Rick Choi

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I think groups have been very aggressive about first-time, they're much better, they're easier procedures, right? If you get them early, you probably have one or two circuits where if you wait 5 or 6 years, you're taking on these, uh, more complex 5 or 6 circuit cases

quote · Single Ventricle / HLHS

if your goal is to be completely off Coumadin, I don't even know if that's a strategy once you've had your atrial arrhythmia, but if you have to be off Coumadin, the only way to probably do that safely with risk is to, to go ahead with catheter ablation

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Rick's statements about Single Ventricle / HLHS 90 statements

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The Role of Trans-Catheter Arrhythmia Management - Patient Based Decision...

Quotation I'm an electrophysiologist and so, uh, sometimes might be inherently dry, but I think this topic is actually interesting. If, if nothing else, because it's controversial and we like controversy Open

Statement In early Boston Fontan data, macro-reentrant atrial tachycardia was ubiquitous out to 20 years Open

Statement After first atrial tachycardia and cardioversion in Fontan patients, risk of future tachycardia is upwards of 80 or 90% Open

Statement While incidence of tachycardia is heavily related to Fontan type, risk of recurrent tachycardia is the same for all Fontan types Open

Quotation if our goal is complete amelioration of atrial tachycardia, I think it's been well documented that atrial, that anti-arrhythmics are not going to get us to a complete suppression of tachycardia Open

Statement Anti-arrhythmic medications do not achieve complete suppression of atrial tachycardia in Fontan patients Open

Statement In multiple studies, essentially 100% of Fontan patients on anti-arrhythmics alone have recurrence of tachycardia over 5 to 6 years Open

Quotation I typically think about the decision to ablate or not to ablate as a dichotomous decision. So we either ablate or we don't ablate, but I think in Fontaine's, I think it's more of a circular loop Open

Quotation The real question is, is ablation a potential off-ramp, uh, for the circular loop or really just another part of the loop itself? Open

Quotation trans catheter ablation is gonna play some role in these patients' life. So it's a bit more of a decision of when, uh, more than it's a decision of, of, uh, if Open

Quotation I'm an electrophysiologist, so I know there's a lot of different uh types for, for us, there's really 3 types Open

Statement Lateral tunnel Fontans have had significantly less incidence of atrial arrhythmias compared to atrial-pulmonary Fontans Open

Statement Data on whether extracardiac conduit has significantly lower arrhythmia incidence than intracardiac conduit is discrepant, with some studies showing significant improvement and others showing less difference Open

Quotation as we change our fontan type, our catheter is now not entering. Uh, the atrial chamber, at least as far as an access point. And so now we have to figure a way out of the conduit, uh, back into the, uh, atrial chamber Open

Quotation with these differing. Fontan styles we've made the, we've had a significant benefit in terms of frequency of tachycardia, but I think we've been making our ablations more difficult procedures Open

Statement In Boston study of ~90 Fontan ablation patients, over half required trans-baffle procedure, with moderate or severe complication rate of about 10% Open

Statement In trans-baffle ablation cases, catastrophic complications included death and major shunts with cyanosis, whereas non-trans-baffle complications were primarily kidney injury Open

Quotation I don't think this has been definitively proved, but I think it's not a, uh, particularly low risk procedure Open

Quotation if you say Fontan and tachycardia, I'm gonna tell you it's macro-oriented, and I'm probably gonna be right Open

Statement In study of 52 Fontan ablation patients, 80 different arrhythmia mechanisms were identified, meaning majority of patients had more than one mechanism Open

Statement In Fontan ablations, macro-reentrant tachycardia was most common type but represented less than half of ablations, with focal atrial tachycardia and AVNRT being important mechanisms Open

Statement Atrial fibrillation as an isolated phenomenon in Fontan patients is relatively rare Open

Statement Ed Walsh felt that atrial tachycardia was a risk factor for sudden death in Fontan patients Open

Statement In several studies, Fontans with arrhythmias do worse than Fontans without arrhythmias in terms of freedom from death or transplant Open

Statement Arrhythmia is a significant predictor of outcome in Fontan risk stratification models Open

Statement It is unknown whether ablating arrhythmia substrates in Fontan patients will change their overall risk of death or transplant Open

