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The Risk of Thromboembolic Complications in Fontan Patients with Atrial Flutter/Fibrillation Treated with Electrical

Jiuann-Huey I Lin1,2, Adam C Kean1, Timothy M Cordes3

  • 1Division of Pediatric Cardiology, Department of Pediatrics, Indiana School of Medicine, 705 Riley Hospital Drive, RR 227, Indianapolis, IN, 46202-5225, USA.

Pediatric Cardiology
|July 17, 2016
PubMed

Insights

Atrial flutter or fibrillation (AFF) is common after the Fontan procedure and increases clot risk. However, electrical cardioversion for AFF in Fontan patients, especially with anticoagulation, shows a very low risk of thromboembolism.

Area of Science:

  • Cardiology
  • Pediatric Cardiology
  • Congenital Heart Disease

Background:

  • Atrial flutter or fibrillation (AFF) is a significant long-term complication following the Fontan procedure.
  • AFF in Fontan patients increases the risk of thromboembolic events, such as stroke and pulmonary embolism.
  • The specific risk of thromboembolism related to electrical cardioversion for AFF in this vulnerable population is not well-defined.

Purpose of the Study:

  • To investigate the incidence and characteristics of thromboembolic complications in Fontan procedure patients undergoing electrical cardioversion for AFF.
  • To evaluate the safety of electrical cardioversion in Fontan patients with AFF, particularly concerning acute thromboembolic events.

Main Methods:

  • Retrospective review of medical records for patients with a history of Fontan operation treated with direct current cardioversion for AFF.
  • Data collection included patient demographics, type of Fontan connection, presence of atrial clots, anticoagulation status, and thromboembolic events (stroke, pulmonary embolism).
  • Analysis of 216 episodes of AFF requiring electrical cardioversion in 57 patients between June 1992 and March 2014.

Main Results:

  • Right atrial or Fontan conduit clots were identified in 57.9% of AFF episodes, with nearly half treated acutely with cardioversion.
  • Intracardiac thrombi were more frequent in patients with atriopulmonary connections (75.8%) compared to lateral tunnel (15.2%) or RVOT (9.1%) Fontan types.
  • While 15.8% of patients experienced stroke and 5.3% had pulmonary emboli during follow-up, none were directly linked to the cardioversion procedure itself.

Conclusions:

  • The presence of thrombus and the risk of thromboembolism are high in Fontan patients with AFF.
  • Electrical cardioversion for AFF in Fontan patients appears to carry a very low risk of acute thromboembolic complications when managed with appropriate anticoagulation.
  • Further research into optimal anticoagulation strategies for Fontan patients with AFF undergoing cardioversion is warranted.

Keywords:
Atrial flutter/fibrillationElectrical cardioversionFontan

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