Catheter ablation as a potential treatment alternative for atrial fibrillation among patients with heart failure with preserved ejection fraction: a retrospective cohort study

Catheter ablation as a potential treatment alternative for atrial fibrillation among patients with heart failure with preserved ejection fraction: a retrospective cohort study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Catheter ablation as a potential treatment alternative for atrial fibrillation among patients with heart failure with preserved ejection fraction: a retrospective cohort study Yang Ping, Wang Guoqiang, Ai Tiantian, Song Mingbao, Yu Xuejun, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3935654/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background In patients with heart failure with reduced ejection fraction, catheter ablation for atrial fibrillation is a useful alternative to drug-induced rhythm control. However, the efficacy of this procedure in patients with heart failure (HF) with preserved ejection fraction (HFpEF) is unclear. Therefore, this study aimed to assess the outcomes of the radiofrequency catheter ablation procedure for atrial fibrillation in patients with HFpEF. Methods The retrospective cohort study included 144 patients with a left ventricular ejection fraction ≥ 50% who underwent catheter ablation for atrial fibrillation for the first time. We compared clinical outcomes, including freedom from atrial arrhythmia recurrence at 12 months, symptom severity decrease measured using the European Heart Rhythm Association (EHRA) score, and all-cause hospitalizations between patients with HFpEF and those without HF. Results Among the 144 patients, 43 (29.9%) had HFpEF and 101 (70.1%) did not have HF. At the 12-month follow-up, significant difference was found in the recurrence rate of atrial arrhythmia between the two groups (41.9%, HFpEF group vs. 13.9%, non-HF group; P < 0.001). Nonetheless, no significant difference was noted in the decrease in symptom severity, evaluated using the reduction in EHRA scores, between the two groups (-1.30 ± 0.60 vs. -1.42 ± 0.55; P = 0.273). Similarly, no significant difference was observed in all-cause hospitalizations between the two groups (9.3% vs. 4.0%; P = 0.239). After adjusting for HFpEF, atrial fibrillation type, age group (age ≥ 75 vs. <75 years), atrial fibrillation duration, chronic obstructive pulmonary disease, and left atrial diameter, a significant association was noted between HFpEF and increased probability of atrial fibrillation recurrence (hazard ratio: 2.56; 95% confidence interval: 1.17–5.61; P = 0.018). Conclusions Despite the significantly lower incidence of arrhythmia-free survival within 12 months of follow-up in patients with HFpEF than in those without HF, catheter ablation for atrial fibrillation significantly reduced symptom severity. The study findings suggest catheter ablation as a potential treatment alternative for atrial fibrillation in patients with HFpEF. Atrial fibrillation Catheter ablation Heart failure with preserved ejection fraction Outcomes Figures Figure 1 Figure 2 Background The coexistence of atrial fibrillation (AF) and heart failure (HF) with preserved ejection fraction (HFpEF) has been frequently reported in the general population, significantly impacting cardiovascular disease and death rates [ 1 , 2 ]. A previous study showed that HF occurs in more than one-third of patients with AF, whereas AF occurs in more than half of patients with HF [ 3 ]. In most previous studies, the proportion of HFpEF in HF was nearly 50% [ 4 – 7 ]. Globally, data from different countries have shown an increasing trend in the prevalence of HFpEF over time [ 8 – 10 ]. The treatment of HF combined with AF presents a current research focus, with catheter ablation (CA) at the forefront of clinical discussions. Many scientific investigations suggest that, compared with antiarrhythmic drugs, CA results in increased sinus rhythm maintenance rate in patients with heart failure with reduced ejection fraction (HFrEF), possibly avoiding the long-term side effects of applying antiarrhythmic drugs. Moreover, the cardiac function and quality of life of these patients improved dramaticallydrastically. Some studies have also reported a decrease in rehospitalization rate due to HF in patients with HFrEF post-CA [ 11 – 13 ]. The latest guidelines strongly advocate for the application of CA in patients of AF and HFrEF [ 14 ]. However, the recurrence rate of AF post-CA remains challenging, and the effect of AF on HFpEF is not well-established [ 15 – 18 ]. Currently, the question of whether patients with HFpEF would benefit from CA for AF remains controversial. A meta-analysis suggested no significant difference in the arrhythmia recurrence rate and security profile between patients without HF or those with HFrEF [ 16 ]. However, another meta-analysis patients with HFpEF were more likely to receive repeat CA compared with patients with HFrEF [ 19 ]. Therefore, to address these gaps in the literature, the present study aimed to compare the clinical outcomes of patients of HFpEF post-CA for AF with those of patients without HF and to explore the potential association between HFpEF and CA outcomes at 12 months. Methods Study design and participants This retrospective cohort study was conducted from September 2017 to October 2022 at Kangxin Hospital in Chongqing, China. Patients who underwent their first CA with a left ventricular ejection fraction (LVEF) ≥ 50% were included. Patients were waived from informed consent due to the retrospective nature of the study by the Ethics Committee of Chongqing Kangxin Hospital. The exclusion criteria were as follows: malignant tumor, lost to follow-up, previous cardiac valve surgery, previous congenital heart disease surgery, hyperthyroidism, and those with incomplete data (Fig. 1 ). Of 163 patients, 144 were eligible for this study. Information regarding the baseline demographics, medical history, auxiliary examinations, and pre-ablation medications were extracted from medical records for analysis. Definitions of HFpEF and the European Heart Rhythm Association score HFpEF was diagnosed using the 2023 criteria established by the Chinese Expert Consensus for Diagnosing and Treating Heart Failure With Preserved Ejection Fraction. In particular, HFpEF was diagnosed when patients met the criteria for New York Heart Association (NYHA) class ≥ II and had LVEF ≥ 50%, paired with at least one of the following conditions: a regular heart rhythm with an N-terminal pro-B-type natriuretic peptide (NT-proBNP) level ≥ 125 pg/mL, an NT-proBNP level ≥ 365 pg/mL in the presence of AF, or E/e’ ≥15 (HFpEF group). Accordingly, patients who met the conditions of NYHA class II/III but did not fulfill other requirements were categorized into the non-HF group. The European Heart Rhythm Association (EHRA) classification has been widely used in clinical research since it was formally proposed. The EHRA classification is used to assess the impact of symptoms associated with AF (palpitations, fatigue, dizziness, chest pain, dyspnea, anxiety) on daily activities. Based on the score, patients are divided into classes spanning from EHRA class Ⅰ (asymptomatic) to class Ⅳ (disabled, unable to perform daily activities) according to the severity of symptoms. Follow-up The clinical outcomes evaluated at the last follow-up included 12-month atrial arrhythmia recurrence-free survival, symptom burden (EHRA score), and AF-related hospitalization. Recurrent arrhythmia was defined as AF, atrial flutter, or atrial tachycardia lasting over 30 seconds after 3 months, as detected using 12-lead electrocardiogram (ECG), 24-h Holter ECG, or an implantable device. At 3, 6, 9, and 12 months post-CA, all patients were required to have completed the 12-lead ECG examination. If arrhythmia symptoms were present, ECG was performed to assess the likelihood of recurrence during the follow-up period. EHRA scores, which were derived from standardized interviews conducted by the same physician at admission and the patient’s last follow-up, were used to assess symptoms. Radiofrequency ablation procedure All patients underwent pre-ablation anticoagulation therapy and transesophageal echocardiography to exclude left atrial thrombosis. Pharmacological anticoagulant and antiarrhythmic management and the invasive ablation protocol were performed in accordance with the recommendations of the guideline. Radiofrequency CA with conscious sedation was performed using irrigated-tip and circular catheters (Biosense Webster, Diamond Bar, CA, USA) to deliver the radiofrequency current and map, respectively. A transseptal approach incorporating the CARTO navigation system (Biosense Webster) was adopted to perform left atrial exploration and reconstruction. Initially, circumferential pulmonary vein ablation was performed, with pulmonary vein isolation and bidirectional conduction block being the final objectives. Further linear and complex fractioned atrial electrogram ablations were promptly performed, with focal ablation targeting non-pulmonary vein foci performed when necessary. In persistent AF cases, sinus rhythm was restored by administering ibutilide or performing cardioversion. Statistical analysis Normally distributed continuous variables are expressed as mean ± standard deviation in accordance with the HFpEF type, whereas non-normally distributed variables are expressed as median and interquartile range. The Student's t -test and Wilcoxon rank-sum test were used for single variable comparisons within the normally and non-normally distributed continuous variables, respectively. For categorical variables, the Chi-square or Fisher’s exact test was used. In patients with HFpEF or those without HF (non-HF patients), the 12-month atrial arrhythmia-free survival rates were illustrated using Kaplan–Meier curves. Multivariate Cox regression included all factors with significant associations emerging from the univariate Cox regression. We identified individual elements that could predict atrial