Fontan patient with brady and tachyarrhythmia issues: Case submitted by Vivienne Ezzat, MBChB

1. While there is no limit to the number of ablations that can be performed in patients with complex atrial arrhythmias in the setting of a Fontan circulation, repeated recurrence after multiple ablations should warrant evaluation for surgical Fontan conversion with Maze operation. 2. SND is common in Fontan patients. 3. In general, patients with Fontan circulation and SND only need an atrial pacemaker. Ventricular pacing should be avoided if at all possible in such patients. 4. Leadless pacemakers have no role in patients with SND since they can currently only be used for ventricular pacing. 5. The presence of an endocardial pacing (or defibrillation) lead should be considered an indication for anticoagulation in Fontan patients. 6. Amiodarone is an excellent short-term option. In patients who need long-term antiarrhythmic therapy, it is important to consider an exit strategy (such as surgical Maze or catheter ablation) in order to stop amiodarone.