Letter from the Editor in Chief

DOI: 10.19102/icrm.2014.050501

John D. Day, MD, FHRS, FACC

Dear Readers,

"Bob’s memory just isn’t the same anymore," his worried wife shared with me during a recent clinic visit. Bob has faithfully taken his anticoagulation therapy, even after a successful atrial fibrillation catheter ablation procedure 10 years ago.

When Bob underwent a cranial MRI, as part of his memory loss work up, he was found to have many cerebral microbleeds. The neurologist suspected that his early dementia was from these many cerebral microbleeds. Could it be that this was an iatrogenic case of dementia? Was his 10 years of anticoagulant use for atrial fibrillation the cause of his dementia?

What are cerebral mircrobleeds?

Cerebral microbleeds can be seen on MRI and may start in midlife and increase over time. In fact, 6.5% of all people age 45-50 have cerebral microbleeds. This number increases to 36% by age 80.

As you might imagine, antiplatelet therapy and anticoagulation therapy both significantly increase the risk of cerebral microbleeds. These microbleeds are likewise associated with dementia.

New Atrial Fibrillation Guidelines

The new atrial fibrillation (AF) guidelines have just come out in the United States. As part of these new guidelines, we have now adopted the CHADS-VASC scoring system to determine which patients require life-long anticoagulation therapy. While the data are very robust for AF stroke prevention with anticoagulation therapy, none of these major studies have reported the accompanying cerebral microbleed risk.

These new guidelines now call for many more new people to be on anticoagulation therapy. This is especially true for women.

Are we too focused on the short term stroke prevention in AF patients, particularly with women, that we fail to take into account the long-term risks that the patient may face including cerebral microbleeds from anticoagulation therapy? For the higher CHADS-VASC scores, life-long anticoagulation therapy makes sense. What about the 35 year old woman with borderline hypertension and only one AF recurrence each year? Should she now take anticoagulants for the rest of her life even if she has had a successful ablation?

Low Long-Term Stroke Risk Following AF Ablation at Experienced Centers

Many centers have now reported that the long-term stroke risk following AF catheter ablation is very low. Is there a bias in which patients are selected for AF ablation to explain these results or could it be that ablation reduces the total arrhythmia burden or converts recurrences to more organized rhythms, such as an atrial tachycardia, with a lower stroke risk? Regardless, the effect of AF ablation still has not been recognized in the latest guideline.

Somehow I think we have lost sight of the total picture with the new AF management guidelines. In my mind, I am not convinced that the long-term stroke risk of a CHADS-VASC score of 1 or 2 (depending on which risk factors are present) justifies all of the risks of life-long anticoagulation therapy, particularly if the patient has had a successful ablation procedure.

Left Atrial Appendage Management

It is with this in mind that I am particularly pleased that we have an excellent review article on left atrial appendage management by Drs. Jorge Romero, Luigi Di Biase, and Andrea Natale. This form of therapy is emerging as an excellent option for decreasing the risk of stroke without all of the potential bleeding complications associated with life-long anticoagulation therapy. It is my hope that the Watchman will be FDA approved by the time this issue of the Journal is published!

The beauty of left atrial appendage management is that it allows for focused therapy in AF stroke prevention rather than exposing the patient to the systemic risk of anticoagulation therapy. Once this therapy is finally approved, it will be interesting to see how it is combined with AF ablation. I can certainly imagine seeing us ablating AF and closing the appendage all in the same procedure.

What do you think? Do the new AF guidelines get the AF anticoagulation issue right? Will you be occluding the left atrial appendage at the time of AF ablation once the Watchman is approved?

Three Difficult Case Presentations

I am also very pleased to share three excellent case reports in this issue of the Journal. These case reports will answer these three difficult clinical questions.

1. How would you approach cardiac resynchronization therapy in a patient with a persistent left subclavian vein?

2. Would you take any special precautions to prevent embolization when extracting leads in a patient with an atrial septal defect?

3. Would you reimplant a pacemaker in an unstable psychiatric patient with complete heart block who purposely destroyed their own pacemaker through chest wall trauma?

Lastly, We are pleased to announce that Dr. Rahul Doshi will be our new Atrial Fibrillation Section Editor. I have known Dr. Doshi since we met during my fellowship days 15 years ago. It has been a joy to watch his career develop over the years and he will certainly be a tremendous addition to the Journal. Welcome aboard Dr. Doshi!

I hope that this issue of the Journal continues to help you in your management of patients with cardiac rhythm challenges. Thank you for being a loyal reader and I look forward to seeing you again with our next issue of the Journal.

Warm regards,

John D. Day, MD, FHRS, FACC
Editor-in-Chief
The Journal of Innovations in Cardiac Rhythm Management
JDay@InnovationsInCRM.com
Director of Heart Rhythm Services
Intermountain Medical Center
Salt Lake City, UT