arrhythmia relapse for 12-months after one ablation process using Cox regression. P-values < 0.05 were considered to indicate a statistically significant difference. SPSS 23.0 statistical software was used to perform data analysis. Results Baseline characteristics The baseline characteristics of the study participants are presented in Table 1 . Among the 144 patients who underwent their first CA for AF within the study duration, 43 (29.9%) had HFpEF. Patients in the HFpEF group were significantly older (71.00 [64.00, 75.00] vs. 63.00 [50.50, 70.00] years; P < 0.001) and had a higher proportion of women (55.8% vs. 37.6%; P = 0.044), more persistent AF (58.1% vs. 29.7%; P < 0.001), higher CHA 2 DS 2 -VASc scores (3.86 ± 2.01 vs. 1.89 ± 1.52; P < 0.001), higher NT-proBNP levels (1361.00 [782.40, 2630.00] vs. 292.70 [90.16, 564.95] pg/mL; P < 0.001), higher D-dimer levels (0.21 [0.15,0.43] vs. 0.15 [0.1, 0.22] mg/L; P = 0.001), lower hemoglobin levels (129.98 ± 17.79 vs. 142.23 ± 16.03 g/dL; P < 0.001), lower estimated glomerular filtration rates (82.52 [65.94, 97.44] vs. 95.68 [81.83, 107.06] mL/min/1.73 m 2 ; P = 0.002), and higher prevalence of coronary artery disease (53.5% vs. 17.8%; P < 0.001) than those in the non-HF group. No significant differences were observed in antiarrhythmic drug (9.3% vs. 9.9%; P = 1.000), beta-blocker (41.9% vs. 48.5%; P = 0.464), and angiotensin-converting enzyme (ACE) inhibitor or angiotensin II receptor blocker (ARB) (34.9% vs. 22.8%; P = 0.131) usage pre-ablation. Echocardiography revealed that patients with HFpEF had a larger left atrial diameter (43.63 ± 4.99 vs. 39.07 ± 5.34 mm; P < 0.001) than non-HF patients. Patients in the HFpEF group had significantly lower left ventricular ejection fraction (60% [54.00%, 65.00%] vs. 63% [59.50%, 67.00%]; P < 0.001), higher pulmonary artery pressure (38.00 [32.00, 47.00] vs. 32.00 [27.00, 36.00] mmHg; P < 0.001), and higher stress-related diastolic dysfunction (E/e’: 15.00 [12.70, 17.00] vs. 11.30 [9.00, 13.90]; P < 0.001) than those in the non-HF group. No clinically relevant differences were observed in intraoperative electrical cardioversion between the two groups (Table 1 ). Table 1 Basic characteristics of the study population Variables Total patients (n = 144) HFpEF group (n = 43, 29.9%) Non-HF group (n = 101, 70.1%) P-value Atrial fibrillation type 0.001 Paroxysmal (%) 89 (61.8) 18 (41.9) 71 (70.3) Persistent (%) 55 (38.2) 25 (58.1) 30 (29.7) Age (years) 65.00 [55, 72.00] 71.00 [64.00, 75.00] 63.00 [50.50, 70.00] < 0.001 Age group (years) 0.025 Age < 75 years 116 (80.6) 28 (65.1) 88 (87.1) Age ≥ 75 years 28 (19.4) 15 (34.9) 13 (12.9) Sex 0.044 Male 82 (56.9) 19 (44.2) 63 (62.4) Female 62 (43.1) 24 (55.8) 38 (37.6) AF duration (years) 1.25 [0.33, 4.00] 1.00 [0.50, 3.00] 2.00 [0.30, 4.00] 0.941 Body mass index (kg/m 2 ) 24.76 ± 3.10 24.68 ± 3.05 24.80 ± 3.14 0.838 Drinking (%) 19 (13.2) 3 (7.0) 16 (15.8) 0.150 Smoking (%) 40 (27.8) 7 (16.3) 33 (32.7) 0.044 Comorbidities Hypertension (%) 77 (53.5) 27 (62.8) 50 (49.5) 0.144 Hyperlipemia (%) 37 (25.7) 7 (16.3) 30 (29.7) 0.092 Coronary artery disease (%) 41 (28.5) 23 (53.5) 18 (17.8) < 0.001 Diabetes mellitus (%) 31 (21.5) 13 (30.2) 18 (17.8) 0.097 Previous stroke (%) 4 (2.8) 2 (7.0) 1 (1) 0.080 COPD (%) 5 (3.5) 2 (4.7) 3 (3) 0.635 Echocardiography Left ventricular ejection fraction (%) 63 [58.00, 66.00] 60 [54.00, 65.00] 63 [59.50, 67.00] 0.001 Left atrial diameter (mm) 40.43 ± 5.63 43.63 ± 4.99 39.07 ± 5.34 < 0.001 Left ventricular end-diastolic diameter(mm) 46.96 ± 4.92 48.00 ± 6.26 46.52 ± 4.18 0.159 E/e’ 12.70 [9.70, 15.43] 15.00 [12.70, 17.00] 11.30 [9.00, 13.90] < 0.001 Pulmonary artery pressure (mmHg) 33.00 [28.00, 39.00] 38.00 [32.00, 47.00] 32.00 [27.00, 36.00] < 0.001 CHA 2 DS 2 -VASc score 2.48 ± 1.90 3.86 ± 2.01 1.89 ± 1.52 < 0.001 Laboratory data Hemoglobin (g/dL) 138.57 ± 17.44 129.98 ± 17.79 142.23 ± 16.03 < 0.001 Serum creatinine (mg/dL) 75.45 ± 18.22 80.89 ± 24.20 73.13 ± 14.51 0.055 D-dimer (mg/L) 0.16 [0.11, 0.26] 0.21 [0.15, 0.43] 0.15 [0.1, 0.22] 0.001 Estimated glomerular filtration rates (mL/min/1.73 m 2 ) 91.48 [76.84, 105.52] 82.52 [65.94, 97.44] 95.68 [81.83, 107.06] 0.002 NT-proBNP level (pg/mL) 503.00 [155.95, 1156.00] 1361.00 [782.40, 2630.00] 292.70 [90.16, 564.95] < 0.001 Pre-ablation medication Antiarrhythmic drug 14 (9.7) 4 (9.3) 10 (9.9) 1.000 Beta-blocker 67 (46.5) 18 (41.9) 49 (48.5) 0.464 ACE inhibitor or ARB 38 (26.4) 15 (34.9) 23 (22.8) 0.131 Intraoperative cardioversion 41 (28.5) 14 (32.6) 27 (26.7) 0.478 COPD, chronic obstructive pulmonary disease; BNP, brain natriuretic peptide; ACE, angiotensin-converting enzyme; ARB, angiotensin II receptor blocker; HFpEF, with a preserved ejection fraction; HF, heart failure; NT-proBNP, N-terminal pro-B-type natriuretic peptide; AF, atrial fibrillation. [insert Table 1 ] Ablation outcomes At the 12-month follow-up, the recurrence of atrial arrhythmia was significantly higher in the HFpEF group than in the non-HF group (41.9% vs. 13.9%, P < 0.001). However, no significant differences were observed in AF symptoms (23.3% vs. 12.9%; P = 0.120) or total EHRA score reduction from baseline (-1.30 ± 0.60 vs. -1.42 ± 0.55; P = 0.273), representing a similar decrease in symptom severity in both the groups. While no significant differences were observed in the usage of antiarrhythmic drugs (67.4% vs. 69.3%; P = 0.825) and beta-blockers (23.3% vs. 24.8%; P = 0.848), patients in the HFpEF group received ACE inhibitor or ARB therapy more frequently than did patients in the non-HF group (53.5% vs. 29.7%, P = 0.007). Further, no significant difference was noted in all-cause hospitalizations(9.3% vs. 4.0%; P = 0.239) (Table 2 ). The Kaplan–Meier curve (Fig. 2 ) illustrates the absence of atrial arrhythmia recurrence after 12 months. A significant reduction was observed in arrhythmia-free survival in the HFpEF group compared with that in the non-HF group (P < 0.0001). Furthermore, HFpEF was associated with an increased likelihood of atrial arrhythmia recurrence after adjusting for HFpEF, AF type, age (≥ 75 vs. <75 years), AF duration, chronic obstructive pulmonary disease, and left atrial diameter [hazard ratio (HR): 2.56; 95% confidence interval (CI): 1.17–5.61; P = 0.018) (Table 3 ). Table 2 Catheter ablation outcomes according to HFpEF status at 12 months Variables Total patients (n = 144) HFpEF group (n = 43, 29.9%) Non-HF group (n = 101, 70.1%) P-value Arrhythmia recurrence 32 (22.2) 18 (41.9) 14 (13.9) 0.000 AF symptoms 23 (16%) 10 (23.3%) 13 (12.9%) 0.120 EHRA score reduction -1.38 ± 0.57 -1.30 ± 0.60 -1.42 ± 0.55 0.273 Medication use Antiarrhythmic drug 99 (68.8) 29 (67.4) 70 (69.3) 0.825 Beta-blocker 35 (24.3) 10 (23.3) 25 (24.8) 0.848 ACE inhibitor or ARB 53 (36.8) 23 (53.5) 30 (29.7) 0.007 All-cause hospitalizations 8 (5.6) 4 (9.3) 4 (4.0) 0.239 EHRA, European Heart Rhythm Association; ACE, angiotensin-converting enzyme; ARB, angiotensin II receptor blocker; HFpEF, heart failure with preserved ejection fraction; HF, heart failure. [insert Table 3] Table 3 Predictors of post-blanking atrial arrhythmia relapse after catheter ablation Variables Univariate Cox regression Multivariate Cox regression HR 95% CI P-value HR 95% CI P-value Persistent AF 3.56 1.71–7.38 0.001 2.48 1.04–5.87 0.040 Age ≥ 75 years 2.42 1.17–5.02 0.018 1.29 0.56–2.95 0.548 Female 1.02 0.51–2.06 0.949 AF duration (years) 1.17 1.06–1.28 0.001 1.15 1.04–1.27 0.005 Body mass index (kg/m 2 ) 1.09 0.97–1.22 0.134 Drinking (%) 0.93 0.33–2.64 0.887 Smoking (%) 0.99 0.46–2.15 0.984 HFpEF (%) 3.57 1.78–7.19 0.000 2.56 1.17–5.61 0.018 Hypertension (%) 0.98 0.49–1.97 0.964 Hyperlipemia (%) 0.63 0.26–1.54 0.315 Coronary artery disease (%) 1.93 0.95–3.91 0.068 COPD (%) 3.75 1.14–12.35 0.030 3.26 0.90–11.77 0.072 Diabetes mellitus (%) 1.04 0.45–2.40 0.930 Left ventricular ejection fraction (%) 0.97 0.92–1.03 0.362 Left atrial diameter (mm) 1.07 1.01–1.13 0.016 1.01 0.93–1.08 0.892 Left ventricular end-diastolic diameter(mm) 0.98 0.91–1.05 0.558 E/e’ 1.00 0.92–1.08 0.946 Pulmonary artery pressure (mmHg) 1.03 0.99–1.06 0.123 CHA 2 DS 2 -VASc score 1.17 0.98–1.39 0.076 Hemoglobin (g/dL) 0.99 0.97–1.01 0.406 Serum creatinine (mg/dL) 1.01 1.00–1.03 0.162 D-dimer (mg/L) 1.20 0.51–2.86 0.679 Estimated glomerular filtration rates (mL/min/1.73 m 2 ) 0.99 0.97–1.01 0.222 Beta-blocker 0.54 0.21–1.39 0.199 CI, confidence interval; HR, hazard ratio; AF, atrial fibrillation; HFpEF, with a preserved ejection fraction; COPD, chronic obstructive pulmonary disease Adjusted for HFpEF, AF type, age (≥ 75 vs. <75 years), AF duration, COPD, and left atrial diameter (total = 6). Discussion In this retrospective cohort study, we investigated the association between HFpEF and outcomes of CA for AF. The results are as follows: First, patients with HFpEF exhibited a lower rate of arrhythmia-free survival after ablation for AF than did those without HF at 12 months. Second, the symptom severity of patients with HFpEF was significantly reduced, as indicated by the EHRA score after CA. Third, no significant increase was noted in all-cause hospitalizations between the HFpEF and non-HF groups. These results suggest that CA can serve as an effective treatment method for patients with HFpEF, despite a higher risk of atrial arrhythmia recurrence than in those without HF. While several studies have evaluated HFpEF as a risk factor for AF recurrence after CA, the results have been inconsistent. In our present study, HFpEF was found to independently increases the risk of atrial arrhythmia recurrence. Patients with HFpEF exhibited significantly lower arrhythmia-free survival rates than those without HF following a 12-month observation period. This finding aligns with the findings of a recent single-center prospective and observational study (n = 79), which revealed an association between HFpEF and elevated rates of atrial arrhythmia recurrences after a median 12-month follow-up [ 20 ]. The results of our present study indicate that HFpEF could increase the recurrence rate of atrial arrhythmia, a conclusion