Natural History and Clinical Predictors of Atrial Tachycardia in Adults With Congenital Heart Disease

Association of reduced peak left atrial strain with supraventricular arrhythmia in adults with congenital heart disease

Atrial arrhythmias are an important cause of morbidity and mortality in adults with congenital heart disease (ACHD). In acquired heart disease, the left atrial (LA) strain has been shown to predict supraventricular tachyarrhythmias (SVT). This study aimed to investigate whether reduced LA strain is associated with SVT in ACHD patients. This retrospective, single-center cohort study collected baseline clinical and echocardiographic data of 206 ACHD patients (157 left heart defect, 49 right heart defect). Patients with sinus rhythm at baseline and a 5-year follow-up (median age 29, IQR 22-41 years) were included. Diagnosis of sustained SVT was determined from clinical reports during the follow-up period. New or recurrent sustained SVT occurred in 16 patients (7.8%, median follow-up of 6.2 years). Patients who developed SVT were older, more likely to have diastolic dysfunction, and had larger LA dimensions, left ventricular mass, and a lower peak LA longitudinal strain (PALS). Lower PALS was associated with higher risk of SVT in patients with left and right heart defects. Patients in the lowest quartile for PALS had a 15.9-fold higher hazard ratio of SVT (95% confidence interval, 4.5 to 56.0, p < 0.001) in comparison with the top three quartiles. PALS provides information about the occurrence of SVT in the ACHD population. Including measurement of LA strain in the follow-up of these patients may allow to better identify patients at risk of future atrial arrhythmias.

The value of ripple mapping in the age of coherent mapping in scar-related atrial tachycardia

BACKGROUND

An accurate display of scar-related atrial tachycardia (ATs) is a key determinant of ablation success. The efficacy of ripple mapping (RM) in identifying the mechanism and critical isthmus of scar-related ATs during coherent mapping is unknown.

METHODS

A total of 97 patients with complex ATs who underwent radiofrequency catheter ablation at our center between October 2018 and September 2022 were included. ATs was mapped using a multielectrode mapping catheter on the CARTO3v7 CONFIDENCE module. Coherent and RM were used to identify the reentrant circuit.

RESULTS

The mechanisms of 128 ATs were analyzed retrospectively (84 anatomic-reentrant ATs and 44 non-anatomic reentrant ATs). The median AT cycle length was 264 ± 25ms. The correct diagnosis was achieved in 83 ATs (68%) using only coherent mapping. Through coherent mapping plus RM, 114 ATs (84.2%) were correctly diagnosed (68% vs. 89%, p = .019). In non-anatomical reentrant ATs, 81% of the diagnostic rate was achieved by reviewing both coherent and ripple mapping compared to reviewing coherent mapping alone (81% vs. 52%, p = .03). Reviewing coherent mapping and ripple mapping showed a higher diagnostic rate in patients who underwent cardiac surgery than those with Coherent mapping alone (64% vs. 88%, p = .04).

CONCLUSION

Coherent mapping combined with RM was superior to coherent mapping alone in identifying the mechanism of scar-related ATs post-cardiac surgery and non-anatomic reentrant ATs.

Updates in Arrhythmia Management in Adult Congenital Heart Disease

Arrhythmias are highly prevalent in adults with congenital heart disease. For the clinician caring for this population, an understanding of pathophysiology, diagnosis, and management of arrhythmia is essential. Herein we review the latest updates in diagnostics and treatment of tachyarrhythmias and bradyarrhythmias, all in the context of congenital anatomy, hemodynamics, and standard invasive palliations for congenital heart disease.

Atrial flutter/fibrillation in adult congenital heart disease: Insights from a large Asian cohort

BACKGROUND

The incidence of atrial fibrillation/atrial flutter (AF/AFL) in general population is lower in Asia compared to Western countries. It is unclear whether a similar trend exists among adults with congenital heart disease (ACHD). We determine the profile, risk factors, and impact of AF/AFL in an Asian ACHD cohort.

