BACKGROUND:To investigate the relationship between circulatory stasis in the left atrial appendage (LAA), as detected by cardiac computed tomography angiography, and atrial fibrillation (AF) recurrence after the initial catheter ablation. METHODS:In this single-center prospective observational study, consecutive patients with nonvalvular AF scheduled for the initial catheter ablation were enrolled from August 2018 to June 2022. The primary end point was AF recurrence (any documented atrial tachyarrhythmia lasting for ≥30 seconds after a 3-month blanking period) during 1 year after catheter ablation. RESULTS:Among the enrolled 548 patients (mean age 65.3±8.8 years and 64.2% men), 131 (23.9%) were with LAA circulatory stasis. Totally, 525 patients completed the 1-year follow-up. AF recurrence was observed in 39.1% (50/128) of patients with circulatory stasis and 19.4% (77/397) of patients without circulatory stasis. The presence of LAA circulatory stasis was significantly associated with AF recurrence (adjusted hazard ratio [HR], 2.41 [95% CI, 1.57-3.72]). The incorporation of circulatory stasis in the LAA significantly improved the predictive accuracy of conventional scoring systems for AF recurrence, with the areas under the curve increasing from 0.524 to 0.616 (P=0.037) for the APPLE score, from 0.516 to 0.617 (P=0.035) for the CAAP-AF score, and from 0.532 to 0.619 (P=0.001) for the CHA2DS2-VASc score. CONCLUSIONS:In patients with nonvalvular AF, circulatory stasis in the LAA could serve as a predictor for AF recurrence following the initial ablation procedure.

Aims Accurate prediction of major adverse cardiovascular events (MACE) is crucial for risk stratification in patients with suspected coronary artery disease. CT myocardial perfusion imaging (CT-MPI) provides various parameters, which may help comprehensively characterize perfusion features. This study aimed to develop a combined model, including clinical risk factors, coronary atherosclerotic characteristics, and radiomic features derived from CT-MPI, to predict MACE. Methods and results 784 patients who underwent coronary CT angiography (CCTA) and CT-MPI from eight hospitals were retrospectively enrolled. Radiomic analysis was performed on eight perfusion parameter maps. Three prediction models were established accordingly: Model 1 (clinical risk factors and coronary atherosclerotic characteristics), Model 2 (incorporating myocardial blood flow values upon Model 1), and Model 3 (integrating radiomic scores upon Model 2). The C-indices for Model 3 in the training, internal validation, and external validation sets were 0.898 (95% confidence interval [CI]: 0.856-0.947), 0.844 (95% CI: 0.780-0.908), and 0.840 (95% CI: 0.791-0.889), respectively, demonstrating significant improvements over Model 1 and Model 2 (all P < 0.05). In the external validation set, Model 3 had the largest time-dependent areas under the curve (AUC) values for 1-, 3-, and 5-year MACE prediction (0.890 [95% CI: 0.831-0.948], 0.880 [95% CI: 0.823-0.938], and 0.837 [95% CI: 0.726-0.949]), compared with Model 1 and Model 2. Conclusion The radiomic features from multiparametric CT-MPI maps simultaneously captured perfusion features associated with MACE at both macrovascular and microvascular levels. The combined model exhibited improved MACE prognostic performance compared with conventional models while maintaining high interpretability.

Background: The necessity of thrombolytic therapy before percutaneous coronary intervention (PCI) in ST-segment elevation myocardial infarction (STEMI) patients remains controversial, requiring further evaluation of potential benefits. Purpose: To explore the efficacy of half-dose recombinant staphylokinase (r-SAK) intravenous bolus before PCI in STEMI patients. Material and Methods: Patients with STEMI were allocated to r-SAK or normal saline groups before PCI. Cardiac magnetic resonance (CMR) at 5 days after MI evaluated cardiac function, myocardial tissue characteristics, and strain. Segments were classified by late gadolinium enhancement (LGE) extent. Results: A total of 64 STEMI patients were divided into the r-SAK group (n = 33) and NS group (n = 31). Patients in the r-SAK group had a significantly higher left ventricular ejection fraction and cardiac output index (P = 0.045 and 0.024). There was no significant difference between the two groups in mapping parameters, infarct size, area at risk, or the incidence of microvascular obstruction (MVO) and intramyocardial hemorrhage (IMH) (all P >0.05). Regardless of the extent of LGE in the segments, patients in the r-SAK group exhibited significantly better segmental longitudinal strain (all P <0.001). In addition, patients from the r-SAK group had a better segmental circumferential strain in LGE segments (P = 0.044). Conclusion: For STEMI patients expected to undergo PCI within 120 min of presentation, a single bolus of half-dose r-SAK administrated before PCI improved short-term cardiac function without increasing incidence of MVO or IMH.

