Bernat, Robert

Schirmer, Stephan H.

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Vol.:(0123456789) Journal of Interventional Cardiac Electrophysiology https://doi.org/10.1007/s10840-023-01487-yCOMMENTARYCan rhythm therapy cure valvular disease?Stephan H. Schirmer1,2  · Robert Bernat3,4Received: 22 December 2022 / Accepted: 17 January 2023 © The Author(s) 2023Atrial fibrillation (AF) is the most common rhythm disorder worldwide, with increasing prevalence. It is associated with significant morbidity through thromboembolism and stroke, but also myocardial remodeling. Registry data indicate that almost 2/3 of the AF patients have significant valvular heart disease (VHD) [1]. There is a bidirectional connection between AF and VHD, in which the causal relationship can-not always be determined. AF is particularly associated with functional tricuspid regurgitation (TR), leaving the structure of the leaflets and chordae normal, whereas regurgitation is primarily caused by changes of the surrounding structures—annular dilatation and dysfunction of the right ventricle [2]. Higher grade TR, although often clinically silent for a long time, can cause severe problems of right heart failure, con-gestion, and also mortality. The relationship between AF and TR has been known for more than half a century [3], yet the concept of atrial function and tricuspid regurgita-tion (AF-TR), as opposed to the well-studied concept of TR based on RV enlargement and dysfunction, has largely been understudied and ignored.Tricuspid valve disease is often under-recognized and underestimated because of the lack of treatment options, although recently, also the tricuspid valve is amenable to modern interventional techniques such as transcatheter edge-to-edge repair (TEER), following years of mitral valve expe-rience. Therefore, elimination or at least reduction of one of the causes of functional TR, i.e., atrial fibrillation, might have an important effect on valve function and potentially also clinical endpoints. The current guidelines on AF and VHD do not address the interplay between the two con-ditions, making the growing body of data on influencing the course of TR by treating AF even more important. The effects of different treatment options for AF on TR have been primarily examined in retrospective studies. A recent investigation points towards one-third of patients with newly diagnosed AF developing moderate or greater TI which was associated with increased risk of mortality in a 13-year fol-low-up [4]. Some studies have indicated that successful cath-eter ablation of atrial fibrillation with durable sinus rhythm may lead to improvement of tricuspid valve function in case of lesser tethering height (< 6 mm) [5].In this issue of the journal, the authors demonstrate marked improvement of formerly severe functional TI in a retrospective cohort analysis of n = 64 patients undergo-ing catheter ablation of AF [6]. They derived the carefully selected cohort from a large single-center database of > 2.000 patients undergoing ablation, of whom the majority did not suffer from severe TI. Moreover, the area of right ventricle and atrium as well as mitral regurgitant jet area improved alongside. Because of this large database and the clear results, the analysis, albeit retrospective in nature, is helpful for clinical evaluation, and the authors should be congratulated on performing the investigation. Patients with persistent AF and only mild symptoms are common, and the decision for an interventional approach of putative prognos-tic value is not always easy to make. The early treatment of AF fits well in the widely advocated strategy of timely TR treatment, regardless of the exact causal relationship between the two entities [7].Yet, the study is somewhat confirmative, although past investigations have included less patients and a lesser degree of severity of TR [8]. In addition, other studies focused on the differences between surgical and catheter ablation and not so much on echocardiographic parameters of TR. A retrospective analysis on > 400 patients undergoing surgi-cal AF ablation during mitral valve surgery confirmed AF recurrence to be associated with progression of TR and right remodeling TR [5]. Not only improvement of the degree of This comment refers to the article available at https:// doi. org/ 10. 