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Catheter Ablation in Pediatric Congenital Heart Disease

2019; Lippincott Williams & Wilkins; Volume: 12; Issue: 11 Linguagem: Inglês

10.1161/circep.119.008019

1941-3149

Jennifer N. Avari Silva, George F. Van Hare,

Atrial Fibrillation Management and Outcomes

HomeCirculation: Arrhythmia and ElectrophysiologyVol. 12, No. 11Catheter Ablation in Pediatric Congenital Heart Disease Free AccessEditorialPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessEditorialPDF/EPUBCatheter Ablation in Pediatric Congenital Heart DiseaseA Modern Perspective Jennifer N. Avari Silva, MD and George F. Van Hare, MD Jennifer N. Avari SilvaJennifer N. Avari Silva Jennifer N. Avari Silva, MD, Washington University in St Louis, Department of Pediatrics, Cardiology, 1 Children's Pl, CB 8116 NWT, St Louis, MO 63108. Email E-mail Address: [email protected] Department of Pediatrics, Division of Cardiology, Washington University School of Medicine, St Louis, MO (J.N.A.S., G.F.V.H.). Department of Biomedical Engineering, Washington University McKelvey School of Engineering, St Louis, MO (J.N.A.S.). and George F. Van HareGeorge F. Van Hare Department of Pediatrics, Division of Cardiology, Washington University School of Medicine, St Louis, MO (J.N.A.S., G.F.V.H.). Originally published14 Nov 2019https://doi.org/10.1161/CIRCEP.119.008019Circulation: Arrhythmia and Electrophysiology. 2019;12:e008019This article is a commentary on the followingArrhythmia Mechanisms and Outcomes of Ablation in Pediatric Patients With Congenital Heart DiseaseSee Article by Houck et alFor he that fights and runs away; May live to fight another day…—Demosthenes, 338BCArrhythmias in pediatric patients with congenital heart disease (CHD) represent a significant cause of morbidity and mortality in these vulnerable children. Unfortunately, to date, there has been no systematic depiction of the arrhythmic substrates and median term clinical outcome measurements in these patients in the more recent era of catheter ablation.In this issue of Circulation: Arrhythmia and Electrophysiology, Houck et al1 present a detailed retrospective 2-institution review of consecutive pediatric patients with CHD who underwent transcatheter ablation from 2007 to 2018, collecting a cohort of 232 patients. Greater than 75% of the patients presented had 2-ventricle substrates or surgical repairs, with Ebstein anomaly being the most common substrate. Accessory pathways were the most common electrophysiological substrate identified, followed by macroreentrant atrial tachycardias. Complete or partial procedural ablation success was achieved in 84% of cases with an adverse event rate of 9.4%. By 3.6 years follow-up, there were recurrent arrhythmias observed in 49% of patients. Importantly, recurrent arrhythmias following initial ablation were found to represent a different or new electrophysiological substrate in 26% of patients who underwent repeat electrophysiology studies. We congratulate the authors on reporting their ablation results such a large group of children with CHD, who for most programs represent a small minority of the total ablation population.There are several noteworthy takeaways. Acute procedural success rates for patients with CHD have remained rather steady in the current area of ablation. Recent data from the Multicenter Pediatric and Congenital EP Quality Initiative registry2 compiled acute procedural success rates across 12 centers with an acute success rate of 84% in patients with CHD. Papagiannis et al3 published a comprehensive retrospective study of over 100 patients with CHD from 16 centers specifically with atrioventricular nodal reentrant tachycardia and showed success rates of ≥82% with long term success of ≥86% at 3.2 years. This is particularly interesting because 22 patients (20%) presented with atypical atrioventricular nodal reentry tachycardia, which is known to have higher rates of procedural failure likely secondary to abnormal anatomy coupled with displaced conduction tissue and challenging access to the slow pathway.Looking at earlier reports from 2004, Hebe et al4 report acute success rates in CHD ablations of 88%. Despite the technological advances made in the field of cardiac ablation over the past 15 years that have demonstrated improvements in procedural success rates for certain patient cohorts, outcomes have not markedly improved