Background:Accurate prediction of left atrial appendage thrombus (LAAT) is critical for stroke prevention in patients with nonvalvular atrial fibrillation (AF). We investigated the incremental value of epicardial fat tissue (EFT) metrics derived from cardiac computed tomography angiography (CCTA) beyond conventional risk factors. Methods:In this retrospective study of 287 AF patients prior to ablation, CCTA was used to measure left atrial appendage volume (LAAV) and EFT volume within 1 mm of the left atrium (EFT1). Multivariate logistic regression analysis identified predictors of LAAT or prethrombotic state (thrombus/spontaneous echo contrast), which were incorporated into a nomogram. Model performance was evaluated using the area under the curve (AUC), calibration plots, and decision curve analysis. Results:The thrombus group exhibited significantly larger LAAV (15.07 ± 2.7 mL vs. 11.94 ± 2.55 mL, p < 0.001) and EFT1 volume (6.39 ± 1.38 mL vs. 5.36 ± 1.47 mL, p < 0.001) compared to the normal/SEC group. Multivariate analysis identified EFT1 (odds ratio [OR] = 1.57 per mL), LAAV (OR = 1.56 per mL), and the CHA2DS2-VA score (OR = 1.34 per point) as independent predictors. The resulting nomogram demonstrated excellent discrimination for LAAT (AUC = 0.851) and for thrombus/SEC (AUC = 0.819), with good calibration and clinical utility. Conclusion:EFT1, the EFT volume immediately adjacent to the left atrium, is strongly associated with LAAT. The novel nomogram integrating EFT1, LAAV, and the CHA2DS2-VA score provides enhanced risk stratification for thrombotic and prethrombotic states in patients with AF.

Pulmonary vein pulsed-field ablation (PFA) is widely regarded as a safe procedure for patients with atrial fibrillation (AF), with sinoatrial disturbances as a rare complication. A 62-year-old female patient with paroxysmal AF underwent ablation using an 8-polar circular PFA catheter. During pulmonary vein isolation (PVI) of the right superior pulmonary vein, an intermittent increase in sinus rate was noted. Recurrent sinoatrial block was observed shortly after the procedure but resolved completely within six hours. This report presents the first documented case of transient sinoatrial node dysfunction as a complication of pulmonary vein PFA. Although the underlying mechanism—whether singular or multifactorial—remains unconfirmed, this case highlights the need for caution when utilizing the 8-polar circular PFA catheter.

Background Pulsed field ablation (PFA) is an emerging nonthermal ablation modality that can penetrate scar tissue more deeply. However, the evidence supporting its application in ventricular arrhythmias (VAs) is limited. This study summarizes relevant research and aims to evaluate the safety and efficacy of PFA in the treatment of premature ventricular contractions (PVCs) or ventricular tachycardia (VT).Methods A computer-based search of PubMed, Embase, and the Cochrane Library identified studies evaluating PFA for VAs from database inception to December 31, 2025. Primary outcomes included acute procedural success rate, short- to mid-term success rate, and perioperative complication rate. A meta-analysis of single-arm studies was performed using a random-effects model with StataMP18.Results Six studies were included, comprising 149 patients (84 with PVCs, 65 with VT). The overall acute success rate was 88% (95% CI: 82%-93%), with PVCs at 88% (95% CI: 79%-95%) and VT at 90% (95% CI: 80%-97%). The short-to-mid-term success rate was 73% (95% CI: 65%-80%) overall, with 80% (95% CI: 70%-89%) for PVCs and 63% (95% CI: 46%-80%) for VT. The overall perioperative complication rate was 15% (95% CI: 6%-26%). PFA for VT ablation had longer procedure and fluoroscopy times, as well as a greater number of PFA applications, compared to PVCs, but with considerable heterogeneity.Conclusions PFA demonstrates a good acute success rate and an acceptable perioperative complication rate in the treatment of VAs. While it shows a higher short-to-mid-term success rate in PVCs patients, its efficacy in VT patients remains limited.

ABSTRACT In patients undergoing alcohol septal ablation for hypertrophic obstructive cardiomyopathy, complete atrioventricular block can be delayed and recurrent. A semi‐permanent pacemaker serves as an effective bridging therapy, allowing for extended monitoring of conduction recovery and may spare selected patients from permanent device implantation.