supported by the consistent findings. Previous studies have shown that diastolic failure may lead to recurrence of AF post-radiofrequency CA [ 21 , 22 ]. In patients with AF, HF increases ventricular pressure, resulting in an increase in atrial wall pressure, promoting left atrial fibrosis, and leading to atrial remodeling through pathological and physiological mechanisms such as calcium-handling abnormalities or neurohormone and adrenergic receptor activation [ 23 , 24 ]. These factors may also contribute to AF progression. Compared to our study, a retrospective cohort study of 547 patients undergoing CA for AF revealed no notable difference in arrhythmia recurrence, irrespective of the use of antiarrhythmic drugs. This was observed after median tracking periods of 50.9 and 31.3 months for the HFpEF and non-HF groups, respectively (P = 0.027) [ 25 ]. Consequently, the disparity in these findings could stem from the distinctive follow-up durations or discrepancies in the populations studied. A single-center prospective study using invasive hemodynamic measurements showed that CA for AF may enhance the living quality of patients with HFpEF (n = 35) [ 26 ], similar to the findings of our study. Another retrospective cohort analysis involving 547 patients similarly observed no significant difference in all-cause hospitalization rates (adjusted HR: 2.05; 95% CI: 1.30–3.23) between the HFpEF and non-HF groups [ 25 ]. Further, a previous study assessing the 12-month post-ablation outcomes reported resolution of HFpEF in 42.9% and 51% of patients after their initial ablation procedure and after several procedures, respectively. These findings suggest a possible causal relationship. HFpEF resolution was closely related to the freedom from recurrence of arrhythmia post-ablation [ 27 ]. Previous studies have shown that AF can induce and exacerbate HF. In AF, the heart rate increases, and the left ventricular end-diastolic filling time decreases, resulting in loss of atrial systolic ability and consequently causing a decrease in cardiac output and activation of neurohormones. In addition, some studies have demonstrated that the rapid ventricular rate can exacerbate the decline in left ventricular function, leading to tachycardiomyopathy and facilitating the occurrence of HF [ 23 , 28 ]. Therefore, patients with HFpEF should theoretically benefit from CA. These findings hold significant implications. While the effectiveness of ablation in patients with AF and HFrEF has been established in terms of maintaining sinus rhythm, enhancing the quality of life, and decreasing hospitalization rates [ 29 , 30 ], whether these advantages also apply to patients with HFpEF remains uncertain. The present study showed that despite the less favorable HFpEF-related outcomes, CA reduced the burden of AF-related symptoms. However, the potential benefits of CA in patients with HFpEF remain unclear. This study has some limitations. First, this retrospective, single-center observational study was limited by its relatively short follow-up period and small sample size. Second, the EHRA grading method is relatively simple, which may cause some errors in grading the severity of AF symptoms. Third, external factors such as mood swings, staying up late, climate change, and lifestyle change can also contribute to the difference in recurrence time, and this study did not account for the effect of potential inducement. Finally, due to a lack of standard equipment for detecting atrial arrhythmias, including an implantable loop monitor, the recurrence of some asymptomatic AF may be overlooked. Therefore, comprehensive, prospective, randomized clinical trials that focus on outcomes of CA for AF in patients with HFpEF are required to establish the effects of ablation on HFpEF outcomes. Conclusions Despite the significantly lower arrhythmia-free survival within 12 months of follow-up among patients with HFpEF than among those without HF, the study findings indicate that applying CA for AF significantly reduces symptom severity in this population. Therefore, additional investigation is required to further assess the clinical efficacy of CA for AF in patients with HFpEF and identify risk factors associated with poor clinical outcomes. Abbreviations ACE angiotensin-converting enzyme AF atrial fibrillation ARB angiotensin II receptor blocker CA catheter ablation CI confidence interval ECG electrocardiogram EHRA European Heart Rhythm Association HFpEF heart failure with preserved ejection fraction HFrEF heart failure with reduced ejection fraction HR hazard ratio NYHA New York Heart Association NT-proBNP N-terminal pro-B-type natriuretic peptide Declarations Ethics approval and consent to participate The study protocol was approved by the Ethics Committee of Chongqing Kangxin Hospital, and all relevant local and clinical regulations were followed. Patients were waived from informed consent due to the retrospective nature of the study by the Ethics Committee of Chongqing Kangxin Hospital. Consent for publication Not applicable. Availability of data and materials The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests. Funding Not applicable. Authors’ contributions YP and WGQ mainly contributed to the study research. YP and ATT were involved in research and data collection. YP performed data analysis, prepared the figures, and made significant contributions to manuscript writing. The manuscript was reviewed and modified by YXJ and WGQ. All authors read and approved the final manuscript. Acknowledgments We would like to thank Editage (www.editage.com) for English language editing. References Vermond RA, Geelhoed B, Verweij N, Tieleman RG, Van der Harst P, Hillege HL, et al. Incidence of atrial fibrillation and relationship with cardiovascular events, heart failure, and mortality: a community-based study from the Netherlands. J Am Coll Cardiol. 2015;66:1000–7. 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J Arrhythm. 2022;38:981–90. Kuck KH, Merkely B, Zahn R, Arentz T, Seidl K, Schlüter M, et al. Catheter ablation versus best medical therapy in patients with persistent atrial fibrillation and congestive heart failure: the randomized AMICA trial. Circ Arrhythm Electrophysiol. 2019;12:e007731. Prabhu S, Taylor AJ, Costello BT, Kaye DM, McLellan AJA, Voskoboinik A, et al. Catheter ablation versus medical rate control in atrial fibrillation and systolic dysfunction: the CAMERA-MRI study. J Am Coll Cardiol. 2017;70:1949–61. Panchal G, Kwok CS, Morley-Davies A, Zachariah D, Phan T. A comparison of clinical outcomes following atrial fibrillation ablation for heart failure patients with preserved or reduced left ventricular function: A systematic review and meta-analysis. Indian Pacing Electrophysiol J. 2022;22:18–23. 10.1016/j.ipej.2021.09.002 . Vecchio N, Ripa L, Orosco A, Tomas L, Mondragón I, Acosta A, et al. Atrial fibrillation in heart failure patients with preserved or reduced ejection fraction. Prognostic significance of rhythm control strategy with catheter ablation. J Atr Fibrillation. 2019;11:2128. Kosiuk J, Van Belle Y, Bode K, Kornej J, Arya A, Rolf S, et al. Left ventricular diastolic dysfunction in atrial fibrillation: predictors and relation with symptom severity. J Cardiovasc Electrophysiol. 2012;23:1073–7. Kosiuk J, Breithardt OA, Bode K, Kornej J, Arya A, Piorkowski C, et al. The predictive value of echocardiographic parameters associated with left ventricular diastolic dysfunction on short- and long-term outcomes of catheter ablation of atrial fibrillation. Europace. 2014;16:1168–74. Prabhu S, Voskoboinik A, Kaye DM, Kistler PM. Atrial fibrillation and heart failure — cause or effect? Heart Lung Circ. 2017;26:967–74. Zhao L, Wang WYS, Yang X. Anticoagulation in atrial fibrillation with heart failure. Heart Fail Rev. 2018;23:563–71. Aldaas OM, Malladi CL, Mylavarapu PS, Lupercio F, Darden D, Han FT, et al. Comparison of outcomes after ablation of atrial fibrillation in patients with heart failure with preserved versus reduced ejection fraction. Am J Cardiol. 2020;136:62–70. Rattka M, Pott A, Kühberger A, Weinmann K, Scharnbeck D, Stephan T, et al. Restoration of sinus rhythm by pulmonary vein isolation improves heart failure with preserved ejection fraction in atrial fibrillation patients. Europace. 2020;22:1328–36. Sugumar H, Nanayakkara S, Vizi D, Wright L, Chieng D, Leet A, et al. A prospective STudy using invAsive haemodynamic measurements foLLowing catheter ablation for AF and early HFpEF: STALL AF-HFpEF. Eur J Heart Fail. 2021;23:785–96. Verma A, Kalman JM, Callans DJ. Treatment of patients with atrial fibrillation and heart failure with reduced ejection fraction. Circulation. 2017;135:1547–63. Marrouche NF, Brachmann J, Andresen D, Siebels J, Boersma L, Jordaens L, et al. Catheter ablation for atrial fibrillation with heart failure. N Engl J Med. 2018;378:417–27. Jones DG, Haldar SK, Hussain W, Sharma R, Francis DP, Rahman-Haley SL, et al. A randomized trial to assess catheter ablation versus rate control in the management of persistent atrial fibrillation in heart failure. J Am Coll Cardiol. 2013;61:1894–903. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3935654","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":273006061,"identity":"a903153a-e34f-4f4b-a21d-d9e09fe081a1","order_by":0,"name":"Yang Ping","email":"","orcid":"","institution":"Chongqing Western Hospital, Jiulongpo District, Chongqing, China","correspondingAuthor":false,"prefix":"","firstName":"Yang","middleName":"","lastName":"Ping","suffix":""},{"id":273006062,"identity":"3923d989-2425-4a98-ae66-1ada62069567","order_by":1,"name":"Wang Guoqiang","email":"","orcid":"","institution":"Chongqing Hygeia Hospital, Shapingba District,Chongqing, China","correspondingAuthor":false,"prefix":"","firstName":"Wang","middleName":"","lastName":"Guoqiang","suffix":""},{"id":273006063,"identity":"5fc23199-f903-4387-b0a4-dd9b65e7294e","order_by":2,"name":"Ai Tiantian","email":"","orcid":"","institution":"Chongqing Kangxin Hospital, Jiangbei District, Chongqing, China","correspondingAuthor":false,"prefix":"","firstName":"Ai","middleName":"","lastName":"Tiantian","suffix":""},{"id":273006064,"identity":"36b5d9c0-a5d1-44ad-a2ab-c33a96913d97","order_by":3,"name":"Song Mingbao","email":"","orcid":"","institution":"Chongqing Western Hospital, Jiulongpo District, Chongqing, China","correspondingAuthor":false,"prefix":"","firstName":"Song","middleName":"","lastName":"Mingbao","suffix":""},{"id":273006065,"identity":"7b024045-a064-4417-919d-de7dc1b6ede1","order_by":4,"name":"Yu Xuejun","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA5UlEQVRIiWNgGAWjYBACgwNAQoKBQY6Nmf/hg4SKGuK1GPOz8zAbPDhzjLAWyQYInTizn4dN8mELM2Et/BI5hg8s2+4wbjjMe6wisYGNgb+9OwGvFjaeM8YGkm3PmA0O86XdSNwhwyBx5uwG/FrYe8wkJNsOsxkcZjC7kXiGjcFAIpeAFmYe8x9ALTwgLQWJbcxEaAHawgDUIiHZzGPGQJwWnmPFEhLnDhvwM7MlSyScOcZD2C8SyRs/S5Qdrm/jP3zw44+KGjn+9l78WkCAWQKJw0NQOQgwfiBK2SgYBaNgFIxYAACbJUQpyt11dAAAAABJRU5ErkJggg==","orcid":"","institution":"Chongqing Western Hospital, Jiulongpo District, Chongqing, China","correspondingAuthor":true,"prefix":"","firstName":"Yu","middleName":"","lastName":"Xuejun","suffix":""},{"id":273006066,"identity":"6d52db07-1a63-45af-9729-95d841b70039","order_by":5,"name":"Liao Xiaoying","email":"","orcid":"","institution":"Chongqing Kangxin Hospital, Jiangbei District, Chongqing, China","correspondingAuthor":false,"prefix":"","firstName":"Liao","middleName":"","lastName":"Xiaoying","suffix":""}],"badges":[],"createdAt":"2024-02-07 03:44:12","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3935654/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3935654/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":51240810,"identity":"d22e2546-a7e9-4751-9230-463ef42c4f14","added_by":"auto","created_at":"2024-02-16 17:37:31","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":177032,"visible":true,"origin":"","legend":"\u003cp\u003eFlow diagram and study protocol\u003c/p\u003e\n\u003cp\u003eLVEF, left ventricular ejection fraction; PDA, patent ductus arteriosus.\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-3935654/v1/d06ba220e2ec21b9cafaf3b0.jpeg"},{"id":51240811,"identity":"d436c2a0-fe95-4a44-a8d1-153ddf1d488f","added_by":"auto","created_at":"2024-02-16 17:37:32","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":188954,"visible":true,"origin":"","legend":"\u003cp\u003eKaplan-Meier of freedom from atrial arrhythmia recurrence\u003c/p\u003e\n\u003cp\u003eHF, heart failure; HFpEF, heart failure with preserved ejection fraction; AF, atrial fibrillation.\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-3935654/v1/78315b876e968f16943421dc.jpeg"},{"id":56358143,"identity":"c510440a-7b92-4a36-acdf-99a86cb65a4a","added_by":"auto","created_at":"2024-05-13 06:51:07","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":894623,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3935654/v1/c3488baa-64fb-4ab0-9438-421f8794bcbf.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Catheter ablation as a potential treatment alternative for atrial fibrillation among patients with heart failure with preserved ejection fraction: a retrospective cohort study","fulltext":[{"header":"Background","content":"\u003cp\u003eThe coexistence of atrial fibrillation (AF) and heart failure (HF) with preserved ejection fraction (HFpEF) has been frequently reported in the general population, significantly impacting cardiovascular disease and death rates [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. A previous study showed that HF occurs in more than one-third of patients with AF, whereas AF occurs in more than half of patients with HF [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. In most previous studies, the proportion of HFpEF in HF was nearly 50% [\u003cspan additionalcitationids=\"CR5 CR6\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Globally, data from different countries have shown an increasing trend in the prevalence of HFpEF over time [\u003cspan additionalcitationids=\"CR9\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe treatment of HF combined with AF presents a current research focus, with catheter ablation (CA) at the forefront of clinical discussions. Many scientific investigations suggest that, compared with antiarrhythmic drugs, CA results in increased sinus rhythm maintenance rate in patients with heart failure with reduced ejection fraction (HFrEF), possibly avoiding the long-term side effects of applying antiarrhythmic drugs. Moreover, the cardiac function and quality of life of these patients improved dramaticallydrastically. Some studies have also reported a decrease in rehospitalization rate due to HF in patients with HFrEF post-CA [\u003cspan additionalcitationids=\"CR12\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. The latest guidelines strongly advocate for the application of CA in patients of AF and HFrEF [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. However, the recurrence rate of AF post-CA remains challenging, and the effect of AF on HFpEF is not well-established [\u003cspan additionalcitationids=\"CR16 CR17\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eCurrently, the question of whether patients with HFpEF would benefit from CA for AF remains controversial. A meta-analysis suggested no significant difference in the arrhythmia recurrence rate and security profile between patients without HF or those with HFrEF [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. However, another meta-analysis patients with HFpEF were more likely to receive repeat CA compared with patients with HFrEF [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Therefore, to address these gaps in the literature, the present study aimed to compare the clinical outcomes of patients of HFpEF post-CA for AF with those of patients without HF and to explore the potential association between HFpEF and CA outcomes at 12 months.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design and participants\u003c/h2\u003e \u003cp\u003eThis retrospective cohort study was conducted from September 2017 to October 2022 at Kangxin Hospital in Chongqing, China. Patients who underwent their first CA with a left ventricular ejection fraction (LVEF)\u0026thinsp;\u0026ge;\u0026thinsp;50% were included. Patients were waived from informed consent due to the retrospective nature of the study by the Ethics Committee of Chongqing Kangxin Hospital. The exclusion criteria were as follows: malignant tumor, lost to follow-up, previous cardiac valve surgery, previous congenital heart disease surgery, hyperthyroidism, and those with incomplete data (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Of 163 patients, 144 were eligible for this study. Information regarding the baseline demographics, medical history, auxiliary examinations, and pre-ablation medications were extracted from medical records for analysis.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eDefinitions of HFpEF and the European Heart Rhythm Association score\u003c/h2\u003e \u003cp\u003eHFpEF was diagnosed using the 2023 criteria established by the Chinese Expert Consensus for Diagnosing and Treating Heart Failure With Preserved Ejection Fraction. In particular, HFpEF was diagnosed when patients met the criteria for New York Heart Association (NYHA) class\u0026thinsp;\u0026ge;\u0026thinsp;II and had LVEF\u0026thinsp;\u0026ge;\u0026thinsp;50%, paired with at least one of the following conditions: a regular heart rhythm with an N-terminal pro-B-type natriuretic peptide (NT-proBNP) level\u0026thinsp;\u0026ge;\u0026thinsp;125 pg/mL, an NT-proBNP level\u0026thinsp;\u0026ge;\u0026thinsp;365 pg/mL in the presence of AF, or E/e\u0026rsquo; \u0026ge;15 (HFpEF group). Accordingly, patients who met the conditions of NYHA class II/III but did not fulfill other requirements were categorized into the non-HF group. The European Heart Rhythm Association (EHRA) classification has been widely used in clinical research since it was formally proposed. The EHRA classification is used to assess the impact of symptoms associated with AF (palpitations, fatigue, dizziness, chest pain, dyspnea, anxiety) on daily activities. Based on the score, patients are divided into classes spanning from EHRA class Ⅰ (asymptomatic) to class Ⅳ (disabled, unable to perform daily activities) according to the severity of symptoms.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eFollow-up\u003c/h2\u003e \u003cp\u003eThe clinical outcomes evaluated at the last follow-up included 12-month atrial arrhythmia recurrence-free survival, symptom burden (EHRA score), and AF-related hospitalization. Recurrent arrhythmia was defined as AF, atrial flutter, or atrial tachycardia lasting over 30 seconds after 3 months, as detected using 12-lead electrocardiogram (ECG), 24-h Holter ECG, or an implantable device. At 3, 6, 9, and 12 months post-CA, all patients were required to have completed the 12-lead ECG examination. If arrhythmia symptoms were present, ECG was performed to assess the likelihood of recurrence during the follow-up period. EHRA scores, which were derived from standardized interviews conducted by the same physician at admission and the patient\u0026rsquo;s last follow-up, were used to assess symptoms.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eRadiofrequency ablation procedure\u003c/h2\u003e \u003cp\u003eAll patients underwent pre-ablation anticoagulation therapy and transesophageal echocardiography to exclude left atrial thrombosis. Pharmacological anticoagulant and antiarrhythmic management and the invasive ablation protocol were performed in accordance with the recommendations of the guideline. Radiofrequency CA with conscious sedation was performed using irrigated-tip and circular catheters (Biosense Webster, Diamond Bar, CA, USA) to deliver the radiofrequency current and map, respectively. A transseptal approach incorporating the CARTO navigation system (Biosense Webster) was adopted to perform left atrial exploration and reconstruction. Initially, circumferential pulmonary vein ablation was performed, with pulmonary vein isolation and bidirectional conduction block being the final objectives. Further linear and complex fractioned atrial electrogram ablations were promptly performed, with focal ablation targeting non-pulmonary vein foci performed when necessary. In persistent AF cases, sinus rhythm was restored by administering ibutilide or performing cardioversion.