Atrial arrhythmia -A window to treat in adult CHD patients

Atrial arrhythmias are common in patients with CHD. Adults with atrial septal defects often come to medical attention after the onset of atrial fibrillation. Treatment of atrial arrhythmias should be individualized and therapy depends on the type of CHD present and the need for intervention. When operative intervention is recommended for CHD, a simultaneous Maze procedure may be beneficial. Medical therapy and cardioversion should be considered for others. The rate of late atrial fibrillation, after surgical ASD closure increases according to age at the time of intervention, with up to 60% of patients having late atrial arrhythmias when ASD closure is done later than age 40 years. These patients require anticoagulation for stroke prevention and either heart rate control or medical and electrical therapy for atrial fibrillation. It is imperative to perform a comprehensive anatomic evaluation in these patients to exclude a lesion that requires intervention. Patients with repaired TOF and severe pulmonary valve regurgitation may be asymptomatic for many years. The initial symptom related to right heart enlargement and secondary progressive tricuspid valve regurgitation may be atrial fibrillation. A comprehensive evaluation by a congenital cardiologist is recommended when patients present with atrial fibrillation prior to considering ablation or other intervention. There should be a high index of suspicion that the atrial fibrillation is due to residua or sequel of CHD. Atrial tachycardia and atrial flutter are also common after operation for CHD and may be scar dependent. A comprehensive evaluation by a congenital cardiologist is recommended for residua or sequela. If the atrial arrhythmias are due to scar, catheter ablation is the recommended treatment. Ventricular arrhythmias are not uncommon in patients with operated CHD or severe ventricular dysfunction. Treatment of ventricular arrhythmias should be individualized and therapy depends on the type of CHD present and the need for intervention. When operative intervention is recommended for CHD, preoperative electrophysiology study may help to guide therapy. ICD’s should be used in adult CHD patients with severe systemic ventricular dysfunction associated with ventricular tachycardia and in other select patients. Adult CHD patients, who are at risk for arrhythmias or have clinical arrhythmias, should be referred to a CHD clinic for evaluation and management.