in the CHD population. Yet, we know that these technologies are being utilized in this population. For example, irrigated tip radiofrequency ablation catheters were over 3× more likely to be utilized in the CHD cohort as compared to the non-CHD cohort2 without an associated improvement in success rates. Future studies assessing the impact of these and other emerging technologies, such as ultrasound/image integration, remote/robotic navigation, and high-density mapping catheters, will likely be forthcoming and may demonstrate improved patient outcomes.Despite the consistency in the rates of acute procedural success, the rates of complications in these complex procedures have been less consistent. Analysis of data from Multicenter Pediatric and Congenital EP Quality Initiative data showed a relatively high complication rate of 16%2 in contrast to the current study.1 The data from Multicenter Pediatric and Congenital EP Quality Initiative are less granular in subcategorizing these complications into major verses minor severity. That being the case, it is quite reasonable to suspect that many of the complications reported into Multicenter Pediatric and Congenital EP Quality Initiative were in fact of only minor severity, which would be more consistent with the data presented by Houck et al.1Another important observation in the study group from Houck et al1 is that recurrent arrhythmias were seen in 49% of patients over 3.6 years of follow-up with a median time to recurrence of 2.5 months, with two-thirds of patients having recurrent symptoms within the first year following ablation. Perhaps unexpectedly, when patients underwent repeat procedures, a different or new arrhythmic substrate was found in 39% of patients, most commonly focal atrial tachycardias. Indeed, this population with recurrent arrhythmias are difficult to treat with documented arrhythmia recurrence observed in 54% of patients after their last repeat procedure.The complex hemodynamics associated with many of these anatomic substrates place these patients are increased risk for acquired arrhythmias, such as macroreentrant and focal atrial tachycardias. This finding was verified in this patient cohort1 but represents an opportunity for the pediatric and congenital electrophysiology community to perhaps reconsider ablation strategy in these patients. In patients without CHD, we often have the opportunity to cure a large percentage of patients ablated in the electrophysiology laboratory—acute success of ≥97% and chronic success of 93%.2 The CHD population, however, is different in that we are often performing surgeries and interventions that are primarily palliative rather than corrective. The high incidence of recurrence reported in the current study suggests that the arrhythmia care of these complex patients should follow a similar path, with a lower expectation for cure but a recognition of the value of clinical improvement.To this end, Houck et al1 devised an arrhythmia severity score, ascertained by scouring the medical records retrospectively to calculate a score both preprocedure and during follow-up period. The arrhythmia score is calculated based on 4 categories: (1) documentation and burden of arrhythmia (none to incessant), (2) arrhythmia severity (asymptomatic to cardiac arrest), (3) need for cardioversion (none to ≥2 cardioversions), and (4) antiarrhythmic medications (none/digoxin only to amiodarone toxicity). Preablation, the median composite score (range, 0–10) for patients (n=83) was 4, with the score significantly decreasing from baseline to 1 to 2 over the 48-month follow-up window. Despite the high recurrence rate of arrhythmias, it is reasonable to infer from the arrhythmia severity score that patients were feeling better with a better quality of life. This is a very reassuring and important finding from these data.Traditional outcome measures for complex ablation procedures have historically focused on arrhythmia recurrence.5 The electrophysiological corollary in the pediatric CHD ablation population to the adult population is atrial fibrillation. Over time, clinical trialists have evolved outcome measures used for patients following atrial fibrillation ablation to include patient-reported outcomes such as severity of symptoms and quality of life, which may significantly improve despite recurrence of atrial fibrillation.6,7 By employing the arrhythmia score as an