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Hodson DZ, Malla A, Su J. Wide Complex Tachycardia in a 16-year-old with Congenital Heart Disease. Pediatr Rev 2024; 45:358-362. [PMID: 38821901 DOI: 10.1542/pir.2022-005766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 11/02/2022] [Accepted: 11/09/2022] [Indexed: 06/02/2024]
Affiliation(s)
| | | | - Jonathan Su
- Division of Pediatric Cardiology, David Geffen School of Medicine at the University of California Los Angeles, Los Angeles, CA
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2
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Di Mambro C, Yammine ML, Tamborrino PP, Giordano U, Righi D, Unolt M, Cantarutti N, Maiolo S, Albanese S, Carotti A, Amodeo A, Galletti L, Drago F. Long-term incidence of arrhythmias in extracardiac conduit Fontan and comparison between systemic left and right ventricle. Europace 2024; 26:euae097. [PMID: 38650062 PMCID: PMC11089577 DOI: 10.1093/europace/euae097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Accepted: 02/16/2024] [Indexed: 04/25/2024] Open
Abstract
AIMS The extracardiac conduit-Fontan (ECC) has become the preferred technique for univentricular heart palliation, but there are currently no data on the incidence of long-term arrhythmias. This study investigated the incidence of arrhythmias and relation to single ventricle morphology in the long-term follow-up (FU) in ECC. METHODS AND RESULTS All patients with ECC performed in our Centre between 1987 and 2017 were included (minimum FU 5 years). Of 353 consecutive patients, 303 [57.8% males, aging 8-50 (median 20) years at last FU] were considered and divided into two groups depending on left (194 in Group 1) or right (109 in Group 2) ventricular morphology. Eighty-five (28%) experienced ≥1 arrhythmic complications, with early and late arrhythmias in 17 (5.6%) and 73 (24.1%) patients, respectively. Notably, late bradyarrhythmias occurred after 6 years in 21 (11%) patients in Group 1, and in 15 (13.8%) in Group 2 [P = 0.48]. Late tachyarrhythmias occurred in 55 (18.2%) patients after 12 years: 33 (17%) in Group 1 and 22 (20.2%) patients in Group 2 [P = 0.5]. Ventricular tachycardias (VT) were documented after 12.5 years in 14 (7.2%) patients of Group 1 and 15 (13.8%) of Group 2 [P = 0.06] with a higher incidence in Group 2 during the FU [P = 0.005]. CONCLUSION Extracardiac conduit is related to a significant arrhythmic risk in the long-term FU, higher than previously reported. Bradyarrhythmias occur earlier but are less frequent than tachyarrhythmias. Interestingly, patients with systemic right ventricle have a significantly higher incidence of VT, especially in a very long FU.
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Affiliation(s)
- Corrado Di Mambro
- Pediatric Cardiology and Cardiac Arrhythmias Complex Unit, Neonatal and Cardiological Area, Bambino Gesù Children’s Hospital IRCCS (European Reference Network for Rare and Low Prevalence Complex Disease of the Heart-ERN GUARD-Heart), Via Torre di Palidoro, 00050 Rome, Italy
| | - Marie Laure Yammine
- Pediatric Cardiology and Cardiac Arrhythmias Complex Unit, Neonatal and Cardiological Area, Bambino Gesù Children’s Hospital IRCCS (European Reference Network for Rare and Low Prevalence Complex Disease of the Heart-ERN GUARD-Heart), Via Torre di Palidoro, 00050 Rome, Italy
| | - Pietro Paolo Tamborrino
- Pediatric Cardiology and Cardiac Arrhythmias Complex Unit, Neonatal and Cardiological Area, Bambino Gesù Children’s Hospital IRCCS (European Reference Network for Rare and Low Prevalence Complex Disease of the Heart-ERN GUARD-Heart), Via Torre di Palidoro, 00050 Rome, Italy
| | - Ugo Giordano
- Sports Medicine Unit, Neonatal and Cardiological Area, Bambino Gesù Children’s Hospital IRCCS, Rome, Italy
| | - Daniela Righi
- Pediatric Cardiology and Cardiac Arrhythmias Complex Unit, Neonatal and Cardiological Area, Bambino Gesù Children’s Hospital IRCCS (European Reference Network for Rare and Low Prevalence Complex Disease of the Heart-ERN GUARD-Heart), Via Torre di Palidoro, 00050 Rome, Italy
| | - Marta Unolt
- Pediatric Cardiology and Cardiac Arrhythmias Complex Unit, Neonatal and Cardiological Area, Bambino Gesù Children’s Hospital IRCCS (European Reference Network for Rare and Low Prevalence Complex Disease of the Heart-ERN GUARD-Heart), Via Torre di Palidoro, 00050 Rome, Italy
| | - Nicoletta Cantarutti
- Pediatric Cardiology and Cardiac Arrhythmias Complex Unit, Neonatal and Cardiological Area, Bambino Gesù Children’s Hospital IRCCS (European Reference Network for Rare and Low Prevalence Complex Disease of the Heart-ERN GUARD-Heart), Via Torre di Palidoro, 00050 Rome, Italy
