Recurrent sustained atrial arrhythmias and thromboembolism in Fontan patients with total cavopulmonary connection (original) (raw)
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Congenital Heart Disease, 2018
Background: Catheter ablation is commonly performed to treat atrial arrhythmias in adult congenital heart disease (ACHD). Despite the frequency of ablations in the ACHD population, predictors of recurrence remain poorly defined. Objective: We sought to determine predictors of arrhythmia recurrence in ACHD patients following catheter ablation for atrial arrhythmias. Methods: We performed a retrospective study of all catheter ablations for atrial arrhythmias performed in ACHD patients between January 12, 2005 and February 11, 2015 at our institution. Prespecified exposures of interest and time from ablation to recurrence were determined via chart review. Results: Among 124 patients (mean age: 45 years) who underwent catheter ablation, 96 (77%) were treated for macro-reentrant atrial tachycardia, 10 (7%) for focal atrial tachycardia, 9 (7%) for atrial fibrillation, 7 (6%) for atrioventricular nodal reentrant tachycardia, and 2 (2%) for atrioventricular reentrant tachycardia. 15 (12%) required transseptal/transbaffle puncture. Fifty-one percent of patients recurred with a median time to recurrence of 1639 days. By univariate and multivariable analysis, body mass index (BMI) and Fontan status were the only variables associated with recurrence. Dose-dependent effect was observed with overweight (HR = 2.37, P = .012), obese (HR = 2.67, P = .009), and morbidly obese (HR = 4.23, P = .003) patients demonstrating an increasing risk for arrhythmia recurrence postablation. There was no significant different in recurrence rates by gender, age, non-Fontan diagnosis, or need for transseptal puncture. Conclusions: In our cohort of ACHD patients, BMI was a significant risk factor for arrhythmia recurrence postablation, independent of Fontan status. These findings may help guide treatment decisions for persistent arrhythmias in the ACHD population.
Circulation: Arrhythmia and Electrophysiology, 2010
Background-Catheter ablation has evolved as a possible curative treatment modality for atrial tachyarrhythmia (AT) in patients with congenital heart defects (CHD). However, data on long-term outcome are scarce. We examined characteristics of recurrent AT after ablation of postoperative AT during long-term follow-up in CHD patients. Methods and Results-CHD patients (nϭ53; 27 men; age, 38Ϯ15 years) referred for catheter ablation of AT were studied during a follow-up period of 5Ϯ3 years. After ablative therapy of the first AT (nϭ53, 27 atrial flutter, cycle lengthϭ288Ϯ81 ms; 22 intra-atrial reentrant tachycardia, cycle lengthϭ309Ϯ81 ms; 5 focal atrial tachycardia, cycle lengthϭ380Ϯ147 ms; success rate, 65%), AT recurred (59% within the first year) in 29 patients; 15 underwent repetitive ablative therapy. Mechanisms underlying recurrent AT were similar in 7 patients (intra-atrial reentrant tachycardia, 2; atrial flutter, 5). The location of arrhythmogenic substrates of recurrent AT (intra-atrial reentrant tachycardia, focal atrial tachycardia) was different for all but 1 patient. After 5Ϯ3 years, 5 patients died of heart failure, 3 were lost to follow-up, and the remaining patients had sinus rhythm (nϭ31), AT (nϭ5), or atrial flutter (nϭ14). Antiarrhythmic drugs were used by 18 (57%) sinus rhythm patients.
Arrhythmias in a Contemporary Fontan Cohort
Journal of the American College of Cardiology, 2010
Objectives-Our aim was to examine the prevalence of arrhythmias and identify independent associations of time to arrhythmia development.