METHODS

We included all ACHD patients diagnosed in an Asia tertiary care center between 2007 and 2018, analyzing AF (sustained and paroxysmal AF) and AFL, collectively./Purpose.

RESULTS

The study encompassed 4391 patients (55.9% women), with 81% having simple, 16.3% moderate and 2.8% severe CHD. AF/AFL was observed in 6.7% of the patients, with 54.6% having paroxysmal AF, 27.3% sustained AF, and 18.1% AFL. Incidence of AF/AFL increased with age and was higher in patients with pulmonary hypertension (PH), severe CHD, and metabolic syndrome. We found a progressive trend in the onset age of arrhythmia: AFL at a younger age, followed by paroxysmal and sustained AF. Risk factors for AF/AFL included severe and moderate CHD, PH, previous interventions, and male sex (odds ratio 11.2 and 3.15, 2.03, 1.75, and 1.71, respectively). When stratifying by CHD severity, PH and male sex were significant risk factors in simple CHD, while only PH in severe CHD. Patients with AF/AFL had a significantly lower major adverse cardiovascular events-free survival rate.

CONCLUSIONS

This large ACHD cohort from Asia exhibited a high incidence of AF/AFL, similar to Western reports. The risk of AF/AFL was primarily associated with hemodynamic factors such as PH and CHD severity.

Tachyarrhythmias in congenital heart disease

The prevalence of congenital heart disease (CHD) in adult patients has risen with advances in diagnostic and surgical techniques. Surgical modifications and hemodynamic changes increase the susceptibility to arrhythmias, impacting morbidity and mortality rates, with arrhythmias being the leading cause of hospitalizations and sudden deaths. Patients with CHD commonly experience both supraventricular and ventricular arrhythmias, with each CHD type associated with different arrhythmia patterns. Macroreentrant atrial tachycardias, particularly cavotricuspid isthmus-dependent flutter, are frequently reported. Ventricular arrhythmias, including monomorphic ventricular tachycardia, are prevalent, especially in patients with surgical scars. Pharmacological therapy involves antiarrhythmic and anticoagulant drugs, though data are limited with potential adverse effects. Catheter ablation is preferred, demanding meticulous procedural planning due to anatomical complexity and vascular access challenges. Combining imaging techniques with electroanatomic navigation enhances outcomes. However, risk stratification for sudden death remains challenging due to anatomical variability. This article practically reviews the most common tachyarrhythmias, treatment options, and clinical management strategies for these patients.

Arrhythmic Burden of Adult Survivors With Repaired Total Anomalous Pulmonary Venous Connection

Background

The long-term outcome of adults with repaired total anomalous pulmonary venous connection (TAPVC) is poorly documented. Therefore, the present study aims to provide current clinical data on adult survivors with repaired TAPVC focusing on arrhythmia.

Methods

Clinical and imaging data (prevalence and type of arrhythmias, symptoms, surgical and medical treatment, echocardiographic and cardiac magnetic resonance haemodynamic parameters) were retrospectively collected from 8 European centres and compared between patients with and without arrhythmias.

Results

Fifty-seven patients were included (age 20 [16-67] years [female 28, 49%]). At the last follow-up, that is, 21 (8-51) years after surgery, 79% and 93% of patients were free of symptoms and cardiac medication, respectively. The prevalence of late arrhythmias was 21%; 9 (16%) patients showed intra-atrial re-entrant tachycardia (IART) and 2 (4%) ventricular arrhythmias. Patients with IART were older (P = 0.018) and 4 (7%) required antiarrhythmic medication. Three patients (5%) underwent an electrophysiological study, and another 3 (5%) underwent pacemaker implantation within 36 months after surgical correction, which were removed in 2 patients after 7 years. Early postoperative arrhythmias (P = 0.005), right ventricular dilatation (P = 0.003), and valvulopathy (P = 0.009) were more often present in patients with late IART.

Conclusions

Adult survivors after isolated-TAPVC repair presented a high prevalence of arrhythmias. Age, right ventricular dilatation, early arrhythmias, and valvular lesions are risk factors for IART. Long-term follow-up is important as some of these currently asymptomatic patients will probably develop arrhythmias in the future.

