BACKGROUND:The optimal long-term antithrombotic strategy in patients with atrial fibrillation (AF) and coronary artery disease (CAD) after successful catheter ablation (CA) remains uncertain. OBJECTIVE:This study aimed to compare the effectiveness and safety of single antiplatelet therapy (SAPT) vs oral anticoagulation (OAC) monotherapy in this population. METHODS:This cohort study used a target trial emulation framework based on data from the China Atrial Fibrillation Registry. Patients with nonvalvular AF and CAD who underwent index CA were screened. Those free from AF recurrence, thromboembolism, or bleeding 12 months after ablation were included and categorized according to antithrombotic regimen at the 12-month landmark. The primary effectiveness outcome was thromboembolism (ischemic stroke or systemic embolism), and the primary safety outcome was bleeding (International Society on Thrombosis and Haemostasis major or clinically relevant nonmajor bleeding). Secondary outcomes included all-cause mortality and net clinical benefit. Inverse probability of treatment weighting was used for confounding adjustment. RESULTS:Among 998 patients (mean age 66.8 years; 26.5% women), 706 received SAPT and 292 OAC monotherapy. Over a mean follow-up of 3.0 years, 19 thromboembolic and 29 bleeding events occurred. After weighting, no statistically significant difference in thromboembolism was observed (hazard ratio [HR], 0.54; 95% confidence interval [CI], 0.18-1.61), whereas SAPT was associated with lower bleeding risk (HR, 0.40; 95% CI, 0.18-0.91). No significant differences were observed in mortality (HR, 0.77; 95% CI, 0.35-1.72) or net clinical benefit (HR, 0.66; 95% CI, 0.36-1.20). CONCLUSION:In this stable postablation population with AF and CAD, SAPT was associated with lower bleeding risk vs OAC monotherapy, whereas no statistically significant difference in thromboembolism was observed.

Atherosclerosis (AS) is a chronic inflammatory disease that underlies major cardiovascular disorders and necessitates early intervention. Central to its pathogenesis is reactive oxygen species-driven inflammation, which exacerbates plaque formation and progression. An ideal therapeutic strategy should simultaneously resolve lipid accumulation and suppress inflammatory pathways to restore homeostasis in the lesional microenvironment. Recently, the proliferation-inducing ligand (APRIL) has emerged as a promising therapeutic target for attenuating atherosclerotic plaque development. Here, we report a cyclodextrin-based, low-toxicity polyhydroxyl cationic vector (cyclodextrin-based ethanolamine-modified poly(glycidyl methacrylate), CD-PGEA-CD), engineered for efficient lipid scavenging and delivery of an APRIL-encoding plasmid (pAPRIL). This integrated nanoplatform (CD-PGEA-CD/pAPRIL) mediates robust APRIL overexpression in vitro concomitant with suppression of key pro-inflammatory cytokines (TNF-alpha and IL-6). In vivo, the system significantly reduced plasma low-density lipoprotein cholesterol (LDL-C) and total cholesterol levels by 40% and 46%, respectively, and achieved near-complete regression of advanced plaques. All-atom molecular dynamics simulations elucidated the strong cholesterol-binding affinity of the platform, demonstrating its superior lipid-clearing efficiency through selective cholesterol sequestration and enhanced membrane interaction dynamics. Together, these findings establish a molecular-to-tissue therapeutic paradigm offering a safe and effective strategy for the treatment of AS.

