Atrial fibrillation ablation: beyond electro-mechanical matters: reply

We thank Dr Martignani et al. for their interest in our work. We totally agree that the drop of ANP level at Day 1 after ablation is probably the consequence of acute atrial damage caused by radiofrequency (RF). An acute atrial endocrine stunning was previously reported with surgical AF ablation. However, in our study, it reverses within 3 days with concomitant elimination of fluid overload. But the most interesting point is that at 3 months, despite extensive RF application, the ANP level was normal in the vast majority of patients being in sinus rhythm, meaning that there is no longer evidence of atrial endocrine injury at 3 months. We also agree that LV function is very difficult to assess in AF and that is the reason why LV dimensions were measured in sinus rhythm just after ablation (Table 2). We also agree that rhythm control strategy has not been proved to be more effective than rate control, but all studies cited by Dr Martignani et al. involved anti-arrhythmic drugs and not catheter ablation. Moreover, the percentage of patients with effective sinus rhythm in the rhythm control group was not so different from the rate control group in these studies (63% vs. 35% in AFFIRM), and the maintenance of sinus rhythm was associated with a decreased risk of death (HR 1⁄4 0.53). Concerning the indication of persistent and permanent AF ablation, the aim of our study was not to promote AF ablation in all patients with persistent/permanent AF. Ablation in this population is a long procedure with a potential risk of complications and requires experienced centres. Those relatively young patients (53+12 years) included in our study were referred for catheter ablation because they were highly symptomatic [asthenia, dyspnoea, and 12% had left ventricular ejection fraction (LVEF) ,50%]. At the present time, there is no doubt that catheter ablation of persistent/ permanent AF ablation should not be performed in asymptomatic patients without LVEF alteration. Concerning the complex interaction between AF and impaired LVEF, the patient’s history is crucial. In cases where AF occurs following the onset of heart failure (HF) without a change in the LVEF, it is unlikely that AF is contributing to the HF. Conversely, some patients with established HF demonstrate further impairment of LVEF following the occurrence of AF and these patients may well benefit from catheter ablation. Rate is not the only factor in these patients as an improvement in LVEF may be seen even in cases of good rate control. In most cases, we agree that it is difficult to assess the impact of AF. However, recent studies have consistently showed a very significant improvement in LV function following AF ablation, suggesting that the deleterious impact of AF has been largely underestimated in the past, when drugs or ‘ablate and pace’ were the only available strategies. To conclude, the strategy to treat patients with persistent/permanent AF has to be tailored to every single patient. The patients must be extremely well informed in this decision process.