Catheter Ablation for Atrial Fibrillation in Adult Congenital Heart Disease: An International Multicenter Registry Study

BACKGROUND

Data on atrial fibrillation (AF) ablation and outcomes are limited in patients with congenital heart disease (CHD). We aimed to investigate the characteristics of patients with CHD presenting for AF ablation and their outcomes.

METHODS

A multicenter, retrospective analysis was performed of patients with CHD undergoing AF ablation between 2004 and 2020 at 13 participating centers. The severity of CHD was classified using 2014 PACES/HRS guidelines. Clinical data were collected. One-year complete procedural success was defined as freedom from atrial tachycardia or AF in the absence of antiarrhythmic drugs or including previously failed antiarrhythmic drugs (partial success).

RESULTS

Of 240 patients, 127 (53.4%) had persistent AF, 62.5% were male, and mean age was 55.2±0.9 years. CHD complexity categories included 147 (61.3%) simple, 69 (28.8%) intermediate, and 25 (10.4%) severe. The most common CHD type was atrial septal defect (n=78). More complex CHD conditions included transposition of the great arteries (n=14), anomalous pulmonary veins (n=13), tetralogy of Fallot (n=8), cor triatriatum (n=7), single ventricle physiology (n=2), among others. The majority (71.3%) of patients had trialed at least one antiarrhythmic drug. Forty-six patients (22.1%) had reduced systemic ventricular ejection fraction <50%, and mean left atrial diameter was 44.1±0.7 mm. Pulmonary vein isolation was performed in 227 patients (94.6%); additional ablation included left atrial linear ablations (25.4%), complex fractionated atrial electrogram (19.2%), and cavotricuspid isthmus ablation (40.8%). One-year complete and partial success rates were 45.0% and 20.5%, respectively, with no significant difference in the rate of complete success between complexity groups. Overall, 38 patients (15.8%) required more than one ablation procedure. There were 3 (1.3%) major and 13 (5.4%) minor procedural complications.

CONCLUSIONS

AF ablation in CHD was safe and resulted in AF control in a majority of patients, regardless of complexity. Future work should address the most appropriate ablation targets in this challenging population.

Interpretation of Typical and Atypical Atrial Flutters by Precision Electrocardiology Based on Intracardiac Recording

Atrial flutter is a term encompassing multiple clinical entities. Clinical manifestations of these arrhythmias range from typical isthmus-dependent flutter to post-ablation microreentries. Twelve-lead electrocardiogram (ECG) is a diagnostic tool in typical flutter, but it is often unable to clearly localize atrial flutters maintained by more complex reentrant circuits. Electrophysiology study and mapping are able to characterize in fine details all the components of the circuit and determine their electrophysiological properties. Combining these 2 techniques can greatly help in understanding the vectors determining the ECG morphology of the flutter waveforms, increasing the diagnostic usefulness of this tool.

Atrial Flutters in Adults with Congenital Heart Disease

The macroreentrant atrial tachycardia is very frequent in the adults with congenital heart disease. The impact of the arrhythmias on this type of patients is related to several factors: the anatomy and physiopathology of the specific congenital heart disease (CHD), the sequelae of the corrective surgery or surgical palliation, the presence of residual lesions (shunt, regurgitation), and the age and the clinical status of the patient and the comorbidities. In turn, the mechanism of the MAT depends on the peculiar features of the conduction's system in the CHD and native and acquired (post-surgery) substrates.