| | - Stella Maiolo
- Pediatric Cardiology and Cardiac Arrhythmias Complex Unit, Neonatal and Cardiological Area, Bambino Gesù Children’s Hospital IRCCS (European Reference Network for Rare and Low Prevalence Complex Disease of the Heart-ERN GUARD-Heart), Via Torre di Palidoro, 00050 Rome, Italy
| | - Sonia Albanese
- Cardiac Surgery Unit, Neonatal and Cardiological Area, Bambino Gesù Children’s Hospital IRCCS, Rome, Italy
| | - Adriano Carotti
- Cardiac Surgery Unit, Neonatal and Cardiological Area, Bambino Gesù Children’s Hospital IRCCS, Rome, Italy
| | - Antonio Amodeo
- Heart Failure, Transplant and Mechanical Assist Device, Neonatal and Cardiological Area, Bambino Gesù Children’s Hospital IRCCS, Rome, Italy
| | - Lorenzo Galletti
- Cardiac Surgery Unit, Neonatal and Cardiological Area, Bambino Gesù Children’s Hospital IRCCS, Rome, Italy
| | - Fabrizio Drago
- Pediatric Cardiology and Cardiac Arrhythmias Complex Unit, Neonatal and Cardiological Area, Bambino Gesù Children’s Hospital IRCCS (European Reference Network for Rare and Low Prevalence Complex Disease of the Heart-ERN GUARD-Heart), Via Torre di Palidoro, 00050 Rome, Italy
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3
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Whittaker-Axon S, Ezzat V, Lowe M, Sawhney V. Coherent mapping to aid interpretation of multiple intraatrial reentrant tachycardias in an atrio-pulmonary Fontan patient. Indian Pacing Electrophysiol J 2024; 24:114-118. [PMID: 38211661 PMCID: PMC11010447 DOI: 10.1016/j.ipej.2024.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 12/21/2023] [Accepted: 01/07/2024] [Indexed: 01/13/2024] Open
Affiliation(s)
| | - Vivienne Ezzat
- Barts Heart Centre, London, UK; Queen Marys University of London, London, UK
| | - Martin Lowe
- Barts Heart Centre, London, UK; Queen Marys University of London, London, UK
| | - Vinit Sawhney
- Barts Heart Centre, London, UK; Queen Marys University of London, London, UK
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4
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Pompa AG, Hale BW. Use of an electroanatomic mapping system with high-density multipolar mapping catheters to guide transvenous atrial pacing lead implantation in a Fontan patient. HeartRhythm Case Rep 2024; 10:49-52. [PMID: 38264119 PMCID: PMC10801093 DOI: 10.1016/j.hrcr.2023.10.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2024] Open
Affiliation(s)
- Anthony G. Pompa
- Division of Pediatric Cardiology, Department of Pediatrics, University of Michigan, Ann Arbor, Michigan
| | - Benjamin W. Hale
- Division of Pediatric Cardiology, Department of Pediatrics, University of Michigan, Ann Arbor, Michigan
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5
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Celermajer DS, Baker DW, Cordina RL, Gatzoulis M, Broberg CS. Common diagnostic errors in adults with congenital heart disease. Eur Heart J 2023; 44:3217-3227. [PMID: 36527303 DOI: 10.1093/eurheartj/ehac717] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 10/07/2022] [Accepted: 11/20/2022] [Indexed: 09/08/2023] Open
Abstract
Owing to the great advances in the care for children with congenital heart disease by paediatric cardiac surgeons and cardiologists, there are ever increasing numbers of patients with congenital heart disease who reach adult life. At some stage during the late teenage years or soon after, these patients 'transition' from paediatric cardiac care to surveillance by cardiologists who look after adults. Many such specialists, however, are more familiar with commoner acquired heart problems such as coronary disease, heart failure, and arrhythmia in structurally normal hearts and less familiar with congenital heart disease. For this reason, international guidelines have suggested that the care of young adults with congenital heart disease take place in designated specialist adult congenital heart disease centres. It remains very important, however, for general cardiologists to have a good understanding of many aspects of adult congenital heart disease, including common pitfalls to avoid and, importantly, when to refer on, to a specialist centre. To help healthcare providers across the spectrum of cardiology practice to address common themes in adult congenital heart disease, this state-of-the-art review provides a series of case vignettes to illustrate frequent diagnostic problems that we have seen in our tertiary-level adult congenital heart disease centres, which are sometimes encountered in general cardiology settings. These include commonly 'missed' diagnoses, or errors with diagnosis or management, in these often very complex patients.
