Emmert, Maximilian Y.

Grünenfelder, J.

Salzberg, Sacha P.

English

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Europe encompasses a very large butdiverse EP community, including physicians withvarious backgrounds and specialities comingfrom many countries and centres, with inherentdifferences regarding clinical practice, imple-mentation of guidelines and their legal implica-tion, access to modern therapies, and healtheconomic systems.Ideally, patient registries can capture suchdifferences in patient management and therebyimprove quality of care. Registries are, however,often associated with significant efforts and costfor the healthcare community, and seldom givesa quick insight into the clinical practice or theiradoption to guidelines. As the Scientific InitiativeCommittee of the European Heart RhythmAssociation (EHRA), we have continued topublish the so-called ‘EP wires’. These aresurveys, consisting of short questionnaires with15–25 questions, accessible via the Internetfor centres which voluntarily has declared theirinterest to participate in EHRA’s, Electrophysi-ology (EP) Network. The aim with these EPWire surveys is to provide a quick insight intocurrent clinical practice and adoption to guide-lines in the EP community in Europe. Wellaware of and recognising the limitations withthese surveys, it is our believe that by spreadingthe results and demonstrating regional and/orgeographical differences regarding use or accessto modern therapies, it may hopefully improvethe situations for many of our patients andcolleagues. Such surveys may also recognizeunmet needs for education.The aim of this specific EP Wire survey was toprovide insight intocurrentpracticeregarding themanagement ofpaediatric arrhythmias inEurope.The survey was based on a questionnaire sent viathe Internet to the EHRA, EP Network Centres.We did not intend to analyse practice amongpaediatric EP centres exclusively. Furthermore,surveys can only reflect the past and what isasked for in a limited number of centres. Wedo,however, welcome theparticipation ofpaedi-atric EP centres and the EP network can bereached on our website.Our results are based on the non-paediatricEP community and in the results we stated:‘Catheter ablation of paediatric arrhythmiaswas exclusively performed by paediatric elec-trophysiologists in only 2.56% of the centres,while EP teams were multidisciplinary in15.36% of hospitals or the same teams per-formed ablations in both children and adultpatients (82.05%)’. This means that mostcentres do perform paediatric ablation, even ifthey may not be the ‘centres only specializedin paediatric arrhythmias’. We believe it isquite common in Europe.Given the limitations with both surveys andregistries, the formerbeing basedon physician’sperception and the latter most often being on avoluntary basis, we still believe that many ofthese EP wires and registries contribute to anincreased awareness of differences in health-care and educational needs.Correct that none of the authors arepaediatric cardiologist, and electrophysiolo-gists only but many with wide experience inpaediatric catheter ablation procedures andrelated publications.3 The volume of ablationprocedures performed is the key for a highquality. We believe that our survey supportsthe need for a continued collaboration withthe paediatric EP community and we welcomea corresponding survey, or a Registry, involvingALL centres performing paediatric ablations.References1. Happonen J, Blom N, Celiker A, Drago F, Hebe J,Janousek J et al. Management of pediatric arrhythmiasin Europe. Europace 2015;17:1884.2. Hernandez-Madrid A, Hocini M, Chen J, Potpara T,Pison L, Blomstrom-Lundqvist C. How are arrhythmiasmanaged in thepaediatricpopulation inEurope?Resultsof the European Heart Rhythm survey. Europace 2014;16:1852–6.3. Brugada J, Blom N, Sarquella-Brugada G, Blomstrom-Lundqvist C, Deanfield J, Janousek J et al. EuropeanHeart Rhythm Association; Association for EuropeanPaediatric and Congenital Cardiology. Pharmaco-logical and non-pharmacological therapy for ar-rhythmias in the pediatric population: EHRA andAEPC-Arrhythmia Working Group joint consensusstatement. Europace 2013;15:1337–82.Antonio Hernandez-Madrid1,*,Jian Chen2, Tatjana Potpara3,Laurent Pison4, Torben BjerregaardLarsen5, Heidi L. Estner6,Derick Todd7, Maria GraziaBongiorni8, Carina Blomstro¨m-Lundqvist9 andon behalf of the Scientific InitiativeCommittee, European Heart RhythmAssociation1Cardiology Department, Ramon y Cajal Hospital,Alcala´ University, CarreteraColmenar Viejo,Madrid 28034, Spain;2Institute of Medicine and Department of HeartDisease, Haukeland University Hospital,University of Bergen, Bergen N-5021, Norway;3School of Medicine, Belgrade University,Cardiology Clinical Centre Serbia, Belgrade11000, Serbia;4Department of Cardiology, MaastrichtUniversity, Medical Centre, Maastricht 6229 HX,The Netherlands;5Department of Cardiology, Aalborg ThrombosisResearch Unit, Aalborg University Hospital,Søndre Skovvej 15, Aalborg DK-9100, Denmark;6Leiterin Interventionelle Elektrophysiologie,Medizinische Klinik und Poliklinik I. Klinikum derUniversitat Munchen, Marchioninistr. 