Statement In Mayo study of 260 Fontan patients with arrhythmia, almost all patients had recurrence of atrial tachycardia regardless of management strategy Open

Statement High recurrence rate in Mayo study was heavily driven by high prevalence of patients on anti-arrhythmic medications alone Open

Statement Catheter ablation in Fontan patients achieved freedom from recurrence in the range of 40 to 50%, not the 95-97% typical of other ablation types Open

Statement In study using clinical arrhythmia severity scores, Fontan patients who underwent ablation had significant improvement in scores following ablation Open

Statement Even in Fontan patients who had recurrence of tachycardia after ablation, there was still some improvement in overall arrhythmia burden, though not as robust as in patients without recurrence Open

Quotation Maybe for some patients, the way to look at this is not a complete suppression of any recurrence, but a tailoring of the overall burden Open

Statement Fontan conversion with arrhythmia surgery achieves freedom from arrhythmia around 50 to 60%, probably not all that different than catheter ablation alone Open

Statement Rick's typical approach is to give Fontan patients one arrhythmia episode and monitor them going forward, either off or on medications, then consider ablation after recurrent atrial arrhythmia Open

Statement Fontan patients with SVT are likely to have recurrence of SVT Open

Quotation I think my main points are, uh, Fontan patients with SVT are likely to have recurrence of SVT Open

Statement Fontan patients with SVT are likely to have recurrence of SVT Open

Quotation I think my main points are, uh, Fontan patients with SVT are likely to have recurrence of SVT Open

Statement Anti-arrhythmic medications are reasonable but unlikely to keep Fontan patients completely tachycardia-free Open

Statement New onset atrial tachycardia or increased tachycardia burden is often an early indicator of other issues in Fontan patients Open

Statement Catheter ablation plays a major role in management of SVT in Fontan patients and is reasonable as either first or second line management Open

Quotation the role of catheter ablation is in evolution is going to continue to change significantly over the next decades based on our changing fontan anatomy Open

Quotation I got to say, at, at the time of most of these procedures, we're rarely, if ever, blessed with that type of macro entrant. They tend to be in the younger patients, I think we've seen they're more scar related to the atriotomy and things like that Open

Statement In surgical ablation data from Chicago, isthmus ablation-only strategy had much worse outcomes than more aggressive strategies, but aggressive strategies bring sinus node dysfunction into the equation Open

Quotation I think even if you go back to the surgical data from Chicago, the isthmus ablation only. The strategy was much worse than these more aggressive strategies. The problem is with the more aggressive strategies you bring science no dysfunction well into the equation Open

Quotation I think they're going to be the same but present at a different stage Open

Quotation we go in and seriously 2/3 sometimes of the atrial tube. Issues essentially scar with no electrical activity Open

Statement In older Fontan patients undergoing ablation, sometimes 2/3 of the atrial tissue is essentially scar with no electrical activity Open

Quotation we go in and seriously 2/3 sometimes of the atrial tube. Issues essentially scar with no electrical activity Open

Statement Extracardiac Fontan patients will have reduced early arrhythmia incidence due to less surgical scarring, but may face same late risk from atrial stretch and fibrosis unless there is true hemodynamic benefit at 20-30 years Open

Quotation My concern would be late. They're still at the same risk of overall stretch and fibrosis and things like this. So those, I don't, I don't really understand why they'd be completely. Uh, free from that style unless there's some sort of true hemodynamic benefit out to 20 or 30 years Open

Quotation for me, the answer is that I would wait for their second episode. I think if that episode is 3 years down the road, but we, you have to talk with them. What's your goal? Open

Statement If Fontan patient's goal is to be completely off Coumadin after atrial arrhythmia, the only way to probably do that safely is to go ahead with catheter ablation Open

Quotation if your goal is to be completely off Coumadin, I don't even know if that's a strategy once you've had your atrial arrhythmia, but if you have to be off Coumadin, the only way to probably do that safely with risk is to, to go ahead with catheter ablation Open

Quotation I think groups have been very aggressive about first-time, they're much better, they're easier procedures, right? If you get them early, you probably have one or two circuits where if you wait 5 or 6 years, you're taking on these, uh, more complex 5 or 6 circuit cases Open

Statement Early ablation procedures in Fontan patients are easier, probably involving one or two circuits, whereas waiting 5-6 years results in more complex cases with 5 or 6 circuits Open

Statement Rick's center has not seen many young patients with atrial arrhythmias, having done lateral tunnels or extracardiac Fontans primarily for a long time Open

Quotation I gotta say we have not seen a lot of young patients with atrial arrhythmias, and we've been doing lateral tunnels or extrac cardiac for a long time primarily Open

Summaries Rick gave as host · 20 summaries

Recaps of other experts' statements, not Rick's own clinical position.

