Catheter ablation of tachycardia arising from the pulmonary venous atrium after surgical repair of congenital heart disease

Moore, Jeremy P.; Russell, Matthew; Mandapati, Ravi; Aboulhosn, Jamil; Shannon, Kevin

doi:10.1016/j.hrthm.2014.11.038

Cited by 13 publications

(8 citation statements)

References 23 publications

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“…IART in patients with ACHD is usually restricted to the right atrial tissue 37 38. In patients with four cardiac chambers in normal orientation, the isthmus between the tricuspid annulus and the inferior vena cava is part of the re-entrant circuit in the majority of patients 5.…”

Section: Long-term Treatment Options Of Svt In Patients With Achdmentioning

confidence: 99%

Management of supraventricular arrhythmias in adults with congenital heart disease

Wasmer

Eckardt

2016

Heart

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Supraventricular arrhythmias are a frequent complication in adults with congenital heart disease (ACHD). The prevalence increases with time since surgery, complexity of the underlying defect, type of repair and older age at surgery. Arrhythmias are the most frequent reason for hospital admission and along with heart failure the leading cause of death. The arrhythmia-associated increase in morbidity and mortality makes their management a key task in patients with ACHD. Intra-atrial re-entry is the most frequent arrhythmia mechanism. Less common arrhythmia mechanisms are supraventricular tachycardias in the presence of an accessory pathway, atrioventricular nodal re-entrant tachycardia or focal tachycardias. Patient management includes stroke prevention, acute termination and prevention of arrhythmia recurrence. Acute treatment depends on patients' symptoms. In cases of haemodynamic instability, immediate cardioversion is warranted. For stable patients, acute treatment includes rate control and termination by antiarrhythmic drugs or electrical cardioversion. Following a symptomatic arrhythmia, catheter ablation or treatment with antiarrhythmic drugs is recommended to prevent recurrences. Advances in mapping and ablation technology are now associated with high success rates of catheter ablation. In patients with a complex substrate recurrence rates of 50% remain high. However, in the presence of side effects and complications associated with long-term antiarrhythmic drug therapy, redo procedures are encouraged by current guidelines.

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Section: Long-term Treatment Options Of Svt In Patients With Achdmentioning

confidence: 99%

Management of supraventricular arrhythmias in adults with congenital heart disease

Wasmer

Eckardt

2016

Heart

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“…The transconduit puncture provides a more direct route to the PVA, but is a difficult procedure that often requires considerable manual force, radiofrequency energy, and often serial balloon dilations to create a large enough orifice for passage of a standard guiding sheath. 9,11,17 Nevertheless, this technique has emerged as the preferred approach at many centers because of inherent advantages when compared with previous methods. 10 The presently described transcaval puncture technique is a modification of the transconduit approach and can be used in a significant proportion of patients after E-TCPC repair.…”

Section: Discussionmentioning

confidence: 99%

“…18 Techniques to insure a safe transcaval puncture that we have used at our center include (1) verification of cavoatrial overlap by angiography within the systemic venous circulation and during levophase in ≥2 fluoroscopic views, (2) intraprocedural transesophageal echocardiography to assess the proposed puncture site and exclude pericardial effusion, and (3) staining of the space between the IVC and PVA with contrast to exclude significant extravasation before entering the PVA. 11 Although extravasation of contrast into the pericardial or pleural space is unlikely to occur in the setting of the typically dense surgical adhesions in this region, the lack of more than minor contrast extravasation during performance of the puncture can be reassuring. Given the present results, we now also recommend preoperative CT angiography to assess the feasibility of this strategy and to guide preprocedural counseling.…”

Section: Discussionmentioning

confidence: 99%

“…9,10 Direct puncture is less invasive than surgical approaches, yet is a challenging procedure that may require multiple attempts, catheter balloon dilation, and occasionally prolonged procedure times. 11 Transcatheter entry to the PVA through an area of native tissue below the extracardiac conduit has been previously reported 11 and may represent a safe and technically straightforward alternative to the transconduit approach.…”

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Transcaval Puncture for Access to the Pulmonary Venous Atrium After the Extracardiac Total Cavopulmonary Connection Operation

