This week we speak with Assistant Professor of Pediatrics at Harvard Medical School, Dr. Audrey Dionne about a recent work she co-authored on the topic of outcomes of ablation in the early postoperative period following congenital heart surgery. Who is a candidate for this intervention and what were the outcomes? How commonly were serious complications encountered and how successful were these procedures? Dr. Dionne reviews these and other aspects of this novel review this week.
https://doi.org/10.1016/j.hrthm.2024.08.061
https://doi.org/10.1016/j.hrthm.2024.08.061
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Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Speaker 1 (00:16):
Welcome to Pdiheart Pediatric Cardiology Today. My name is doctor
Robert Pass and I'm the host of this podcast. I
am Professor of Pediatrics at the Icon School of Medicine
at Mount Sinai, where I'm also the Chief of Pediatric Cardiology.
Thank you for joining me for this three hundred and
forty fourth episode of Pdheart. I hope everybody enjoyed last
week's replay episode on hypoplastic left heart syndrome and outcomes
(00:37):
of twelve years following staged reconstruction. For those of you
who are interested in single ventrical physiology, I'd certainly recommend
you take a listen to last week's episode with our guest,
doctor Karen Goldberg. As I say every week, if you'd
like to get in touch with me, my email is
easy to remember. It's Pdheart at gmail dot com. This
week we move into the world of cardiac critical care
(00:59):
as well as electrophysiology. The title of the work is
Efficacy and Safety of early post operative Oblation in Patients
with congenital heart Disease. The first author of this work
is Sarah Kerr and the senior author Audrey Dion. And
this group comes to us from Boston, Children's Hospital, Department
of Pediatrics, Department of Surgery, and Department of Cardiology. When
(01:21):
we're done reviewing this paper, we're lucky to have doctor
Audrey Dione, the senior author of this work, join us
to discuss it. Therefore, let's get onto this interesting paper
and then a conversation with its senior author. This week's
work starts with some comments about arrhythmias following congenital heart surgery,
and the authors mention that it is a common occurrence,
and they review the reasons such as the combination of
(01:43):
incisions in the mayacardium as well as inflammation, eschemia, reperfusion, injury, inotropes,
electrolyte abnormalities and elevations, and atronergic tones, essentially suggesting that
this is a virtual witches brew for arrhythmia. The authors
then explain what we in our fields all which is
that these arrhythmias are thankfully usually transient, and this is
(02:04):
the most important reason that we do not routinely ablate
these arrhythmias in this setting, but rarely there are medically
refractory cases where consideration for an ablation might be appropriate.
In the author's contrast, how in the post operative setting,
medical management is always the first line, with ablation a
very far distant second, with how in the outpatient setting
(02:26):
ablation often takes first in line in our offerings for arrhythmia.
They then review how there is essentially nearly no information
on what happens at electrophysiology study and ablation in the
post operative setting, and so with this as a background
state that quote, we report on the safety and effics
the outcomes of electrophysiological study in the early post operative
(02:47):
period in patients with congenital heart disease, with most patients
undergoing EPs during surgical hospitalization, and the authors emphasize that
these were critically ill patients in the ICU with refractory arrhythmias.
Compare those who had an EPs during the first three
months after surgery with those who underwent later procedures three
to twelve months after surgery. The authors explained that this
(03:10):
was a retrospective study of all children and young adults
who underwent an EPs with ablation within twelve months of
open heart surgery between two thousand and twenty twenty one
at Boston Children's Hospital. The electrophysiological procedures were done in
a standard way with standard equipment for the past twenty years,
and they explained that for this work, acute success was
(03:30):
defined as elimination of all targeted A rhythmias. Partial success
was if some but not all targeted A rhythmias were
eliminated or empirical when it was impossible to see if
the ablation worked because they may not have been inducible
arrhythmias at the time of ablation, the authors recorded the
complications or adverse events of the procedure. For this work,
(03:51):
they categorized the arrhythmias into four types, and these being
macroreentran atrial or ventricular arrhythmias like IART or monomorphic VT arrhythmia,
is due to enhanced automaticity like atrial ventricular ectopy or
junctional like topic tachycardia, accessory pathway mediate attachycardia, and finally
av noto reentrant tachycardia. For this work, recurrence of arrhythmia
(04:14):
was defined as documented rhythmia on ECG twenty four hour
halter and or pacemaker. The authors used a twelve point
clinical arrhythmia severity score to quantify the arrhythmia burden before,
during hospitalization, and at follow up and Table I shows
what goes into that arrhythmia scoring system, and on to
the results. Over the twenty year period, there were twenty
(04:35):
eight thousand, nine hundred and two operations performed, of which
twenty four patients or zero point one percent, underwent an
EP study with ablation within three months of surgery and
twenty six or zero point one percent in the three
to twelve months following surgery. And so right off, it's
clear to mention that this is a very rare cohort
(04:56):
of patients who went for blation in the early or
mid term following surger. Most of the patients had either
so called great or moderate cardiac anatomy complexity, meaning that
the vast majority had more than straightforward anatomy. And what
were the post operative rhythmias in this cohort, well, these
were iart or atrial flutter in thirty three percent or
(05:18):
eight patients, ectopic atrial tachycardia in twenty one percent or
five patients, av notal re entrant tachycardia in two patients,
junctional ectopic tachycardian one, and an unspecified atrial arrhythmia in
one of note. Multiple mechanisms for tachycardi were actually seen
in seven patients or twenty nine percent, with the combinations
(05:39):
being ectopic atrial tachycardiaan IART in three or thirteen percent
IART and JET in one, ectopic atrial tachycardian, an accessory
pathway in one, and finally one unlucky patient with three
rhythmias IART, atrial fibrillation, and ventricular tachycardia. Perhaps not surprisingly,
seventy five percent of those undergoing ablations had ventricular dysfunction,
(06:02):
with forty six percent having moderate or severe dysfunction and
twenty nine percent mild dysfunction. Also not shockingly, ninety six
percent of the patients were on anti rhythmic therapy at
the time of the electrophysiological study, with nearly half on two,
perhaps reflecting the difficult time that the EP and ICU
doctors were having in controlling these arrhythmias. The indication for
(06:25):
ablation in all but one case was a rhythmia that
was refractory to medical management. The medium timing of electrophysiologic
study and ablation was post operative day thirty two, with
thirty eight percent happening before discharge from the hospital from surgery.
