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Introduction: Patients with atrial fibrillation (AF) and concomitant moderate-to-severe mitral stenosis (MS) are listed as a contraindicated population to direct oral anticoagulant (DOAC) because of the traditional tenet of high stroke risk, despite scarce evidence. With accumulating data, we sought to conduct a systematic meta-analysis to preliminarily explore the efficacy and safety of DOAC versus warfarin in patients with AF and concomitant significant MS., Methods: We searched the Medline, Embase databases, and the Cochrane Library (assessed October 10th, 2022) for eligible studies. Risk ratios (RRs) and 95% confidence intervals (CIs) were synthesized in Stata 16.1 (StataCorp)., Results: In random-effects meta-analyses, DOACs demonstrated a similar risk of stroke or systemic embolism (RR 0.51; 95% CI 0.09-2.96), all-cause death (RR 0.81; 95% CI 0.35-1.87), major or clinically relevant non-major bleeding (RR 0.57; 95% CI 0.24-1.39), and silent cerebral ischemia (RR 1.01; 95% CI 0.64-1.58) when compared with warfarin., Conclusions: DOACs were similar to warfarin in the efficacy and safety profiles in patients with AF and concomitant significant MS. Future evidence is expected from other large trials., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Stroke and thromboembolism in nonvalvular atrial fibrillation (NVAF) primarily arise from thrombi or sludge in the left atrial appendage (LAA). Comprehensive insight into the characteristics of these formations is essential for effective risk assessment and management., Methods: We conducted a single-center retrospective observational of 176 consecutive NVAF patients with confirmed atrial/appendage thrombus or sludge determined by a pre-ablation transesophageal echocardiogram (TEE) from December 2017 to April 2019. We obtained clinical and echocardiographic characteristics, including left atrial appendage emptying velocity (LAAeV) and filling velocity (LAAfV). Data analysis focused on identifying the morphology and location of thrombus or sludge. Patients were divided into the solid thrombus and sludge groups, and the correlation between clinical and echocardiographic variables and thrombotic status was analyzed., Results: Morphological classification: In total, thrombi were identified in 78 patients, including 71 (40.3%) mass and 7 (4.0%) lamellar, while sludge was noted in 98 (55.7%). Location classification: 92.3% (72/78) of patients had thrombus confined to the LAA; 3.8% (3/78) had both LA and LAA involvement; 2.7% (2/78) had LA, LAA and RAA extended into the RA, the remained 1.2%(1/78) was isolated to RAA. 98.0% (96/98) of patients had sludge confined to the LAA; the remaining 2.0% (2/98) were present in the atrial septal aneurysm, which protrusion of interatrial septum into the RA. The thrombus and sludge groups showed low LAAeV (19.43 ± 9.59 cm/s) or LAAfV (17.40 ± 10.09 cm/s). Only LA dimension ≥ 40 mm was independently associated with the thrombus state in the multivariable model., Conclusion: This cohort study identified rare thrombus morphology and systematically summarized the classification of thrombus morphology. The distribution of thrombus and sludge outside limited to LAA was updated, including bilateral atrial and appendage involvement and rare atrial septal aneurysm sludge. LAAeV and LAAfV were of limited value in distinguishing solid thrombus from sludge., Clinical Trial Number: ChiCTR-OCH-13,003,729., (© 2024. The Author(s).)

Background: Left bundle branch block (LBBB) and atrial fibrillation (AF) are commonly coexisting conditions. The impact of LBBB on catheter ablation of AF has not been well determined. This study aims to explore the long-term outcomes of patients with AF and LBBB after catheter ablation., Methods: Forty-two patients with LBBB of 11,752 patients who underwent catheter ablation of AF from 2011 to 2020 were enrolled as LBBB group. After propensity score matching in a 1:4 ratio, 168 AF patients without LBBB were enrolled as non-LBBB group. Late recurrence and a composite endpoint of stroke, all-cause mortality, and cardiovascular hospitalization were compared between the two groups., Results: Late recurrence rate was significantly higher in the LBBB group than that in the non-LBBB group (54.8% vs. 31.5%, p = .034). Multivariate analysis showed that LBBB was an independent risk factor for late recurrence after catheter ablation of AF (hazard ratio [HR] 2.19, 95% confidence interval [CI] 1.09-4.40, p = .031). LBBB group was also associated with a significantly higher incidence of the composite endpoint (21.4% vs. 6.5%, HR 3.98, 95% CI 1.64-9.64, p = .002)., Conclusions: LBBB was associated with a higher risk for late recurrence and a higher incidence of composite endpoint in the patients underwent catheter ablation., (© 2024 Wiley Periodicals LLC.)

Background: Atrial fibrillation (AF) has been linked to an increased risk of cardiovascular death, overall mortality and heart failure in patients with type 2 diabetes mellitus (T2DM). The present study investigated the additive effects of paroxysmal AF on left ventricular (LV) function and deformation in T2DM patients with or without AF using the cardiovascular magnetic resonance feature tracking (CMR-FT) technique., Methods: The present study encompassed 225 T2DM patients differentiated by the presence or absence of paroxysmal AF [T2DM(AF+) and T2DM(AF-), respectively], along with 75 age and sex matched controls, all of whom underwent CMR examination. LV function and global strains, including radial, circumferential and longitudinal peak strain (PS), as well as peak systolic and diastolic strain rates (PSSR and PDSR, respectively), were measured and compared among the groups. Multivariable linear regression analysis was used to examine the factors associated with LV global strains in patients with T2DM., Results: The T2DM(AF+) group was the oldest, had the highest LV end‑systolic volume index, lowest LV ejection fraction and estimated glomerular filtration rate compared to the control and T2DM(AF-) groups, and presented a shorter diabetes duration and lower HbA1c than the T2DM(AF-) group. LV PS-radial, PS-longitudinal and PDSR-radial declined successively from controls through the T2DM(AF-) group to the T2DM(AF+) group (all p < 0.001). Compared to the control group, LV PS-circumferential, PSSR-radial and PDSR-circumferential were decreased in the T2DM(AF+) group (all p < 0.001) but preserved in the T2DM(AF-) group. Among all clinical indices, AF was independently associated with worsening LV PS-longitudinal (β = 2.218, p < 0.001), PS-circumferential (β = 3.948, p < 0.001), PS-radial (β = - 8.40, p < 0.001), PSSR-radial and -circumferential (β = - 0.345 and 0.101, p = 0.002 and 0.014, respectively), PDSR-radial and -circumferential (β = 0.359 and - 0.14, p = 0.022 and 0.003, respectively)., Conclusions: In patients with T2DM, the presence of paroxysmal AF further exacerbates LV function and deformation. Proactive prevention, regular detection and early intervention of AF could potentially benefit T2DM patients., (© 2024. The Author(s).)

Meticulous understanding of the mechanisms underpinning mitral regurgitation in atrial fibrillation (AF) patients is crucial to optimize therapeutic strategies. The morphologic characteristics of mitral valves in atrial functional mitral regurgitation (FMR) patients with and without left ventricular (LV) dysfunction were evaluated by high volume rate (HVR) three-dimensional transesophageal echocardiography (3D-TEE). In our study, 68 of 265 AF patients who underwent 3D-TEE were selected, including 36 patients with AF, FMR, and preserved LV function (AFMR group) and 32 patients with AF, FMR, and LV dysfunction (VFMR group). In addition, 36 fever patients without heart disease were included in the control group. Group comparisons were performed by one-way analysis of variance for continuous variables. The left atrium (LA) was enlarged in the AFMR and VFMR groups compared with the control group. The mitral annulus (MA) in the AFMR group was enlarged and flattened compared with the control group and was smaller than in the VFMR group. The annulus area fraction was significantly diminished in the AFMR and VFMR groups, indicative of reduced MA contractility. The posterior mitral leaflet (PML) angle was smallest in the AFMR group and largest in the control group, whereas the distal anterior mitral leaflet angle did not significantly differ among the three groups. LA remodeling causes expansion of the MA and reduced MA contractility, disruption of the annular saddle shape, and atriogenic PML tethering. Comparison of atrial FMR patients with and without LV dysfunction indicates that atriogenic PML tethering is an important factor that aggravates FMR. HVR 3D-TEE improves the 3D temporal resolution greatly., (© 2023. The Author(s).)

