is high&#46;<a class="elsevierStyleCrossRef" href="#bib0705"><span class="elsevierStyleSup">42</span></a></p><p id="par0290" class="elsevierStylePara elsevierViewall">Unfortunately CAVB is irreversible and hence a permanent pacemaker is necessary in 80&#37; of cases&#44;<a class="elsevierStyleCrossRef" href="#bib0690"><span class="elsevierStyleSup">39</span></a> which improves long-term survival and reduces presyncope and syncope&#44; even in asymptomatic cases&#46;<a class="elsevierStyleCrossRefs" href="#bib0510"><span class="elsevierStyleSup">3&#44;28&#44;48</span></a></p><p id="par0295" class="elsevierStylePara elsevierViewall">The latest indications for pacemaker implantation in children with CAVB are summarized in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0300" class="elsevierStylePara elsevierViewall">Pacemaker implantation is technically challenging&#44; and various complications have been reported due to both the size of the patients and their rapid growth&#44; and the presence of cardiac malformations&#46;<a class="elsevierStyleCrossRefs" href="#bib0525"><span class="elsevierStyleSup">6&#44;66</span></a> The task is further complicated by the small size of the vessels involved and the significant discrepancy between the size of the device and of the child&#39;s body&#46;<a class="elsevierStyleCrossRefs" href="#bib0825"><span class="elsevierStyleSup">66&#44;67</span></a></p><p id="par0305" class="elsevierStylePara elsevierViewall">Opinions differ concerning the best approach&#44; mode of stimulation&#44; and location of the pulse generator&#46;<a class="elsevierStyleCrossRef" href="#bib0510"><span class="elsevierStyleSup">3</span></a></p><p id="par0310" class="elsevierStylePara elsevierViewall">With regard to approach&#44; the current options are epicardial and endocardial &#40;transvenous&#41; pacing&#46; The most appropriate approach depends on body size&#44; age&#44; venous diameter&#44; and presence of congenital cardiac defects&#46;<a class="elsevierStyleCrossRef" href="#bib0830"><span class="elsevierStyleSup">67</span></a> Access can be via lateral thoracotomy&#44; sternotomy or a subxiphoid approach&#46;</p><p id="par0315" class="elsevierStylePara elsevierViewall">There is agreement that epicardial pacing is the first-line option in children weighing less than 15-20 kg and with structurally normal hearts<a class="elsevierStyleCrossRefs" href="#bib0510"><span class="elsevierStyleSup">3&#44;66&#8211;68</span></a> and when venous access to the heart is not feasible&#44; especially in a univentricular heart&#46;<a class="elsevierStyleCrossRef" href="#bib0575"><span class="elsevierStyleSup">16</span></a> However&#44; periodic reviews are needed to reduce the rate of complications&#46;<a class="elsevierStyleCrossRefs" href="#bib0840"><span class="elsevierStyleSup">69&#44;70</span></a></p><p id="par0320" class="elsevierStylePara elsevierViewall">Transvenous implantation of an endocardial pacemaker via tributaries of the superior vena cava or branches of the iliac veins is minimally invasive and has a low risk of malfunction&#44; although the risk of systemic thrombosis is higher and the rate of venous occlusion is 25&#37;&#46;<a class="elsevierStyleCrossRefs" href="#bib0845"><span class="elsevierStyleSup">70&#8211;72</span></a></p><p id="par0325" class="elsevierStylePara elsevierViewall">Intracardiac shunts increase the risk of systemic embolism and may need to be corrected before pacemaker implantation&#46;<a class="elsevierStyleCrossRef" href="#bib0575"><span class="elsevierStyleSup">16</span></a> According to Khairy et al&#46;&#44; endocardial pacing in patients with intracardiac shunts is associated with less frequent lead replacement compared to epicardial pacing&#44; but incurs a higher thromboembolic risk that is not reduced by anticoagulation&#46;<a class="elsevierStyleCrossRef" href="#bib0855"><span class="elsevierStyleSup">72</span></a></p><p id="par0330" class="elsevierStylePara elsevierViewall">Complications of a transvenous approach include lead dislodgement&#44; pocket hematoma or bleeding&#44; pneumothorax&#44; heart perforation&#44; cardiac tamponade&#44; and infection&#46;<a class="elsevierStyleCrossRef" href="#bib0575"><span class="elsevierStyleSup">16</span></a> The most common complication is infection&#44; which has an incidence of 1-8&#37; and is the most frequent indication for lead removal&#44; which in turn results in heart perforation in 1-2&#37; of cases and death in 0&#46;1-0&#46;4&#37;&#46;<a class="elsevierStyleCrossRefs" href="#bib0575"><span class="elsevierStyleSup">16&#44;73</span></a></p><p id="par0335" class="elsevierStylePara elsevierViewall">The small body size of the patients means that the chest wall is not a feasible location for the generator&#44; and so the abdominal wall is generally used&#46;<a class="elsevierStyleCrossRefs" href="#bib0510"><span class="elsevierStyleSup">3&#44;66</span></a> In children weighing less than 2&#46;5 kg&#44; the generator can be placed in the pleural cavity&#44; which affords better protection&#46;<a class="elsevierStyleCrossRef" href="#bib0865"><span class="elsevierStyleSup">74</span></a></p><p id="par0340" class="elsevierStylePara elsevierViewall">A recent study by Costa et al&#46; assessed the long-term results of epicardial pacemaker implantation with subxiphoid access&#46; They concluded that the technique is viable and had excellent results and system longevity&#44; reducing surgical