Cardiac Rhythm Management
Articles Articles 2015 January

Letter from the Editor in Chief

DOI: 10.19102/icrm.2015.060101


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Dear Readers,

It is with great pleasure that I write this letter to welcome you to the New Year. The past year was very prolific for the field of electrophysiology, particularly atrial fibrillation (AF). Year 2015 appears to be similarly promising as we expect the results of many studies investigating the impact of new technologies on the outcome of catheter ablation for AF. These technologies include contact force sensing, assessment of ablation lesion formation, and advanced mapping for the delineation of targets in persistent AF. Another area that has gathered significant interest the past year, and is expected to continue to do so in 2015, is the association between AF and the outcome of different disease states. This area is highlighted in the important article by Cesario et al. in this issue of the Journal. The authors described the prevalence and impact of AF in patients with CRT-D devices. A total of 63,866 patients with 2,173 first shock episodes were included in the study. The incidence of AF was found to be 47.1% and this arrhythmia was responsible for a large number of inappropriate shocks. AF was also found to be associated with an increased mortality risk and more importantly that risk was higher with larger burden of AF.

The association between AF and worsened clinical outcome has been studied extensively recently. Just over the past 6 months several reports have detailed this relationship in different patient populations. One study reported that AF increased stroke and mortality rate after transcatheter aortic valve replacement. The same association was found between AF and outcome of CABG. Another study reported that pre-existing AF is associated with increased risk of death in patients admitted with pneumonia. A fourth study showed a worse clinical outcome in patients with myocardial infarction in the presence of AF. AF was also found to be a predictor of mortality in patients with hypertrophic cardiomyopathy. It is certainly possible that AF is only a marker of the severity of the disease in all these studies. However one can argue that AF could have impacted the survival of the patients directly. AF can cause rapid ventricular rate, loss of atrio-ventricular synchrony, compromise of biventricular pacing, thromboembolic events, and can lead to a need for anticoagulation and antiarrhythmic medications, all of which can negatively impact the clinical outcome.

Like many of you I treat a large number of patients with AF. On many occasions the patients are symptomatic and decision for restoring normal sinus rhythm is straightforward. Not uncommonly we face situations where the benefit of restoring sinus rhythm is less clear. The numerous reports describing an association between AF and worsened outcome of different disease states are concerning. I believe that more studies are needed to determine if sustained restoration of normal sinus rhythm is beneficial in patients with apparently “silent” AF.

Best wishes for a healthy New Year,


Moussa Mansour, MD, FHRS, FACC
The Journal of Innovations in Cardiac Rhythm Management
Director, Cardiac Electrophysiology Laboratory,
Director, Atrial Fibrillation Program
Massachusetts General Hospital
Boston, MA