To the Editor The clinical implication of left atrial reverse remodeling has received substantial focus. Hasegawa et al. demonstrated that a higher pre-procedural rate between atrial natriuretic peptide (ANP) and B-type natriuretic peptide was associated with increased left atrial reverse remodeling following sinus rhythm restoration by catheter ablation in patients with persistent atrial fibrillation (1). However, several concerns regarding these findings have been raised, and we trust that addressing them will improve the work.
The detailed mechanism underlying their findings is unclear. The authors speculated that persistent atrial fibrillation might decrease the number of left atrial myocardial cells and exacerbate left atrial fibrosis, causing a decline in the synthesis of ANP in the left atrium (1). However, other experimental studies have shown that an increased left atrial pressure increases the secretion of ANP (2). If baseline voltage maps are available, we highly encourage the authors to examine the correlation between the area of low-voltage lesions and the serum ANP levels. If their hypothesis is correct, a wider low-voltage lesion would be associated with lower serum ANP levels.
The authors added several ablations, including at the left atrial roof line, mitral isthmus line, and complex fractionated electrogram, for continued atrial fibrillation following standard catheter ablation (1). These procedures, in general, exacerbate left atrial stiffness and likely disturb left atrial reverse remodeling (3). Such procedures might also be potential confounders of left atrial reverse remodeling that should be incorporated in the analyses.
The implications of their findings merit further discussion. Most of the participants in their study had a CHADS2 score <2 (1). Such patients can enjoy freedom from anti-coagulation therapy if sinus rhythm is maintained following catheter ablation. Furthermore, their participants had stable hemodynamics, as those with heart failure were excluded from the study (1). Thus, the clinical implication of left atrial reverse remodeling in such a relatively healthy cohort might be unclear and require further discussion.
The authors state that they have no Conflict of Interest (COI).
References
- 1. Hasegawa Y, Okada S, Sanada A, et al. The atrial natriuretic peptide-to-brain natriuretic peptide ratio predicts left atrial reverse remodeling after rhythm control therapy in patients with persistent atrial fibrillation. Intern Med 62: 3283-3290, 2023. [DOI] [PMC free article] [PubMed] [Google Scholar]
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