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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Atrial fibrillation is the most common arrhythmia in clinical practice&#46; Its prevalence increases with age and it is also more common in patients with other forms of heart disease&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">A recently published study on the healthcare burden of atrial fibrillation examined an extensive remote monitoring database of patients &#40;n&#61;21<span class="elsevierStyleHsp" style=""></span>391&#41; with an implanted cardiac device&#46; The study found that a high percentage of these patients &#40;36&#46;5&#37;&#41; experienced atrial fibrillation&#46; Among this group&#44; the prevalence of heart failure &#40;HF&#41; was markedly higher at 44&#37;&#44; which may be attributed to the specific characteristics of these patients &#40;who had cardiac resynchronization therapy devices&#44; implantable cardioverter-defibrillators&#44; and pacemakers&#41;&#46; Additionally&#44; the study revealed that healthcare resource use was greater among patients with atrial fibrillation than in those without the condition&#44; mainly due to adverse clinical events&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">2</span></a> Atrial fibrillation is thus a public health problem&#44; and treatments aimed at improving prognosis are welcome&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Ablation has become the primary form of therapy for atrial fibrillation&#46; It has proved more effective than medication for a wide range of patients&#44; reducing the arrhythmia burden and hospitalizations while improving overall quality of life&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">3</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The results are even more impressive in the subset of patients with HF and reduced left ventricular ejection fraction &#40;LVEF&#41;&#46; There is clear evidence of a reduction in hard endpoints&#44; including mortality&#46; This is true for the majority of patients&#44; including both those with milder and those with more advanced forms of HF&#44; and even those on a waiting list for heart transplantation&#46; The CASTLE AF trial compared atrial fibrillation ablation with medical therapy in patients with HF and showed a significant reduction in a composite primary endpoint of death or hospitalization&#46; The trial also found that all-cause mortality was reduced in patients who underwent atrial fibrillation ablation&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">4</span></a> The CASTLE-HTx trial studied a population with advanced HF on a waiting list for heart transplantation &#40;these patients had been excluded from other trials&#41;&#46; Again&#44; there was a benefit in a composite endpoint of mortality&#44; urgent transplantation&#44; or left ventricular &#40;LV&#41; assist device implantation&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">5</span></a> There is now evidence that atrial fibrillation ablation is indicated in patients with HF across a broad spectrum of the disease &#8211; from milder to more advanced forms&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">In patients with HF and reduced LVEF&#44; there are basically two clinical scenarios&#58; patients with a known cause of HF who also have atrial fibrillation&#44; and those in whom the arrhythmia is the cause of the depression in LV function &#40;arrhythmia-induced cardiomyopathy&#41;&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Not all HF patients respond to atrial fibrillation ablation&#46; It is tempting to speculate that some patients with a better response share the same characteristics as patients without HF &#8211; mainly paroxysmal forms of atrial fibrillation and without a severely dilated left atrium&#46; It is also tempting to assume that HF patients who are stable in sinus rhythm but begin to suffer bouts of atrial fibrillation&#44; with a consequent worsening of clinical status&#44; will benefit the most&#46; However&#44; information regarding the best HF candidates and those with a higher likelihood of response is scarce&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Several variables have been found to be predictive of success&#46; In the Fibrosis-HF study&#44; the presence of fibrosis was assessed during ablation using voltage maps from the mapping system&#46; Patients with left atrial &#40;LA&#41; fibrosis were older and more likely to have diabetes&#46; Fibrosis was more prevalent in the LA anterior wall&#44; followed by the LA septum and posterior wall&#46; Patients with LA fibrosis &#40;30&#37; of the cohort&#41; were less likely to recover LVEF after ablation&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">6</span></a> Another study&#44; by Zhao et al&#46;&#44; showed that absence of LA fibrosis and an LV diameter of less than 50 mm were good predictors of success&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">7</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Another group described a score &#8211; the Antwerp score &#8211; to identify the best candidate for ablation&#46; This score attributes points to various clinical characteristics in patients with HF undergoing atrial fibrillation ablation&#44; namely a known etiology for HF &#40;2 points&#41;&#44; wide QRS &#40;1 point&#41;&#44; severe atrial dilation &#40;1 point&#41;&#44; and paroxysmal atrial fibrillation &#40;1 point&#41;&#46; The higher the score&#44; the lower the likelihood of response&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">8</span></a> This score was recently validated in a multicenter study that included four centers and 605 patients&#46; In this study&#44; the Antwerp score performed well in predicting recovery of LV function after ablation&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">9</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">The paper by Borges-Rosa et al&#46; published in the current issue of the <span class="elsevierStyleItalic">Journal</span><a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">10</span></a> sets out to address the question of finding the best ablation candidates with HF and atrial fibrillation&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">This study examined 100 patients with HF and reduced LVEF who underwent atrial fibrillation ablation&#46; The large number of patients analyzed is impressive&#46; In the recently published RIQAFA study&#44; which is a snapshot registry of quality indicators in atrial fibrillation ablation in Portugal&#44; only 5&#46;74&#37; of patients had severe LV dysfunction&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">11</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">The success rate in this group was excellent &#8211; 82&#37; were