Long-term management of SVT and AF
Drug therapy to prevent recurrence can be used based on the severity of
symptoms and hemodynamic compromise during the index event. For the
prevention of PSVT, beta-blockers (except atenolol), especially
metoprolol, or verapamil are first-line agents in patients without
pre-excitation on resting ECG. For the prevention of PSVT in patients
with Wolff-Parkinson-White (WPW) syndrome, flecainide or propafenone are
recommended instead.
In patients with AF, rhythm control should be considered the preferred
treatment strategy during pregnancy. For either rhythm or rate control
strategy, the use of oral beta-blockers is recommended. Digoxin and
verapamil should be considered for rate control of atrial tachycardia
(AT) or AF only if beta-blockers fail. Flecainide, propafenone, or
sotalol, in those without structural heart disease, should be considered
to prevent PSVT, AT, and AF if AV nodal blocking agents fail.
Episodes of atrial flutter are usually not well tolerated in patients
with congenital heart disease, and, in these cases, electrical
cardioversion should, therefore, be performed to restore sinus rhythm.
In cases of drug-refractory and poorly tolerated PSVT, catheter ablation
with nonfluoroscopic electroanatomical mapping and catheter navigation
systems, in experienced centers, should be considered. If possible, it
should be postponed to the second trimester. A suggested workflow can be
seen in figure 2.