trauma by placing the generator submuscularly in the preperitoneal space&#44; reducing cardiac fibrosis&#44; and diminishing the effect of the child&#39;s growth on the system by using a rectilinear trajectory&#46;<a class="elsevierStyleCrossRef" href="#bib0825"><span class="elsevierStyleSup">66</span></a></p><p id="par0345" class="elsevierStylePara elsevierViewall">In epicardial pacing&#44; ventricular lead placement improves mechanical synchrony and contraction efficiency&#46;<a class="elsevierStyleCrossRef" href="#bib0870"><span class="elsevierStyleSup">75</span></a> Apical pacing in the right ventricle is a common approach&#44; but left ventricular apical or lateral wall pacing result in better left ventricular function and are thus currently recommended&#46;<a class="elsevierStyleCrossRef" href="#bib0875"><span class="elsevierStyleSup">76</span></a></p><p id="par0350" class="elsevierStylePara elsevierViewall">Lead placement in the right ventricular lateral wall or outflow tract is associated with left ventricular dysfunction and dyssynchrony&#46;<a class="elsevierStyleCrossRef" href="#bib0870"><span class="elsevierStyleSup">75</span></a> Implantation in the posterior ventricle is also possible&#44; but increases the risk of cardiac and coronary compression and sudden death&#46;<a class="elsevierStyleCrossRefs" href="#bib0880"><span class="elsevierStyleSup">77&#8211;80</span></a></p><p id="par0355" class="elsevierStylePara elsevierViewall">The type of pacemaker to be used depends on the patient&#39;s body size&#44; level of activity and ventricular function&#46;<a class="elsevierStyleCrossRefs" href="#bib0900"><span class="elsevierStyleSup">81&#8211;83</span></a></p><p id="par0360" class="elsevierStylePara elsevierViewall">Some authors report that VVI pacing is more likely to lead to left ventricular dysfunction than DDD pacing&#46;<a class="elsevierStyleCrossRef" href="#bib0915"><span class="elsevierStyleSup">84</span></a> However&#44; multicenter studies have shown little difference between the two modes in terms of mortality&#44; cardiac function and quality of life&#46;<a class="elsevierStyleCrossRefs" href="#bib0920"><span class="elsevierStyleSup">85&#8211;87</span></a></p><p id="par0365" class="elsevierStylePara elsevierViewall">VVI pacemakers are often the first option in smaller children due to their smaller area&#46; When the child reaches a certain weight&#44; a second&#44; atrial lead can be added&#59; this change to a dual-chamber system improves quality of life and cardiac function&#44; smaller ventricular dimensions and lower natriuretic peptide levels&#46;<a class="elsevierStyleCrossRefs" href="#bib0900"><span class="elsevierStyleSup">81&#8211;83</span></a> However&#44; the risk-benefit ratio of further invasive surgery and the need for future reviews must be taken into account&#46;<a class="elsevierStyleCrossRefs" href="#bib0935"><span class="elsevierStyleSup">88&#44;89</span></a></p><p id="par0370" class="elsevierStylePara elsevierViewall">AV synchrony should be preserved&#44; since dyssynchronous and non-physiological activation induces pacemaker-induced cardiomyopathy in 7&#37; of patients with permanent pacing&#44; leading to pathological myocardial remodeling and ventricular dilatation&#46;<a class="elsevierStyleCrossRef" href="#bib0955"><span class="elsevierStyleSup">92</span></a></p><p id="par0375" class="elsevierStylePara elsevierViewall">Permanent His bundle pacing has fewer adverse effects on right ventricular function and cardiac function in general&#46;<a class="elsevierStyleCrossRefs" href="#bib0945"><span class="elsevierStyleSup">90&#44;91</span></a> Although technically demanding&#44; especially in pediatric patients&#44; it may become an alternative option in the near future&#46;<a class="elsevierStyleCrossRefs" href="#bib0955"><span class="elsevierStyleSup">92&#8211;94</span></a></p><p id="par0380" class="elsevierStylePara elsevierViewall">Recommendations for pacemaker implantation in pediatric patients with CAVB are summarized in <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0385" class="elsevierStylePara elsevierViewall">The first case reported in Portugal of pediatric cardiac resynchronization in a case of cardiomyopathy induced by right ventricular pacing due to CAVB showed improved ejection fraction&#44; reduced left ventricular end-diastolic diameter and significantly reduced mitral regurgitation&#44; as well as improvement in New York Heart Association function class from III-IV to I&#46;<a class="elsevierStyleCrossRef" href="#bib0970"><span class="elsevierStyleSup">95</span></a></p><p id="par0390" class="elsevierStylePara elsevierViewall">Fujioka et al&#46; successfully applied a staged therapeutic approach to a premature low-birth-weight infant&#46; Following diagnosis of CAVB and myocarditis in the 27th week of pregnancy&#44; with a fetal atrial rate of 152 bpm and ventricular rate of 48 bpm&#44; 4 mg&#47;day of dexamethasone was administered&#46; Cesarean delivery took place at 29 weeks and two days due to fetal distress&#44; and temporary right ventricular pacing &#40;120 bpm&#41; was begun&#46; A second lead was subsequently implanted in the ventricular apex and prednisolone &#40;1 mg&#47;kg&#47;day for two weeks&#41; and IGIV &#40;1 g&#47;day for three days&#41; were administered&#46; Permanent pacemaker implantation &#40;VVI mode at 120 bpm&#41; was performed on day 64&#46;<a class="elsevierStyleCrossRef" href="#bib0975"><span