Impact of atrial arrhythmias on outcome in adults with congenital heart disease
International Journal of Cardiology, 2017
Background: Adults with congenital heart disease (ACHD) are affected by atrial arrhythmias (AA). To elucidate the impact of AA on prognosis, we aimed to determine the impact of AA on death, heart failure and stroke in ACHD patients in a prospective nationwide clinical registry. Methods: All patients aged ≥18 years included in the CONCOR registry per October 1st 2015 were analysed. Prior AA was defined as atrial fibrillation, atrial flutter or unspecified AA before inclusion in CONCOR and new-onset AA as a first documented AA during follow-up. The outcomes were death, first stroke and first admission for heart failure (HF). Results: The study cohort comprised 14,224 patients (baseline median age 33.6 [IQR 23-47], male 49.5%, AA n = 1501, complex defect 10.3%, repaired defect 58.9%). Median follow-up was 6.5 years [IQR 3-10]. Adjusting for age, sex, repair status and defect severity, patients with prior AA had higher mortality and more HF admissions, but no increased risk of stroke compared to those without AA (HR = 2.11; 95% CI = 1.79-2.49; p b 0.001, HR = 4.06; 95% CI = 2.66-6.19; p b 0.001 and HR = 1.09; 95% CI = 0.71-1.68; p = 0.698, respectively). New-onset AA during follow-up was significantly associated with stroke (HR = 2.04; 95% CI = 1.05-3.96; p = 0.036). Conclusions: ACHD patients with prior AA have a 2-fold increased risk of death and a 4-fold increased risk of heart failure, but no increased risk for stroke compared to those without AA. Defect severity and age appear to be more important risk factors for stroke than prior AA. Stroke risk is increased only after conversion of new onset AA.
Journal of the American College of Cardiology, 2017
BACKGROUND Atrial arrhythmias are the most common complication encountered in the growing and aging population with congenital heart disease. OBJECTIVES This study sought to assess the types and patterns of atrial arrhythmias, associated factors, and age-related trends. METHODS A multicenter cohort study enrolled 482 patients with congenital heart disease and atrial arrhythmias, age 32.0 AE 18.0 years, 45.2% female, from 12 North American centers. Qualifying arrhythmias were classified by a blinded adjudicating committee. RESULTS The most common presenting arrhythmia was intra-atrial re-entrant tachycardia (IART) (61.6%), followed by atrial fibrillation (28.8%), and focal atrial tachycardia (9.5%). The proportion of arrhythmias due to IART increased with congenital heart disease complexity from 47.2% to 62.1% to 67.0% in patients with simple, moderate, and complex defects, respectively (p ¼ 0.0013). Atrial fibrillation increased with age to surpass IART as the most common arrhythmia in those 50yearsofage(51.250 years of age (51.2% vs. 44.2%; p < 0.0001). Older age (odds ratio [OR]: 1.024 per year; 95% confidence interval [CI]: 1.010 to 1.039; p ¼ 0.001) and hypertension (OR: 2.00; 95% CI: 1.08 to 3.71; p ¼ 0.029) were independently associated with atrial fibrillation. During a mean follow-up of 11.3 AE 9.4 years, the predominant arrhythmia pattern was paroxysmal in 62.3%, persistent in 28.2%, and permanent in 9.5%. Permanent atrial arrhythmias increased with age from 3.1% to 22.6% in patients <20 years to 50yearsofage(51.250 years, respectively (p < 0.0001). CONCLUSIONS IART is the most common presenting atrial arrhythmia in patients with congenital heart disease, with a predominantly paroxysmal pattern. However, atrial fibrillation increases in prevalence and atrial arrhythmias progressively become permanent as the population ages.