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eNormally distributed continuous variables are expressed as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation in accordance with the HFpEF type, whereas non-normally distributed variables are expressed as median and interquartile range. The Student's \u003cem\u003et\u003c/em\u003e-test and Wilcoxon rank-sum test were used for single variable comparisons within the normally and non-normally distributed continuous variables, respectively. For categorical variables, the Chi-square or Fisher\u0026rsquo;s exact test was used. In patients with HFpEF or those without HF (non-HF patients), the 12-month atrial arrhythmia-free survival rates were illustrated using Kaplan\u0026ndash;Meier curves. Multivariate Cox regression included all factors with significant associations emerging from the univariate Cox regression. We identified individual elements that could predict atrial arrhythmia relapse for 12-months after one ablation process using Cox regression. P-values\u0026thinsp;\u0026lt;\u0026thinsp;0.05 were considered to indicate a statistically significant difference. SPSS 23.0 statistical software was used to perform data analysis.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e\n \u003ch2\u003eBaseline characteristics\u003c/h2\u003e\n \u003cp\u003eThe baseline characteristics of the study participants are presented in Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e. Among the 144 patients who underwent their first CA for AF within the study duration, 43 (29.9%) had HFpEF. Patients in the HFpEF group were significantly older (71.00 [64.00, 75.00] vs. 63.00 [50.50, 70.00] years; P\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and had a higher proportion of women (55.8% vs. 37.6%; P\u0026thinsp;=\u0026thinsp;0.044), more persistent AF (58.1% vs. 29.7%; P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), higher CHA\u003csub\u003e2\u003c/sub\u003eDS\u003csub\u003e2\u003c/sub\u003e-VASc scores (3.86\u0026thinsp;\u0026plusmn;\u0026thinsp;2.01 vs. 1.89\u0026thinsp;\u0026plusmn;\u0026thinsp;1.52; P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), higher NT-proBNP levels (1361.00 [782.40, 2630.00] vs. 292.70 [90.16, 564.95] pg/mL; P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), higher D-dimer levels (0.21 [0.15,0.43] vs. 0.15 [0.1, 0.22] mg/L; P\u0026thinsp;=\u0026thinsp;0.001), lower hemoglobin levels (129.98\u0026thinsp;\u0026plusmn;\u0026thinsp;17.79 vs. 142.23\u0026thinsp;\u0026plusmn;\u0026thinsp;16.03 g/dL; P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), lower estimated glomerular filtration rates (82.52 [65.94, 97.44] vs. 95.68 [81.83, 107.06] mL/min/1.73 m\u003csup\u003e2\u003c/sup\u003e; P\u0026thinsp;=\u0026thinsp;0.002), and higher prevalence of coronary artery disease (53.5% vs. 17.8%; P\u0026thinsp;\u0026lt;\u0026thinsp;0.001) than those in the non-HF group. No significant differences were observed in antiarrhythmic drug (9.3% vs. 9.9%; P\u0026thinsp;=\u0026thinsp;1.000), beta-blocker (41.9% vs. 48.5%; P\u0026thinsp;=\u0026thinsp;0.464), and angiotensin-converting enzyme (ACE) inhibitor or angiotensin II receptor blocker (ARB) (34.9% vs. 22.8%; P\u0026thinsp;=\u0026thinsp;0.131) usage pre-ablation. Echocardiography revealed that patients with HFpEF had a larger left atrial diameter (43.63\u0026thinsp;\u0026plusmn;\u0026thinsp;4.99 vs. 39.07\u0026thinsp;\u0026plusmn;\u0026thinsp;5.34 mm; P\u0026thinsp;\u0026lt;\u0026thinsp;0.001) than non-HF patients. Patients in the HFpEF group had significantly lower left ventricular ejection fraction (60% [54.00%, 65.00%] vs. 63% [59.50%, 67.00%]; P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), higher pulmonary artery pressure (38.00 [32.00, 47.00] vs. 32.00 [27.00, 36.00] mmHg; P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and higher stress-related diastolic dysfunction (E/e\u0026rsquo;: 15.00 [12.70, 17.00] vs. 11.30 [9.00, 13.90]; P\u0026thinsp;\u0026lt;\u0026thinsp;0.001) than those in the non-HF group. No clinically relevant differences were observed in intraoperative electrical cardioversion between the two groups (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eBasic characteristics of the study population\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"5\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eVariables\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eTotal patients\u003c/p\u003e\n \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;144)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eHFpEF group\u003c/p\u003e\n \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;43, 29.9%)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eNon-HF group\u003c/p\u003e\n \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;101, 70.1%)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eP-value\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAtrial fibrillation type\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eParoxysmal (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e89 (61.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e18 (41.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e71 (70.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePersistent (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e55 (38.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e25 (58.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e30 (29.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAge (years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e65.00 [55, 72.00]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e71.00 [64.00, 75.00]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e63.00 [50.50, 70.00]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAge group (years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.025\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAge\u0026thinsp;\u0026lt;\u0026thinsp;75 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e116 (80.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e28 (65.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e88 (87.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAge\u0026thinsp;\u0026ge;\u0026thinsp;75 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e28 (19.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e15 (34.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13 (12.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.044\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e82 (56.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e19 (44.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e63 (62.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e62 (43.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e24 (55.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e38 (37.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAF duration (years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.25 [0.33, 4.00]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.00 [0.50, 3.00]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.00 [0.30, 4.00]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.941\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBody mass index (kg/m\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e24.76\u0026thinsp;\u0026plusmn;\u0026thinsp;3.10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e24.68\u0026thinsp;\u0026plusmn;\u0026thinsp;3.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e24.80\u0026thinsp;\u0026plusmn;\u0026thinsp;3.14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.838\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDrinking (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e19 (13.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3 (7.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16 (15.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.150\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSmoking (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e40 (27.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e7 (16.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e33 (32.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.044\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eComorbidities\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHypertension (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e77 (53.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e27 (62.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e50 (49.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.144\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHyperlipemia (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e37 (25.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e7 (16.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e30 (29.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.092\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCoronary artery disease (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e41 (28.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e23 (53.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e18 (17.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDiabetes mellitus (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e31 (21.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e13 (30.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e18 (17.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.097\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePrevious stroke (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4 (2.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2 (7.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.080\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCOPD (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e5 (3.