Aims: The clinical correlates and outcomes of asymptomatic atrial fibrillation (AF) in hospitalized patients are largely unknown. We aimed to investigate the clinical correlates and in-hospital outcomes of asymptomatic AF in hospitalized Chinese patients., Methods and Results: We conducted a cross-sectional registry study of inpatients with AF enrolled in the Improving Care for Cardiovascular Disease in China-Atrial Fibrillation Project between February 2015 and December 2019. We investigated the clinical characteristics of asymptomatic AF and the association between the clinical correlates and the in-hospital outcomes of asymptomatic AF. Asymptomatic and symptomatic AF were defined according to the European Heart Rhythm Association score. Asymptomatic patients were more commonly males (56.3%) and had more comorbidities such as hypertension (57.4%), diabetes mellitus (18.6%), peripheral artery disease (PAD; 2.3%), coronary artery disease (55.5%), previous history of stroke/transient ischaemic attack (TIA; 17.9%), and myocardial infarction (MI; 5.4%); however, they had less prevalent heart failure (9.6%) or left ventricular ejection fractions ≤40% (7.3%). Asymptomatic patients were more often hospitalized with a non-AF diagnosis as the main diagnosis and were more commonly first diagnosed with AF (23.9%) and long-standing persistent/permanent AF (17.0%). The independent determinants of asymptomatic presentation were male sex, long-standing persistent AF/permanent AF, previous history of stroke/TIA, MI, PAD, and previous treatment with anti-platelet drugs. The incidence of in-hospital clinical events such as all-cause death, ischaemic stroke/TIA, and acute coronary syndrome (ACS) was higher in asymptomatic patients than in symptomatic patients, and asymptomatic clinical status was an independent risk factor for in-hospital all-cause death, ischaemic stroke/TIA, and ACS., Conclusion: Asymptomatic AF is common among hospitalized patients with AF. Asymptomatic clinical status is associated with male sex, comorbidities, and a higher risk of in-hospital outcomes. The adoption of effective management strategies for patients with AF should not be solely based on clinical symptoms., Competing Interests: Conflict of interest: None declared., (© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.)

Background: Due to the anatomically adjacent relationship between the left atrium (LA) and esophagus, energy delivery on the posterior wall of LA is limited. The aim of this study was to evaluate the feasibility of a novel esophageal retractor (SAFER) with an inflatable C-curve balloon during atrial fibrillation (AF) ablation., Method: Nine patients underwent AF ablation assisted with the SAFER. After inflation, the esophagus was deviated laterally away from the intended ablation site of the posterior wall under local anesthesia. The extent of mechanical esophageal deviation (MED) was evaluated under fluoroscopy, defined as the shortest distance from the trailing esophageal edge to the closest point of the ablation line. Gastroscopy was performed before and after ablation. The target ablation index used in all LA sites including the posterior wall was 400-450 after effective MED. All adverse events during the periprocedural period were recorded., Results: The mean deviation distance achieved 16.2 ± 9.6 mm away from the closest ablation point of the pulmonary vein lesion set. With respect to the individual left and right pulmonary vein lesion sets, the deviation distance was 19.7 ± 11.5 and 12.7 ± 6.8 mm, respectively. The extent of deviation was 0 to 5 mm, 5.1 to 10 mm, or >10 mm in 0(0%), 7(38.9%), and 11(61.1%), respectively. Procedural success was achieved in all patients without acute reconnection. There was only one esophageal complication which manifested as esophageal erosion and this patient experienced throat pain possibly related to the SAFER retractor with no clinical sequelae., Conclusion: Esophageal deviation with the novel eccentric balloon is a novel feasible choice during AF ablation, enabling adequate energy delivery to the posterior wall of LA. Additional prospective randomized controlled studies are required for further validation., (© 2023 Wiley Periodicals LLC.)

Objective: Type 2 diabetes mellitus (T2DM) and anemia are related to some cardiovascular diseases and can predict poor outcomes. Both of them can damage the heart in their own ways, but their combined effects have not been well explored. This study aimed to explore the combined effects of T2DM and anemia and the interaction between left atrial (LA) and left ventricular (LV) function by cardiac magnetic resonance (CMR)., Materials and Methods: A total of 177 T2DM patients without anemia, 68 T2DM patients with anemia and 73 sex-matched controls were retrospectively enrolled in this study from June 2015 to September 2022. Their LA phasic function and LV function parameters were compared to explore the combined effects of T2DM and anemia and the interaction between LA and LV function. Univariate and multivariate linear regression were done to explore the independent factors influencing LA phasic function and LV function., Results: Compared with controls and T2DM patients without anemia, T2DM patients with anemia were older and had higher heart rate, higher creatinine, lower estimated glomerular filtration rate (eGFR) and lower hemoglobin (Hb) (all p < 0.05). LV global longitudinal peak strain (GLPS) significantly declined from T2DM patients with anemia to T2DM patients without anemia to controls (p < 0.001). LA volumetric function and strain were significantly impaired in T2DM patients with anemia compared with the other groups (all p < 0.05). In addition to age, eGFR, Hb and HbA1c, the LV GLPS was independently associated with all LA phasic strains (LA reservoir strain, β =0.465; LA conduit strain, β = 0.450; LA pump strain, β = 0.360, all p < 0.05). LA global conduit strain, total LA ejection fraction (LAEF) and active LAEF were independently associated with LV GLPS and LVEF., Conclusion: Both LA and LV function were severely impaired in T2DM patients with anemia, and T2DM and anemia were independently associated with LA phasic function. Deleterious interaction between LA function and LV function would happen in T2DM patients with or without anemia. Timely and effective monitoring and management of both LA and LV function will benefit T2DM patients., (© 2023. The Author(s).)

Background: Evidence on outcomes of catheter ablation (CA) for atrial fibrillation (AF) in patients with autoimmune disease (AD) is limited., Hypothesis: Patients with AD had worse outcomes after CA procedures for AF., Methods: A retrospective analysis was performed in patients undergoing AF ablation between 2012 and 2021. The risk of recurrence after ablation was investigated in patients with AD and a 1:4 propensity score matched non-AD group., Results: We identified 107 patients with AD (64 ± 10 years, female 48.6%) who were matched with 428 non-AD patients (65 ± 10 years, female 43.9%). Patients with AD exhibited more severe AF-related symptoms. During the index procedure, a higher proportion of AD patients received nonpulmonary vein trigger ablation (18.7% vs. 8.4%, p = 0.002). Over a median follow-up of 36.3 months, patients with AD experienced a similar risk of recurrence with the non-AD group (41.1% vs. 36.2%, p = 0.21, hazard ratio [HR]: 1.23, 95% confidence interval [CI]: 0.86-1.76) despite a higher incidence of early recurrences (36.4% vs. 13.5%, p = 0.001). Compared with non-AD patients, patients with connective tissue disease were at an increased risk of recurrence (46.3% vs. 36.2%, p = 0.049, HR: 1.43, 95% CI: 1.00-2.05). Multivariate Cox regression analysis showed that the duration of AF history and corticosteroid therapy were independent predictors of postablation recurrence in patients with AD., Conclusions: In patients with AD, the risk of recurrence after ablation for AF during the follow-up was comparable with non-AD patients, but a higher risk of early recurrence was observed. Further research into the impact of AD on AF treatment is warranted., (© 2023 The Authors. Clinical Cardiology published by Wiley Periodicals LLC.)

Background: The relative effectiveness of anticoagulation agents in patients with atrial fibrillation (AF) who survive an intracranial hemorrhage (ICH) is unknown. This study was performed to examine the comparative effectiveness of different oral anticoagulation (OAC) on clinical outcomes in this group of patients., Methods: We performed a Bayesian network meta-analysis of randomized controlled trials (RCTs) and observational studies comparing different OAC (direct oral anticoagulant [DOAC] and warfarin) for the treatment of patients with AF who sustained ICH. Outcomes included repeat ICH, thromboembolic events, and all-cause mortality. The values derived from the surface under the cumulative ranking curve were obtained to rank the treatment hierarchy., Results: We identified 12 studies (two RCTs and ten observational studies) involving 23,265 patients; 346 patients were treated with any OAC agents; 5,006 received DOAC; 5,271 received warfarin; 12,007 received antiplatelet or no therapy, and 635 did not received relevant therapy. Both DOAC and warfarin (RR, 0.58; 95% CI, 0.45-0.74; RR, 0.83; 95% CI, 0.69-0.98) were superior to antiplatelet or no therapy in preventing thromboembolic events. Moreover, DOAC also showed superiority in preventing thromboembolic events (RR, 0.70; 95% CI, 0.58-0.83), repeat ICH (RR, 0.52; 95% CI, 0.40-0.67), and all-cause mortality (RR, 0.51; 95% CI, 0.46-0.56) than warfarin., Conclusions: Our study suggests DOACs may be a reasonable alternative to anti-platelet therapy and warfarin for patients with AF who experienced ICH. However, given the available evidence is primarily observational, further validation by ongoing trials directly comparing these two classes of drugs are needed., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: In randomized studies, the strategy of pulmonary vein antral isolation (PVI) plus linear ablation has failed to increase success rates for persistent atrial fibrillation (PeAF) ablation when compared with PVI alone. Peri-mitral reentry related atrial tachycardia due to incomplete linear block is an important cause of clinical failures of a first ablation procedure. Ethanol infusion (EI) into the vein of Marshall (EI-VOM) has been demonstrated to facilitate a durable mitral isthmus linear lesion., Objective: This trial is designed to compare arrhythmia-free survival between PVI and an ablation strategy termed upgraded '2C3L' for the ablation of PeAF., Study Design: The PROMPT-AF study (clinicaltrials.gov 04497376) is a prospective, multicenter, open-label, randomized trial using a 1:1 parallel-control approach. Patients (n = 498) undergoing their first catheter ablation of PeAF will be randomized to either the upgraded '2C3L' arm or PVI arm in a 1:1 fashion. The upgraded '2C3L' technique is a fixed ablation approach consisting of EI-VOM, bilateral circumferential PVI, and 3 linear ablation lesion sets across the mitral isthmus, left atrial roof, and cavotricuspid isthmus. The follow-up duration is 12 months. The primary end point is freedom from atrial arrhythmias of >30 seconds, without antiarrhythmic drugs, in 12 months after the index ablation procedure (excluding a blanking period of 3 months)., Conclusions: The PROMPT-AF study will evaluate the efficacy of the fixed '2C3L' approach in conjunction with EI-VOM, compared with PVI alone, in patients with PeAF undergoing de novo ablation., Competing Interests: Conflict of interest None reported., (Copyright © 2023 The Author(s). Published by Elsevier Inc. All rights reserved.)

