Ablation of Atrial Arrhythmias in Postoperative Congenital Heart Disease Patients
Have We Reached the Upper Limit of Success or Is It Time for a Paradigm Shift in Strategy?
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- arrhythmias, cardiac
- catheter ablation
- defibrillators, implantable
- magnetic resonance imaging
- tachycardia, supraventricular
See Article by Klehs et al
Development of sustained atrial arrhythmias in patients with congenital heart disease (CHD) becomes more common years after successful anatomic repair despite early decreases in hemodynamic burden on the heart after surgical repair.1 Surgical incisions required to open the heart to allow access to holes and abnormal valve anatomy may be associated with atrial arrhythmias in the early postoperative period. More commonly, these incisions set-up boundaries of slow conduction or regions of conduction block that facilitate the occurrence of either focal or reentrant atrial arrhythmias as described in the report by Klehs et al.2 The average time to onset of these arrhythmias was 22±12 years in this study, similar to previous reports.1,3,4 One may ask, why so long after surgery?
Patients presenting with atrial tachycardia (AT) may be asymptomatic as noted in 27 of 144 (19%) of the study patients or have a more concerning clinical presentation with palpitations, dyspnea, chest pain, or syncope.1 For those with implantable cardioverter defibrillators, atrial arrhythmias are one of the more common triggers for inappropriate shocks. Less commonly, sudden cardiac arrest may be the first sign of presentation.5
Once faced with a patient with sustained AT, the clinician must decide on what form of treatment might be best. Choices include antiarrhythmic drug treatment, antitachycardia pacing, or ablation. Although radiofrequency ablation of the tachycardia substrate has been endorsed in the 2014 PACES (Pediatric and Congenital Electrophysiology Society) consensus document,6 this decision would seem appropriate if ablation had a higher success rate and lower complication rate in the long-term than does antiarrhythmic drug therapy, but how do the 2 approaches really stack …