Mechanisms and outcomes of catheter ablation for biatrial tachycardia in adults with congenital heart disease

Heart Rhythm. 2021 Nov;18(11):1833-1841. doi: 10.1016/j.hrthm.2021.06.1193. Epub 2021 Jun 25.

Abstract

Background: Biatrial tachycardia (BiAT) is a rare form of macroreentry not previously characterized in adults with congenital heart disease (ACHD).

Objective: The purpose of this study was to determine the prevalence, mechanisms, and outcomes of catheter ablation for BiAT in ACHD.

Methods: All ACHD undergoing catheter ablation for macroreentrant atrial tachycardia over a 10-year period were evaluated for evidence of BiAT. Patients were categorized as prior Senning, Fontan, or other biventricular operation. A novel biatrial global activation histogram (GAH) analysis was used to demonstrate the presence of interatrial connections (IACs).

Results: Among 263 ACHD, BiAT was identified at 11 procedures in 10 patients (4.2%; median age 35 years; 30% male). The congenital category was Fontan in 6, Senning in 3, and biventricular in 2. Diagnosis of BiAT was associated with ablation era and mapping technology (P <.001) and could be confirmed with a novel GAH mapping approach for normally septated atrial connections. Catheter ablation targeted an IAC in 5 cases (Bjork Fontan and biventricular operations), a posterior isthmus in 3 (Senning operation), and the cavotricuspid isthmus or equivalent in 3 (lateral tunnel [LT] Fontan). Recurrence was isolated to ablation to sites at the expected location of the Bachmann bundle, and durable success could be achieved after repeat ablation.

Conclusion: BiAT occurs in approximately 4% of ACHD but is likely underrecognized. BiAT could be targeted at an IAC for normally septated atria and at a conventional critical isthmus after Senning and LT Fontan operations.

Keywords: Adult congenital heart disease; Biatrial tachycardia; Catheter ablation; Congenital heart disease; Epicardial connections; Intra-atrial reentrant tachycardia.

MeSH terms

  • Adult
  • Catheter Ablation / methods*
  • Female
  • Heart Defects, Congenital / physiopathology
  • Heart Defects, Congenital / surgery*
  • Humans
  • Male
  • Tachycardia, Supraventricular / etiology*
  • Tachycardia, Supraventricular / physiopathology
  • Tachycardia, Supraventricular / surgery*