class="elsevierStyleSup">96</span></a></p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Future prospects</span><p id="par0395" class="elsevierStylePara elsevierViewall">Gene therapy for biological pacing&#44; using an adenovirus as vector in cardiomyocytes&#44; is a promising research field in constant development&#46;<a class="elsevierStyleCrossRef" href="#bib0510"><span class="elsevierStyleSup">3</span></a></p><p id="par0400" class="elsevierStylePara elsevierViewall">Antagonism of molecular pathways&#44; particularly of MMP-2&#44; is based on discoveries that link these pathways with increased inflammation and fibrosis&#46;<a class="elsevierStyleCrossRef" href="#bib0535"><span class="elsevierStyleSup">8</span></a></p><p id="par0405" class="elsevierStylePara elsevierViewall">Measurement of molecules including NT-proBNP can be used as a short-term diagnostic aid when no alterations are observed on imaging studies&#46;<a class="elsevierStyleCrossRef" href="#bib0535"><span class="elsevierStyleSup">8</span></a></p><p id="par0410" class="elsevierStylePara elsevierViewall">A study of 38 patients showed that permanent His bundle pacing preserves left ventricular function and cardiac synchrony as compared with right ventricular septal pacing&#46;<a class="elsevierStyleCrossRef" href="#bib0955"><span class="elsevierStyleSup">92</span></a></p><p id="par0415" class="elsevierStylePara elsevierViewall">Micropacemakers are an alternative under development to treat progressive CAVB associated with hydrops and may be applied in future projects&#46;<a class="elsevierStyleCrossRef" href="#bib0980"><span class="elsevierStyleSup">97</span></a></p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Conclusions</span><p id="par0420" class="elsevierStylePara elsevierViewall">Although rare&#44; CAVB is an important and treatable cause of pediatric mortality&#46; Its etiology is predominantly autoimmune&#44; mothers of affected fetuses usually being diagnosed with SLE or SS&#46;</p><p id="par0425" class="elsevierStylePara elsevierViewall">Various genetic polymorphisms and inflammatory markers are associated with the condition&#44; which is caused by fibrosis and calcification of the AV node and conduction tissue&#46;</p><p id="par0430" class="elsevierStylePara elsevierViewall">Maternal risk is higher in cases of autoimmune disease&#44; hypothyroidism or infection during pregnancy&#44; which may explain why only 2-5&#37; of pregnancies in which autoimmune disease is the only risk factor result in CAVB&#46;</p><p id="par0435" class="elsevierStylePara elsevierViewall">Fetal echocardiography remains the diagnostic gold standard&#46;</p><p id="par0440" class="elsevierStylePara elsevierViewall">Regarding therapy&#44; effective antagonism of the inflammatory cascade is of value to prevent the genesis and evolution of AV block&#46;</p><p id="par0445" class="elsevierStylePara elsevierViewall">In most cases&#44; monitoring of the pregnancy until birth is all that is recommended&#46; Postnatally&#44; pacemaker implantation is necessary in the majority of affected infants&#46;</p><p id="par0450" class="elsevierStylePara elsevierViewall">New techniques aimed at reducing morbidity and mortality have been proposed and continue to be studied&#46; Some have been applied in clinical practice with satisfactory results&#44; but most have only been analyzed in small samples or isolated cases&#44; so there is still hesitancy and uncertainty concerning the use of these therapies&#46;</p><p id="par0455" class="elsevierStylePara elsevierViewall">Further studies are therefore required to optimize both diagnosis and treatment&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conflicts of interest</span><p id="par0460" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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          "titulo" => "Introduction"
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          "titulo" => "Etiology"
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          "identificador" => "sec0015"
          "titulo" => "Genetic alterations"
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          "identificador" => "sec0020"
          "titulo" => "Maternal risk factors"
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          "titulo" => "Pathophysiology"
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          "identificador" => "sec0030"
          "titulo" => "Clinical manifestations"
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          "identificador" => "sec0035"
          "titulo" => "Diagnosis"
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          "titulo" => "Treatment"
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              "identificador" => "sec0045"
              "titulo" => "Prenatal"
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          "titulo" => "Postnatal"
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          "titulo" => "Future prospects"
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          "titulo" => "Conclusions"
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          "titulo" => "Conflicts of interest"
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    "fechaRecibido" => "2018-02-28"
    "fechaAceptado" => "2019-09-23"
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          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec1504608"
          "palabras" => array:5 [