responders to the therapy&#46; The number of complications was low&#44; even in a population of very sick patients&#44; and this is related to the group&#39;s experience&#58; it is a high-volume center for atrial fibrillation ablation&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Borges-Rosa et al&#46;&#8217;s study has two main objectives&#58; to validate the Antwerp score proposed by Bogarti et al&#46;&#59; and to identify predictors of the success of atrial fibrillation ablation in this population&#46; In their analysis&#44; the Antwerp score demonstrated good discriminatory power between responders and non-responders&#44; which is in line with previously published results&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">However&#44; the predictors of success are not all the same as those identified in the Antwerp model&#46; In Borges-Rosa et al&#46;&#8217;s population&#44; the factors identified as predictors of response were as follows&#58; clinical suspicion of tachycardia-induced cardiomyopathy &#40;which is in fact the same as the absence of a specific etiology&#41;&#59; QRS width &#40;a marker of severity and prognosis&#41; in HF patients&#59; and LV volumes&#46; By contrast&#44; LA diameter and type of atrial fibrillation were not predictors of response in this study&#46; This can likely be explained by differences in the populations studied and by the small number of patients in the study&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">This study has several limitations &#40;some acknowledged by the authors&#41;&#44; including the single-center retrospective nature of the analysis&#44; the lack of a comparison group&#44; and inability to accurately quantify atrial fibrillation burden &#40;few patients had a cardiac device implanted&#41;&#46; A significant limitation is the lack of information on patient selection&#44; raising questions about selection bias&#46; We do not know how many patients this cohort was selected from or whether patients with more advanced forms of heart disease &#40;valvular&#44; ischemic&#44; or cardiomyopathy&#41; were accepted to undergo ablation&#46; This is even more important because the number of suspected tachycardia-induced cardiomyopathy cases was very high and also because this parameter is used in the model to predict response&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">The data presented are not new&#44; but they add to the available evidence&#44; and are also the first available on this issue from a Portuguese center&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">In conclusion&#44; this paper confirms the existing idea that the best candidates for atrial fibrillation ablation among HF patients are those in whom no other cause of HF can be identified&#46; Better tools to identify these patients are still needed because in fact&#44; most of the time&#44; the diagnosis of atrial tachycardia-induced cardiomyopathy is made retrospectively after successful ablation with complete recovery of LV function&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">12</span></a></p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0085" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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Atrial fibrillation ablation in patients with heart failure: Which patients are most likely to respond?
Ablação da fibrilhação auricular em doentes com insuficiência cardíaca - quais são os doentes com maior probabilidade de resposta?
Diogo Cavaco
Serviço de Cardiologia do Hospital de Santa Cruz e Serviço de Cardiologia do Hospital da Luz Lisboa, Lisboa, Portugal
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Atrial fibrillation is the most common arrhythmia in clinical practice&#46; Its prevalence increases with age and it is also more common in patients with other forms of heart disease&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">A recently published study on the healthcare burden of atrial fibrillation examined an extensive remote monitoring database of patients &#40;n&#61;21<span class="elsevierStyleHsp" style=""></span>391&#41; with an implanted cardiac device&#46; The study found that a high percentage of these patients &#40;36&#46;5&#37;&#41; experienced atrial fibrillation&#46; Among this group&#44; the prevalence of heart failure &#40;HF&#41; was markedly higher at 44&#37;&#44; which may be attributed to the specific characteristics of these patients &#40;who had cardiac resynchronization therapy devices&#44; implantable cardioverter-defibrillators&#44; and pacemakers&#41;&#46; Additionally&#44; the study revealed that healthcare resource use was greater among patients with atrial fibrillation than in those without the condition&#44; mainly due to adverse clinical events&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">2</span></a> Atrial fibrillation is thus a public health problem&#44; and treatments aimed at improving prognosis are welcome&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Ablation has become the primary form of therapy for atrial fibrillation&#46; It has proved more effective than medication for a wide range of patients&#44; reducing the arrhythmia burden and hospitalizations while improving overall quality of life&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">3</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The results are even more impressive in the subset of patients with HF and reduced left ventricular ejection fraction &#40;LVEF&#41;&#46; There is clear evidence of a reduction in hard endpoints&#44; including mortality&#46; This is true for the majority of patients&#44; including both those with milder and those with more advanced forms of HF&#44; and even those on a waiting list for heart transplantation&#46; The CASTLE AF trial compared atrial fibrillation ablation with medical therapy in patients with HF and showed a significant reduction in a composite primary endpoint of death or hospitalization&#46; The trial also found that all-cause mortality was reduced in patients who underwent atrial fibrillation ablation&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">4</span></a> The CASTLE-HTx trial studied a population with advanced HF on a waiting list for heart transplantation &#40;these patients had been excluded from other trials&#41;&#46; Again&#44; there was a benefit in a composite endpoint of mortality&#44; urgent transplantation&#44; or left ventricular &#40;LV&#41; assist device implantation&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">5</span></a> There is now evidence that atrial fibrillation ablation is indicated in patients with HF across a broad spectrum of the disease &#8211; from milder to more advanced forms&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">In patients with HF and reduced LVEF&#44; there are