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2 (4.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3 (3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.635\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEchocardiography\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLeft ventricular ejection fraction (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e63 [58.00, 66.00]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e60 [54.00, 65.00]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e63 [59.50, 67.00]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLeft atrial diameter (mm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e40.43\u0026thinsp;\u0026plusmn;\u0026thinsp;5.63\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e43.63\u0026thinsp;\u0026plusmn;\u0026thinsp;4.99\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e39.07\u0026thinsp;\u0026plusmn;\u0026thinsp;5.34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLeft ventricular end-diastolic diameter(mm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e46.96\u0026thinsp;\u0026plusmn;\u0026thinsp;4.92\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e48.00\u0026thinsp;\u0026plusmn;\u0026thinsp;6.26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e46.52\u0026thinsp;\u0026plusmn;\u0026thinsp;4.18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.159\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eE/e\u0026rsquo;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e12.70 [9.70, 15.43]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e15.00 [12.70, 17.00]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11.30 [9.00, 13.90]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePulmonary artery pressure (mmHg)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e33.00 [28.00, 39.00]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e38.00 [32.00, 47.00]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e32.00 [27.00, 36.00]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCHA\u003csub\u003e2\u003c/sub\u003eDS\u003csub\u003e2\u003c/sub\u003e-VASc score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.48\u0026thinsp;\u0026plusmn;\u0026thinsp;1.90\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3.86\u0026thinsp;\u0026plusmn;\u0026thinsp;2.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.89\u0026thinsp;\u0026plusmn;\u0026thinsp;1.52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLaboratory data\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHemoglobin (g/dL)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e138.57\u0026thinsp;\u0026plusmn;\u0026thinsp;17.44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e129.98\u0026thinsp;\u0026plusmn;\u0026thinsp;17.79\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e142.23\u0026thinsp;\u0026plusmn;\u0026thinsp;16.03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSerum creatinine (mg/dL)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e75.45\u0026thinsp;\u0026plusmn;\u0026thinsp;18.22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e80.89\u0026thinsp;\u0026plusmn;\u0026thinsp;24.20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e73.13\u0026thinsp;\u0026plusmn;\u0026thinsp;14.51\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.055\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eD-dimer (mg/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.16 [0.11, 0.26]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.21 [0.15, 0.43]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.15 [0.1, 0.22]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEstimated glomerular filtration rates (mL/min/1.73 m\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e91.48 [76.84, 105.52]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e82.52 [65.94, 97.44]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e95.68 [81.83, 107.06]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.002\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNT-proBNP level (pg/mL)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e503.00 [155.95, 1156.00]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1361.00 [782.40, 2630.00]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e292.70 [90.16, 564.95]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePre-ablation medication\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAntiarrhythmic drug\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e14 (9.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4 (9.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10 (9.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBeta-blocker\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e67 (46.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e18 (41.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e49 (48.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.464\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eACE inhibitor or ARB\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e38 (26.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e15 (34.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e23 (22.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.131\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIntraoperative cardioversion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e41 (28.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e14 (32.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e27 (26.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.478\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\"\u003eCOPD, chronic obstructive pulmonary disease; BNP, brain natriuretic peptide; ACE, angiotensin-converting enzyme; ARB, angiotensin II receptor blocker; HFpEF, with a preserved ejection fraction; HF, heart failure; NT-proBNP, N-terminal pro-B-type natriuretic peptide; AF, atrial fibrillation.\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cp\u003e[insert Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e]\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\n \u003ch2\u003eAblation outcomes\u003c/h2\u003e\n \u003cp\u003eAt the 12-month follow-up, the recurrence of atrial arrhythmia was significantly higher in the HFpEF group than in the non-HF group (41.9% vs. 13.9%, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). However, no significant differences were observed in AF symptoms (23.3% vs. 12.9%; P\u0026thinsp;=\u0026thinsp;0.120) or total EHRA score reduction from baseline (-1.30\u0026thinsp;\u0026plusmn;\u0026thinsp;0.60 vs. -1.42\u0026thinsp;\u0026plusmn;\u0026thinsp;0.55; P\u0026thinsp;=\u0026thinsp;0.273), representing a similar decrease in symptom severity in both the groups. While no significant differences were observed in the usage of antiarrhythmic drugs (67.4% vs. 69.3%; P\u0026thinsp;=\u0026thinsp;0.825) and beta-blockers (23.3% vs. 24.8%; P\u0026thinsp;=\u0026thinsp;0.848), patients in the HFpEF group received ACE inhibitor or ARB therapy more frequently than did patients in the non-HF group (53.5% vs. 29.7%, P\u0026thinsp;=\u0026thinsp;0.007). Further, no significant difference was noted in all-cause hospitalizations(9.3% vs. 4.0%; P\u0026thinsp;=\u0026thinsp;0.239) (Table \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e). The Kaplan\u0026ndash;Meier curve (Fig. \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e) illustrates the absence of atrial arrhythmia recurrence after 12 months. A significant reduction was observed in arrhythmia-free survival in the HFpEF group compared with that in the non-HF group (P\u0026thinsp;\u0026lt;\u0026thinsp;0.0001). Furthermore, HFpEF was associated with an increased likelihood of atrial arrhythmia recurrence after adjusting for HFpEF, AF type, age (\u0026ge;\u0026thinsp;75 vs. \u0026lt;75 years), AF duration, chronic obstructive pulmonary disease, and left atrial diameter [hazard ratio (HR): 2.56; 95% confidence interval (CI): 1.17\u0026ndash;5.61; P\u0026thinsp;=\u0026thinsp;0.018) (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eCatheter ablation outcomes according to HFpEF status at 12 months\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"5\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eVariables\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eTotal patients\u003c/p\u003e\n \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;144)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eHFpEF group\u003c/p\u003e\n \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;43, 29.9%)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eNon-HF group\u003c/p\u003e\n \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;101, 70.1%)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eP-value\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eArrhythmia recurrence\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e32 (22.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e18 (41.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e14 (13.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAF symptoms\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e23 (16%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e10 (23.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e13 (12.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.120\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEHRA score reduction\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-1.38\u0026thinsp;\u0026plusmn;\u0026thinsp;0.57\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e-1.30\u0026thinsp;\u0026plusmn;\u0026thinsp;0.60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e-1.42\u0026thinsp;\u0026plusmn;\u0026thinsp;0.55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.273\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMedication use\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAntiarrhythmic drug\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e99 (68.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e29 (67.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e70 (69.