Thromboprophylaxis for atrial arrhythmias in congenital heart disease: A multicenter study
Background: There is a paucity of data to guide decisions regarding thromboprophylaxis for atrial arrhythmias in congenital heart disease. Methods: A retrospective multicenter cohort study enrolled patients with documented sustained atrial arrhyth-mias and congenital heart disease from 12 North American centers to quantify thromboembolic and bleeding rates associated with antiplatelet and anticoagulation therapy, and explore associated factors. A blinded committee adjudicated all qualifying arrhythmias and outcomes. Results: A total of 482 patients, 45.2% female, age 32.0 ± 18.0 years, were followed for 11.3 ± 9.4 years since the qualifying arrhythmia. Antiplatelet therapy was administered to 37.8%, anticoagulation to 54.4%, and neither to 7.9%. Congenital heart disease complexity was simple, moderate, and severe in 18.5%, 34.4%, and 47.1%, respectively. Freedom from thromboembolic events was 84.7 ± 2.7% at 15 years, with no difference between anticoagulation versus antiplatelet therapy (P = 0.97). Congenital heart disease complexity was independently associated with thromboembolic events, with rates of 0.00%, 0.93%, and 1.95%/year in those with simple, moderate , and severe forms (P b 0.001). CHADS 2 and CHA 2 DS 2-VASc scores were not predictive of thromboembolic risk. Annualized bleeding rates with antiplatelet and anticoagulation therapy were 0.66% and 1.82% (P = 0.039). In multivariable analyses, anticoagulation [hazard ratio (HR) 4.76, 95% CI (1.05–21.58), P = 0.043] and HAS-BLED score [HR 3.15, 95% CI (1.02, 9.78), P = 0.047] were independently associated with major bleeds.
International journal of cardiology, 2018
Supraventricular ectopic complexes (SVEC) are known risk factors of recurrent atrial fibrillation (AF). However, the impact of SVEC in different age groups is unknown. We aimed to investigate the risk of AF recurrence with higher SVEC burden in patients ±57years, respectively, after treatment with antiarrhythmic medication (AAD) or catheter ablation (CA). In total, 260 patients with LVEF >40% and age ≤70 years were randomized to AAD (N=132) or CA (N=128) as first-line treatment for paroxysmal AF. All patients underwent 7-day Holter monitoring at baseline, and after 3, 6, 12, 18 and 24months and were categorized according to median age ±57years. We used multivariate Cox regression analyses and we defined high SVEC burden at 3months of follow-up as the upper 75th percentile >195SVEC/day. AF recurrence was defined as AF ≥1min, AF-related cardioversion or hospitalization. Age >57years were significantly associated with higher AF recurrence rate after CA (58% vs 36%, p=0.02). Af...
Atrial Arrhythmias in Adults With Congenital Heart Disease
Circulation, 2009
Background-Atrial arrhythmias increase disease burden in the general adult population. Adults with congenital heart lesions constitute a rapidly growing group of patients with cardiovascular disease. We hypothesized that atrial arrhythmias increase with age and impair health outcomes in this population. Methods and Results-We conducted a population-based analysis of prevalence, lifetime risk, mortality, and morbidity associated with atrial arrhythmias in adults with congenital heart disease from l983 to 2005. In 38 428 adults with congenital heart disease in 2005, 5812 had atrial arrhythmias. Overall, the 20-year risk of developing atrial arrhythmia was 7% in a 20-year-old subject and 38% in a 50-year-old subject. More than 50% of patients with severe congenital heart disease reaching age 18 years developed atrial arrhythmias by age 65 years. In patients with congenital heart disease, the hazard ratio of any adverse event in those with atrial arrhythmias compared with those without was 2.50 (95% confidence interval, 2.38 to 2.62; PϽ0.0001), with a near 50% increase in mortality (hazard ratio, 1.47; 95% confidence interval, 1.37 to 1.58; PϽ0.001), more than double the risk of morbidity (stroke or heart failure) (hazard ratio, 2.21; 95% confidence interval, 2.07 to 2.36; PϽ0.001), and 3 times the risk of cardiac interventions (hazard ratio, 3.00; 95% confidence interval, 2.81 to 3.20; PϽ0.001). Conclusions-Atrial arrhythmias occurred in 15% of adults with congenital heart disease. The lifetime incidence increased steadily with age and was associated with a doubling of the risk of adverse events. An increase in resource allocation should be anticipated to deal with this increasing burden.