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Background Valvular calcification (VC) is an independent risk factor for cardiovascular diseases. The relationship between VC and atrial fibrillation is not clear. Hypothesis We treated the aortic valve, mitral valve, and tricuspid valve as a whole and considered the possible association between VC and recurrence of persistent atrial fibrillation (PsAF) after radiofrequency catheter ablation (RFCA). Methods This study involved 2687 PsAF patients who underwent RFCA. Data were collected to explore the relationship between VC and outcome. VC was defined by echocardiography in aortic valve, mitral valve, or tricuspid valve. After 1 year follow‐up, subgroup analysis, mixed model regression analysis, and score system analysis were performed. The external validation of 133 patients demonstrated the accuracy of this clinical prediction model. Results Overall, 2687 inpatients were assigned to the recurrence group (n = 682) or the no recurrence group (n = 2005) with or without VC. Compared to patients with no recurrence, the incidence of VC was higher in recurrence patients. Recurrence was present in 18.5%, 34.9%, 39.3%, and 52.0% of the four groups, which met VC numbers of 0, 1, 2, and 3, respectively. After adjustment for potential confounding factors, VC was an independent risk factor for AF recurrence in several models. For multivariable logistic regression, a scoring system was established based on the regression coefficient. The receiver operating characteristic area of the scoring system was 0.787 in the external validation cohort. Conclusions VC was an independent risk factor for AF recurrence in PsAF after RFCA. The scoring system may be a useful clinical tool to assess AF recurrence. In 2687 persistent atrial fibrillation (PsAF) undergoing radiofrequency catheter ablation, valvular calcification was an independent risk factor for AF recurrence after 1‐year follow‐up. For multivariable logistic regression, a scoring system was established based on the regression coefficient.

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.

Background Atrial fibrillation (AF) and heart failure with preserved ejection fraction (HFpEF) often coexist, worsening each other’s progression and contributing to poor outcomes. Frailty, a syndrome characterized by vulnerability to stressors, is highly prevalent in AF and HFpEF patients and has been associated with adverse outcomes such as stroke, hospitalization, and mortality. However, the specific prognostic implications of varying degrees of frailty in AF comorbid HFpEF patients remain unclear. This study investigates the relationship between frailty, measured using a deficit accumulation frailty index (FI), and adverse outcomes, particularly stroke, in this patient population. Methods This post hoc analysis of the TOPCAT randomized control trial included 721 patients with AF and HFpEF from the Americas classified into three groups based on FI: Group 1 (FI < 0.3), Group 2 (FI 0.3–0.4), and Group 3 (FI ≥ 0.4). The primary outcome was stroke, and secondary outcomes included heart failure hospitalization, cardiovascular death, and all-cause mortality. Cox proportional hazards models and Kaplan–Meier analyses were used to assess the association between frailty status and outcomes. A dose–response relationship was evaluated using restricted cubic splines. Results 97.8% AF comorbid HFpEF patients were diagnosed frailty in this cohort. During a mean follow-up of 36 ± 19 months, stroke incidence was significantly higher in Groups 2 and 3 compared with Group 1 (adjusted HR for Group 2: 5.01 [95% CI, 2.00–12.53]; P  = 0.001 and Group 3: 6.35 [95% CI, 2.26–17.86]; P  < 0.001). A linear dose–response relationship between FI and stroke risk was observed. Higher frailty was also associated with increased cardiovascular and all-cause mortality but not significantly with heart failure hospitalization.

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. This trial is designed to compare arrhythmia-free survival between PVI and an ablation strategy termed upgraded ‘2C3L’ for the ablation of PeAF. 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). 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.

This study aims to investigate if there is a difference in the safety and efficacy of catheter ablation of atrial fibrillation (AF) between patients with bioprosthetic mitral valve replacement (MVR) and those with mechanical MVR. A total of 23,794 patients who underwent the first-time catheter ablation of AF were screened. Patients with a history of surgical AF ablation, left atrial appendage closure, or resection were excluded from the study. There were 21 patients in the bioprosthetic MVR group and 85 patients in the mechanical MVR group were included in the study. After a median follow-up of 17.9 (14.4, 21.4) months, AF recurrence rates were similar between the two groups (52.4% vs. 50.6%, log-rank p  = 0.527). Persistent AF was independently associated with AF recurrence (HR 1.83, [95% CI 1.00–3.33], p  < 0.05). Mitral isthmus block rates were 78.6% in the bioprosthetic MVR group and 69.6% in the mechanical MVR group ( p  = 0.508). No instances of catheter entrapment were reported in this study. Two pseudoaneurysm and one acute cerebral infarction occurred in the mechanical MVR group. The safety and effectiveness of AF catheter ablation were comparable between patients with mechanical MVR and those with bioprosthetic MVR.

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. In this study conducted at Beijing Anzhen Hospital, we investigated the association between autoimmune diseases (AD) and procedural characteristics and recurrence after catheter ablation for atrial fibrillation in 107 patients with AD (AD group) and 428 propensity score‐matched patients without AD (non‐AD group). During the index procedure, a higher proportion of AD patients received nonpulmonary vein trigger ablation. Over a median follow‐up of 36.3 months, patients with AD experienced a similar risk of recurrence with the non‐AD group despite a higher incidence of early recurrences.

