Derejko Paweł, Rybicka Justyna, Biernacka Elżbieta Katarzyna, Walczak Franciszek, Kowalski Mirosław, Urbanek Piotr, Bodalski Robert, Orczykowski Michał, Oręziak Artur, Duliban Joanna, Hoffman Piotr, Szumowski Łukasz
Department of Cardiac Arrhythmias, Institute of Cardiology, Warsaw, Poland.
Kardiol Pol. 2016;74(8):762-771. doi: 10.5603/KP.a2015.0214. Epub 2015 Nov 17.
Atrial tachyarrhythmias are a leading source of morbidity and mortality after Fontan-type procedures and antiarrhythmic drug therapy is often ineffective in these patients.
To evaluate short- and long-term outcomes of radiofrequency current ablation for atrial tachycardia (AT) in patients after the Fontan procedure, and to report clinical, electrophysiological and electroanatomical characteristics of these arrhythmias.
We retrospectively analysed data obtained in 8 patients (5 males, 3 females) after the Fontan procedure who underwent ablation for AT between 2002 and 2013. In order to compare the clinical impact of arrhythmia before and after ablation, we used the modified arrhythmia score, ranging from 0 (no arrhythmia activity) to 12 (very severe arrhythmia). In all patients, electroanatomical mapping using the CARTO system was performed, allowing semiquantification of low-voltage (< 0.5 mV) areas and scars.
Seven patients had an atriopulmonary connection and 1 patient had an extracardiac conduit. The mean patient age was 9.4 ± 3.1 years at the time of the Fontan procedure and 26.2 ± 4.6 years at the time of the first ablation. A total of 18 ablations were performed with no complications, 1 to 4 (median 2.5) procedures per patient. In patients who had more than 1 ablation, the mean time from the first to the last procedure was 34.8 months (range 1-64 months). In individual patients, 1 to 4 (median 2.5) different ATs were observed, with the mean tachycardia cycle length of 334 ± 95 ms. In 6 patients, low-voltage area (< 0.5 mV) comprised 25-50% of the right atrium, and in two others it comprised 10-25% and < 10% of the right atrium, respectively. Seven procedures were fully successful (ablation of all ATs), 7 were partially successful (ablation of only some AT, including clinical arrhythmia, but not of all ATs) and 4 were unsuccessful (failed ablation of clinical AT). The mean procedural, fluoroscopy and ablation times were 176 ± 54.6, 13.7 ± 5.7 and 21.7 ± 11.9 min, respectively. Freedom from arrhythmia during the mean follow-up of 58.6 ± 46 months (range 11-127 months) since the last procedure was obtained in 4 patients. The median arrhythmia score after the last ablation was significantly reduced compared to baseline (4.5 vs. 8; p < 0.05).
Catheter ablation of AT in patients after the Fontan procedure is safe but its acute and long-term efficacy is limited. Due to complex and extensive substrate, along with complex anatomy, recurrences are frequent and patients may require repeat ablation procedures. Suppression of arrhythmia is associated with an improved clinical status of the patients.
房性快速性心律失常是Fontan类手术后发病和死亡的主要原因，抗心律失常药物治疗对这些患者往往无效。
评估Fontan手术后患者行射频电流消融治疗房性心动过速（AT）的短期和长期疗效，并报告这些心律失常的临床、电生理和电解剖学特征。
我们回顾性分析了2002年至2013年间8例（5例男性，3例女性）Fontan手术后接受AT消融治疗患者的数据。为了比较消融前后心律失常的临床影响，我们使用了改良心律失常评分，范围从0（无心律失常活动）到12（非常严重的心律失常）。所有患者均使用CARTO系统进行电解剖标测，从而对低电压（<0.5 mV）区域和瘢痕进行半定量分析。
7例患者采用心房-肺连接术，1例患者采用心外管道。Fontan手术时患者的平均年龄为9.4±3.1岁，首次消融时为26.2±4.6岁。共进行了18次消融，无并发症发生，每位患者进行1至4次（中位数2.5次）手术。接受多次消融的患者，从首次手术到最后一次手术的平均时间为34.8个月（范围1 - 64个月）。在个体患者中，观察到1至4种（中位数2.5种）不同的AT，平均心动过速周期长度为334±95 ms。6例患者中，低电压区域（<0.5 mV）占右心房的25% - 50%，另外2例患者中，该区域分别占右心房的10% - 25%和<10%。7次手术完全成功（所有AT均被消融），7次部分成功（仅消融了部分AT，包括临床心律失常，但并非所有AT），4次手术失败（临床AT消融失败）。平均手术时间、透视时间和消融时间分别为176±54.6、13.7±5.7和21.7±11.9分钟。自最后一次手术后，在平均58.6±46个月（范围11 - 127个月）的随访期间，4例患者无心律失常发作。与基线相比，最后一次消融后的心律失常评分中位数显著降低（4.5对8；p<0.05）。
Fontan手术后患者行导管消融治疗AT是安全的，但其急性和长期疗效有限。由于基质复杂广泛以及解剖结构复杂，复发频繁，患者可能需要重复消融手术。心律失常的抑制与患者临床状况的改善相关。