QuestionIs discontinuation of guideline-directed medical therapy (GDMT) after catheter ablation feasible and safe in patients with atrial fibrillation (AF) with improved cardiac function?FindingsIn this randomized clinical trial of 50 patients with AF and heart failure (HF) with improved ejection fraction (suspected with AF-mediated cardiomyopathy), phased GDMT withdrawal in those with normalized left ventricular ejection fraction and sinus rhythm resulted in HF deterioration in 3 of 23 patients (13%) compared with none in the continuation group. This was not a statistically significant difference.MeaningAlthough this study did not find significantly more HF deterioration in patients who discontinued GDMT vs those who continued, further studies are needed to determine whether GDMT can be safely discontinued in this population. This pilot randomized clinical trial assesses whether phased withdrawal of heart failure medication in patients who have undergone catheter ablation for atrial fibrillation (AF) and experienced improvements in cardiac function is feasible and safe. ImportanceWithdrawal of guideline-directed medical therapy (GDMT) for heart failure (HF) is common after atrial fibrillation (AF) catheter ablation and recovery of cardiac function, but safety remains uncertain.ObjectiveTo assess the feasibility and safety of phased GDMT withdrawal in patients with AF with highly suspected AF-mediated cardiomyopathy after catheter ablation.Design, Setting, and ParticipantsThis open-label pilot randomized clinical trial included adult patients who were enrolled and randomized from April 13, 2023, to September 19, 2024, at Beijing Anzhen Hospital, China, with a 6-month follow-up. Eligible patients were those with suspected AF-mediated cardiomyopathy at 3 months after ablation, defined by sinus rhythm at 3 months after ablation, absence of other suspected cardiomyopathies, improvement of left ventricular ejection fraction (LVEF) from 45% or less to 55% or more, normalized LV end-diastolic diameter (LVEDD), N-terminal pro-brain natriuretic peptide (NT-proBNP) levels less than 250 ng/L, and no HF symptoms or signs.InterventionsPatients were randomly assigned in a 1:1 ratio to phased GDMT withdrawal or GDMT continuation.Main Outcomes and MeasuresThe primary end point was HF deterioration, defined as LVEF decline more than 10% to less than 55%, LVEDD increase more than 10% and beyond normal, NT-proBNP levels doubling to more than 400 ng/L, or worsening HF signs or symptoms. Secondary outcomes included cardiovascular events, changes in echocardiographic and cardiac magnetic resonance (CMR) parameters, NT-proBNP levels, Kansas City Cardiomyopathy Questionnaire-12 (KCCQ-12) scores, atrial arrhythmia recurrence, and adverse drug events.ResultsAmong 50 patients enrolled and randomized, 47 completed follow-up (median [IQR] age, 56.0 [48.0-60.5] years; 37 males [78.7%]), including 23 (48.9%) in the GDMT withdrawal group and 24 (51.1%) in the continuation group. HF deterioration occurred in 3 patients with GDMT withdrawal (13.0%) and 0 with GDMT continuation (0%) (P = .11). Early GDMT reinitiation in 3 patients with HF deterioration showed recovery of LVEF or NT-proBNP. No cardiovascular events occurred. Median (IQR) echocardiographic (LVEF: 0% [-3.0% to 3.5%] vs 1.5% [-5.0% to 5.0%]), CMR (LVEF: -2.1% [-7.2% to 4.6%] vs 2.9% [-2.6% to 7.4%]), and KCCQ-12 score (0 [0 to 0.5] vs 0) changes were similar between groups. Median (IQR) NT-proBNP levels declined more in the GDMT continuation group than the withdrawal group (-25.7 [-33.6 to -6.7] pg/mL vs 2.7 [-21.4 to 24.2] pg/mL; P = .03). Adverse drug events were more frequent in the GDMT continuation group than the withdrawal group (5 [20.8%] vs 0 [0%]; P = .050). Arrhythmia recurrence rates were comparable (GDMT withdrawal: 3 [13.0%] vs continuation: 3 [12.5%]).Conclusions and RelevanceIn this pilot randomized clinical trial of carefully selected patients with AF with normalized cardiac function and sinus rhythm after catheter ablation, 13% of patients with GDMT withdrawal experienced HF deterioration, whereas drug-related complications were more common in the continuation group, suggesting that further studies are needed to determine whether GDMT can be safely discontinued in this population.Trial RegistrationChinese Clinical Trial Registry Identifier: ChiCTR2300077439

