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

Catheter ablation in congenital heart diseases: a French nationwide study

BACKGROUND AND AIMS

Current evidence on catheter ablation for patients with congenital heart disease (CHD) is derived from small, retrospective studies. This study aims to provide insights from a nationwide contemporary registry.

METHODS

This prospective study included all CHD patients referred for catheter ablation from 2020 to July 2024 across 28 French centres. The primary outcome was the rate of per-procedural acute success. Secondary outcomes included complications as well as freedom from arrhythmia recurrence.

RESULTS

A total of 1135 consecutive catheter ablation procedures were performed in 998 patients (mean age 46.1 ± 16 years, 55.5% male). The main primary clinical arrhythmias targeted were atrial flutter/tachycardia in 677 (59.6%), atrial fibrillation in 195 (17.2%), ventricular arrhythmia in 188 (16.6%), and atrioventricular reentrant tachycardia in 38 (3.3%), with significant variations in patterns observed based on the underlying substrate. Clinical arrhythmia was successfully ablated in 1071 patients (94.4%). The mean number of arrhythmias targeted per procedure was 1.5 ± 0.7, with overall acute success rates exceeding 90% for all arrhythmias except for ventricular arrhythmias (86.7%). Acute complication occurred in 43 procedures (3.8%), including 1 (0.1%) death. The overall 1- and 2-year recurrence-free rates were 77.3% (95% confidence interval 74.2%-80.4%) and 68.4% (95% confidence interval 64.7%-72.3%), respectively. Significant variations in recurrence rates were noted based on the type of arrhythmia and the underlying CHD.

CONCLUSIONS

Catheter ablation in patients with CHD demonstrates highly favourable acute outcomes and a low complication rate. Recurrence rates during follow-up vary depending on the targeted arrhythmia and the underlying CHD. These findings should be considered in the benefit-risk assessment.

In-hospital outcomes of catheter ablation in atrial arrhythmias: a nationwide analysis of 2,901 patients with adult congenital heart disease compared to 787,995 without

BACKGROUND

Advances in pediatric cardiology and congenital heart surgery have increased the adult population with congenital heart disease (CHD), now facing long-term complications like atrial arrhythmias. Given the limited data and safety concerns in this unique and vulnerable patient group, this study analyzes in-hospital outcomes of atrial catheter ablation in CHD patients versus non-CHD patients from a German nationwide real-world registry.

METHODS

Using health records, all atrial catheter ablation procedures in Germany from 2008 to 2021 were analyzed. After adjustment for confounders, safety performance endpoints were compared between patients with and without CHD.

RESULTS

From 2008 to 2021, 790,896 patients underwent right or left atrial catheter ablation in Germany. Of these, 1004 patients were classified as simple CHD, 1,054 patients as moderate CHD and 843 patients as complex CHD. Age at time of procedure was lower with increasing complexity of the CHD. Atypical atrial flutter (5.5% vs. 21.8%; p < 0.001) and other atrial tachycardias (21.2% vs. 42.2%; p < 0.001) occurred more often in patients with complex CHD compared to patients without. Combined ablation in both atria was more often performed in complex CHD. Despite higher complexity, in-hospital mortality (< 0.2%) and other investigated complications were rare. After adjustment for baseline characteristics, type of arrhythmia and ablation location, the relative risk for serious adverse events (combination of mortality, stroke, intracerebral bleeding or pericardiocentesis) did not show a significant difference for patients with CHD.

CONCLUSION

Even in patients with CHD, complications are rare and after adjustment, no differences were identified concerning serious adverse events. Therefore, an ablation should not be generally avoided in patients with CHD due to concerns about complications although an individualized evaluation of the anatomy must be taken into account.

Right atrial volume index and right atrial volume predict atrial fibrillation recurrence: A meta-analysis

BACKGROUND

Atrial volume index and atrial volume have recently been identified as predictors of atrial fibrillation (AF) recurrence following electrical cardioversion or radiofrequency ablation. However, most studies have reported the relationship between LAVI/LAV and AF recurrence, whereas there is little information on the relationship between RAVI/RAV and AF recurrence. Therefore, we performed a meta-analysis to assess the relationship between the risk of AF recurrence and RAVI/RAV in patients with AF who underwent electrical cardioversion or radiofrequency ablation.

METHODS

CNKI, Wanfang Database, Pubmed, Embase, Cochrane Library, and Web of Science were searched up to October 01, 2024. A meta-analysis of relative risk data from prospective and retrospective cohort studies that reported on the relationship between the risk of AF recurrence and RAVI/RAV in patients with AF after electrical cardioversion or radiofrequency ablation was performed.

