LETTER TO THE EDITOR
Atrial fibrillation ablation:role of patient enrollment and follow-up in clinical results
Pietro Turco, MDa,
Giuseppe Stabile, MDa,
Antonio De Simone, MDa and
Bilal El Jamal, MDa
a Servizio di Elettrofisiologia ed Elettrostimolazione, Villa Maria Cecilia Hospital, Via Corriera 1, 48010 Cotignola-RA, Italy
pietro.turco{at}tin.it
In the August 7, 2002, issue of the Journal, Marrouche et al. (1) reported their experience about circular mapping and ablation of the pulmonary vein (PV) for treatment of atrial fibrillation (AF). In group 2 (190) patients they reported, during a follow-up of 10 months, a success rate of 94% in paroxysmal AF, 90% in persistent AF, and 80% in permanent AF. They concluded that isolation of focal triggers initiating in PV appeared an effective cure for AF independently from the duration of AF and left atrial site.
Pappone et al. (2), with Carto (three-dimension electroanatomical mapping)-assisted anatomical encircling of PV, reported 85% and 68% success rates for paroxysmal and permanent AF, respectively. Haissaguerre et al. (3), with electrophysiologic PV insulation (similar to Marrouche’s) reported clinical success rates of 93%, 73%, and 55% in patients with 1, 2, and 3 or more arrhythmogenic PV foci in paroxysmal AF (mean of 74%) and 60% in chronic AF where left atrial size appears to be a limiting factor (4).
The reason for better results by Marrouche et al. (1) could be found in patient enrollment and/or follow-up. Concerning enrollment, was it selective or not? If the investigators enrolled only patients in whom PV focal trigger initiated AF (documented?), especially in paroxysmal AF, the results might not be comparable with other studies. Moreover, in patients with coexisting atrial flutter and AF, was PV ablation combined with right isthmus ablation? Nabar et al. (5) demonstrated that patients who have recurrences of both atrial flutter and AF could be cured by safer inferior vena cava to tricuspid annulus (IVC-TA) isthmus ablation only: they showed up to 73% success rate. Our experience (6) confirmed that if atrial flutter is detected during infusion of 1C antiarrhythmic drug for AF (1C atrial flutter), right isthmus ablation is highly effective in curing AF.
The follow-up was scheduled at 1, 3, 6, and 12 months’ postablation; Holter recording was made before discharge and at 3 and 6 months. Scheduled electrocardiogram (ECG) or Holter ECG monitoring could not be effective in detecting short-lasting paroxysmal AF episodes, because Savelieva et al. (7) documented a high incidence of asymptomatic AF episodes in patients with AF treated by cardioversion. Van Noord et al. (8) in the VERDICT study indicate that daily transtelephone ECG recording is an effective method to detect arrhythmia recurrence in follow-up of AF patients.
We are convinced that daily transtelephone ECG recording is effective in monitoring AF patients cured by PV isolation (electrophysiologic or anatomical approach) during follow-up; because it is expensive treatment, it could be used for three months only (for example, from the 3rd to 15th week) and then weekly.
Finally, Marrouche et al. do not mention the incidence of left or right atrial flutter as reported by others (3). Again, the answer may be patient selection, because the more damaged the atrium the more sensitive to slow conduction and reentry around anatomical obstacle.
Thus, to avoid atrial flutter we routinely perform PV encircling ablation with linear right (IVC-TA) and left (from mitral annulus to low pulmonary vein) isthmus ablation with electrophysiological validation (no-linked double potential on ablation line during moving pacing site).
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References
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- Marrouche NF, Dresing T, Cole C, et al. Circular mapping and ablation of the pulmonary vein for treatment of atrial fibrillation. J Am Coll Cardiol. 2002;40:464–474[Abstract/Free Full Text]
- Pappone C, Oreto G, Rosanio S, et al. Atrial electroanatomical remodelling after circumferential radiofrequency pulmonary vein ablation. Circulation. 2001;104:2539–2544[Abstract/Free Full Text]
- Haissaguerre M, Shah DC, Jais P, et al. Electrophysiological end point for catheter ablation of atrial fibrillation initiated from multiple pulmonary venous foci. Circulation. 2000;101:1409–1417[Abstract/Free Full Text]
- Haissaguerre M, Jais P, Shah DC, et al. Catheter ablation of chronic atrial fibrillation targeting the reinitiating triggers. J Cardiovasc Electrophysiol. 2000;11:2–10[Medline]
- Nabar A, Rodriguez LM, Timmermans C, Van den Dool A, Smeets JL, Wellens HJ. Effect of right atrial isthmus ablation on the occurrence of atrial fibrillation. Observations in four patient groups having type I atrial flutter with or without associated atrial fibrillation. Circulation. 1999;99:1441–1445[Abstract/Free Full Text]
- Stabile G, De Simone A, Turco P, et al. Response to flecainide infusion predicts long-term success of hybrid pharmacological and ablation therapy in patients with atrial fibrillation. J Am Coll Cardiol. 2001;37:1639–1644[Abstract/Free Full Text]
- Savelieva I, Camm AJ. Clinical relevance of silent atrial fibrillation: prevalence, prognosis, quality of life, and management. J Interv Card Electrophysiol. 2000;4:369–382[CrossRef][Medline]
- Van Noord T, Van Gelder IC, Tieleman RG, et al. VERDICT: the Verapamil versus Digoxin Cardioversion Trial: a randomized study on the role of calcium lowering for maintenance of sinus rhythm after cardioversion of persistent atrial fibrillation. J Cardiovasc Electrophysiol. 2001;12:766–769[CrossRef][Medline]
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