BACKGROUND Thyroid dysfunction has been proved to contribute to the occurrence of atrial fibrillation (AF), leading to the development of AF in animal models and clinical populations. This single-center study investigated the relationship between ultra-sensitive thyroid-stimulating hormone (uTSH) levels and the recurrence of atrial fibrillation (AF) in 575 hospitalized patients who had undergone catheter ablation. MATERIAL AND METHODS The study enrolled 575 hospitalized patients with AF who needed catheter ablation, 105 were non-first catheter ablation patients, and 470 were first catheter ablation (CA) patients. Before ablation, fasting biochemical indexes, including uTSH, were detected. Patients were classified according to uTSH quartile. The presence of AF was confirmed by 12-lead electrocardiogram or 24-h ambulatory electrocardiogram. RESULTS A total of 105 (18.44%) patients had undergone catheter ablation of AF twice or more. Univariate logistic regression analysis showed no significant relationship between uTSH and AF recurrence (HR, 1.047; 95% CI 0.986-1.111; P=1.127). Multivariate logistic regression analysis indicated that compared with low quartiles (Q1 OR, 0.71, 95% CI: 0.35-1.46; P=0.36; Q2 OR 0.71, 95% CI 0.36-1.39; P=0.31;Q3 OR 0.22, 95% CI 0.09-0.53; P=0.001), high quartiles of uTSH had a higher risk of AF recurrence. After adjusting for sex, the risk of AF recurrence in the high quartile uTSH was higher in males than in the low quartile (Q1 OR, 0.60, 95% CI: 0.29-1.26; P=0.18;Q2 OR, 0.52, 95% CI, 0.24-1.13; P=0.09;Q3 OR, 0.42, 95% CI, 0.18-0.94; P=0.03), but not in women. CONCLUSIONS Serum TSH levels in male patients treated for AF with cardiac ablation were significantly associated with AF recurrence.

BACKGROUND This study from a single center in Beijing, China, included 412 patients with atrial fibrillation (AF) who underwent radiofrequency catheter ablation. We aimed to determine whether pre-ablation serum lipid levels were related to recurrence of atrial fibrillation (RAF). MATERIAL AND METHODS A total of 412 patients with AF who underwent radiofrequency catheter ablation were enrolled in the study. Fasting levels of triglycerides (TG), high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C) and total cholesterol (TC), were measured at baseline before ablation, and patients were classified according to lipid level quartiles (Q1-Q4). RAF was affirmed via 24-h electrocardiography or 12-lead electrocardiography. RESULTS A total of 82 (19.90%) patients experienced RAF. After adjusting for other relevant factors and sex, univariate logistic regression analysis revealed LDL-C (hazard ratio [HR], 1.17; 95% confidence interval [CI], 0.93-1.47) and TC (HR, 1.17; 95% CI, 0.96-1.42) levels were not significantly related to RAF. Multivariate logistic regression analysis revealed that, compared with the highest quartile (Q4), female patients with lower quartiles of TC had higher RAF, especially Q3 (HR, 16.24; 95% CI, 1.14-231.56). LDL-C levels were higher in Q1 than in Q4 but lower in Q2 and Q3 than in Q4 (Q1: HR, 1.34; 95% CI, 0.08-18.89; Q2: HR, 0.09, 95% CI, 0.06-1.52; Q3: HR, 0.02, 95% CI, 0.14-0.57). CONCLUSIONS This study showed RAF in almost 20% of treated patients and RAF was significantly related to pre-ablation serum levels of LDL-C and TC in women.

Background: Perimitral atrial tachycardia (PMAT) is the most frequent type of iatrogenic atrial tachycardia (AT) after atrial fibrillation (AF) ablation. Vein of Marshall ethanol infusion (EIVOM) is a promising technique in mitral isthmus (MI) ablation., Methods: A total of 165 patients with PMAT were divided into three groups according to ablation strategies, including RF only group (n = 89), RF-EIVOM group (initial RF ablation with adjunctive EIVOM, n = 28), and EIVOM-RF group (first-step EIVOM with touch-up RF ablation, n = 48). Acute and follow-up procedure outcomes were evaluated., Results: PMAT terminated in 89.9%, 89.3%, and 93.7% of patients in RF only, RF-EIVOM and EIVOM-RF groups, respectively (p = .715), with complete MI block achieved in 80.9%, 89.3%, and 95.8% of patients (EIVOM-RF vs. RF only, p = .012). First-step utilization of EIVOM was associated with a significant shortening of RF ablation time at MI (EIVOM-RF 2.1 ± 1.3 min, RF only 7.9 ± 5.9 min, RF-EIVOM 6.8 ± 5.8 min; p < .001) and a decrease in the proportion of patients need ablation within coronary sinus (CS, EIVOM-RF 14.6%, RF only 61.8%, RF-EIVOM 64.3%; p < .001). After a mean follow-up of 12.1 ± 6.2 months, AF/AT recurred in 39 (43.8%), 6 (21.4%), and 12 (25.0%) patients in RF only, RF-EIVOM, and EIVOM-RF group (RF-EIVOM vs. RF only, p = .026; EIVOM-RF vs. RF only, p = .022)., Conclusions: EIVOM was associated with an enhanced acute MI block rate as well as reduced AF/AT recurrence. First-step utilization of EIVOM promises to significantly simplify the RF ablation process., Condensed Abstract: PMAT is the most common type of iatrogenic AT after AF ablation procedures. EIVOM contributed to a higher acute MI block rate and lower arrhythmia recurrence risk during follow-up. First-step utilization of EIVOM significantly reduced the need for radiofrequency ablation at MI and inside CS with the advantage of creating a homogenous, transmural lesion and eliminating epicardial connections., (© 2022 Wiley Periodicals LLC.)

Background: Debates exist in the repeat ablation strategy for patients with recurrence presenting as persistent atrial fibrillation (AF) after initial persistent AF ablation., Objective: To compare the outcome between the "2C3L" and "extensive ablation" approach in patients undergoing repeat procedures for recurrent persistent AF., Methods: Propensity-score matching was performed in 196 patients with AF recurrence undergoing repeat ablation, and 79 patients treated with "2C3L" strategy were matched to 79 patients treated with "extensive ablation" strategy. The "2C3L" approach included pulmonary vein isolation, mitral isthmus, left atrial roof, and cavotricuspid isthmus ablation, while the "extensive ablation" strategy included extensive ablation of a variety of other targets aiming to terminate the AF. The primary outcome was freedom from any atrial tachyarrhythmia after 24-h ambulatory monitoring follow-up for 12 months., Results: No statistically significant difference was found between the primary outcome between the "2C3L" and the "extensive ablation" group [70.9% vs. 69.6%, p = .862; 95% confidence interval (CI) -12.8 to 15.3], although the "extensive ablation" group had a significantly high proportion of AF termination (19.0% for "2C3L" vs. 41.8% for "extensive ablation" group, p = .002; 95% CI 8.5-35.9). And AF termination was not related to the primary outcome in multifactorial regression. At 40 ± 22 months after the repeat procedure, the primary outcome was also comparable (57.0 % for "2C3L" vs. 48.1% for "extensive ablation" group, p = .265; 95% CI -6.6 to 23.7)., Conclusion: The outcome between the "2C3L" and "extensive ablation" approaches was comparable in patients undergoing repeat procedures for recurrent persistent AF., (© 2022 Wiley Periodicals LLC.)

Background: Atrial fibrillation (AF) and stable coronary artery disease (SCAD) frequently coexist. This study aimed to assess the long-term outcome of catheter ablation in patients with paroxysmal AF and SCAD., Methods: In total, 12,104 patients with paroxysmal AF underwent catheter ablation in the Chinese Atrial Fibrillation Registry between 2011 and 2019 were screened. A total of 441 patients with SCAD were matched with patients without SCAD in a 1:4 ratio. The primary endpoint was AF recurrence after single ablation. The composite secondary endpoints were thromboembolism, coronary events, major bleeding, all-cause death., Results: Over a mean follow-up of 46.0 ± 18.9 months, the recurrence rate in patients with SCAD was significantly higher after a single ablation (49.0% vs. 41.9%, p = .03). The very late recurrence rate of AF in the SCAD group was also significantly higher than that in the control group (38.9% vs. 31.2%;p = .04). In multivariate analysis, adjusted with the female, smoking, duration of AF, previous thromboembolism, COPD, and statins, SCAD was independently associated with AF recurrence (adjusted HR, 1.19 [1.02-1.40], p = .03). The composite secondary endpoints were significantly higher in the SCAD group (12.70% vs. 8.54%, p = .02), mainly due to thromboembolism events (8.16% vs. 4.41%, p < .01)., Conclusions: SCAD significantly increased the risk of recurrence after catheter ablation of paroxysmal AF. The incidence of thromboembolic events after catheter ablation of paroxysmal AF in the patients with SCAD was significantly higher than that in those without SCAD., (© 2022 Wiley Periodicals LLC.)