Ninety six percent of patients either had spontaneous or inducible
arrhythmia during the procedure, which is always good news for
(06:45):
the electrophysiologist, and the median procedural time was one hundred
and fifty one minutes. Okay, now for the important question,
how well did it work and did anyone get hurt? Well,
the procedure was acutely successful in twenty one or eighty
eight percent of the arrhythmia mechanisms, and an empirical lesion
set was placed in two patients and was unsuccessful in one.
(07:06):
The unsuccessful procedure was a left sided actopic atrial tachycardia,
and the procedure had to be aborted after a transceptal
needle punctured the left and tricular outflow tract with the
resultant hematoma. The author's report that the wire was removed
but no emergency surgery was required. The patient had a
VSD closure with an aortic root replacement and an RV
(07:27):
to PA conduit, and ultimately, seven days later went back
to the cath lab where the transseptal was successfully performed
and the oblation was successful. Overall, there were four complications
affecting eight percent, with the major one being the one
I just mentioned. There was one moderate complication and two
minor ones. Arrhythmius occurred in fifty eight percent of patients
(07:48):
that follow up of three point two years, and recurrence
was seen in thirty three percent prior to leaving the hospital. However,
the burden of arrhythmia was markedly decreased in follow up,
including those who had a recurrence. The authors report that
eight patients went back for repeat ablation within a year,
and there were multiple reattempts in four of Note seven
(08:09):
of the patients who underwent ablation, or thirty percent died
at a median of zero point six years after surgery,
though not due to arrhythmia or electrophysiological study, highlighting for
us that these were amongst the most sick post operative patients.
In their discussion, the authors repeat that most post operative
arrhythmias can be managed medically, but they state that rarely
(08:30):
electrophysiological study with ablation for refractory or life threatening arrhythmias
can be performed in the post operative period with what
they believe is reasonable acute success and limited morbidity. Despite
the critically ill nature of these patients. They contrast the
timing of these cases to those of other literature on
post operative ablation, showing that most of the other prior
(08:51):
works highlight how these are generally required much later, typically
in periods measured in years, not days from surgery. The
investigators then address the relation relatively high recurrence rate that
is seen in the study and demonstrate how this sort
of recurrence rate is not particularly different from other series
of congenital heart disease ablations not done in the immediate
post operative period, and they emphasize how despite recurrence rates,
(09:14):
the burden of arrhythmia as measured by a clinical arrhythmia
score was lower. During follow up of this early ablation cohort,
they mentioned that the one difference that they observed when
comparing the very early less than three month cohorts to
the greater than three month cohort was the length of
the procedure, explaining that the early electrophysiological patients had shorter
procedural times. They suggest that it is possible that given
(09:37):
the level of illness of these patients, the operators were
naturally more interested in moving forward quickly by targeting the
clinical arrhythmia. Importantly, the recurrence rate were the same in
the early versus the late cases, despite the shorter half time.
The authors mentioned the complications seen, including the hemotomin that
we discussed, a bradycardia induced torsades, a point requiring a
(10:00):
pacemaker after an iart ablation, first degree harp block, and
a pseudoaneurysm, and suggest that none of those were due
to the post operative status of the patient. They suggest
that the complication rate compared favorably to other series of
complication rates in the congenital heart disease patient who undergoes ablation.
In regards to limitations, they referenced the small and heterogeneous
(10:20):
sample size in one institution and the absence of standard
means of referral for electrophysiology study and ablation. They also
mention all of the patients who may have seemed so
sick as to not actually be candidates for an EP study,
resulting in a form of ascertainment bias, and they are
quick to suggest that these results should not be generalized
to all centers. The authors conclude by reviewing that zero
(10:44):
point one percent of post operative patients received early electrophysiology
and ablation for refractory or life threatening arrhythmias. And how
these results were similar between the early zero to three
month ablation candidates and those who were done a little
later between three and twelve months post up. They end
by stating, and I quote, a better understanding of outcomes
(11:04):
of electrophysiology study in the early post operative period may
help clinicians with decision making as well as to inform
families well. This is an interesting work again showing that catheterization,
this time an electrophysiology CAF in the post op patient
has a role in the management of the post operative
congenital heart surgical patient. Clearly, the vast majority of patients
(11:25):
can at least be managed acutely medically. However, these data
are reassuring that in good hands, in the right patient,
the risk of these procedures are not zero, but low
enough to warrant consideration for EP study and oblation when
it seems that the patient is not getting better despite
aggressive medical management. I do find it of interest that
the shorter, earlier procedures were just as effective as the later,
(11:47):
longer ones, where the group was presumably being more careful
and perhaps trying harder to eradicate other less clinically relevant arrhythmias.
