Arrhythmias in adults with congenital heart disease and heart failure

Right Ventricular Electrophysiology and Arrhythmias in Adults With Congenital Heart Disease: Scientific Basis for Management

Right ventricular (RV) dysfunction and arrhythmias are major concerns in adults with congenital heart disease (CHD). The relationship between RV dysfunction and arrhythmogenesis is bidirectional, with structural and electrical remodeling contributing to arrhythmia development and, conversely, arrhythmias exacerbating RV failure. In addition to an RV in the standard subpulmonary position failing because of pressure and/or volume overload, other phenotypes associated with RV dysfunction in CHD include transposition of the great arteries with a systemic (subaortic) RV and univentricular hearts with a predominant RV morphology. The RV is better suited for low-pressure workloads. When it supports the systemic circulation, the RV undergoes remodeling changes that promote arrhythmias, which can provoke a cycle of worsening dysfunction and arrhythmogenesis. Arrhythmias can worsen RV dysfunction by impairing hemodynamic stability, reducing cardiac output, provoking dyssynchrony, and inducing tachycardia-induced cardiomyopathy. Cellular mechanisms, including myocardial fibrosis, dysregulation of ion channels, and abnormal gap junction function, are central to this process, facilitating both re-entrant and triggered arrhythmias. Conduction disturbances, whether inherent or caused by fibrosis or pacing, compound these effects, aggravating both RV dysfunction and arrhythmia perpetuation. Management strategies must be comprehensive and include pre-emptive approaches to minimize arrhythmias, alongside early detection. Individualized therapies may include catheter ablation and cardiac implantable electronic devices, with treatment tailored to the specific RV phenotype and arrhythmia type. In this review we emphasize the importance of personalized interventions to prevent the vicious cycle of RV dysfunction and arrhythmias in CHD. Further research is essential to optimize therapeutic strategies and address care-limiting knowledge gaps.

Recent Advances in Cardiac Resynchronization Therapy: Current Treatment and Future Direction

Cardiac Resynchronization Therapy (CRT) has been established as a major component of heart failure management, resulting in a significant reduction in patient morbidity and death for patients with increased QRS duration, low left ventricular ejection fraction (LVEF), and high risk of arrhythmias. The ability to synchronize both ventricles, lower heart failure hospitalizations, and optimize clinical outcomes are some of the attractive characteristics of biventricular pacing, or CRT. However, the high rate of CRT non-responders has led to the development of new modalities including leadless CRT pacemakers (CRT-P) and devices focused on conduction system pacing (CSP). This comprehensive review aims to present recent findings from CRT clinical trials and systematic reviews that have been published that will likely guide future directions in patient care.

Beyond Seizures: the enigma of cardioinhibitory malignant vasovagal syncope in a complicated pregnancy journey

A pregnant woman in her late 20s with a history of epilepsy since childhood presented with recurrent loss of consciousness and witnessed twitching and involuntary muscle contractions. She had hyperemesis during pregnancy reporting four previous miscarriages attributed to seizures. During evaluation in cardiac telemetry and while suffering from severe nausea, the patient experienced prolonged ventricular asystole resulting in convulsive syncope and was diagnosed with cardioinhibitory malignant vasovagal syncope (CMVS). Initiation of levetiracetam was recommended for 6 months, and after undergoing dual-chamber pacemaker placement, her neurological symptoms resolved despite persistent hyperemesis during the first trimester, leading to a successful vaginal delivery. 4 years later, the patient remains asymptomatic. This case emphasises the importance of conducting a thorough differential diagnosis in patients with atypical seizure presentations, the multidisciplinary approach required to assure optimal outcomes in cardio-obstetric cases and the role of selective pacemaker placement in patients with documented prolonged ventricular asystole associated with CMVS.

Ischemic Stroke in Adults With Congenital Heart Disease: Cumulative Incidence and Associated Factors

BACKGROUND

When more patients with congenital heart disease reach adult age, increased incidence of long-term complications, including ischemic stroke, are expected. The aim of this study was to analyze cumulative incidence of ischemic stroke, associated factors, and case fatality in adult congenital heart disease.