Objective:To evaluate the effects of music intervention on heart rate variability (HRV). Methods:The protocol of this systematic review has been submitted for registration in the PROSPERO databa se, an international prospective register for sys tematic reviews, with ID number CRD420261283257. Data sources included electronic databases searched from inception through January 2026. Randomized clinical trials comparing music intervention with control were included. The primary outcomes were changes in HRV parameters after music intervention or control compared to baseline within each group. Mean differences (MD) with 95% confidence intervals (CI) were calculated for continuous variables. The methodological quality of the studies was assessed according to the Cochrane Handbook. Publication bias was evaluated using funnel plots and Egger's regression test. Results:A total of 24 randomized controlled trials involving 1,295 participants were analyzed. The meta-analysis demonstrated that music intervention significantly increased high-frequency power in normalized units (HFnu) compared to control groups (MD = 7.05, 95% CI: 1.00-13.10, p = 0.02), while significantly decreasing low-frequency power in normalized units (LFnu) (MD = -4.94, 95% CI: -9.13 to -0.76, p = 0.02). Subgroup analyses revealed that patients with stress/anxiety/fear/sleep disorders showed the most substantial improvements across multiple HRV parameters. Short-term interventions (≤30 min) were particularly effective for enhancing HFnu, and participant-selected music yielded superior outcomes compared to standardized music. The overall evidence quality was rated as moderate for the primary outcomes. Conclusion:Music intervention significantly improved LFnu and HFnu compared to control groups. People with emotional disorders can improve their HRV through music intervention. Systematic review registration:PROSPERO, Identifier: CRD420261283257.

INTRODUCTION:Left bundle branch area pacing (LBBAP) represents an essential physiological pacing technique, and conduction system (CS) capture can be achieved even in the absence of detectable CS potential. We aimed to measure the distance between the electrode tip and the left ventricular conduction system (LVCS) during LBBAP. METHODS AND RESULTS:Sixteen canines are evenly divided into two groups: (1) conduction system pacing (CSP) group, including left bundle branch pacing (LBBP) and left fascicular pacing (LFP); (2) left ventricular septal pacing (LVSP) group. A three-dimensional electroanatomical mapping (EAM) system used to visualize the LVCS and guide electrode implantation. Pathological specimens are used to measure the distances between the electrode tip and LVCS, as well as the depth and angle of electrode implantation. Group 1 showed electrode tip-to-LVCS distance ≤ 2 mm versus > 2 mm in Group 2. Significant differences existed in pacing and pathological parameters between groups: stimulus to left ventricular activation time (Stim-LVAT) (48.75 ± 2.38 ms vs. 59.75 ± 2.05 ms, p < 0.01), Stim-Retro-His interval (21.00 ± 2.27 ms vs. 44.50 ± 2.83 ms, p < 0.01), QRS duration (89.50 ± 4.34 ms vs. 109.88 ± 5.96 ms, p < 0.01), the depth of electrode implantation (10.38 ± 0.53 mm vs. 9.35 ± 0.76 mm, p < 0.01), the angle of electrode implantation (76.88° ± 11.32° vs. 55.63° ± 12.66°, p < 0.01), and the distance between the electrode tip and the LVCS (0.69 ± 0.66 mm vs. 3.06 ± 0.28 mm, p < 0.01). CONCLUSION:When the distance between the electrode tip and LVCS is ≤ 2 mm, the CS could be captured at outputs of ≤ 1.5 V/0.5 ms.

In some arrhythmia centers, intraprocedural guidance using fluoroscopy alone remains the mainstream approach for left atrial appendage closure (LAAC). This study aims to synthesize recent literature and assess the feasibility of fluoroscopy‑guided LAAC performed without echocardiography. A computer-based search was conducted in PubMed, Embase, and the Cochrane Library for studies comparing fluoroscopy alone versus fluoroscopy combined with echocardiography for LAAC, from the inception of each database to September 13, 2025. Summary analysis was conducted using Review Manager 5.4. This meta-analysis included 7 studies with 2,472 patients, 1,358 in the Fluoroscopy group and 1,114 in the combined fluoroscopy‑echocardiography group (Standard group). Both groups achieved high immediate procedural success rates, with a higher rate in the Standard group (RR 0.98, 95