The impact of alternative energy technology investment on environment and food security in northern Ethiopia

Energy is a key factor in the economic development. Currently, however, millions of people across the world suffer from energy poverty, having little or no access to energy for cooking, lighting, heating, cooling, or using information and communication technologies. Objective of this study was to investigate the domestic energy sources for households and the impact of biomass use as a source of energy on the environment and food insecurity in the drought-affected northern highlands of Ethiopia. A total of 398 household heads were interviewed using a structured questionnaire, whereas 16 focus group discussions and 12 key informant interviews were conducted. Descriptive data analysis techniques were used to analyze quantitative data while content analysis methods were used to analyze qualitative data. The use of traditional biomass fuels such as firewood, charcoal, crop residue, animal dung, and biomass residue that can be combusted were prevalent in the area, which aggravated the degradation of agricultural lands. As commented by the majority of respondents, the move towards the adoption of modern energy sources was not common due to finance (98%), access (97%), durability (97%) and lack of awareness (93%). The findings showed that land degradation has been severe to the extent that no grain yield can be collected from crop production. As a result, people were exposed to both chronic and transitory food insecurity, and hence the majority of people make their living on food aid. In food-insecure areas, relying on biomass energy could increase land degradation or retard the speed of land restoration, which adversely affects agricultural production and food security. Investing in alternative energy technologies can improve the environment, food security, and people's health.

Adults with tetralogy of Fallot show specific features of cerebral small vessel disease: the BACH San Donato study

Life expectancy in adults with congenital heart disease (ACHD) has increased. As these patients grow older, they experience aging-related diseases more than their healthy peers. To better characterize this field, we launched the multi-disciplinary BACH (Brain Aging in Congenital Heart disease) San Donato study, that aimed at investigating signs of brain injury in ACHD. Twenty-three adults with repaired tetralogy of Fallot and 23 age- and sex-matched healthy controls were prospectively recruited and underwent brain magnetic resonance imaging. White matter hyperintensities (WMHs) were segmented using a machine-learning approach and automatically split into periventricular and deep. Cerebral microbleeds were manually counted. A subset of 14 patients were also assessed with an extensive neuropsychological battery. Age was 41.78 ± 10.33 years (mean ± standard deviation) for patients and 41.48 ± 10.28 years for controls (p = 0.921). Albeit not significantly, total brain (p = 0.282) and brain tissue volumes (p = 0.539 for cerebrospinal fluid, p = 0.661 for grey matter, p = 0.793 for white matter) were lower in ACHD, while total volume (p = 0.283) and sub-classes of WMHs (p = 0.386 for periventricular WMHs and p = 0.138 for deep WMHs) were higher in ACHD than in controls. Deep WMHs were associated with poorer performance at the frontal assessment battery (r = -0.650, p = 0.012). Also, patients had a much larger number of microbleeds than controls (median and interquartile range 5 [3–11] and 0 [0–0] respectively; p < 0.001). In this study, adults with tetralogy of Fallot showed specific signs of brain injury, with some clinical implications. Eventually, accurate characterization of brain health using neuroimaging and neuropsychological data would aid in the identification of ACHD patients at risk of cognitive deterioration.

Tachykarde Rhythmusstörungen bei EMAH – Aspekte der katheterinterventionellen Therapie

Tachykarde Rhythmusstörungen bei Erwachsenen mit angeborenem Herzfehler (EMAH) haben großen Einfluss auf Morbidität und Letalität dieser Patientengruppe. Sie basieren in der Mehrzahl auf erworbenen Substraten, die eine typische Langzeitfolge des angeborenen Herzfehlers (AHF) insbesondere nach herzchirurgischen Eingriffen darstellen. Antiarrhythmika können akut effektiv eingesetzt werden, sind aber als langfristige Behandlungsstrategie meist wenig verlässlich zur Unterdrückung von Tachykardierezidiven. Zusätzlich können Kontraindikationen bestehen bei eingeschränkter Ventrikelfunktion, hämodynamischen Rest-Fehlbelastungen, bradykardem Grundrhythmus sowie Arzneimittelnebenwirkungen. Vor diesem Hintergrund hat sich die katheterinterventionelle Ablationsbehandlung in den beiden letzten Jahrzehnten als Therapie der Wahl für die Mehrheit der Tachykardieformen bei EMAH mit zunehmend hohen Erfolgs- und niedrigen Komplikationsquoten etabliert.

Contemporary Patients With Congenital Heart Disease: Uniform Atrial Tachycardia Substrates Allow for Clear Ablation Endpoints With Improved Long-Term Outcome

[Figure: see text].