1007/ s10840- 022- 01410-x * Stephan H. Schirmer  schirmer@kardiopraxis-schirmer.de1 Kardiopraxis Schirmer, Am Altenhof 8, 67655 Kaiserslautern, Germany2 Saarland University, Homburg/Saar, Germany3 Marienhospital Aachen, Aachen, Germany4 Unversität Osijek, Osijek, Croatia Journal of Interventional Cardiac Electrophysiology1 3tricuspid regurgitation but also amelioration of right ven-tricular geometry is reported following catheter ablation of persistent AF. As with other reports, due to its retrospec-tive and single center nature, the conclusions which can be deducted from the present investigation are limited. Ideally, a prospective study is necessary to reliably evaluate the effect of catheter ablation of AF on functional TR. Beyond this, we can only assume that the amelioration of echocar-diographic parameters translates into clinical benefit—show-ing a reduction of hard clinical endpoints such as right heart decompensation, hospitalization, or even death would be the ultimate goal.In summary, the current analysis adds to the body of (mostly retrospective) data suggesting a beneficial effect of rhythm therapy on functional right heart parameters, particu-larly tricuspid regurgitation. While there are clear general recommendations on the early and aggressive use of catheter ablation in treating AF, its adjunct positive effects on TR, as documented in the present paper, add to this concept.Funding Open Access funding enabled and organized by Projekt DEAL.Open Access This article is licensed under a Creative Commons Attri-bution 4.0 International License, which permits use, sharing, adapta-tion, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http:// creat iveco mmons. org/ licen ses/ by/4. 0/.References 1. Lip GY, Laroche C, Dan GA, Santini M, Kalarus Z, Rasmussen LH, Oliveira MM, Mairesse G, Crijns HJ, Simantirakis E, Atar D, Kirchhof P, Vardas P, Tavazzi L, Maggioni AP. A prospective survey in European Society of Cardiology member countries of atrial fibrillation management: baseline results of EURObserva-tional Research Programme Atrial Fibrillation (EORP-AF) Pilot General Registry. Europace. 2014;16:308–19. 2. Ortiz-Leon XA, Posada-Martinez EL, Trejo-Paredes MC, Ivey-Miranda JB, Pereira J, Crandall I, DaSilva P, Bouman E, Brooks A, Gerardi C, Houle H, Hur DJ, Lin BA, McNamara RL, Lombo-Lievano B, Akar JG, Arias-Godinez JA, Sugeng L. Tricuspid and mitral remodelling in atrial fibrillation: a three-dimensional echocardiographic study. Eur Heart J Cardiovasc Imaging. 2022;23:944–55. 3. Gould L, Weber D, Schaffer AI, O'Connor RA. Does atrial fibrillation lead to tricuspid insufficiency? Am J Cardiol. 1965;16:188–94. 4. Patlolla SH, Schaff HV, Nishimura RA, Stulak JM, Chamberlain AM, Pislaru SV, Nkomo VT. Incidence and burden of tricuspid regurgitation in patients with atrial fibrillation. J Am Coll Cardiol. 2022;80:2289–98. 5. Wang J, Li S, Ye Q, Ma X, Zhao Y, Han J, Li Y, Zheng S, Liu K, He M, Yu W, Sun J, Meng X. Catheter ablation or surgical therapy in moderate-severe tricuspid regurgitation caused by long-standing persistent atrial fibrillation. Propensity score analysis. J Cardiothorac Surg. 2020;15:277. 6. Nishiwaki S, Watanabe S, Yoneda F, Tanaka M, Aizawa T, Yamagami S, Komasa A, Kawaji T, Yoshizawa T, Kohjitani H, Morimoto T, Kimura T, S. S. Impact of catheter ablation on functional tricuspid regurgitation in patients with atrial fibrilla-tion. J Interv Card Electrophysiol. 2023. https:// doi. org/ 10. 1007/ s10840- 022- 01410-x. 7. Ruf TF, Gößler TAM, von Bardeleben RS. Understanding atrial fibrillation and atrial secondary tricuspid regurgitation: the chicken or the egg? J Am Coll Cardiol. 2022;80:2299–300. 8. Markman TM, Plappert T, De Feria AA, Levin M, Amankwah N, Sheth S, Gertz ZM, Schaller RD, Marchlinski FE, Rame JE, Frankel DS. Improvement in tricuspid regurgitation following catheter ablation of atrial fibrillation. J Cardiovasc Electrophysiol. 2020;31:2883–8.Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Can rhythm therapy cure valvular disease?

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Can rhythm therapy cure valvular disease?

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