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Abstract

The management of arrhythmias in adults with congenital heart disease (CHD) remains one of the most demanding challenges in modern cardiology. These patients face a unique triad of complex anatomy, altered hemodynamics, and extensive surgical scar tissue—together creating the perfect substrate for complex tachyarrhythmias. The recent article by Elhodhod et al., titled “Outcomes of Radiofrequency Catheter Ablation in Congenital Heart Disease: A Retrospective Analysis of Arrhythmia Subtypes and Recurrence Rates” provides a valuable and sobering perspective from a high-volume tertiary center in Egypt [1]. This work not only contributes to the global literature but also underscores the stark disparities in resource availability and how these limitations directly influence patient outcomes.
The study retrospectively examined 50 ablation procedures in 48 patients, reporting an acute success rate of 80% and a six-month freedom-from-arrhythmia rate of 52%. The safety profile was commendable, with complications occurring in only 6% of cases, all managed successfully. These results—particularly the acute success rate—are consistent with those from well-established centers in North America and Europe [2,3]. Such findings highlight that even without universal access to the most advanced technologies, skilled electrophysiologists can achieve impressive outcomes, reinforcing the pivotal role of operator expertise in CHD ablation.
Yet, the details reveal a critical narrative. The most common CHD substrate was Ebstein’s anomaly (40%), while the predominant arrhythmia was atrioventricular reentrant tachycardia (AVRT) (52%). This contrasts sharply with data from Western registries, where repaired Tetralogy of Fallot and intra-atrial reentrant tachycardia (IART) are more commonly encountered [2,4]. This discrepancy suggests a potential selection bias: patients with the most complex post-surgical substrates may not be referred for, or granted access to, ablation—possibly due to perceived procedural complexity or limited resources.
Instead, the cohort reflects a population where accessory pathway ablation, though challenging in Ebstein’s anomaly, is more routinely pursued.
Perhaps the most telling finding is the high recurrence rate (33% at six months) and its strongest predictor: a reduced left ventricular ejection fraction (EF). While EF is a well-recognized prognostic marker, the recurrence rate here is notably higher than the 10–20% reported in studies where 3D electroanatomical mapping (EAM) is standard [3,5]. The limited use of 3D EAM, as the authors note, is a likely key factor. Far from being a luxury, EAM is indispensable in complex CHD: it clarifies atypical anatomy, enables safer navigation with less fluoroscopy, and confirms lesion durability through activation and voltage mapping. Attempting ablation in a dilated, scarred atrium without 3D guidance is akin to navigating a labyrinth blindfolded. The high recurrence rate, therefore, is an expected consequence of incomplete lesion sets or missed pathways concealed within intricate anatomical structures.
This underscores the central dilemma illuminated by this paper: the gap between technical feasibility and long-term efficacy. The study demonstrates that ablation can be performed safely with conventional tools. However, to truly change the natural history of disease—by preventing years of drug toxicity, recurrent hospitalizations, and tachycardiomyopathy—advanced technology is essential, not optional. The authors’ recommendation that “3D electroanatomical mapping is a crucial tool and should be considered essential for complex cases” deserves amplification. This is the paramount message not only for clinicians but also for healthcare systems and policymakers.
The challenges described by Elhodhod et al. [1] are not unique to Egypt; they reflect the reality of many electrophysiology units worldwide, including in wealthier nations where resources remain unevenly distributed. Their findings call for urgent global action on several fronts:

Advocacy for Resource Allocation: The international cardiology community must champion improved access to advanced mapping systems in developing regions. Partnerships, structured training programs, and innovative financing models can make these technologies more widely available.
Procedural Planning: In resource-limited centers, careful patient selection is crucial. While AVNRT or typical atrial flutter can often be ablated successfully using conventional methods, complex substrates such as Ebstein’s anomaly, Fallot, or atypical atrial tachycardias should ideally be referred to centers equipped with 3D mapping to prevent repeat procedures and prolonged pharmacotherapy.
Future Research: The suggestion to explore artificial intelligence-assisted mapping is visionary. AI could streamline workflows, enhance precision, and reduce the learning curve, making complex ablations more reproducible and globally accessible.

In conclusion, Elhodhod and colleagues offer an honest, insightful account of the realities of CHD ablation in a resource-constrained setting. Their work highlights both the dedication of clinicians and the systemic inequities that persist. Achieving procedural success is only half the battle; securing durable outcomes requires commitment to equipping centers with the necessary technologies. Bridging this global equity gap in electrophysiology is the next frontier in ensuring that all patients with congenital heart disease—regardless of geography—have access to the best possible care.
References

Elhodhod OMA, Allam LE, Eldawy HSH, El-damanhoury HM, Zarif JK. Outcomes of Radiofrequency Catheter Ablation in Congenital Heart Disease: A Retrospective Analysis of Arrhythmia Subtypes and Recurrence Rates. Pak Heart J. 2025;58(03):321-8.
Waldmann V, Amet D, Zhao A, Ladouceur M, Otmani A, Karsenty C, et al. Catheter ablation in adults with congenital heart disease: A 15-year perspective from a tertiary centre. Arch Cardiovasc Dis. 2021;114(6-7):455-64. DOI: 10.1016/j.acvd.2020.12.005
Ueda A, Suman-Horduna I, Mantziari L, Gujic M, Marchese P, Ho SY, et al. Contemporary outcomes of supraventricular tachycardia ablation in congenital heart disease: a single-center experience in 116 patients. Circ Arrhythm Electrophysiol. 2013;6(3):606-13. DOI: 10.1161/CIRCEP.113.000415
Liang JJ, Frankel DS, Parikh V, Lakkireddy D, Mohanty S, Burkhardt JD, et al. Safety and outcomes of catheter ablation for atrial fibrillation in adults with congenital heart disease: A multicenter registry study. Heart Rhythm. 2019;16(6):846-52. DOI: 10.1016/j.hrthm.2018.12.024
Liang JJ, Frankel DS, Parikh V, Lakkireddy D, Mohanty S, Burkhardt JD, et al. Safety and outcomes of catheter ablation for atrial fibrillation in adults with congenital heart disease: A multicenter registry study. Heart Rhythm. 2019;16(6):846-852. DOI: 10.1016/j.hrthm.2018.12.024
Karbassi A, Nair K, Harris L, Wald RM, Roche SL. Atrial tachyarrhythmia in adult congenital heart disease. World J Cardiol. 2017;9(6):496-07. DOI: 10.4330/wjc.v9.i6.496