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Surgical repair of ASD before the 25 years of age has been shown to reduce the incidence of
arrhythmias, such as atrial flutter and fibrillation (AF), but patients over age 40 years may
remain at risk of atrial arrhythmias. 9,10 Up to 68% of patients who present with preoperative
AF may remain in AF after successful ASD closure 11 whereas, in patients over 40 years old,
post-operative AF develops in 823% over the next 7 to 10 years. 9,10 More data exist in
patients subjected to transcatheter closure of ASD that has been found beneficial, regardless
of age. 11 New-onset AF occurs in 7% of patients after transcatheter PFO closure and 12% of
patients with underlying ASD over the next 20 months. 12 A history of previous arrhythmia and
age >40 years at closure are associated with increased incidence of AF. 1315 Usually, patients
with pre-existing persistent AF remain in AF after device closure of their ASD 11 whereas, in
4567% of the patients, resolution of paroxysmal atrial arrhythmias may be seen. 16 Thus, ASD
is associated with an increased incidence of AF, regardless of therapy, especially in patients >40
years. Transcatheter ASD closure may trigger early transient arrhythmias; persistent AF is
unlikely to be affected, but paroxysmal arrhythmias may improve, although the likelihood
decreases with age. Catheter ablation in experienced centres is recommended (Table 50.1). If
ASD does not require closure on haemodynamic grounds, closure is unlikely to abolish flutter
or AF. Post-surgical flutters require electroanatomic mapping for defining the isthmus since
they can be CTI- or non-CTI-dependent or both.

Approximately 10% of patients develop incisional or CTI dependent atrial flutter within the next
35 years after repair. 17 There is usually RBBB in the resting ECG of the majority of patients,
and SVT are conducted with RBBB aberration, but this pattern also occurs in 25% of VT in this
setting. Development of atrial flutter can be an indication of worsening ventricular function and
tricuspid regurgitation, and reassessment for surgical revision may be indicated.

Accessory AV and atriofascicular pathways occur in up to 25% of patients and are more often
right-sided and multiple than in patients without the disorder. 18,19 AF, atrial flutter, and AT
may also occur. RBBB is usually present and, in the presence of a right-sided accessory pathway,
ventricular pre-excitation can mask the ECG evidence of RBBB. LBBB tachycardias can be due
to antidromic AVRT or conduction over a bystander accessory pathway. Depending on the
severity of the malformation and the arrhythmia, SVT can produce cyanosis and severe
symptoms or sudden death due to rapid conduction to the ventricles during AF or atrial flutter
when an accessory pathway is present. Preoperative (success rates 7589%, with recurrence
in 3035%) 20,21 or surgical ablation are recommended in the presence of SVT to avoid
recurrent arrhythmias and instability in the perioperative period.