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Affiliation(s)
- David S Celermajer
- Sydney Medical School, University of Sydney, Sydney, NSW 2006, Australia
- Department of Cardiology, Royal Prince Alfred Hospital, Missenden Rd, Camperdown, NSW 2050, Australia
| | - David W Baker
- Sydney Medical School, University of Sydney, Sydney, NSW 2006, Australia
- Department of Cardiology, Royal Prince Alfred Hospital, Missenden Rd, Camperdown, NSW 2050, Australia
| | - Rachael L Cordina
- Sydney Medical School, University of Sydney, Sydney, NSW 2006, Australia
- Department of Cardiology, Royal Prince Alfred Hospital, Missenden Rd, Camperdown, NSW 2050, Australia
| | - Michael Gatzoulis
- Adult Congenital Heart Centre and National Centre for Pulmonary Hypertension, Royal Brompton Hospital, London, UK
- National Heart and Lung Institute, Imperial College School of Medicine, London, UK
| | - Craig S Broberg
- Knight Cardiovascular Institute, Oregon Health and Science University, Portland, OR, USA
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6
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Laubham M, Blais B, Kamp AN. Atrial Arrhythmias in Adults with Fontan Palliation. Cardiol Ther 2023; 12:473-487. [PMID: 37495769 PMCID: PMC10423191 DOI: 10.1007/s40119-023-00326-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 07/14/2023] [Indexed: 07/28/2023] Open
Abstract
Single ventricle physiology is a rare form of congenital heart disease and was, historically, a uniformly lethal condition. However, the atriopulmonary Fontan operation, and its successive iterations, the lateral tunnel and extracardiac conduit Fontan, became the fundamental approach to treating single ventricle heart disease. Over time, dysrhythmias are some of the most common complications with Fontan physiology, compounding morbidity and mortality. Atrial arrhythmias are prevalent in the Fontan population and occur in about 15-60% of patients with Fontan palliation, increasingly with age. Diagnosing atrial arrhythmias in patients with Fontan palliation may be challenging because of low voltage amplitudes arising from myopathic atrial tissue making it difficult to clearly assess atrial depolarization on surface electrocardiograms (ECG), vague symptoms not suggestive of tachyarrhythmia, or atrial arrhythmia with ventricular rates below 100 beats per minute. Intra-atrial reentrant tachycardia (IART) is the most common type of supraventricular tachycardia in adults with Fontan palliation. Acute management of atrial arrhythmias in patients with Fontan palliation involves prompt assessment of a patient's hemodynamic stability, anticoagulation and thrombosis risk, systemic ventricular function, and risk of sedation or anesthesia if needed. Long-term management of atrial arrhythmias is often multifactorial and may include long-term anti-arrhythmic therapy, permanent pacing, and ablation. The best approach for the management of atrial arrhythmias in adults with Fontan palliation is patient-specific and involves collaboration between congenital electrophysiologists, adult congenital cardiologists, and the patient.
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Affiliation(s)
- Matthew Laubham
- Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, 43205, USA.
| | - Ben Blais
- Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, 43205, USA
- The Ohio State University School of Medicine, Columbus, OH, USA
| | - Anna N Kamp
- Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, 43205, USA
- The Ohio State University School of Medicine, Columbus, OH, USA
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Mondésert B, Moore JP, Khairy P. Cardiac Implantable Electronic Devices in the Fontan Patient. Can J Cardiol 2022; 38:1048-1058. [PMID: 35588949 DOI: 10.1016/j.cjca.2022.04.024] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2022] [Revised: 04/18/2022] [Accepted: 04/19/2022] [Indexed: 12/22/2022] Open
Abstract
As a result of remarkable progress in operative techniques and cardiology care during childhood, Fontan patients continue to age and require team-based multidisciplinary expertise to manage complications encountered in adulthood. They face particular challenges in terms of altered hemodynamic stressors, cardiac and hepatic failure, and arrhythmias. Arrhythmias in Fontan patients are highly prevalent and associated with underlying anatomy, surgical technique, and postoperative sequelae. Diagnostic tools, treatments, and device strategies for arrhythmias in Fontan patients should be adapted to the specific anatomy, type of surgical repair, and clinical status. Great strides in our understanding of arrhythmia mechanisms, options and techniques to obtain access to relevant cardiac structures, and application of both old and new technologies have contributed to improving cardiac implantable electronic device (CIED) therapies for this unique population. In this state-of-the-art review, we discuss the various arrhythmias encountered in Fontan patients, their diagnosis, and options for treatment and prevention, with a focus on CIEDs. Throughout, access challenges particular to the Fontan circulation are considered. Recently developed technologies, such as the sub-cutaneous implantable cardioverter defibrillator carry the potential to be transformative but require awareness of Fontan-specific issues. Moreover, new leadless pacing technology represents a promising strategy that may soon become applicable to Fontan patients with sinus node dysfunction. CIEDs are essential tools in managing Fontan patients but the complex clinical scenarios that arise in this patient population are among the most challenging for the congenital electrophysiologist.
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Affiliation(s)
- Blandine Mondésert
- Adult Congenital Heart Disease Center, Montreal Heart Institute, Medicine Department, Université de Montréal, Montreal, Canada.