Moore

Hendrickson

Brunengraber

et al. 2015

Circ: Arrhythmia and Electrophysiology

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MethodsAfter approval from the Institutional Review Board, the Pediatric Cardiology and Ahmanson/UCLA Adult Congenital Heart Disease databases were searched for all patients who had undergone prior E-TCPC between 2005 and 2015. Those patients without computed tomography (CT) imaging after the E-TCPC operation were excluded from further study. Patient characteristics including baseline demographics, congenital diagnosis, surgical history, arrhythmia history, and hemodynamic data were recorded.All postoperative CT studies were reviewed in blinded fashion by 1 electrophysiologist and 1 radiologist. Three-dimensional reconstructions of CT examinations were performed using DICOM viewer © 2015 American Heart Association, Inc. Original Article Circ Arrhythm ElectrophysiolBackground-Patients with surgically palliated total cavopulmonary connection are at risk for recurrent atrial arrhythmia requiring catheter ablation. Transcatheter procedures for those with extracardiac conduits (extracardiac-total cavopulmonary connection) are perhaps the most challenging because of exclusion of the venous circulation from the arrhythmia substrate. Puncture through the inferior vena cava to the pulmonary venous atrium may be an effective route for access in these patients. Methods and Results-The pediatric and adult congenital surgical databases were explored for patients with extracardiactotal cavopulmonary connection and postoperative computed tomography imaging to assess for the presence of clinically relevant (>3 mm) apposition between the inferior vena cava and pulmonary venous atrium (cavoatrial overlap). The degree of overlap between the structures was measured by 2 blinded reviewers. Patients were stratified by surgical repair in childhood versus adult congenital heart disease. Thirty-seven patients were identified, with cavoatrial overlap observed in 9 (36%) of pediatric and 1 (9%) of adult congenital heart disease-repaired patients. Time elapsed after surgery was associated with cavoatrial overlap in the pediatric cohort (P=0.034) and was identified in all pediatric patients with computed tomography imaging ≥8 years after surgery. Three patients underwent successful transcaval puncture during the study period without complication. Conclusions-Puncture through a region of overlap between the inferior vena cava and pulmonary venous atrium is feasible. Cavoatrial overlap is present in a substantial proportion of patients undergoing extracardiac-total cavopulmonary connection in childhood and is associated with a longer time elapsed since surgery. (Circ Arrhythm Electrophysiol.

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“…32,33 Left-sided MRATs (see Figure 1) are generally related to gaps along surgical lines and anatomical barriers, such as the mitral valve or the pulmonary veins 29 and can be interrupted by localised ablation at those sites, but with a lower success rate and a higher recurrence rate than CTI ablation. [34][35][36][37][38][39] Catheter ablation requires complete lines of block, preferably at the narrowest isthmus, which can be challenging, particularly at the mitral isthmus.…”

Section: Clinical Arrhythmiasmentioning

confidence: 99%

Supraventricular Arrhythmias in Patients with Adult Congenital Heart Disease

Lundqvist

Potpara

Malmborg

2017

Arrhythmia &Amp; Electrophysiology Review

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Access at: www.AERjournal.comWith the advent of successful surgical repairs and modern diagnostic techniques, an increasing number of patients with congenital heart disease survive to adulthood. Despite these improvements, the surgical corrective atrial incisions performed during childhood lead to subsequent myocardial scarring that have the inherent risk of harbouring substrates for macro-reentrant atrial tachycardias (MRATs). Apart from surgical conduction barriers such as patches, conduits and surgical scars, there are also natural barriers including valve annuli and venous orifices that potentially may become critical substrates for tachyarrhythmias. 1The 20-year risk of developing atrial arrhythmias among patients with adult congenital heart disease (ACHD) was 7 % in a patient aged 20 years and 38 % in a patient aged 50 years in a population-based study. Apart from these tachyarrhythmias, patients with ACHD also have an increased risk of pump failure, stroke and sudden cardiac death (SCD). 6 Although the incidence of SCD is low (0.09 % per year) in the CHD population, it is higher compared with age-matched controls 7 and related to arrhythmias in 14 % of all deaths after initial repair. hearts have the highest risk of SCD (2-9 % per decade). [8][9][10] In the German National Register for Congenital Heart Defects for adult patients, the mortality rate during a median follow-up of 3.7 years was 9.2 % among 2596 patients, with heart failure (27.6 %) and SCD (23.0 %) as the leading causes of death. 11 Deceased patients had a more complex CHD and extracardiac comorbidities.The treatment of CHD imposes certain safety considerations when choosing antiarrhythmic drugs while various cardiac anatomical barriers and required operator expertise should be taken into account when referring patients for catheter ablation. The complex cardiac anatomy and haemodynamic changes require special precautions related to the increased risk of pro-arrhythmia when using antiarrhythmic drugs and the need for specialised expertise and sophisticated mapping systems when complex catheter ablation procedures are performed.Pre-procedural cardiac imaging with a variety of methodologies can assist with venous access to the heart, determining details of native cardiovascular anatomy and the nature of corrective surgery and evaluation of ventricular function. Reviewing all tachycardias from prior ECGs is also important before the procedure. The success rates after catheter ablation in patients with ACHD is somewhat lower compared with the general population, with acute and long-term success rates AbstractAn increasing number of patients with congenital heart disease survive to adulthood; such prolonged survival is related to a rapid evolution of successful surgical repairs and modern diagnostic techniques. Despite these improvements, corrective atrial incisions performed at surgery still lead to subsequent myocardial scarring harbouring a potential substrate for macro-reentrant atrial tachycardia. Macroreentrant atrial tachycardias are the mo...

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Catheter ablation of tachycardia arising from the pulmonary venous atrium after surgical repair of congenital heart disease

Cited by 13 publications

References 23 publications

Management of supraventricular arrhythmias in adults with congenital heart disease

Management of supraventricular arrhythmias in adults with congenital heart disease

Transcaval Puncture for Access to the Pulmonary Venous Atrium After the Extracardiac Total Cavopulmonary Connection Operation

Supraventricular Arrhythmias in Patients with Adult Congenital Heart Disease

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