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• W3153605019 abstract "Central MessageThe way we monitor for atrial fibrillation is changing to intermittent rhythm strips, which will yield determinations of burden. Physicians will need to determine new definitions of success.See Article page 1387. The way we monitor for atrial fibrillation is changing to intermittent rhythm strips, which will yield determinations of burden. Physicians will need to determine new definitions of success. See Article page 1387. In this issue of the Journal, Li and colleagues1Li X. Li M. Shao Y. Gu W. Ni B. Gu J. et al.Thoracoscopic ablation delays progression from paroxysmal to persistent atrial fibrillation.J Thorac Cardiovasc Surg. 2023; 165: 1387-1394Abstract Full Text Full Text PDF Scopus (1) Google Scholar follow a small cohort of patients with paroxysmal atrial fibrillation (PAF) and previous cerebrovascular or peripheral thromboembolism, without previous intervention, who underwent stand-alone thoracoscopic pulmonary vein isolation and left atrial appendage excision. They compared these patients with a smaller group who opted for medical management. After controlling for CHA2DS2-VASc score (ie, congestive heart failure; hypertension; age ≥75 years; diabetes mellitus, stroke, or transient ischemic attack; vascular disease; age 65-74 years; sex category), the authors found that pulmonary vein isolation delayed progression of PAF. This study has serious limitations, hindering applicability. The control group comprised patients who refused surgery and therefore were not equivalent controls. The study group did not meet indications for stand-alone ablation, as they were not refractory to drug therapy and had not failed catheter ablation.2Calkins H. Hindricks G. Cappato R. Kim Y.H. Saad E.B. Aguinaga L. et al.2017 HRS/EHRA/ECAS/APHRS/SOLAECE expert consensus statement on catheter and surgical ablation of atrial fibrillation.Heart Rhythm. 2017; 14: e275-e444Abstract Full Text Full Text PDF PubMed Scopus (1130) Google Scholar Because few surgeons would perform stand-alone ablation on these patients, study applicability is questionable. The authors justified operating by stating that the patients had high HAS-BLED scores and would be at risk from anticoagulation on medical therapy. There are problems with this justification. First, balancing stroke against bleeding, patients with greater HAS-BLED scores still derive net benefit from anticoagulation.3Olesen J.B. Lip G.Y. Lindhardsen J. Lane D.A. Ahlehoff O. Hansen M.L. et al.Risks of thromboembolism and bleeding with thromboprophylaxis in patients with atrial fibrillation: a net clinical benefit analysis using a ‘real world' nationwide cohort study.Thromb Haemost. 2011; 106: 739-749Crossref PubMed Scopus (389) Google Scholar,4Friberg L. Rosenqvist M. Lip G.Y. Net clinical benefit of warfarin in patients with atrial fibrillation: a report from the Swedish atrial fibrillation cohort study.Circulation. 2012; 125: 2298-2307Crossref PubMed Scopus (383) Google Scholar Second, patients with high CHA2DS2-VASc scores and previous stroke should be anticoagulated for life.5January C. Wann L. Alpert J. Calkins H. Chen L. Cigarroa J. et al.2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: executive summary: a report of the American College of Cardiology/American Heart Association task force on practice guidelines and the Heart Rhythm Society.J Am Coll Cardiol. 2014; 64: 2246-2280Crossref Scopus (750) Google Scholar,6January C. Wann L. Calkins H. Chen L. Cigarroa J. Cleveland J. et al.2019 AHA/ACC/HRS focused update of the 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association task force on clinical practice guidelines and the Heart Rhythm Society.J Am Coll Cardiol. 2019; 74: 104-132Crossref PubMed Scopus (1102) Google Scholar Finally, decisions regarding anticoagulation should be based on patient's stroke risk, not success or failure of ablation.5January C. Wann L. Alpert J. Calkins H. Chen L. Cigarroa J. et al.2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: executive summary: a report of the American College of Cardiology/American Heart Association task force on practice guidelines and the Heart Rhythm Society.J Am Coll Cardiol. 2014; 64: 2246-2280Crossref Scopus (750) Google Scholar Despite these shortcomings, there are some intriguing lessons here. The authors used a success end point of delay in the progression of PAF. Although there is now a catheter ablation study looking at delay in progression of PAF,7Kuck H. Lebedev D. Mikhaylov E. Romanov A. Gellér L. Kalejs O. et al.Catheter ablation or medical therapy to delay progression of atrial fibrillation: the randomized controlled atrial fibrillation progression trial (ATTEST).Europace. 