Atrial fibrillation ablation: beyond electro-mechanical matters

Since atrial fibrillation is the most frequent arrhythmia in the western world (with a predictable increase in the future, due to aging), treatment strategy has gained outstanding interest also for social and economic implications.1 Recently, Sacher et al.2 focused on endocrine and mechanical implications of sinus rhythm (SR) restoration after radiofrequency ablation (RFA). The SR was associated with decrease in ANP and BNP coupled with an improvement in mechanical cardiac function in patients with and without impaired left ventricular ejection fraction (LVEF) after RFA. However, some observations are needed: (i) ANP and BNP concentrations drop the day after RFA despite volume overload (due to the use of irrigated catheters as evidenced by a significant weight increase) with a subsequent raise on Day 3 followed by a lesser decrease at the 3 month assay. Considering the slow pace of atrial reverse remodelling after SR restoration and the more pronounced decrease of ANP with respect to BNP on Day 1, it could be argued that the use of extensive RFA may induce a kind of ‘atrial endocrine stunning’ which overcome and anticipate the following modification induced by SR; (ii) to date, rhythm control strategy is not proved to be more effective in improving prognosis,3–7 in particular in early onset AF, since the ease in restoration of SR could be related with easy-to-treat AF and/or less severe associated cardiovascular disease. Altogether these data suggest to limit more aggressive strategies for difficult- to-treat AF, despite enrolment criterion in Sacher's study in which AF onset widely ranged from 1 month to 6 years; (iii) Sacher's study suggests that catheter ablation for AF is successful in the majority of patients and associated with substantial improvements in LV function; anyway, the difficulties that exist when assessing LV function in patients with AF should be taken into account.