outcome measure, the authors are making a step towards incorporating quality of life measures for ablation success.In 338BC, Demosthenes is attributed has saying "For he that fights and runs away, lives to fight another day" after deserting his peers on the battlefield at the Battle of Chaeronea. He lived for an additional 15 years as a professional lawyer. Perhaps our lesson to learn from history is to bravely face these complex arrhythmias in CHD knowing that the best strategy is to fight and run so that we may be able to fight again when future arrhythmias arise.DisclosuresDr Van Hare does not have any relevant conflicts of interest to disclose. Dr Silva is a cofounder, inventor, chief medical officer, and board of directors for SentiAR, Inc. No direct conflict of disclosure. She receives research support from Abbott, AliveCor and participates in the Clinical Events Committee and Data Safety Monitoring Board for Cardialen.FootnotesThe opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.Jennifer N. Avari Silva, MD, Washington University in St Louis, Department of Pediatrics, Cardiology, 1 Children's Pl, CB 8116 NWT, St Louis, MO 63108. Email [email protected]eduReferences1. Houck CA, Chandler SF, Bogers AJJC, Triedman JK, Walsh EP, de Groot NMS, Abrams DJ. Arrhythmia mechanisms and outcomes of ablation in pediatric patients with congenital heart disease.Circ Arrhythm Electrophysiol. 2019; 12:e007663. doi: 10.1161/CIRCEP.119.007663LinkGoogle Scholar2. Dubin AM, Jorgensen NW, Radbill AE, Bradley DJ, Silva JN, Tsao S, Kanter RJ, Tanel RE, Trivedi B, Young ML, Pflaumer A, McCormack J, Seslar SP. What have we learned in the last 20 years? A comparison of a modern era pediatric and congenital catheter ablation registry to previous pediatric ablation registries.Heart Rhythm. 2019; 16:57–63. doi: 10.1016/j.hrthm.2018.08.013CrossrefMedlineGoogle Scholar3. Papagiannis J, Beissel DJ, Krause U, Cabrera M, Telishevska M, Seslar S, Johnsrude C, Anderson C, Tisma-Dupanovic S, Connelly D, Avramidis D, Carter C, Kornyei L, Law I, Von Bergen N, Janusek J, Silva J, Rosenthal E, Willcox M, Kubus P, Hessling G, Paul T; Pediatric and Congenital Electrophysiology Society. Atrioventricular nodal reentrant tachycardia in patients with congenital heart disease: outcome after catheter ablation.Circ Arrhythm Electrophysiol. 2017; 10:e004869. doi: 10.1161/CIRCEP.116.004869LinkGoogle Scholar4. Hebe J, Hansen P, Ouyang F, Volkmer M, Kuck KH. Radiofrequency catheter ablation of tachycardia in patients with congenital heart disease.Pediatr Cardiol. 2000; 21:557–575. doi: 10.1007/s002460010134CrossrefMedlineGoogle Scholar5. Terricabras M, Verma A, Morillo CA. Measuring success in ablation of atrial fibrillation: time for a paradigm shift?Circ Arrhythm Electrophysiol. 2018; 11:e006582. doi: 10.1161/CIRCEP.118.006582LinkGoogle Scholar6. Wokhlu A, Monahan KH, Hodge DO, Asirvatham SJ, Friedman PA, Munger TM, Bradley DJ, Bluhm CM, Haroldson JM, Packer DL. Long-term quality of life after ablation of atrial fibrillation the impact of recurrence, symptom relief, and placebo effect.J Am Coll Cardiol. 2010; 55:2308–2316. doi: 10.1016/j.jacc.2010.01.040CrossrefMedlineGoogle Scholar7. Mantovan R, Macle L, De Martino G, Chen J, Morillo CA, Novak P, Calzolari V, Khaykin Y, Guerra PG, Nair G, Torrecilla EG, Verma A. Relationship of quality of life with procedural success of atrial fibrillation (AF) ablation and postablation AF burden: substudy of the STAR AF randomized trial.Can J Cardiol. 2013; 29:1211–1217. doi: 10.1016/j.cjca.2013.06.006CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited ByKapa S, Chung M, Gopinathannair R, Noseworthy P, Eckhardt L, Leal M, Wan E and Wang P (2020) Year in Review in Cardiac Electrophysiology, Circulation: Arrhythmia and Electrophysiology, 13:6, Online publication date: 1-Jun-2020.Related articlesArrhythmia Mechanisms and Outcomes of Ablation in Pediatric Patients With Congenital Heart DiseaseCharlotte A. Houck, et al. Circulation: Arrhythmia and Electrophysiology. 2019;12 November 2019Vol 12, Issue 11 Advertisement Article InformationMetrics © 2019 American Heart Association, Inc.https://doi.org/10.1161/CIRCEP.119.008019PMID: 31722542 Originally publishedNovember 14, 2019 Keywordstachycardiacongenital heart diseaseelectrophysioogycatheter ablationEditorialsPDF download Advertisement SubjectsArrhythmiasCongenital Heart DiseaseElectrophysiologyPediatrics