| | - Jeremy P Moore
- Division of Cardiology, Department of Medicine, Ahmanson/UCLA Adult Congenital Heart Disease Center, Los Angeles, CA; UCLA Cardiac Arrhythmia Center, UCLA Health System, Los Angeles, CA; Division of Cardiology, Department of Pediatrics, UCLA Health System, Los Angeles, CA
| | - Paul Khairy
- Adult Congenital Heart Disease Center, Montreal Heart Institute, Medicine Department, Université de Montréal, Montreal, Canada
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8
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Kamp AN, Nair K, Fish FA, Khairy P. Catheter ablation of atrial arrhythmias in patients post-Fontan. Can J Cardiol 2022; 38:1036-1047. [PMID: 35240252 DOI: 10.1016/j.cjca.2022.02.023] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 02/18/2022] [Accepted: 02/20/2022] [Indexed: 12/25/2022] Open
Abstract
Atrial arrhythmias are highly prevalent in the aging Fontan population and contribute importantly to morbidity and mortality. Although the most common arrhythmia is scar-based intra-atrial re-entrant tachycardia, various other arrhythmias may occur including focal atrial tachycardia, atrioventricular node-dependent tachycardias, and atrial fibrillation. The type and prevalence of atrial arrhythmia is determined, in part, by the underlying congenital defect and variant of Fontan surgery. While the cumulative incidence of atrial tachyarrhythmias has decreased substantially from the atriopulmonary anastomosis to the more recent total cavopulmonary connection Fontan, the burden of atrial arrhythmias remains substantial. Management is often multi-faceted and can include anticoagulation, anti-arrhythmic drug therapy, pacing, and cardioversion. Catheter ablation plays a key role in arrhythmia control. Risks and benefits must be carefully weighed. Among the important considerations are the clinical burden of arrhythmia, ventricular function, hemodynamic stability in tachycardia, suspected arrhythmia mechanisms, risks associated with anaesthesia, venous access, approaches to reaching the pulmonary venous atrium, and accompanying co-morbidities. Careful review of surgical notes, electrocardiographic tracings, and advanced imaging is paramount, with particular attention to anatomic abnormalities such as venous obstructions and displaced conduction systems. Despite numerous challenges, ablation of atrial arrhythmias is effective in improving clinical status. Nevertheless, onset of new arrhythmias is common during long-term follow-up. Advanced technologies such as high-density mapping catheters and remote magnetic guided ablation carry the potential to further improve outcomes. Fontan patients with atrial arrhythmias should be referred to centers with dedicated expertise in congenital heart disease including catheter ablation, anaesthesia support, and advanced imaging.
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Affiliation(s)
- Anna N Kamp
- Nationwide Children's Hospital, Ohio State University, Columbus, OH, USA
| | - Krishnakumar Nair
- University Health Network, Toronto General Hospital, Toronto, Canada
| | - Frank A Fish
- Vanderbilt University Medical Center, Nashville, TN, USA; and
| | - Paul Khairy
- Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada.
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9
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Driesen BW, Voskuil M, Grotenhuis HB. Current Treatment Options for the Failing Fontan Circulation. Curr Cardiol Rev 2022; 18:e060122200067. [PMID: 34994331 PMCID: PMC9893132 DOI: 10.2174/1573403x18666220106114518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 10/22/2021] [Accepted: 11/16/2021] [Indexed: 11/22/2022] Open
Abstract
The Fontan operation was introduced in 1968. For congenital malformations, where biventricular repair is unsuitable, the Fontan procedure has provided a long-term palliation strategy with improved outcomes compared to the initially developed procedures. Despite these improvements, several complications merely due to a failing Fontan circulation, including myocardial dysfunction, arrhythmias, increased pulmonary vascular resistance, protein-losing enteropathy, hepatic dysfunction, plastic bronchitis, and thrombo-embolism, may occur, thereby limiting the life-expectancy in this patient cohort. This review provides an overview of the most common complications of Fontan circulation and the currently available treatment options.
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Affiliation(s)
- Bart W. Driesen
- Department of Pediatric Cardiology, Wilhelmina Children’s Hospital, University Medical Center, Utrecht, Utrecht, The Netherlands
- Department of Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands
- Department of Cardiology, Laurentius Ziekenhuis, Roermond, The Netherlands
| | - Michiel Voskuil
- Department of Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Heynric B. Grotenhuis
- Department of Pediatric Cardiology, Wilhelmina Children’s Hospital, University Medical Center, Utrecht, Utrecht, The Netherlands
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10
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Ablation of intra-atrial reentrant tachycardias in adults with congenital heart disease: islands, isthmuses, channels, and walls. Curr Opin Cardiol 2022; 37:46-53. [PMID: 34711710 DOI: 10.1097/hco.0000000000000938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW The adult congenital heart patient population is rapidly growing due to increasing survival rates, and they often face chronic physiologic challenges as sequalae of both their defects and repairs. Among the most common sequalae are arrhythmias. Here we describe intra-atrial reentrant tachycardia (IART), one of the most commonly seen arrhythmias in the adult congenital heart population, and the approaches to successful ablation in adult congenital heart patients. RECENT FINDINGS IART has increasing ablation success rates due to the increasing exposure of electrophysiologists to congenital cases, advances in technology, and the increasing application of both our pediatric congenital knowledge and adult acquired knowledge to the adult congenital population. SUMMARY IART is a frequently seen arrhythmia in the adult congenital population, and it can have life-threatening consequences in the setting of congenital disease. Ablation techniques and treatment rates have improved over time, despite the challenges these cases present to clinicians; success of the ablation depends on careful, often creative, preplanning, and understanding of the complex individualized anatomy and circuits of the patient.
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Abstract
PURPOSE Adults with congenital heart disease (ACHD) are a rapidly growing population with ever-increasing complexity, and intensive care unit (ICU) management is often necessary. This review summarizes common cardiovascular and non-cardiovascular complications in ACHD and provides a framework for ICU care. RECENT FINDINGS Heart failure is the leading cause of hospitalization and mortality in ACHD. Varied anatomy and repairs, as well as differing physiological complications, limit generalized application of management algorithms. Recent studies suggest that earlier mechanical support in advanced cases is feasible and potentially helpful. Cardiac arrhythmias are poorly tolerated and often require immediate attention. Other complications requiring intensive care include infections such as endocarditis and COVID-19, pulmonary hypertension, renal failure, hepatic dysfunction, coagulopathy, and stroke. Successful ICU care in ACHD requires a multi-disciplinary approach with careful consideration of anatomy, physiology, and associated comorbidities. Few studies have formally examined ICU management in ACHD and further research is necessary.