METHODS AND RESULTS

The study is based on Swedish national registers on congenital heart disease and stroke. Patients with congenital heart disease were followed between 2001 and 2018 for first-ever ischemic stroke events (ischemic stroke due to patent foramen ovale excluded). Factors possibly associated with ischemic stroke were analyzed using Cox regression models. Out of 8914 adult patients with congenital heart disease, 108 suffered ischemic stroke over a mean period of 7.6±4.7 years. The mean age at ischemic stroke was 53.8 years, and the cumulative incidence was 0.15% at 1 year, 0.5% at 5 years, and 1.5% at 10 years. In multivariable analysis, age (hazard ratio [HR], 1.04 [95% CI, 1.03-1.06]), diabetes (HR, 2.9 [95% CI, 1.3-6.4]), ejection fraction <50% (HR, 1.9 [95% CI, 1.1-3.4]), atrial septal defect (HR, 3.0 [95% CI, 1.03-8.5]), and aortic valve lesions (HR, 4.8 [95% CI, 1.6-14.1]) were associated with increased risk. Among those with ischemic stroke, approximately half were on antithrombotic treatment (anticoagulants or antiplatelets) before admission. Case fatality was 6.5%.

CONCLUSIONS

The cumulative incidence of ischemic stroke was 1.5% after 10 years. In adult congenital heart disease, the type of heart lesion, diabetes, ejection fraction <50%, and age were important factors associated with ischemic stroke. Despite a relatively young age, mortality is a significant threat. At time of the ischemic stroke event, approximately half of the patients were on antithrombotic treatment.

Early postoperative tachyarrhythmias in adult congenital heart surgery: an eight-year review at a tertiary university hospital in Thailand

Background

Tachyarrhythmias are a common and significant complication following surgery for adult congenital heart disease (CHD), adversely affecting morbidity. This study aimed to assess the incidence, characteristics, and risk factors of early postoperative tachyarrhythmias in adults undergoing CHD surgery.

Methods

We conducted a retrospective cohort study at Siriraj Hospital, Bangkok, Thailand, including 311 adult patients who underwent elective CHD surgeries from March 2013 to November 2020. We analyzed demographic and surgical data, focusing on new-onset tachyarrhythmias requiring interventions such as antiarrhythmic drugs or cardioversion.

Results

The patient cohort had a median age of 34 years (range, 18-78 years), with 34.7% male, predominantly diagnosed with atrial and ventricular septal defects (54.7%), and severe pulmonary regurgitation post-tetralogy of Fallot repair (22.2%). Postoperative tachyarrhythmias occurred in 12.9% of patients, with atrial fibrillation (AF; 67.5%) and atrial flutter (AFL; 14.5%) being the most frequent. Independent risk factors for tachyarrhythmias included older age [adjusted odds ratio (OR) =1.26 per 5-year increment; 95% confidence interval (CI): 1.12-1.42; P<0.001] and left atrial enlargement (adjusted OR=2.78; 95% CI: 1.31-5.85; P=0.007).

Conclusions

Early postoperative tachyarrhythmias are prevalent in adults undergoing CHD surgery, with advanced age and left atrial enlargement as significant risk factors. These findings underscore the importance of early detection and management of septal defects and advocate for enhanced screening and healthcare strategies to reduce postoperative complications in this population.

Successful catheter ablation in an octogenarian with persistent atrial fibrillation complicated by cor triatriatum sinister: a case report

Background

Cor triatriatum sinister (CTS) is a rare congenital heart defect sometimes complicated with atrial fibrillation (AF). Catheter ablation (CA) relieves the AF-associated symptoms, but CA for AF with CTS has been reported rarely. Because CTS can be associated with other congenital heart disease, detailed preoperative assessment is important.