Background The adherence of oral anticoagulant (OAC) therapy among nonvalvular atrial fibrillation (NVAF) patients with acute ischemic stroke (AIS) in China during recent years was unclear, and the possible factors that influenced the initiation and persistent use of OAC were needed to be explored. Methods A total of 1085 NVAF patients, who experienced new‐onset and nonfatal AIS from August 2011 to December 2020 during follow‐ups in the China Atrial Fibrillation Registry (China‐AF), were enrolled. Information including patients' demographic characteristics, medical history, medication usage, which were collected before and after the index stroke, were used in the analysis. Results OAC was initiated in 40% (434/1085) NVAF patients within 3 months after new‐onset AIS. High‐reimbursement‐rate insurance coverage (odds ratio [OR]: 1.51, 95% confidence interval [CI]: 1.03–2.22, p = .036), 3‐month‐peri‐stroke AF episodes (OR: 2.63, 95% CI: 1.88–3.69, p < .001), and pre‐stroke OAC usage (OR: 8.92, 95% CI: 6.01–13.23, p < .001), were positively associated with initiation of OAC within 3 months after new‐onset AIS, while age (OR: 0.98, 95% CI: 0.96–1.00, p = .024), female (OR: 0.63, 95% CI: 0.44–0.90, p = .012) and higher modified HASBLED score (OR: 0.45, 95% CI: 0.37–0.55, p < .001) were negatively associated with it. Among 3‐month‐post‐stroke OAC users, history of radiofrequency ablation (hazard ratio: 1.65, 95% CI: 1.16–2.35; p = .006) was positively associated with non‐persistence of OAC usage. Conclusions In China, the proportion of NVAF patients who initiated OAC therapy since new‐onset AIS was still low. More efforts are needed on improving patients' adherence to anticoagulant therapy.

Background and aimThere is a lack of evidence comparing anticoagulation and antiplatelet therapy during the midperiod time after left atrial appendage closure (LAAC) in clinical practice (the “early period” is defined as “45 days” after LAAC for a single procedure of LAAC and “3 months” after LAAC for a combined therapy of LAAC and catheter ablation; we defined the time between the “early period” and 6 months following LAAC as the “midperiod”). Our study aims to assess the safety and effectiveness of different anticoagulant therapies in patients undergoing the LAAC procedure with the WATCHMAN device during the midperiod after LAAC implantation in clinical practice.MethodsThis prospective, single-center cohort study included 374 consecutive patients undergoing percutaneous LAAC with the Watchman device. Patients were divided into two groups: oral anticoagulation (OAC) and antiplatelet therapy (APT). The primary composite endpoint was cardiac mortality, ischemic stroke/ transient ischemic attacks/systemic embolism, and major bleeding events after 6 months following the procedure. The secondary endpoints are cardiovascular death, device-related thrombosis (DRT) events, and each component of the primary endpoint.ResultsThe risk of the primary outcome in the APT group and the OAC group had no statistical difference in multivariable Cox regression (adjusted HR = 0.76; 95% CI: 0.40–1.49; P  = 0.447). The secondary endpoints—including cardiac mortality, cardiovascular death, ischemic stroke/systemic embolism, major bleeding events, and DRT events—did not statistically differ between the two groups.ConclusionDuring the midperiod time after LAAC implantation with the WATCHMAN device, OAC therapy may demonstrate similar safety and efficacy compared with dual antiplatelet therapy.

Background: “Atrial fibrillation Better Care” (ABC) pathway has been proposed to improve the management of patients suffered from atrial fibrillation (AF). This integrated or holistic management approach comprise of three aspects, including “A” Avoid stroke or Anticoagulation; “B” Better symptom control with rate or rhythm control strategies; “C” Cardiovascular risk factor and Concomitant diseases management. We aimed to confirm the beneficial evidence of ABC pathway compliance in a Chinese AF cohort.Method and Results: From the Chinese Atrial Fibrillation registry (CAFR) dataset, a total of 19,187 non-valvular AF patients were enrolled, of which 4.365 (22.8%) were ABC pathway compliant (ABC compliance group). During a median follow-up of 4.1 ± 1.8 years, The incident rate of all-cause death in ABC compliance group and non-ABC compliance group is 2.7 and 1.1 per 100 person-year ( p < 0.001), the incident rate of ischemic stroke is 1.3 and 0.8% per 100 person-year ( p < 0.001), the incident rate of composite outcome, which consist of all-cause death, ischemic stroke and intracranial hemorrhage, is 3.8 and 1.9 per 100 person-year ( p < 0.001). On Cox multivariable analysis, ABC pathway shows an independently association with reduction of all-cause death [hazard ratio (HR) = 0.82; 95% confidence interval (CI) = 0.70–0.95] and the composite outcome (HR 0.86, 95% CI 0.76–0.96). The increasingly components of ABC integrated care compliance is associated with lower risk of all-cause death and composite events.Conclusion: In a large cohort of Chinese AF patients, ABC pathway compliance shows an independently association with reduction of all-cause death and composite outcome of all-cause death, ischemic stroke and intracranial hemorrhage. Better compliance of ABC integrated care contributes to lower HR for adverse events.

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