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Affiliation(s)
- Payton Kendsersky
- Department of Medicine, Duke University Medical Center, Durham, NC USA
| | - Richard A. Krasuski
- Division of Cardiology, Duke University Medical Center, DUMC 3010, Durham, NC 27710 USA
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12
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Fitzgerald JL, Collins NJ, Leitch J, Downar E, Nair K, Jackson N. Atrial fibrillation ablation without pulmonary vein isolation in an atriopulmonary Fontan circulation. HeartRhythm Case Rep 2020; 5:534-538. [PMID: 31890567 PMCID: PMC6926191 DOI: 10.1016/j.hrcr.2019.07.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Affiliation(s)
- John L Fitzgerald
- Department of Cardiology, John Hunter Hospital, Newcastle, Australia
| | | | - James Leitch
- Department of Cardiology, John Hunter Hospital, Newcastle, Australia
| | - Eugene Downar
- Toronto General Hospital, University Health Network, Toronto, Canada
| | - Krishnakumar Nair
- Toronto General Hospital, University Health Network, Toronto, Canada
| | - Nicholas Jackson
- Department of Cardiology, John Hunter Hospital, Newcastle, Australia
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13
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Arrigoni SC, van den Heuvel F, Willems TP, Veeger NJGM, Schoof P, Ebels T. Autologous Right Auricular Versus PTFE Cavopulmonary Lateral Tunnel: Influence of Surgical Technique on Arrhythmias. World J Pediatr Congenit Heart Surg 2019; 10:686-693. [PMID: 31701828 DOI: 10.1177/2150135119874034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND To compare the incidence of arrhythmias and the overall survival at long-term follow-up of the right auricular baffle technique (RA) versus Gore-Tex® (GT) baffle as intra-atrial cavopulmonary lateral tunnel, as well as the Nakata index and tunnel dimensions on cardiac magnetic resonance. METHODS Data were retrospectively collected. Serial 24-hour Holter recordings and cardiac magnetic resonance findings of the two groups were compared. RESULTS There was no significant difference in the estimated freedom from arrhythmias (87% at 10 years and 78% at 15 years vs 80% at 10 years and 70% at 15 years in RA and GT, respectively; P = .44) nor cumulative survival (86% at 10 years and 84% at 15 years vs 97% at 10 years and 81% at 15 years in RA and GT, respectively; P = .8). Also, no difference between the groups was observed in the Nakata index. The tunnel dimensions on cardiac magnetic resonance were significantly wider in the RA group. In reference to other potential risk indicators, using Cox proportional hazard regression analysis, only age (5 years or older at the time of total cavopulmonary connection) was associated with an increased risk for both arrhythmia and mortality. CONCLUSIONS This study demonstrated that there was no difference in freedom from arrhythmias, Nakata index, or survival between the two groups. This study confirmed the growth potential of the right auricular tunnel. However, the growth of the tunnel did not influence the incidence of arrhythmias.
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Affiliation(s)
- Sara C Arrigoni
- Department of Cardiothoracic Surgery, University Medical Centre Groningen, University of Groningen, Groningen, Netherlands
| | - Freek van den Heuvel
- Department of Pediatric Cardiology, University Medical Centre Groningen, University of Groningen, Groningen, Netherlands
| | - Tineke P Willems
- Department of Radiology, University Medical Centre Groningen, University of Groningen, Groningen, Netherlands
| | - Nic J G M Veeger
- Department of Epidemiology, University Medical Centre Groningen, University of Groningen, Groningen, Netherlands
| | - Paul Schoof
- Department of Cardiothoracic Surgery, University Medical Centre Groningen, University of Groningen, Groningen, Netherlands
| | - Tjark Ebels
- Department of Cardiothoracic Surgery, University Medical Center Amsterdam, University of Amsterdam, Amsterdam, Netherlands
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Rychik J, Atz AM, Celermajer DS, Deal BJ, Gatzoulis MA, Gewillig MH, Hsia TY, Hsu DT, Kovacs AH, McCrindle BW, Newburger JW, Pike NA, Rodefeld M, Rosenthal DN, Schumacher KR, Marino BS, Stout K, Veldtman G, Younoszai AK, d'Udekem Y. Evaluation and Management of the Child and Adult With Fontan Circulation: A Scientific Statement From the American Heart Association. Circulation 2019; 140:e234-e284. [PMID: 31256636 DOI: 10.1161/cir.0000000000000696] [Citation(s) in RCA: 407] [Impact Index Per Article: 81.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
It has been 50 years since Francis Fontan pioneered the operation that today bears his name. Initially designed for patients with tricuspid atresia, this procedure is now offered for a vast array of congenital cardiac lesions when a circulation with 2 ventricles cannot be achieved. As a result of technical advances and improvements in patient selection and perioperative management, survival has steadily increased, and it is estimated that patients operated on today may hope for a 30-year survival of >80%. Up to 70 000 patients may be alive worldwide today with Fontan circulation, and this population is expected to double in the next 20 years. In the absence of a subpulmonary ventricle, Fontan circulation is characterized by chronically elevated systemic venous pressures and decreased cardiac output. The addition of this acquired abnormal circulation to innate abnormalities associated with single-ventricle congenital heart disease exposes these patients to a variety of complications. Circulatory failure, ventricular dysfunction, atrioventricular valve regurgitation, arrhythmia, protein-losing enteropathy, and plastic bronchitis are potential complications of the Fontan circulation. Abnormalities in body composition, bone structure, and growth have been detected. Liver fibrosis and renal dysfunction