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Khoshknab M, Zghaib T, Xu L, Markman T, Mavroudis C, Desjardins B, Nazarian S. Noninvasive Visualization of the Atrioventricular Conduction System Using Cardiac Computed Tomography. JAMA Cardiol 2024:2821146. [PMID: 39046719 PMCID: PMC11270265 DOI: 10.1001/jamacardio.2024.2012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2024] [Accepted: 05/24/2024] [Indexed: 07/25/2024]
Abstract
Importance Noninvasive localization of the compact atrioventricular node and the proximal specialized conduction system (AVCS) would enhance planning for transcatheter aortic valve and complex or congenital heart disease surgical procedures. Objective To test the hypothesis that preprocedure contrast-enhanced cardiac computed tomography (CECT) can accurately localize the AVCS by identification of the fat that insulates the conductive myocardium. Design, Setting, and Participants This was a prospective cohort study that took place at an academic tertiary care center. Included in the study were patients with CECT acquired less than 1 month before atrial fibrillation ablation and electroanatomic localization of the His electrogram signal on electroanatomic mapping (EAM) between January 2022 and January 2023. Exposures Preprocedure CECT. Main Outcomes and Measures The distance from the His electrogram signal to the fat segmentation encompassing the AVCS on CECT, after registration of the images to EAM. Results Among 20 patients (mean [SD] age, 66 [10] years; 15 male [75%]) in the cohort, the mean (SD) attenuation of the AVCS fat segmentation was 2.9 (21.5) Hounsfield units. The mean (SD) distance from the His electrogram to the closest AVCS fat voxel was 3.3 (1.6) mm. Conclusions and Relevance Results of this cohort study suggest that CECT could accurately localize the fatty tissue that insulates the AVCS from surrounding atrial and ventricular myocardium and may enhance the efficacy and safety of procedures targeting the conduction system and structures in its proximity.
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Affiliation(s)
- Mirmilad Khoshknab
- Division of Medicine, Section of Cardiac Electrophysiology, Hospital of the University of Pennsylvania, Philadelphia
| | - Tarek Zghaib
- Division of Medicine, Section of Cardiac Electrophysiology, Hospital of the University of Pennsylvania, Philadelphia
| | - Lingyu Xu
- Division of Medicine, Section of Cardiac Electrophysiology, Hospital of the University of Pennsylvania, Philadelphia
| | - Timothy Markman
- Division of Medicine, Section of Cardiac Electrophysiology, Hospital of the University of Pennsylvania, Philadelphia
| | - Constantine Mavroudis
- Department of Surgery, Division of Cardiac Surgery, Hospital of the University of Pennsylvania, Philadelphia
| | - Benoit Desjardins
- Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia
| | - Saman Nazarian
- Division of Medicine, Section of Cardiac Electrophysiology, Hospital of the University of Pennsylvania, Philadelphia
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Joglar JA, Chung MK, Armbruster AL, Benjamin EJ, Chyou JY, Cronin EM, Deswal A, Eckhardt LL, Goldberger ZD, Gopinathannair R, Gorenek B, Hess PL, Hlatky M, Hogan G, Ibeh C, Indik JH, Kido K, Kusumoto F, Link MS, Linta KT, Marcus GM, McCarthy PM, Patel N, Patton KK, Perez MV, Piccini JP, Russo AM, Sanders P, Streur MM, Thomas KL, Times S, Tisdale JE, Valente AM, Van Wagoner DR. 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2024; 149:e1-e156. [PMID: 38033089 PMCID: PMC11095842 DOI: 10.1161/cir.0000000000001193] [Citation(s) in RCA: 286] [Impact Index Per Article: 286.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2023]
Abstract
AIM The "2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation" provides recommendations to guide clinicians in the treatment of patients with atrial fibrillation. METHODS A comprehensive literature search was conducted from May 12, 2022, to November 3, 2022, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. Additional relevant studies, published through November 2022, during the guideline writing process, were also considered by the writing committee and added to the evidence tables, where appropriate. STRUCTURE Atrial fibrillation is the most sustained common arrhythmia, and its incidence and prevalence are increasing in the United States and globally. Recommendations from the "2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" and the "2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing atrial fibrillation and thromboembolic risk assessment, anticoagulation, left atrial appendage occlusion, atrial fibrillation catheter or surgical ablation, and risk factor modification and atrial fibrillation prevention have been developed.
