The importance of cardiac imaging in patients with congenital heart disease

Atrial arrhythmia is a common complication in patients with congenital heart disease (CHD). Dr Ivo Roca-Luque’s (Hospital Clinic de Barcelona, Spain) focused on the importance of imaging techniques to personalise ablation procedures for cardiac and atrial anatomy and atrial substrate to improve ablation success in this population [1].

In the past decades, surveillance of patients with CHD has improved, leading to a 31% mortality reduction. These patients now grow older, thus increasing the prevalence of intra-atrial re-entrant tachycardia (IART), which is not only associated with severe clinical symptoms but also with cardiac transplant and an approximately 5-fold increased risk of death.

The substrate leading to atrial flutter in patients with CHD were several slow conduction areas and blocking regions (e.g. scars), cavotricuspid isthmus (CTI)-related flutter, or a combination of both. The most frequent circuit is CTI-related IART (51%), followed by non-CTI-related IART (27.7%), and a combination thereof (21.3%). Atrial substrate of arrhythmia can be analysed even without present arrhythmia, as exemplified in the Figure [1].

Figure: Atrial substrate of intra-atrial re-entrant tachycardia (IART). Adapted from [1,2]



Right: imaging from a patient with 2 scars in the posterior wall with scar tissue (grey) and healthy tissue (purple). Left: a counter-clockwise posterior wall IART is shown around the 2 scars. The circuit of arrhythmia could be predicted by electro-anatomical mapping in sinus rhythm.
Figure kindly provided by Dr Roca-Luque.

After ablation, patients with CHD suffer a high rate of IART recurrence. Notably, atypical flutter and complex anatomy are related with higher recurrence rates. Imaging of full cardiac and atrial anatomy using MRI and activation mapping can thus aid the selection of a suitable ablation procedure.

In summary, IART is a severe and frequent complication in patients with CHD and substrate mapping plays a key role in analysing circuits. Imaging and analysis of atrial substrate and cardiac and vascular anatomy before the ablation procedure are important as almost 10% of CHD patients have vascular or anatomic abnormalities. Dr Roca-Luque concluded that “imaging to predict IART substrate can help to improve ablation success.”

1. 
   
   1. Roca-Luque I. Ablation of atrial arrhythmias in patients with congenital heart disease: does cardiac imaging predict the response to therapy? EHRA 2021 Congress, 23-25 April.
   2. Roca-Luque I, et al. Europace 2018;20(2):353–361.

 

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Posted on 16 June 202127 March 2024