The role of prophylactic cavotricuspid isthmus (CTI) ablation remains controversial in atrial fibrillation (AF) patients without atrial flutter (AFL). Given the strong association between AF, AFL, and age, this study aimed to evaluate the impact of additional CTI ablation on recurrence-free survival, with a focus on age-stratified outcomes. Between June 2020 and June 2022, 1226 paroxysmal AF patients without AFL who underwent first AF catheter ablation at Beijing Anzhen Hospital were enrolled. 899 patients underwent pulmonary vein isolation (PVI) alone (PVI group) and remaining 327 patients underwent additional CTI ablation (PVI + CTI group). Both groups were stratified into four age quartiles to assess age-related recurrence risk. Over a median 36.6-month follow-up, prophylactic CTI ablation did not have a better outcome in overall population. In the PVI + CTI group, the oldest age quartile (> 70 years) was independently associated with a lower risk of recurrence compared with the youngest quartile (≤ 56 years; adjusted HR 0.41, 95

This study investigated the association between serum uric acid (UA) levels and atrial fibrillation (AF) burden in Chinese patients with AF. In this cross-sectional study, AF burden was defined as the proportion of AF duration to total monitoring time, recorded by a patch device over ≥24 hours. Serum UA levels were measured at the start of monitoring. Multivariate logistic regression was used to assess associations. A total of 952 patients with AF (66.4% women; median age 64 years) were included. A 1-SD increase in UA (91.4 μmol/L) was associated with elevated risk of persistent AF (adjusted OR: 1.32; 95% CI: 1.12–1.55; P < 0.001). The highest UA quintile had a greater risk of persistent AF than the lowest quintile of patients (adjusted OR: 2.43; 95% CI: 1.49–3.98; P for trend < 0.001). Serum UA levels are positively associated with AF burden in a dose-dependent manner. UA might serve as an accessible biomarker and potential therapeutic target for AF burden assessment.

Objectives: Real-world data on oral anticoagulant (OAC) use patterns and dosing appropriateness in patients with nonvalvular atrial fibrillation (AF) remain limited in China. This study aims to characterize trends in OAC prescribing and assess the dosing appropriateness of direct oral anticoagulants (DOAC) in nonvalvular AF. Methods: This is a retrospective secondary analysis of the prospective China-AF Registry (ChiCTR-OCH-13003729, registered on October 22, 2013), using data from patients with nonvalvular AF who were discharged on OAC between 2011 and 2022. Real-world trends in warfarin versus DOAC use and dosing appropriateness were evaluated. Predictors of inappropriate DOAC dosing were identified. Results: Among the included patients, 10,205 received warfarin and 15,084 received DOAC. The proportion of DOAC prescriptions increased from 0% in 2011 to 98% after 2020, whereas warfarin use declined from 99.74% to 1.99%. The shift accelerated after 2017, coinciding with the inclusion of dabigatran and rivaroxaban into the National Reimbursement Drug List. DOAC were less frequently prescribed to high-risk patients, including those with higher CHA 2 DS 2 -VASc (congestive heart failure, hypertension, age [≥75 years earns 2 points, 65–74 years earns 1 point], diabetes mellitus, prior stroke, transient ischemic attack, or thromboembolism [2 points], vascular disease [e.g., prior myocardial infarction, peripheral artery disease], and female sex category) and hypertension, abnormal renal/liver function, stroke, bleeding history or predisposition, labile international normalized ratio, elderly (>65 years), drugs/alcohol use (HAS-BLED) scores, older age, and lower creatinine clearance (all P for trend < 0.05). Inappropriate dosing was more prevalent in these higher-risk groups ( P for trend < 0.001). Older age was independently associated with inappropriate dosing (per 10 years, odds ratio [OR] = 1.39; 95% confidence interval [CI], 1.29–1.51; P < 0.001). In contrast, male (OR = 0.77; 95% CI, 0.65–0.91; P = 0.002), prescriptions post-2017 (OR = 0.12; 95% CI, 0.07–0.20; P < 0.001), persistent AF (OR = 0.78; 95% CI, 0.67–0.92; P = 0.002), and dabigatran use (OR = 0.020; 95% CI, 0.020–0.028; P < 0.001) were associated with lower odds of inappropriate dosing. Conclusions: From 2011 to 2022, OAC prescribing in China shifted dramatically from warfarin to DOAC, with more rapid DOAC adoption after the 2017 National Reimbursement Drug List update. Although DOAC dosing appropriateness improved over time, inappropriate dosing remained common in higher-risk patients, particularly older adults.