BACKGROUND Low-density lipoprotein cholesterol (LDL-C) reduction improves cardiovascular outcomes. This study investigates the relationship between lipid levels and outcomes in patients with nonvalvular atrial fibrillation by LDL-C quarters. MATERIAL AND METHODS Patients with atrial fibrillation were enrolled from 31 typical hospitals in China. Of 19 515 patients, 6775 with nonvalvular atrial fibrillation (NVAF) were followed for 5 years or until an event occurred. RESULTS Hyperlipidemia was not an independent risk factor for stroke/thromboembolism and cardiovascular mortality among patients with NVAF (hazard ratio 0.82, 95% CI 0.7-0.96, P=0.82). When patients were divided into quartiles according to LDL-C levels at the time of enrollment (Q1, <1.95; Q2, 1.95-2.51; Q3, 2.52-3.09; and Q4, >3.09 mmol/L), as LDL-C increased, events tapered off according to Kaplan-Meier curves for patients who were without oral anticoagulants and off statins (non-OAC; log-rank=8.3494, P=0.0393) and for those with oral anticoagulants (OAC; log-rank=6.7668 P=0.0797). This relationship was stronger for patients who were without OAC treatment and off statins than for those with OAC treatment. The relationship was not significant in patients with or without OAC and on statins (log-rank=2.5080, P=0.4738). This relationship also existed in patients with CHA₂DS₂-VASc scores <2 (log-rank=5.893, P=0.1167). For those with CHA2DS2-VASc scores ≥2 (log-rank=6.6163, P=0.0852), the relationship was stronger. CONCLUSIONS In patients with NVAF using standard or no lipid-lowering medication, low plasma LDL-C levels were related to an increased risk of stroke/thromboembolism and cardiovascular mortality.

Objective: To investigate theoptimal idarucizumab (dabigatran antagonist) usage strategy for patients with acute pericardial tamponade receiving uninterrupted dabigatran during catheter ablation for atrial fibrillation (AF)., Methods: Ten patients presenting acute pericardial tamponade while receiving uninterrupted dabigatran during catheter ablation for AF in Beijing Anzhen Hospital from January 2019 to July 2020 were enrolled and retrospectively analyzed. A "wait and see" strategy of idarucizumab was carried out for all patients; in brief, idarucizumab was applied following pericardiocentesis, comprehensive evaluation of bleeding and hemostasis., Results: There were five males, five paroxysmal AF, and the average age of the patients was 64.0 ± 9.8 years. Among the 10 patients, four were treated with dabigatran 110 mg, six were treated with dabigatran 150 mg, and one was simultaneously given clopidogrel. The average time from pericardial tamponade to the last dose of dabigatran was 8.2 ± 3.4 h. All patients underwent pericardiocentesis successfully, and the average drainage volume was 322.5 ml (220.0 ± 935.0 ml). For reversal anticoagulation, six patients received protamine, and five patients received idarucizumab. Of the five patients who were treated with idarucizumab, four presented exact hemostasis, except for one patient who underwent continuous drainage and finally received surgery repair. The average time to restart anticoagulation was 1.1 ± 0.3 days after the procedure, and no rebleeding, embolism or deaths were observed., Conclusion: The "wait and see" strategy of idarucizumab for acute pericardial tamponade during the perioperative period of catheter ablation for AF may be safe and feasible., (© 2021 Wiley Periodicals LLC.)

Background: Atrial fibrillation (AF) and stable coronary artery disease (SCAD) frequently coexist., Hypothesis: To investigate the prognosis of catheter ablation versus drug therapy in patients with AF and SCAD., Methods: In total, 25 512 patients with AF in the Chinese AF Registry between 2011 and 2019 were screened for SCAD. 815 patients with AF and SCAD underwent catheter ablation therapy were matched with patients by drug therapy in a 1:1 ratio. Primary end point was composite of thromboembolism, coronary events, major bleeding, and all-cause death. The secondary endpoints were each component of the primary endpoint and AF recurrence., Results: Over a median follow-up of 45 ± 23 months, the patients in the catheter ablation group had a higher AF recurrence-free rate (53.50% vs. 18.41%, p < .01). In multivariate analysis, there was no significant difference between the strategy of catheter ablation and drug therapy in primary composite end point (adjusted HR 074, 95%CI 0.54-1.002, p = .0519). However, catheter ablation was associated with fewer all-cause death independently (adjusted HR 0.36, 95%CI 0.22-0.59, p < .01). In subgroup analysis, catheter ablation was an independent risk factor for all-cause death in the high-stroke risk group (adjusted HR 0.39, 95%CI 0.23-0.64, p < .01), not in the low-medium risk group (adjusted HR 0.17, 95%CI 0.01-2.04, p = .17)., Conclusions: In the patients with AF and SCAD, catheter ablation was not independently associated with the primary composite endpoint compared with drug therapy. However, catheter ablation was an independent protective factor of all-cause death., (© 2021 The Authors. Clinical Cardiology published by Wiley Periodicals LLC.)

Introduction: Catheter ablation for atrial fibrillation (AF-CA) in patients with situs inversus dextrocardia (SID) can be challenging because of the contrary anatomy and associated anomalies. Cases and literature regarding AF-CA in SID are rare and provide little information. Our study aims to present an improved procedure, ablation strategies, and evaluate the safety and outcomes of AF-CA in patients with AF and SID., Methods: A total of 10 patients with AF-SID (mean age, 60.4 ± 15.7 years; six paroxysmal AF, four persistent atrial fibrillation [PeAF]) were enrolled. For the improved procedure, images obtained by preacquired computed tomography and three-dimensional electroanatomical mapping, integrating intracardiac echocardiography, and x-ray imaging data are necessary to optimize the transseptal puncture and ablation procedure., Results: All patients successfully underwent 13 AF-CA procedures without complications, including three patients received repeat procedures. However, two PeAF patients presented sick sinus syndrome (SSS) after the AF-CA procedure, and one underwent permanent pacemaker implantation therapy during hospitalization. During the follow-up period (6-72 months), the outcomes were not favorable: three patients (30%) maintained sinus rhythm (SR) after the initial procedure; after repeated procedures, the overall SR rate was 40% (four patients)., Conclusion: With the improved strategy, AF-CA can be safely and effectively performed with low radiation exposure in patients with SID. However, the long-term outcomes were not favorable, even when managed at a tertiary center by a team of specialists. Moreover, patients with PeAF might also have masked SSS, which should be carefully considered., (© 2020 Wiley Periodicals LLC.)

Background: Atrial fibrillation (AF) is common in abdominal solid organ transplant recipients and a cause of morbidity and mortality in this population. However, the outcomes of catheter ablation (CA) in transplant recipients with AF remain unclear. This study aimed to elucidate the outcomes of CA in renal and hepatic transplant recipients., Methods and Results: Between 2015 and 2019, 14 transplant recipients (nine with kidney transplantation and five with liver transplantation) were enrolled from among 10,741 AF patients and underwent CA at Anzhen Hospital. Another 56 patients matched by age, sex, and AF type were selected as the control group (four controls for each transplant recipient). During a mean follow-up of 30.0 ± 13.3 months after the initial procedure, 10 (71.4%) of the transplant patients, compared to 41 (73.2%) of the control patients, remained free from AF recurrence (p = 1.000). A repeated procedure was performed in one transplant patient and in six control subjects. Consequently, 11 (78.6%) of the transplant patients, compared to 46 (82.1%) of controls, were in sinus rhythm after the repeated ablation (p = .715). Notably, Kaplan-Meier analysis did not demonstrate any significant differences in the atrial arrhythmia-free rate after the initial and repeated procedure between the two groups. Vascular complications were identified in one transplant patient and two control subjects, while no life-threatening complications were observed in either group. There was no transient allograft dysfunction in transplant recipients after CA., Conclusion: CA is safe and effective in abdominal solid transplant recipients, and maybe an optimal therapeutic strategy for this group., (© 2020 Wiley Periodicals LLC.)

