Elsevier

Heart Rhythm

Volume 17, Issue 10, October 2020, Pages 1752-1758
Heart Rhythm

Clinical
Ablation
Ten-year outcomes of transcaval cardiac puncture for catheter ablation after extracardiac Fontan surgery

https://doi.org/10.1016/j.hrthm.2020.05.007Get rights and content

Background

Although they are at lower risk, patients with previous extracardiac conduit (EC) Fontan still may require catheter ablation for supraventricular arrhythmia.

Objective

The purpose of this study was to determine the optimal approach to pulmonary venous atrium (PVA) access after EC Fontan operation.

Methods

All electrophysiological procedures requiring PVA over a 10-year period at the UCLA Medical Center were reviewed. PVA was grouped by transcaval cardiac puncture (TCP) or direct conduit puncture. Procedural characteristics and outcomes were compared.

Results

Between June 2009 and November 2019, 23 electrophysiological procedures requiring PVA access were performed in 17 EC Fontan patients (53% male; median age 25 years; interquartile range 11–34). Cavoatrial overlap was identified in 14 patients by preprocedural imaging (10 cardiac computed tomography, 4 cardiac magnetic resonance). PVA access was obtained via TCP in 11, direct conduit puncture in 6, pre-existing fenestration in 5, and pulmonary artery puncture in 1. Time to PVA was significantly shorter for TCP vs direct conduit puncture (0.2 vs 1.1 hours, respectively; P = .03). The only predictor of successful TCP was the length of cavoatrial overlap by preprocedural imaging (14 vs 3 mm; P = .02). No procedural complications occurred. No change in oxygen saturation was noted, and no evidence of residual shunting was detected by follow-up echocardiography.

Conclusion

TCP is feasible in most patients after EC Fontan surgery and can be predicted by preprocedural advanced imaging. TCP is associated with shorter time to PVA and was uncomplicated in this single-center study. Preoperative assessment of cavoatrial overlap should be considered before catheter ablation for EC Fontan.

Introduction

The Fontan operation for palliation of single ventricular anatomy has seen iterative improvements over the past several decades associated with progress in the understanding of cavopulmonary flow dynamics and atrial arrhythmogenesis. The most common surgical technique used in the modern era is the extracardiac conduit (EC), with one of the major perceived benefits being a lower risk for atrial arrhythmia.1 However, supraventricular arrhythmias still develop after the EC Fontan and, together with the inherent challenges in obtaining access to the pulmonary venous atrium (PVA), can pose significant difficulties for catheter ablation.

Historically, direct conduit puncture has been the most common approach to PVA access,2, 3, 4, 5, 6 with various techniques and modifications proposed to improve outcomes.4,7 A simplified approach, namely, the transcaval cardiac puncture (TCP) technique, was previously suggested based on advanced imaging analysis in a population of EC Fontan patients. This approach involves direct needle puncture through a segment of the inferior vena cava (IVC) or hepatic vein adjacent to the wall of the PVA for a more facile entry.8 However, at the time of the initial report, clinical experience with the technique was limited.5,8 The objective of the present study was to provide updated results from a single center using a first-line TCP approach for catheter ablation of clinical arrhythmia in patients after the EC Fontan operation. It was hypothesized that TCP could be used for most patients and that it would provide a simplified yet safe and effective approach to PVA access for catheter ablation.

Section snippets

Study design and population

After approval was obtained from the Institutional Review Board, the electrophysiology database at the UCLA Medical Center was queried for all catheter ablation procedures performed for patients after EC Fontan operation, beginning with the first case report of transconduit puncture in 2009.2 Patients were included if access to the PVA was attempted (1) in order to treat clinically significant supraventricular tachycardia with catheter ablation or (2) if required for preoperative substrate

Baseline population characteristics

During the period between June 2009 and November 2019, a total of 23 electrophysiological procedures were performed in 17 patients with previous EC conduit Fontan surgery (53% male; median age 25 years [11–34]) (Table 1). The most common congenital diagnosis was unbalanced atrioventricular (AV) canal (6), followed by hypoplastic left heart syndrome (3) and tricuspid atresia (3). Eight patients had a diagnosis of heterotaxy syndrome. EC Fontan surgery was performed at a median of 12 years

Discussion

This study reports the 10-year outcomes of a uniform approach to PVA access for patients after EC Fontan surgery. Although the technical approach was refined over the course of the study, the overall emphasis on primary TCP based on preprocedural imaging was consistently and prospectively applied. This allowed for assessment of TCP feasibility and outcomes for patients with EC Fontan surgery with relative confidence in a more generalized application. The key finding of this study was that TCP

Conclusion

TCP is feasible in most patients after EC Fontan surgery and can be predicted by preprocedural advanced imaging. TCP is associated with shorter time to PVA and was uncomplicated in this single-center study. Preoperative assessment of cavoatrial overlap should be considered before catheter ablation for EC Fontan.

Acknowledgment

The authors wish to thank Heather Macken for her assistance with CARTO image processing.

Cited by (0)

Funding Sources: The authors have no funding sources to disclose.

Disclosures: The authors have no conflicts of interest to disclose.

View full text