Current Treatment Options of Fontan Arrhythmias: Management
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Pediatric and Congenital Heart Disease (G Singh, Section Editor)
Current Treatment Options of Fontan Arrhythmias: Management Mayme Marshall, MD Mohammad Alnoor, MD Seshadri Balaji, MBBS, MRCP (UK), PhD* Address * Department of Pediatrics, Division of Cardiology, Oregon Health & Science University, 707 SW Gaines Street, CDRC-P, Portland, OR, 97239, USA Email: [email protected]
Published online: 10 October 2020 * Springer Science+Business Media, LLC, part of Springer Nature 2020
Topical Collection on Pediatric and Congenital Heart Disease Keywords Fontan I Arrhythmia I Atrial flutter I Supraventricular tachycardia I Ablation I Fontan conversion
Abstract Purpose of the review Arrhythmias are a common complication of patients with single ventricle anatomy who undergo the Fontan operation. This review will address current management strategies for acute and chronic arrhythmias. Recent findings Alterations to surgical techniques, newer antiarrhythmic medications, and improvements in catheter ablation procedures have improved the management of patients with arrhythmias following Fontan palliation. Summary Arrhythmias predict poor prognosis for Fontan patients. Early and aggressive management of arrhythmias improve patient outcomes. For bradyarrhythmias, management strategies strive to maximize atrial pacing and minimize ventricular pacing. For tachyarrhythmias, urgent evaluation and aggressive interventions strive to convert and maintain sinus rhythm. Strategies include antiarrhythmic medications, catheter ablation, and early referral for Fontan conversion and arrhythmia surgery for those who do not respond. There is much interest in prophylactic arrhythmia surgery at the time of initial Fontan operation; however, the future role remains to be elucidated.
Introduction There is a complex relationship between the conduction and mechanical systems of the heart. When rhythm issues arise, Fontan patients develop cardiac dysfunction, valve
regurgitation, atrial dilation, and ultimately worsening of arrhythmias. For patients who undergo the Fontan operation, arrhythmias are an important indicator of clinical
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deterioration leading to Fontan failure, transplantation, or death [1]. Numerous studies have shown atrial tachyarrhythmias have a prevalence up to 60% at 20 years following Fontan surgery [2–4, 5••]. Advances in technique and surgical modifications including transition from the original atriopulmonary connection (APC) type of Fontan to the intracardiac lateral tunnel (ILT) and the extracardiac conduit (ECC) have improved the incidence and severity of arrhythmias. However, as the ILT and ECC Fontan cohorts age, the efficacy of these modifications will be better elucidated. This review will cover current
management strategies for late arrhythmias (9 30 days following initial Fontan procedure). Acute management strategies largely involve maintaining hemodynamic stability, pacing, cardioversion, or medication initiation. Chronic arrhythmia management strategi
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