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Affiliation(s)
| | | | | | | | | | | | - Anita Deswal
- ACC/AHA Joint Committee on Clinical Practice Guidelines liaison
| | | | | | | | | | - Paul L Hess
- ACC/AHA Joint Committee on Performance Measures liaison
| | | | | | | | | | - Kazuhiko Kido
- American College of Clinical Pharmacy representative
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Joglar JA, Chung MK, Armbruster AL, Benjamin EJ, Chyou JY, Cronin EM, Deswal A, Eckhardt LL, Goldberger ZD, Gopinathannair R, Gorenek B, Hess PL, Hlatky M, Hogan G, Ibeh C, Indik JH, Kido K, Kusumoto F, Link MS, Linta KT, Marcus GM, McCarthy PM, Patel N, Patton KK, Perez MV, Piccini JP, Russo AM, Sanders P, Streur MM, Thomas KL, Times S, Tisdale JE, Valente AM, Van Wagoner DR. 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2024; 83:109-279. [PMID: 38043043 PMCID: PMC11104284 DOI: 10.1016/j.jacc.2023.08.017] [Citation(s) in RCA: 95] [Impact Index Per Article: 95.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2023]
Abstract
AIM The "2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Patients With Atrial Fibrillation" provides recommendations to guide clinicians in the treatment of patients with atrial fibrillation. METHODS A comprehensive literature search was conducted from May 12, 2022, to November 3, 2022, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. Additional relevant studies, published through November 2022, during the guideline writing process, were also considered by the writing committee and added to the evidence tables, where appropriate. STRUCTURE Atrial fibrillation is the most sustained common arrhythmia, and its incidence and prevalence are increasing in the United States and globally. Recommendations from the "2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" and the "2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing atrial fibrillation and thromboembolic risk assessment, anticoagulation, left atrial appendage occlusion, atrial fibrillation catheter or surgical ablation, and risk factor modification and atrial fibrillation prevention have been developed.
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Choi SH, Yu HT, Kim D, Park JW, Kim TH, Uhm JS, Joung B, Lee MH, Hwang C, Pak HN. Late recurrence of atrial fibrillation 5 years after catheter ablation: predictors and outcome. Europace 2023; 25:euad113. [PMID: 37099677 PMCID: PMC10228616 DOI: 10.1093/europace/euad113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 04/04/2023] [Indexed: 04/28/2023] Open
Abstract
AIMS Atrial fibrillation (AF) is a chronic progressive disease that continuously recurs even after successful AF catheter ablation (AFCA). We explored the mechanism of long-term recurrence by comparing patient characteristics and redo-ablation findings. METHODS AND RESULTS Among the 4248 patients who underwent a de novo AFCA and protocol-based rhythm follow-up at a single centre, we enrolled 1417 patients [71.7% male, aged 60.0 (52.0-67.0) years, 57.9% paroxysmal AF] who experienced clinical recurrences (CRs), and divided them according to the period of recurrence: within one year (n = 645), 1-2 years (n = 339), 2-5 years (n = 308), and after 5 years (CR>5 yr, n = 125). We also compared the redo-mapping and ablation outcomes of 198 patients. In patients with CR>5 yr, the proportion of paroxysmal AF was higher (P = 0.031); however, the left atrial (LA) volume (quantified by computed tomography, P = 0.003), LA voltage (P = 0.003), frequency of early recurrence (P < 0.001), and use of post-procedure anti-arrhythmic drugs (P < 0.001) were lower. A CR>5 yr was independently associated with a low LA volume [odds ratio (OR) 0.99 (0.98-1.00), P = 0.035], low LA voltage [OR 0.61 (0.38-0.94), P = 0.032], and lower early recurrence [OR 0.40 (0.23-0.67), P < 0.001]. Extra-pulmonary vein triggers during repeat procedures were significantly greater in patients with a CR>5 yr, despite no difference in the de novo protocol (P for trend 0.003). The rhythm outcomes of repeat ablation procedures did not differ according to the timing of the CR (log-rank P = 0.330). CONCLUSIONS Patients with a later CR exhibited a smaller LA volume, lower LA voltage, and higher extra-pulmonary vein triggers during the repeat procedure, suggesting AF progression.
