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.