Ann Thorac Surg 2010;89:340-341. doi:10.1016/j.athoracsur.2009.08.023
© 2010 The Society of Thoracic Surgeons
Correspondence
Intermediate Outcome of Surgical Atrial Fibrillation Correction With the CryoMaze Procedure
Thorsten Hanke, MD,
Efstratios I. Charitos, MD,
Ulrich Stierle, MD,
Hans-H. Sievers, MD,
Martin Misfeld, MD, PhD
University of Lübeck, Clinic for Cardiac and Thoracic Vascular Surgery, Ratzeburger Allee 160, Lübeck, 23538 Germany
(Email: thorstenhanke{at}yahoo.com).
To the Editor:
| Dr Hanke discloses that he has a financial relationship with Medtronic GmbH.
|
We read the article from Gammie and colleagues [1] with great interest, and we congratulate the authors on their thoughtful and thorough follow-up after surgical ablation therapy. In our opinion, a few remarks with respect to the guideline confirmed definitions and follow-up strategies ought to be mentioned.
As mentioned by Ad [2] a need for standardization as proposed by the Heart Rhythm Society [3] when reporting on atrial fibrillation (AF) issues is inevitable, and in any case, it is necessary. To most properly evaluate the success of ablation therapy among the different groups of AF, the newest AF classification system ought to be taken into consideration [3].
For clinical trial evaluation, the guidelines strongly propose long-time postoperative heart rhythm surveillance (ie, transtelephonic transmission for a 4-week period or 72-hour Holter monitoring). This important issue has been performed very well by the Gammie and colleagues [1] group by even using a 2-week Holter monitoring strategy. However, as mentioned in their series, electrocardiographic documentation ranged from 1 to 14 days, and longer-term heart rhythm documentation has only been available in 75% of the patients, indicating a reduced patient compliance with respect to external heart rhythm documentation. However, it has been shown that monthly 24-hour Holter monitoring with respect to AF recurrence detection is significantly superior to 7-day continuous monitoring per year, which is slightly superior to 30-day monitoring [4]. By using implantable monitor devices, the issue of patient compliance and "snapshot" heart rhythm surveillance with the danger of success misinterpretation can be overcome. This has been successfully shown by the Martinek group [5], but heart rhythm documentation in this study was achieved with dual-chamber pacemaker devices, inevitably requiring lead implantation into the right heart chambers. By perioperatively implanting a small leadless monitoring device subcutaneously after surgical ablation therapy, we were able to detect a remarkable superiority of this heart rhythm surveillance technique when compared with quarterly performed 24-hour Holter monitoring with respect to AF recurrence detection [6]. In addition, patient compliance was extensively reduced because quarterly performed interrogation of the device only takes approximately 5 minutes. Furthermore, the measurement for "AF burden" is calculated by real time AF recurrence for the whole postoperative observational period and not only for a short time period; thus, therapeutical options (ie, anticoagulation or medical anti-arrhythmic strategy) are based on a more thorough and safe fundament.
In conclusion, we believe that it would be appropriate to perform an intensified heart rhythm follow-up strategy, as performed by Gammie and coworkers [1], but with the drawbacks of their strategy in mind, we further advise continuous heart rhythm monitoring as achieved with an implantable event recorder due to the "real life" AF recurrence detection, although the issue of device electrocardiographic storage capacity and AF over-sensing or under-sensing, or both, is still a technical issue of debate. However, we believe that this new and intensified continuous follow-up strategy ought to be adopted by the AF ablation procedure guidelines.
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References
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- Gammie JS, Didolkar P, Krowsoski LS, et al. Long-term outcomes of surgical atrial fibrillation correction with the CryoMaze procedure Ann Thorac Surg 2009;87:1452-1459.[Abstract/Free Full Text]
- Ad N. The surgical treatment for atrial fibrillation: a call for standardization J Thorac Cardiovasc Surg 2008;135:727-728.[Free Full Text]
- Calkins H, Brugada J, Packer DL, et al. HRS/EHRA/ECAS expert Consensus Statement on catheter and surgical ablation of atrial fibrillation: recommendations for personnel, policy, procedures and follow-up. A report of the Heart Rhythm Society (HRS) Task Force on catheter and surgical ablation of atrial fibrillation. Heart Rhythm 2007;4:816-861.[Medline]
- Ziegler PD, Koehler JL, Mehra R. Comparison of continuous versus intermittent monitoring of atrial arrhythmias Heart Rhythm 2006;3:1445-1452.[Medline]
- Martinek M, Aichinger J, Nesser HJ, Ziegler PD, Purerfellner H. New insights into long-term follow-up of atrial fibrillation ablation: full disclosure by an implantable pacemaker device J Cardiovasc Electrophysiol 2007;18:818-823.[Medline]
- Hanke T, Charitos EI, Stierle U, et al. Twenty-four-hour holter monitor follow-up does not provide accurate heart rhythm status after surgical atrial fibrillation ablation therapy Circulation 2009;120(suppl I):S177-S184.[Abstract/Free Full Text]
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