BACKGROUND:The impact of body mass index (BMI) on the outcomes of radiofrequency catheter ablation (RFCA), including atrial fibrillation (AF) recurrence rate, cardiac remodelling, and quality of life (QoL), remains uncertain. METHODS:We analysed 12 104 first-time RFCA patients from the China-AF registry, stratified by BMI: under/normal weight (< 25 kg/m2), overweight (25-29.9 kg/m2), and obese (≥ 30 kg/m2). The primary outcome was AF recurrence. Exploratory outcomes included 12-month echocardiographic parameters and Atrial Fibrillation Effect on Quality-of-Life (AFEQT) scores. Multivariable Cox regression, median regression, restricted cubic splines (RCS), and subgroup analyses were performed. RESULTS:In this cohort (median age 61.55 years, 32.6% female), obese patients were significantly younger with higher comorbidities burdens. Over a median follow-up of 47.5 months, 4932 (40.8%) patients experienced AF recurrence. BMI exhibited a linear, dose-dependent association with recurrence risk (fully adjusted HR 1.01, 95% CI, 1.00-1.02; obese HR 1.16, 95% CI: 1.05-1.28), consistent across primary analyses, sensitivity analyses using Chinese BMI classification standards, and subgroups (with stronger associations in males, < 65 years, persistent AF), without significant interactions across these subgroups (all pinteraction > 0.05). Exploratory analyses suggested obesity was linked to nonlinearly higher 12-month left ventricular end-diastolic diameter (LVEDD; 2.17 mm, 95% CI: 0.79-3.55) and left ventricular wall thickness (LVWT; 0.81 mm, 95% CI: 0.45-1.17) versus under/normal-weight, with nonlinear association in primary analysis (both pnonlinear < 0.05). CONCLUSION:Higher BMI exhibits a linear association with AF recurrence post-RFCA. Obesity is linked to nonlinear adverse remodelling (LVEDD and LVWT).

Abstract BACKGROUND Atrial fibrillation (AF) remains difficult to explain using a single focal-driver or rotor-centered mechanism across disease stages. We tested whether progressive atrial substrate remodeling can drive a critical transition toward turbulence-like, decentralized multi-wavelet electrical activity. METHODS We constructed a controlled two-dimensional atrial reaction-diffusion model with six graded substrate-remodeling stages. We evaluated effective wavelength, theoretical wavelet capacity, AF inducibility, vulnerable-window dynamics, spatial randomness, temporal memory, spectral dispersion, nonlinear indices, virtual ablation response and ERP-prolongation reverse mechanistic testing. RESULTS Progressive remodeling shortened effective wavelength from 12.0 to 2.4 cm and increased theoretical wavelet capacity from 0.69 to 17.36. Inducibility rose sigmoidally as wavelength shortened, with a model-derived transition near lambda50=4.5 cm. Advanced substrates showed increased wavebreak, spatial randomness, short-memory dynamics, broad spectral dispersion, positive nonlinear indices and resistance to random local ablation. Culprit atrial premature beats within the vulnerable window efficiently triggered AF, whereas counter-pacing at 20 to 35 ms reduced inducibility from 52% to 11% in stage 2. CONCLUSIONS In this controlled model, AF initiation and maintenance were linked to substrate-dependent wavelength, wavelet capacity and vulnerable-window triggering. The model-derived transition provides a testable framework for future high-density mapping, patient-specific modeling and device-based studies. Clinical Perspective WHAT IS KNOWN? Pulmonary-vein ectopy, acute autonomic or metabolic triggers and other perturbation sources can initiate paroxysmal or self-limited AF, particularly when they fall into a transient physiological atrial vulnerable window. Substrate remodeling with refractory-period shortening, slow conduction and fibrosis is recognized as a key determinant of AF maintenance, but a quantitative wavelength threshold separating trigger-dependent AF from self-maintaining turbulence-like AF has not been established. WHAT THE STUDY ADDS In this controlled two-dimensional model, the inducibility analysis provides a quantitative estimate of an effective transition near 4.5 cm, offering a measurable framework for examining AF maintenance beyond focal-driver or rotor-centered explanations. The model links perturbation-source strength, physiological vulnerable-window timing and substrate capacity into a single framework, explaining how apparently physiological AF initiation can become pathological sustained AF when wavelength shortens and wavelet capacity increases. A virtual counter-pacing experiment shows that time-locked stimulation after a culprit atrial premature beat can pre-empt local excitability, close the vulnerable window and reduce AF inducibility, suggesting a testable trigger-interception strategy.

