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Electrophysiological characteristics of atrial tachycardia recurrence: Relevance to catheter ablation strategies in adults with congenital heart disease

  • Jeremy P. Moore
    Correspondence
    Address reprint requests and correspondence: Dr Jeremy P. Moore, Division of Cardiology, Department of Medicine, Ahmanson/UCLA Adult Congenital Heart Disease Center, 100 Medical Plaza Drive, Suite 770, Los Angeles, CA 90095.
    Affiliations
    Division of Cardiology, Department of Medicine, Ahmanson/UCLA Adult Congenital Heart Disease Center, Los Angeles, California

    UCLA Cardiac Arrhythmia Center, UCLA Health System, Los Angeles, California

    Division of Cardiology, Department of Pediatrics, UCLA Health System, Los Angeles, California
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  • Austin Burrows
    Affiliations
    David Geffen School of Medicine, Los Angeles, California
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  • Roberto G. Gallotti
    Affiliations
    Division of Cardiology, Department of Medicine, Ahmanson/UCLA Adult Congenital Heart Disease Center, Los Angeles, California

    UCLA Cardiac Arrhythmia Center, UCLA Health System, Los Angeles, California

    Division of Cardiology, Department of Pediatrics, UCLA Health System, Los Angeles, California
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  • Kevin M. Shannon
    Affiliations
    Division of Cardiology, Department of Medicine, Ahmanson/UCLA Adult Congenital Heart Disease Center, Los Angeles, California

    UCLA Cardiac Arrhythmia Center, UCLA Health System, Los Angeles, California

    Division of Cardiology, Department of Pediatrics, UCLA Health System, Los Angeles, California
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Published:October 07, 2021DOI:https://doi.org/10.1016/j.hrthm.2021.10.003

      Background

      Catheter ablation outcomes for adults with congenital heart disease (ACHD) are described, but recurrence mechanisms remain largely unknown.

      Objective

      The purpose of this study was to identify the electrophysiological characteristics of atrial tachycardia (AT) recurrence in ACHD.

      Methods

      ACHD atrial tachycardia procedures over a 10-year period were explored for AT or atrial fibrillation (AF) recurrence.

      Results

      At 299 procedures in 250 ACHD (mean age 39 ± 15 years; 130 [52%] male), 464 ATs (360 intra-atrial reentrant tachycardia, 104 focal AT; median 2 [IQR 1–3] ATs per procedure) were targeted. Complete (n = 256 [86%]) or partial (n = 37 [12%]) success was achieved in 98% of procedures. Over a median of 3.0 (IQR 1.4–5.3) years of follow-up, 67 patients (27%) developed AT/AF recurrence after the index procedure. Repeat vs index tachycardias were more often focal AT (26/69 [38%] vs 73/378 [19%]; P < .001), demonstrated longer cycle length (325 ms vs 280 ms; P = .003), required isoproterenol (34/69 [50%] vs 121/378 [32%]; P = .03), and involved the pulmonary venous atrium (PVA)/septum (26/69 [38%] vs 67/378 [18%]; P < .001). AF history (hazard ratio [HR] 2.0; interquartile range [IQR] 1.2–3.4; P = .01), incomplete success (HR 3.6; IQR 2.1–6.4; P < .001), and PVA substrate (HR 2.1; IQR 1.2–3.5; P = .006) were independently associated with AT/AF recurrence. With complete index procedure success and no AF history, 5-year actuarial freedom from AT/AF and AT alone were 77% and 80%.

      Conclusion

      After catheter ablation in ACHD, repeat ATs were more frequently focal, required isoproterenol administration, or involved intra-atrial reentrant tachycardia within the PVA or atrial septum. Negative factors were partial success, index PVA substrate, and remote history of AF. These data support aggressive pharmacological provocation to eliminate all inducible tachycardias and coexisting PVA substrates at index procedures for ACHD.

