Eur J Cardiothorac Surg 2009;35:923-924. doi:10.1016/j.ejcts.2009.02.010
Copyright © 2009, European Association for Cardio-thoracic Surgery. Published by Elsevier. All rights reserved.
Reply to Hanke et al.
Jiangang Wang,
Xu Meng*
Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, PR China
Received 3 February 2009;
accepted 6 February 2009.
* Corresponding author. Tel.: +86 10 64453010; fax: +86 10 64453010. (Email: mxu{at}263.net).
Key Words: Left atrium • Cavotricuspid isthmus • Long-standing persistent • Atrial fibrillation
I thank Hanke et al. for their interest and comments [1] about our recently published article of randomized comparison of left atrial (LA) and biatrial radiofrequency ablation [2]. This letter is in response to their comments.
- 1. The aim of LA ablation combined with cavotricuspid isthmus ablation is to achieve a totally bidirectional conduction block of LA. In our study, LA ablation lesions include isolation of the pulmonary veins, the mitral isthmus, the inter-atrial septum, the LA roof, the coronary sinus and cavotricuspid isthmus. Calò et al. also designed LA ablation combined with cavotricuspid isthmus [3]. Actually both of these were not the LA ablation alone. By using the terms LA and biatrial ablation is confusing indeed, but they were just different strategies. As the mechanism of AF, the concept of ‘trigger and substrate’ with left atrium as the predominant site for AF still remains valid. Most of atrial tachycardia following AF ablation arises from the LA. Patients may also experience typical atrial flutter arising from the cavotricuspid isthmus of AF [4]. Although bipolar ablation system has a better transmurality, there is still a conduction gap which may exist in mitral isthmus between LA and right atrium. So the LA combined with cavotricuspid isthmus ablation also could prevent atrial tachycardia after AF ablation.
- 2. As for the nomenclature, ‘long-standing persistent’ and ‘surgical ablation procedure’ are more appropriate than ‘permanent’ and ‘modified Maze procedure’, respectively in our study.
- 3. AF recurrence in the early postoperative period is not related to long-term success, but early recurrence of AF carries an independent risk of treatment failure and is necessary to be described in the result [5]. We evaluate the efficacy of AF ablation from the results of 24 h Holter after three months. The data of early AF recurrence might be valuable for the further study about the relationship between the early and the late recurrence of AF.
- 4. Although long-term continuous rhythm surveillance as well as usage of a defined nomenclature might be of an additional benefit, 24 h Holter monitoring is an acceptable minimal monitoring strategy for patients enrolled in a clinical trial and is recommended at three to six months intervals for one to two years following ablation. But it will increase the medical cost to the patient after valve and ablation surgery, especially in a developing country. Also in our opinion, pure sinus rhythm after AF ablation shows no clinic significance. For instance, if AF/flutter/tachycardia episode is present and lasts for only 30 s per year, does that means the AF ablation failed or is it necessary that we should do medical intervention with it?
References
- Hanke T, Misfeld M, Stierle U, Sievers H-H. Re: prospective randomized comparison of left atrial and biatrial radiofrequency ablation in the treatment of atrial fibrillation. Eur J Cardiothorac Surg 2009;35(5):922-923.[Free Full Text]
- Wang J, Xu Meng X, Li H, Cui Y, Han J, Xu C. Prospective randomized comparison of left atrial and biatrial radiofrequency ablation in the treatment of atrial fibrillation. Eur J Cardiothorac Surg 2009;35:116-122.[Abstract/Free Full Text]
- Calò L, Lamberti F, Loricchio ML, De Ruvo E, Colivicchi F, Bianconi L, Pandozi C, Santini M. Left atrial ablation versus biatrial ablation for persistent and permanent atrial fibrillation: a prospective and randomized study. J Am Coll Cardiol 2006;47:2504-2512.[Abstract/Free Full Text]
- Scharf C, Veerareddy S, Ozaydin M, Chugh A, Hall B, Cheung P, Good E, Pelosi Jr. F, Morady F, Oral H. Clinical significance of inducible atrial flutter during pulmonary vein isolation in patients with atrial fibrillation. J Am Coll Cardiol 2004;43:2057-2062.[Abstract/Free Full Text]
- Klemm HU, Ventura R, Rostock T, Brandstrup B, Risius T, Meinertz T, Willems S. Correlation of symptoms to ECG diagnosis following atrial fibrillation ablation. J Cardiovasc Electrophysiol 2006;17:146-150.[CrossRef][Medline]