BACKGROUND:Despite the growing use of catheter ablation for atrial fibrillation, large-scale studies assessing the efficacy and safety of oral anticoagulation (OAC) after ablation, particularly in patients with high stroke risk, remain limited. METHODS:This prospective study enrolled consecutive patients from the China-AF (China Atrial Fibrillation) registry between August 2011 and June 2022. Stroke risk was stratified by CHA2DS2-VA score as low (0-1), intermediate (2), or high (≥3). The study end points were thromboembolism (ischemic stroke or systemic embolism), and bleeding (International Society on Thrombosis and Hemostasis major bleeding and clinically relevant non-major bleeding). A 6-month landmark analysis was applied to evaluate the association of OAC with end points using incidence rates and Cox models. RESULTS:Among 13 669 patients (median follow-up, 4.0 years), 2637 continued and 11 032 discontinued OAC at the 6-month landmark. OAC was not associated with reduced thromboembolism risk across low- (adjusted hazard ratio [aHR], 1.11 [95% CI, 0.70-1.77]; P=0.649), intermediate- (aHR, 0.64 [95% CI, 0.36-1.16]; P=0.141) or high-stroke risk patients (aHR, 1.05 [95% CI, 0.74-1.48]; P=0.801). In contrast, continued OAC was associated with higher bleeding risk, including clinically relevant non-major bleeding across stroke risk strata, and International Society on Thrombosis and Hemostasis major bleeding among high-risk patients (aHR, 2.32 [95% CI, 1.19-4.50]; P=0.013). These results were consistent across subgroups and sensitivity analyses. CONCLUSIONS:In this large, real-world cohort of patients with atrial fibrillation undergoing catheter ablation, continued OAC was not associated with lower thromboembolic risk, but with higher major bleeding risk among patients with CHA2DS2-VA scores ≥3. These findings support individualized post-ablation anticoagulation strategies and warrant future investigation. REGISTRATION:URL: https://www.clinicaltrials.gov; Unique Identifier: NCT06987825.

Atrial fibrillation (AF) increases the risk of stroke and heart failure, yet accurate quantification of AF burden in daily life remains difficult. Although smartwatch photoplethysmography (PPG) supports continuous monitoring, complex rhythms and signal noise can impair burden estimation. We developed an AI-enhanced dual-modal framework that combines continuous watch-based PPG (W-PPG) with intermittent single-lead watch-based ECG (W-ECG). A hybrid convolutional neural network-long short-term memory model uses high-fidelity W-ECG segments as dynamic anchors to correct long-term W-PPG classifications. In this prospective validation study, 1,054 patients with AF undergoing catheter ablation (mean age, 62.1 years) were evaluated against patch-based ECG as the reference standard. After ECG-based correction, the system achieved 98.60% sensitivity and 99.27% specificity. The mean absolute percentage error of AF burden decreased by 23.4%, from 1.11% to 0.85%, while the Pearson correlation remained 0.9988. This dual-modal approach offers a scalable and clinically practical solution for long-term AF monitoring, improving burden estimation beyond PPG-only devices without requiring continuous multi-lead ECG. It may support personalized AF management and large-scale cardiovascular screening in real-world settings. (NCT06552468)

