Book Review

Atrial Fibrillation: From Bench to Bedside

N Engl J Med 2008; 359:1190-1191September 11, 2008

Article

Atrial Fibrillation: From Bench to Bedside
(Contemporary Cardiology.) Edited by Andrea Natale and José Jalife. 453 pp., illustrated. Totowa, NJ, Humana Press, 2008. $99.50. ISBN: 978-1-58829-856-0

Atrial fibrillation has become the focus of intense investigation over the past several years, owing to its clinical importance, an increased understanding of its pathophysiology, and the development of new therapies. Andrea Natale and José Jalife, leaders in clinical investigation and basic investigation, respectively, have assembled in this book an important snapshot of current advances in the field, drawing on many experts who have a true “bench to bedside” perspective.

The use of ablation in the treatment of atrial fibrillation has captured the greatest attention in journals and at national meetings, and it is a major focus of this book. However, the first half of the book is devoted to important noninterventional concerns. It opens with excellent discussions of epidemiology, the economic burden to society, and the cost-effectiveness of various strategies for the treatment of atrial fibrillation.

The seven chapters on the pathophysiology, molecular mechanisms, and genetics of atrial fibrillation are especially strong. The phenomenon of electrical remodeling is recognized as resulting from, and perpetuating, atrial fibrillation; this important topic is addressed in multiple complementary chapters. Two chapters that overlap substantially (in contrast with other chapters) discuss the genetics of atrial fibrillation from basic and clinical perspectives. Despite the current enthusiasm for ablation, many patients still receive medical therapy and will continue to require such treatment. Chapter 11, “Review of Recent Trials of Medical Therapy for Atrial Fibrillation,” goes far beyond its stated title, providing comprehensive tabular listings of indications and properties of pharmaceutical agents. The chapter discussing the current role of medical therapy also addresses drug options. Although the development of antiarrhythmic agents for the treatment of atrial fibrillation is briefly considered here and in other chapters, the editors might have considered a separate chapter specifically dedicated to this topic.

The dominant section of the book tackles invasive therapy and opens with an outstanding treatise on applied cardiac anatomy. (The color graphics used throughout the book are especially valuable, including excellent anatomical photographs and illustrations.) This section serves as a nice complement to the chapters that follow, which discuss the fundamentals of ablation: catheters, energy sources, and power delivery.

Four chapters explain techniques for catheter-based ablation. Consistent with the nascent condition of this discipline, the strategies discussed in these chapters sometimes corroborate and sometimes contradict each other. In each case, however, the descriptions and figures are of a high quality. Natale and colleagues, in chapter 18, synthesize alternative strategies and describe the potential for hybrid techniques that draw from two or more approaches.

The first invasive treatment for atrial fibrillation was the surgical “maze,” and the role of surgery as a stand-alone therapy or as a complement to other options continues to evolve. Surgical techniques, including traditional epicardial maze-type procedures, epicardial surgery, and minimally invasive approaches, are described in separate chapters by leaders in the field.

The book appropriately addresses complications of catheter ablation. One chapter, devoted exclusively to the issues surrounding pulmonary-vein stenosis, includes a synthesis of published literature and new observations. A broader description of complications is offered elsewhere in the book, but in combination with a discussion of the definition of successful treatment. The book might have benefited from expanded coverage of these important topics as well as a separate analysis of the definition of ablation success. The definition of successful treatment is not as simple as an absence of symptoms, because asymptomatic, or silent, atrial fibrillation affects patients before and after ablation. Even success, as some have defined it, may require a second procedure; in a later section of the book, one chapter addresses catheter ablation of left atrial flutter, an important and common complication of ablation for atrial fibrillation.

It is anticipated that future techniques for catheter ablation will be even safer and more effective. The chapters on imaging and evolving technologies provide a glimpse of investigational options. Especially intriguing are new balloon procedures, which include the cryothermal balloon catheter, the high-intensity focused ultrasound balloon catheter, and laser ablation.

I congratulate the editors for a timely and important book. The contributors are leaders in their fields, the chapters are exhaustively referenced, and the graphics are outstanding. Although this book may appeal primarily to the interventional clinical cardiac electrophysiologist, it would be a worthwhile investment for the surgeon, internist, or cardiologist with an interest in this rapidly evolving and important topic.

Richard L. Page, M.D.
University of Washington School of Medicine, Seattle, WA 98195
rpage@u.washington.edu