Aims: We aimed to investigate the safety of discontinuing oral anticoagulation (OAC) therapy after apparently successful atrial fibrillation (AF) ablation, using data from the Chinese Atrial Fibrillation Registry study., Methods and Results: We identified 4512 consecutive patients who underwent successful AF ablation between August 2011 and December 2017. Of them, 3149 discontinued OAC 3 months post-ablation (Off-OAC group) and 1363 continued OAC beyond this period (On-OAC group). Regular follow-up examinations were undertaken to detect AF recurrence, monitor OAC therapy, and measure clinical outcomes. Primary outcomes included thromboembolic and major bleeding (MB) events experienced beyond 3 months after ablation. Low thromboembolic and MB event rates were noted in the on-treatment analysis. The incidence rates for thromboembolism were 0.54 [95% confidence interval (CI) 0.39-0.76] and 0.86 (95% CI 0.56-1.30) per 100 patient-years, and that for MB events were 0.19 (95% CI 0.11-0.34) and 0.35 (95% CI 0.18-0.67) per 100 patient-years, for the Off-OAC and On-OAC groups over mean follow-up periods of 24.2 ± 14.7 and 23.0 ± 13.6 months, respectively. Similar results were observed in the intention-to-treat analysis. Previous history of ischaemic stroke (IS)/transient ischaemic attack (TIA)/systemic embolism (SE) [hazard ratio (HR) 3.40, 95% CI 1.92-6.02; P < 0.01] and diabetes mellitus (HR 2.06, 95% CI 1.20-3.55, P = 0.01) were independently associated with thromboembolic events, while OAC discontinuation (HR 0.71, 95% CI 0.41-1.23, P = 0.21) remained insignificant in multivariable analysis., Conclusions: This study suggests that it may be safe to discontinue OAC in post-ablation patients under diligent monitoring, in the absence of AF recurrence, history of IS/TIA/SE, and diabetes mellitus. However, further large-scale randomized trials are required to confirm this., Trial Registration: Chinese Clinical Trial Registry ChiCTR-OCH-13003729. URL: http://www.chictr.org.cn/showproj.aspx?proj=5831., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2019. For permissions, please email: journals.permissions@oup.com.)

Background: Impact of body mass index (BMI) on all-cause mortality in atrial fibrillation (AF) patients remains controversial., Methods: A total of 10,942 AF patients were prospectively enrolled and categorized into four BMI groups: underweight (BMI < 18.5 kg/m 2 ), normal weight (BMI 18.5-24 kg/m 2 ), overweight (BMI 24-28 kg/m 2 ) and obesity (BMI ≥ 28 kg/m 2 ). The primary outcome was all-cause mortality. Different Cox proportional hazards models were performed to evaluate the association between BMI and all-cause mortality., Results: During a median follow-up of 30 months (IQR 18-48 months), 862 deaths events occurred. Compared to normal BMI, higher BMI was associated with a lower mortality risk (overweight: HR 0.70; 95% CI 0.61-0.81, P < 0.0001 and obesity: HR 0.54; 95% CI 0.44-0.67, P < 0.0001) and lower BMI was associated with a higher mortality risk (HR 2.23, 95% CI 1.67-2.97, P < 0.0001)., Conclusion: A reversed relationship between BMI and all-cause mortality in AF patients was found. Higher risk of mortality was observed in underweight patients compared to patients with a normal BMI, while overweight and obese patients had a lower risk of all-cause mortality., Clinical Trial Registration: URL: http://www.chictr.org.cn/showproj.aspx?proj=5831. Unique identifier: ChiCTR-OCH-13003729.

BACKGROUND Oral anticoagulants (OACs) such as warfarin and non-VKA oral anticoagulants (NOACs) have been recommended for patients with atrial fibrillation (AF) who are at risk for stroke. Whether NOACs have a higher persistence than warfarin is still unclear. This is especially true in China. MATERIAL AND METHODS Data from a large hospital-based cohort in China (China-AF Registry) from 2011 to 2017 were used for this study. Non-valvular AF patients with newly initiated OACs were included. A time-to-event approach was used to analyze patient persistence. The survival distributions of persistence were compared using the log-rank test. A multivariable Cox regression model was used to explore predictors of warfarin and NOACs non-persistence. RESULTS Patients with newly initiated warfarin (n=4845) or NOACs (n=854) were included in this study. Persistence rates at 1, 2, and 3 years were 93.2%, 89.4%, and 87.2% in the warfarin group and 88.8%, 84.3%, and 81.3% in the NOAC group respectively. Non-persistence was significantly higher with NOACs than with warfarin. On multivariate analysis, age <75 years old, outpatient clinic visits, asymptomatic AF, paroxysmal AF, duration of AF <3 years, history of peptic ulcer, and no previous TIA, stroke or thromboembolism were strong predictors of warfarin non-persistence, while in the NOACs group, age <75 years old, outpatient clinic visits, lower education status and no history of congestive heart failure were predictors. CONCLUSIONS Treatment persistence of NOACs was lower than that of warfarin among Chinese patients with AF. Patients with characteristics of non-persistence predictors need special attention to maintain their therapy.

Background Previous studies have provided conflicting results as to whether women are at higher risk than men for thromboembolism in the setting of atrial fibrillation ( AF ). We investigated whether women with AF were at higher risk of ischemic stroke in the China-AF (China Atrial Fibrillation Registry) Study. Methods and Results A total of 19 515 patients were prospectively enrolled between August 2011 and December 2016 in the China- AF Study. After exclusion of patients receiving anticoagulation or ablation therapy, 6239 patients (2574 women) with results from at least 6 months of follow-up were used for the analysis. Cox proportional hazards models were performed to evaluate whether female sex was an independent risk factor for thromboembolism after multivariate adjustment. The primary outcome was the time to the first occurrence of ischemic stroke or systemic embolism. After a mean follow-up of 2.81±1.46 years, 152 female patients reached the primary outcome, as compared with 172 male patients. Crude incidence rates of thromboembolism between women and men were of borderline statistical significance (2.08 versus 1.68 per 100 patient-years, P=0.058). After multivariable analysis, female sex was not independently associated with an increased thromboembolism risk (hazard ratio 1.09, 95% confidence interval 0.86-1.39). There was no significant difference in thromboembolism risk by sex stratified by age and presence or absence of risk factors ( P for interaction all >0.1). Conclusions Although crude incidence rates of thromboembolism were higher in Chinese female patients with AF compared with male patients, female sex did not emerge as an independent risk factor for thromboembolism on multivariate analysis. Clinical Trial Registration URL : http://www.chictr.org.cn/ . Unique identifier: Chi CTR - OCH -13003729.

Background:  Anti-coagulant therapy satisfaction for patients with atrial fibrillation is a critical issue, which impacts on their treatment adherence and clinical outcomes. The disadvantages of long-term warfarin treatment are well-described, and novel oral anti-coagulants have become an alternative option., Materials and Methods:  We compared patient-reported treatment satisfaction with dabigatran versus warfarin in non-valvular atrial fibrillation (NVAF) patients in China. Treatment satisfaction was assessed using the Anti-Clot Treatment Scale (ACTS) questionnaire, which included a 12-item ACTS Burdens scale and a 3-item ACTS Benefits scale., Results:  Among 834 patients, 246 patients (29.5%) were taking dabigatran and the others were on warfarin. Propensity score matching was employed to identify 182 patient pairs with balanced baseline characteristics. The global ACTS Burdens score and the global ACTS Benefits score were comparable between the dabigatran and warfarin groups (44.86 ± 3.95 vs. 44.28 ± 3.51, p  = 0.423; 11.49 ± 2.92 vs. 11.42 ± 3.03, p  = 0.194, respectively). The monthly cost of dabigatran was significantly higher compared with that of warfarin due to a lack of insurance coverage (USD 176.78 ± 9.15 vs. USD 2.49 ± 0.76, p  = 0.000). The discontinuation rate of dabigatran was significantly higher than warfarin at the 6-month follow-up (33.5% vs. 19.2%, p  = 0.003). Adjusted logistic regression showed that dabigatran was associated with a significant greater odds of non-persistence (odds ratio: 2.13, 95% confidence interval: 1.27-3.59, p  = 0.004)., Conclusion:  Dabigatran therapy in patients with NVAF in China associated with no improvement in satisfaction and a higher discontinuation rate compared with warfarin therapy largely due to increased economic burden., Competing Interests: Dr. Chang-Sheng Ma received honoraria from Bristol-Myers Squibb (BMS), Pfizer, Johnson & Johnson, Boehringer-Ingelheim (BI) and Bayer for giving lectures. Dr. Jian-Zeng Dong also received honoraria from Johnson & Johnson for giving lectures. The other authors report no conflicts of interest., (Georg Thieme Verlag KG Stuttgart · New York.)

BACKGROUND Dyslipidemia is the most frequent comorbidity in patients with cardiovascular disease. However, studies examining the relationship between blood lipid profiles and AF have produced inconsistent results. MATERIAL AND METHODS A total of 651 patients were enrolled into 3 groups: Healthy controls (n=64), Paroxysmal AF (PAF; n=270), and Continuous AF (CAF; n=317). All enrolled patients underwent routine baseline 12-lead electrocardiography (ECG) and 24-h dynamic ECG along with blood testing, which included the following: complete metabolic panel, hepatic function, renal function, circulating thyroxine, fasting high-density lipoprotein cholesterol (HDL -C), low-density lipoprotein cholesterol (LDL-C), triglycerides (TG), and total cholesterol (TC). RESULTS Patients with AF had significantly higher levels of triglycerides (TG), lower levels of LDL-C-c, and lower levels of HDL-C (p<0.05). TC (OR 0.979, p<0.9247) and TG (OR 0.945, p<0.6496) were negatively and linearly associated with PAF, while TG (OR 0.807, p=0.2042), LDL-C (OR 0.334, p=0.0036), and HDL-C (OR 0.136, p=0.0002) were negatively and linearly associated with CAF. CONCLUSIONS Compared to healthy controls, patients with AF had lower blood lipid levels, especially LDL-c and HDL-c levels. Hypolipoproteinemia may increase patient susceptibility to developing AF.

