Symptoms-guided assessment of atrial fibrillation recurrence after radiofrequency pulmonary vein ablation: is it a reliable strategy?

LETTERS TO THE EDITOR

Symptoms-guided assessment of atrial fibrillation recurrence after radiofrequency pulmonary vein ablation: is it a reliable strategy?

P. R. Benchimol-Barbosa; José Barbosa Filho

Hospital Central Aristarcho Pessoa, Corpo de Bombeiros Militar do Estado do Rio de Janeiro, Hospital Universitário Pedro Ernesto, Universidade do Estado do Rio de Janeiro, Universidade Gama Filho - Rio de Janeiro, RJ - Brazil

^{Mailing Address}

Dear Editor,

The impact of symptom-guided perception of atrial fibrillation (AF) recurrence after pulmonary vein radiofrequency ablation (PVRFA) has raised serious concern as a potential flaw in taking into account successful procedures. Although the definition of success may vary, bidirectional block through ablated regions is unnecessary in order to achieve a successful procedure¹, and in previously symptomatic patients short and long-term success of PVRFA is focused on detection of symptomatic episodes². Thus, asymptomatic AF episodes are not necessarily credited as recurrence. It is noteworthy that, as a potentially curative procedure, successful PVRFA implies long-term maintenance of sinus rhythm and further reduction of AF-related morbidities, e.g. cardio-embolism. Therefore, anticoagulant withdrawal is the aim.

Using seven-day continuous ambulatory ECG monitoring, Hindricks et al³ demonstrated that asymptomatic recurrence of AF increased from 5% to roughly 36% during a 12-month follow-up. Same authors³ reported that when symptom-guided, a 70% rate of freedom of AF episodes after PVRFA in a six-month follow-up was observed. Rate of freedom decreased from 70% to 50% when assessed by seven-day continuous ambulatory ECG monitoring, and further to 45% when transtelephonic ECG transmission was employed.

In this scenario, the actual rate of recurrence of AF episodes after PVRFA is proposed as being higher than previously reported using similar techniques⁴ and is clearly dependent on the strategy employed for analysis, whether symptom-guided or ECG-guided. These findings bring about a two-fold concern: do eventual cardio-embolic events represent an issue in this population? Is continued oral anticoagulation needed to prevent prospective embolic events? Based on present information, caution and direct monitoring of heart rhythm after otherwise successful PVRFA may be mandatory in order to determine whether oral anticoagulants could be safely withdrawn in high risk patients.

REFERENCES

1. Scanavacca M, Sosa E. Ablação por cateter da fibrilação atrial. Técnicas e resultados. Arq Bras Cardiol 2005; 85(4):295-301.

2. Piorkowski C, Kottkamp H, Tanner H, Kobza R, Nielsen JC, Arya A et al. Value of different follow-up strategies to assess the efficacy of circumferential pulmonary vein ablation for the curative treatment of atrial fibrillation. J Cardiovasc Electrophysiol 2005; 16(12):1286-92.

3. Hindricks G, Piorkowski C, Tanner H, Kobza R, Gerds-Li JH, Carbucicchio C et al. Perception of atrial fibrillation before and after radiofrequency catheter ablation: relevance of asymptomatic arrhythmia recurrence. Circulation 2005; 112(3):307-13.

4. Kottkamp H, Tanner H, Kobza R, Schirdewahn P, Dorszewski A, Gerds-Li JH et al. Time courses and quantitative analysis of atrial fibrillation episode number and duration after circular plus linear left atrial lesions: trigger elimination or substrate modification: early or delayed cure? J Am Coll Cardiol 2004; 44(4):869-77.

Received on 02/04/06

Accepted on 02/24/06

Publication Dates

• Publication in this collection
  31 Jan 2007
• Date of issue
  May 2006