Case summary

An 80-year-old man was referred to our institution for shortness of breath that had persisted for 2 months when he was first diagnosed with AF. Transthoracic echocardiography revealed an enlarged left atrium (LA) divided into two chambers by a membrane. Transoesophageal echocardiography showed the membrane extending from the fossa ovalis (FO) to the Coumadin ridge, with the accessory (dorsal) chamber (AC) in closer proximity to the FO. Computed tomography showed that all pulmonary veins (PVs) flowed into the AC, with no PV anomalies. No other heart anomaly was identified, with no thrombus in the LA. With these findings, PV isolation (PVI) with CA was considered safe. Transseptal puncture was performed with intracardiac echocardiography for precise catheterization of the AC. Pulmonary vein isolation was performed successfully. The patient was discharged 4 days after the procedure, without any complications. His symptoms improved post-procedure, and sinus rhythm was maintained without antiarrhythmic drug therapy during the 18-month follow-up.

Discussion

Cor triatriatum sinister is a rare anomaly that accounts for 0.1% of all congenital heart diseases. Cor triatriatum sinister sometimes complicated with symptomatic AF. Detailed preoperative anatomical assessment with multiple imaging modalities helped us achieve safe and effective CA for a patient with AF and CTS, even in an octogenarian.

Arrhythmias in Adult Congenital Heart Disease Heart Failure

Heart failure and arrhythmias represent 2 major causes of mortality and morbidity in adults with congenital heart disease. Arrhythmias and heart failure are interdependent, and one may exacerbate the other. Treatment of one also has a positive impact on the other. Management approaches need to be multifaceted, including pharmacotherapy, optimization of hemodynamic status with catheter-based or surgical interventions, and specific management of arrhythmia with device or catheter ablation therapy.

2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The "2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation" provides recommendations to guide clinicians in the treatment of patients with atrial fibrillation.

METHODS

A comprehensive literature search was conducted from May 12, 2022, to November 3, 2022, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. Additional relevant studies, published through November 2022, during the guideline writing process, were also considered by the writing committee and added to the evidence tables, where appropriate.

STRUCTURE

Atrial fibrillation is the most sustained common arrhythmia, and its incidence and prevalence are increasing in the United States and globally. Recommendations from the "2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" and the "2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing atrial fibrillation and thromboembolic risk assessment, anticoagulation, left atrial appendage occlusion, atrial fibrillation catheter or surgical ablation, and risk factor modification and atrial fibrillation prevention have been developed.

2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The "2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Patients With Atrial Fibrillation" provides recommendations to guide clinicians in the treatment of patients with atrial fibrillation.

METHODS

A comprehensive literature search was conducted from May 12, 2022, to November 3, 2022, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. Additional relevant studies, published through November 2022, during the guideline writing process, were also considered by the writing committee and added to the evidence tables, where appropriate.

STRUCTURE

Atrial fibrillation is the most sustained common arrhythmia, and its incidence and prevalence are increasing in the United States and globally. Recommendations from the "2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" and the "2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing atrial fibrillation and thromboembolic risk assessment, anticoagulation, left atrial appendage occlusion, atrial fibrillation catheter or surgical ablation, and risk factor modification and atrial fibrillation prevention have been developed.

Biological Age in Congenital Heart Disease-Exploring the Ticking Clock

Over the past 50 years, there has been a major shift in age distribution of patients with congenital heart disease (CHD) thanks to significant advancements in medical and surgical treatment. Patients with CHD are, however, never cured and face unique challenges throughout their lives. In this review, we discuss the growing data suggesting accelerated aging in this population. Adults with CHD are more often and at a younger age confronted with age-related cardiovascular complications such as heart failure, arrhythmia, and coronary artery disease. These can be related to the original birth defect, complications of correction, or any residual defects. In addition, and less deductively, more systemic age-related complications are seen earlier, such as renal dysfunction, lung disease, dementia, stroke, and cancer. The occurrence of these complications at a younger age makes it imperative to further map out the aging process in patients across the spectrum of CHD. We review potential feasible markers to determine biological age and provide an overview of the current data. We provide evidence for an unmet need to further examine the aging paradigm as this stresses the higher need for care and follow-up in this unique, newly aging population. We end by exploring potential approaches to improve lifespan care.