BACKGROUND AND AIMS:Hemolysis-related renal failure after pulsed field ablation (PFA) has been described in recently published cases, we reported the incidence of bilirubin elevation after PFA utilizing a novel hexaspline PFA catheter. METHODS:PFA was performed in patients with paroxysmal atrial fibrillation using novel hexaspline PFA catheter, and serum bilirubin, hemoglobin and renal function were measured at baseline and the next day post ablation. RESULTS:A total of 94 patients were analyzed, and 30 of 94 (31.9%) patients had obvious total bilirubin elevation the next day post PFA. In the 30 patients, 26 (86.7%) patients had a predominantly indirect hyperbilirubinemia, suggesting a likely presence of PFA-induced hemolysis. The liver enzyme contents post ablation were normal in all patients and no signs of hemolytic anemia and renal function injury were detected. The impact factors associated with indrect hyperbilirubinemia were also analyzed and higher number of applications tented to produce PFA-induced hemolysis. More than 86.5 applications seem to have a better sensivity and specificity to predict hemolysis. CONCLUSION:Intravascular hemolysis can occur after utilizing novel hexaspline catheter, but the severity of hemolysis was mild and temporary. The number of applications appears to be a determining factor leading to hemolysis.

Objectives: Some arrhythmia targets are located in the epicardium or deep myocardium, which could be reached through the vascular approach. However, it is difficult to deliver ablation catheters to the distal vessels and their branches. In small vessels, the energy released is limited, and the risk of ablation is increased. The objective of this study was to design a linear catheter with pulsed field energy that is suitable for ablation in the distal vessels and to verify its efficacy and safety in canines. Methods: A total of eight canines were randomly assigned to two observation groups: a 48-hour group (N=4) and a 30-day group (N=4). A 3 F 10-pole pulsed field ablation catheter was employed to ablate in the great cardiac vein, the middle cardiac vein, the anterior interventricular vein, and the distal small branches of the cardiac venous system. The characteristics of the ablation lesions were observed both grossly and microscopically. Results: The surgical procedure was completed successfully. Pulsed field energy can travel through the fatty tissue to form a lesion in the cardiomyocytes. The mean depth of the lesion in the 30-day group (2.37±0.53 mm) was found to be reduced by 39% (P<0.001) in comparison to that observed in the 48-hour group (3.92±0.62 mm). Additionally, a transition zone of incomplete injury was discerned in the junction area of the 48-hour group. Canines exhibited no adverse effects intraoperatively nor postoperatively, and no appreciable damage was observed in the adjacent small arteries or the surrounding organs. Conclusion: The pulsed field energy from small blood vessels can cause lasting, continuous lesions to the myocardium and is safe to use. The 3 F liner pulsed field ablation catheter has been proven to be efficacious and safe, with promising indications for future application. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: none I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes Data are available within the article or its supplementary materials. The authors confirm that the data supporting the findings of this study are available within the article or its supplementary materials.

Background:The impact of sodium-glucose cotransporter-2 inhibitors (SGLT2i) on post-ablation atrial fibrillation (AF) recurrence is still unclear. Accordingly, we investigated whether exposure to SGLT2i reduces post-ablation AF recurrence among individuals with heart failure (HF) or type 2 diabetes mellitus (T2DM). Methods:We carried out a structured search of PubMed, Embase, and the Cochrane Library from database launch through August 17, 2025. Pooled analyses were generated with RevMan 5.4 and Stata 18. Results:11 studies were included, comprising 2 randomized controlled trials (RCTs) and 9 retrospective cohort studies, with a total of 7,664 individuals. Among them, 3,390 received SGLT2i therapy, and 4,274 received non-SGLT2i therapy. Compared with the non-SGLT2i, SGLT2i was linked to decreased post-ablation AF recurrence (RR: 0.61, 95% CI: 0.52-0.71, p < 0.001). Subgroup analyses showed consistent reductions in recurrence risk in individuals with AF and T2DM (RR: 0.74, 95% CI: 0.68-0.80, p < 0.001) as well as those with AF and HF (RR: 0.61, 95% CI: 0.50-0.74, p < 0.001). Furthermore, SGLT2i corresponded to reduced all-cause mortality (RR: 0.66, 95% CI: 0.48-0.91, p = 0.010), fewer rehospitalization (RR: 0.79, 95% CI: 0.72-0.88, p < 0.001), and a lower incidence of thromboembolic events (RR: 0.56, 95% CI: 0.36-0.86, p = 0.009). Conclusions:Use of SGLT2i was linked to reduced post-ablation AF recurrence, and this association was consistent in AF individuals with T2DM as well as those with HF. Additionally, SGLT2i therapy correlated with reduced risks of all-cause mortality, rehospitalization, and thromboembolic events. Systematic Review Registration:identifier CRD420251125971.

