European Heart Journal Advance Access originally published online on September 14, 2008
European Heart Journal 2008 29(22):2818-2819; doi:10.1093/eurheartj/ehn403
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Atrial fibrillation ablation: beyond electro-mechanical matters
Institute of Cardiology
S. Orsola-Malpighi Hospital
University of Bologna
Via Massarenti, 9
Bologna 40139
Italy
Tel: +39 051 349 858
Fax: +39 051 344 859
Email: cristian.martignani{at}gmail.com
Institute of Cardiology
S. Orsola-Malpighi Hospital
University of Bologna
Via Massarenti, 9
Bologna 40139
Italy
Institute of Cardiology
S. Orsola-Malpighi Hospital
University of Bologna
Via Massarenti, 9
Bologna 40139
Italy
Institute of Cardiology
S. Orsola-Malpighi Hospital
University of Bologna
Via Massarenti, 9
Bologna 40139
Italy
Institute of Cardiology
S. Orsola-Malpighi Hospital
University of Bologna
Via Massarenti, 9
Bologna 40139
Italy
Institute of Cardiology
S. Orsola-Malpighi Hospital
University of Bologna
Via Massarenti, 9
Bologna 40139
Italy
Institute of Cardiology
S. Orsola-Malpighi Hospital
University of Bologna
Via Massarenti, 9
Bologna 40139
Italy
Since atrial fibrillation is the most frequent arrhythmia in the western world (with a predictable increase in the future, due to aging), treatment strategy has gained outstanding interest also for social and economic implications.1
Recently, Sacher et al.2 focused on endocrine and mechanical implications of sinus rhythm (SR) restoration after radiofrequency ablation (RFA). The SR was associated with decrease in ANP and BNP coupled with an improvement in mechanical cardiac function in patients with and without impaired left ventricular ejection fraction (LVEF) after RFA.
However, some observations are needed: (i) ANP and BNP concentrations drop the day after RFA despite volume overload (due to the use of irrigated catheters as evidenced by a significant weight increase) with a subsequent raise on Day 3 followed by a lesser decrease at the 3 month assay. Considering the slow pace of atrial reverse remodelling after SR restoration and the more pronounced decrease of ANP with respect to BNP on Day 1, it could be argued that the use of extensive RFA may induce a kind of ‘atrial endocrine stunning’ which overcome and anticipate the following modification induced by SR; (ii) to date, rhythm control strategy is not proved to be more effective in improving prognosis,3–7 in particular in early onset AF, since the ease in restoration of SR could be related with easy-to-treat AF and/or less severe associated cardiovascular disease. Altogether these data suggest to limit more aggressive strategies for difficult- to-treat AF, despite enrolment criterion in Sacher's study in which AF onset widely ranged from 1 month to 6 years; (iii) Sacher's study suggests that catheter ablation for AF is successful in the majority of patients and associated with substantial improvements in LV function; anyway, the difficulties that exist when assessing LV function in patients with AF should be taken into account.
Whether AF is a cause or consequence of heart failure is a hard topic: the contribution of AF to left ventricular dysfunction is difficult to evaluate in an individual patient particularly when both co-exist in the initial presentation. The spectrum of relationship between AF and HF is wide, ranging from cases of left ventricular dysfunction as a direct result of AF (i.e. true tachycardiomyopathy) to cases where no relationship exists at all, with many intermediate cases where a primary form of left ventricular dysfunction coexists with a secondary component provoked by a concealed or occult tachycardiomyopathy.8
In this view, definition of the specific role of AF in the single patient and quantification of the chance of SR maintenance may help tailor the treatment of AF, which in many subjects may entail even aggressive strategies for rhythm control if these could retard the progression of the associated cardiovascular disease and possibly affect long-term prognosis.
Choice of AF treatment is not a straightforward therapy but a complex approach firstly based on the broad baseline clinical picture that has to be refined according to patient's response and to the evolving clinical characteristics: further insights into the complex interplay between AF and HF are crucial for the progress of optimal therapeutic strategy.
References
- Boriani G, Diemberger I, Martignani C, Biffi M, Branzi A. The epidemiological burden of atrial fibrillation: a challenge for clinicians and health care systems. Eur Heart J (2006) 27:893–894.
[Free Full Text] - Sacher F, Corcuff JB, Schraub P, Le Bouffos V, Georges A, Jones SO, Lafitte S, Bordachar P, Hocini M, Clementy J, Haissaguerre M, Bordenave L, Roudaut R, Jais P. Chronic atrial fibrillation ablation impact on endocrine and mechanical cardiac functions. Eur Heart J (2008) 29:1290–1295.
[Abstract/Free Full Text] - Corley SD, Epstein AE, DiMarco JP, Domanski MJ, Geller N, Greene HL, Josephson RA, Kellen JC, Klein RC, Krahn AD, Mickel M, Mitchell LB, Nelson JD, Rosenberg Y, Schron E, Shemanski L, Waldo AL, Wyse DG. Relationships between sinus rhythm, treatment, and survival in the Atrial Fibrillation Follow-Up Investigation of Rhythm Management (AFFIRM) Study. Circulation (2004) 109:1509–1513.
[Abstract/Free Full Text] - Lafuente-Lafuente C, Mouly S, Longas-Tejero MA, Mahe I, Bergmann JF. Antiarrhythmic drugs for maintaining sinus rhythm after cardioversion of atrial fibrillation: a systematic review of randomized controlled trials. Arch Intern Med (2006) 166:719–728.
[Abstract/Free Full Text] - Hohnloser SH, Kuck KH. Atrial fibrillation—maintaining sinus rhythm versus ventricular rate control: the PIAF trial. Pharmacological Intervention in Atrial Fibrillation. J Cardiovasc Electrophysiol (1998) 9(8 Suppl):S121–S126.[Web of Science][Medline]
- Carlsson J, Miketic S, Windeler J, Cuneo A, Haun S, Micus S, Walter S, Tebbe U. Randomized trial of rate-control versus rhythm-control in persistent atrial fibrillation: the Strategies of Treatment of Atrial Fibrillation (STAF) study. J Am Coll Cardiol (2003) 41:1690–1696.
[Abstract/Free Full Text] - Opolski G, Torbicki A, Kosior DA, Szulc M, Wozakowska-Kaplon B, Kolodziej P, Achremczyk P. Rate control vs rhythm control in patients with nonvalvular persistent atrial fibrillation: the results of the Polish How to Treat Chronic Atrial Fibrillation (HOT CAFE) Study. Chest (2004) 126:476–486.[CrossRef][Web of Science][Medline]
- Boriani G, Biffi M, Diemberger I, Martignani C, Branzi A. Rate control in atrial fibrillation: choice of treatment and assessment of efficacy. Drugs (2003) 63:1489–1509.[CrossRef][Web of Science][Medline]
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