Reply to the Letter Titled, “How to Predict Left Atrial Reverse Remodeling Following Catheter Ablation for Atrial Fibrillation”

The Authors Reply We thank Dr. Kataoka and a colleague for their interest in our recently published paper assessing the usefulness of the atrial natriuretic peptide-to-brain natriuretic peptide (ANP/BNP) ratio for predicting left atrial (LA) reverse remodeling after catheter ablation (CA) in persistent atrial fibrillation patients with LA enlargement (1).

In their letter to the editor, they expressed three concerns about the findings of our study. First, they suggested the need to include data on baseline voltage maps in the analysis to clarify the association between LA fibrosis and serum ANP levels. Although we agree with the importance of their proposal, unfortunately we have limited data on voltage maps obtained during sinus rhythm, making it difficult to clarify the association. They cited previous experimental data stating that a higher LA pressure would increase the secretion of ANP, but it should be noted that other experimental data showed that the primary stimulus for ANP release is atrial wall stretch, not pressure (2). A further investigation of the relationship between serum ANP levels and other clinical factors will be needed.

Second, Kataoka et al. mentioned the impact of additional ablation on LA reverse remodeling. We confirmed that the rate of patients who received further ablation in addition to pulmonary vein isolation was similar between the responders and non-responders (17% vs. 12%, p=0.53).

Third, Kataoka et al. noted that many of the patients in our study were mild cases (with relatively low CHADS₂ scores and excluding those with heart failure) and expressed concern about the clinical implications of predicting LA reverse remodeling. As they noted in their letter, patients with low CHADS₂ scores may be able to discontinue anticoagulation if sinus rhythm is maintained after CA. For such patients, it would be worthwhile to attempt CA even if they are asymptomatic. Predicting reverse remodeling prior to ablation would be of great significance for treatment selection. The benefits of LA reverse remodeling have already been discussed in our paper. The ANP/BNP ratio in patients with heart failure is strongly influenced by the left ventricular function as well as the LA function, and its interpretation requires further verification. Presumably, predicting LA reverse remodeling in such a cohort would require a combination of multiple parameters rather than a single one.

The authors state that they have no Conflict of Interest (COI).