IC: Do you think that the debate between rhythm and rate control will change in the future?
　　《国际循环》：你认为未来在节律控制和心率控制之间的争论会有所改变吗?
　　Dr. Valderrabanno: I think the debate has been taken out-of-context. The data from the AFFIRM trail， where they compared rate versus rhythm control， has been misunderstood. If you asked a hundred electrophysiologists whether they preferred to control sinus rhythm or AF， a 100 of them would say rhythm. AFFRIM showed this in a post-hoc analysis. Patients in AFFIRM that happened to be in sinus rhythm had half the morality. We know that sinus rhythm is better. However， the tools we have to achieve this are horrible， especially the drugs. If the CABANA trial shows that ablation can reduce risk of stroke and improve overall mortality， then that will settle the debate. There are two interesting studies， one of which was published the NEJM by Natales group CHF (?) study that took patients with HF and AF. They did the most aggressive rhythm control—which is ablation—and the most aggressive rate control—AV node ablation and biventricular pacemaker implant. These were high-risk patients with low ejection fraction. The ejection fraction increase in those that had a rhythm control ablation. It was too small to look at mortality， but that may be the way to go. You have to deliver the ablation in a safe way and this is a complex procedure with more risks than we like to admit. However， if it works， we may be able to avoid the toxic effects of a drug.
　　Valderrabanno博士:我认为这种辩论被断章取义。来自AFFIRM试验中比较节律控制和心率控制的数据被误解了。如果你问一百个电生理学家，他们是更倾向于转复窦性心律还是维持房颤心律，100人都会说维持窦律。AFFRIM试验析因分析中，窦性心律的患者碰巧有着半数的死亡率。我们知道窦性节律是更好的，然而用来实现窦律的工具很可怕，尤其是药物。如果CABANA试验表明消融可以降低卒中风险和死亡率，那么这将平息这场争论。有两个有趣的研究，其中一个是由Natales小组在NEJM上发表的研究，入选心力衰竭合并房颤的患者，进行最激进的节律控制治疗——导管消融，以及最激进的心率控制治疗——房室结消融和双心室起搏器植入，在这些低射血分数的高危患者中，进行导管消融的节律控制治疗组患者的射血分数升高。虽然该研究的样本量太小，无法评估死亡率，但这可能是将来要走的路。我们必须使用安全的方法进行导管消融，因为这是一个复杂的过程，并且风险远大于我们所愿意承认的范围。然而，如果它确实有效，也许能够使我们避免药物的毒性作用。