My concern would be late. They're still at the same risk of overall stretch and fibrosis and things like this. So those, I don't, I don't really understand why they'd be completely. Uh, free from that style unless there's some sort of true hemodynamic benefit out to 20 or 30 years
My concern would be late. They're still at the same risk of overall stretch and fibrosis and things like this. So those, I don't, I don't really understand why they'd be completely. Uh, free from that style unless there's some sort of true hemodynamic benefit out to 20 or 30 years
The Role of Trans-Catheter Arrhythmia Management - Patient Based Decision...
▶Ep 5 · 0:40
quoteI'm an electrophysiologist and so, uh, sometimes might be inherently dry, but I think this topic is actually interesting. If, if nothing else, because it's controversial and we like controversy↗
▶Ep 5 · 0:40
quoteI'm an electrophysiologist and so, uh, sometimes might be inherently dry, but I think this topic is actually interesting. If, if nothing else, because it's controversial and we like controversy↗
▶Ep 5 · 1:45
host_summaryIn early Boston Fontan data, macro-reentrant atrial tachycardia was ubiquitous out to 20 years↗
▶Ep 5 · 1:45
epidemiologicalIn early Boston Fontan data, macro-reentrant atrial tachycardia was ubiquitous out to 20 years↗
▶Ep 5 · 2:13
host_summaryAfter first atrial tachycardia and cardioversion in Fontan patients, risk of future tachycardia is upwards of 80 or 90%↗
▶Ep 5 · 2:13
epidemiologicalAfter first atrial tachycardia and cardioversion in Fontan patients, risk of future tachycardia is upwards of 80 or 90%↗
▶Ep 5 · 2:29
host_summaryWhile incidence of tachycardia is heavily related to Fontan type, risk of recurrent tachycardia is the same for all Fontan types↗
▶Ep 5 · 2:29
clinicalWhile incidence of tachycardia is heavily related to Fontan type, risk of recurrent tachycardia is the same for all Fontan types↗
▶Ep 5 · 2:40
host_summaryAnti-arrhythmic medications do not achieve complete suppression of atrial tachycardia in Fontan patients↗
▶Ep 5 · 2:40
quoteif our goal is complete amelioration of atrial tachycardia, I think it's been well documented that atrial, that anti-arrhythmics are not going to get us to a complete suppression of tachycardia↗
▶Ep 5 · 2:40
quoteif our goal is complete amelioration of atrial tachycardia, I think it's been well documented that atrial, that anti-arrhythmics are not going to get us to a complete suppression of tachycardia↗
▶Ep 5 · 2:40
clinicalAnti-arrhythmic medications do not achieve complete suppression of atrial tachycardia in Fontan patients↗
▶Ep 5 · 2:52
epidemiologicalIn multiple studies, essentially 100% of Fontan patients on anti-arrhythmics alone have recurrence of tachycardia over 5 to 6 years↗
▶Ep 5 · 2:52
host_summaryIn multiple studies, essentially 100% of Fontan patients on anti-arrhythmics alone have recurrence of tachycardia over 5 to 6 years↗
▶Ep 5 · 3:00
quoteI typically think about the decision to ablate or not to ablate as a dichotomous decision. So we either ablate or we don't ablate, but I think in Fontaine's, I think it's more of a circular loop↗
▶Ep 5 · 3:00
quoteI typically think about the decision to ablate or not to ablate as a dichotomous decision. So we either ablate or we don't ablate, but I think in Fontaine's, I think it's more of a circular loop↗
▶Ep 5 · 3:24
quoteThe real question is, is ablation a potential off-ramp, uh, for the circular loop or really just another part of the loop itself?↗
▶Ep 5 · 3:24
quoteThe real question is, is ablation a potential off-ramp, uh, for the circular loop or really just another part of the loop itself?↗
▶Ep 5 · 3:47
quotetrans catheter ablation is gonna play some role in these patients' life. So it's a bit more of a decision of when, uh, more than it's a decision of, of, uh, if↗
▶Ep 5 · 3:47
quotetrans catheter ablation is gonna play some role in these patients' life. So it's a bit more of a decision of when, uh, more than it's a decision of, of, uh, if↗
▶Ep 5 · 4:11