This makes me wonder if there might be some lessons
for all of us electrophysiologists in the approach the investigators
used for the early oblations. Haste may in some circumstances
make waste, but we also know that the longer a
(12:08):
patient lies on that CAF table under anesthesia, the greater
the opportunity for something bad to occur. It's a fine balance,
but I wonder if there's a signal there in the
generally similar outcomes despite maybe cutting a few corners. Well,
there's a bit to unpack, and so in the interest
of time, let's move forward to our conversation with the
work's senior author. Joining us now to discuss this week's
(12:31):
work is the work's senior author, Doctor Audrey Dione. Doctor
Dione is a systant Professor of Pediatrics at the Harvard
Medical School, where she is a pediatric electrophysiologist as well
as general cardiologist. She's a graduate of the University of
Sherbrook in Quebec, Canada for medical school, and she completed
her residency in pediatrics at the Saint Justine Children's Hospital,
(12:51):
also in Quebec. Following this, she came to Boston Children's Hospital,
where she completed her Categorical Cardiology Fellowship as well as
Electrophysiology Fellowship. She is a very well published author in
many arenas within cardiology, including electrophysiology and Kawasaki disease, where
she is viewed as a major authority. It is the
light to welcome her to PD heart. Welcome Audrey to
(13:13):
PD heart.
Speaker 2 (13:14):
I'm here now with doctor audre Gione from Boston Children's Hospital. Audrey.
Really appreciate your joining us this week on PD heart.
Speaker 3 (13:20):
Thank you very much for the invitation.
Speaker 2 (13:22):
Thank you, Audrey very much enjoyed this week's work. Very
important practical paper. You know, combinations of a arrhythmias I
noticed in your work were common, accounting for nearly a
third of all of the oblations that you did in
this post operative cohort. And I wondered if you retrospectively
believe that it was this combination that may have been
(13:43):
the reason that you were not able to more traditionally
manage these arrhythmias with medications. And I also wondered how
successful were you when you ablated patients who had many
different mechanisms.
Speaker 3 (13:55):
Yeah, I think that's a very interesting finding.
Speaker 4 (13:58):
And we looked at the patient in our core that
needed oblation versus just all of our overall post operative
arithnia patient And it's hard to put a number depending
on the groups that you make, but multiple mechanisms were
presented about four to ten percent of patients no more,
and in this series it's almost a term. It's difficult
(14:22):
to prove. I'm sure it contributed to the challenge of
managing the patient twitter it's with one arhythmia triggering the
other and then getting us an m vicious cycles. But
I think what's even more interesting is from the twelve
patients that we had with multiple mechanism in the post
operative period at the time of ep study, only one
(14:43):
and multiple mechanism and the others that we could not
find the other mechanism where we could not induce it.
I think you may expect that some of the mechanism
like JET or VT would be insient and result or
some some of them may be difficult to use with
more automatic orithmia like EAT, but there were many flutter
(15:05):
circuits that we were not able to find in the lab.
Interesting as far as like as successful were we It's
very small subgroups, so it's hard to do meaningful stitsistic.
But three of the four acutely unsuccessful procedures weren't patients
with multiple mechanism, and then nine out of the twelve
of those patients also had recurrence of SVT. So do
(15:28):
you think it's a more challenging group of patients? How
is it that the procedures were less likely to be
successful even though we only had one mechanism, And it's
not because we accounted for not being able to get
all the mechanism. That's the part I don't know yet,
but I think that's probably an interesting group to look
more into.
Speaker 2 (15:47):
Interesting watri. I was wondering if you could offer for
the audience, why it is it you think that the
majority of the patients who were uplated or it wasn't
really the majority, but a large number of them had recurrences.
Is this simply a reflection of the complexity of these
patients and a arrhythmias or is there something more to it?
I mean, how do these numbers compare you review this
(16:09):
a little bit in the discussion of your paper. How
do they compare to other series of oblations of a
rhythmias and congenital heart patients.
Speaker 4 (16:17):
So, I think a recurrence rate post abation and congenital
our disease is just I in general, it's approximately after patient.
It was a case in our court, it was a
case in the literature, so I'm not sure it's related
to the early post operative status.
Speaker 3 (16:31):
But I think a good news is that although.
Speaker 4 (16:33):
The actual number of recurrences, I think the burden of
arythnia was significant leads doing follow ups. So when you
take into account of the eurythnia burden score, including all
sustains the urythnia, the severity of their symptom, any cardioversion
or how often do they need a cardioversion, and the
type of entire rythmic midigation that they need, we make
(16:54):
a big difference. And that difference persists up to the
two years follow up that we did. So I think
we all get discouraged by a recurrence. I think looking
at the big picture here is important, and I think
anypcetty integration still makes a significant impact on the burden
and the quality of life, And maybe that thirty second
recurrence is not the full story.
Speaker 2 (17:16):
Yeah, I have to say, Atrea. As I was reading,
my very limited experience with postop oblation felt very similar
to what you described. I've also had the experience where
I blated maybe an eat in the next day, the
patient had a different eat, but it was a much
easier to control one which previously was completely uncontrollable on meds.
(17:37):
So I think success or failure can be measured in
different ways, and I think you demonstrated that in this work.
Now I'm going to ask you a provocative question, Audrey.
You know, early ablated patients in your study generally had
shorter procedure times, and yet they had a similar recurrence
rate as those who were blated later after surgery in
(17:58):
what were general longer procedures assume because when patients were
not quite as acutely ill, you know, they were longer.
And I was wondering if you could give your best
guess about why the procedural times were lower in the
early ablated group, and also comment on whether you think
that there are lessons learned from being able to ablate
complex a arrhythmias in shorter timeframes with a similar efficacy
(18:22):
and safety. I mean, given the notion that the longer
a patient lies on the table in a procedure, the
higher chances for a mishap, do you think that this
observation that you had similar success rates despite much shorter
procedure times. May argue for shorter procedural times in general
for ablation, even if not performed in the early post
(18:42):
top sick patient.
