Atrial fibrillation ablation in adults with congenital heart disease on uninterrupted oral anticoagulation is safe and efficient
The prevalence of atrial fibrillation (AF) is significantly higher in adults with congenital heart disease (ACHD) compared to patients without congenital heart disease (CHD). As AF in ACHD patients might have significant hemodynamic consequences, rhythm control is particularly desirable but rarely achieved by antiarrhythmic drugs. The aim of this study was to investigate safety and long-term outcome of AF ablation in ACHD patients.
All ACHD patients (n = 46) that underwent AF ablation at our centre from 2013 to 2017 were included in the study. CHD was classified as simple (46%), moderate (41%) or complex (13%). The majority of patients (61%) suffered from persistent AF (paroxysmal AF 39%). Persistent AF was present in 57% of patients with simple, in 58% of patients with moderate and 83% of patients with complex CHD. All patients underwent radiofrequency (RF) ablation on uninterrupted oral anticoagulation. Pulmonary vein isolation (PVI) was performed in patients with paroxysmal AF, whereas patients with persistent AF underwent PVI and ablation of complex fractionated atrial electrograms (CFAE).
No major complications occurred. Single-procedure success after 18 months off antiarrhythmic drugs was 61% for paroxysmal AF and 29% for persistent AF (p = 0.003). Multiple procedures (mean 2.1 ± 1.4) increased long-term success to 82% for paroxysmal AF and 48% for persistent AF (p = 0.05). Long-term ablation success was 64% for simple, 62% for moderate and 50% for complex CHD patients.
AF ablation in ACHD patients is feasible and safe regardless of CHD complexity. Success rates in patients with paroxysmal AF are high and comparable to patients without CHD. In ACHD patients with persistent AF, success rates of ablation are markedly reduced which might be due to a different and/or more extensive (bi-)atrial substrate. In the cohort of complex ACHD patients with persistent AF as the dominant AF type, long-term success of AF ablation is limited.
KeywordsAtrial fibrillation Atrial fibrillation ablation Adults with congenital heart disease Oral anticoagulation Pulmonary vein isolation
- 1.Khairy P, Van Hare GF, Balaji S, Berul CI, Cecchin F, Cohen MI, Daniels CJ, Deal BJ, Dearani JA, Groot N, Dubin AM, Harris L, Janousek J, Kanter RJ, Karpawich PP, Perry JC, Seslar SP, Shah MJ, Silka MJ, Triedman JK, Walsh EP, Warnes CA (2014) PACES/HRS expert consensus statement on the recognition and management of arrhythmias in adult congenital heart disease: developed in partnership between the Pediatric and Congenital Electrophysiology Society (PACES) and the Heart Rhythm Society (HRS). Endorsed by the governing bodies of PACES, HRS, the American College of Cardiology (ACC), the American Heart Association (AHA), the European Heart Rhythm Association (EHRA), the Canadian Heart Rhythm Society (CHRS), and the International Society for Adult Congenital Heart Disease (ISACHD). Heart Rhythm 11:e102–165CrossRefGoogle Scholar
- 3.Bhatt AB, Foster E, Kuehl K, Alpert J, Brabeck S, Crumb S, Davidson WR Jr, Earing MG, Ghoshhajra BB, Karamlou T, Mital S, Ting J, Tseng ZH (2015) American Heart Association council on clinical C: congenital heart disease in the older adult: a scientific statement from the American Heart Association. Circulation 131:1884–1931CrossRefGoogle Scholar
- 5.Hernandez-Madrid A, Paul T, Abrams D, Aziz PF, Blom NA, Chen J, Chessa M, Combes N, Dagres N, Diller G, Ernst S, Giamberti A, Hebe J, Janousek J, Kriebel T, Moltedo J, Moreno J, Peinado R, Pison L, Rosenthal E, Skinner JR, Zeppenfeld K (2018) Group ESCSD: arrhythmias in congenital heart disease: a position paper of the European Heart Rhythm Association (EHRA), Association for European Paediatric and Congenital Cardiology (AEPC), and the European Society of Cardiology (ESC) working group on grown-up congenital heart disease, endorsed by HRS, PACES, APHRS, and SOLAECE. Europace 20:1719–1753CrossRefGoogle Scholar
- 6.Khairy P, Van Hare GF, Balaji S, Berul CI, Cecchin F, Cohen MI, Daniels CJ, Deal BJ, Dearani JA, Groot N, Dubin AM, Harris L, Janousek J, Kanter RJ, Karpawich PP, Perry JC, Seslar SP, Shah MJ, Silka MJ, Triedman JK, Walsh EP, Warnes CA (2014) PACES/HRS expert consensus statement on the recognition and management of arrhythmias in adult congenital heart disease: developed in partnership between the Pediatric and Congenital Electrophysiology Society (PACES) and the Heart Rhythm Society (HRS) Endorsed by the governing bodies of PACES, HRS, the American College of Cardiology (ACC), the American Heart Association (AHA), the European Heart Rhythm Association (EHRA), the Canadian Heart Rhythm Society (CHRS), and the International Society for Adult Congenital Heart Disease (ISACHD). Can J Cardiol 30:e1–e63CrossRefGoogle Scholar
