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Fontan Global Case Conference Richard J. Czosek, MD 6/28/17
The Role of Catheter Ablation in Fontan Arrhythmia Control: Patient Based Decision Making Fontan Global Case Conference Richard J. Czosek, MD 6/28/17
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Patient 1 20 yo with non-fenestrated extra-cardiac Fontan who recently had their first episode of atrial tachycardia They were cardioverted without issue and are now on Coumadin Currently 3 months from this first episode of tachycardia currently on no anti-arrhythmic medications Patient 2 43 yo with a atrio-pulmonary Fontan with history of multiple cardioversions for atrial tachycardia with recent increase in symptomatology and 3-4 episodes in the past 12 months History previous ablation procedure 4 years prior Currently on Coumadin as well as amiodarone with continued breakthrough episodes of tachycardia
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Prevalence of Atrial Flutter/IART in Fontan
Fishberger, et al., Jour. Thor. Card. Surgery, 1997
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Role of Trans-catheter Ablation
Medication DCCV Surgical Ablation Pacing Rate Control
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Recurrence of Atrial Tachycardia
Egbe et al., Int. Journ. Of Cardiology, 2016
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Risk of Atrial Tachycardia Recurrence
Egbe et al, American Heart Journal, 2017
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To ablate or not to ablate
Don’t Ablate
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When to ablate? Ablation DCCV/ Pacing Fontan + Arrhythmia Medications/
Rate Control
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Fontan Patient Decision Tools
Trans-catheter Ablation Medications Surgical Ablation Medications Trans-catheter Ablation Surgical Ablation Decision Fontan Patient Atrial Arrhythmia Surgical Ablation Medications Decision Tools Patient Age Fontan Type Tachycardia Type Frequency of Tachycardia Patient Risk Factors Rate of Tachycardia Patient Preference Physician Preference Center philosophy Monitor for Recurrence Medications Trans-catheter Ablation
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Trans-catheter Ablation
Patient Decision Tools Fontan Type Tachycardia Type Frequency of Tachycardia Patient Risk Factors Rate of Tachycardia Patient Preference Physician Preference Center philosophy Patient Age
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Trans-catheter Ablation
Patient Decision Tools Fontan Type Tachycardia Type Frequency of Tachycardia Patient Risk Factors Rate of Tachycardia Patient Preference Physician Preference Center philosophy Patient Age
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Atrial Arrhythmia and Fontan Type
“Classic” Style Fontan Atrio-pulmonary Fontan Lateral Tunnel Fontan/Intra-atrial Conduit Extra-cardiac Conduit Fontan Fenestrated Kutty et al., Heart, 2015
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Fontan Cardiac Type Fishberger, et al., Jour. Thor. Card. Surgery, 1997
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Classic vs Lateral Tunnel Fontan
Atrio-pulmonary Fontan Stamm et al., Journ. Thor. Card. Surgery, 2001
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Effect of Fontan Type Balaji et al., Cong. Heart Disease, 2013
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Atrio-pulmonary Fontan
Effect of Fontan Type Extra-Cardiac Fontan Lateral Tunnel Fontan Atrio-pulmonary Fontan Pundi et al., Cong. Heart Disease, 2016
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Collins et al, Amer. Heart Journal, 2000
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Access to Tachycardia Substrate
Kutty et al., Heart, 2015
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Access in Differing Styles of Fontan
Frequency of Tachycardia Classic Fontan Lateral Tunnel Extra-Cardiac Ease of Ablation Classic Fontan Lateral Tunnel Extra-Cardiac
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Accessing Substrate In Extra-cardiac Fontan
Moore et al., Heart Rhythm, 2016 Moore et al., Circulation Arr. Elect., 2015
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Risks of Fontan Ablation
Correa et al., JAHA, 2013
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Risks of Fontan Ablation
Correa et al., JAHA, 2013
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Trans-catheter Ablation
Decision Tools Fontan Type Tachycardia Type Frequency of Tachycardia Patient Risk Factors Rate of Tachycardia Patient Preference Physician Preference Center philosophy Patient Age
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Fontan Arrhythmia Mechanism
Arrhythmias Number % of All (n=80) % of Ablations (n=59) Macro-reentrant 25 31% 42% Focal Atrial Tachycardia 8 10% 14% AVNRT 13 16% 22% AVRT 4 5% 7% VT 5 6% 8% Twin Node Undefined 21 26% n/a 57 procedures on 52 patients 80 arrhythmias identified Correa et al, Circ Arrhythm Electrophys, 2014
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Atrial Fibrillation Takahashi et al, Europace, 2008
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Trans-catheter Ablation
Decision Tools Fontan Type Tachycardia Type Frequency of Tachycardia Patient Risk Factors Rate of Tachycardia Patient Preference Physician Preference Center philosophy Patient Age
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Trans-catheter Ablation
Decision Tools Fontan Type Tachycardia Type Frequency of Tachycardia Patient Risk Factors Rate of Tachycardia Patient Preference Physician Preference Center philosophy Patient Age
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Risk Factors for SCD in Fontan
Walsh E, et al, Heart Rhythm, 2014
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Arrhythmia Influence on Fontan
Diller et al, European Heart Journal, 2010
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Risk of Mortality in Fontan
Fontan Type Clinical arrhythmias Symptoms of heart failure Diller et al, Eur. Heart Journal, 2010
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Trans-catheter Ablation
Decision Tools Fontan Type Tachycardia Type Frequency of Tachycardia Patient Risk Factors Rate of Tachycardia Patient Preference Physician Preference Center philosophy
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What is The Goal of Fontan Ablation?