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.825\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBeta-blocker\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e35 (24.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e10 (23.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e25 (24.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.848\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eACE inhibitor or ARB\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e53 (36.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e23 (53.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e30 (29.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.007\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAll-cause hospitalizations\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8 (5.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4 (9.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4 (4.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.239\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cp\u003eEHRA, European Heart Rhythm Association; ACE, angiotensin-converting enzyme; ARB, angiotensin II receptor blocker; HFpEF, heart failure with preserved ejection fraction; HF, heart failure.\u003c/p\u003e\n \u003cp\u003e[insert Table 3]\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable id=\"Tab3\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003ePredictors of post-blanking atrial arrhythmia relapse after catheter ablation\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"7\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eVariables\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003eUnivariate Cox regression\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003eMultivariate Cox regression\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eHR\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e95% CI\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eP-value\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eHR\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e95% CI\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eP-value\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePersistent AF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3.56\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.71\u0026ndash;7.38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.04\u0026ndash;5.87\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.040\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAge\u0026thinsp;\u0026ge;\u0026thinsp;75 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.17\u0026ndash;5.02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.018\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.56\u0026ndash;2.95\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.548\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.51\u0026ndash;2.06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.949\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAF duration (years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.06\u0026ndash;1.28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.04\u0026ndash;1.27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.005\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBody mass index (kg/m\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.09\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.97\u0026ndash;1.22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.134\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDrinking (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.93\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.33\u0026ndash;2.64\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.887\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSmoking (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.99\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.46\u0026ndash;2.15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.984\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHFpEF (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3.57\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.78\u0026ndash;7.19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.56\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.17\u0026ndash;5.61\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.018\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHypertension (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.98\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.49\u0026ndash;1.97\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.964\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHyperlipemia (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.63\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.26\u0026ndash;1.54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.315\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCoronary artery disease (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.93\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.95\u0026ndash;3.91\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.068\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCOPD (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3.75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.14\u0026ndash;12.35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.030\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3.26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.90\u0026ndash;11.77\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.072\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDiabetes mellitus (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.45\u0026ndash;2.40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.930\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLeft ventricular ejection fraction (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.97\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.92\u0026ndash;1.03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.362\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLeft atrial diameter (mm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.07\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.01\u0026ndash;1.13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.016\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.93\u0026ndash;1.08\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.892\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLeft ventricular end-diastolic diameter(mm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.98\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.91\u0026ndash;1.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.558\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eE/e\u0026rsquo;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.92\u0026ndash;1.08\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.946\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePulmonary artery pressure (mmHg)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.99\u0026ndash;1.06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.123\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCHA\u003csub\u003e2\u003c/sub\u003eDS\u003csub\u003e2\u003c/sub\u003e-VASc score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.98\u0026ndash;1.39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.076\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHemoglobin (g/dL)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.99\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.97\u0026ndash;1.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.406\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSerum creatinine (mg/dL)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.00\u0026ndash;1.03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.162\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eD-dimer (mg/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.51\u0026ndash;2.86\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.679\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEstimated glomerular filtration rates (mL/min/1.73 m\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.99\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.97\u0026ndash;1.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.222\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBeta-blocker\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.21\u0026ndash;1.39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.199\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\"\u003eCI, confidence interval; HR, hazard ratio; AF, atrial fibrillation; HFpEF, with a preserved ejection fraction; COPD, chronic obstructive pulmonary disease\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\"\u003eAdjusted for HFpEF, AF type, age (\u0026ge;\u0026thinsp;75 vs. \u0026lt;75 years), AF duration, COPD, and left atrial diameter (total\u0026thinsp;=\u0026thinsp;6).\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this retrospective cohort study, we investigated the association between HFpEF and outcomes of CA for AF. The results are as follows: First, patients with HFpEF exhibited a lower rate of arrhythmia-free survival after ablation for AF than did those without HF at 12 months. Second, the symptom severity of patients with HFpEF was significantly reduced, as indicated by the EHRA score after CA. Third, no significant increase was noted in all-cause hospitalizations between the HFpEF and non-HF groups. These results suggest that CA can serve as an effective treatment method for patients with HFpEF, despite a higher risk of atrial arrhythmia recurrence than in those without HF.