On 2014 Mar 10, Gaetano Santulli commented:

Dr. Marrouche and colleagues (1) found in their elegant study that left atrial fibrosis, quantified by delayed enhancement magnetic resonance imaging (DE-MRI) is independently associated with likelihood of recurrent arrhythmia in patients with atrial fibrillation (AF) undergoing catheter ablation. Their results also reveal that a hypertensive state was significantly associated with the amount of atrial fibrosis. The potential explanations reported by the Authors to discuss the relationship between hypertension and atrial fibrosis appear not completely satisfactory. Indeed, the Authors considered the hypertensive disease just as a discreet, not continue, variable, defined as systolic blood pressure > 160 mmHg, without providing any information on the pharmacological regimen of the enrolled patients. Given the acknowledged functional role of specific anti-hypertensive drugs, including angiotensin converting enzyme inhibitors and angiotensin receptor blockers, in preventing atrial electrical and structural remodelling (2), it would be of interest to see the results of their analysis conducted considering these parameters. It also would be interesting to know the influence of statins or polyunsaturated fatty acids (3), since the Authors show that 30% of their patients had dyslipidemia. Lastly, several studies demonstrated that patients with AF display a reverse atrial remodelling at 1-year follow up after ablation, evaluated via ultrasound analysis or through inflammatory markers, collagen turnover, and natriuretic peptides (4). Do the Authors have any data on atrial remodelling?

Conflict of Interest Disclosures: None.

References 1. Marrouche NF, Wilber D, Hindricks G, et al. Association of atrial tissue fibrosis identified by delayed enhancement MRI and atrial fibrillation catheter ablation: the DECAAF study. JAMA. Feb 5 2014;311(5):498-506. 2. Ehrlich JR, Hohnloser SH, Nattel S. Role of angiotensin system and effects of its inhibition in atrial fibrillation: clinical and experimental evidence. European heart journal. Mar 2006;27(5):512-518. 3. Savelieva I, Camm J. Statins and polyunsaturated fatty acids for treatment of atrial fibrillation. Nature clinical practice. Cardiovascular medicine. Jan 2008;5(1):30-41. 4. Reant P, Lafitte S, Jais P, et al. Reverse remodeling of the left cardiac chambers after catheter ablation after 1 year in a series of patients with isolated atrial fibrillation. Circulation. Nov 8 2005;112(19):2896-2903.

Celestino Sardu, MD (¹), Gaetano Santulli, MD, PhD,(²) ¹Second University of Naples, Naples, Italy; ²Columbia University, New York, NY, USA

On 2014 Mar 10, Gaetano Santulli commented:

Dr. Marrouche and colleagues (1) found in their elegant study that left atrial fibrosis, quantified by delayed enhancement magnetic resonance imaging (DE-MRI) is independently associated with likelihood of recurrent arrhythmia in patients with atrial fibrillation (AF) undergoing catheter ablation. Their results also reveal that a hypertensive state was significantly associated with the amount of atrial fibrosis. The potential explanations reported by the Authors to discuss the relationship between hypertension and atrial fibrosis appear not completely satisfactory. Indeed, the Authors considered the hypertensive disease just as a discreet, not continue, variable, defined as systolic blood pressure > 160 mmHg, without providing any information on the pharmacological regimen of the enrolled patients. Given the acknowledged functional role of specific anti-hypertensive drugs, including angiotensin converting enzyme inhibitors and angiotensin receptor blockers, in preventing atrial electrical and structural remodelling (2), it would be of interest to see the results of their analysis conducted considering these parameters. It also would be interesting to know the influence of statins or polyunsaturated fatty acids (3), since the Authors show that 30% of their patients had dyslipidemia. Lastly, several studies demonstrated that patients with AF display a reverse atrial remodelling at 1-year follow up after ablation, evaluated via ultrasound analysis or through inflammatory markers, collagen turnover, and natriuretic peptides (4). Do the Authors have any data on atrial remodelling?

Conflict of Interest Disclosures: None.

References 1. Marrouche NF, Wilber D, Hindricks G, et al. Association of atrial tissue fibrosis identified by delayed enhancement MRI and atrial fibrillation catheter ablation: the DECAAF study. JAMA. Feb 5 2014;311(5):498-506. 2. Ehrlich JR, Hohnloser SH, Nattel S. Role of angiotensin system and effects of its inhibition in atrial fibrillation: clinical and experimental evidence. European heart journal. Mar 2006;27(5):512-518. 3. Savelieva I, Camm J. Statins and polyunsaturated fatty acids for treatment of atrial fibrillation. Nature clinical practice. Cardiovascular medicine. Jan 2008;5(1):30-41. 4. Reant P, Lafitte S, Jais P, et al. Reverse remodeling of the left cardiac chambers after catheter ablation after 1 year in a series of patients with isolated atrial fibrillation. Circulation. Nov 8 2005;112(19):2896-2903.

Celestino Sardu, MD (¹), Gaetano Santulli, MD, PhD,(²) ¹Second University of Naples, Naples, Italy; ²Columbia University, New York, NY, USA