      Keywords

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      References

        • Klehs S.
        • Schneider H.E.
        • Backhoff D.
        • Paul T.
        • Krause U.
        Radiofrequency catheter ablation of atrial tachycardias in congenital heart disease: results with special reference to complexity of underlying anatomy.
        Circ Arrhythm Electrophysiol. 2017; 10e005451
        • Grubb C.S.
        • Lewis M.
        • Whang W.
        • et al.
        Catheter ablation for atrial tachycardia in adults with congenital heart disease: electrophysiological predictors of acute procedural success and post-procedure atrial tachycardia recurrence.
        JACC Clin Electrophysiol. 2019; 5: 438-447
        • Waldmann V.
        • Amet D.
        • Zhao A.
        • et al.
        Catheter ablation of intra-atrial reentrant/focal atrial tachycardia in adult congenital heart disease: value of final programmed atrial stimulation.
        Heart Rhythm. 2020; 17: 1953-1959
        • de Groot N.M.
        • Zeppenfeld K.
        • Wijffels M.C.
        • et al.
        Ablation of focal atrial arrhythmia in patients with congenital heart defects after surgery: role of circumscribed areas with heterogeneous conduction.
        Heart Rhythm. 2006; 3: 526-535
        • Kalman J.M.
        • VanHare G.F.
        • Olgin J.E.
        • Saxon L.A.
        • Stark S.I.
        • Lesh M.D.
        Ablation of ‘incisional’ reentrant atrial tachycardia complicating surgery for congenital heart disease—use of entrainment to define a critical isthmus of conduction.
        Circulation. 1996; 93: 502-512
        • Love B.A.
        • Collins K.K.
        • Walsh E.P.
        • Triedman J.K.
        Electroanatomic characterization of conduction barriers in sinus/atrially paced rhythm and association with intra-atrial reentrant tachycardia circuits following congenital heart disease surgery.
        J Cardiovasc Electrophysiol. 2001; 12: 17-25
        • Triedman J.K.
        • Alexander M.E.
        • Love B.A.
        • et al.
        Influence of patient factors and ablative technologies on outcomes of radiofrequency ablation of intra-atrial re-entrant tachycardia in patients with congenital heart disease.
        J Am Coll Cardiol. 2002; 39: 1827-1835
        • Roca-Luque I.
        • Rivas-Gandara N.
        • Dos Subira L.
        • et al.
        Long-term follow-up after ablation of intra-atrial re-entrant tachycardia in patients with congenital heart disease: types and predictors of recurrence.
        JACC Clin Electrophysiol. 2018; 4: 771-780
        • Waldmann V.
        • Amet D.
        • Zhao A.
        • et al.
        Catheter ablation in adults with congenital heart disease: a 15-year perspective from a tertiary centre.
        Arch Cardiovasc Dis. 2021; 114: 455-464
        • Yap S.C.
        • Harris L.
        • Silversides C.K.
        • Downar E.
        • Chauhan V.S.
        Outcome of intra-atrial re-entrant tachycardia catheter ablation in adults with congenital heart disease: negative impact of age and complex atrial surgery.
        J Am Coll Cardiol. 2010; 56: 1589-1596
        • de Groot N.M.
        • Atary J.Z.
        • Blom N.A.
        • Schalij M.J.
        Long-term outcome after ablative therapy of postoperative atrial tachyarrhythmia in patients with congenital heart disease and characteristics of atrial tachyarrhythmia recurrences.
        Circ Arrhythm Electrophysiol. 2010; 3: 148-154
        • Warnes C.A.
        • Williams R.G.
        • Bashore T.M.
        • et al.
        ACC/AHA 2008 guidelines for the management of adults with congenital heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Develop Guidelines on the Management of Adults With Congenital Heart Disease). Developed in Collaboration With the American Society of Echocardiography, Heart Rhythm Society, International Society for Adult Congenital Heart Disease, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons.
        J Am Coll Cardiol. 2008; 52: e143-e263
        • Calkins H.
        • Willems S.
        • Gerstenfeld E.P.
        • et al.
        Uninterrupted dabigatran versus warfarin for ablation in atrial fibrillation.
        N Engl J Med. 2017; 376: 1627-1636
      1. Moore JP, Bowman H, Gallotti RG, Shannon KM. Mechanisms and outcomes of catheter ablation for biatrial tachycardia in adults with congenital heart disease [published online ahead of print June 25, 2021]. Heart Rhythm. https://doi.org/10.1016/j.hrthm.2021.06.1193.

        • Moore J.P.
        • Buch E.
        • Gallotti R.G.
        • Shannon K.M.
        Ultrahigh-density mapping supplemented with global chamber activation identifies noncavotricuspid-dependent intra-atrial re-entry conduction isthmuses in adult congenital heart disease.
        J Cardiovasc Electrophysiol. 2019; 30: 2797-2805
        • Collins K.K.
        Location of acutely successful radiofrequency catheter ablation of intraatrial reentrqant tachycardia.
        Am J Cardiol. 2000; 86: 969
        • Seslar S.P.
        • Alexander M.E.
        • Berul C.I.
        • Cecchin F.
        • Walsh E.P.
        • Triedman J.K.
        Ablation of nonautomatic focal atrial tachycardia in children and adults with congenital heart disease.
        J Cardiovasc Electrophysiol. 2006; 17: 359-365
        • Gallotti R.G.
        • Madnawat H.
        • Shannon K.M.
        • Aboulhosn J.A.
        • Nik-Ahd F.
        • Moore J.P.
        Mechanisms and predictors of recurrent tachycardia after catheter ablation for d-transposition of the great arteries after the Mustard or Senning operation.
        Heart Rhythm. 2017; 14: 350-356
        • Steinberg J.S.
        • Romanov A.
        • Musat D.
        • et al.
        Prophylactic pulmonary vein isolation during isthmus ablation for atrial flutter: the PReVENT AF Study I.
        Heart Rhythm. 2014; 11: 1567-1572
        • Schneider R.
        • Lauschke J.
        • Tischer T.
        • et al.
        Pulmonary vein triggers play an important role in the initiation of atrial flutter: initial results from the prospective randomized Atrial Fibrillation Ablation in Atrial Flutter (Triple A) trial.
        Heart Rhythm. 2015; 12: 865-871