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Canadian Journal of Cardiology

Catheter Ablation of Atrial Arrhythmias in Patients Post-Fontan

Published:February 28, 2022DOI:https://doi.org/10.1016/j.cjca.2022.02.023

      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. Although 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 multifaceted and can include anticoagulation, anti-arrhythmic drug therapy, pacing, and cardioversion. Catheter ablation plays a key role in control of arrhythmia. 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 comorbidities. 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 centres with dedicated expertise in congenital heart disease including catheter ablation, anaesthesia support, and advanced imaging.

      Résumé

      Les arythmies auriculaires sont très fréquentes chez les patients vieillissants ayant subi l’intervention de Fontan et contribuent de façon importante à la morbidité et à la mortalité. Bien que l’arythmie la plus fréquente soit la tachycardie par réentrée intra-auriculaire sur cicatrice chirurgicale, diverses autres arythmies peuvent survenir, notamment la tachycardie auriculaire focale, les tachycardies atrioventriculaires nodales et la fibrillation auriculaire. Le type et la prévalence de l’arythmie auriculaire sont déterminés, en partie, par l’anomalie congénitale sous-jacente et le type d’intervention de Fontan. Bien que l’incidence cumulative des tachyarythmies auriculaires ait diminué considérablement par suite du passage de l’anastomose atriopulmonaire à l’anastomose cavopulmonaire totale de Fontan, plus récente, le fardeau des arythmies auriculaires demeure considérable. La prise en charge est souvent multiforme et peut inclure l’anticoagulation, la pharmacothérapie antiarythmique, la stimulation et la cardioversion. L’ablation par cathéter joue un rôle clé dans la maîtrise de l’arythmie. Les risques et les avantages doivent être soigneusement soupesés. Parmi les facteurs importants à prendre en compte figurent le fardeau clinique de l’arythmie, la fonction ventriculaire, la stabilité hémodynamique en cas de tachycardie, les mécanismes d’arythmie soupçonnés, les risques associés à l’anesthésie, l’accès veineux, les techniques utilisées pour atteindre l’atrium gauche et les maladies concomitantes. Il est primordial de revoir soigneusement les notes chirurgicales, les tracés électrocardiographiques et les clichés d’imagerie avancée, en portant une attention particulière aux anomalies anatomiques, telles que les obstructions veineuses et le déplacement des voies de conduction. En dépit des nombreuses difficultés qui s’y rattachent, l’ablation des arythmies auriculaires est efficace pour améliorer l’état clinique des patients. Néanmoins, l’apparition de nouvelles arythmies est fréquente pendant la période de suivi à long terme. Les technologies de pointe, telles que la cartographie à haute densité par cathéter et l’ablation sous téléguidage magnétique, offrent le potentiel d’améliorer encore plus les résultats. Les patients qui ont subi l’intervention de Fontan et qui présentent des arythmies auriculaires doivent être dirigés vers des établissements spécialisés en cardiopathie congénitale, notamment dans les domaines de l’ablation par cathéter, du soutien anesthésique et de l’imagerie avancée.
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