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Affiliation(s)
- Sung Hwa Choi
- Division of Cardiology, Department of Internal Medicine, Yonsei University Health System, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Republic of Korea
| | - Hee Tae Yu
- Division of Cardiology, Department of Internal Medicine, Yonsei University Health System, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Republic of Korea
| | - Daehoon Kim
- Division of Cardiology, Department of Internal Medicine, Yonsei University Health System, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Republic of Korea
| | - Je-Wook Park
- Division of Cardiology, Department of Internal Medicine, Yonsei University Health System, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Republic of Korea
| | - Tae-Hoon Kim
- Division of Cardiology, Department of Internal Medicine, Yonsei University Health System, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Republic of Korea
| | - Jae-Sun Uhm
- Division of Cardiology, Department of Internal Medicine, Yonsei University Health System, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Republic of Korea
| | - Boyoung Joung
- Division of Cardiology, Department of Internal Medicine, Yonsei University Health System, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Republic of Korea
| | - Moon-Hyoung Lee
- Division of Cardiology, Department of Internal Medicine, Yonsei University Health System, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Republic of Korea
| | - Chun Hwang
- Division of Cardiology, Department of Internal Medicine, Yonsei University Health System, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Republic of Korea
| | - Hui-Nam Pak
- Division of Cardiology, Department of Internal Medicine, Yonsei University Health System, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Republic of Korea
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Chhay C, Hsu CY, Chang SL, Lin YJ, Lo LW, Hu YF, Chung FP, Chang TY, Lin CY, Hung Y, Liu CM, Kuo L, Liu SH, Ahli L, Kuo MJ, Cheng WH, Kao PH, Chen WT, Khac TCN, Lin WS, Chen SA. Electrophysiological characteristics of epicardial breakthrough during catheter ablation of perimitral atrial flutter. Front Cardiovasc Med 2022; 9:1030916. [PMID: 36465473 PMCID: PMC9712778 DOI: 10.3389/fcvm.2022.1030916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 10/24/2022] [Indexed: 11/04/2023] Open
Abstract
Introduction Unsuccessful endocardial ablation for perimitral atrial flutter (AFL) could be attributed by the epicardial bridging. Objective This study aimed to investigate the electrophysiological characteristics of epicardial breakthrough during catheter ablation of perimitral AFL. Materials and methods This retrospective study recruited 40 patients who received successful catheter ablation of perimitral AFL from January 2016 to June 2021. The patients were divided into two groups: group 1 (n = 18) successful endocardial ablation, and group 2 (n = 22) successful epicardial ablation following unsuccessful endocardial ablation owing to incomplete mitral block or unachievable termination AFL. The local electrogram (EGM) interval of coronary sinus (CS) duration perimitral AFL was measured before catheter ablation. Results There was no significant difference in the baseline characteristics between the two groups. In group 2, 60% of successful epicardial ablation was performed in intra-CS ablation and 40% in VOM ethanol infusion. Group 2 patients had a longer EGM interval of distal CS than that in group 1 (CS1-2: 64.2 17.5 vs. 42.4 0.09 ms, P = 0.008, CS3-4: 57.13 19.4 vs. 43.8 7.5 ms; P = 0.001). The conduction velocity at successful site was slower in group 2 compared to group 1 (0.18 0.05 vs. 0.75 0.19 m/s, P = 0.040). In the multivariate analysis, distal EGM interval (CS1-2) was identified as independent predictor of the need of epicardial ablation with the optimal cutoff of 49 ms. Conclusion Longer EGM interval in distal CS during perimitral AFL was observed in perimitral AFL patients with epicardial breakthrough following endocardial-failed ablation, which may be associated with the need of epicardial ablation.