Ripple mapping-guided atrial tachycardia ablation following open-heart surgery

Ripple mapping can make the visualization of activation conduction on a 3-dimensional voltage map and is useful tool for scar-related organized atrial tachycardia (AT). This study sought to assess the efficacy of ripple mapping for interpreting reentrant circuits and critical isthmus in postoperative ATs. 34 consecutive patients with a history of mitral valve surgery (mean age, 54.5 ± 12.4 years) underwent high density (HD) RM during ATs with CARTO3v4 CONFIDENSE system. The voltage activation threshold was determined by RM over a bipolar voltage map. The identification of underlying mechanisms and ablation setting was based on RM without reviewing activation mapping. A total of 41 ATs (35 spontaneous, 6 induced) were characterized. 39 reentry circuits were successfully mapped (cycle length, 256 ± 43 ms). Of the 41 ATs, 28 were confirmed by ripple mapping alone (68%), and 12 (29%) by ripple mapping and entrainment mapping. Of 12 ATs in the left atrium, 9 (75%) needed entrainment to confirm, compared with 5 (17.8%) in the right atrium. Primary endpoint after initial ablation set was achieved in 32 of the 34 patients (94.1%). Freedom from atrial arrhythmias was 79.4% after the follow-up of 12 ± 5 months. Of the seven patients with recurrence, three underwent the repeated catheter ablation. Ripple mapping precisely delineated reentrant circuits in post-cardiac surgery AT resulting in a high success rate of ablation. Entrainment maneuvers remain useful for elucidation of complex AT circuits.

Difference in the prevalence of intracardiac thrombus on the first presentation of atrial fibrillation versus flutter in the pediatric and congenital heart disease population

INTRODUCTION

Guidelines recommend trans-esophageal echocardiography (TEE) for patients with atrial fibrillation (AF) or atrial flutter (AFL) for >48 h, due to risk of intracardiac thrombus formation. With growing evidence that AFL in adults with structurally normal hearts has less thrombogenic potential compared to AF, and the need for TEE questioned, we compared prevalence of intracardiac thrombus detected by TEE in pediatric and congenital heart disease (CHD) patients presenting in AF and AFL.

METHODS/RESULTS

Single-center, cross-sectional analysis for unique first-time presentations of patients for either AF, AFL, or intra-atrial reentrant tachycardia (IART) between 2000 and 2019. Patients were categorized by presenting arrhythmia (AF vs. AFL/IART), with the exclusion of other forms of atrial tachycardia, hemodynamic instability, chronic anti-coagulation before TEE, and presentation for a reason other than TEE examination for thrombus. A total of 201 patients had TEE with co-diagnosis of AF or AFL. Of these, 105 patients (29 AF, 76 AFL) met inclusion criteria, with no difference in age between AF (median 24.9 years; IQR 18.6-38.3 years) and AFL/IART (23.3 years; 15.4-38.4 years). The prevalence of thrombus in the entire cohort was 9.5%, with no difference between AF (13.8%) and AFL groups (7.9%), p = .46. Patients with thrombus demonstrated no difference in age, systemic ventricular function, cardiac complexity, or CHADS2/CHA2DS2VASc score at presentation.

CONCLUSIONS

The risk for intracardiac thrombus is high in the pediatric and CHD population, with no apparent distinguishing factors to warrant a change in the recommendations for TEE, with all levels of cardiac complexity being at risk for clot.