2021; 23: 362-369Crossref PubMed Scopus (56) Google Scholar this end point is extremely uncommon in surgical literature and not accepted by the current consensus statements as valid. Our first reaction would be to reject this as an objective of surgical ablation. However, we know from longitudinal studies8Khiabani A. MacGregor M. Bakir N. Manghelli J. Sinn L.A. Maniar H.S. et al.The long-term outcomes and durability of the Cox-maze IV procedure for atrial fibrillation.J Thorac Cardiovasc Surg. May 5, 2020; 165: 1387-1394Google Scholar that “success” by the Consensus Statement definition2Calkins H. Hindricks G. Cappato R. Kim Y.H. Saad E.B. Aguinaga L. et al.2017 HRS/EHRA/ECAS/APHRS/SOLAECE expert consensus statement on catheter and surgical ablation of atrial fibrillation.Heart Rhythm. 2017; 14: e275-e444Abstract Full Text Full Text PDF PubMed Scopus (1130) Google Scholar diminishes over time. Further, we know that success defined as “less than 30-seconds of continuous AF, atrial flutter, or atrial tachycardia” is arbitrary and impractical. Already there are calls to change the way we quantify atrial fibrillation.9Chen L.Y. Chung M.K. Allen L.A. Ezekowitz M. Furie K.L. McCabe P. et al.Atrial fibrillation burden: moving beyond atrial fibrillation as a binary entity: a scientific statement from the American Heart Association.Circulation. 2018; 137: e623-e644Crossref PubMed Scopus (218) Google Scholar Sophisticated methodologies have been developed to quantify atrial fibrillation burden from daily rhythm strips.10Blackstone E.H. Chang H.L. Rajeswaran J. Parides M.K. Ishwaran H. Li L. et al.Biatrial maze procedure versus pulmonary vein isolation for atrial fibrillation during mitral valve surgery: new analytical approaches and end points.J Thorac Cardiovasc Surg. 2019; 157: 234-243Abstract Full Text Full Text PDF PubMed Scopus (23) Google Scholar More importantly, the way we assess rhythm is changing and being driven more by industry (direct-to-consumer products)11Sturman S. Best Buy is set to enter the healthcare space.https://www.healthcareglobal.com/public-health/best-buy-set-enter-healthcare-spaceDate accessed: August 21, 2018Google Scholar and patient choice than by societal guidelines. Wearable health monitoring technology is being developed12Falter M. Budts W. Goetschalckx K. Cornelissen V. Buys R. Accuracy of Apple Watch measurements for heart rate and energy expenditure in patients with cardiovascular disease: cross-sectional study.JMIR Mhealth Uhealth. 2019; 7: e11889Crossref PubMed Scopus (52) Google Scholar and adopted in an exponential fashion.13Edgerton J.R. Wearable technology and intermittent health care monitoring: the wave is here, the tsunami is coming.J Thorac Cardiovasc Surg. 2019; 157: 244-245Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar Patients can now easily and economically record intermittent rhythm strips.14AlivecorBridging the gap between wearables and healthcare.https://www.alivecor.com/technology/Date accessed: August 21, 2018Google Scholar, 15Bumgarner J.M. Lambert C.T. Hussein A.A. Cantillon D.J. Baranowski B. Wolski K. et al.Smartwatch algorithm for automated detection of atrial fibrillation.J Am Coll Cardiol. 2018; 71: 2381-2388Crossref PubMed Scopus (253) Google Scholar, 16Turakhia M. Desai M. Hedlin H. Rajmane A. Talati N. Ferris T. et al.Rationale and design of a large-scale, app-based study to identify cardiac arrhythmias using a smartwatch: the Apple Heart Study.Am Heart J. 2018; 2: 66-75Google Scholar, 17Seshadri D. Bittel B. Browsky D. Houghtaling P. Drummond C. Desai M. et al.Accuracy of Apple Watch for detection of atrial fibrillation.Circulation. 2020; 141: 702-703Crossref PubMed Scopus (64) Google Scholar Electrophysiologists are struggling to deal with the volume of patient-generated data.18Tarakji K. Silva J. Chen L. Turakhia M. Perez M. Attia Z. et al.Digital health and the care of the patient with arrhythmia.Circ Arrhythm Electrophysiol. 2020; 13: 11Crossref Scopus (12) Google Scholar Not only is wearable technology available, but intermittent rhythm assessment can be acquired more economically than continuous monitoring. Undoubtedly, the way we judge outcomes will change. However, it is critically important that our professional societies develop new universally accepted measures of success to compare different ablation strategies. This is a clarion call to develop a new consensus and a broader set of ablation end points. Will we adopt a definition of success for which the only end point is complete elimination of the arrhythmia? Or will we be like Sisyphus, settling for getting closer each time but resigned to not always reaching the plateau of arrhythmia elimination? Thoracoscopic ablation delays progression from paroxysmal to persistent atrial fibrillationThe Journal of Thoracic and Cardiovascular SurgeryVol. 165Issue 4PreviewThe study objective was to determine whether mini-invasive transthoracoscopic atrial fibrillation ablation can delay the progression of atrial fibrillation from paroxysmal to persistent. Full-Text PDF" @default.
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• W3153605019 title "Commentary: What is the measure of success for atrial fibrillation ablation? Is a reduction in arrhythmia burden sufficient?" @default.
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