AIMS:Though pulsed-field ablation (PFA) has demonstrated an excellent safety profile in reducing collateral injury to the oesophagus and phrenic nerve, it is still associated with specific effects, including electrode heating, haemolysis, and electrolysis due to excessive energy dispersion. This study aims to assess whether saline irrigation during PFA application could mitigate these risks. METHODS AND RESULTS:To comprehensively evaluate the effect of irrigation with the variable-loop circular catheter (VLCC), the following experiments were performed: (i) ex-vivo potato model: to evaluate the lesion depth, bubble formation, and thermal effects in different irrigation regimens; (ii) in vitro blood pool and cardiac ablation: to determine the haemolysis status and tissue temperature change after PFA; (iii) in vivo swine ablation (n = 8), and (iv) clinical randomized trial (n = 25): to compare the efficacy and safety profile between low (4 mL/min) and high (30 mL/min) flow irrigation using the VLCC. Though peak core temperatures at 5 mm depth were all < 50°C under low- and high-irrigation, high irrigation significantly mitigated the instant electrode and deep tissue heating both in the potato and isolated cardiac models. Ex vivo potato slices showed that high-flow irrigation produced the deepest lesion sets when compared to low-flow irrigation (5.94 ± 0.29 mm vs. 5.36 ± 0.33 mm, P = 0.043). Assessment from a high-speed camera and bubble detector demonstrated that high-flow irrigation significantly reduced the total number of gaseous bubbles (54.50 IQR 53.00-56.75 vs. 82.00 IQR 72.00-83.00, P < 0.001) and eliminated the occurrence of larger bubbles. The high-flow irrigation group showed a smaller increase in the level of free haemoglobin immediately after the procedure across the blood pool, swine, and clinical models. Haptoglobin and lactate dehydrogenase levels were also attenuated by high irrigation in the in vivo swine model and clinical trial. One swine in the low-irrigation group developed an acute cerebral lesion (3 mm). The clinical trial confirmed that the incidence of silent cerebral lesions was significantly lower in the high-flow irrigation group (16.7% vs. 66.7%, P = 0.036). CONCLUSION:Proper saline irrigation during PFA with VLCC may mitigate electrode-associated haemolysis, reduce electrode and tissue temperature, limit bubble aggregation, and be associated with a lower incidence of silent cerebral lesions, the clinical significance of which remains unclear.

Aim: To evaluate the long-term impact of obstructive sleep apnea (OSA) risk profile on atrial fibrillation (AF) recurrence after catheter ablation in patients with paroxysmal AF. Methods: This prospective study enrolled 161 patients with paroxysmal AF undergoing initial ablation. Patients were stratified by the Berlin Questionnaire (BQ) into high-risk (n = 94) and low-risk (n = 67) OSA groups. Atrial tachyarrhythmias occurring within the initial three months were defined as early recurrence, whereas recurrence beyond three months was defined as late recurrence. A subgroup of 71 patients with recurrence underwent a redo ablation. Results: After 16.1 ± 0.4 years, multivariable models revealed that a BQ-defined high OSA risk was independently associated with early recurrence (odds ratio [OR] 1.99, 95% confidence interval [CI] 1.02-3.86, P = 0.043), whereas it was not independently associated with late recurrence after the initial procedure (hazard ratio [HR] 1.05, 95%CI: 0.70-1.57, P = 0.810). Cox regression identified early recurrence (HR 2.95, 95%CI: 1.99-4.39, P < 0.001) and baseline high-sensitivity C-reactive protein (hs-CRP; HR 1.02, 95%CI: 1.00-1.03, P = 0.022) as independent predictors of late recurrence after the initial procedure. Following redo ablation, early recurrence remained a strong independent predictor (HR 5.93, 95%CI: 2.13-16.50, P < 0.001). Conclusions: The BQ-defined high OSA risk was an independent predictor of early recurrence; however, it was not significantly associated with late recurrence after AF ablation. Early recurrence was the strongest predictor of long-term outcome, highlighting the importance of management during the post-procedural blanking period.