BackgroundWhite matter hyperintensity (WMH) is a common finding in brain magnetic resonance imaging (MRI), but its relationship with coronary plaque characteristics remains unclear.PurposeTo evaluate the association between coronary computed tomography angiography (CCTA)-derived plaque characteristics and WMH in brain MRI.Material and MethodsCCTA and brain MRI of 392 consecutive patients were retrospectively collected. Degree of total WMH was evaluated based on Fazekas scale (0-6) and classified into mild (0-2) and moderate-to-severe (3-6) groups. Besides demographic and clinical data, morphological and quantitative parameters (e.g. aortic ulcer, Agatston Score, diameter stenosis, plaque volume, plaque length) were also evaluated based on CCTA. Chi-square (or Fisher's exact) test and Student's t-test (or Wilcoxon's signed-rank test) were used for comparing variables between two groups when appropriate. Multivariate logistic regression analyses were applied to identify the independent variables associated with moderate-to-severe WMH.ResultsPatients with moderate-to-severe WMH showed older age, larger plaque burden, plaque length, volume of noncalcified and calcified plaque, higher total cholesterol, triglyceride, low-density lipoprotein, Agatston Score, and higher proportion of male, hypertension, diabetes, aortic ulcer, and obstructive coronary artery disease (CAD) (all P  < 0.05). Age (odds ratio [OR]=1.061, 95% confidence interval [CI]=1.013-1.111; P = 0.012), plaque burden (OR=15.259, 95% CI=2.466-94.412; P = 0.003), obstructive CAD (OR=8.020, 95% CI=3.628-17.727; P <0.001), and Agatston Score (OR=1.004, 95% CI=1.002-1.006; P <0.001) were found to be independently associated with moderate-to-severe WMH.ConclusionOlder age, larger plaque burden, higher Agatston score, and obstructive CAD were prone to moderate-to-severe WMH.

AIM The aim of this study was to evaluate atrioventricular block (AVB) in acute myocarditis (AM) patients and compare the differences between the non-AVB and AVB groups, as well as between nonadvanced AVB and advanced AVB subgroups using cardiac magnetic resonance (CMR). MATERIALS AND METHODS This retrospective single-centre study enrolled 105 AM patients admitted between June 2018 and April 2024 (53 non-AVB, 34 nonadvanced AVB,and 18 advanced AVB patients). CMR functional and tissue parameters were analysed. Adverse clinical outcomes were defined as death, heart failure decompensation requiring hospital readmission, or implantable cardioverter-defibrillator or cardiac resynchronisation therapy implantation. RESULTS A total of 105 patients were included (49.50% male), with a median age of 34 years. Most patients showed no evidence of ongoing AVB during CMR examination. The AVB group exhibited a significantly increased heart rate (HR) and reduced left ventricular ejection fraction (LVEF) (both p<0.05). The advanced AVB group had elevated extracellular volume (ECV) values across multiple segments (all p<0.05), while other tissue parameters had no significant differences. Additionally, the ECV of the basal superior ventricular septum effectively discriminated advanced AVB from nonadvanced AVB. Notably, adverse events occurred exclusively in three advanced patients with elevated ECV of the basal superior ventricular septum (p=0.016). CONCLUSION Increased ECV of the basal superior ventricular septum independently distinguished advanced AVB from nonadvanced AVB and was related to poor clinical outcome.