quoteI'm an electrophysiologist, so I know there's a lot of different uh types for, for us, there's really 3 types↗
▶Ep 5 · 4:11
quoteI'm an electrophysiologist, so I know there's a lot of different uh types for, for us, there's really 3 types↗
▶Ep 5 · 4:37
host_summaryLateral tunnel Fontans have had significantly less incidence of atrial arrhythmias compared to atrial-pulmonary Fontans↗
▶Ep 5 · 4:37
epidemiologicalLateral tunnel Fontans have had significantly less incidence of atrial arrhythmias compared to atrial-pulmonary Fontans↗
▶Ep 5 · 4:45
epidemiologicalData on whether extracardiac conduit has significantly lower arrhythmia incidence than intracardiac conduit is discrepant, with some studies showing significant improvement and others showing less difference↗
▶Ep 5 · 4:45
host_summaryData on whether extracardiac conduit has significantly lower arrhythmia incidence than intracardiac conduit is discrepant, with some studies showing significant improvement and others showing less difference↗
▶Ep 5 · 5:23
quoteas we change our fontan type, our catheter is now not entering. Uh, the atrial chamber, at least as far as an access point. And so now we have to figure a way out of the conduit, uh, back into the, uh, atrial chamber↗
▶Ep 5 · 5:23
quoteas we change our fontan type, our catheter is now not entering. Uh, the atrial chamber, at least as far as an access point. And so now we have to figure a way out of the conduit, uh, back into the, uh, atrial chamber↗
▶Ep 5 · 5:40
quotewith these differing. Fontan styles we've made the, we've had a significant benefit in terms of frequency of tachycardia, but I think we've been making our ablations more difficult procedures↗
▶Ep 5 · 5:40
quotewith these differing. Fontan styles we've made the, we've had a significant benefit in terms of frequency of tachycardia, but I think we've been making our ablations more difficult procedures↗
▶Ep 5 · 6:11
host_summaryIn Boston study of ~90 Fontan ablation patients, over half required trans-baffle procedure, with moderate or severe complication rate of about 10%↗
▶Ep 5 · 6:11
epidemiologicalIn Boston study of ~90 Fontan ablation patients, over half required trans-baffle procedure, with moderate or severe complication rate of about 10%↗
▶Ep 5 · 6:30
clinicalIn trans-baffle ablation cases, catastrophic complications included death and major shunts with cyanosis, whereas non-trans-baffle complications were primarily kidney injury↗
▶Ep 5 · 6:30
host_summaryIn trans-baffle ablation cases, catastrophic complications included death and major shunts with cyanosis, whereas non-trans-baffle complications were primarily kidney injury↗
▶Ep 5 · 6:50
quoteI don't think this has been definitively proved, but I think it's not a, uh, particularly low risk procedure↗
▶Ep 5 · 6:50
quoteI don't think this has been definitively proved, but I think it's not a, uh, particularly low risk procedure↗
▶Ep 5 · 7:37
quoteif you say Fontan and tachycardia, I'm gonna tell you it's macro-oriented, and I'm probably gonna be right↗
▶Ep 5 · 7:37
quoteif you say Fontan and tachycardia, I'm gonna tell you it's macro-oriented, and I'm probably gonna be right↗
▶Ep 5 · 7:52
epidemiologicalIn study of 52 Fontan ablation patients, 80 different arrhythmia mechanisms were identified, meaning majority of patients had more than one mechanism↗
▶Ep 5 · 7:52
host_summaryIn study of 52 Fontan ablation patients, 80 different arrhythmia mechanisms were identified, meaning majority of patients had more than one mechanism↗
▶Ep 5 · 8:05
epidemiologicalIn Fontan ablations, macro-reentrant tachycardia was most common type but represented less than half of ablations, with focal atrial tachycardia and AVNRT being important mechanisms↗
▶Ep 5 · 8:05
host_summaryIn Fontan ablations, macro-reentrant tachycardia was most common type but represented less than half of ablations, with focal atrial tachycardia and AVNRT being important mechanisms↗
▶Ep 5 · 8:30
clinicalAtrial fibrillation as an isolated phenomenon in Fontan patients is relatively rare↗