Importance:The overall success rate of circumferential pulmonary vein isolation (CPVI) treatment in patients with paroxysmal atrial fibrillation (AF) remains suboptimal, especially in older patients. Objective:To explore the incremental benefit of low-voltage-area ablation after CPVI in older patients with paroxysmal AF. Design, Setting, and Participants:This randomized clinical trial was an investigator-initiated trial to compare the efficacy of additional low-voltage-area ablation beyond CPVI vs CPVI alone in older patients with paroxysmal AF. Participants were patients aged 65 to 80 years with paroxysmal AF who were referred for catheter ablation. They were enrolled in 14 tertiary hospitals in China from April 1, 2018, to August 3, 2020, and follow-up occurred through August 15, 2021. Interventions:Patients were randomized (1:1) to undergo CPVI plus low-voltage-area ablation or CPVI alone. Low-voltage areas were defined as areas with amplitude less than 0.5 mV in more than 3 adjacent points. If low-voltage areas existed, additional substrate ablation was performed in the CPVI plus group but not the CPVI alone group. Main Outcomes and Measures:The primary end point of the study was freedom from atrial tachyarrhythmia as documented by electrocardiogram during a clinical visit or lasting longer than 30 seconds during Holter recordings occurring after a single ablation procedure. Results:Among 438 patients who were randomized (mean [SD] age, 70.5 [4.4] years; 219 men [50%]), 24 (5.5%) did not complete the blanking period and were not included for efficacy analysis. After a median follow-up of 23 months, the recurrence rate of atrial tachyarrhythmia was significantly lower in the CPVI plus group (31/209 patients, 15%) compared with the CPVI alone group (49/205, 24%; hazard ratio [HR], 0.61; 95% CI, 0.38-0.95; P = .03). In subgroup analyses, among all patients with low-voltage area, CPVI plus substrate modification was associated with a 51% decreased risk of ATA recurrence compared with CPVI alone (HR, 0.49; 95% CI, 0.25-0.94; P = .03). Conclusions and Relevance:This study found that additional low-voltage-area ablation beyond CPVI decreased the ATA recurrence in older patients with paroxysmal AF compared with CPVI alone. Our findings merit further replication by larger trials with longer follow-up. Trial Registration:ClinicalTrials.gov Identifier: NCT03462628.

Transcatheter radiofrequency ablation has been widely introduced for the treatment of tachyarrhythmias. The demand for catheter ablation continues to grow rapidly as the level of recommendation for catheter ablation. Traditional catheter ablation is performed under the guidance of X-rays. X-rays can help display the heart contour and catheter position, but the radiobiological effects caused by ionizing radiation and the occupational injuries worn caused by medical staff wearing heavy protective equipment cannot be ignored. Three-dimensional mapping system and intracardiac echocardiography can provide detailed anatomical and electrical information during cardiac electrophysiological study and ablation procedure, and can also greatly reduce or avoid the use of X-rays. In recent years, fluoroless catheter ablation technique has been well demonstrated for most arrhythmic diseases. Several centers have reported performing procedures in a purposefully designed fluoroless electrophysiology catheterization laboratory (EP Lab) without fixed digital subtraction angiography equipment. In view of the lack of relevant standardized configurations and operating procedures, this expert task force has written this consensus statement in combination with relevant research and experience from China and abroad, with the aim of providing guidance for hospitals (institutions) and physicians intending to build a fluoroless cardiac EP Lab, implement relevant technologies, promote the standardized construction of the fluoroless cardiac EP Lab.

Background Atrial fibrillation (AF) has been a worldwide health issue with increasing prevalence and mortality. Recently, increasing attention has been gained to the relationship between heart rate variability (HRV) and the clinical prognosis of AF catheter ablation. We aimed to evaluate the prognostic value of HRV in AF recurrence. Methods We systematically searched Web of Science, PubMed, and Embase from inception until 17 August 2022 to conduct the systematic review and meta-analysis. We included the studies reporting the predictive value of HRV parameters for AF recurrence or in which HRV parameters in AF recurrence and non-recurrence groups were individually reported. Results Finally, we enrolled 16 studies, including 2,352 patients. Higher rMSSD could independently predict AF recurrence following catheter ablation (OR: 1.02, 95% CI: 1.00–1.04; p = 0.03). Higher HF (OR: 1.55, 95% CI: 1.05–2.28; p = 0.03) and lower LF/HF (OR: 1.12, 95% CI: 1.03–1.20; p = 0.004) could independently predict AF recurrence within 1 year. Higher SDNN (OR: 1.02, 95% CI: 101–1.02; p = 0.0006) could independently predict AF recurrence among patients with paroxysmal AF. Almost all HRV parameters within 3 days after catheter ablation and lnHF, lnLF, and rMSSD at 3 months after catheter ablation performed significant differences in AF recurrence and non-recurrence groups. Conclusion Heart rate variability, especially higher rMSSD (within short-term and long-term periods), was closely related to recurrent AF following catheter ablation, highlighting the clinical importance of HRV in the prognosis of AF following catheter ablation.