Outcomes of Atrial Arrhythmia Surgery in Patients With Congenital Heart Disease: A Systematic Review

Background The improved life expectancy of patients with congenital heart disease is often accompanied by the development of atrial tachyarrhythmias. Similarly, the number of patients requiring redo operations is expected to continue to rise as these patients are aging. Consequently, the role of arrhythmia surgery in the treatment of atrial arrhythmias is likely to become more important in this population. Although atrial arrhythmia surgery is a well-established part of Fontan conversion procedures, evidence-based recommendations for arrhythmia surgery for macroreentrant atrial tachycardia and atrial fibrillation in other patients with congenital heart disease are still lacking. Methods and Results Twenty-eight studies were included in this systematic review. The median reported arrhythmia recurrence was 13% (interquartile range, 4%-26%) during follow-up ranging from 3 months to 15.2 years. A large variation in surgical techniques was observed. Based on the acquired data, biatrial lesions are more effective in the treatment of atrial fibrillation than exclusive right-sided lesions. Right-sided lesions may be more appropriate in the treatment of macroreentrant atrial tachycardia; evidence for the superiority of additional left-sided lesions is lacking. There are not enough data to support the use of exclusive left-sided lesions. Theoretically, prophylactic atrial arrhythmia surgery may be beneficial in this population, but evidence is currently limited. Conclusions To be able to provide recommendations for arrhythmia surgery in patients with congenital heart disease, future studies should report outcomes according to the type of preoperative arrhythmia, underlying congenital heart disease, lesion set, and energy source. This is essential for determining which surgical techniques should ideally be applied under which circumstances.

Impact of Transcatheter Device Closure of Atrial Septal Defect on Atrial Arrhythmias Propensity in Young Adults

Atrial septal defect (ASD) is a condition that requires early intervention because of the consequences over the right-side heart. Chronic atrial stretching promotes atrial conduction delay and the imbalance of the conduction homogeneity, which lead to the propensity to atrial arrhythmias (AA). We aim to evaluate the impact of transcatheter closure of ASD on atrial vulnerability markers leading to late AA in young adults. We conducted a prospective, longitudinal study in one hundred patients (mean age 25.2 ± 5.4 years) who underwent transcatheter closure of ASD at Cardiocentro Pediátrico William Soler. P-wave maximum (P_max) and P-wave dispersion (P_d) were analyzed from 12-lead electrocardiogram. Left-side and right-side intraatrial and interatrial electromechanical delay (EMD) were measured with tissue Doppler imaging. Both electrocardiographic and echocardiographic analyses were performed during the study period. Compared to baseline, there was a significant reduction in P max (p ≤ 0.001) and P_d (p ≤ 0.001) after 3 months of procedure. All atrial electromechanical coupling parameters significantly reduced at 6 months of ASD closure and tend to remain at lower values till the last evaluation. Over 9.2 ± 1.6 years of follow-up, 15 subjects (15%) developed AA, of which intraatrial reentrant tachycardia (66.6%) became the main rhythm disturbance. Intra-right atrial EMD ≥ 16 ms (HR 4.08, 95% CI 1.15-14.56; p = 0.03) and P_d 45 ms (HR 1.66, 95% CI 1.06-2.59; p = 0.02) were identified as predictors of late AA. Transcatheter device closure of ASD in young adults promotes a significant reduction of electrocardiographic and echocardiographic markers of AA vulnerability, which persist during the long-term follow-up. Nevertheless, P_d and interatrial EMD were identified as independent risk factors of AA.

Efficacy and safety of catheter ablation for atrial fibrillation in congenital heart disease - A systematic review and meta-analysis

BACKGROUND

Prevalence of atrial fibrillation (AF) in patients with congenital heart disease (CHD) is on the rise. Anti-arrhythmic drugs are usually the first line of treatment in CHD, however, it is often ineffective and poorly tolerated. We aimed to perform a systematic review to assess the efficacy and safety of catheter ablation for AF in CHD.

METHODS

We performed a comprehensive search on catheter ablation for atrial fibrillation in congenital heart disease up until July 2019 through several electronic databases.

RESULTS

Ablation of AF in patients with CHD had a modest 12 months AF freedom ranging from 32.8% to 63%, which can be increased by subsequent/repeat ablation. The complexity of CHD appears to have a significant effect on a study but not in others. Catheter ablation in ASD and persistent left superior vena cava had a high success rate. Overall, catheter ablation is safe whichever the type of CHD is.