Hiroshi Nakagawa et al. Circulation, 2001
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Outcomes in Fontan Patients With Atrial Arrhythmias
Egbe et al, Amer. Heart Journal., 2016
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Outcomes in Fontan Patients With Atrial Arrhythmias
Egbe et al, Amer. Heart Journal., 2016
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Correa et al., Circulation Arrhythmia Elect., 2015
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Fontan Conversion/Arrhythmia Surgery
Deal et al., Brit. Med. Journal, 2012
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Risk of Atrial Tachycardia Recurrence
Egbe et al, American Heart Journal, 2017
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Trans-catheter Ablation Recurrent Atrial Arrhythmia
Decision Patient Age Fontan Type Frequency of Tachycardia Patient Preference Fontan Patient Atrial Arrhythmia DCCV +/- Meds Recurrent Atrial Arrhythmia Surgical Ablation Decision Patient Age Fontan Type Patient Risk Factors Patient Preference Physician Preference Decision Patient Age Fontan Type Frequency of Tachycardia Patient Preference
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Conclusions Fontan patients with SVT are likely to have recurrence of SVT Anti-arrhythmic medications are reasonable but unlikely to keep patients tachycardia free New onset Atrial Tachycardia or increased tachycardia burden is often an early indicator of other issues Catheter ablation plays a major role in management of SVT in Fontan patients and is reasonable as first or second line management We need to clearly define our goals The role of catheter ablation varies based on center and patient preference The role of catheter ablation is likely to change significantly over the next decades with change in Fontan anatomy
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Patient 1 20 yo with non-fenestrated extra-cardiac Fontan who recently had their first episode of atrial tachycardia They were cardioverted without issue and are now on Coumadin Currently 3 months from this first episode of tachycardia currently on no anti-arrhythmic medications Question 1 Recommend catheter ablation as a first line treatment strategy Recommend monitoring without ablation or anti-arrythmic medication Recommend starting anti-arrhythmic medication without ablation Other
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Patient 2 43 yo with a atrio-pulmonary Fontan with history of multiple cardioversions for atrial tachycardia with recent increase in symptomatology and 3-4 episodes in the past 12 months History previous ablation procedure 4 years prior Currently on Coumadin as well as amiodarone with continued breakthrough episodes of tachycardia Question 2 Recommend catheter ablation with continued anti- arrhythmic mediations Recommend monitoring without ablation or anti-arrythmic medication change Recommend starting a new anti-arrhythmic medication or changing anti-arrhythmic medication without ablation Other
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Cincinnati Children's Hospital Medical Center
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Sudden Death in Fontan Gallego et al, Amer. Journ. Card., 2012
Diller et al, European Heart Journal, 2010
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Is There Disease Specific Risk of SCD?
Gallego et al, Amer. Journ. Card., 2012
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Sudden Death in Fontan’s
Khairy et al., Circulation
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Sudden Death in Fontan Pundi et al., Cong. Heart Disease, 2016
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The Role of Surgical Ablation
Deal et al., Brit. Med. Journal, 2012
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Definition of Success in Fontan Ablation
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Arrhythmic Influence on Single Fontan
Diller et al, European Heart Journal, 2010
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Fontan Arrhythmia Mechanism
Arrhythmias Number % of All (n=80) % of Ablations (n=59) Macro-reentrant 25 31% 42% Focal Atrial Tachycardia 8 10% 14% AVNRT 13 16% 22% AVRT 4 5% 7% VT 5 6% 8% Twin Node Undefined 21 26% n/a 57 procedures on 52 patients 80 arrhythmias identified Access to pulmonary venous atrium Fenestration - 16 Trans-septal - 17 Retrograde - 2 Correa et al, Circ Arrhythm Electrophys, 2014
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