are common and may progress over time. Cognitive, neuropsychological, and behavioral deficits are highly prevalent. As a testimony to the success of the current strategy of care, the proportion of adults with Fontan circulation is increasing. Healthcare providers are ill-prepared to tackle these challenges, as well as specific needs such as contraception and pregnancy in female patients. The role of therapies such as cardiovascular drugs to prevent and treat complications, heart transplantation, and mechanical circulatory support remains undetermined. There is a clear need for consensus on how best to follow up patients with Fontan circulation and to treat their complications. This American Heart Association statement summarizes the current state of knowledge on the Fontan circulation and its consequences. A proposed surveillance testing toolkit provides recommendations for a range of acceptable approaches to follow-up care for the patient with Fontan circulation. Gaps in knowledge and areas for future focus of investigation are highlighted, with the objective of laying the groundwork for creating a normal quality and duration of life for these unique individuals.
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15
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Moore BM, Anderson R, Nisbet AM, Kalla M, du Plessis K, d’Udekem Y, Bullock A, Cordina RL, Grigg L, Celermajer DS, Kalman J, McGuire MA. Ablation of Atrial Arrhythmias After the Atriopulmonary Fontan Procedure. JACC Clin Electrophysiol 2018; 4:1338-1346. [DOI: 10.1016/j.jacep.2018.08.012] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Revised: 07/17/2018] [Accepted: 08/13/2018] [Indexed: 10/28/2022]
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Affiliation(s)
- Gunter Balling
- Department of Pediatric Cardiology and Congenital Heart Diseases, German Heart Center, Technical University Munich, Munich, Germany.
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Lim HG, Lee JR, Kim YJ. The Effects of Modification to Lateral Tunnel Fontan Procedure for Prophylactic Arrhythmia Surgery. Ann Thorac Surg 2017; 104:197-204. [DOI: 10.1016/j.athoracsur.2016.11.033] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2016] [Revised: 10/30/2016] [Accepted: 11/07/2016] [Indexed: 11/16/2022]
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Abstract
Patients with repaired or unrepaired congenital heart anomalies are at increased risk for arrhythmia development throughout their lives, often paralleling the need for reoperations for hemodynamic residua. The ability to incorporate arrhythmia surgery into reoperations can result in improvement in functional class and decreased need for antiarrhythmic medications. Every reoperation for congenital heart disease can be viewed as an opportunity to assess the electrical and arrhythmia substrates and to intervene to improve the arrhythmias and the hemodynamic condition of the patient. The authors review and summarize the operative techniques for arrhythmia surgery that are based on the arrhythmia mechanisms.
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Affiliation(s)
- Barbara J Deal
- Feinberg School of Medicine, Northwestern University, 303 East Chicago Avenue, Chicago, IL 60611, USA.
| | - Constantine Mavroudis
- Johns Hopkins Children's Heart Surgery, Florida Hospital for Children, 2501 N Orange Avenue, Suite 540, Orlando, FL 32804, USA
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19
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Cardiopulmonary exercise test in adults with prior Fontan operation: The prognostic value of serial testing. Int J Cardiol 2017; 235:6-10. [DOI: 10.1016/j.ijcard.2017.02.140] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2016] [Revised: 02/09/2017] [Accepted: 02/27/2017] [Indexed: 11/17/2022]
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20
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Li D, Fan Q, Hirata Y, Ono M, An Q. Arrhythmias After Fontan Operation with Intra-atrial Lateral Tunnel Versus Extra-cardiac Conduit: A Systematic Review and Meta-analysis. Pediatr Cardiol 2017; 38:873-880. [PMID: 28271152 DOI: 10.1007/s00246-017-1595-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2016] [Accepted: 02/21/2017] [Indexed: 02/05/2023]
Abstract
Current studies on the incidence of arrhythmias after the intra-atrial lateral tunnel (ILT) Fontan operation and the extra-cardiac conduit (ECC) Fontan operation are limited, with controversial results. This systematic review aimed to compare the prevalence of arrhythmias in patients who underwent ECC or ILT Fontan. Relevant studies comparing the incidence of arrhythmias and pacemaker implantation in ILT with ECC were identified through a literature search using MEDLINE, EMBASE, and the cochrane central register of controlled trials. The outcome measures included baseline characteristics, early (≤30 days) and late (>30 days) arrhythmias and pacemaker implantation. 16 publications involving 3499 patients were included. In the meta-analysis, although the overall risk of early arrhythmias was lower for the ILT group, statistically, no significant difference was observed (odds ratio [OR] 0.78; 95% confidence interval [CI] 0.61-1.01; p = 0.06). Similarly, there was no significant difference between the two cohorts in the incidence of postoperative permanent pacemaker therapy (OR 1.36; 95% CI 0.86-2.14; p = 0.19). However, we found significantly increased incidence of late arrhythmias in ILT group compared with ECC group (OR 1.96; 95% CI 1.64-2.35; p < 0.01). Although our systematic review and meta-analysis suggested that there was no significant difference in early arrhythmias and in pacemaker implantation between the ILT and ECC groups, ECC procedure could significantly lower the risk of late arrhythmias after Fontan surgery. Given that some limitations cannot be overcome, well-designed randomized controlled trials are needed to confirm our findings.