CONCLUSION

Catheter ablation for AF in CHD had modest efficacy that can be increased by subsequent/repeat ablation and it also has an excellent safety profile. Ablation in complex CHD could also have similar efficacy, however, it is preferably done by experts in a high volume tertiary center.

Catheter Ablation for Atrial Tachycardia in Adults With Congenital Heart Disease: Electrophysiological Predictors of Acute Procedural Success and Post-Procedure Atrial Tachycardia Recurrence

OBJECTIVES

This study sought to determine the electrophysiological predictors of acute procedural success and of post-ablation recurrence of atrial tachyarrhythmias (ATs) in our adult congenital heart disease (ACHD) population undergoing catheter ablation for treatment of AT.

BACKGROUND

Catheter ablation is frequently performed to treat persistent AT in ACHD. The predictors of post-ablation AT recurrence have not been well studied in the ACHD population.

METHODS

The authors performed a retrospective study of all catheter ablations for treatment of AT performed in ACHD patients between December 1, 2005, and July 20, 2017, at Columbia University Medical Center. Pre-specified clinical and procedural data of interest and the time from ablation to recurrence were determined by chart and procedure report review.

RESULTS

A total of 140 patients (mean age: 45 years) underwent catheter ablation for 182 AT. Of the AT, 179 (93%) were intra-atrial macro-re-entrant tachycardia, and 12 (7%) had a focal origin. The presence of a single mechanism was a predictor of acute procedural success that could be achieved in 89% of the patients. At a median of 49.9 months, 62 patients (44%) had recurrent AT. Time to recurrence was significantly shorter (12.5 months) for recurrent AT in 13 of the 20 patients with previous Fontan procedure. By multivariable analysis, acute procedural success was a positive predictor and prior surgical maze procedure was a negative predictor of AT-free survival. Of the 62 patients with recurrent AT, 42 (68%) had a second catheter ablation procedure, and in 22 of these, the AT mechanism was different than previously observed.

CONCLUSIONS

Catheter ablation for AT in ACHD patients is an effective method of arrhythmia control. More than 1 AT mechanism per patient is common. Acute procedural success is a predictor of freedom from AT recurrence. The majority of patients achieve multiple arrhythmia-free years.

Long-term outcome of catheter ablation for atrial tachyarrhythmias in patients with atrial septal defect

PURPOSE

This study aimed to evaluate efficacy, safety, and long-term outcome of radiofrequency catheter ablation (RFCA) for atrial tachyarrhythmia (ATa) in patients with atrial septal defect (ASD).

METHODS

Seventy-five ASD patients with ATa (52% atrial fibrillation, AF) were enrolled. Electrophysiological study and RFCA were performed, with endpoints of index and multiple procedures as follows: (a) atrial tachycardia/atrial flutter (AT/AFL), absence of inducibility of any atrial arrhythmia and (b) AF, circumferential pulmonary vein ablation (CPVA, paroxysmal AF), bidirectional block of lines, and disappearance of complex fractionated atrial electrograms (persistent and long-standing persistent (LSP)-AF).

RESULTS

Cumulative success rate at 1-year follow-up was 79.9% and dropped to 59.0% at a median follow-up of 63 months (range, 14-114 months) for multiple procedures (mean 1.6 ± 0.7 [1-3]). Freedom from ATa after multiple procedures was achieved in 75% patients with AT/AFL and 43.6% patients with AF (P = 0.006 for comparison). In multivariate analysis, older age at ASD correction (HR, 1.033 [95% CI, 1.008-1.059]; P = 0.01), ASD diameter before correction (HR, 1.054 [95% CI, 1.006-1.105]; P = 0.027), and first-diagnosed ATa type (AF; HR, 2.25 [95% CI, 1.03-4.92]; P = 0.042) were significant independent predictors of ATa recurrence. Patients with more risk factors had higher risk of ATa recurrence.

CONCLUSIONS

The long-term outcome of RFCA for ATa outcome was favorable for AT/AFL while mediocre for AF. ATa recurrence was more common in patients with older age at ASD correction, larger ASD diameter before correction, and first-diagnosed AF. Patients with more risk factors had higher ATa recurrence risk.