BACKGROUND:nGENTM generator is a new-generation radiofrequency (RF) energy device widely used in the catheter ablation of atrial fibrillation. Compared with SMARTABLATETM (SMA), a lower displayed impedance of nGEN can be observed during electrophysiology procedures. However, whether this impedance disparity affects ablation lesion size remains unelucidated. METHODS:Fresh ex vivo porcine hearts were used for the experiment. Impedance of the same marked points on porcine left ventricle was measured using both generators. Ablations were performed at varying RF power (35 W, 45 W) and ablation index (AI; 400, 450, 550). Five lesions for each combination of settings were created with both generators and their lesion sizes were compared. RESULTS:The impedance of nGEN was notably lower than SMA (78.1±3.2Ω vs. 87.5±4.2Ω, p < 0.05). Under identical application settings, lesion depth, maximum length, and volume did not differ significantly between the two generators in any of the groups. Surface measurements of maximum diameter and area also showed no significant differences except at 45 W/AI  =  450, where nGEN generated significantly larger values than SMA (6.5 [6.4-6.9]mm vs. 5.8 [5.5-6.0]mm; 22.8 [22.5-24.4]mm2 vs. 20.3 [18.8-20.5]mm2; all p < 0.05). Lesion depth, maximum length, and volume of both generators were strongly correlated with AI (nGEN: r = 0.796, r = 0.657, r = 0.769; SMA: r = 0.794, r = 0.678, r = 0.733; all p < 0.05). CONCLUSIONS:nGEN displays lower impedance than SMA. Lesion sizes are overall comparable between the two generators in AI-guided ablation, with the exception of surface measurements at 45 W/AI  =  450.

BACKGROUND:Nonvalvular atrial fibrillation (NVAF) patients with low CHA2DS2-VASc scores still have a risk of atrial thrombus formation. This study aims to identify these patients' risk factors for intracardiac thrombus or sludge. METHODS:We conducted a retrospective study of 919 consecutive hospitalized NVAF or atrial flutter patients with a CHA2DS2-Vas score ≤ 1 (male) and ≤ 2 (female) who underwent transesophageal echocardiogram (TEE) before catheter ablation at Beijing An Zhen Hospital from November 2016 to December 2017. We collected the clinical and echocardiographic characteristics of the patients. RESULTS:Excluding seven patients with hypertrophic cardiomyopathy, 919 patients, including 17 identified left atrial appendage (LAA) thrombus/sludge and 902 without LAA thrombus/sludge, were included. Among 17 patients with LAA thrombus/sludge, 16 (94.1%) had non-paroxysmal AF. A subgroup analysis was conducted in 403 non-paroxysmal atrial fibrillation (AF) patients. 87.8% had spontaneous echo contrast (SEC), 59.3% had severe or more severe SEC, and 4.0% had thrombus/sludge. In the multivariable model, female (odds ratio [OR] 4.612, 95% [CI] 1.454-14.627, p = 0.009) and LA diameter ≥ 45 mm (OR 13.340, [CI] 3.601, 49.415, p < 0.001) remained significantly independently associated with LAA thrombus/sludge. CONCLUSION:Among patients with NVAF and CHA2DS2-VASc scores ≤ 1 (male) and ≤ 2 (female), those non-paroxysmal AF patients who were female and had an LA ≥ 45 mm still had a risk of LAA thrombus/sludge formation.