Speaker 4 (18:45):
Yeah, so, I think this was somewhat of an unexpected finding,
but I think it's an important one. The groups are similar.
It's not because they had different arrhythmia. It's not because
they were more likely to have different mechanism. They were
really the same target and make chanism. The one difference
is the patient a qutly, we're sicker. They were more
likely to be insupated. They were more likely to be
(19:05):
on ECMO than the ones that we took glitter to
the lab. So, at least personally, when I take a
very sick kid to the lab or in an incessant ritnia,
we tend to go in with a goal to get
rid of this seritinia and then get up before we
get into trouble. There seems to be enough to make
them better, both acutely and also longer term. I think
(19:26):
when patient comes to the lab more electively as outpatient,
we may not be as conscious of the impact of
longer procedure time on the risk of complication. That they have,
or at least I probably am not. We go in
and we want to get rid of everything that we can,
and we want to watch them longer to make sure
that they don't have recurrence, and we want to do
(19:47):
more diagnostic maneuvers to make sure we're not missing anything,
or we want to target the flutter circuit three, four,
five or six that we find. But I think the
lesson here is maybe that doesn't make it big difference,
and especially like I think in our sickest congenital eye
disease patient or in our adult congenital even though they're
not early post up, they may still be sick and
(20:09):
get a significant complication from these procedures. So it maybe
worth thinking in some of our patient and doing more.
Speaker 2 (20:18):
Yeah, sometimes the enemy of good is better, I think. Well,
for those of you in the audience, it's as usual,
it's late in the evening and doctor Dion was nice
enough to speak with us after a very long day
of have patient clinics. So I'm going to finish up
with one final question, Auchery, with the insights that you've
(20:38):
come to from your review with your co authors, do
you think that there are some post operative arrhythmias that
maybe we typically treat medically, in which maybe we should
be more aggressive advocating for an ablation attempt even in
the post operative period. Who do you think should be
getting ablated early after surgery and maybe not managed with
(21:00):
more conservative, non invasive treatments. It seemed like in this
work pretty much everybody who went to the lab had
already failed some kind of traditional therapy. But I was
wondering if, as you were looking through all these data,
if there was a group of patients that you thought,
you know, maybe in retrospect, I would be good to
think about more aggressive invasive treatment.
Speaker 4 (21:22):
So I think it's important to remember that most post
operative aritnia can be mysically managed and that many do
go away in the first few months after surgery. So
to put things in perspective, this was twenty four patients
that were ablated at zero to three months and twenty
six in the three to twelve month post up out
of almost twenty nine thousand surgery. So this is definitely
a very small subset over a twenty year period. Yes,
(21:46):
I think a subset of patient for whom it may
be needed and in whom we can probably do it
safely is you know, I think post aparithnias are in
many ways that a reflection of our sick patients are
they get better, the ritnia get better. But I think
there's a subset of patient for whom ritnia is really
what makes them sick, That's what keeps them in the ICU,
(22:07):
that's what keeps them intimated, or that's why they're on ECHMO.
I think this is probably the group that may deserve
earlier intervention, especially because we know that being the ICU
longer gets you more morbidity and complication from lank of state.
So I think that's the group that may benefit from
earlier ablation. Those in the urritnia is really what's preventing
(22:29):
them from moving forward post up, and not just one
of the manifestations of their post operative course.
Speaker 2 (22:36):
Yeah, very wise words, indeed, and I'll definitely give them
thought myself the next time I'm in that circumstance which
seems to affect all electrophysiologists, the difficult post op arrhythmia. Well, Audrey,
I can't thank you enough for joining us this week.
I know must have been difficult to find these the
zero point one percent of cases who needed to go
(22:59):
early to the calf lap for ablation, but I really
think we all learned a great deal about it, and
I want to congratulate you in all of your many
co investigators, and thank you so much for joining us
this week on Pedheart.
Speaker 3 (23:10):
Thank you for having me for your great podcast. Thank you.
Speaker 1 (23:14):
I hope you enjoyed doctor Dean's comments about her work
as much as I did. I think our final point
about this being a very rare group of patients was
an important one. There are, of course, many reasons for
this sort of intervention being rare, but the most important
is that most of these rhythmias will improve with temporary
medical control followed by the tincture of time. However, I
(23:36):
do think she made an important point about how maybe
we should be giving oblation a bit more consideration in
the post operative patient when the arrhythmia itself is the
cause of prolonged hospitalization or hemodynamic instability. I hope you
found her comments as interesting as I did, and I
wish to thank her once again for taking time from
her very busy schedule to speak with us this week
(23:56):
on pd Heart. To conclude this three hundred and forty
fourth episode of pd Hart Pediatric Cardiology Today, we end
with the wonderful American tenor Neil Schikoff, who last week
turned seventy six. Chikoff was the son of a canter
and studied singing with his father in Brooklyn, New York,
and many other singing teachers, notably the great Franco Correlli,
(24:17):
and he sang at the Metropolitan Opera in the nineteen
nineties up to the early two thousands. At times he
suffered from stage fright, but he had a wonderful presence
on stage and was considered one of the great tenors
of the past fifty years. Today we hear him in
a role for which he was justly famous, that of
Vertaire and Messenet's opera of the same name, and he
sings the famous aria poor Cuimer reve. Thank you very
(24:41):
much for joining me for this episode, and thanks once
again to doctor dion. I hope everybody has a good
week ahead.
Speaker 5 (25:00):
The s s SoCon.