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Affiliation(s)
- Chheng Chhay
- Heart Rhythm Center and Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Cardiovascular Department, Faculty of Medicine, University of Health Sciences, Phnom Penh, Cambodia
| | - Chu-Yu Hsu
- Heart Rhythm Center and Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Division of Cardiology, Department of Internal Medicine, Taoyuan Armed Forces General Hospital, Taoyuan, Taiwan
- Division of Cardiology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Shih-Lin Chang
- Heart Rhythm Center and Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Faculty of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Yenn-Jiang Lin
- Heart Rhythm Center and Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Faculty of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Li-Wei Lo
- Heart Rhythm Center and Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Faculty of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Yu-Feng Hu
- Heart Rhythm Center and Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Faculty of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Fa-Po Chung
- Heart Rhythm Center and Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Faculty of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Ting-Yung Chang
- Heart Rhythm Center and Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Faculty of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Chin-Yu Lin
- Heart Rhythm Center and Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Faculty of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Yuan Hung
- Division of Cardiology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Chih-Min Liu
- Heart Rhythm Center and Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Faculty of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Ling Kuo
- Heart Rhythm Center and Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Faculty of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Shin-Huei Liu
- Heart Rhythm Center and Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Faculty of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Lia Ahli
- Heart Rhythm Center and Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Ming-Jen Kuo
- Heart Rhythm Center and Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Faculty of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Wen-Han Cheng
- Heart Rhythm Center and Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Faculty of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Pei-Heng Kao
- Heart Rhythm Center and Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Wei-Tso Chen
- Heart Rhythm Center and Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Thien Chuong-Nguyen Khac
- Heart Rhythm Center and Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Wei-Shiang Lin
- Division of Cardiology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Shih-Ann Chen
- Heart Rhythm Center and Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Faculty of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Taichung Veterans General Hospital, Taichung, Taiwan
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Zhang F, Liu J, Fang P, Wang X, Wang J, Wei Y, Yang H. Assessing the impact of blocking distal coronary sinus-left atrial muscular connection on inducible rate of atrial fibrillation and follow-up recurrence in persistent atrial fibrillation patients with different fibrotic degrees of left atrial: A retrospective study. Front Cardiovasc Med 2022; 9:987590. [PMID: 36312226 PMCID: PMC9606224 DOI: 10.3389/fcvm.2022.987590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Accepted: 09/27/2022] [Indexed: 11/13/2022] Open
Abstract
Background The musculature of the coronary sinus (CS), especially its distal connection with the post wall of the left atrial (LA), has been associated with the genesis and maintenance of atrial flutter (AFL) and atrial fibrillation (AF). However, the relative contributions of the distal coronary sinus (CSD)-LA connection to PersAF with various degrees of atrial fibrosis remain unknown. Objective This study aimed to explore the different roles of blocking the CSD-LA connection in the induction of acute AF and middle-term follow-up of recurrence among PersAF patients with various degrees of LA fibrosis. Methods and results A retrospective cohort of 71 patients with drug-refractory and symptomatic PersAF underwent ablation for the first time were studied. The population was divided into two groups according to disconnection of the CSD-LA or not. All patients enrolled accepted the unified ablation procedure (circumferential pulmonary vein isolation, non-pulmonary vein trigger ablation and ablation of the CSD-LA connection). Group A (n = 47) successfully blocked the CSD-LA electrical connection and Group B (n = 24) failed. Twenty-five patients could be induced into sustained AF in the Group A compared to 20 in the Group B (53.2 vs. 83.3%, p = 0.013). After a mean follow-up of 185 ± 8 days, 24 (33.8%) patients experienced atrial arrhythmia recurrences. The Group A had significantly fewer recurrences (25.5%) compared to Group B (50%). Meanwhile, in Group A, the ROC curve analysis suggested that in the case of blocking CSD-LA, low voltage area (LVA) of LA can act as a predictive factor for acute AF induction (AUC = 0.943, Cut-off = 0.190, P < 0.001) with sensitivity and specificity of 92.3 and 90.5%, and middle-term recurrence (AUC = 0.889, Cut-off = 0.196, P < 0.001) with sensitivity and specificity of 100 and 65.7%. Conclusion Disconnection of CSD-LA could reduce the inducible rate of acute AF and the recurrences of atrial arrhythmia during middle-term follow-up. The PersAF patients with CSD-LA muscular connection blocked, experienced a higher acute AF inducible rate with larger proportion of LVA of LA (≥19%) and a higher recurrent rate of atrial arrhythmias with a larger proportion of LA fibrosis (≥19.6%).
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