ESC Congress FA eBook 2016 - 25

ESC CONGRESS 2016
IN REVIEW

FOCUS ON ARRHYTHMIAS
SELECTED UPDATES

Managing Atrial Fibrillation in
a Complex Environment
Written by Maria Vinall

Josef Kautzner, MD, Institute for Clinical and Experimental Medicine, Prague, Czech Republic,
suggested that in some patients, atrial fibrillation (AF) may not be just an arrhythmia but a manifestation of cardiovascular disease.
While some patients have AF as an isolated arrhythmia, others present with a morphological or
functional substrate as well as enlarged atria and/or low voltage. There have been no conclusive
studies in humans, however, that demonstrate that AF itself creates a morphological substrate and
some pathologic studies show no differences in atrial fibrosis or in circuit reentrancy in patients
with AF versus those without [de Oliveira M et al. Cardiovasc Pathol. 2013]. There are a number of
factors, however, that point to a 'different' type of AF in some patients. For example, it has been
noted that patients with long-standing AF and rheumatic heart disease have a very high prevalence of atrial amyloidosis. Thus it may be that persistent AF is associated with amyloid deposition
in some patients, which in turn leads to low voltage or disruption of conduction [Leone O et al.
Eur Heart J. 2004]. Progressive obesity is associated with changes in atrial size, conduction, histology, and the expression of profibrotic mediators [Abed HS et al. Heart Rhythm. 2013]. In addition,
elevated left atrial (LA) pressure is closely associated with electroanatomical remodeling of the LA
and is an independent predictor for recurrence of AF after ablation (Figure 1) [Park J et al. Heart
Rhythm. 2014]. Similar, yet unpublished data were obtained in our department measuring LA
pressure both at rest and during handgrip. About one-third of patients presented with LA hypertension and showed significantly worse outcome of catheter ablation for AF. Other data show that
patients with risk factors have substantially better results in maintaining sinus rhythm when on
previously ineffective antiarrhythmic medication. This suggests that in certain proportion of cases
AF is not just an arrhythmia but a marker of cardiovascular disease.
Prashanthan Sanders, MD, Centre for Heart Rhythm Disorders, University of Adelaide, Royal
Adelaide Hospital, Adelaide, Australia, sees a role for lifestyle modification to lessen the burden of
AF. Treating the primary causes of AF reverses atrial remodeling, reduces symptoms, and improves
the maintenance of sinus rhythm (SR).

Official Peer-Reviewed
Highlights From

Figure 1. Left Atrial Peak Pressure and AF Recurrence
B

Overall Patients

100

AF Free Survival, %

Patients Followed > 1 year

LA peak pressure
< 19 mm Hg

LA peak pressure
≥ 19 mm Hg

Log Rank P = .028

AF Free Survival, %

LA peak pressure
< 19 mm Hg

90
LA peak pressure
≥ 19 mm Hg
80

Log Rank P = .028

10
15
Follow-Up, months

AF, atrial fibrillation; LA, left atrial.
Reprinted from Park J et al. High left atrial pressures are associated with advanced electroanatomical remodeling of left atrium and independent predictors for
clinical recurrence of atrial fibrillation after catheter ablation. Heart Rhythm 2014;11(6):953-60. By permission of Elsevier. Copyright © 2014 Heart Rhythm Society.

Official Peer-Reviewed Highlights From ESC Congress 2016

Table of Contents for the Digital Edition of ESC Congress FA eBook 2016