80 Retrograde aortic access of the pulmonary venous atrium provides equivalent outcomes to right atrial or transeptal access of the left atrium in patients with congenital heart disease

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IntroductionPatients with congenital heart disease may suffer atrial arrhythmia where the target chamber can either be reached easily from a direct or transeptal approach, or may have a relatively excluded atrium where a retrograde aortic approach to the pulmonary venous atrium is required. We hypothesised that ablation outcomes in both groups will be similar.MethodsRetrospective analyses of patients with congenital heart disease (CHD) undergoing ablation of atrial arrhythmia at Barts Heart Centre over one year. Patients were divided into three groups based on access to the chamber of interest; Group 1) right atrial arrhythmia accessed directly; Group 2) left atrial arrhythmia accessed through the interatrial septum (transeptal puncture or via patent ASD); Group 3) arrhythmia in an excluded atrium accessed via retrograde aortic approach. Follow-up was at 3 and 6 months with ambulatory electrocardiographic monitoring for arrhythmia recurrence.Results49 patients with CHD undergoing atrial arrhythmia ablation were included. Group 1, 2 and 3 comprised of 33, 10 and 6 patients respectively. Vast majority had atrial septal defect/repair (35%) and repaired tetralogy of Fallot (17%). Of the patients in whom retrograde access was performed, three had a Fontan circulation, two had a transposition with Senning/Mustard Repair, and one had a surgically repaired ASD with a calcified septum not amenable to transseptal puncture. The most common procedure for group 1 was cavo-tricuspid isthmus ablation (63%), group 2 – AF ablation (62%), and group 3 atrial tachycardia ablation (50%) (p<0.001 between groups). Between groups 1, 2 and 3 there was no difference in procedure time (171±116, 204±94 and 245±35 min, p=0.23), or fluoroscopy time (6±11, 10±7 and 14±22 min, p=0.40). There was no difference in freedom from atrial arrhythmia between groups 1, 2 and 3 (70%, 50% and 67%, p=0.52), at mean follow-up of 6±3 months. There was no difference in complications between group 1 (5%), group 2 (17%) and group 3 (17%, p=0.38). The one complication in the retrograde access group was a femoral arterial pseudo-aneurysm.ConclusionPatients with congenital heart disease and an excluded atrium requiring ablation via retrograde aortic access can benefit from comparable outcomes to CHD patients who undergo ablation via a conventional right or left atrial approach. The retrograde aortic approach can be performed with equivalent procedure time, fluoroscopy time, and risk of complications compared with standard right or left atrial access.

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