15,Munchen D-81377, Germany;7Institute of Cardiovascular Medicine and Science,Liverpool Heart and Chest Hospital, ThomasDrive, Liverpool L14 3PE, UK;8Second Cardiology Department, UniversityHospital of Pisa, Pisa 56100, Italy;9Department of Cardiology, Institution of MedicalScience, Uppsala University, Uppsala 75185,Sweden*Corresponding author. Tel: +34 913369006;fax: +34 913368183. E-mail:antoniomadri@gmail.comdoi:10.1093/europace/euu402Published online 13 February 2015Left atrial appendage closureto prevent stroke in patientswith atrial fibrillation: a callfor the heart team approachWith great interest we read the EHRA/EAPCIexpert consensus statement on catheter-basedleft atrial appendage (LAA) occlusion.1 It isimportant to emphasize that the seminal effortsto address the LAA originate from open-heartsurgery, specifically Madden’s seminal reporton surgical LAA amputation in 1949, which hasdriven innovation and the development of lessinvasive catheter-based approaches to achieveLAA closure.Current data have led to early clinical adop-tion of this seemingly attractive therapy. In thisregard, the incorporation of surgically appliedepicardial closure devices may offer an interest-ing adjunct for selected patients. Unfortunately,the expert panel just states that ‘. . .. In addition,a number of other minimally invasive surgicaland percutaneous devices including the AtriClip,Cardioablate, and Aegis, are at various stages ofadvanced animal studies or first in man experi-ments . . .’.1We believe it is important to also include thesurgical devices in this statement. The clinical ex-perience with these surgically placed devices issubstantial and can be found in many peerreviewed journals. First, the AtriClip has beenimplanted in humans since 2007. Over 40 000devices have been sold since CE mark andFDA approval. Data on this effective device aresubstantial.2,3 Next, the long-term imaging con-trolled data on the AtriClip further substantiatethese positive results of complete and durableclosure, presenting the first data on durabilityofLAA closure.3 Second, there is an anotherepi-cardial closuredevice, theTiger-Paw(MAQUETMedical Systems USA, Wayne, NJ, USA) appro-ved by the FDA yielding similar short-termsafety and efficacy results as the aforementionedAtriClip (Atricure, West Chester, OH, USA).4Third, and most importantly, thoracoscopicLAA amputation with 3 months computed tom-ography control with a linear stapler has beenreported in a stand-alone fashion by Ohtsukaet al.5 LAA stapler amputation has long been anintegral part of surgical minimal invasive atrialfibrillation ablation. The results are summarizedLetters to the Editor 1885in two review papers, reporting on over 1000patients also highlight feasibility, safety and effi-cacy of routine surgical LAA amputation.6Before any type of intervention, importantanatomical and morphological considerationsare mandatory to more accurately predict inwhich patients a complete and durable trans-catheter closure is not likely to be achieved. Inthese cases, referral for minimally invasive surgi-cal LAA closure should be considered as anoption.Webelieve thatonlyamore focusedcol-laboration between cardiologists and cardio-thoracic surgeons (the heart team approach) inregard to device and patient selection wouldenable a 100% successful LAA closure in all-comers. In regards to stroke prevention obviouslymore data, and ideally a prospective randomizedtrial would be necessary.References1. Meier B, Blaauw Y, Khattab AA, Lewalter T, Sievert H,Tondo C et al. Ehra/eapci expert consensus statementon catheter-based left atrial appendage occlusion.Europace 2014;16:1397–416.2. Ailawadi G, Gerdisch MW, Harvey RL, Hooker RL,Damiano RJ Jr, Salamon T et al. Exclusion of the leftatrial appendage with a novel device: early results ofa multicenter trial. J Thorac Cardiovasc Surg 2011;142:1002–9, 1009–e1001.3. Emmert MY, Puippe G, Baumuller S, Alkadhi H,Landmesser U, Plass A et al. Safe, effective anddurable epicardial left atrial appendage clip occlu-sion in patients with atrial fibrillation undergoingcardiac surgery: first long-term results from a pro-spective device trial. Eur J Cardio-Thorac Surg 2014;45:126–31.4. Slater AD, Tatooles AJ, Coffey A, Pappas PS,Bresticker M, Greason K et al. Prospective clini-cal study of a novel left atrial appendage occlusiondevice. Ann Thorac Surg 2012;93:2035–8; discussion2038–2040.5. Ohtsuka T, Ninomiya M, Nonaka T, Hisagi M, Ota T,Mizutani T. Thoracoscopic stand-alone left atrial ap-pendectomy for thromboembolism prevention innonvalvular atrial fibrillation. J Am Coll Cardiol 2013;62:103–7.6. Krul SP, Driessen AH, Zwinderman AH, vanBoven WJ, Wilde AA, de Bakker JM et al. Navigatingthe mini-maze: systematic review of the first resultsand progress of minimally-invasive surgery in the treat-ment of atrial fibrillation. Int J Cardiol 2013;166:132–40.Sacha P. Salzberg1,*, J. Gru¨nenfelder1and Maximilian Y. Emmert21HeartClinic, Hirslanden Hospital, Wittelikerstr.40, Zurich 8032, Switzerland;2Clinic for Cardiovascular Surgery, UniversityHospital, Zurich, Switzerland*Corresponding author: Tel: +41 44 387 97 00;fax: +41 44 387 97 20.E-mail address: sacha.salzberg@hirslanden.chLetters to the Editor1886

Left atrial appendage closure to prevent stroke in patients with atrial fibrillation: a call for the heart team approach

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Left atrial appendage closure to prevent stroke in patients with atrial fibrillation: a call for the heart team approach

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