International Journal of Cardiology 181 (2015) 104–105

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Letter to the editor

Catheter ablation of longstanding persistent atrial fibrillation: Let sleeping dogs lie☆ Akinori Sairaku ⁎,1, Yukiko Nakano 1, Yasuki Kihara 1 Department of Cardiovascular Medicine, Hiroshima University Graduate School of Biomedical and Health Sciences, Hiroshima, Japan

a r t i c l e

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Article history: Received 25 November 2014 Accepted 1 December 2014 Available online 3 December 2014 Keywords: Longstanding persistent atrial fibrillation Catheter ablation Adjunctive ablation strategies

I appreciate Prof. Amasyali's interest in our work and his instructive suggestion [1]. I agree with his concept that the outcome after ablation of atrial fibrillation (AF) depends on the extent of atrial remodeling. As is well known, the longer the AF burden is, the greater the remodeling of the atrium [2]. That is the major reason why the outcome of pulmonary vein isolation in patients with paroxysmal AF is favorable while that in patients with longstanding persistent AF is unacceptably low [3]. To fill this gap, various adjunctive ablation strategies have been developed to modify the remodeled atrium, such as ablation targeting complex fractionated atrial electrograms, linear ablation and ganglionated plexus ablation [3]. Some meta-analyses reported that some of those adjunctive ablation strategies contributed to an improvement in the rate of freedom from AF after ablation of longstanding persistent AF [4]. However, there is still no consensus about whether those adjunctive ablation strategies should be used in all patients with longstanding persistent AF [3]. Patients with longstanding persistent AF are checked more carefully for any asymptomatic recurrences of AF than those with paroxysmal AF [5]. Further, they usually have to take stronger antiarrhythmic agents for a longer period of time after the ablation. Namely, many efforts are made to treat patients with longstanding persistent AF. Nevertheless, to date, they still do not enjoy a satisfactory outcome of ablation [6]. Apart from its lower outcome, ablation of longstanding persistent AF has several problems. (1) Atrial tachycardias emerging after ablation afflict some patients with palpitations that they have never ☆ Disclosure: This work is not supported by any external funding. ⁎ Corresponding author at: Department of Cardiovascular Medicine, Hiroshima University Graduate School of Biomedical and Health Sciences, 1-2-3 Kasumi, Minamiku, Hiroshima 734-8551, Japan. E-mail address: [email protected] (A. Sairaku). 1 This author takes responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation.

http://dx.doi.org/10.1016/j.ijcard.2014.12.016 0167-5273/© 2014 Elsevier Ireland Ltd. All rights reserved.

experienced before [7]. (2) Pacemakers are implanted in some patients because of sinus node dysfunction revealed after the ablation [8]. (3) Periprocedural stroke events occur at a higher rate as compared to ablation of paroxysmal AF [9]. (4) A considerable number of patients receive frequent electrical cardioversions or repeated ablation procedures, after the initial procedure [5,10]. Not surprisingly, all those problems never occur if patients do not undergo ablation. Importantly, patients with longstanding persistent AF often have no symptoms. It is certain that there are patients with longstanding persistent AF who enjoy a significant benefit from catheter ablation. Nonetheless, considering the aforementioned negative aspects, invasive cardiac electrophysiologists should be careful when determining the candidates for catheter ablation of longstanding persistent AF. Now is the time to reconsider the Oath of Hippocrates. Conflict of interest The authors report no relationships that could be construed as a conflict of interest. References [1] B. Amasyali, A. Kilic, A. Dogan, The type of atrial fibrillation recurrence after catheter ablation for persistent atrial fibrillation: what does it mean? Int. J. Cardiol. 176 (2014) 525–526. [2] M.C. Wijffels, C.J. Kirchhof, R. Dorland, M.A. Allessie, Atrial fibrillation begets atrial fibrillation. A study in awake chronically instrumented goats, Circulation 92 (1995) 1954–1968. [3] H. Calkins, K.H. Kuck, R. Cappato, et al., HRS/EHRA/ECAS expert consensus statement on catheter and surgical ablation of atrial fibrillation: recommendations for patient selection, procedural techniques, patient management and follow-up, definitions, endpoints, and research trial design: a report of the Heart Rhythm Society (HRS) Task Force on Catheter and Surgical Ablation of Atrial Fibrillation. Developed in partnership with the European Heart Rhythm Association (EHRA), a registered branch of the European Society of Cardiology (ESC) and the European Cardiac Arrhythmia Society (ECAS); and in collaboration with the American College of Cardiology (ACC), American Heart Association (AHA), the Asia Pacific Heart Rhythm Society (APHRS), and the Society of Thoracic Surgeons (STS). Endorsed by the governing bodies of the American College of Cardiology Foundation, the American Heart Association, the European Cardiac Arrhythmia Society, the European Heart Rhythm Association, the Society of Thoracic Surgeons, the Asia Pacific Heart Rhythm Society, and the Heart Rhythm Society, Heart Rhythm. 9 (2012) 632–696 (e21). [4] R.M. Hayward, G.A. Upadhyay, T. Mela, et al., Pulmonary vein isolation with complex fractionated atrial electrogram ablation for paroxysmal and nonparoxysmal atrial fibrillation: a meta-analysis, Heart Rhythm. 8 (2011) 994–1000. [5] A. Sairaku, Y. Nakano, N. Oda, et al., How many electrical cardioversions should be applied for repetitive recurrences of atrial arrhythmias following ablation of persistent atrial fibrillation? Europace 13 (2011) 1703–1708. [6] E. Arbelo, J. Brugada, G. Hindricks, et al., Atrial Fibrillation Ablation Pilot Study Investigators. The atrial fibrillation ablation pilot study: a European Survey on

A. Sairaku et al. / International Journal of Cardiology 181 (2015) 104–105 Methodology and results of catheter ablation for atrial fibrillation conducted by the European Heart Rhythm Association, Eur. Heart J. 35 (2014) 1466–1478. [7] F. Morady, H. Oral, A. Chugh, Diagnosis and ablation of atypical atrial tachycardia and flutter complicating atrial fibrillation ablation, Heart Rhythm. 6 (2009) S29–S32. [8] A. Sairaku, Y. Nakano, N. Oda, et al., Prediction of sinus node dysfunction in patients with long-standing persistent atrial fibrillation using the atrial fibrillatory cycle length, J. Electrocardiol. 45 (2012) 141–147.

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[9] L. Di Biase, J.D. Burkhardt, P. Santangeli, et al., Periprocedural stroke and bleeding complications in patients undergoing catheter ablation of atrial fibrillation with different anticoagulation management: results from the Role of Coumadin in Preventing Thromboembolism in Atrial Fibrillation (AF) Patients Undergoing Catheter Ablation (COMPARE) randomized trial, Circulation 129 (2014) 2638–2644. [10] R.R. Tilz, A. Rillig, A.M. Thum, et al., Catheter ablation of long-standing persistent atrial fibrillation: 5-year outcomes of the Hamburg Sequential Ablation Strategy, J. Am. Coll. Cardiol. 60 (2012) 1921–1929.

Catheter ablation of longstanding persistent atrial fibrillation: Let sleeping dogs lie.

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