RESULTS

The results showed that patients with AF recurrence had a higher mean right atrial volume index (RAVI) compared to patients with no recurrence. After electrical cardioversion or radiofrequency ablation, RAVI can independently predict the recurrence of AF (OR = 1.06, 95%CI (1.02, 1.11)). The average right atrial volume (RAV) of patients with AF recurrence was higher than that of patients without AF recurrence. After electrical cardioversion or radiofrequency ablation, RAV can independently predict the recurrence of AF (OR = 1.02, 95%CI (1.00, 1.05)).

CONCLUSION

Patients with AF recurrence after electrical cardioversion or radio frequency ablation had higher mean RAVI and RAV compared to patients with no recurrence. After electrical cardioversion or radiofrequency ablation in patients with AF, higher levels of RAVI and RAV increase the chance of recurrence of AF.

[Cardiac arrhythmias in adults with congenital heart disease]

In patients with congenital heart disease, cardiac arrhythmias are complex and require a thorough understanding of the anatomy, past surgical and interventional procedures, and the specific electric processes. Supraventricular tachycardias commonly present as emergency situations and should be treated immediately, particularly when there is an underlying complex malformation. Establishing sinus rhythm is usually superior to pure frequency control for hemodynamic reasons. Catheter ablation should be preferred over medical treatment, even though several procedures are often necessary. In addition, bradycardia is seen more frequently in congenital heart defects; this could be aggravated by antiarrhythmic drugs. There are significant differences between the indications and techniques used for pacemaker implantation in patients with congenital heart defects and those without. Patients with complex congenital heart diseases have an increased risk of thromboembolism; therefore, an individual and early indication for low-threshold oral anticoagulation is necessary; direct oral anticoagulants can also be used for this purpose. In risk stratification for sudden cardiac death, the principles of general guidelines are often not applicable, and individualized decisions are required. Recently, a new general risk score for congenital heart disease has been developed. The treatment of cardiac arrhythmias in patients with congenital heart disease should always be performed in close cooperation with specialized centers.

Severe hypoxemia after radiofrequency ablation for atrial fibrillation in palliatively repaired tetralogy of Fallot: A case report

BACKGROUND

Patients with tetralogy of Fallot (TOF) often have arrhythmias, commonly being atrial fibrillation (AF). Radiofrequency ablation is an effective treatment for AF and does not usually cause severe postoperative hypoxemia, but the risk of complications may increase in patients with conditions such as TOF.

CASE SUMMARY

We report a young male patient with a history of TOF repair who developed severe hypoxemia after radiofrequency ablation for AF and was ultimately confirmed to have a new right-to-left shunt. The patient subsequently underwent atrial septal occlusion and eventually recovered.

CONCLUSION

Radiofrequency ablation may cause iatrogenic atrial septal injury; thus possible complications should be predicted in order to ensure successful treatment and patient safety.

Atrial arrhythmia predicts late events and mortality in patients with D-transposition of the great arteries and atrial switch repair

Aims

Patients with D-transposition of the great arteries (D-TGA) and atrial switch experience late morbidity and mortality related to atrial arrhythmias and systemic right ventricular (SRV) failure. We sought to analyze the influence of atrial arrhythmias on long-term outcomes in this group.

Methods

A retrospective review of all patients with D-TGA and atrial switch followed at a tertiary care center was performed.

Results

148 patients (63.5 % male; age 30.4 ± 10.6 years) were followed for 12 ± 9.8 years. Death or cardiac transplantation occurred in 22(15 %) patients and heart failure hospitalization occurred in 30(20 %) patients.Atrial arrhythmias were documented in 82(55.4 %) patients. Atrial fibrillation at the first visit (Kaplan-Meier estimate, p = 0.003) and atrial fibrillation as a time-dependent variable (HR 3.50, p = 0.006) predicted increased risk of death or cardiac transplantation. A triad of atrial fibrillation, prolonged QRS duration/RBBB, and severe SRV dysfunction (SRV EF < 35 %) emerged as a unique signature of a higher-risk population.Atrial tachycardia and flutter, while not associated with mortality, increased the risk of heart failure hospitalization (HR 3.5, p = 0.001). Moreover, 2/6 cases of resuscitated sudden cardiac arrest were caused by atrial flutter, and more patients received inappropriate shocks for atrial arrhythmias(16 %) than appropriate shocks(2.3 %).

Conclusion

In D-TGA patients with atrial switch, there is a complex interplay between atrial arrhythmias and the SRV. Key ECG parameters, arrhythmia events and sequelae create a unique patient-specific fingerprint strongly associated with future events and mortality. This higher-risk cohort will need further characterization to delineate who may benefit from preemptive arrhythmia intervention.