▶Ep 5 · 8:30
clinicalAtrial fibrillation as an isolated phenomenon in Fontan patients is relatively rare↗
▶Ep 5 · 10:18
opinionEd Walsh felt that atrial tachycardia was a risk factor for sudden death in Fontan patients↗
▶Ep 5 · 10:18
host_summaryEd Walsh felt that atrial tachycardia was a risk factor for sudden death in Fontan patients↗
▶Ep 5 · 10:38
host_summaryIn several studies, Fontans with arrhythmias do worse than Fontans without arrhythmias in terms of freedom from death or transplant↗
▶Ep 5 · 10:38
epidemiologicalIn several studies, Fontans with arrhythmias do worse than Fontans without arrhythmias in terms of freedom from death or transplant↗
▶Ep 5 · 10:52
clinicalArrhythmia is a significant predictor of outcome in Fontan risk stratification models↗
▶Ep 5 · 10:52
host_summaryArrhythmia is a significant predictor of outcome in Fontan risk stratification models↗
▶Ep 5 · 11:00
opinionIt is unknown whether ablating arrhythmia substrates in Fontan patients will change their overall risk of death or transplant↗
▶Ep 5 · 11:00
opinionIt is unknown whether ablating arrhythmia substrates in Fontan patients will change their overall risk of death or transplant↗
▶Ep 5 · 11:47
epidemiologicalIn Mayo study of 260 Fontan patients with arrhythmia, almost all patients had recurrence of atrial tachycardia regardless of management strategy↗
▶Ep 5 · 11:47
host_summaryIn Mayo study of 260 Fontan patients with arrhythmia, almost all patients had recurrence of atrial tachycardia regardless of management strategy↗
▶Ep 5 · 11:56
host_summaryHigh recurrence rate in Mayo study was heavily driven by high prevalence of patients on anti-arrhythmic medications alone↗
▶Ep 5 · 11:56
epidemiologicalHigh recurrence rate in Mayo study was heavily driven by high prevalence of patients on anti-arrhythmic medications alone↗
▶Ep 5 · 12:05
host_summaryCatheter ablation in Fontan patients achieved freedom from recurrence in the range of 40 to 50%, not the 95-97% typical of other ablation types↗
▶Ep 5 · 12:05
epidemiologicalCatheter ablation in Fontan patients achieved freedom from recurrence in the range of 40 to 50%, not the 95-97% typical of other ablation types↗
▶Ep 5 · 12:31
epidemiologicalIn study using clinical arrhythmia severity scores, Fontan patients who underwent ablation had significant improvement in scores following ablation↗
▶Ep 5 · 12:31
host_summaryIn study using clinical arrhythmia severity scores, Fontan patients who underwent ablation had significant improvement in scores following ablation↗
▶Ep 5 · 12:52
host_summaryEven in Fontan patients who had recurrence of tachycardia after ablation, there was still some improvement in overall arrhythmia burden, though not as robust as in patients without recurrence↗
▶Ep 5 · 12:52
epidemiologicalEven in Fontan patients who had recurrence of tachycardia after ablation, there was still some improvement in overall arrhythmia burden, though not as robust as in patients without recurrence↗
▶Ep 5 · 13:03
quoteMaybe for some patients, the way to look at this is not a complete suppression of any recurrence, but a tailoring of the overall burden↗
▶Ep 5 · 13:03
quoteMaybe for some patients, the way to look at this is not a complete suppression of any recurrence, but a tailoring of the overall burden↗
▶Ep 5 · 13:23
clinicalFontan conversion with arrhythmia surgery achieves freedom from arrhythmia around 50 to 60%, probably not all that different than catheter ablation alone↗
▶Ep 5 · 13:23
clinicalFontan conversion with arrhythmia surgery achieves freedom from arrhythmia around 50 to 60%, probably not all that different than catheter ablation alone↗
▶Ep 5 · 13:35
opinionRick's typical approach is to give Fontan patients one arrhythmia episode and monitor them going forward, either off or on medications, then consider ablation after recurrent atrial arrhythmia↗
▶Ep 5 · 13:35
opinionRick's typical approach is to give Fontan patients one arrhythmia episode and monitor them going forward, either off or on medications, then consider ablation after recurrent atrial arrhythmia↗