Summaries Rick gave as host · Single Ventricle / HLHS 20 summaries

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The Role of Trans-Catheter Arrhythmia Management - Patient Based Decision...

Host summary Rick Choi summarizing the discussion: In early Boston Fontan data, macro-reentrant atrial tachycardia was ubiquitous out to 20 years Open

Host summary Rick Choi summarizing the discussion: After first atrial tachycardia and cardioversion in Fontan patients, risk of future tachycardia is upwards of 80 or 90% Open

Host summary Rick Choi summarizing the discussion: While incidence of tachycardia is heavily related to Fontan type, risk of recurrent tachycardia is the same for all Fontan types Open

Host summary Rick Choi summarizing the discussion: Anti-arrhythmic medications do not achieve complete suppression of atrial tachycardia in Fontan patients Open

Host summary Rick Choi summarizing the discussion: In multiple studies, essentially 100% of Fontan patients on anti-arrhythmics alone have recurrence of tachycardia over 5 to 6 years Open

Host summary Rick Choi summarizing the discussion: Lateral tunnel Fontans have had significantly less incidence of atrial arrhythmias compared to atrial-pulmonary Fontans Open

Host summary Rick Choi summarizing the discussion: Data on whether extracardiac conduit has significantly lower arrhythmia incidence than intracardiac conduit is discrepant, with some studies showing significant improvement and others showing less difference Open

Host summary Rick Choi summarizing the discussion: In Boston study of ~90 Fontan ablation patients, over half required trans-baffle procedure, with moderate or severe complication rate of about 10% Open

Host summary Rick Choi summarizing the discussion: In trans-baffle ablation cases, catastrophic complications included death and major shunts with cyanosis, whereas non-trans-baffle complications were primarily kidney injury Open

Host summary Rick Choi summarizing the discussion: In study of 52 Fontan ablation patients, 80 different arrhythmia mechanisms were identified, meaning majority of patients had more than one mechanism Open

Host summary Rick Choi summarizing the discussion: In Fontan ablations, macro-reentrant tachycardia was most common type but represented less than half of ablations, with focal atrial tachycardia and AVNRT being important mechanisms Open

Host summary Rick Choi summarizing the discussion: Ed Walsh felt that atrial tachycardia was a risk factor for sudden death in Fontan patients Open

Host summary Rick Choi summarizing the discussion: In several studies, Fontans with arrhythmias do worse than Fontans without arrhythmias in terms of freedom from death or transplant Open

Host summary Rick Choi summarizing the discussion: Arrhythmia is a significant predictor of outcome in Fontan risk stratification models Open

Host summary Rick Choi summarizing the discussion: In Mayo study of 260 Fontan patients with arrhythmia, almost all patients had recurrence of atrial tachycardia regardless of management strategy Open

Host summary Rick Choi summarizing the discussion: High recurrence rate in Mayo study was heavily driven by high prevalence of patients on anti-arrhythmic medications alone Open

Host summary Rick Choi summarizing the discussion: Catheter ablation in Fontan patients achieved freedom from recurrence in the range of 40 to 50%, not the 95-97% typical of other ablation types Open

Host summary Rick Choi summarizing the discussion: In study using clinical arrhythmia severity scores, Fontan patients who underwent ablation had significant improvement in scores following ablation Open

Host summary Rick Choi summarizing the discussion: Even in Fontan patients who had recurrence of tachycardia after ablation, there was still some improvement in overall arrhythmia burden, though not as robust as in patients without recurrence Open

Host summary Rick Choi summarizing the discussion: In surgical ablation data from Chicago, isthmus ablation-only strategy had much worse outcomes than more aggressive strategies, but aggressive strategies bring sinus node dysfunction into the equation Open