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Eur J Cardiothorac Surg 2006;29:127-128
© 2006 Elsevier Science NL

Letter to the Editor

Do we need to further probe the utility of these (energy) probes?

Department of Cardiothoracic Surgery, Glasgow Royal Infirmary, 16 Alexandra Parade, Glasgow G31 2ER, UK

Received 19 September 2005; accepted 31 October 2005.

^_* Tel.: +44 141 2114731/5645206; fax: +44 141 5520987/2114845. (Email: mishrapk_25{at}yahoo.com).

Key Words: Atrial fibrillation • Energy probes • Ablation

I read with interest the recent article by Chaput et al. [1] in the European Journal of Cardio-Thoracic Surgery where they have discussed the long-term implications of conversion to sinus rhythm following valve surgery. I would like to congratulate them for this timely article which has helped to dispel many myths associated with atrial fibrillation versus sinus rhythm in the postoperative period. Lately, atrial fibrillation has been accused to play a role in almost every complication occurring in the early/late postoperative period. No wonder multinational companies jumped to create hype and simultaneously came up with multiple energy probes to perform concomitant anti-AF procedures. Glossy pamphlets accompanying these energy probes have managed to send a strong message to the scientific community. Some authors have claimed curative treatment of AF with radiofrequency ablation techniques, but long-term benefits are debatable [2]. Besides, several other authors have reported potential complications which can occur with the use of these probes [3].

This article emphasises the fact once again that the great majority of patients who are in AF preoperatively continue to be so in the postoperative period without any impact on long-term survival or embolic events [1]. Postoperative AF is a significant risk factor for long-term mortality only for patients who are in preoperative sinus rhythm [1]. Time tested notion that the control of ventricular response and anticoagulation is more important rather than getting obsessed with the rhythm has been emphasised in several studies [4]. What we need is a robust predictive risk model for occurrence of AF postoperatively in patients who are in sinus rhythm before surgery. Risk stratification of these patients as to which of them will develop a persistent AF will be a tall order, as isolated episodes of AF are not uncommon in the postoperative period.

Critics might say that this was an observational study and we should take results from such studies with a pinch of salt. It will be a valid criticism of this study but then we do not have data from randomised trials to prove the benefits of conversion to sinus rhythm postoperatively either. Another limitation of this study is the impact on quality of life following conversion to sinus rhythm which the authors have not tried to answer. Some recent articles have reported a significant improvement in the quality of life in symptomatic AF on medical management undergoing catheter radiofrequency ablation [5]. Whether this benefit extends to patients following valve surgery needs to be evaluated. The benefit will most likely differ depending on preoperative LV function.

It is interesting to note that 43% patients had mitral valve replacement and only 4% had mitral valve repair [1]. Was it an institutional policy or the etiology of the valvular disorder which forced them to perform so many mitral valve replacements? It will also be worth knowing whether a chordal preservation technique and the choice of prosthesis (mechanical vs bioprosthesis) had any impact on occurrence of AF postoperatively.

We need large multicenter randomised controlled trials of surgical AF ablation procedures. It sounds harsh but in my opinion we need to further probe the utility of these (energy) probes.

References

1. Chaput M, Bouchard D, Demers P, Perrault LP, Cartier R, Carrier M, Page P, Pellerin M. Conversion to sinus rhythm does not improve long-term survival after valve surgery: insights from a 20-year follow-up study. Eur J Cardiothorac Surg 2005;28(2):206-210.[Abstract/Free Full Text]
2. Mohr FW, Fabricius AM, Falk V, Autschbach R, Doll N, Von Oppell U, Diegeler A, Kottkamp H, Hindricks G. Curative treatment of atrial fibrillation with intraoperative radiofrequency ablation: short-term and midterm results. J Thorac Cardiovasc Surg 2002;123(5):919-927.[Abstract/Free Full Text]
3. Doll N, Borger MA, Fabricius A, Stephan S, Gummert J, Mohr FW, Hauss J, Kottkamp H, Hindricks G. Esophageal perforation during left atrial radiofrequency ablation: is the risk too high?. J Thorac Cardiovasc Surg 2003;125(4):836-842.[Abstract/Free Full Text]
4. Hohnloser SH, Kuck KH, Lilienthal J. Rhythm or rate control in atrial fibrillation—pharmacological intervention in atrial fibrillation (PIAF): a randomised trial. Lancet 2000;356(9244):1789-1794.[CrossRef][Medline]
5. Chen MS, Marrouche NF, Khaykin Y, Gillinov AM, Wazni O, Martin DO, Rossillo A, Verma A, Cummings J, Erciyes D, Saad E, Bhargava M, Bash D, Schweikert R, Burkhardt D, Williams-Andrews M, Perez-Lugones A, Abdul-Karim A, Saliba W, Natale A. Pulmonary vein isolation for the treatment of atrial fibrillation in patients with impaired systolic function. J Am Coll Cardiol 2004;43(6):1004-1009.[Abstract/Free Full Text]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Mishra, P. K. Search for Related Content PubMed PubMed Citation Articles by Mishra, P. K. Related Collections Cardiac - other Electrophysiology - arrhythmias