Atrial Fibrillation Ablation in Congenital Heart Disease: Therapeutic Challenges and Future Perspectives

The increasing prevalence of atrial fibrillation (AF) in adults with congenital heart disease raises significant questions regarding its management. The unique underlying anatomic and physiological background further adds to the difficulty in eliminating the AF burden in these patients. Herein, we provide an overview of the current knowledge on the pathophysiology and risk factors for AF in adult congenital heart disease, with a special focus on the existing challenges in AF ablation. Emerging imaging modalities and ablation techniques might have a role to play. Evidence regarding the safety and efficacy of AF ablation in adult congenital heart disease is summarized, especially for patients with an atrial septal defect, Ebstein anomaly of the tricuspid valve, tetralogy of Fallot, and Fontan circulation. Finally, any remaining gaps in knowledge and potential areas of future research are highlighted.

Atrial fibrillation in adult congenital heart disease and the general population

BACKGROUND

Atrial fibrillation (AF) in adult patients with congenital heart disease (ACHD) may appear early, depending on individual characteristics.

OBJECTIVES

The goals of this study were to investigate the epidemiological spectrum of AF in the entire cohort of ACHD and compare it with that in the general population.

METHODS

A retrospective study was performed in the nationwide cohort 2000-2014 with AF onset during 2003-2014.

RESULTS

In the cohort of ACHD, 2350 patients had AF; the incidence increased with age, plateauing around age 70. In patients aged 25-29, 45-49, 65-69, 75-79, and ≥80 years, the annual incidence was 1.3, 7.9, 20.6, 23.7, and 21.4/1000 per year, respectively. In the general population without CHD, 347,979 patients had AF; the annual incidence was <1/1000 per year in those aged <55 years but increased steadily with age (3.6, 8.6, and 14.2/1000 per year in aged 65-69, 75-79, and ≥80 years, respectively). Compared with individuals without ACHD, ACHD patients aged <50 years and those aged both 50-54 and 55-59 years exhibited a 20-fold and 10-fold higher incidence of AF, respectively. Patients with complex congenital heart disease and Ebstein's anomaly had the highest risk of AF (cumulative risk >10% by age 50 and >20% by age 60), followed by those with tetralogy of Fallot, tricuspid atresia, endocardial cushion defect, and secundum atrial septal defect (cumulative risk >5% by age 50 and >10% by age 60).

CONCLUSION

Compared with individuals without ACHD, AF in patients with ACHD likely appeared 30 years earlier, with a 10- to 20-fold higher incidence plateauing around age 70. Yet, incidence in individuals without ACHD continued to increase. AF burden in patients with ACHD is not expected to increase in a never-ending way.

Transseptal Puncture Guided by Three-Dimensional Electroanatomical Mapping: Early Experience Using a Simplified Approach in Adults with Congenital Heart Disease

AIMS

The widespread use of three-dimensional (3D) mapping systems and echocardiography in the field of cardiac electrophysiology has made it possible to perform transseptal punctures (TSP) with low or no fluoroscopy. However, such attempts in adults with congenital heart disease (ACHD) who have previously undergone surgical or interventional treatment are limited. Therefore, we sought to explore the feasibility and safety of an approach to perform zero- or low-fluoroscopy TSP in ACHD patients undergoing left atrial cardiac ablation procedures.

METHODS AND RESULTS

This study included 45 ACHD patients who underwent TSP for ablation of left-sided tachycardias (left atrium or pulmonary venous atrium). Computed tomography (CT) of the heart was performed in all patients prior to ablation. 3D mapping of the right-sided heart chambers before TSP was used to superimpose the registered anatomy, which was subsequently used for the mapping-guided TSP technique. TSP was performed with zero-fluoroscopy in 27 patients, and the remaining 18 patients had a mean fluoroscopy exposure of 315.88 ± 598.43 μGy.m² and a mean fluoroscopy duration of 1.9 ± 5.4 min. No patient in this cohort experienced TSP-related complications.

CONCLUSION

Our study describes a fluoroscopy-free or low-dose fluoroscopy approach for TSP in ACHD patients undergoing catheter ablation of left-sided tachyarrhythmias who had been previously treated surgically or interventionally due to congenital heart defects. By superimposing 3D electroanatomic mapping with cardiac CT anatomy, this protocol proved to be highly effective, feasible and safe.

Hidden problems in a case of atrial fibrillation

Atrial fibrillation (AF) is the most common cardiac arrhythmia. However, the relation between congenital heart defects and the predisposition to AF is not fully understood. A 65-year-old male was admitted into the emergency department due to progressive dyspnea, orthopnea, palpitations, and edema. Transthoracic echocardiogram showed bi-atrial enlargement and dysplasia of the mitral leaflets with severe mitral regurgitation. Also, a membrane was noted in the LA, dividing the chamber into two parts, suggestive of cor triatriatum sinister. Coronary computed tomography angiography demonstrated a soft tissue septum in the left atrium. Multimodal evaluation is of vital importance for a complete approach, since, detected in time, it has an excellent prognosis.