            0 => "Congenital atrioventricular block"
            1 => "Neonatal lupus"
            2 => "Pacemaker"
            3 => "Pathophysiology"
            4 => "Prenatal diagnosis"
          ]
        ]
      ]
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        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palavras-chave"
          "identificador" => "xpalclavsec1504607"
          "palabras" => array:5 [
            0 => "Bloqueio auriculoventricular cong&#233;nito"
            1 => "L&#250;pus neonatal"
            2 => "<span class="elsevierStyleItalic">Pacemaker</span>"
            3 => "Fisiopatologia"
            4 => "Diagn&#243;stico pr&#233;-natal"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Congenital atrioventricular block &#40;CAVB&#41;&#44; classified as such when diagnosed in utero&#44; at birth or during the first month of life&#44; is a rare condition with an estimated incidence between 1&#47;15 000 and 1&#47;22 000 live births&#46; It is now accepted that the pathophysiology of this condition is predominantly associated with an immunologically mediated response to the conduction system&#44; which occurs due to transplacental passage of maternal autoantibodies from mothers diagnosed&#44; in most cases&#44; with systemic lupus erythematosus or Sj&#246;gren syndrome&#46; Fetal echocardiography continues to be the diagnostic gold standard&#44; however there are other techniques with good results and advantages&#46; Regarding therapeutics&#44; both pharmacological measures and cardiac stimulation techniques have been developed to increase the safety of procedures&#44; decrease associated mortality and morbidity&#44; and provide a better quality of life for patients&#44; although there are disagreements in deciding the best therapeutic plan&#46; This review aims to summarize and elucidate the best diagnostic approach as well as the best therapeutic strategies&#46; A search was performed in the PubMed and Science Direct databases of articles published and accepted for publication&#46; The following search terms were used&#58; &#8220;Congenital atrioventricular block&#8221;&#44; &#8220;Neonatal lupus&#8221;&#44; &#8220;Pacemaker&#8221;&#44; &#8220;Pathophysiology&#8221;&#44; &#8220;Electrophysiology&#8221;&#44; and &#8220;Prenatal diagnosis&#8221;&#46; Articles in Portuguese and English were selected&#46; No time constraints were used&#46; Repeated articles were excluded from the two databases&#46;</p></span>"
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        "titulo" => "Resumo"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">O bloqueio auriculoventricular cong&#233;nito &#40;BAVC&#41;&#44; assim classificado quando diagnosticado <span class="elsevierStyleItalic">in utero</span>&#44; ao nascimento ou durante o primeiro m&#234;s de vida&#44; &#233; uma patologia rara com uma incid&#234;ncia estimada que varia entre 1&#47;15&#46;000 e 1&#47;22&#46;000 nados vivos&#46; &#201; atualmente aceite que a fisiopatologia inerente a esta condi&#231;&#227;o est&#225; predominantemente associada a uma resposta imunologicamente mediada contra o sistema de condu&#231;&#227;o que ocorre devido &#224; passagem transplacent&#225;ria de autoanticorpos maternos de m&#227;es diagnosticadas&#44; na maioria dos casos&#44; com l&#250;pus eritematoso sist&#233;mico &#40;LES&#41; ou s&#237;ndrome de Sj&#246;gren &#40;SS&#41;&#46; A ecocardiografia fetal continua a ser o <span class="elsevierStyleItalic">gold-standard</span> diagn&#243;stico&#44; contudo existem outras t&#233;cnicas com bons resultados e vantagens relativamente &#224; primeira&#46; No que concerne &#224; terap&#234;utica&#44; tanto as estrat&#233;gias farmacol&#243;gicas quanto as t&#233;cnicas de estimula&#231;&#227;o card&#237;aca t&#234;m evolu&#237;do no sentido de aumentar a seguran&#231;a dos procedimentos&#44; diminuir a mortalidade e morbilidade associadas e promover uma maior qualidade de vida dos doentes&#44; continuando&#44; apesar disso&#44; a existir diverg&#234;ncias no momento de decidir qual o melhor plano terap&#234;utico&#46; Deste modo&#44; esta revis&#227;o tem como objetivo o resumo e a clarifica&#231;&#227;o da melhor abordagem diagn&#243;stica&#44; bem como das melhores estrat&#233;gias terap&#234;uticas&#46; Foi feita uma pesquisa nas bases de dados Pubmed e Science Direct de artigos publicados e aceites para publica&#231;&#227;o&#46; Foram utilizadas as seguintes express&#245;es de pesquisa&#58; &#8220;Congenital atrioventricular block&#8221;&#44; &#8220;Neonatal lupus&#8221;&#44; &#8220;Pacemaker&#8221;&#44; &#8220;Pathophysiology&#8221;&#44; &#8220;Electrophysiology&#8221;&#44; &#8220;Prenatal diagnosis&#8221;&#46; Foram selecionados artigos escritos em portugu&#234;s e ingl&#234;s&#46; N&#227;o foram utilizadas restri&#231;&#245;es temporais&#46; Foram exclu&#237;dos artigos repetidos nas duas bases de dados&#46;</p></span>"
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          "leyenda" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">bpm&#58; beats per minute&#59; CR&#58; class of recommendation&#59; IVIG&#58; intravenous immunoglobulin&#59; LE&#58; level of evidence&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Cause&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Treatment&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">CR&#47;LE&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " rowspan="4" align="left" valign="\n