AIMS:As a novel technique, left bundle branch area pacing (LBBAP) can achieve excellent resynchronization in heart failure (HF) patients with left bundle branch block (LBBB). This study used cardiovascular magnetic resonance (CMR) to evaluate the scar burden at the lead deployment site and its ability to predict the echocardiographic response. METHODS AND RESULTS:Eighty-seven HF patients with LBBB and a left ventricular ejection fraction (LVEF)≤ 35% who underwent CMR examination and successful LBBAP implantation were retrospectively enrolled. Based on the results of the 6-month echocardiographic assessment after LBBAP, a response was defined as a reduction in the left ventricular end-systolic volume (LVESV) of ≥ 15%, and a super-response was defined as an improvement in the LVEF of ≥ 20% or greater than 50%. The myocardial scar, including global, septum, free wall, lateral and scar around lead deployment sites, was assessed by CMR. LBBAP achieved an 86.2% response rate and a 50.6% super-response rate. Compared with other LGE parameters, a superior negative linear correlation was found between the scar load around lead deployment site and LVESV reduction and improvement in LVEF, indicating that for every 1% increase in the scar burden of the lead deployment site, the delta LVESV decreased by 0.94%, and the delta LVEF decreased by 0.43%. The scar around lead deployment site can strongly predict responders and super-responders [area under the receiver operating characteristic curve (AUC: 0.87 and 0.76), respectively]. In patients with scars around deployment sites > 12.3% (cut-off values based on the Youden's index), the rates of response and super-response decreased substantially to 56.0% and 16.0%, respectively. CONCLUSION:The scar burden around lead deployment site as assessed by CMR, which is commonly located around the mid anteroseptum, can predict the echocardiographic response. Assessment of myocardial late gadolinium enhancement in the lead deployment site is recommended.

Background:The long-term effects of early thrombolytic therapy administered within 120 minutes of the first medical contact and before primary percutaneous coronary intervention (PCI) on left ventricular (LV) and left atrial (LA) function in ST-segment elevation myocardial infarction (STEMI) patients remain unknown. This study aimed to explore the long-term effects of early recombinant staphylokinase (r-SAK) thrombolysis administered up to 120 minutes before primary PCI on the LV and LA function of STEMI patients using cardiac magnetic resonance (CMR) imaging. Methods:This retrospective study analyzed the one-year follow-up CMR imaging data of STEMI patients enrolled in the multi-center, prospective OPTIMA-5 trial, conducted from November 2021 to August 2022. Patients were randomized to receive either a single half-dose of 5 mg r-SAK or normal saline (NS) before primary PCI. LV and LA functional parameters were compared between groups using appropriate statistical tests. Results:A total of 66 patients were included (r-SAK, n=32; NS, n=34). Compared to the NS group, the r-SAK group had a significantly higher cardiac index (2.77 vs. 2.41 L/min/m2, P=0.018), LV stroke volume index (42.18 vs. 37.77 mL/m2, P=0.029), LV wall thickening (49.86% vs. 44.36%, P<0.001), and LV wall motion (6.02 vs. 5.57 mm, P=0.015). The segmental circumferential strain of the non-infarcted myocardium was also superior (-19.36% vs. -17.90%, P<0.001). In relation to LA function, the r-SAK group showed better LA conduit function [change in left atrial volume index (△LAVI): 8.27 vs. 5.69 mL/m2, P=0.004], LA passive ejection fraction (27.34% vs. 20.68%, P=0.007), passive strain (21.80% vs. 17.05%, P=0.045), and peak early negative strain rate (-1.80 vs. -1.50 1/s, P=0.043). Conclusions:The early administration of r-SAK thrombolysis before primary PCI significantly improves long-term LV and LA function in STEMI patients, suggesting a potential strategy for enhancing cardiac recovery.

The OPTIMA-5 study demonstrated that a single bolus of half-dose recombinant staphylokinase (r-SAK) before primary percutaneous coronary intervention (PCI) significantly improved the patency of infarct related artery in patients with ST-elevation myocardial infarction (STEMI) expected to undergo PCI within 120 minutes. This study aimed to investigate the 1-year clinical outcome and the effect of the r-SAK antibody on a second r-SAK thrombolysis in OPTIMA-5 patients. The clinical outcome was major adverse cardiovascular events (MACE) within 360 days. Patients' r-SAK antibodies were determined on days 90 ± 7, 180 ± 7, and 360 ± 14 after thrombolysis, and in-vitro r-SAK antibody neutralization experiments were performed to explore an optimal interval for a second r-SAK thrombolysis. Results showed that the MACE incidence was numerically lower in r-SAK group compared with normal saline (NS) group (14.0% vs. 20.0%, HR 0.67, 95% CI: 0.34-1.32; log-rank P=0.245). The r-SAK antibody levels in r-SAK group decreased by time, but kept significantly higher than those in NS group on days 90 ± 7 (2.96 ± 0.68 vs. 0.22 ± 0.53, P<0.001), 180 ± 7 (2.19 ± 0.74 vs. 0.44 ± 0.65, P<0.001) and 360 ± 14 (1.73 ± 0.97 vs. 0.37 ± 0.71, P<0.001). The in-vitro r-SAK antibody neutralization experiments illustrated that the thrombolysis rate decreased exponentially as the antibody titer increased from 1.90 to 2.20 (67.80 ± 14.19% vs. 44.32 ± 21.54%, P< 0.0001). Therefore, for STEMI patients expected to undergo PCI within 120 minutes, a single bolus of half-dose r-SAK before primary PCI may reduce 1-year MACE risk. The r-SAK antibody lasts over 1 year, and a second r-SAK thrombolysis may not be indicated until 1 year after the first r-SAK thrombolysis if necessary.

