MANAGEMENT OF ATRIAL-FLUTTER AFTER THE FONTAN PROCEDURE

Objectives. The purpose of this study was to review the management of atrial flutter occurring after the Fontan procedure. Background. Atria l flutter occurs frequently after the Fontan procedure and is often he modynamically poorly tolerated. Methods. The patients' charts were rev iewed for relevant information. Results. Between 1984 and 1999, 18 pat ients had atrial flutter after the Fontan procedure. The underlying he art defect was tricuspid atresia in nine, mitral atresia in six and do uble inlet left ventricle in three. All but three patients had undergo ne previous palliative surgery. The time interval from Fontan operatio n to atrial flutter was <1 day to 16 years (mean 3.7 years). Seven had early atrial flutter before leaving the hospital. Electrophysiologic study in 15 showed sinus node dysfunction in 12. Atrial flutter was in ducible in all patients, and 13 had >1 flutter configuration. Digoxin and a variety of other antiarrhythmic agents (mean 2.7 drugs/patient) were tried with poor results. Only digoxin, amiodarone, flecainide and propafenone showed some benefit when used alone or in combination. An titachycardia pacemakers were implanted in 16 patients (endocardial 14 , epicardial 2) and, with drugs, were useful in 8 (50%). Because atria l flutter was resistant to treatment, right atriectomy was performed i n three patients (with benefit in two, one death), successful radiofre quency catheter His bundle ablation in one patient and catheter ablati on of atrial flutter in three patients (two failed, one partial succes s). One patient underwent heart transplantation, and two died suddenly , Another died of complications after an elective epicardial pacemaker replacement procedure. Conclusions. Atrial flutter after the Fontan p rocedure is difficult to control. Aggressive drug and antitachycardia pacemaker therapy help about half of the patients. When these measures fail, other options, such as atriectomy, His bundle ablation or cathe ter ablation of atrial flutter, need consideration. The risk of sudden death justifies the use of such aggressive treatment methods.