Atrial fibrillation in adult congenital heart disease in Asia

IntroductionWith the improvement of long-term survival of patients with congenital heart disease (CHD), complications such as atrial fibrillation (AF) have become a concern. This study aimed to determine the epidemiology data and risk factors of AF in adult CHD (ACHD) patients and evaluate the impact of AF on late outcomes using a large ACHD cohort in Asia. MethodThis study enrolled all CHD patients older than 18 years of age diagnosed with CHD at National Taiwan University Hospital between 2007 and 2018. Data on patients clinical characteristics, electrocardiogram, Holter reports, and follow-up information were collected. AF status was classified as sustained AF, paroxysmal AF, or intra-atrial reentry tachycardia (IART). CHD was categorized as simple, severe, or complex CHD (single ventricle). Primary endpoint was defined as cerebrovascular accidents (CVA) or death. ResultThe study included 4403 patients (55.9% women), with 16.4% having severe and 2.9% having complex CHD. The cumulative incidence of AF was 6.9% (54.8% paroxysmal AF, 26.9% sustained AF, and 18.4% IART), which is comparable to the Western countries. The incidence increased with age and was higher in patients with pulmonary hypertension (PH, 27%), complex CHD (12.7%), and metabolic syndrome. The mean onset age of IART, paroxysmal, and sustained AF was 35.7{+/-}15.8, 48.4{+/-}19.3, and 56.9{+/-}14.2 years, respectively. Multivariate Cox regression analysis revealed that male sex, PH, and severe and complex CHD were the most critical risk factors for AF (odds ratio 1.67, 1.91, 3.55, and 12.6, respectively). The 70-year CVA-free survival rate was 67.1% in patients with AF (vs. 80.5% in those without AF, p<0.001). However, multivariate Cox regression analysis identified male sex, PH, severe and complex CHD, and genetic syndrome as the most significant risk factors of the primary endpoint (odds ratio 1.76, 3.38, 2.62 and 19.3, and 8.91, respectively). ConclusionsThis large ACHD cohort showed a high cumulative incidence of AF, similar to the Western countries, which increased with age, PH, and CHD severity. CVA-free survival was more closely associated with these factors than with AF.