Management for atrial arrhythmias in adults with complex congenital heart disease

ABSTRACT

Introduction

The prevalence of congenital heart disease (CHD) is steadily increasing among adults. Atrial arrhythmias are frequent late complications and are associated with substantial morbidity.

Areas covered

We discuss key considerations regarding management strategies for atrial arrhythmias in common forms of CHD and offer future perspectives.

Expert opinion

An appreciation of the types of atrial arrhythmias encountered in patients with diverse forms of CHD, combined with the growing clinical and research experience, appears to be yielding favorable results, whereas little progress has been made on the antiarrhythmic drug front, indications for anticoagulation have considerably evolved. Advances in interventional techniques have propelled catheter ablation to the forefront to treat a variety of atrial arrhythmias in patients with complex CHD. Nevertheless, much work remains to be done to elucidate underlying pathophysiology, triggers, and critical substrates that predispose patients with specific CHD malformations to develop atrial arrhythmias. Future advances could allow for the implementation of individualized, possibly preemptive, approaches to arrhythmia management. With the prevalence of atrial fibrillation on the rise in the aging population with CHD, concerted efforts must be directed toward optimizing patient selection for catheter ablation as well as refining procedural aspects to safely and more effectively improve long-term outcomes.

KEYWORDS:

• Adult congenital heart disease
• atrial arrhythmias
• catheter ablation
• heart defect
• anticoagulation

Article highlights

• Atrial arrhythmias are common in adults with CHD, with a prevalence estimated at around 15% and a lifetime incidence >50% in patients with complex defects

• A rhythm control strategy (maintenance of sinus rhythm) is generally the preferred initial approach to management considering the potential hemodynamic consequences of atrial arrhythmias in this population

• Catheter ablation outcomes have substantially improved such that ablation is increasingly performed as first-line therapy for atrial arrhythmias in patients with CHD

• Much remains to be elucidated regarding atrial fibrillation in patients with CHD, such as specific underlying mechanisms and optimal management approaches (including the substrate to target during catheter ablation)

• The prevalence of stroke is high in patients with CHD and atrial arrhythmias, underscoring the importance of thromboprophylaxis. The experience with NOACs is expanding, but indications remain controversial for certain subgroups, such as those with Fontan palliation or cyanotic heart disease

• Atrial arrhythmias in adults with CHD should be managed in specialized centers with multidisciplinary expertise

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

P Khairy is supported by the André Chagnon research chair in electrophysiology and congenital heart disease.