Importance:Although Valsalva maneuver (VM) remains the guideline-directed emergent treatment for supraventricular tachycardia (SVT), its success rate remains suboptimal. Objective:To assess the efficacy of a novel handheld Valsalva assist device, which can assist in achieving and maintaining target intrathoracic pressures, in improving sinus rhythm restoration rates in patients with SVT. Design, Setting, and Participants:This single-center, open-label randomized clinical trial conducted at Beijing Anzhen Hospital randomized patients with SVT (aged 16-80 years, enrolled between April 2022 and April 2023) undergoing electrophysiological study at a tertiary hospital. Data analysis was completed from January 2024 to January 2025. Intervention:Participants received either device-assisted VM (n = 106) or standard VM (n = 106) during induced SVT. Main Outcomes and Measures:The primary outcome was immediate cardioversion success (12-lead electrocardiogram-confirmed sinus rhythm within 1 minute) postintervention by intention-to-treat analysis. Results:A total of 212 patients were randomized, among whom 210 completed the randomly assigned VM and were included in the primary analysis (106 in the standard VM group and 104 in the device-assisted VM group). Mean (SD) patient age was 48.4 (14.0) years, and 114 patients (54.8%) were female. After 2 VMs, 67 of 106 participants in the VM with device assist group (63.2%) vs 31 of 106 participants in the standard VM group (29.2%) converted to sinus rhythm within 1 minute (odds ratio, 4.16; 95% CI, 2.36-7.47; P < .001). Conclusions and Relevance:Per the results of this randomized clinical trial, the handheld Valsalva assist device significantly enhances VM effectiveness, providing a potentially implementable solution for SVT management. Trial Registration:ClinicalTrials.gov Identifier: NCT06622772.

Background:Effective rate control is important in the management of atrial fibrillation (AF). However, the relationship between resting heart rate (RHR) and adverse outcomes in hospitalized patients remains uncertain. Objective:This study was to evaluate the association between RHR and in-hospital outcomes. Methods:Data from the Improving Care for Cardiovascular Disease in China-AF project from 2014 to 2019 were retrospectively analyzed. The primary outcome was the composite of in-hospital all-cause mortality and in-hospital acute heart failure (AHF). Secondary outcomes included stroke/transient ischemic attack (TIA) and bleeding during hospitalization. Logistic regression analyses were used to assess the association between RHR and outcomes. Results:Our study included 12,775 patients hospitalized for AF in 236 hospitals. Logistic regression analyses using different models showed a significant association between RHR exceeding 80 bpm and an increased risk of the primary outcome (adjusted OR: 1.79 [95% CI: 1.44-2.22]). A positive association between RHR and the primary outcome was identified with RHR ≥ 80 bpm. Marginal effect analyses showed that patients with advanced AF types were at higher risk across the range of RHR. Conversely, catheter ablation, but not antiarrhythmic drug use, was associated with a decreased risk. Conclusion:A significant association was identified between RHR and adverse outcomes in patients hospitalized for AF, where RHR exceeding 80 bpm was associated with an increased risk. Trial Registration: ClinicalTrials.gov identifier: NCT02309398.

BACKGROUND:Tumor necrosis factor superfamily 14 (TNFSF14) has been implicated in the pathogenesis of cardiovascular disease, including atrial fibrillation (AF). However, its role in predicting AF recurrence after catheter ablation (CA) remains unexplored. OBJECTIVE:This study aimed to evaluate the predictive value of TNFSF14 for AF recurrence post-ablation. METHODS:A total of 263 AF patients undergoing CA were enrolled and stratified into two groups based on AF recurrence during a mean follow-up of 363 ± 144 days. Plasma TNFSF14 levels were measured by enzyme-linked immunosorbent assay (ELISA). Cox proportional hazards models were employed to examine the association between TNFSF14 levels and AF recurrence, while Receiver Operating Characteristic (ROC) analysis was used to assess predictive performance. RESULTS:AF recurrence occurred in 81 patients (30.8%). Patients with recurrence exhibited significantly higher baseline TNFSF14 levels (1.21 ± 0.24 vs. 1.02 ± 0.29 ng/mL, p < 0.001). Elevated TNFSF14 levels were independently associated with AF recurrence (Adjusted hazard ratio (aHR): 3.65, 95% CI: 2.19-6.09, p < 0.001). ROC analysis demonstrated moderate predictive power for TNFSF14 (AUC: 0.70). Incorporating TNFSF14 levels into the ATLAS score and BNP significantly enhanced the predictive performance for recurrence, as evidenced by improved time-dependent AUC, decision curve analysis, net reclassification improvement (NRI: 0.36, p < 0.001) and integrated discrimination improvement (IDI: 0.08, p = 0.012). CONCLUSIONS:TNFSF14 is a promising biomarker for predicting AF recurrence after CA. It holds potential for inclusion in future personalized risk models for AF recurrence.