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Affiliation(s)
- Dongxu Li
- Department of Cardiovascular Surgery, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang, Chengdu, 610041, Sichuan, People's Republic of China
- Department of Cardiac Surgery, Graduate School of Medicine, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Qiang Fan
- Department of Cardiovascular Surgery, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang, Chengdu, 610041, Sichuan, People's Republic of China
| | - Yasutaka Hirata
- Department of Cardiac Surgery, Graduate School of Medicine, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Minoru Ono
- Department of Cardiac Surgery, Graduate School of Medicine, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Qi An
- Department of Cardiovascular Surgery, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang, Chengdu, 610041, Sichuan, People's Republic of China.
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Egbe AC, Connolly HM, Khan AR, Niaz T, Said SS, Dearani JA, Warnes CA, Deshmukh AJ, Kapa S, McLeod CJ. Outcomes in adult Fontan patients with atrial tachyarrhythmias. Am Heart J 2017; 186:12-20. [PMID: 28454826 DOI: 10.1016/j.ahj.2016.12.015] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2016] [Accepted: 12/24/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND The optimal management strategy for atrial tachyarrhythmia in the Fontan population is unknown. METHODS Retrospective review of 264 adult Fontan patients with atrial tachyarrhythmia evaluating 3 clinically adopted scenarios: antiarrhythmic drug (AAD) therapy, catheter ablation (CA), and Fontan conversion (FC). These patients were followed up at Mayo Clinic from 1994 to 2014. The study objective was to compare freedom from atrial tachyarrhythmia recurrence (AR) and occurrence of composite adverse events (stroke, heart failure hospitalization, death, or heart transplant) between treatment groups. RESULTS The age of atrial tachyarrhythmia onset was 25 ± 4 years, time from Fontan operation was 13 ± 6 years, follow-up was 74 ± 18 months, atriopulmonary Fontan was 215 (81%), and atrial flutter/intra-atrial reentry tachycardia was 173 (65%). In those managed with AAD (n = 110), freedom from AR was 7% at 60 months. Catheter ablation (n = 31) was associated with an acute procedural success of 94%, and freedom from AR was 41% at 60 months. Fontan conversion (n = 33) resulted in a perioperative mortality of 3%, and freedom from AR was 51% at 60 months. Fontan conversion and CA were similar with regard to AR (P = .14) and significantly better compared with AAD (P < .0001). Adverse events were found to occur more frequently in the patients with AR (P < .0001) and the patients treated with AAD only (P < .0001). CONCLUSIONS Catheter ablation and FC operations are associated with less recurrence of atrial tachyarrhythmia compared with AAD. Atrial tachyarrhythmias are more likely to recur in patients with a longer history of the arrhythmia and are associated with more adverse events. Early referral to a specialty center for these interventions should be considered.
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Egbe AC, Connolly HM, Dearani JA, Bonnichsen CR, Niaz T, Allison TG, Johnson JN, Poterucha JT, Said SM, Ammash NM. When is the right time for Fontan conversion? The role of cardiopulmonary exercise test. Int J Cardiol 2016; 220:564-8. [DOI: 10.1016/j.ijcard.2016.06.209] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2016] [Revised: 06/23/2016] [Accepted: 06/25/2016] [Indexed: 11/29/2022]
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Egbe AC, Connolly HM, McLeod CJ, Ammash NM, Niaz T, Yogeswaran V, Poterucha JT, Qureshi MY, Driscoll DJ. Thrombotic and Embolic Complications Associated With Atrial Arrhythmia After Fontan Operation. J Am Coll Cardiol 2016; 68:1312-9. [DOI: 10.1016/j.jacc.2016.06.056] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2016] [Revised: 05/25/2016] [Accepted: 06/21/2016] [Indexed: 10/21/2022]
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Wasmer K, Eckardt L. Management of supraventricular arrhythmias in adults with congenital heart disease. Heart 2016; 102:1614-9. [PMID: 27312002 DOI: 10.1136/heartjnl-2015-309068] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2016] [Accepted: 05/23/2016] [Indexed: 01/21/2023] Open
Abstract
Supraventricular arrhythmias are a frequent complication in adults with congenital heart disease (ACHD). The prevalence increases with time since surgery, complexity of the underlying defect, type of repair and older age at surgery. Arrhythmias are the most frequent reason for hospital admission and along with heart failure the leading cause of death. The arrhythmia-associated increase in morbidity and mortality makes their management a key task in patients with ACHD. Intra-atrial re-entry is the most frequent arrhythmia mechanism. Less common arrhythmia mechanisms are supraventricular tachycardias in the presence of an accessory pathway, atrioventricular nodal re-entrant tachycardia or focal tachycardias. Patient management includes stroke prevention, acute termination and prevention of arrhythmia recurrence. Acute treatment depends on patients' symptoms. In cases of haemodynamic instability, immediate cardioversion is warranted. For stable patients, acute treatment includes rate control and termination by antiarrhythmic drugs or electrical cardioversion. Following a symptomatic arrhythmia, catheter ablation or treatment with antiarrhythmic drugs is recommended to prevent recurrences. Advances in mapping and ablation technology are now associated with high success rates of catheter ablation. In patients with a complex substrate recurrence rates of 50% remain high. However, in the presence of side effects and complications associated with long-term antiarrhythmic drug therapy, redo procedures are encouraged by current guidelines.