▶Ep 5 · 14:16
clinicalFontan patients with SVT are likely to have recurrence of SVT↗
▶Ep 5 · 14:16
quoteI think my main points are, uh, Fontan patients with SVT are likely to have recurrence of SVT↗
▶Ep 5 · 14:16
quoteI think my main points are, uh, Fontan patients with SVT are likely to have recurrence of SVT↗
▶Ep 5 · 14:16
clinicalFontan patients with SVT are likely to have recurrence of SVT↗
▶Ep 5 · 14:23
clinicalAnti-arrhythmic medications are reasonable but unlikely to keep Fontan patients completely tachycardia-free↗
▶Ep 5 · 14:23
clinicalAnti-arrhythmic medications are reasonable but unlikely to keep Fontan patients completely tachycardia-free↗
▶Ep 5 · 14:30
clinicalNew onset atrial tachycardia or increased tachycardia burden is often an early indicator of other issues in Fontan patients↗
▶Ep 5 · 14:30
clinicalNew onset atrial tachycardia or increased tachycardia burden is often an early indicator of other issues in Fontan patients↗
▶Ep 5 · 14:37
opinionCatheter ablation plays a major role in management of SVT in Fontan patients and is reasonable as either first or second line management↗
▶Ep 5 · 14:37
opinionCatheter ablation plays a major role in management of SVT in Fontan patients and is reasonable as either first or second line management↗
▶Ep 5 · 14:48
quotethe role of catheter ablation is in evolution is going to continue to change significantly over the next decades based on our changing fontan anatomy↗
▶Ep 5 · 14:48
quotethe role of catheter ablation is in evolution is going to continue to change significantly over the next decades based on our changing fontan anatomy↗
▶Ep 5 · 15:35
quoteI got to say, at, at the time of most of these procedures, we're rarely, if ever, blessed with that type of macro entrant. They tend to be in the younger patients, I think we've seen they're more scar related to the atriotomy and things like that↗
▶Ep 5 · 15:35
quoteI got to say, at, at the time of most of these procedures, we're rarely, if ever, blessed with that type of macro entrant. They tend to be in the younger patients, I think we've seen they're more scar related to the atriotomy and things like that↗
▶Ep 5 · 16:06
epidemiologicalIn surgical ablation data from Chicago, isthmus ablation-only strategy had much worse outcomes than more aggressive strategies, but aggressive strategies bring sinus node dysfunction into the equation↗
▶Ep 5 · 16:06
quoteI think even if you go back to the surgical data from Chicago, the isthmus ablation only. The strategy was much worse than these more aggressive strategies. The problem is with the more aggressive strategies you bring science no dysfunction well into the equation↗
▶Ep 5 · 16:06
quoteI think even if you go back to the surgical data from Chicago, the isthmus ablation only. The strategy was much worse than these more aggressive strategies. The problem is with the more aggressive strategies you bring science no dysfunction well into the equation↗
▶Ep 5 · 16:06
host_summaryIn surgical ablation data from Chicago, isthmus ablation-only strategy had much worse outcomes than more aggressive strategies, but aggressive strategies bring sinus node dysfunction into the equation↗
▶Ep 5 · 16:45
quoteI think they're going to be the same but present at a different stage↗
▶Ep 5 · 16:45
quoteI think they're going to be the same but present at a different stage↗
▶Ep 5 · 16:50
quotewe go in and seriously 2/3 sometimes of the atrial tube. Issues essentially scar with no electrical activity↗
▶Ep 5 · 16:50
quotewe go in and seriously 2/3 sometimes of the atrial tube. Issues essentially scar with no electrical activity↗
▶Ep 5 · 16:50
clinicalIn older Fontan patients undergoing ablation, sometimes 2/3 of the atrial tissue is essentially scar with no electrical activity↗
▶Ep 5 · 16:50
clinicalIn older Fontan patients undergoing ablation, sometimes 2/3 of the atrial tissue is essentially scar with no electrical activity↗
▶Ep 5 · 17:02
