New developments in catheter ablation for patients with congenital heart disease

ABSTRACT

Introduction: There are numerous challenges to catheter ablation in patients with congenital heart disease (CHD), including access to cardiac chambers, distorted anatomies, displaced conduction systems, multiple and/or complex arrhythmia substrates, and excessively thickened walls, or interposed material.

Areas covered: Herein, we review recent developments in catheter ablation strategies for patients with CHD that are helpful in addressing these challenges.

Expert opinion: Remote magnetic navigation overcomes many challenges associated with vascular obstructions, chamber access, and catheter contact. Patients with CHD may benefit from a range of ablation catheter technologies, including irrigated-tip and contact-force radiofrequency ablation and focal and balloon cryoablation. High-density mapping, along with advances in multipolar catheters and interpolation algorithms, is contributing to new mechanistic insights into complex arrhythmias. Ripple mapping allows the activation wave front to be tracked visually without prior assignment of local activation times or window of interest, and without interpolations of unmapped regions. There is growing interest in measuring conduction velocities to identify arrhythmogenic substrates. Noninvasive mapping with a multielectrode-embedded vest allows prolonged bedside monitoring, which is of particular interest in those with non-sustained or multiple arrhythmias. Further studies are required to assess the role of radiofrequency needle catheters and stereotactic radiotherapy in patients with CHD.

KEYWORDS:

• Congenital heart disease
• arrhythmia
• catheter ablation
• remote magnetic navigation
• high-density mapping

Article highlights

• Electroanatomic mapping systems are indispensable tools for catheter ablation in CHD that offer a framework for multimodal data merging.

• Combining electroanatomic mapping with irrigated-tip radiofrequency ablation results in significantly higher success rates in patients with CHD.

• Focal cryoablation is particularly helpful for perinodal substrates in patients with displaced or difficult to predict locations of the conduction system.

• High-density mapping with multi-electrode catheters is providing new insights into complex arrhythmia mechanisms.

• Remote magnetic navigation provides enhanced catheter maneuverability and reach, thereby overcoming many of the challenges associated with accessing the arrhythmogenic substrate of interest in patients with vascular limitations or complex anatomies.

• Developments in non-invasive mapping and focused stereotactic radiotherapy carry the potential to improve outcomes in selected patients with CHD and complex arrhythmias.

• In order for patients to derive maximum benefit from technological advances, increasing the compatibility between available tools is required for seamless integration.

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. M Le Bloa received a training grant from the Société Industrielle et Commerciale de Produits Alimentaires (SICPA).