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                  \t\t\t\t">Autoimmune</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Observation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">I&#47;A&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Structurally normal heart&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Dexamethazone&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">IIb&#47;B&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">1st- or 2nd-degree block with evidence of inflammation &#40;pericardial effusion&#44; ventricular dilatation&#44; hyperechogenicity of the atrial walls or reduced biventricular contractility&#41;Prophylactic&#44; to reduce mortality and cardiomyopathy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">IVIG&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">IIb&#47;B&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Not recommended for prophylaxis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Beta-adrenergic agonists&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">IIa&#47;C&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Heart rate &#60;55 bpm&#44; fetal hydrops&#44; congenital malformations or cardiac dysfunction&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " rowspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Cardiac malformations</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Observation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">I&#47;A&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Beta-adrenergic agonists&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">IIa&#47;C&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Heart rate &#60;55 bpm&#44; fetal hydrops&#44; congenital malformations or cardiac dysfunction&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Idiopathic&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Observation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">I&#47;A&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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                0 => "xTab2888128.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Treatment of congenital atrioventricular block in utero &#40;adapted from <a class="elsevierStyleCrossRef" href="#bib0625"><span class="elsevierStyleSup">26</span></a>&#41;&#46;</p>"
        ]
      ]
      1 => array:8 [
        "identificador" => "tbl0010"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
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          0 => array:3 [
            "identificador" => "at2"
            "detalle" => "Table "
            "rol" => "short"
          ]
        ]
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">bpm&#58; beats per minute&#59; CAVB&#58; congenital atrioventricular block&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">ESC guidelines<a class="elsevierStyleCrossRef" href="#bib0985"><span class="elsevierStyleSup">98</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">ACCF&#47;AHA&#47;HRS guidelines<a class="elsevierStyleCrossRef" href="#bib0990"><span class="elsevierStyleSup">99</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">ESC pediatric guidelines<a class="elsevierStyleCrossRef" href="#bib0575"><span class="elsevierStyleSup">16</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2nd- or 3rd-degree CAVB&#44; symptomatic&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Class I&#44; level C&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Class I&#44; level C&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Class I&#44; level C&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2nd- or 3rd-degree CAVB&#44; asymptomatic with ventricular dysfunction&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Class I&#44; level C&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Class I&#44; level B&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Class I&#44; level C&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2nd- or 3rd-degree CAVB&#44; asymptomatic with prolonged QT interval&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Class I&#44; level C&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">-&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Class I&#44; level C&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2nd- or 3rd-degree CAVB&#44; asymptomatic with complex ventricular ectopy or wide QRS escape rhythm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Class I&#44; level C&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Class I&#44; level B&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Class I&#44; level B&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2nd- or 3rd-degree CAVB&#44; asymptomatic with abrupt ventricular pauses &#62;2-3 basic cycle length&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Class I&#44; level C&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Class IIa&#44; level B&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Class I&#44; level B&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3rd-degree CAVB&#44; asymptomatic &#43; ventricular rate &#60;55 bpm or with congenital heart disease &#43; ventricular rate &#60;70 bpm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">-&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Class I&#44; level C&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Class I&#44; level