Speaker 4 (25:15):
So pot.
Speaker 6 (25:19):
For mispa.
Speaker 5 (25:34):
E oiadrong w your source of what.
Speaker 7 (26:25):
Pastic hospital calls ex
Speaker 5 (27:04):
S
Welcome to Pdiheart Pediatric Cardiology Today. My name is doctor
Robert Pass and I'm the host of this podcast. I
am Professor of Pediatrics at the Icon School of Medicine
at Mount Sinai, where I'm also the Chief of Pediatric Cardiology.
Thank you for joining me for this three hundred and
forty fourth episode of Pdheart. I hope everybody enjoyed last
week's replay episode on hypoplastic left heart syndrome and outcomes
(00:37):
of twelve years following staged reconstruction. For those of you
who are interested in single ventrical physiology, I'd certainly recommend
you take a listen to last week's episode with our guest,
doctor Karen Goldberg. As I say every week, if you'd
like to get in touch with me, my email is
easy to remember. It's Pdheart at gmail dot com. This
week we move into the world of cardiac critical care
(00:59):
as well as electrophysiology. The title of the work is
Efficacy and Safety of early post operative Oblation in Patients
with congenital heart Disease. The first author of this work
is Sarah Kerr and the senior author Audrey Dion. And
this group comes to us from Boston, Children's Hospital, Department
of Pediatrics, Department of Surgery, and Department of Cardiology. When
(01:21):
we're done reviewing this paper, we're lucky to have doctor
Audrey Dione, the senior author of this work, join us
to discuss it. Therefore, let's get onto this interesting paper
and then a conversation with its senior author. This week's
work starts with some comments about arrhythmias following congenital heart surgery,
and the authors mention that it is a common occurrence,
and they review the reasons such as the combination of
(01:43):
incisions in the mayacardium as well as inflammation, eschemia, reperfusion, injury, inotropes,
electrolyte abnormalities and elevations, and atronergic tones, essentially suggesting that
this is a virtual witches brew for arrhythmia. The authors
then explain what we in our fields all which is
that these arrhythmias are thankfully usually transient, and this is
(02:04):
the most important reason that we do not routinely ablate
these arrhythmias in this setting, but rarely there are medically
refractory cases where consideration for an ablation might be appropriate.
In the author's contrast, how in the post operative setting,
medical management is always the first line, with ablation a
very far distant second, with how in the outpatient setting
(02:26):
ablation often takes first in line in our offerings for arrhythmia.
They then review how there is essentially nearly no information
on what happens at electrophysiology study and ablation in the
post operative setting, and so with this as a background
state that quote, we report on the safety and effics
the outcomes of electrophysiological study in the early post operative
(02:47):
period in patients with congenital heart disease, with most patients
undergoing EPs during surgical hospitalization, and the authors emphasize that
these were critically ill patients in the ICU with refractory arrhythmias.
Compare those who had an EPs during the first three
months after surgery with those who underwent later procedures three
to twelve months after surgery. The authors explained that this
(03:10):
was a retrospective study of all children and young adults
who underwent an EPs with ablation within twelve months of
open heart surgery between two thousand and twenty twenty one
at Boston Children's Hospital. The electrophysiological procedures were done in
a standard way with standard equipment for the past twenty years,
and they explained that for this work, acute success was
(03:30):
defined as elimination of all targeted A rhythmias. Partial success
was if some but not all targeted A rhythmias were
eliminated or empirical when it was impossible to see if
the ablation worked because they may not have been inducible
arrhythmias at the time of ablation, the authors recorded the
complications or adverse events of the procedure. For this work,
(03:51):
they categorized the arrhythmias into four types, and these being
macroreentran atrial or ventricular arrhythmias like IART or monomorphic VT arrhythmia,
is due to enhanced automaticity like atrial ventricular ectopy or
junctional like topic tachycardia, accessory pathway mediate attachycardia, and finally
av noto reentrant tachycardia. For this work, recurrence of arrhythmia
(04:14):
was defined as documented rhythmia on ECG twenty four hour
halter and or pacemaker. The authors used a twelve point
clinical arrhythmia severity score to quantify the arrhythmia burden before,
during hospitalization, and at follow up and Table I shows
what goes into that arrhythmia scoring system, and on to
the results. Over the twenty year period, there were twenty
(04:35):
eight thousand, nine hundred and two operations performed, of which
twenty four patients or zero point one percent, underwent an
EP study with ablation within three months of surgery and
twenty six or zero point one percent in the three
to twelve months following surgery. And so right off, it's
clear to mention that this is a very rare cohort
(04:56):
of patients who went for blation in the early or
mid term following surger. Most of the patients had either
so called great or moderate cardiac anatomy complexity, meaning that
the vast majority had more than straightforward anatomy. And what
were the post operative rhythmias in this cohort, well, these
were iart or atrial flutter in thirty three percent or
(05:18):
eight patients, ectopic atrial tachycardia in twenty one percent or
five patients, av notal re entrant tachycardia in two patients,
junctional ectopic tachycardian one, and an unspecified atrial arrhythmia in
one of note. Multiple mechanisms for tachycardi were actually seen
in seven patients or twenty nine percent, with the combinations
(05:39):
being ectopic atrial tachycardiaan IART in three or thirteen percent
IART and JET in one, ectopic atrial tachycardian, an accessory
pathway in one, and finally one unlucky patient with three
rhythmias IART, atrial fibrillation, and ventricular tachycardia. Perhaps not surprisingly,
seventy five percent of those undergoing ablations had ventricular dysfunction,
(06:02):
with forty six percent having moderate or severe dysfunction and
twenty nine percent mild dysfunction. Also not shockingly, ninety six
percent of the patients were on anti rhythmic therapy at
the time of the electrophysiological study, with nearly half on two,
perhaps reflecting the difficult time that the EP and ICU
doctors were having in controlling these arrhythmias. The indication for
(06:25):
ablation in all but one case was a rhythmia that
was refractory to medical management. The medium timing of electrophysiologic
study and ablation was post operative day thirty two, with
thirty eight percent happening before discharge from the hospital from surgery.