Purpose: Thyroid dysfunction affects the outcomes of atrial fibrillation (AF) catheter ablation. However, it remains unclear if the variations in thyroid function, especially in the triiodothyronine levels, are associated with AF recurrence in euthyroid subjects. This study investigated the associations of thyroid hormone levels with arrhythmia recurrence after AF catheter ablation in euthyroid patients., Methods: A total of 1115 consecutive AF patients who underwent catheter ablation were prospectively enrolled and had their thyroid function measured prior to the procedure. The serum free triiodothyronine (FT 3 ), free tetraiodothyronine (FT 4 ), and thyroid-stimulating hormone (TSH) levels were assessed as predictors of recurrence and were adjusted for potential confounders. The subjects were divided into five quintile groups according to the FT 3 , FT 4 , and TSH levels, respectively., Results: After a median follow-up of 723 days (interquartile range, 180-1070), 47.2% of patients experienced recurrence. After multivariate adjustment, subject in the lowest and highest FT 3 quintiles showed increased risk of recurrence (hazard ratio [HR] 1.60, 95% confidence interval [CI] 1.26-2.03, P < 0.01, and HR 1.47, 95% CI 1.16-1.87, P < 0.01, respectively), compared to the median quintile of FT 3 levels. Regarding the FT 4 level, the highest quintile group showed a higher risk of recurrence (HR 1.27, 95% CI 1.01-1.60, P = 0.04). The TSH levels were not associated with AF recurrence., Conclusions: Both high and low FT 3 levels were associated with AF recurrence after catheter ablation. High-normal FT 4 levels were also related to AF recurrence; however, no association was found between normal TSH levels and AF recurrence.

Cardioembolic stroke due to atrial fibrillation (AF) and/or rheumatic heart disease (RHD) often involves hemorrhagic transformation (HT), and we examined whether leukoaraiosis (LA) was associated with HT in these cases. We prospectively enrolled 251 patients who were admitted to two hospitals within one month of experiencing cardioembolic stroke due to AF/RHD. LA severity was assessed using three visual rating scales. HT was identified in 99 patients (39.4%) based on baseline computed tomography (CT) and post-admission magnetic resonance imaging or second CT. Univariate analysis identified risk of HT as higher in the presence of frontal LA based on the age-related white matter changes scale and in the presence of anterior LA based on the VSS scale. Multivariate analysis confirmed that moderate to severe LA was independently associated with higher HT risk. Of the various sites affected in LA, frontal LA correlated with highest risk of HT (OR 3.199, 95%CI 1.555-6.580). These results suggest that moderate to severe LA, especially at periventricular and anterior sites, is associated with HT after cardioembolic stroke due to AF/RHD. These findings suggest the need to take LA into account as a HT risk factor when considering the use of anticoagulation and thrombolysis in these patients., (Copyright © 2017. Published by Elsevier B.V.)

Background: For repeat treatment with paroxysmal atrial fibrillation (PAF) recurrence, gap-closure at pulmonary vein ostia alone is not enough. Many recent studies indicated that ganglionated plexi (GPs) denervation could reduce the recurrence of AF. However, it is unclear whether the clinical outcomes of additional GP ablation plus pulmonary veins (PVs ) reisolation during a repeat procedure were associated with less recurrence in PAF patients. The purpose of this study was to evaluate if a repeat procedure of GP ablation (GPA) combining repeated procedure of pulmonary vein isolation (re-PVI), i.e., gap-closure, can offer additional benefit for patients with PAF recurrence., Method: A total of 123 consecutive patients with PAF recurrence who underwent success repeat procedures were retrospectively analyzed in our center (2014-2015). Note that 64 patients (group 1, GPA group) were performed with GPA plus re-PVI, while 59 patients (group 2, re-PVI group) had re-PVI (gap-closure) alone. Organized atrial tachycardias (OATs) documented or induced at the end of the procedure were all mapped and ablated. Patients were scheduled for a 12-month follow-up. Clinical presentation and outcome data for the two groups were assessed., Result: At the 12-month follow-up 58 of 64 patients (90.6%) in group 1 and 46 of 59 patients (78%) in group 2 remained in sinus rhythm (SR) off antiarrhythmia drugs (AADs) (P = 0.045)., Conclusion: GPA conferred incremental benefit when performed in addition to re-PVI in patients with PAF recurrence; the GPA group yielded higher success rates than the re-PVI group., (© 2017 Wiley Periodicals, Inc.)

In this study, the left atrial appendage (LAA) structure and morphology were assessed using real-time three-dimensional transesophageal echocardiography (RT3D-TEE) and enhanced cardiac computed tomography (CT) scanning, and the two measurements obtained using these different techniques were compared. Two hundred nonvalvular atrial fibrillation (NVAF) patients who were prepared to undergo radiofrequency ablation were enrolled, and 62 controls were enrolled prospectively. RT3D-TEE and CT were performed, and the following parameters were measured: LAA orifice diameter, area, depth, maximum volume, and emptying velocity. The differences between the NVAF patients and controls were compared, and the differences and correlations in the LAA parameters between the two imaging techniques were assessed. The NVAF patients had significantly bigger orifice sizes, orifice areas, and maximum volumes, and lower emptying rates. The AF cohort had roughly equal proportions of the four morphological types, whereas the controls predominantly had the windsock type. A Bland-Altman analysis demonstrated that the LAA measurements obtained using RT3D-TEE were lower than those obtained with the CT. However, linear regression analysis showed the good correlations between the RT3D-TEE and CT measurements of the LAA orifice area, depth and volume (r = 0.86, 0.63, and 0.75, respectively). The use of RT3D-TEE for the visualization and quantitative analysis of LAA parameters is feasible, and the obtained measurements correlate well with those obtained with cardiac CT. This technique may be an ideal tool for guiding LAA occlusion procedures, and combining these two methods may enhance the accuracy of LAA measurements.

Objectives: To provide a road map of pulmonary vein (PV) and left atrial (LA) variants in patients with atrial fibrillation (AF) before catheter ablation procedure using cardiac CT., Methods: Cardiac CT was performed in 1420 subjects for accurate anatomical information, including 710 patients with AF and 710 matched controls without AF. PV variants, PV ostia and spatial orientation, LA enlargement, and left atrial diverticulum (LAD) were measured, respectively. Differences between these two groups were also respectively compared. Some risk factors for the occurrence of LAD were analyzed., Results: In total, PV variants were observed in 202 (28.5 %) patients with AF patients and 206 (29.0 %) controls without AF (p = 0.8153). The ostial sizes of all accessory veins were generally smaller than those of the typical four PVs (p = 0.0153 to 0.3958). There was a significant difference of LA enlargement between the AF and control groups (36.3 % vs. 12.5 %, p < 0.0001), while the prevalence of LAD was similar in these two groups (43.2 % vs. 41.9 %, p = 0.6293)., Conclusion: PV variants are common. Detailed knowledge of PVs and LA variants are helpful for providing anatomical road map to determine ablation strategy., Key Points: • PVs variants are helpful for providing anatomical road map to ablation. • PV variants are common. • DSCT could recognize these anatomic features before ablation as a non-invasive imaging.

Background and Aims: The presence of atrial fibrillation (AF) markedly increases the risk of stroke and mortality in patients. Whether AF is a risk factor for myocardial infarction (MI) is discrepant from current studies. The aim of this meta-analysis was to ascertain the association of AF with incident MI., Methods: Studies were identified through PubMed, CENTRAL, EMBASE, reviews and reference lists of relevant papers. Results of the MI outcome were presented as hazard ratio (HR) and 95% confidence interval (CI). Statistical analyses were performed with Stata 12.0 (Stata Corp LP, College Station, Texas, USA)., Results: Twelve studies, with a total of 169,306 patients, were included in the analysis. AF was associated with a 47% increased risk of MI (HR:1.47; 95% CI: 1.21-1.80; p = 0.000; I 2  = 84.1%), while in patients free of coronary heart disease at baseline the risk could be increased by 71% (HR:1.71; 95% CI: 1.36-2.14; p = 0.000; I 2  = 83.1%). Moreover, patients with AF had higher MI risk in the studies with lower mean age (<60 years) (HR:1.66; 95% CI: 1.26-2.20; p = 0.000; I 2  = 82.9%) than in the studies with higher mean age (≥60 years) (HR:1.35; 95% CI: 1.00-1.82; p = 0.000; I 2  = 84.9%). Sex difference also existed, and the association between AF and MI was stronger in women (HR:2.02; 95% CI: 1.60-2.56; p = 0.017; I 2  = 61.0%) than in men (HR:1.44; 95% CI: 1.13-1.84; p = 0.000; I 2  = 76.1%)., Conclusions: AF is associated with an increased risk of incident MI, especially in patients free of coronary heart disease at baseline, young patients and women. The findings need confirmation in well-designed observational trials., (Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.)