C&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2nd- or 3rd-degree CAVB&#44; asymptomatic &#43; ventricular rate &#60;50 bpm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Class I&#44; level C&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">-&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">-&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2nd- or 3rd-degree postoperative CAVB&#44; permanent 7 days after the intervention or with no expectation of resolution&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Class I&#44; level B&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Class I&#44; level B&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Class I&#44; level B&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Transient postoperative 3rd-degree CAVB&#44; with residual bifascicular block&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Class IIa&#44; level C&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Class IIb&#44; level C&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Class IIb&#44; level C&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2nd- or 3rd-degree CAVB &#43; neuromuscular disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">-&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">-&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Class I&#44; level B&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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                0 => "xTab2888129.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Indications for permanent pacemaker implantation in children with congenital atrioventricular block &#40;adapted from <a class="elsevierStyleCrossRefs" href="#bib0575"><span class="elsevierStyleSup">16&#44;98&#44;99</span></a>&#41;&#46;</p>"
        ]
      ]
      2 => array:8 [
        "identificador" => "tbl0015"
        "etiqueta" => "Table 3"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at3"
            "detalle" => "Table "
            "rol" => "short"
          ]
        ]
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">LV&#58; left ventricular&#59; RV&#58; right ventricular&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Patient size&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Access&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Pacing mode&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Ventricular lead placement&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " rowspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;10 kg</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Epicardial&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">VVIR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">LV apex&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Endocardial &#40;when epicardial access fails&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">DDD&#40;R&#41; &#40;in case of a specific hemodynamic indication&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">RV septum&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " rowspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10-20 kg</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Epicardial&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">VVIR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">LV apex&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Endocardial&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">DDD&#40;R&#41; &#40;in case of a specific hemodynamic indication&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">RV septum&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " rowspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#62;20 kg</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Endocardial&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">DDD&#40;R&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">RV septum&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Epicardial &#40;e&#46;g&#46; concomitant with other cardiac surgery&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">VVIR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">LV apex or free wall&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Recommendations for pacemaker implantation in pediatric patients with congenital atrioventricular block &#40;adapted from <a class="elsevierStyleCrossRef" href="#bib0575"><span class="elsevierStyleSup">16</span></a>&#41;&#46;</p>"
        ]
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      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0015"
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            0 => array:3 [
              "identificador" => "bib0500"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Do all children with congenital complete atrioventricular block require permanent pacing&#63;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
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                        "fecha" => "2003"
                        "volumen" => "3"
                        "paginaInicial" => "178"
                        "paginaFinal" => "183"
                        "link" => array:1 [
                          0 => array:2 [ …2]
                        ]
                      ]
                    ]
                  ]
                ]
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            1 => array:3 [