Ninety six percent of patients either had spontaneous or inducible
arrhythmia during the procedure, which is always good news for
(06:45):
the electrophysiologist, and the median procedural time was one hundred
and fifty one minutes. Okay, now for the important question,
how well did it work and did anyone get hurt? Well,
the procedure was acutely successful in twenty one or eighty
eight percent of the arrhythmia mechanisms, and an empirical lesion
set was placed in two patients and was unsuccessful in one.
(07:06):
The unsuccessful procedure was a left sided actopic atrial tachycardia,
and the procedure had to be aborted after a transceptal
needle punctured the left and tricular outflow tract with the
resultant hematoma. The author's report that the wire was removed
but no emergency surgery was required. The patient had a
VSD closure with an aortic root replacement and an RV
(07:27):
to PA conduit, and ultimately, seven days later went back
to the cath lab where the transseptal was successfully performed
and the oblation was successful. Overall, there were four complications
affecting eight percent, with the major one being the one
I just mentioned. There was one moderate complication and two
minor ones. Arrhythmius occurred in fifty eight percent of patients
(07:48):
that follow up of three point two years, and recurrence
was seen in thirty three percent prior to leaving the hospital. However,
the burden of arrhythmia was markedly decreased in follow up,
including those who had a recurrence. The authors report that
eight patients went back for repeat ablation within a year,
and there were multiple reattempts in four of Note seven
(08:09):
of the patients who underwent ablation, or thirty percent died
at a median of zero point six years after surgery,
though not due to arrhythmia or electrophysiological study, highlighting for
us that these were amongst the most sick post operative patients.
In their discussion, the authors repeat that most post operative
arrhythmias can be managed medically, but they state that rarely
(08:30):
electrophysiological study with ablation for refractory or life threatening arrhythmias
can be performed in the post operative period with what
they believe is reasonable acute success and limited morbidity. Despite
the critically ill nature of these patients. They contrast the
timing of these cases to those of other literature on
post operative ablation, showing that most of the other prior
(08:51):
works highlight how these are generally required much later, typically
in periods measured in years, not days from surgery. The
investigators then address the relation relatively high recurrence rate that
is seen in the study and demonstrate how this sort
of recurrence rate is not particularly different from other series
of congenital heart disease ablations not done in the immediate
post operative period, and they emphasize how despite recurrence rates,
(09:14):
the burden of arrhythmia as measured by a clinical arrhythmia
score was lower. During follow up of this early ablation cohort,
they mentioned that the one difference that they observed when
comparing the very early less than three month cohorts to
the greater than three month cohort was the length of
the procedure, explaining that the early electrophysiological patients had shorter
procedural times. They suggest that it is possible that given
(09:37):
the level of illness of these patients, the operators were
naturally more interested in moving forward quickly by targeting the
clinical arrhythmia. Importantly, the recurrence rate were the same in
the early versus the late cases, despite the shorter half time.
The authors mentioned the complications seen, including the hemotomin that
we discussed, a bradycardia induced torsades, a point requiring a
(10:00):
pacemaker after an iart ablation, first degree harp block, and
a pseudoaneurysm, and suggest that none of those were due
to the post operative status of the patient. They suggest
that the complication rate compared favorably to other series of
complication rates in the congenital heart disease patient who undergoes ablation.
In regards to limitations, they referenced the small and heterogeneous
(10:20):
sample size in one institution and the absence of standard
means of referral for electrophysiology study and ablation. They also
mention all of the patients who may have seemed so
sick as to not actually be candidates for an EP study,
resulting in a form of ascertainment bias, and they are
quick to suggest that these results should not be generalized
to all centers. The authors conclude by reviewing that zero
(10:44):
point one percent of post operative patients received early electrophysiology
and ablation for refractory or life threatening arrhythmias. And how
these results were similar between the early zero to three
month ablation candidates and those who were done a little
later between three and twelve months post up. They end
by stating, and I quote, a better understanding of outcomes
(11:04):
of electrophysiology study in the early post operative period may
help clinicians with decision making as well as to inform
families well. This is an interesting work again showing that catheterization,
this time an electrophysiology CAF in the post op patient
has a role in the management of the post operative
congenital heart surgical patient. Clearly, the vast majority of patients
(11:25):
can at least be managed acutely medically. However, these data
are reassuring that in good hands, in the right patient,
the risk of these procedures are not zero, but low
enough to warrant consideration for EP study and oblation when
it seems that the patient is not getting better despite
aggressive medical management. I do find it of interest that
the shorter, earlier procedures were just as effective as the later,
(11:47):
longer ones, where the group was presumably being more careful
and perhaps trying harder to eradicate other less clinically relevant arrhythmias.