Background: Atrial fibrillation (AF) is associated with increased incidence of cardiovascular disease, and hence, statin therapy is indicated in majority of AF patients., Methods and Results: We analyzed data from the Chinese Atrial Fibrillation Registry (CAFR) involving 11,496 AF patients from 2011 to 2014. Practice patterns of statin therapy and factors associated with statin underuse were analyzed. Based on the 2013 ACC/AHA cholesterol management guidelines, statins should be recommended for 67.4% (7720/11,461) of AF participants in CAFR, but only 43.4% (3352/7720) with appropriate indications were taking statins. Statin underuse in AF patients was independently associated with male sex, tertiary hospital treatment, outpatient attendance, and absence of 'high risk' cardiovascular risk factors (overweight, diabetes, coronary heart disease, stroke/transient ischemic attack/peripheral embolism and hypertension)., Conclusions: A high proportion of Chinese AF patients had indications for statin therapy. Evidence-based statin prescribing was suboptimal in this population. Greater efforts should be made to improve a holistic approach to cardiovascular risk management in the Chinese AF population., (Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.)

Background: Verification of bidirectional block is important for mitral isthmus (MI) ablation. However, recurrent perimitral reentry exists despite apparently MI block., Objective: The purpose of this study was to identify and investigate the characteristics of the ridge breakthrough despite apparent bidirectional MI block and related reentry., Methods: In 60 patients undergoing MI ablation and achieving the criteria of bidirectional block when assessed on the line, the pattern under differential pacing was reassessed at the ridge away from the line to check whether a breakthrough existed. Also, activation and entrainment mapping was performed in 7 patients with ridge-related reentry (RRR) to investigate its possible mechanism., Results: A ridge breakthrough was found in 7 of 60 patients (11.7%) apparently fulfilling the criteria of bidirectional block. The delay from pacing artifact during distal coronary sinus pacing was shorter at the ridge than on the line (95.6 ± 11.7 ms vs 130.9 ± 15.3 ms; P < .001). In 7 patients with RRR, the left atrial endocardial activation time accounted for 58.5% ± 3.2% of the tachycardia cycle length (TCL) and wide double potential could be recorded on the line. The post-pacing interval (PPI) - TCL after entrainment at the ridge was shorter than that on the line (11.4 ± 3.9 ms vs 34.3 ± 6.6 ms; P < .001), and in 2 patients in whom entrainment from the coronary sinus was possible, the PPI - TCL was 15 and 18 ms, respectively., Conclusion: Apparent bidirectional MI block despite a ridge breakthrough is not uncommon and may lead to RRR, while the line is not part of the reentry., (Copyright © 2016. Published by Elsevier Inc.)

Background and Purpose: Reported rates of oral anticoagulation (OAC) use have been low among Chinese patients with atrial fibrillation (AF). With improved awareness, changing guidelines, this situation may be changing over time. We aimed to explore the current status and time trends of OAC use in Beijing., Methods: We used the data set from the Chinese Atrial Fibrillation Registry (CAFR), a prospective, multicenter, hospital-based registry study involving 20 tertiary and 12 nontertiary hospitals in Beijing. A total of 11 496 patients with AF were enrolled from 2011 to 2014., Results: Seven thousand nine hundred seventy-seven eligible patients were included in this ancillary study. The proportions of OAC use were 36.5% (2268/6210), 28.5% (333/1168), and 21.4% (128/599) for patients with CHA2DS2-VASc scores ≥2, 1, and 0, respectively. Persistent AF, history of stroke/transient ischemic attack/peripheral embolism, diabetes mellitus, higher body mass index, and tertiary hospital management were factors positively associated with OAC use, whereas older age, previous bleeding, hypercholesterolemia, and established coronary artery disease were factors negatively associated with OAC use. Among patients with CHADS2 scores ≥2 and CHA2DS2-VASc scores ≥2, the proportion of OAC use increased from 31.3% to 64.5% and 30.2% to 57.7%, respectively, from 2011 to 2014. Variation in OAC use was substantial among different hospitals., Conclusions: An improvement of OAC use among Chinese patients with AF in Beijing is observed in recent years although only 36.5% of patients with CHA2DS2-VASc score ≥2 received OAC. However, variations between different hospitals were large, suggesting that better education and awareness are needed to improve efforts for stroke prevention among AF patients., Clinical Trial Registration: URL: http://www.chictr.org.cn/showproj.aspx?proj=5831. Unique identifier: ChiCTR-OCH-13003729., (© 2016 American Heart Association, Inc.)

Background: Warfarin is the most common oral anticoagulant to decrease the stroke risk associated with atrial fibrillation (AF). There are very few prospective studies that have explored whether warfarin has an association with damage on renal function in Chinese patients with nonvalvular AF (NVAF). The aim of this study was to evaluate the effects of warfarin on renal function and study the factors associated with kidney dysfunction in Chinese adult NVAF patients without dialysis therapy., Methods: From January 2011 to December 2013, a total of 951 NVAF patients from 18 hospitals were enrolled. The estimated glomerular filtration rate (eGFR) was calculated from baseline and follow-up serum creatinine levels. Kaplan-Meier survival curves compared the survival of a ≥25% decline in eGFR (hereafter, endpoint), while Cox models estimated hazard ratios (HR s) and 95% confidence intervals for this event after adjustment for age, gender, and selected potential risk factors for renal dysfunction. Cox regression analysis of the various clinical potential variables was performed to identify the predictors of a ≥25% decline in eGFR., Results: After a 58-month follow-up, 951 NVAF patients were divided by observation into warfarin (n = 655) and no anticoagulation groups (n = 296) and 120 (12.6%) patients experienced renal endpoint. Kaplan-Meier survival curves showed that the survival period was not different in the two groups (χ2 = 0.178, log-rank P= 0.67), but patients with systolic blood pressure (SBP) <140 mmHg have significant difference with patients with SBP ≥140 mmHg (χ2 = 4.903, log-rank P= 0.03). Multivariate Cox regression analysis revealed baseline eGFR and SBP as independent predictors of the endpoint, with HR s of 1.00, and 1.02, respectively., Conclusion: In patients with NVAF, eGFR and SBP are associated with the deterioration of kidney function while Warfarin is not the risk factor of the ≥25% decline in eGFR., Trial Registration: Chinese Clinical Trial Registry (No. ChiCTR-OCH-13003729); http://www.chictr.org.cn/showproj.aspx?proj = 5831.

Background: Previous studies have described the impact of mitral isthmus (MI) anatomy on the likelihood of achieving MI linear block in patients with native mitral valves (NMV) who underwent atrial fibrillation (AF) ablation. However, none have investigated that issue in AF patients with mechanical mitral valve replacements (MMVR)., Methods and Results: Twenty-nine consecutive patients who developed symptomatic persistent AF post-MMVR and referred for ablation were enrolled. Twenty-nine patients with NMV who underwent ablation of persistent AF during the same period were matched. With preprocedural cardiac computed tomographic imaging, MI anatomical features of all the participants were analyzed. Pouched MI was observed in 19 (65.5%) MMVR patients versus to 6 (20.7%) controls (P = 0.001). Bidirectional linear block across MI was achieved in 21 (72.4%) MMVR patients and 22 (75.9%) in the controls (P = 0.764). In the multivariable analysis, pouched MI was an independent predictor of incomplete MI block., Conclusions: Pouched MI accounts for the majority of AF patients with MMVR and may be associated with incomplete bidirectional linear block of MI., (© 2015 Wiley Periodicals, Inc.)

Background: The effects of omega-3 polyunsaturated fatty acids (PUFA) on the prevention of postoperative atrial fibrillation (POAF) are inconclusive in current studies. Moreover, the most appropriate composition of PUFA to play the protective role is unclear. The aim of this meta-analysis was to ascertain the protective role of PUFA on POAF and the most appropriate composition., Methods: Studies were identified through PubMed, CENTRAL, EMBASE, reviews and reference lists of relevant papers. The odds ratio (OR) was calculated for POAF. Statistical analyses were performed with Review Manager 5.0., Results: Eleven randomised controlled trials with 3137 patients were included in the analysis. The use of PUFA alone did not reduce the incidence of POAF compared with the control (OR: 0.76; 95% confidence interval [CI]: 0.57-1.03; P=0.08; I(2)=52%). However, combination therapy with PUFA and vitamins C and E reduced the incidence of POAF by 68% (OR: 0.32; 95%CI: 0.17-0.60; P=0.0005; I(2)=38%). Subgroup analysis indicated that the ratio of EPA/DHA 1:2 was effective in preventing POAF (OR: 0.35; 95%CI: 0.24-0.50; P<0.00001; I(2)=0%), while the ratio not 1:2 failed., Conclusions: Combination therapy with PUFA and vitamins C and E is effective in the prevention of POAF while PUFA alone is not. The ratio of EPA/DHA may influence the incidence of POAF, and 1:2 may be most appropriate. Studies about PUFA on the prevention of POAF are still worthwhile to be conducted in the future., (Copyright © 2014 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier B.V. All rights reserved.)

