Predittori di recidiva delle aritmie atriali post ablazione transcatetere in pazienti con cardiopatia congenita dell'adulto
Year: 2026
Type: dissertation
Study design: Observational Study
Abstract: Introduction - Congenital heart disease represents the most common congenital defect. Thanks to advances in medicine and cardiac surgery, over 90% of patients with congenital heart disease now reach adulthood, entering the cohort of Adults with Congenital Heart Disease (ACHD). Atrial arrhythmias, affecting up to 50% of ACHD patients, significantly increase the risk of heart failure (HF) and mortality. Radiofrequency catheter ablation (RFCA) is the first-line therapy, but its long-term efficacy remains variable. The present study therefore aims to identify the clinical and instrumental predictors of arrhythmic recurrence after RFCA, with the goal of achieving a more personalized clinical and therapeutic management in ACHD patients. Methods - In the context of this study, patients who underwent RFCA for atrial arrhythmias between 2007 and 2025 at the Fondazione Monasterio in Pisa and Massa were retrospectively enrolled. Patients underwent standard baseline clinical and instrumental evaluations, and some of them also underwent cardiac magnetic resonance (CMR) imaging and cardiopulmonary exercise testing (CPET). Acute procedural success was defined as the intraprocedural termination of the arrhythmia, in the presence of bidirectional block of the ablation lines and the absence of inducibility of sustained tachyarrhythmias. For the long-term efficacy analysis, only patients with acute procedural success were considered. The primary efficacy endpoint was freedom from recurrence of atrial arrhythmias during follow-up. Follow-up was censored at the detection of arrhythmic recurrence on baseline ECG or 24-hour Holter monitoring, at the time of any cardiac surgical or percutaneous intervention, or at the last available visit. Results - The study population, consisting of 79 ACHD patients with a mean age at the first EPS of 46.03 ± 15.97 years, showed a clear prevalence of moderate complexity congenital heart disease (74.68%), with Tetralogy of Fallot as the most frequent diagnosis (60.76%). Macroreentrant atrial tachycardias (MRAT) were the predominant form (56 patients, 70.8%), followed by focal atrial tachycardia (FAT) in 10 (12.7%), atrioventricular reentrant tachycardias (AVNRT/AVRT) in 7 (8.9%), and atrial fibrillation (AF) in 6 patients (7.6%). Acute procedural success was achieved in 83.5% of cases (66 patients); 3 patients were lost to follow-up. Focusing on the 63 patients in whom procedural success was achieved, 35 (55.6%) recurrences of atrial arrhythmias were documented after the first RFCA procedure. Among the patients with arrhythmic recurrence, 21 (60%) underwent a redo ablation, and of these, 4 (11.4%) underwent a second one. At the end of the follow-up (which included 63 patients), there were 16 recurrences, and the freedom from arrhythmic events rate was 74.6%. On univariate logistic regression analysis, the factors significantly associated with a higher risk of recurrence were: female sex (OR 3.7), left ventricular dysfunction (OR 2.71), and left atrial dilation (>40 ml/m2) assessed by CMR (OR 9.12). On multivariate logistic regression, the presence of left atrial dilation was the only independent predictor of recurrence. This association was also confirmed by univariate Cox analysis and Kaplan-Meier survival curves, which showed a significantly shorter recurrence-free time in patients with a dilated left atrium compared to those with normal atrial dimensions (log-rank 10.351; p = 0.001). Conclusions - The results of the present study indicate that the long-term efficacy of atrial arrhythmia ablation in ACHD patients is primarily influenced by the degree of cardiac remodeling and, in particular, by the presence of left atrial dilation, which emerges as the only independent predictor of recurrence. This finding highlights the crucial role of the left heart sections even in patients predominantly affected by right heart conditions. The early identification of left atrial dilation through advanced imaging could therefore allow for better prognostic stratification, guide the timing of the ablative intervention, and favor personalized therapeutic strategies, with the potential to improve clinical outcomes and the quality of life in this complex patient population.
Author: SIMI, GIULIA
Language: Italian
Subfield: Cardiology and Cardiovascular Medicine
Field: Medicine
Domain: Health Sciences
Open Access status: green
OpenAlex ID: W7199169335