European Heart Journal Advance Access originally published online on July 13, 2005
European Heart Journal 2005 26(16):1688; doi:10.1093/eurheartj/ehi368
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Towards a unified strategy for atrial fibrillation ablation?: reply
Arrhythmia and Electrophysiology Center
Policlinico San Donato
University of Milan
20097 Milan
Italy
E-mail address:
riccardo.cappato{at}grupposandonato.it
I thank Drs Pappone and Santinelli for their interest in my editorial titled ‘Towards more effective techniques for catheter ablation of atrial fibrillation: to aim for electrical disconnection of pulmonary veins or not’?1 The authors observe that adding ablation lines at the left posterior wall and the mitral isthmus to the anatomical circumferential ablation (ACA) catheter technique for the treatment of paroxysmal or persistent atrial fibrillation is associated with a significantly lower incidence (from 10.0 to 3.9%) of iatrogenic left atrial flutter during long-term follow-up2 and that this lower incidence may justify an extended use of their technique. I have to admit that the manuscript quoted by Pappone and Santinelli had not been published yet at the time of final submission of my editorial to the European Heart Journal. Nevertheless, the arguments raised by the authors offer an interesting opportunity for debate.
Although the technique proposed by Pappone and Santinelli to limit the incidence of left atrial flutter in these patients is of interest and accurately investigated, the following observations should be carefully considered before it can be proposed in clinical practice. First, a 4% incidence of left atrial flutter in response to ACA is not a poor figure, particularly if one considers the drug refractoriness of this arrhythmia and the deterioration in quality of life that it may produce when compared with pre-ablation. Secondly, this figure is obtained at the expense of additional pulses deployed in the left atrium, outside of the area delimited by the ACA design. Of interest, recent findings indicate that post-ablation left atrial flutter originate and perpetuate within the territory delimited by the ACA design, and that re-isolation of the pulmonary vein (PV) antrum effectively prevents left atrial flutter recurrence.3 As a result of this observation, PV electrical disconnection rather than empirically designed ACA would appear to have a better rationale for prevention of late left atrial flutter; also, PV electrical disconnection would not require adding ablation lines at the left posterior wall and the mitral annulus. Finally, the data from Pappone and Santinelli reflect the experience of a single centre and are in need of confirmation from a multi-centre experience. As outlined in a recent survey conducted worldwide on catheter ablation of atrial fibrillation, the results obtained in daily clinical practice from a heterogeneous set of EP laboratories show considerably lower efficacy than those reported from pioneering centres;4 I would not be surprised, if the same observation held true with regard to the incidence of post-ablation left atrial flutter in patients receiving ACA technique.
References
- Cappato R. Towards more effective techniques for catheter ablation of atrial fibrillation: to aim for electrical disconnection of pulmonary veins or not? Eur Heart J 2005;26:627–630.
[Free Full Text] - Pappone C, Manguso F, Vicedomini G, Gugliotta F, Santinelli O, Ferro A, Gulletta S, Sala S, Sora N, Paglino G, Augello G, Agricola E, Zangrillo A, Alfieri O, Santinelli V. Prevention of iatrogenic atrial tachycardia after ablation of atrial fibrillation. A prospective randomized study comparing circumferential pulmonary ablation with a modified approach. Circulation 2004;110:3036–3042.
[Abstract/Free Full Text] - Ouyang F, Baensch D, Ernst S, Schaumann A, Hachiya H, Chen M, Chun J, Falk P, Khanedani A, Antz M, Kuck KH. Complete isolation of left atrium surrounding the pulmonary veins. New insights from the double lasso technique in paroxysmal atrial fibrillation. Circulation 2004;110:2090–2096.
[Abstract/Free Full Text] - Cappato R, Calkins H, Chen SA, Davies W, Iesaka Y, Kalman J, Kim YH, Klein G, Packer D, Skanes A. Worlwide survey on the methods, efficacy and safety of catheter ablation for human atrial fibrillation. Circulation 2005;111:1100–1105.
[Abstract/Free Full Text]
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