Successful treatment involves assessing both the arrhythmia and the contributing hemodynamic changes and addressing both when indicated and feasible. Early experience in adults with unoperated atrial septal defects and atrial arrhythmias demonstrated the importance of an integrated approach for arrhythmia and hemodynamic problems; similar principles apply to patients with tetralogy of Fallot, Ebstein anomaly, and single-ventricle physiology; these patients are at highest risk of arrhythmia development, with concurrent hemodynamic abnormalities. For example, patients with ASD who underwent surgery before the age of 25 years had better long-term outcomes and a lower incidence of atrial arrhythmias than those who underwent surgery later in life.475 Closure of significant atrial septal defects in adults even later in life improves morbidity and survival476 but is associated with new (7%) or recurrent (60%) AT.475 Arrhythmias still can be treated successfully when they develop later after surgical corrections; catheter ablation of atrial arrhythmias associated with ASD repair is highly successful, with acute success rates reported as 93% to 100%.449,458,477 Therefore, patients with unoperated significant ASD and arrhythmias should undergo ablation of the AT, as well as closure of the ASD. The choice of catheter versus surgical approaches to therapy is determined by anatomic features of the ASD likely to be successfully addressed with a catheter approach. No randomized comparison trials of catheter versus surgical closure of ASD combined with arrhythmia intervention have been reported. Surgical closure of large ASDs combined with arrhythmia surgery for AT or fibrillation can be safely performed, with 6.5% occurrence of AF reported during 2 years of follow-up.478 IIa B-NR Intravenous ibutilide or procainamide can be effective for acute treatment in ACHD patients and atrial flutter who are See Online Data Supplement 20. 