              "identificador" => "bib0505"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Long-term follow up of children with congenital complete atrioventricular block and the impact of pacemaker therapy"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [ …3]
                        ]
                      ]
                    ]
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                      "Revista" => array:6 [
                        "tituloSerie" => "Europace"
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                      ]
                    ]
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              ]
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            2 => array:3 [
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              "etiqueta" => "3"
              "referencia" => array:1 [
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                      "autores" => array:1 [
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                        ]
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                    ]
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                  "host" => array:1 [
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                      "Revista" => array:6 [
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                        "volumen" => "175"
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            3 => array:3 [
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              "etiqueta" => "4"
              "referencia" => array:1 [
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                      "autores" => array:1 [
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                  "host" => array:1 [
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                      "doi" => "10.1038/nrrheum.2015.29"
                      "Revista" => array:6 [
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            4 => array:3 [
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                      "autores" => array:1 [
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            5 => array:3 [
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              "etiqueta" => "6"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
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                      "titulo" => "Perinatal arrhythmias - diagnosis and treatment"
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                        0 => array:2 [
                          "etal" => true
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                    0 => array:1 [
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                        "volumen" => "21"
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              "identificador" => "bib0530"
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              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Exome sequencing identifies compound heterozygous mutations in SCN5A associated with congenital complete heart block in the Thai population"
                      "autores" => array:1 [
                        0 => array:2 [
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                          "autores" => array:3 [ …3]
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                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1155/2016/3684965"
                      "Revista" => array:5 [
                        "tituloSerie" => "Dis Markers"
                        "fecha" => "2016"
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              ]
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            7 => array:3 [
              "identificador" => "bib0535"
              "etiqueta" => "8"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Serum biomarkers of inflammation&#44; fibrosis&#44; and cardiac function in facilitating diagnosis&#44; prognosis&#44; and treatment of anti-SSA&#47;Ro-associated cardiac neonatal lupus"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [ …3]
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                      ]
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                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jacc.2015.06.1088"
                      "Revista" => array:6 [
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                        "fecha" => "2015"
                        "volumen" => "66"
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            8 => array:3 [
              "identificador" => "bib0540"
              "etiqueta" => "9"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Analysis of the A-V conduction defect in complete heart block utilizing His bundle electrograms"
                      "autores" => array:1 [
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                          "etal" => true
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                        "fecha" => "1970"
                        "volumen" => "41"
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                        "paginaFinal" => "448"
                        "link" => array:1 [
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            9 => array:3 [
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              "etiqueta" => "10"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Risk of congenital complete heart block in newborns of mothers with anti-Ro&#47;SSA antibodies detected by counterimmunoelectrophoresis&#58; a prospective study of 100 women"
