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Canadian Journal of Cardiology

Technological Advances in Arrhythmia Management Applied to Adults With Congenital Heart Disease

Published:October 04, 2019DOI:https://doi.org/10.1016/j.cjca.2019.06.034

      Abstract

      Arrhythmias are a leading cause of morbidity in adults with congenital heart disease. Numerous challenges to managing arrhythmias include vascular access issues, intracardiac shunts, unconventional locations of the conduction system, and anatomical complexities. Technological advances are improving our ability to diagnose and treat arrhythmias. Implantable loop recorders and various technologies developed for consumers to record electrocardiographic tracings using smartphone applications, watches, and dedicated portable devices are expanding our armamentarium of diagnostic tools. Remote magnetic-guided catheter ablation is enhancing access to otherwise difficult to reach arrhythmia substrates. Cryoablation allows perinodal arrhythmias to be safely treated in patients with displaced or difficult to predict locations of the atrioventricular conduction system. Interventions that minimize radiation exposure to near 0 levels are gaining interest and pulmonary vein isolation procedures to treat atrial fibrillation are increasingly performed. Cardiac implantable electronic devices compatible with magnetic resonance imaging have become the norm. Subcutaneous defibrillators and leadless pacemakers are providing effective solutions to patients in whom transvenous leads are contraindicated or not desired. His-bundle pacing is emerging as a viable option to provide more physiological pacing. Progressive advances in multicomponent communicating leadless devices carry the promise of providing leadless dual chamber pacing and cardiac resynchronization therapy in the near future. The safety of transvenous lead extraction procedures is likely to improve with advances such as the low-pressure balloon to manage superior vena cava lacerations. Awareness of these developments and referral to sites with dedicated expertise could contribute to further improving outcomes in adults with congenital heart disease.

      Résumé

      Les arythmies sont une des principales causes de morbidité chez les adultes atteints d’une cardiopathie congénitale. Les nombreux défis dans la prise en charge des arythmies comprennent les problèmes liés à l’accès vasculaire, les shunts intracardiaques, la configuration inhabituelle du système de conduction et les complexités anatomiques. Les avancées technologiques améliorent notre capacité à diagnostiquer et à traiter les arythmies. Les enregistreurs en boucle implantables et diverses technologies mises au point pour permettre aux consommateurs d’enregistrer des tracés électrocardiographiques au moyen d’applications pour téléphones intelligents, de montres ou d’appareils portables dédiés élargissent notre arsenal d’outils diagnostiques. L’ablation à distance par cathéter guidé magnétiquement améliore l’accès à des substrats anatomiques de l’arythmie qui seraient autrement difficiles à atteindre. La cryoablation permet de traiter sans danger les arythmies périnodales chez les patients dont le système de conduction auriculoventriculaire est déplacé ou localisé de façon difficilement prévisible. Les interventions permettant de réduire au minimum l’exposition au rayonnement, à des niveaux presque nuls, suscitent de plus en plus d’intérêt, et les interventions d’isolement des veines pulmonaires pour le traitement de la fibrillation auriculaire sont de plus en plus pratiquées. Les dispositifs cardiaques électroniques implantables compatibles avec l’imagerie par résonance magnétique sont devenus la norme. Les défibrillateurs sous-cutanés et les stimulateurs cardiaques sans électrodes offrent des solutions efficaces aux patients chez qui les électrodes transveineuses sont contre-indiquées ou non souhaitées. La stimulation du faisceau de His s’affirme peu à peu comme une option viable de stimulation plus physiologique. Les avancées progressives dans la conception de dispositifs multicomposants de communication sans électrodes permettent d’espérer l’avènement prochain de traitements comme la stimulation double chambre et la resynchronisation cardiaque sans électrodes. L’innocuité des interventions d’extraction des électrodes par voie intraveineuse sera probablement améliorée grâce aux avancées comme l’utilisation du ballon à faible pression dans la prise en charge des lacérations de la veine cave supérieure. La connaissance de ces progrès et l’orientation vers des sites fondés sur une expertise spécialisée pourraient contribuer à la poursuite de l’amélioration des résultats thérapeutiques pour les adultes atteints de cardiopathie congénitale.
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