PURPOSE:To estimate mean pulmonary arterial pressure (mPAP) and pulmonary vascular resistance (PVR) using cardiac magnetic resonance (CMR) in connective tissue disease-associated pulmonary arterial hypertension (CTD-PAH). MATERIALS AND METHODS:This retrospective study included 144 CTD patients (50 CTD-nonPAH, 70 CTD-PAH derivation, 24 CTD-PAH validation) from September 2017 to March 2024. Patients underwent both CMR and right heart catheterization (RHC) within 7 days. CMR parameters, including ventricular volumes, and pulmonary arterial hemodynamics, were measured and compared with RHC-derived mPAP and PVR. Multivariate regression models for mPAP and PVR were developed and validated. Spearman's correlation and Bland-Altman analysis were used to assess model accuracy. RESULTS:Ventricular mass index (VMI), interventricular septum (IVS) angle, and IVS curvature correlated strongly with RHC-based mPAP (r=0.73, 0.71, and -0.69; all P<0.01). A right ventricular ejection fraction (RVEF) threshold of 22 % was identified: when RVEF > 22 %, mPAP and RVEF were negatively correlated (P<0.001); no correlation was found when RVEF ≤ 22 % (P=0.657). For RVEF > 22 %, the following CMR model was established to predict mPAP: 32.454 + (42.616 × VMI) - (19.276 × IVS curvature). Another CMR model for predicting PVR was developed: 8.664 + (28.495 × VMI) - (0.053 × RVESVI) - (7.206 × RV SV/ESV). Validation demonstrated good correlations with RHC (mPAP: r=0.679; PVR: r=0.625, both P≤0.001). Bland-Altman analysis confirmed agreement between CMR and RHC. CONCLUSIONS:CMR provides a noninvasive method for estimating mPAP and PVR in CTD-PAH patients, with potential utility in pulmonary hemodynamic assessment.

Journal Article Gender-specific associations and circulating proteins in myocardial infarction: potential causal relationships Get access Yi Xu, Yi Xu Department of Pharmacy, Lianyungang Clinical College of Nanjing Medical University, No. 6 Zhenhua Road, Lianyungang, Jiangsu 222000, China Corresponding author. Email: [email protected] Search for other works by this author on: Oxford Academic PubMed Google Scholar Tianpu Feng, Tianpu Feng Graduate Training Base of Jinzhou Medical University at Lianyungang First People's Hospital, Lianyungang, China Search for other works by this author on: Oxford Academic PubMed Google Scholar Yuanyuan Huang Yuanyuan Huang Department of Emergency and Critical Care Medicine, The Affiliated Lianyungang Hospital of Xuzhou Medical University, Lianyungang, China Search for other works by this author on: Oxford Academic PubMed Google Scholar European Heart Journal, ehaf111, https://doi.org/10.1093/eurheartj/ehaf111 Published: 07 March 2025

To date, data about pulsed field ablation (PFA) for ventricular arrhythmias are limited, and cardiac magnetic resonance (CMR) characteristics of acute and chronic PFA lesions in the ventricles have not been described. This study sought to examine feasibility and efficacy of premature ventricular complex (PVC) ablation using focal PFA, as well as assess acute and chronic lesion characteristics using CMR. This was a prospective, single-arm study performed at two centers in China. Consecutive patients with frequent, symptomatic PVCs were consented and recruited. All procedures were performed using a comprehensive cardiac PFA system. PVC burden evaluation and CMR were performed before the procedure, within 3 days, and at approximately 6 months post-procedure. Twelve patients (mean age 54 ± 14 years, 41.7