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                          "etal" => true
                          "autores" => array:3 [ …3]
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                  "host" => array:1 [
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                        "fecha" => "2001"
                        "volumen" => "44"
                        "paginaInicial" => "1832"
                        "paginaFinal" => "1835"
                        "link" => array:1 [
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            10 => array:3 [
              "identificador" => "bib0550"
              "etiqueta" => "11"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Outcome of pregnancies in patients with anti-SSA&#47;Ro antibodies&#58; a study of 165 pregnancies&#44; with special focus on electrocardiographic variations in the children and comparison with a control group"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [ …3]
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                  "host" => array:1 [
                    0 => array:2 [
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                      "Revista" => array:6 [
                        "tituloSerie" => "Arthritis Rheum"
                        "fecha" => "2004"
                        "volumen" => "50"
                        "paginaInicial" => "3187"
                        "paginaFinal" => "3194"
                        "link" => array:1 [
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              "identificador" => "bib0555"
              "etiqueta" => "12"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "High maternal expression of SIGLEC1 on monocytes as a surrogate marker of a type I interferon signature is a risk factor for the development of autoimmune congenital heart block"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [ …3]
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                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1136/annrheumdis-2016-210927"
                      "Revista" => array:6 [
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                        "fecha" => "2017"
                        "volumen" => "76"
                        "paginaInicial" => "1476"
                        "paginaFinal" => "1480"
                        "link" => array:1 [
                          0 => array:2 [ …2]
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            12 => array:3 [
              "identificador" => "bib0560"
              "etiqueta" => "13"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Ultrasound findings in fetal congenital heart block associated with maternal anti-Ro&#47;SSA and anti-La&#47;SSB antibodies"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [ …3]
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                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1097/RUQ.0000000000000112"
                      "Revista" => array:6 [
                        "tituloSerie" => "Ultrasound Q"
                        "fecha" => "2015"
                        "volumen" => "31"
                        "paginaInicial" => "34"
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            13 => array:3 [
              "identificador" => "bib0565"
              "etiqueta" => "14"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Cardiac manifestations of neonatal lupus&#58; a review of autoantibody-associated congenital heart block and its impact in an adult population"
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                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [ …3]
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                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1097/CRD.0b013e31823c808b"
                      "Revista" => array:6 [
                        "tituloSerie" => "Cardiol Rev"
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                        "volumen" => "20"
                        "paginaInicial" => "72"
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                          0 => array:2 [ …2]
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            14 => array:3 [
              "identificador" => "bib0570"
              "etiqueta" => "15"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Autoimmune congenital heart block&#58; complex and unusual situations"
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                          "etal" => true
                          "autores" => array:3 [ …3]
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                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1177/0961203315624024"
                      "Revista" => array:6 [
                        "tituloSerie" => "Lupus"
                        "fecha" => "2016"
                        "volumen" => "25"
                        "paginaInicial" => "116"
                        "paginaFinal" => "128"
                        "link" => array:1 [
                          0 => array:2 [ …2]
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              "identificador" => "bib0575"
              "etiqueta" => "16"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:1 [
                      "autores" => array:1 [
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