# Catheter Ablation and Device Therapy in Patients With Transthyretin Amyloid Cardiomyopathy: A Review of Non‐Pharmacological Therapy

## TL;DR

This review discusses how to manage arrhythmias in patients with transthyretin amyloid cardiomyopathy using catheter ablation and device therapy.

## Contribution

The paper provides a focused review on non-pharmacological treatment strategies for arrhythmias in ATTRwt-CM patients.

## Key findings

- ATTRwt-CM often coexists with atrial fibrillation, atrial flutter, and atrial tachycardia, requiring arrhythmia management.
- Device therapy is frequently needed for bradycardia and ventricular arrhythmias in these patients.
- Catheter ablation for atrial arrhythmias and device therapy are essential for comprehensive management of arrhythmias in ATTRwt-CM.

## Abstract

In recent years, the number of cases diagnosed with wild‐type transthyretin amyloid cardiomyopathy (ATTRwt‐CM) has been increasing. However, ATTRwt‐CM frequently coexists with atrial fibrillation (AF), atrial flutter (AFL), and atrial tachycardia (AT), often necessitating management for arrhythmias. Additionally, ventricular arrhythmias sometimes occur, or conduction disturbances often develop, requiring management for bradycardia, frequently needing device therapy such as pacemakers, implantable cardioverter defibrillators (ICDs), or cardiac resynchronization therapy defibrillators. Therefore, for arrhythmia specialists, who primarily focus on non‐pharmacological treatments, arrhythmias associated with ATTRwt‐CM are unavoidable encounters, and becoming proficient in their management is increasingly important and considered essential. However, we sometimes encounter AF, AFL, or AT that are extremely difficult to treat with catheter ablation, and there are many situations to struggle with: how to manage each arrhythmia and whether catheter ablation should be performed at all. Furthermore, while the usefulness of ICDs for primary prevention of sudden cardiac death remains a subject of debate, we occasionally encounter patients with ventricular arrhythmias in fact. This review primarily addresses and focuses on catheter ablation therapy for atrial arrhythmias associated with ATTRwt‐CM, as well as device therapy for bradyarrhythmias and ventricular arrhythmias, aiming to provide insights for treatment planning in the future as a total management approach to arrhythmia in ATTRwt‐CM patients, especially for arrhythmia specialists.

Transthyretin cardiomyopathy (ATTR‐CM) frequently coexists with atrial fibrillation, atrial flutter, and atrial tachycardia as well as occasionally ventricular arrhythmias and often conduction abnormalities, necessitating management for arrhythmias. Therefore, for arrhythmia specialists, the ability to diagnose ATTR‐CM and proficiency in arrhythmia management is increasingly important and considered essential. This review summarizes management approaches and indications for catheter ablation in various atrial arrhythmias associated with ATTR‐CM, as well as device therapy for bradyarrhythmias and ventricular arrhythmias, aiming to provide insights for treatment planning in the future as a total management approach to arrhythmia in ATTR‐CM patients, especially for arrhythmia specialists.