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Affiliation(s)
- Kristina Wasmer
- Division of Clinical and Experimental Electrophysiology, Department of Cardiology and Angiology, University Hospital Münster, Münster, Germany
| | - Lars Eckardt
- Division of Clinical and Experimental Electrophysiology, Department of Cardiology and Angiology, University Hospital Münster, Münster, Germany
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Wasmer K, Köbe J, Diller G, Eckardt L. [Arrhythmia in adults with congenital heart defects : Incidence, substrates, and mechanisms]. Herzschrittmacherther Elektrophysiol 2016; 27:75-80. [PMID: 27216033 DOI: 10.1007/s00399-016-0427-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2016] [Accepted: 03/26/2016] [Indexed: 06/05/2023]
Abstract
Arrhythmia management is one of the main challenges in the treatment of adult patients with congenital heart disease (ACHD). Apart from heart failure, arrhythmias are mainly responsible for morbidity and mortality in these patients. Supraventricular tachycardia is more frequent than ventricular arrhythmias and is not only associated with debilitating symptoms, but is often as threatening as ventricular tachycardia. The incidence depends on the underlying defect, type, and time of repair. For the overall ACHD population the incidence of supraventricular tachycardia is up to 50 % and increases with age and time since surgery. Arrhythmia substrate relates to structural abnormalities due to the congenital defect and most importantly to the amount of incisions and material used for repair. In addition, poor hemodynamic conditions influence substrate through dilatation, hypertrophy, and fibrosis. Both supraventricular and ventricular arrhythmias are due to a macroreentrant mechanism in the vast majority of patients, but focal arrhythmias occasionally occur as well.
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Affiliation(s)
- Kristina Wasmer
- Abteilung für Rhythmologie, Department für Kardiologie und Angiologie, Universitätsklinikum Münster (UKM), Albert-Schweitzer-Campus 1, Gebäude A1, 48149, Münster, Deutschland.
| | - Julia Köbe
- Abteilung für Rhythmologie, Department für Kardiologie und Angiologie, Universitätsklinikum Münster (UKM), Albert-Schweitzer-Campus 1, Gebäude A1, 48149, Münster, Deutschland
| | - Gerhard Diller
- Zentrum für Erwachsene mit angeborenen Herzfehlern, Department für Kardiologie und Angiologie, Universitätsklinikum Münster (UKM), Albert-Schweitzer-Campus 1, Gebäude A1, 48149, Münster, Deutschland
| | - Lars Eckardt
- Abteilung für Rhythmologie, Department für Kardiologie und Angiologie, Universitätsklinikum Münster (UKM), Albert-Schweitzer-Campus 1, Gebäude A1, 48149, Münster, Deutschland
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Egbe AC, Connolly HM, Niaz T, McLeod CJ. Outcome of direct current cardioversion for atrial arrhythmia in adult Fontan patients. Int J Cardiol 2016; 208:115-9. [DOI: 10.1016/j.ijcard.2016.01.209] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2015] [Revised: 01/16/2016] [Accepted: 01/22/2016] [Indexed: 10/22/2022]
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27
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Abstract
PURPOSE OF REVIEW As perioperative survival following the Fontan procedure has improved and more patients are reaping the benefits of physiologic palliation, the costs of longstanding systemic venous hypertension and the functional limitations of a single ventricle are becoming clearer. Arrhythmias, heart failure, protein-losing enteropathy, hepatic cirrhosis, pulmonary hypertension, and ventricular dysfunction are common in late survivors and result in significant morbidity and mortality. Current research is focused on characterizing late morbidities and developing risk-prediction models for worse outcomes in long-term survivors. RECENT FINDINGS Ten-year survival following the Fontan procedure is now 94-98%; however, estimated conditional survival in survivors aged above 18 years is 60% at 40 years of age. Atrial arrhythmias and heart failure are the leading causes of morbidity and mortality. Hypoplastic left heart syndrome, hepatic dysfunction, decreased exercise tolerance, lower quality of life, and markers of neurohormonal activation have been associated with worse outcome. Improvements in exercise tolerance are seen with selective pulmonary vasodilator therapy and exercise training. Heart transplant continues to be an effective therapy for end-stage Fontan failure, and reports of the use of traditional mechanical assist devices and the development of right heart assist devices in the setting of passive venous flow are ongoing. SUMMARY Over a generation has passed since the Fontan procedure revolutionized the care of patients with a single ventricle. Data generated from retrospective and prospective observational studies in long-term survivors are identifying patients at risk.
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