Dysrhythmias in patients with a complete atrioventricular septal defect: From surgery to early adulthood

Objective

Outcomes after surgical repair of complete atrioventricular septal defect (cAVSD) have improved. With advancing age, the risk of development of dysrhythmias may increase. The aims of this study were to (1) examine development of sinus node dysfunction (SND), atrial and ventricular tachyarrhythmias, and (2) study progression of atrioventricular conduction abnormalities in young adult patients with repaired cAVSD.

Study design

In this retrospective multicenter study, 74 patients (68% female) with a cAVSD repaired in childhood were included. Patients’ medical files were evaluated for occurrence of SND, atrioventricular conduction block (AVB), atrial and ventricular tachyarrhythmias.

Results

Median age at repair was 6 months (interquartile range 3‐10) and median age at last follow‐up was 24 years (interquartile range 21‐28). SND occurred after a median of 17 years (interquartile range 11‐19) after repair in 23% of patients, requiring pacemaker implantation in two patients (12%). Regular supraventricular tachycardia was observed in three patients (4%). Atrial fibrillation and ventricular tachyarrhythmias were not observed. Twenty‐seven patients (36%) had first‐degree AVB, which was self‐limiting in 16 (59%) and persistent in 10 (37%) patients. One patient developed third‐degree AVB 7 days after left atrioventricular valve replacement. Spontaneous type II second‐degree AVB occurred in a 28‐year‐old patient. Both patients underwent pacemaker implantation.

Conclusions

Clinically significant dysrhythmias were uncommon in young adult patients after cAVSD repair. However, three patients required pacemaker implantation for either progression of SND or spontaneous type II second‐degree AVB. Longer follow‐up should point out whether dysrhythmias will progress or become more prevalent with increasing age.

Catheter Ablation for Atrial Fibrillation in Adults With Congenital Heart Disease: Lessons Learned From More Than 10 Years Following a Sequential Ablation Approach

OBJECTIVES

This study aimed to evaluate the impact, safety, and success of atrial fibrillation (AF) ablation in adults with congenital heart disease (ACHD) transferring ablation strategies established in normal hearts.

BACKGROUND

AF is an emerging arrhythmia in ACHD.

METHODS

Fifty-seven consecutive ACHD (median age 51.1 ± 14.8 years) with drug-refractory AF were analyzed who underwent catheter ablation between 2004 and 2017. CHD was classified according to its complexity into mild (61.4%), moderate (17.5%), and severe (21.1%) lesions. AF ablation was performed in 104 procedures following a sequential ablation approach.

RESULTS

Of the 57 patients, 30 underwent corrective surgery, 6 underwent palliative surgery, 5 had catheter interventions, and 16 were natural survivors. Follow-up was available for all patients (median 41 ± 36 months). The median duration of cyanosis was 9.2 ± 19.7 years, and the time of volume or pressure overload prior to corrective surgery or intervention was 26.1 ± 21.2 years and 18.1 ± 15.8 years, respectively. The Kaplan-Meier estimate for arrhythmia-free survival following the index ablation procedure was 63% for 1 year and 22% for 5 years. Performing subsequent ablation procedures (2.0 ± 0.5), the Kaplan-Meier estimate significantly improved, with 99% for 1 year and 83% for 5 years (p < 0.01). Five patients died during follow-up due to their underlying CHD condition or underwent transplantation.

CONCLUSIONS

AF ablation strategies established in normal hearts can be transferred to ACHD. The treatment is safe and effective with acceptable long-term results. Varying anatomical pre-conditions and the heterogeneous population itself are challenging and contribute toward a higher reablation rate. Therefore, AF ablation in ACHD should be reserved for dedicated and highly specialized teams.

Noteworthy Literature published in 2017 for Congenital Cardiac Anesthesiologists

This review focuses on the literature published during the 13 months from December 2016 to December 2017 that is of interest to anesthesiologists taking care of children and adults with congenital heart disease. Five themes are addressed during this time period and 100 peer-reviewed articles are discussed.