- 8.Kuck KH, Furnkranz A, Chun KR, Metzner A, Ouyang F, Schluter M, Elvan A, Lim HW, Kueffer FJ, Arentz T, Albenque JP, Tondo C, Kuhne M, Sticherling C, Brugada J (2016) Fire, investigators ICE: cryoballoon or radiofrequency ablation for symptomatic paroxysmal atrial fibrillation: reintervention, rehospitalization, and quality-of-life outcomes in the FIRE and ICE trial. Eur Heart J 37:2858–2865CrossRefGoogle Scholar
- 9.Cappato R, Calkins H, Chen SA, Davies W, Iesaka Y, Kalman J, Kim YH, Klein G, Natale A, Packer D, Skanes A, Ambrogi F, Biganzoli E (2010) Updated worldwide survey on the methods, efficacy, and safety of catheter ablation for human atrial fibrillation. Circ Arrhythm Electrophysiol 3:32–38CrossRefGoogle Scholar
- 10.Ammar-Busch S, Bourier F, Reents T, Semmler V, Telishevska M, Kathan S, Hofmann M, Hessling G, Deisenhofer I (2017) Ablation of complex fractionated electrograms with or without ADditional LINEar lesions for persistent atrial fibrillation (the ADLINE trial). J Cardiovasc Electrophysiol 28:636–641CrossRefGoogle Scholar
- 11.Sohns C, Nurnberg JH, Hebe J, Duckeck W, Ventura R, Konietschke F, Cao C, Siebels J, Volkmer M (2018) Catheter ablation for atrial fibrillation in adults with congenital heart disease: lessons learned from more than 10 years following a sequential ablation approach. JACC Clin Electrophysiol 4:733–743CrossRefGoogle Scholar
- 12.Liang JJ, Frankel DS, Parikh V, Lakkireddy D, Mohanty S, Burkhardt JD, Natale A, Szilagyi J, Gerstenfeld EP, Moore JP, Collins KK, Kay JD, Santangeli P, Marchlinski FE, Sauer WH, Nguyen DT (2018) Safety and outcomes of catheter ablation for atrial fibrillation in adults with congenital heart disease: a multicenter registry study. Heart Rhythm 16:846–852CrossRefGoogle Scholar
- 13.Kottmaier M, Jilek C, Berglar S, Reents T, Bourier F, Semmler V, Telishevska M, Koch-Buttner K, Lengauer S, Kornmayer M, Rousseva E, Brooks S, Hadamitzky M, Kolb C, Hessling G, Deisenhofer I (2019) Exclusion of left atrial thrombus by dual-source cardiac computed tomography prior to catheter ablation for atrial fibrillation. Clin Res Cardiol 108:150–156CrossRefGoogle Scholar
- 15.Lincoff AM, Bittl JA, Harrington RA, Feit F, Kleiman NS, Jackman JD, Sarembock IJ, Cohen DJ, Spriggs D, Ebrahimi R, Keren G, Carr J, Cohen EA, Betriu A, Desmet W, Kereiakes DJ, Rutsch W, Wilcox RG, de Feyter PJ, Vahanian A, Topol EJ (2003) Investigators R-: bivalirudin and provisional glycoprotein IIb/IIIa blockade compared with heparin and planned glycoprotein IIb/IIIa blockade during percutaneous coronary intervention: REPLACE-2 randomized trial. JAMA 289:853–863CrossRefGoogle Scholar
- 17.Cappato R, Marchlinski FE, Hohnloser SH, Naccarelli GV, Xiang J, Wilber DJ, Ma CS, Hess S, Wells DS, Juang G, Vijgen J, Hugl BJ, Balasubramaniam R, De Chillou C, Davies DW, Fields LE, Natale A, Investigators VA (2015) Uninterrupted rivaroxaban vs. uninterrupted vitamin K antagonists for catheter ablation in non-valvular atrial fibrillation. Eur Heart J 36:1805–1811CrossRefGoogle Scholar
- 18.Kirchhof P, Haeusler KG, Blank B, De Bono J, Callans D, Elvan A, Fetsch T, Van Gelder IC, Gentlesk P, Grimaldi M, Hansen J, Hindricks G, Al-Khalidi HR, Massaro T, Mont L, Nielsen JC, Nolker G, Piccini JP, De Potter T, Scherr D, Schotten U, Themistoclakis S, Todd D, Vijgen J, Di Biase L (2018) Apixaban in patients at risk of stroke undergoing atrial fibrillation ablation. Eur Heart J 39:2942–2955CrossRefGoogle Scholar
- 19.Calkins H, Gerstenfeld EP, Schilling R, Verma A, Willems S (2015) Committee R-CSS: RE-CIRCUIT study-randomized evaluation of dabigatran etexilate compared to warfarin in pulmonary vein ablation: assessment of an uninterrupted periprocedural anticoagulation strategy. Am J Cardiol 115:154–155CrossRefGoogle Scholar
- 20.Kottmaier M, Bourier F, Pausch H, Reents T, Semmler V, Telishevska M, Koch-Buttner K, Lennerz C, Lengauer S, Kornmayer M, Rousseva E, Brooks S, Brkic A, Ammar-Busch S, Kaess B, Dillier R, Grebmer C, Kolb C, Hessling G, Deisenhofer I (2018) Safety of uninterrupted periprocedural edoxaban versus phenprocoumon for patients who underwent left atrial catheter ablation procedures. Am J Cardiol 121:445–449CrossRefGoogle Scholar
- 23.Deneke T, Jais P, Scaglione M, Schmitt R, Dib L, Christopoulos G, Schade A, Mugge A, Bansmann M, Nentwich K, Muller P, Krug J, Roos M, Halbfass P, Natale A, Gaita F, Haines D (2015) Silent cerebral events/lesions related to atrial fibrillation ablation: a clinical review. J Cardiovasc Electrophysiol 26:455–463CrossRefGoogle Scholar