opinionExtracardiac Fontan patients will have reduced early arrhythmia incidence due to less surgical scarring, but may face same late risk from atrial stretch and fibrosis unless there is true hemodynamic benefit at 20-30 years↗
▶Ep 5 · 17:02
opinionExtracardiac Fontan patients will have reduced early arrhythmia incidence due to less surgical scarring, but may face same late risk from atrial stretch and fibrosis unless there is true hemodynamic benefit at 20-30 years↗
▶Ep 5 · 17:05
quoteMy concern would be late. They're still at the same risk of overall stretch and fibrosis and things like this. So those, I don't, I don't really understand why they'd be completely. Uh, free from that style unless there's some sort of true hemodynamic benefit out to 20 or 30 years↗
▶Ep 5 · 17:05
quoteMy concern would be late. They're still at the same risk of overall stretch and fibrosis and things like this. So those, I don't, I don't really understand why they'd be completely. Uh, free from that style unless there's some sort of true hemodynamic benefit out to 20 or 30 years↗
▶Ep 5 · 18:39
quotefor me, the answer is that I would wait for their second episode. I think if that episode is 3 years down the road, but we, you have to talk with them. What's your goal?↗
▶Ep 5 · 18:39
quotefor me, the answer is that I would wait for their second episode. I think if that episode is 3 years down the road, but we, you have to talk with them. What's your goal?↗
▶Ep 5 · 18:43
opinionIf Fontan patient's goal is to be completely off Coumadin after atrial arrhythmia, the only way to probably do that safely is to go ahead with catheter ablation↗
▶Ep 5 · 18:43
opinionIf Fontan patient's goal is to be completely off Coumadin after atrial arrhythmia, the only way to probably do that safely is to go ahead with catheter ablation↗
▶Ep 5 · 18:48
quoteif your goal is to be completely off Coumadin, I don't even know if that's a strategy once you've had your atrial arrhythmia, but if you have to be off Coumadin, the only way to probably do that safely with risk is to, to go ahead with catheter ablation↗
▶Ep 5 · 18:48
quoteif your goal is to be completely off Coumadin, I don't even know if that's a strategy once you've had your atrial arrhythmia, but if you have to be off Coumadin, the only way to probably do that safely with risk is to, to go ahead with catheter ablation↗
▶Ep 5 · 19:01
quoteI think groups have been very aggressive about first-time, they're much better, they're easier procedures, right? If you get them early, you probably have one or two circuits where if you wait 5 or 6 years, you're taking on these, uh, more complex 5 or 6 circuit cases↗
▶Ep 5 · 19:01
quoteI think groups have been very aggressive about first-time, they're much better, they're easier procedures, right? If you get them early, you probably have one or two circuits where if you wait 5 or 6 years, you're taking on these, uh, more complex 5 or 6 circuit cases↗
▶Ep 5 · 19:01
clinicalEarly ablation procedures in Fontan patients are easier, probably involving one or two circuits, whereas waiting 5-6 years results in more complex cases with 5 or 6 circuits↗
▶Ep 5 · 19:01
clinicalEarly ablation procedures in Fontan patients are easier, probably involving one or two circuits, whereas waiting 5-6 years results in more complex cases with 5 or 6 circuits↗
▶Ep 5 · 19:46
clinicalRick's center has not seen many young patients with atrial arrhythmias, having done lateral tunnels or extracardiac Fontans primarily for a long time↗
▶Ep 5 · 19:46
quoteI gotta say we have not seen a lot of young patients with atrial arrhythmias, and we've been doing lateral tunnels or extrac cardiac for a long time primarily↗
▶Ep 5 · 19:46
quoteI gotta say we have not seen a lot of young patients with atrial arrhythmias, and we've been doing lateral tunnels or extrac cardiac for a long time primarily↗
▶Ep 5 · 19:46
clinicalRick's center has not seen many young patients with atrial arrhythmias, having done lateral tunnels or extracardiac Fontans primarily for a long time↗
