European Heart Journal Advance Access originally published online on July 2, 2008
European Heart Journal 2008 29(17):2184-2185; doi:10.1093/eurheartj/ehn301
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How to assess the efficacy of catheter ablation of atrial fibrillation: reply
Department of Electrophysiology
University Hospital Hamburg-Eppendorf
Heart Center
Hamburg
Germany
Department of Electrophysiology
University Hospital Hamburg-Eppendorf
Heart Center
Hamburg
Germany
Email: d.steven{at}uke.uni-hamburg.de
The reliability of rhythm monitoring in order to achieve consistent follow-up data in patients who underwent catheter ablation for atrial fibrillation (AF) is still not satisfying.
Currently, Holter monitoring is widely used to evaluate the success rates after catheter ablation. Unfortunately, storage capacity of such ECG devices is limited and recording intervals cover only a small portion of the entire follow-up period. Very recently, new implantable loop-recorder devices have been introduced to validate catheter ablation success rates in those patients.1 Since all these devices lack the ability to obtain intracardiac electrograms, we sought to investigate the ‘real’ AF burden in our study using previously implanted dual-chamber devices.2
In the current issue of this journal, Martignani et al. remarked on the accessibility of AF recurrence after catheter ablation stressing the limitation of even a continuous intracardiac Holter monitoring as it was performed by implanted dual-chamber devices with appropriate detection and storage algorithms.
Writing this letter, we are grateful having the opportunity to comment on some of those remarks: (i) loss of data during a follow-up, even if digital data are stored appropriately as it is assumingly performed by Holter ECGs, implantable loop recorders or dual-chamber devices can never be excluded even if it appears unlikely if data are properly obtained by specially trained physicians or technicians. (ii) We also absolutely agree that AF only can be appropriately diagnosed by either 12-lead surface ECG or intracardiac tracings; the latter can be provided by an atrial lead tracing obtained by the devices used in our study. Whenever intracardiac electrograms (EGMs) of atrial high-frequency episodes were available, they were manually reviewed in order to discern between atrial tachycardia and atrial fibrillation by A–A interval stability analysis. As mentioned in the limitation section of the paper, we cannot exclude that (iii) some of the episodes where no EGM was available and which were allocated to AF may also have been atrial tachycardias. Therefore, the recurrence rates of AF were potentially overestimated in our manuscript. Especially, in patients with persistent AF, the occurrence of subsequent atrial arrhythmias other than AF is well known to be one of the first steps achieving lasting sinus rhythm in those patients. It is notable that these consecutive arrhythmias have favourable outcomes during a second or third procedure.3,4
Despite there is no proof of (iv) cost-effectiveness of catheter ablation, the success rates in paroxysmal AF are >70%, thus pulmonary vein isolation has a class IIa indication (evidence level B) according to the recent guidelines.5 Nademanee et al.6 showed that patients after catheter ablation profit from maintaining sinus rhythm in terms of mortality during a 5 year follow-up (92 vs. 64%). Additional information and data from larger cohorts are needed to proof the socio-economic benefit of catheter ablation in patients with atrial fibrillation.
Appropriate assessment of the ‘real’ AF burden is still one of the major challenges to reliably assess the outcome after interventional treatment. A close follow-up is required for patients who underwent catheter ablation for AF, facing the potential underestimation of AF burden in order to avoid premature therapeutical consequences especially regarding the risk of thrombo-embolic events.
References
- Brignole M, Bellardine Black CL, Bloch Thomsen PE, Sutton R, Moya A, Stadler RW, Cao J, Messier M, Huikuri HV. Improved arrhythmia detection in implantable loop recorders. J Cardiovasc Electrophysiol (2008) (in press).
- Steven D, Rostock T, Lutomsky B, Klemm H, Servatius H, Drewitz I, Friedrichs K, Ventura R, Meinertz T, Willems S. What is the real atrial fibrillation burden after catheter ablation of atrial fibrillation? A prospective rhythm analysis in pacemaker patients with continuous atrial monitoring. Eur Heart J (2008) 29:1037–1042.
[Abstract/Free Full Text] - Haissaguerre M, Hocini M, Sanders P, Sacher F, Rotter M, Takahashi Y, Rostock T, Hsu LF, Bordachar P, Reuter S, Roudaut R, Clementy J, Jais P. Catheter ablation of long-lasting persistent atrial fibrillation: clinical outcome and mechanisms of subsequent arrhythmias. J Cardiovasc Electrophysiol (2005) 16:1138–1147.[CrossRef][Web of Science][Medline]
- Haissaguerre M, Sanders P, Hocini M, Takahashi Y, Rotter M, Sacher F, Rostock T, Hsu LF, Bordachar P, Reuter S, Roudaut R, Clementy J, Jais P. Catheter ablation of long-lasting persistent atrial fibrillation: critical structures for termination. J Cardiovasc Electrophysiol (2005) 16:1125–1137.[CrossRef][Web of Science][Medline]
- Fuster V, Ryden LE, Cannom DS, Crijns HJ, Curtis AB, Ellenbogen KA, Halperin JL, Le Heuzey JY, Kay GN, Lowe JE, Olsson SB, Prystowsky EN, Tamargo JL, Wann S, Smith SC Jr., Jacob AK, Adam CD, Anderson JL, Antman EM, Halperin JL, Hunt SA, Nishimura R, Ornato JP, Page RL, Riegel B, Priori SG, Blanc JJ, Budaj A, Camm AJ, Dean V, Deckers JW, Despres C, Dickstein K, Lekakis J, McGregor K, Metra M, Morais J, Osterspey A, Tamargo JL, Zamorano JL. ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation: full text: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 guidelines for the management of patients with atrial fibrillation) developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society. Europace (2006) 8:651–745.
[Free Full Text] - Nademanee K, Schwab MC, Kosar EM, Karweck M, Moran MD, Visessook N, Michael AD, Ngarmukos T. Clinical outcomes of catheter substrate ablation for high-risk patients with atrial fibrillation. J Am Coll Cardiol (2008) 51:843–849.
[Abstract/Free Full Text]
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