This makes me wonder if there might be some lessons
for all of us electrophysiologists in the approach the investigators
used for the early oblations. Haste may in some circumstances
make waste, but we also know that the longer a
(12:08):
patient lies on that CAF table under anesthesia, the greater
the opportunity for something bad to occur. It's a fine balance,
but I wonder if there's a signal there in the
generally similar outcomes despite maybe cutting a few corners. Well,
there's a bit to unpack, and so in the interest
of time, let's move forward to our conversation with the
work's senior author. Joining us now to discuss this week's
(12:31):
work is the work's senior author, Doctor Audrey Dione. Doctor
Dione is a systant Professor of Pediatrics at the Harvard
Medical School, where she is a pediatric electrophysiologist as well
as general cardiologist. She's a graduate of the University of
Sherbrook in Quebec, Canada for medical school, and she completed
her residency in pediatrics at the Saint Justine Children's Hospital,
(12:51):
also in Quebec. Following this, she came to Boston Children's Hospital,
where she completed her Categorical Cardiology Fellowship as well as
Electrophysiology Fellowship. She is a very well published author in
many arenas within cardiology, including electrophysiology and Kawasaki disease, where
she is viewed as a major authority. It is the
light to welcome her to PD heart. Welcome Audrey to
(13:13):
PD heart.
Speaker 2 (13:14):
I'm here now with doctor audre Gione from Boston Children's Hospital. Audrey.
Really appreciate your joining us this week on PD heart.
Speaker 3 (13:20):
Thank you very much for the invitation.
Speaker 2 (13:22):
Thank you, Audrey very much enjoyed this week's work. Very
important practical paper. You know, combinations of a arrhythmias I
noticed in your work were common, accounting for nearly a
third of all of the oblations that you did in
this post operative cohort. And I wondered if you retrospectively
believe that it was this combination that may have been
(13:43):
the reason that you were not able to more traditionally
manage these arrhythmias with medications. And I also wondered how
successful were you when you ablated patients who had many
different mechanisms.
Speaker 3 (13:55):
Yeah, I think that's a very interesting finding.
Speaker 4 (13:58):
And we looked at the patient in our core that
needed oblation versus just all of our overall post operative
arithnia patient And it's hard to put a number depending
on the groups that you make, but multiple mechanisms were
presented about four to ten percent of patients no more,
and in this series it's almost a term. It's difficult
(14:22):
to prove. I'm sure it contributed to the challenge of
managing the patient twitter it's with one arhythmia triggering the
other and then getting us an m vicious cycles. But
I think what's even more interesting is from the twelve
patients that we had with multiple mechanism in the post
operative period at the time of ep study, only one
(14:43):
and multiple mechanism and the others that we could not
find the other mechanism where we could not induce it.
I think you may expect that some of the mechanism
like JET or VT would be insient and result or
some some of them may be difficult to use with
more automatic orithmia like EAT, but there were many flutter
(15:05):
circuits that we were not able to find in the lab.
Interesting as far as like as successful were we It's
very small subgroups, so it's hard to do meaningful stitsistic.
But three of the four acutely unsuccessful procedures weren't patients
with multiple mechanism, and then nine out of the twelve
of those patients also had recurrence of SVT. So do
(15:28):
you think it's a more challenging group of patients? How
is it that the procedures were less likely to be
successful even though we only had one mechanism, And it's
not because we accounted for not being able to get
all the mechanism. That's the part I don't know yet,
but I think that's probably an interesting group to look
more into.
Speaker 2 (15:47):
Interesting watri. I was wondering if you could offer for
the audience, why it is it you think that the
majority of the patients who were uplated or it wasn't
really the majority, but a large number of them had recurrences.
Is this simply a reflection of the complexity of these
patients and a arrhythmias or is there something more to it?
I mean, how do these numbers compare you review this
(16:09):
a little bit in the discussion of your paper. How
do they compare to other series of oblations of a
rhythmias and congenital heart patients.
Speaker 4 (16:17):
So, I think a recurrence rate post abation and congenital
our disease is just I in general, it's approximately after patient.
It was a case in our court, it was a
case in the literature, so I'm not sure it's related
to the early post operative status.
Speaker 3 (16:31):
But I think a good news is that although.
Speaker 4 (16:33):
The actual number of recurrences, I think the burden of
arythnia was significant leads doing follow ups. So when you
take into account of the eurythnia burden score, including all
sustains the urythnia, the severity of their symptom, any cardioversion
or how often do they need a cardioversion, and the
type of entire rythmic midigation that they need, we make
(16:54):
a big difference. And that difference persists up to the
two years follow up that we did. So I think
we all get discouraged by a recurrence. I think looking
at the big picture here is important, and I think
anypcetty integration still makes a significant impact on the burden
and the quality of life, And maybe that thirty second
recurrence is not the full story.
Speaker 2 (17:16):
Yeah, I have to say, Atrea. As I was reading,
my very limited experience with postop oblation felt very similar
to what you described. I've also had the experience where
I blated maybe an eat in the next day, the
patient had a different eat, but it was a much
easier to control one which previously was completely uncontrollable on meds.
(17:37):
So I think success or failure can be measured in
different ways, and I think you demonstrated that in this work.
Now I'm going to ask you a provocative question, Audrey.
You know, early ablated patients in your study generally had
shorter procedure times, and yet they had a similar recurrence
rate as those who were blated later after surgery in
(17:58):
what were general longer procedures assume because when patients were
not quite as acutely ill, you know, they were longer.
And I was wondering if you could give your best
guess about why the procedural times were lower in the
early ablated group, and also comment on whether you think
that there are lessons learned from being able to ablate
complex a arrhythmias in shorter timeframes with a similar efficacy
(18:22):
and safety. I mean, given the notion that the longer
a patient lies on the table in a procedure, the
higher chances for a mishap, do you think that this
observation that you had similar success rates despite much shorter
procedure times. May argue for shorter procedural times in general
for ablation, even if not performed in the early post
(18:42):
top sick patient.
Speaker 4 (18:45):
Yeah, so, I think this was somewhat of an unexpected finding,
but I think it's an important one. The groups are similar.