basically two clinical scenarios&#58; patients with a known cause of HF who also have atrial fibrillation&#44; and those in whom the arrhythmia is the cause of the depression in LV function &#40;arrhythmia-induced cardiomyopathy&#41;&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Not all HF patients respond to atrial fibrillation ablation&#46; It is tempting to speculate that some patients with a better response share the same characteristics as patients without HF &#8211; mainly paroxysmal forms of atrial fibrillation and without a severely dilated left atrium&#46; It is also tempting to assume that HF patients who are stable in sinus rhythm but begin to suffer bouts of atrial fibrillation&#44; with a consequent worsening of clinical status&#44; will benefit the most&#46; However&#44; information regarding the best HF candidates and those with a higher likelihood of response is scarce&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Several variables have been found to be predictive of success&#46; In the Fibrosis-HF study&#44; the presence of fibrosis was assessed during ablation using voltage maps from the mapping system&#46; Patients with left atrial &#40;LA&#41; fibrosis were older and more likely to have diabetes&#46; Fibrosis was more prevalent in the LA anterior wall&#44; followed by the LA septum and posterior wall&#46; Patients with LA fibrosis &#40;30&#37; of the cohort&#41; were less likely to recover LVEF after ablation&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">6</span></a> Another study&#44; by Zhao et al&#46;&#44; showed that absence of LA fibrosis and an LV diameter of less than 50 mm were good predictors of success&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">7</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Another group described a score &#8211; the Antwerp score &#8211; to identify the best candidate for ablation&#46; This score attributes points to various clinical characteristics in patients with HF undergoing atrial fibrillation ablation&#44; namely a known etiology for HF &#40;2 points&#41;&#44; wide QRS &#40;1 point&#41;&#44; severe atrial dilation &#40;1 point&#41;&#44; and paroxysmal atrial fibrillation &#40;1 point&#41;&#46; The higher the score&#44; the lower the likelihood of response&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">8</span></a> This score was recently validated in a multicenter study that included four centers and 605 patients&#46; In this study&#44; the Antwerp score performed well in predicting recovery of LV function after ablation&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">9</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">The paper by Borges-Rosa et al&#46; published in the current issue of the <span class="elsevierStyleItalic">Journal</span><a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">10</span></a> sets out to address the question of finding the best ablation candidates with HF and atrial fibrillation&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">This study examined 100 patients with HF and reduced LVEF who underwent atrial fibrillation ablation&#46; The large number of patients analyzed is impressive&#46; In the recently published RIQAFA study&#44; which is a snapshot registry of quality indicators in atrial fibrillation ablation in Portugal&#44; only 5&#46;74&#37; of patients had severe LV dysfunction&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">11</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">The success rate in this group was excellent &#8211; 82&#37; were responders to the therapy&#46; The number of complications was low&#44; even in a population of very sick patients&#44; and this is related to the group&#39;s experience&#58; it is a high-volume center for atrial fibrillation ablation&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Borges-Rosa et al&#46;&#8217;s study has two main objectives&#58; to validate the Antwerp score proposed by Bogarti et al&#46;&#59; and to identify predictors of the success of atrial fibrillation ablation in this population&#46; In their analysis&#44; the Antwerp score demonstrated good discriminatory power between responders and non-responders&#44; which is in line with previously published results&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">However&#44; the predictors of success are not all the same as those identified in the Antwerp model&#46; In Borges-Rosa et al&#46;&#8217;s population&#44; the factors identified as predictors of response were as follows&#58; clinical suspicion of tachycardia-induced cardiomyopathy &#40;which is in fact the same as the absence of a specific etiology&#41;&#59; QRS width &#40;a marker of severity and prognosis&#41; in HF patients&#59; and LV volumes&#46; By contrast&#44; LA diameter and type of atrial fibrillation were not predictors of response in this study&#46; This can likely be explained by differences in the populations studied and by the small number of patients in the study&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">This study has several limitations &#40;some acknowledged by the authors&#41;&#44; including the single-center retrospective nature of the analysis&#44; the lack of a comparison group&#44; and inability to accurately quantify atrial fibrillation burden &#40;few patients had a cardiac device implanted&#41;&#46; A significant limitation is the lack of information on patient selection&#44; raising questions about selection bias&#46; We do not know how many patients this cohort was selected from or whether patients with more advanced forms of heart disease &#40;valvular&#44; ischemic&#44; or cardiomyopathy&#41; were accepted to undergo ablation&#46; This is even more important because the number of suspected tachycardia-induced cardiomyopathy cases was very high and also because this parameter is used in the model to predict response&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">The data presented are not new&#44; but they add to the available evidence&#44; and are also the first available on this issue from a Portuguese center&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">In conclusion&#44; this paper confirms the existing idea that the best candidates for atrial fibrillation ablation among HF patients are those in whom no other cause of HF can be identified&#46; Better tools to identify these patients are still needed because in fact&#44; most of the time&#44; the diagnosis of atrial tachycardia-induced cardiomyopathy is made retrospectively after successful ablation with complete recovery of LV function&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">12</span></a></p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0085" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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