BackgroundThe development of pulsed field ablation (PFA) as a new technique for pulmonary vein isolation (PVI) has been advancing rapidly in recent years. My team's previous work has shown the safety and long-term efficacy of bipolar asymmetric pulses in animal experiments. However, in ongoing clinical trials, we have observed that atrial fibrillation (AF) recurs in some patients after surgery, but the rhythm returns to normal without surgical intervention after seven days, and there is no recurrence in the follow-up.Based on this observation, we have proposed the hypothesis that myocardial cell apoptosis may play a role in AF recurrence after PFA. Our team has designed animal experiments to verify this hypothesis and further investigate the process of PFA-induced cardiomyocyte apoptosis.MethodsPulse field ablation was performed on 15 dogs and the animals were dissected at various time points after the operation (immediately, 3 days, 7 days, 30 days, and 150 days). To obtain ablation voltage maps, electroanatomic mapping was performed before and after ablation and before dissection. The ablation area was also subjected to HE and TUNEL staining to analyze apoptosis and pathological results.ResultsThe edge area of the ablation in the pulmonary vein (PV) demonstrated continuous dynamic changes from 0 to 2 h after the operation and a slight expansion of the ablation range was observed in the long-term follow-up. Myocardial intima hyperplasia was observed from 0 to 7 days. Local apoptosis was detected from 0 to 2 h and massive, concentrated apoptosis was observed at 3 days. No recurrence of apoptosis was seen at 7 days, 30 days, and 150 days.ConclusionsThe results of this study showed that after pulse field ablation (PFA), the central ablation area of the canine heart experienced immediate cardiomyocyte death. Meanwhile, cardiomyocytes in the edge ablation area underwent apoptosis, which began from 0 to 2 h post-operation and ended between 3 and 7 days. This process occurred simultaneously with intimal thickening.In the long-term follow-up group, there was no recovery of isolation and no recurrence of cardiomyocyte apoptosis, and no change was observed in the endomyocardial intima.

INTRODUCTION:The anatomical substrate for idiopathic left ventricular tachycardia (ILVT) remains speculative. Purkinje networks surrounding false tendons (FTs) might be involved in the reentrant circuit of ILVT. The objective was to evaluate the anatomical and electrophysiological features of false tendons FTs in relation to ILVT.METHODS:Intracardiac echocardiography (ICE) was conducted on patients with ILVT. The relationship of the FTs with ILVT was determined using electro-anatomical mapping.RESULTS:Electrophysiological evaluation and radiofrequency ablation were conducted in 23 consecutive patients with ILVT. FTs were identified in 19/23 cases (82.6%) with P1 potentials during VT recorded at the FT in 14 of these patients (73.7%). Three FT types were identified. In type 1, the FT attached the septum to the base of the posteromedial papillary muscle (PPM) (4/19); type 2 FTs ran between the septum and the PPM apex (3/19), while in type 3, the connection occurred between the septum and apex (11/19) or between the septum and the LV free wall (1/19). The effective ILVT ablation sites were situated at the FT-PPM (3/19) and the FT-septum (16/19) attachment sites.CONCLUSIONS:This series demonstrates the association between Purkinje fibers and FTs during catheter ablation of ILVT and verifies that left ventricular FTs are an important substrate in this type of tachycardia.

Objectives: The objective was to evaluate the anatomical and electrophysiological features of false tendons (FTs) in relation to idiopathic left ventricular tachycardia (ILVT). Background: The anatomical substrate for the ILVT remains speculative. Purkinje network surrounding the FTs might be involved in the reentrant circuit of ILVT.Methods: Intracardiac echocardiography (ICE) was conducted on patients with ILVT. The relationship of the FTs with ILVT was determined using electro-anatomical mapping.Results: Electrophysiological evaluation and radiofrequency ablation were conducted on 21 consecutive ILVT patients with ILVT. FTs were identified in 15/21 cases (71.4%) with P1 potentials during VT recorded at the FT in four of these patients (26.7%). Three FT types were identified. In type 1, the FT attached the septum to the base of the posteromedial papillary muscle (PPM) (4/21); type 2 FTs ran between the septum and the PPM apex (3/21), while in type 3, the connection occurred between the septum and apex (7/21) or between the septum and the LV free wall (1/21). The effective ILVT ablation sites were situated at the FT-PPM (3/15) and the FT-septum (12/15) attachment sites.Conclusions: This is the first case series to demonstrate the association between Purkinje fibers and FTs during catheter ablation of ILVT and to verify that the left ventricle FT association is responsible for this type of tachycardia.