It's not because they had different arrhythmia. It's not because
they were more likely to have different mechanism. They were
really the same target and make chanism. The one difference
is the patient a qutly, we're sicker. They were more
likely to be insupated. They were more likely to be
(19:05):
on ECMO than the ones that we took glitter to
the lab. So, at least personally, when I take a
very sick kid to the lab or in an incessant ritnia,
we tend to go in with a goal to get
rid of this seritinia and then get up before we
get into trouble. There seems to be enough to make
them better, both acutely and also longer term. I think
(19:26):
when patient comes to the lab more electively as outpatient,
we may not be as conscious of the impact of
longer procedure time on the risk of complication. That they have,
or at least I probably am not. We go in
and we want to get rid of everything that we can,
and we want to watch them longer to make sure
that they don't have recurrence, and we want to do
(19:47):
more diagnostic maneuvers to make sure we're not missing anything,
or we want to target the flutter circuit three, four,
five or six that we find. But I think the
lesson here is maybe that doesn't make it big difference,
and especially like I think in our sickest congenital eye
disease patient or in our adult congenital even though they're
not early post up, they may still be sick and
(20:09):
get a significant complication from these procedures. So it maybe
worth thinking in some of our patient and doing more.
Speaker 2 (20:18):
Yeah, sometimes the enemy of good is better, I think. Well,
for those of you in the audience, it's as usual,
it's late in the evening and doctor Dion was nice
enough to speak with us after a very long day
of have patient clinics. So I'm going to finish up
with one final question, Auchery, with the insights that you've
(20:38):
come to from your review with your co authors, do
you think that there are some post operative arrhythmias that
maybe we typically treat medically, in which maybe we should
be more aggressive advocating for an ablation attempt even in
the post operative period. Who do you think should be
getting ablated early after surgery and maybe not managed with
(21:00):
more conservative, non invasive treatments. It seemed like in this
work pretty much everybody who went to the lab had
already failed some kind of traditional therapy. But I was
wondering if, as you were looking through all these data,
if there was a group of patients that you thought,
you know, maybe in retrospect, I would be good to
think about more aggressive invasive treatment.
Speaker 4 (21:22):
So I think it's important to remember that most post
operative aritnia can be mysically managed and that many do
go away in the first few months after surgery. So
to put things in perspective, this was twenty four patients
that were ablated at zero to three months and twenty
six in the three to twelve month post up out
of almost twenty nine thousand surgery. So this is definitely
a very small subset over a twenty year period. Yes,
(21:46):
I think a subset of patient for whom it may
be needed and in whom we can probably do it
safely is you know, I think post aparithnias are in
many ways that a reflection of our sick patients are
they get better, the ritnia get better. But I think
there's a subset of patient for whom ritnia is really
what makes them sick, That's what keeps them in the ICU,
(22:07):
that's what keeps them intimated, or that's why they're on ECHMO.
I think this is probably the group that may deserve
earlier intervention, especially because we know that being the ICU
longer gets you more morbidity and complication from lank of state.
So I think that's the group that may benefit from
earlier ablation. Those in the urritnia is really what's preventing
(22:29):
them from moving forward post up, and not just one
of the manifestations of their post operative course.
Speaker 2 (22:36):
Yeah, very wise words, indeed, and I'll definitely give them
thought myself the next time I'm in that circumstance which
seems to affect all electrophysiologists, the difficult post op arrhythmia. Well, Audrey,
I can't thank you enough for joining us this week.
I know must have been difficult to find these the
zero point one percent of cases who needed to go
(22:59):
early to the calf lap for ablation, but I really
think we all learned a great deal about it, and
I want to congratulate you in all of your many
co investigators, and thank you so much for joining us
this week on Pedheart.
Speaker 3 (23:10):
Thank you for having me for your great podcast. Thank you.
Speaker 1 (23:14):
I hope you enjoyed doctor Dean's comments about her work
as much as I did. I think our final point
about this being a very rare group of patients was
an important one. There are, of course, many reasons for
this sort of intervention being rare, but the most important
is that most of these rhythmias will improve with temporary
medical control followed by the tincture of time. However, I
(23:36):
do think she made an important point about how maybe
we should be giving oblation a bit more consideration in
the post operative patient when the arrhythmia itself is the
cause of prolonged hospitalization or hemodynamic instability. I hope you
found her comments as interesting as I did, and I
wish to thank her once again for taking time from
her very busy schedule to speak with us this week
(23:56):
on pd Heart. To conclude this three hundred and forty
fourth episode of pd Hart Pediatric Cardiology Today, we end
with the wonderful American tenor Neil Schikoff, who last week
turned seventy six. Chikoff was the son of a canter
and studied singing with his father in Brooklyn, New York,
and many other singing teachers, notably the great Franco Correlli,
(24:17):
and he sang at the Metropolitan Opera in the nineteen
nineties up to the early two thousands. At times he
suffered from stage fright, but he had a wonderful presence
on stage and was considered one of the great tenors
of the past fifty years. Today we hear him in
a role for which he was justly famous, that of
Vertaire and Messenet's opera of the same name, and he
sings the famous aria poor Cuimer reve. Thank you very
(24:41):
much for joining me for this episode, and thanks once
again to doctor dion. I hope everybody has a good
week ahead.
Speaker 5 (25:00):
The s s SoCon.
Speaker 4 (25:15):
So pot.
Speaker 6 (25:19):
For mispa.
Speaker 5 (25:34):
E oiadrong w your source of what.
Speaker 7 (26:25):
Pastic hospital calls ex
Speaker 5 (27:04):
S
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