BACKGROUND:Calciphylaxis, also termed calcific uremic arteriolopathy (CUA) in patients with end-stage kidney disease (ESKD), is a rare and fatal condition characterized by cutaneous ischemic necrosis. METHODS:Three patients with calciphylaxis and metastatic pulmonary calcification (MPC) were treated with human amnion-derived mesenchymal stem cells (hAMSCs). Effects were evaluated using the Visual Analogue Scale (VAS), modified Bates-Jensen Wound Assessment Tool for CUA (BWAT-CUA), wound quality of life questionnaire (Wound-QoL), and histological analysis. MPC was assessed by high-resolution CT (HRCT) and 99ᵐTc-methylene diphosphonate (99ᵐTc-MDP) bone scans.99ᵐTc-labeled macroaggregated albumin (99ᵐTc-MAA) pulmonary perfusion imaging was conducted for the first time in patients with MPC. RESULTS:Three patients exhibited wound healing and improvement in skin symptoms. Two months before CUA, asymptomatic MPC was detected in Patient 1, who was treated with hAMSCs for 15 months. The condition progressed to chest pain and dyspnea. HRCT and 99ᵐTc-MDP bone scans showed worsening calcification, particularly in the upper and mid-thoracic lobes.99ᵐTc-MAA pulmonary perfusion imaging revealed impaired or absent blood perfusion in the areas of metastatic calcification. Patient 1 died from respiratory failure. Patients 2 and 3 had asymptomatic MPC at calciphylaxis diagnosis. After 2 months of treatment, Patient 2, showed no significant imaging improvement and passed away 6 months after discontinuing hAMSC treatment. Patient 3 has shown no significant progression of pulmonary lesions and continues hAMSC therapy. CONCLUSION:We reported personalized early, noninvasive diagnosis and regenerative treatments for calciphylaxis patients with MPC. Although the current hAMSC treatment regimen is effective for skin lesions, its impact on MPC requires further investigation.

The Optimal Management of Antithrombotic and Thrombolytic Agents-5 (OPTIMA-5) study demonstrated that a single bolus of half the standard dose of recombinant staphylokinase (r-SAK) before primary percutaneous coronary intervention (PCI) significantly improved the patency of the infarct-related artery in patients with ST-segment elevation myocardial infarction (STEMI), who were expected to undergo PCI within 120 min. The present study aimed to investigate the one-year clinical outcomes and the effect of the anti-r-SAK antibodies on a second r-SAK thrombolysis in OPTIMA-5 patients. The clinical outcome measured was major adverse cardiovascular events (MACE) within 360 days. Patients' anti-r-SAK antibody levels were determined on day 90 (f 7 days), day 180 (f 7 days), and day 360 (f 14 days) after thrombolysis, and in vitro r-SAK antibody neutralization experiments were performed to explore an optimal interval for a second r-SAK thrombolysis. Results showed that the MACE incidence was numerically lower in the r-SAK group compared with the normal saline (NS) group (14.0% vs. 20.0%, hazard ratio [HR] = 0.67, 95% confidence interval [CI]: 0.34-1.32; log-rank P = 0.245). The anti-r-SAK antibody levels in the r-SAK group decreased with time, but remained significantly higher than those in the NS group on day 90 (f 7 days) (2.96 f 0.68 vs. 0.22 f 0.53, P < 0.001), day 180 (f 7 days) (2.19 f 0.74 vs. 0.44 f 0.65, P < 0.001), and day 360 (f 14 days) (1.73 f 0.97 vs. 0.37 f 0.71, P < 0.001). The in vitro anti-r-SAK antibody neutralization experiments demonstrated that the thrombolysis rate decreased exponentially as the antibody titer increased from 1.90 to 2.20 (67.80% f 14.19% vs. 44.32% f 21.54%, P < 0.000 1). Therefore, for STEMI patients who are expected to undergo PCI within 120 min, a single bolus of half-dose r-SAK before primary PCI may reduce the one-year MACE risk. The anti-r-SAK antibody persists over one year, and a second r-SAK thrombolysis may not be indicated until at least one year after the first administration, if necessary.

