Technical Refinements for Ablation in Adults with Complex Vascular and Intracardiac Anatomy, Including Difficult Transseptal Access

The vast complexity of congenital heart disease and the variety of surgical approaches demand a creative approach to invasive therapies for arrhythmias. Many of the pre- and post-surgical anatomic iterations, and their consequences on arrhythmia substrates, are discussed in chapters dedicated to specific anatomic variants, along with respective strategies for management. Despite specific differences, there are several common considerations and strategies to facilitate invasive arrhythmia management. Much of the treatment of congenital heart disease started with the innovative application of tools, technology, and therapies that were originally developed or approved for more common disease entities or patient populations. Despite the potentially unfavorable market forces, pediatric and congenital electrophysiologists have consistently been at the forefront in developing and applying techniques and technology for a complex and challenging patient population. The potential for any technology to improve current treatment modalities should be considered. However, the rare and heterogeneous nature of complex congenital heart disease makes it challenging to develop a strong evidence base sufficient to definitively guide broad application of new tools or technologies. Accordingly, clinical equipoise and open discussion of risks and benefits are vital to ensuring quality, humanistic care for this unique population.