Background: Symptomatic prolonged sinus pauses on termination of atrial fibrillation (AF) are an accepted indication for pacemaker implantation. We evaluated the outcome of AF ablation in patients with paroxysmal AF-related tachycardia-bradycardia syndrome and compared the efficacy of catheter ablation with permanent pacing plus antiarrhythmic drugs (AADs)., Methods and Results: Patients with prolonged symptomatic sinus pauses on termination of AF were retrospectively analyzed. Forty-three consecutive patients who underwent catheter ablation (ABL group) were compared to 57 patients who underwent permanent pacing plus AADs (PM group). All 43 patients in the ABL group fulfilled Class I indication for pacemaker implantation at baseline but they actually underwent AF ablation. Reevaluation after 20.1 ± 9.6 months of follow-up showed that 41 patients (95.3%) did no longer need a pacemaker (Class III indication). Total cardiac-related rehospitalization was not significantly different between the two groups (P = 0.921). Tachycardia-related hospitalization was significantly higher in the PM group than the ABL group (14.0% and 0%, P = 0.029). More patients in the PM group were on AADs (PM 40.4%, ABL 4.7%, P < 0.001) while sinus rhythm maintenance was remarkably higher in the ABL group at the end of follow-up (83.7% vs 21.1% in PM group, P < 0.001)., Conclusions: In patients with paroxysmal AF-related tachycardia-bradycardia syndrome, AF ablation seems to be superior to a strategy of pacing plus AAD. Pacemaker implantation can be waived in the majority of patients after a successful ablation., (©2014, The Authors. Journal compilation ©2014 Wiley Periodicals, Inc.)

Aims: The ratio of early transmitral flow velocity (E) to early diastolic mitral annular velocity (e') was applied as a non-invasive index to assess left ventricular filling pressure (LVFP). However, the reliability of E/e' was undermined in patients with atrial fibrillation (AF). Recently, a novel method entitled 'dual Doppler' was established, which allows simultaneous recording and display of E and e'. Our study investigates whether the dual-Doppler method improves the reliability of E/e' in AF patients., Methods and Results: Forty-nine patients with non-valvular AF underwent conventional echocardiography, dual-Doppler echocardiography, and cardiac catheterization within 4 h. Of 22 patients (45%c) with increased LVFP (>15 mmHg), higher E/e' measured by both conventional tissue Doppler imaging (TDI) and dual-Doppler method was observed. Conventional echocardiographic variables were correlated with LVFP (E/e'(sep), r = 0.404, E/e'(lat), r = 0.487), but E/e' measured synchronously in the dual-Doppler mode yielded a better correlation (E/e'(synchronous sep), r = 0.754, E/e'(synchronous lat), r = 0.765). The intra- and interobserver variability of the dual-Doppler method was significantly lower than the conventional TDI method., Conclusion: Good correlations were found between E/e'' and LVFP in patients with AF, particularly in the dual-Doppler mode. E/e' measured by the dual-Doppler method can therefore be applied to assess diastolic dysfunction in AF patients.

Background Left ventricular thrombus (LVT) is a common complication of dilated cardiomyopathy (DCM), causing morbidity and mortality. Methods This study retrospectively analyzed patients with DCM from January 2002 to August 2020 in Beijing Anzhen Hospital. Clinical characteristics were compared between the LVT group and the age and sex 1:4 matched with the LVT absent group. The receiver operator characteristic (ROC) curve was plotted to evaluate the diagnostic value of D-dimer predicting LVT occurrence in DCM. Results A total of 3,134 patients were screened, and LVT was detected in 72 (2.3%) patients on echocardiography. The patients with LVT had higher D-dimer, fibrinogen, and lower systolic blood pressure than those without LVT. The ejection fraction (EF) was lower and left ventricular end-systolic diameter was larger in the LVT group. Severe mitral regurgitation (MR) was more common in the LVT absent groups. The prevalence of atrial fibrillation was lower in the LVT group. The ROC curve analysis yielded an optimal cut-off value of 444 ng/mL DDU (D-dimer units) for D-dimer to predict the presence of LVT. Multivariable binary logistic regression analysis revealed that EF (OR = 0.90, 95% CI = 0.86–0.95), severe MR (OR = 0.19, 95% CI = 0.08–0.48), and D-dimer level (OR = 15.4, 95% CI = 7.58–31.4) were independently associated with LVT formation. Conclusion This study suggested that elevated D-dimer levels (>444 ng/mL DDU) and reduced EF were independently associated with increased risk of LVT formation. Severe MR could decrease the incidence of LVT. [ABSTRACT FROM AUTHOR]

Aims The clinical correlates and outcomes of asymptomatic atrial fibrillation (AF) in hospitalized patients are largely unknown. We aimed to investigate the clinical correlates and in-hospital outcomes of asymptomatic AF in hospitalized Chinese patients. Methods and results We conducted a cross-sectional registry study of inpatients with AF enrolled in the Improving Care for Cardiovascular Disease in China-Atrial Fibrillation Project between February 2015 and December 2019. We investigated the clinical characteristics of asymptomatic AF and the association between the clinical correlates and the in-hospital outcomes of asymptomatic AF. Asymptomatic and symptomatic AF were defined according to the European Heart Rhythm Association score. Asymptomatic patients were more commonly males (56.3%) and had more comorbidities such as hypertension (57.4%), diabetes mellitus (18.6%), peripheral artery disease (PAD; 2.3%), coronary artery disease (55.5%), previous history of stroke/transient ischaemic attack (TIA; 17.9%), and myocardial infarction (MI; 5.4%); however, they had less prevalent heart failure (9.6%) or left ventricular ejection fractions ≤40% (7.3%). Asymptomatic patients were more often hospitalized with a non-AF diagnosis as the main diagnosis and were more commonly first diagnosed with AF (23.9%) and long-standing persistent/permanent AF (17.0%). The independent determinants of asymptomatic presentation were male sex, long-standing persistent AF/permanent AF, previous history of stroke/TIA, MI, PAD, and previous treatment with anti-platelet drugs. The incidence of in-hospital clinical events such as all-cause death, ischaemic stroke/TIA, and acute coronary syndrome (ACS) was higher in asymptomatic patients than in symptomatic patients, and asymptomatic clinical status was an independent risk factor for in-hospital all-cause death, ischaemic stroke/TIA, and ACS. Conclusion Asymptomatic AF is common among hospitalized patients with AF. Asymptomatic clinical status is associated with male sex, comorbidities, and a higher risk of in-hospital outcomes. The adoption of effective management strategies for patients with AF should not be solely based on clinical symptoms. [ABSTRACT FROM AUTHOR]

Aims: We aimed to investigate the safety of discontinuing oral anticoagulation (OAC) therapy after apparently successful atrial fibrillation (AF) ablation, using data from the Chinese Atrial Fibrillation Registry study.Methods and Results: We identified 4512 consecutive patients who underwent successful AF ablation between August 2011 and December 2017. Of them, 3149 discontinued OAC 3 months post-ablation (Off-OAC group) and 1363 continued OAC beyond this period (On-OAC group). Regular follow-up examinations were undertaken to detect AF recurrence, monitor OAC therapy, and measure clinical outcomes. Primary outcomes included thromboembolic and major bleeding (MB) events experienced beyond 3 months after ablation. Low thromboembolic and MB event rates were noted in the on-treatment analysis. The incidence rates for thromboembolism were 0.54 [95% confidence interval (CI) 0.39-0.76] and 0.86 (95% CI 0.56-1.30) per 100 patient-years, and that for MB events were 0.19 (95% CI 0.11-0.34) and 0.35 (95% CI 0.18-0.67) per 100 patient-years, for the Off-OAC and On-OAC groups over mean follow-up periods of 24.2 ± 14.7 and 23.0 ± 13.6 months, respectively. Similar results were observed in the intention-to-treat analysis. Previous history of ischaemic stroke (IS)/transient ischaemic attack (TIA)/systemic embolism (SE) [hazard ratio (HR) 3.40, 95% CI 1.92-6.02; P < 0.01] and diabetes mellitus (HR 2.06, 95% CI 1.20-3.55, P = 0.01) were independently associated with thromboembolic events, while OAC discontinuation (HR 0.71, 95% CI 0.41-1.23, P = 0.21) remained insignificant in multivariable analysis.Conclusions: This study suggests that it may be safe to discontinue OAC in post-ablation patients under diligent monitoring, in the absence of AF recurrence, history of IS/TIA/SE, and diabetes mellitus. However, further large-scale randomized trials are required to confirm this.Trial Registration: Chinese Clinical Trial Registry ChiCTR-OCH-13003729. URL: http://www.chictr.org.cn/showproj.aspx?proj=5831. [ABSTRACT FROM AUTHOR]