Identifying arrhythmias in adults with congenital heart disease by 24-h ambulatory electrocardiography

A comparison of ECG-based home monitoring devices in adults with CHD

BACKGROUND

Various electrocardiogram (ECG)-based devices are available for home monitoring, but the reliability in adults with CHD is unknown. Therefore, we determined the accuracy of different ECG-based devices compared to the standard 12-lead ECG in adult CHD.

METHODS AND RESULTS

This is a single-centre, prospective, cross-sectional study in 176 consecutive adults with CHD (54% male, age 40 ± 16.6 years, 24% severe CHD, 84% previous surgery, 3% atrial fibrillation (AF), 24% right bundle branch block). Diagnostic accuracy of the Withings Scanwatch (lead I), Eko DUO (precordial lead), and Kardia 6L (six leads) was determined in comparison to the standard 12-lead ECG on several tasks: 1) AF classification (percentage correct), 2) QRS-morphology classification (percentage correct), and 3) ECG intervals calculation (QTc time ≤ 40 ms difference). Both tested AF algorithms had high accuracy (Withings: 100%, Kardia 6L: 97%) in ECGs that were classified. However, the Withings algorithm classified fewer ECGs as inconclusive (5%) compared to 31% of Kardia (p < 0.001). Physician evaluation of Kardia correctly classified QRS morphology more frequently (90% accuracy) compared to Eko DUO (84% accuracy) (p = 0.03). QTc was underestimated on all ECG-based devices (p < 0.01). QTc duration accuracy was acceptable in only 51% of Withings versus 70% Eko and 74% Kardia (p < 0.001 for both comparisons).

CONCLUSIONS

Although all devices demonstrated high accuracy in AF detection, the Withings automatic algorithm had fewest uninterpretable results. Kardia 6L was most accurate in overall evaluation such as QRS morphology and QTc duration. These findings can inform both patients and caregivers for optimal choice of home monitoring.

Recent Developments in Cardiology Procedures for Adult Congenital Heart Disease: The Anesthesiologist's Perspective

Many children born today with congenital heart disease can expect to live long into adulthood. Improvements in surgical technique and anesthetic and perioperative care have significantly increased the number of survivors. Unfortunately, as these patients progress through life they frequently require further interventions. Although surgical intervention may be required frequently, these patients can be managed in the cardiac catheterization or electrophysiology laboratory. Surgical correction of tetralogy of Fallot can leave patients with pulmonary valve dysfunction later in life. A percutaneous approach is now available for these patients, which can obviate the need for resternotomy. During deployment of the valve, anesthesiologists should be aware that compression of coronary arteries can occur. Adult congenital heart disease (ACHD) patients often require pacemaker/implantable cardioverter- defibrillator (ICD) insertion or ablation therapy. These patients may have altered cardiac anatomy, which can make endovascular procedures extremely challenging. Recent developments have made these procedures safer and more efficient. A number of congenital cardiac conditions can also be associated with orofacial abnormalities. ACHD patients, as a result, can present with challenging airways. The catheterization laboratory may not be the optimum environment for the anesthesiologist to manage a difficult airway. The requirement of transesophageal echocardiography for some cath eterization procedures needs to be considered when deciding on an airway management plan. Knowledge of the underlying cardiac anatomy and the planned procedure is advised when providing anesthesia for this complex patient group outside the theater setting.

Living with Tricuspid Atresia: Case Report with Review of Literature

Tricuspid atresia (TA) is a rare congenital heart defect in which the right atrioventricular connection, the tricuspid valve, is absent. As a result, there is no direct communication between the right atrium and right ventricle. Surgical treatment, including the Fontan procedure, is indicated yet palliative, leaving patients with various lifelong complications. A comprehensive literature review revealed a paucity of evidence-based education on the identification, evaluation, management, treatment, and life span implications of TA. We present a case of TA from birth through adulthood, while simultaneously assessing the literature, to report the most current evidence relative to living with TA after surgical palliation. In addition, the embryology, methods of prenatal and postnatal diagnosis, potential complications, management, anticipatory guidance, and educational needs of both parents and patient are discussed.

