Device Management for the Control Atrial Tachyarrhythmia in Patients with Fontan Circulation. A Single Center Experience

Aims. Atrial tachyarrhythmias (AT) are common after Fontan (FO) operation and detrimental to FO hemodynamic, thus a correct arrhythmic management strongly impacts on outcome and quality of life. Our aim was to evaluate the utility of arrhythmic management and remote monitoring (RM) with pacemaker (PM) in patients with FO for the control of AT episodes and for the maintenance of hemodynamic stability.

Methods. The population included patients who received an epicardic PM after atrio-pulmonary (AP) or cavo-pulmonary (CP) FO. All patients attended remote device monitoring (RM) every 3 months and outpatient visit every 6 months.

Results. A total of 24 patients (13 CP and 11 AP) were included in the study, male for the 50%, with a mean age at PM implantation of 16.9 years. Eleven (45.8%) of them underwent PM implantation after CP conversion (redo-FO) with surgical atrial ablation for hemodynamic instability and untreatable AT. The implanted PM was monocameral in 2 (8.3%) cases, bicameral in 20 (83.3%) cases and biventricular in 2 (8.3%) cases. PM stimulation was AAI for the 62.5% and DDD (complete AV block) for the 20.8%; the spontaneous rhythm was
present in the 16.7% (backup VVI). During a mean follow of 9.2 years, one patient died for heart failure and one patient underwent heart transplantation. The 37.5% of the total population and the 66.7% of redo-FO patients presented at least one episode of sustained AT detected with RM. The prompt detecting of AT episodes with RM led to an outpatient visit for therapy adjustment. In 3 cases a concealed causing factor was detected (severe anemia, hyperthyroidism, pulmonary infection). Currently 9 (37.5%) patients are on antiarrhythmic therapy and only 2 (8.3%) patients still have paroxysmal, uncontrolled AT episodes.

Conclusion: Arrhythmic management and RM with PM is efficacy to guide medical therapy of AT and to prevent hemodynamic instability in FO circulation. In patients with untreatable AT, CP conversion with surgical atrial ablation and PM implantation resulted a safe and successful strategy.