The edge effect (EE) of isolated restenosis at one or both ends of a stent is not reduced by drug-eluting stent (DES). The purpose of the study was to investigate the long-term outcome of 1-year subclinical DES-EE (sDES-EE), which was defined as any reduction in the minimal lumen area (MLA) at stent edge without any evidence of clinical ischemia. A total of 252 patients were enrolled from one of our previous randomized controlled studies, who were detected by optical coherence tomography (OCT) immediately after DES implantation and 1 year later. The primary endpoint was EE-related target lesion failure (EE-TLF) at 5 years. Secondary endpoints were the changes of morphologies and composition of stent edge plaque, and each component of EE-TLF. sDES-EE at 1 year was significantly correlated with EE-TLF at 5 years by binary logistic regression analysis after propensity scoring. The most valuable cutoff value of sDES-EE at 1 year was a 25% MLA reduction at the stent edge, according to receiver operating characteristic analysis, which showed a major increase in lipid normalized total volume (0.99 ± 0.25 mm3 vs. -0.21 ± 0.06 mm3, p = 0.025) and lipid percent atheroma volume (3.92 ± 1.34% vs. -1.22 ± 0.78%, p = 0.029). EE-TLF at 5 years was significantly higher in the sDES-EE group than in the non-sDES-EE group (15.6% vs. 4.1%, p = 0.001). sDES-EE with MLA reduction ≥ 25% at the stent edge at 1 year after PCI was an independent predictor of EE-TLF at 5 years, which was mainly caused by the progression of lipid components measured by OCT. ClinicalTrials.gov. Number NCT02140801. http://www.clinicaltrials.gov . identifier: NCT02140801.

The Agatston coronary artery calcification score (CACS) is utilized as an index to assess coronary artery calcification (CAC). The objective of this study was to investigate the characteristics of CACS in patients with end-stage kidney disease (ESKD) and establish a predictive model to evaluate the risk of severe CAC in these patients.

OBJECTIVES:To investigate whether negative remodeling (NR) detected by intravascular ultrasound (IVUS) of the side branch ostium (SBO) would affect in-stent neointimal hyperplasia (NIH) at the one-year follow-up and the clinical outcome of target lesion failure (TLF) at the long-term follow-up for patients with left main bifurcation (LMb) lesions treated with a two-stent strategy. METHODS:A total of 328 patients with de novo true complex LMb lesions who underwent a 2-stent strategy of percutaneous coronary intervention (PCI) treatment guided by IVUS were enrolled in this study. We divided the study into two phases. Of all the patients, 48 patients who had complete IVUS detection pre- and post-PCI and at the 1-year follow-up were enrolled in phase I analysis, which aimed to analyze the correlation between NR and in-stent NIH at SBO at the 1-year follow-up. If the correlation was confirmed, the cutoff value of the remodeling index (RI) for predicting NIH ≥ 50% was analyzed next. The phase II analysis focused on the incidence of TLF as the primary endpoint at the 1- to 5-year follow-up for all 328 patients by grouping based on the cutoff value of RI. RESULTS:In phase I: according to the results of a binary logistic regression analysis and receiver operating characteristic (ROC) analysis, the RI cutoff value predicting percent NIH ≥ 50% was 0.85 based on the ROC curve analysis, with a sensitivity of 85.7%, a specificity of 88.3%, and an AUC of 0.893 (0.778, 1.000), P = 0.002. In phase II: the TLR rate (35.8% vs. 5.3%, P < 0.0001) was significantly higher in the several NR (sNR, defined as RI ≤ 0.85) group than in the non-sNR group. CONCLUSION:The NR of LCxO is associated with more in-stent NIH post-PCI for distal LMb lesions with a 2-stent strategy, and NR with RI ≤ 0.85 is linked to percent NIH area ≥ 50% at the 1-year follow-up and more TLF at the 5-year follow-up.