Electrocardiographic patch devices and contemporary wireless cardiac monitoring

Cardiac electrophysiologic derangements often coexist with disorders of the circulatory system. Capturing and diagnosing arrhythmias and conduction system disease may lead to a change in diagnosis, clinical management and patient outcomes. Standard 12-lead electrocardiogram (ECG), Holter monitors and event recorders have served as useful diagnostic tools over the last few decades. However, their shortcomings are only recently being addressed by emerging technologies. With advances in device miniaturization and wireless technologies, and changing consumer expectations, wearable “on-body” ECG patch devices have evolved to meet contemporary needs. These devices are unobtrusive and easy to use, leading to increased device wear time and diagnostic yield. While becoming the standard for detecting arrhythmias and conduction system disorders in the outpatient setting where continuous ECG monitoring in the short to medium term (days to weeks) is indicated, these cardiac devices and related digital mobile health technologies are reshaping the clinician-patient interface with important implications for future healthcare delivery.

Tachyarrhythmias and catheter ablation in adult congenital heart disease

Advances in surgical technique have had an immense impact on longevity and quality of life in patients with congenital heart disease. However, an inevitable consequence of these surgical successes is the creation of a unique patient population whose anatomy, surgical history and haemodynamics result in the development of a challenging and complex arrhythmia substrate. Furthermore, this patient group remains susceptible to the arrhythmias seen in the general adult population. It is through a thorough appreciation of the cardiac structural defect, the surgical corrective approach, and haemodynamic impact that the most effective arrhythmia care can be delivered. Catheter ablation techniques offer a highly effective management option but require a meticulous attention to the real-time integration of anatomical and electrophysiological information to identify and eliminate the culprit arrhythmia substrate. This review describes the current approach to the interventional management of patients with tachyarrhythmias in the context of congenital heart disease.

Management of arrhythmias in patients with a tetralogy of Fallot

Although arrhythmias are commonly found in patients with all different types of congenital heart disease, perhaps no patient is at higher risk of late development of arrhythmias that may result in sudden death than in the patient following tetralogy of Fallot repair. Despite major improvement in the surgical repair of this disease, a significant percentage of these patients continue to remain at risk for the late development of arrhythmias, and a small percentage will develop life-threatening arrhythmias and sudden death. Which patients remain at highest risk is still not clearly delineated. Diligent arrhythmia surveillance and aggressive treatment strategies are necessary to minimise this risk. This article highlights important strategies to manage arrhythmia development and prevention in this patient population.

Arrhythmias in adult congenital heart disease: the year in review

PURPOSE OF REVIEW

Management of arrhythmias is an integral component of care for adults with congenital heart disease (CHD). Our objective was to highlight the important advances from the year 2012 regarding arrhythmias in adult CHD, with a focus on diagnostic considerations, acute management, catheter ablation, and device therapy.

RECENT FINDINGS

During the course of 2012, Holter studies suggested that routine screening was helpful in guiding the clinical decisions for certain patient subgroups, such as adults with tetralogy of Fallot. Supportive evidence was provided for the common practice of anticoagulation and/or screening for intracardiac thrombosis by transesophageal echocardiography prior to electrically cardioverting atrial tachyarrhythmias. Advances in catheter ablation, particularly robotic magnetic navigation, offer new hope for patients in whom access to arrhythmia substrates is not feasible by standard means. The subcutaneous defibrillator emerged as an innovative solution of great interest to the patients at risk of sudden death in whom transvenous lead implantation is unachievable or contraindicated. Finally, 2012 ended with a major milestone: the establishment of physician certification in adult CHD by the American Board of Medical Specialties.

SUMMARY

The year 2012 witnessed important advances in the diagnosis and management of arrhythmias in adults with CHD.

Management of late arrhythmias in adults with repaired congenital heart disease

OPINION STATEMENT

As survival of patients with congenital heart disease improves with surgery and the population of patients with repaired adult congenital heart disease (ACHD) age, understanding complications such as arrhythmias has become more important. Arrhythmias account for significant morbidity and mortality in the ACHD population. Atrial arrhythmias occur in 15 % of patients with ACHD and, in patients with severe congenital heart disease (CHD), more than 50 % develop atrial arrhythmias by the age of 65 years [1]. This article aims to give an overview of arrhythmias seen in the ACHD population and the treatment modalities available now.