Objective:To evaluate the association between the duration of atrial fibrillation(AF)or atrial flutter(AFL)and stroke events recorded in cardiovascular implantable electronic devices(CIED)and stroke events as well as the intervention effect of anticoagulant therapy.Methods:The study included 2 342 patients with sinus rhythm who received dual CIED in Department of Cardiology Tianjin Chest Hospital between January 2015 to December 2019.Atrial high-rate episodes(AHRE)(electro-cardiogram documented AF/AFL or intracavitary electrogram confirmed AF/AFL, AHRE>6 min and≥250 beats/min)were recorded.Anticoagulant therapy and stroke events were obtained during follow up period.The effects of the longest AHRE duration and CHA 2DS 2-VASc score on subsequent risk of ischemic stroke were evaluated with time dependent covariate Cox models. Results:Among 2 136 patients[mean age(68.9±9.6)years, 868 male]during mean follow-up of 42 months, the longest single episode of AHRE lasted<1.0 h in 79/2 136 patients(3.7%), 1.0-5.9 h in 93(4.4%), 6.0-23.9 h in 135(6.3%) and ≥24.0 h in 211(9.9%). AHRE duration≥6 h was associated with an increased risk of subsequent stroke(adjusted hazard ratio[ HR]=3.8, P<0.05), and the stroke risk was higher when AHREs were longer than 24 hours( HR=17.3, P<0.01). Anticoagulation therapy was associated with reduced stroke risk in those patient who had anticoagulant indication(male patients with CHA 2DS 2-VASc score≥1 or in female patients with CHA 2DS 2-VASc score≥2). Conclusion:Patients with AF≥6 h had an increased risk of ischemic stroke.Regular anticoagulant therapy could reduce the risk of stroke The use of anticoagulant was reasonable in patients with AF≥6 h.

BACKGROUND Benefits of adjunctive ablation strategies beyond circumferential pulmonary vein isolation (CPVI) are uncertain in patients with persistent atrial fibrillation (PeAF).OBJECTIVES This study sought to compare clinical outcomes of CPVI plus low-voltage area (LVA) modification during STABLE-SR (SubsTrate ABlation in the LEft Atrium during Sinus Rhythm) vs circumferential pulmonary vein isolation (CPVI) alone in patients with PeAF.METHODS From March 2018 to August 2019, 300 patients with PeAF who underwent de novo ablation were recruited and prospectively randomized to either STABLE-SR group (n = 150) or CPVI alone (n = 150) group. In the STABLE-SR group, after CPVI, high-density voltage mapping of left atrium (LA) was performed during sinus rhythm, and additive ablation targeted LVA and complex electrograms, if any were present. All the ablations were titrated by ablation index. The primary endpoint was freedom from documented atrial arrhythmias lasting for $30 s without the use of antiar-rhythmic drugs, after a single ablation procedure and blanking period of 3 months.RESULTS After 18 months, atrial-arrhythmia-free survival did not differ significantly between STABLE-SR group and CPVI alone group (67.2% vs 67.4%; HR: 0.89; 95% CI: 0.55-1.36; P = 0.52). Only around one-half of the patients (50.2%) had abnormal LA substrate with a medium LVA burden of 4.6% (2.1%-9.5%). However, the success rate differs dramatically between patients with normal vs abnormal LA substrate (84.8% vs 60.9%; P < 0.001).CONCLUSIONS Additional LVA ablation did not improve successful rates of CPVI in this PeAF cohort, of whom one-half had normal LA substrate. Voltage map could identify patients with PeAF with normal LA substrate who can achieve excellent rhythm control with CPVI alone. (CPVI Alone Versus CPVI Plus Electrophysiological Substrate Ablation in the LA During SR for the Treatment of Non-PAF [STABLE-SR_II]; NCT03448562) (J Am Coll Cardiol EP 2022;8:882-891) (c) 2022 by the American College of Cardiology Foundation.