Background: Calciphylaxis, which mostly affects individuals with end stage kidney disease (ESKD), is also known as calcific uremic arteriolopathy (CUA). It is a rare and fatal disease that manifests with calcification and thrombosis of microvessels, ischemia, and necrosis in skin tissues(ORPHA:280062). Histopathological features of extracutaneous tissues of CUA patients undergoing human amnion derived mesenchymal stem cell (hAMSC) treatment remain unknown. Methods: A female CUA patient, treated with hAMSCs for 20 months, passed away due to stroke. Histopathological features of her extracutaneous tissues were compared with those of ESKD patients (n = 7). Raman spectroscopy was applied to identify the composition of calcifications. The distribution of hAMSCs, derived from the amnion of a male fetus, in tissues of the CUA patient was determined by detecting the Y chromosome using reverse-transcription polymerase chain reaction. Results: Microvessel lesions were more prevalent in the extracutaneous tissues of the CUA patient than in those of ESKD patients, although the regenerated skin showed normal histological characteristics. The CUA patient exhibited calcifications of microvessel media, including the microvessels in the lungs, kidneys, spleen, pancreas, and uterus. Her mitral valve and kidney displayed severe calcification, identified as calcium phosphate with some calcium carbonate. hAMSCs were not detected in the tissues of the CUA patient. Conclusion: Under the treatment strategy with hAMSCs, based on the effects of skin regeneration, microvascular lesions in the extracutaneous tissues of the CUA patient were more severe than those in ESKD patients. CUA should be considered a systemic disease when identifying treatment targets. ### Competing Interest Statement The authors have declared no competing interest. ### Clinical Protocols ### Funding Statement The National Natural Science Foundation of China (81270408, 81570666, 81730041, and 81671447), the International Society of Nephrology (ISN) Clinical Research Program (18-01-0247), Construction Program of Jiangsu Provincial Clinical Research Center Support System (BL2014084), Jiangsu Province Key Medical Personnel Project (ZDRCA2016002), CKD Anemia Research Foundation from China International Medical Foundation (Z-2017-24-2037), Outstanding Young and Middle-Aged Talents Support Program of The First Affiliated Hospital of Nanjing Medical University (Jiangsu Province Hospital), the National Key Research and Development Program of China (2017YFC1001303), the Program of Jiangsu Province Clinical Medical Center (YXZXB2016001, BL2012009), the State Key Laboratory of Reproductive Medicine Program (SKLRM-GC201803), and the Program of Jiangsu Commission of Health (H201605), Jiangsu Province Hospital (the First Affiliated Hospital with Nanjing Medical University) Clinical Capacity Enhancement Project (JSPH-MA-2023-7), Jiangsu Provincial Medical Key Discipline(Laboratory) Cultivation Unit(JSDW202206). All authors declared no competing interests. The study was supported by the ISN Mentorship Program and the authors thank Professor Marcello Tonelli (University of Calgary, Canada) for his helpful comments on the draft of the manuscript. We thank LetPub (www.letpub.com) for its linguistic assistance during the preparation of this manuscript. ### 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: Ethics Committee of the First Affiliated Hospital with Nanjing Medical University in China gave ethical approval for this work. 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 All data produced in the present work are contained in the manuscript

Purpose: The aim of this study was to explore the association of cardiac CT-based left atrium (LA) structural and functional parameters and left atrial epicardial adipose tissue (LA-EAT) parameters with postablation atrial fibrillation (AF) recurrence within 2 years. Materials and Methods: Contrast-enhanced cardiac CT images of 286 consecutive AF patients (median age: 65 y; 97 females) who underwent initial ablation between June 2018 and June 2020 were retrospectively analyzed. Structural and functional parameters of LA, including maximum and minimum volume and ejection fraction of LA and left atrial appendage (LAA), and LA-EAT volume, were measured. The body surface area indexed maximum and minimum volume of LA (LAVImax, LAVImin) and LAA (LAAVImax, LAAVImin), and LA-EAT volume index (LA-EATVI) were calculated. Independent predictors of AF recurrence were determined using Cox regression analysis. The clinical predictors were added to the imaging predictors to build a combined model (clinical+imaging). The predictive performance of the clinical, imaging, and combined models was assessed using the area under the receiver operating characteristics curve (AUC). Results: A total of 108 (37.8%) patients recurred AF within 2 years after ablation at a median follow-up of 24 months (IQR=11, 32). LA and LAA size and LA-EAT volume were significantly increased in patients with AF recurrence (P<0.05). After the multivariable regression analysis, LA-EATVI, LAAVImax, female sex, AF duration, and stroke history were independent predictors for AF recurrence. The combined model exhibited superior predictive performance compare to the clinical model (AUC=0.712 vs. 0.641, P=0.023) and the imaging model (AUC=0.712 vs. 0.663, P=0.018). Conclusion: Cardiac CT-based LA-EATVI and LAAVImax are independent predictors for postablation AF recurrence within 2 years and may provide a complementary value for AF recurrence risk assessment.