Ventricular Arrhythmias in Adults With Congenital Heart Disease, Part II: JACC State-of-the-Art Review

There are marked variations in the incidence of sudden cardiac death (SCD) and in the substrates for ventricular arrhythmias (VAs) across the gamut of congenital heart defects. In this 2-part review, patients with higher-risk forms of congenital heart disease (CHD) were conceptually categorized into those with discrete anatomic isthmuses for macro-reentrant ventricular tachycardia (VT) (Group A) and those with more diffuse or less well-defined substrates (Group B) that include patchy or extensive myocardial fibrosis. The latter category encompasses CHD lesions such as Ebstein anomaly, transposition of the great arteries with a systemic right ventricle (RV), and congenital aortic stenosis. For Group B patients, polymorphic VT and ventricular fibrillation account for a higher proportion of VA. The prognostic value of programmed ventricular stimulation is less well established, and catheter ablation plays a less prominent role. As cardiomyopathies evolve over time, pathophysiological mechanisms for VA among Groups A and B become increasingly blurred.

Robotic magnetic-guided catheter ablation in patients with congenital heart disease: a systematic review and pooled analysis

BACKGROUND

Robotic magnetic navigation (RMN) has emerged as a potential solution to overcome challenges associated with catheter ablation of arrhythmias in patients with congenital heart disease (CHD).

OBJECTIVES

To assess safety and efficacy of RMNguided catheter ablation in patients with CHD.

DESIGN AND METHODS

A systematic review and pooled analysis was conducted on patients with CHD who underwent RMNguided catheter ablation. Random effects models were used to generate pooled estimates with the inverse variance method used for weighting studies.

RESULTS

Twentyfour nonoverlapping records included 167 patients with CHD, mean age 36.5 years, 44.6% female. Type of CHD was simple in 27 (16.2%), moderate in 32 (19.2%), and complex in 106 (63.5%). A total of 202 procedures targeted 260 arrhythmias, the most common being macroreentrant atrial circuits. The mean procedural duration was 207.5 minutes, with a mean fluoroscopy time of 12.1 minutes. The pooled acute success rate was 89.2% [95% CI (77.8%, 97.4%)]. Freedom from arrhythmia recurrence was 84.5% [95% CI (72.5%, 94.0%)] over a mean follow-up of 24.3 months. The procedural complication rate was 3.5% with no complication attributable to RMN technology.

CONCLUSION

RMN-guided ablation appears to be safe and effective across a variety of arrhythmia substrates and types of CHD.

Prognostic implications of atrial fibrillation in adults with Ebstein anomaly

OBJECTIVE

Supraventricular arrhythmias are common in adults with Ebstein anomaly (EA). However, there are limited data about prognostic implications of atrial fibrillation (AF) in this population. Accordingly, our aim was to assess the clinical profile and burden of AF in adults with EA, and the relationship between AF and outcomes.

METHODS AND RESULTS

Six hundred eighty-two consecutive adults with a median age of 36 (24-49) years from Mayo Clinic, Minnesota, USA, between 2003 and 2020 were included. Sustained episodes of AF, clinical, echocardiographic, rhythm and surgical data were collected. Prevalence of AF at baseline was 18% (126 patients); the first episode occurred at a mean age of 43±17 years. Patients with AF were older, were more likely men, and had hypertension, renal dysfunction, cardiac devices, and more advanced right-sided and left-sided remodelling. During a median follow-up of 156 (81-240) months, 62 patients (11%) developed incident AF. At the last encounter, prevalence of AF was 28% (188 patients); of those, 63 (34%) had recurrent AF. Hospitalisation for heart failure (HF) occurred in 51 patients (7%). AF (HR 2.32, 95% CI 1.18 to 4.47; p=0.01) was independently associated with hospitalisation for HF. All-cause death occurred in 53 patients (8%); it was more frequent in those with AF in the univariable analysis, although it did not remain significant in the multivariable analysis.

CONCLUSIONS

AF in EA develops at relatively young ages with one-third of the cohort exhibiting a recurrent pattern. Patients with AF had a higher prevalence of comorbidities and worse right-sided and left-sided cardiac remodelling. AF was independently associated with HF hospitalisation.