The Role of Trans-Catheter Arrhythmia Management - Patient Based Decision...
With Dr. Rick Choi · StayCurrentMD
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What the experts said
Atrial fibrillation as an isolated phenomenon in Fontan patients is relatively rare
It is unknown whether ablating arrhythmia substrates in Fontan patients will change their overall risk of death or transplant
Fontan conversion with arrhythmia surgery achieves freedom from arrhythmia around 50 to 60%, probably not all that different than catheter ablation alone
Rick'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
Fontan patients with SVT are likely to have recurrence of SVT
Anti-arrhythmic medications are reasonable but unlikely to keep Fontan patients completely tachycardia-free
New onset atrial tachycardia or increased tachycardia burden is often an early indicator of other issues in Fontan patients
Catheter ablation plays a major role in management of SVT in Fontan patients and is reasonable as either first or second line management
In older Fontan patients undergoing ablation, sometimes 2/3 of the atrial tissue is essentially scar with no electrical activity
Extracardiac 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
Mayo Clinic Fontan arrhythmia data was largely from atrial-pulmonary Fontan patients
If 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
Early 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
Rick's center has not seen many young patients with atrial arrhythmias, having done lateral tunnels or extracardiac Fontans primarily for a long time
In early Boston Fontan data, macro-reentrant atrial tachycardia was ubiquitous out to 20 years
After first atrial tachycardia and cardioversion in Fontan patients, risk of future tachycardia is upwards of 80 or 90%
While incidence of tachycardia is heavily related to Fontan type, risk of recurrent tachycardia is the same for all Fontan types
Anti-arrhythmic medications do not achieve complete suppression of atrial tachycardia in Fontan patients
In multiple studies, essentially 100% of Fontan patients on anti-arrhythmics alone have recurrence of tachycardia over 5 to 6 years
Lateral tunnel Fontans have had significantly less incidence of atrial arrhythmias compared to atrial-pulmonary Fontans
Data 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
In Boston study of ~90 Fontan ablation patients, over half required trans-baffle procedure, with moderate or severe complication rate of about 10%
In trans-baffle ablation cases, catastrophic complications included death and major shunts with cyanosis, whereas non-trans-baffle complications were primarily kidney injury
In study of 52 Fontan ablation patients, 80 different arrhythmia mechanisms were identified, meaning majority of patients had more than one mechanism
In 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
Ed Walsh felt that atrial tachycardia was a risk factor for sudden death in Fontan patients
In several studies, Fontans with arrhythmias do worse than Fontans without arrhythmias in terms of freedom from death or transplant
Arrhythmia is a significant predictor of outcome in Fontan risk stratification models
In Mayo study of 260 Fontan patients with arrhythmia, almost all patients had recurrence of atrial tachycardia regardless of management strategy
High recurrence rate in Mayo study was heavily driven by high prevalence of patients on anti-arrhythmic medications alone
Catheter ablation in Fontan patients achieved freedom from recurrence in the range of 40 to 50%, not the 95-97% typical of other ablation types
In study using clinical arrhythmia severity scores, Fontan patients who underwent ablation had significant improvement in scores following ablation
Even 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
In 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