\u003c/p\u003e \u003cp\u003eWhile several studies have evaluated HFpEF as a risk factor for AF recurrence after CA, the results have been inconsistent. In our present study, HFpEF was found to independently increases the risk of atrial arrhythmia recurrence. Patients with HFpEF exhibited significantly lower arrhythmia-free survival rates than those without HF following a 12-month observation period. This finding aligns with the findings of a recent single-center prospective and observational study (n\u0026thinsp;=\u0026thinsp;79), which revealed an association between HFpEF and elevated rates of atrial arrhythmia recurrences after a median 12-month follow-up [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. The results of our present study indicate that HFpEF could increase the recurrence rate of atrial arrhythmia, a conclusion supported by the consistent findings. Previous studies have shown that diastolic failure may lead to recurrence of AF post-radiofrequency CA [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. In patients with AF, HF increases ventricular pressure, resulting in an increase in atrial wall pressure, promoting left atrial fibrosis, and leading to atrial remodeling through pathological and physiological mechanisms such as calcium-handling abnormalities or neurohormone and adrenergic receptor activation [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. These factors may also contribute to AF progression.\u003c/p\u003e \u003cp\u003eCompared to our study, a retrospective cohort study of 547 patients undergoing CA for AF revealed no notable difference in arrhythmia recurrence, irrespective of the use of antiarrhythmic drugs. This was observed after median tracking periods of 50.9 and 31.3 months for the HFpEF and non-HF groups, respectively (P\u0026thinsp;=\u0026thinsp;0.027) [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Consequently, the disparity in these findings could stem from the distinctive follow-up durations or discrepancies in the populations studied.\u003c/p\u003e \u003cp\u003eA single-center prospective study using invasive hemodynamic measurements showed that CA for AF may enhance the living quality of patients with HFpEF (n\u0026thinsp;=\u0026thinsp;35) [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e], similar to the findings of our study. Another retrospective cohort analysis involving 547 patients similarly observed no significant difference in all-cause hospitalization rates (adjusted HR: 2.05; 95% CI: 1.30\u0026ndash;3.23) between the HFpEF and non-HF groups [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Further, a previous study assessing the 12-month post-ablation outcomes reported resolution of HFpEF in 42.9% and 51% of patients after their initial ablation procedure and after several procedures, respectively. These findings suggest a possible causal relationship. HFpEF resolution was closely related to the freedom from recurrence of arrhythmia post-ablation [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Previous studies have shown that AF can induce and exacerbate HF. In AF, the heart rate increases, and the left ventricular end-diastolic filling time decreases, resulting in loss of atrial systolic ability and consequently causing a decrease in cardiac output and activation of neurohormones. In addition, some studies have demonstrated that the rapid ventricular rate can exacerbate the decline in left ventricular function, leading to tachycardiomyopathy and facilitating the occurrence of HF [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Therefore, patients with HFpEF should theoretically benefit from CA. These findings hold significant implications. While the effectiveness of ablation in patients with AF and HFrEF has been established in terms of maintaining sinus rhythm, enhancing the quality of life, and decreasing hospitalization rates [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e], whether these advantages also apply to patients with HFpEF remains uncertain. The present study showed that despite the less favorable HFpEF-related outcomes, CA reduced the burden of AF-related symptoms. However, the potential benefits of CA in patients with HFpEF remain unclear.\u003c/p\u003e \u003cp\u003eThis study has some limitations. First, this retrospective, single-center observational study was limited by its relatively short follow-up period and small sample size. Second, the EHRA grading method is relatively simple, which may cause some errors in grading the severity of AF symptoms. Third, external factors such as mood swings, staying up late, climate change, and lifestyle change can also contribute to the difference in recurrence time, and this study did not account for the effect of potential inducement. Finally, due to a lack of standard equipment for detecting atrial arrhythmias, including an implantable loop monitor, the recurrence of some asymptomatic AF may be overlooked. Therefore, comprehensive, prospective, randomized clinical trials that focus on outcomes of CA for AF in patients with HFpEF are required to establish the effects of ablation on HFpEF outcomes.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eDespite the significantly lower arrhythmia-free survival within 12 months of follow-up among patients with HFpEF than among those without HF, the study findings indicate that applying CA for AF significantly reduces symptom severity in this population. Therefore, additional investigation is required to further assess the clinical efficacy of CA for AF in patients with HFpEF and identify risk factors associated with poor clinical outcomes.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"633\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"18.009478672985782%\" valign=\"top\"\u003e\n \u003cp\u003eACE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"81.99052132701422%\" valign=\"top\"\u003e\n \u003cp\u003eangiotensin-converting enzyme\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"18.009478672985782%\" valign=\"top\"\u003e\n \u003cp\u003eAF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"81.99052132701422%\" valign=\"top\"\u003e\n \u003cp\u003eatrial fibrillation\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"18.009478672985782%\" valign=\"top\"\u003e\n \u003cp\u003eARB\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"81.99052132701422%\" valign=\"top\"\u003e\n \u003cp\u003eangiotensin II receptor blocker\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"18.009478672985782%\" valign=\"top\"\u003e\n \u003cp\u003eCA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"81.99052132701422%\" valign=\"top\"\u003e\n \u003cp\u003ecatheter ablation\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"18.009478672985782%\" valign=\"top\"\u003e\n \u003cp\u003eCI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"81.99052132701422%\" valign=\"top\"\u003e\n \u003cp\u003econfidence interval\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"18.009478672985782%\" valign=\"top\"\u003e\n \u003cp\u003eECG\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"81.99052132701422%\" valign=\"top\"\u003e\n \u003cp\u003eelectrocardiogram\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"18.009478672985782%\" valign=\"top\"\u003e\n \u003cp\u003eEHRA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"81.99052132701422%\" valign=\"top\"\u003e\n \u003cp\u003eEuropean Heart Rhythm Association\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"18.009478672985782%\" valign=\"top\"\u003e\n \u003cp\u003eHFpEF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"81.99052132701422%\" valign=\"top\"\u003e\n \u003cp\u003eheart failure with preserved ejection fraction\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"18.009478672985782%\" valign=\"top\"\u003e\n \u003cp\u003eHFrEF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"81.99052132701422%\" valign=\"top\"\u003e\n \u003cp\u003eheart failure with reduced ejection fraction\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"18.009478672985782%\" valign=\"top\"\u003e\n \u003cp\u003eHR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"81.99052132701422%\" valign=\"top\"\u003e\n \u003cp\u003ehazard ratio\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"18.009478672985782%\" valign=\"top\"\u003e\n \u003cp\u003eNYHA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"81.99052132701422%\" valign=\"top\"\u003e\n \u003cp\u003eNew York Heart Association\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"18.009478672985782%\" valign=\"top\"\u003e\n \u003cp\u003eNT-proBNP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"81.99052132701422%\" valign=\"top\"\u003e\n \u003cp\u003eN-terminal pro-B-type natriuretic peptide\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study protocol was approved by the Ethics Committee of Chongqing Kangxin Hospital, and all relevant local and clinical regulations were followed.\u0026nbsp;Patients were waived from informed consent due to the retrospective nature of the study by the Ethics Committee of Chongqing Kangxin Hospital.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eYP and WGQ mainly contributed to the study research. YP and ATT were involved in research and data collection. YP performed data analysis, prepared the figures, and made significant contributions to manuscript writing. The manuscript was reviewed and modified by YXJ and WGQ. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to thank Editage (www.editage.com) for English language editing.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eVermond RA, Geelhoed B, Verweij N, Tieleman RG, Van der Harst P, Hillege HL, et al. Incidence of atrial fibrillation and relationship with cardiovascular events, heart failure, and mortality: a community-based study from the Netherlands. J Am Coll Cardiol. 2015;66:1000\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKotecha D, Chudasama R, Lane DA, Kirchhof P, Lip GY. 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Atrial fibrillation in cardiac resynchronization recipients with and without prior arrhythmic history. How much of arrhythmia is too much? Cardiol J. 2015;22:267\u0026ndash;75.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSilva-Cardoso J, Zharinov OJ, Ponikowski P, Naditch-Br\u0026ucirc;l\u0026eacute; L, Lewalter T, Brette S, et al. Heart failure in patients with atrial fibrillation is associated with a high symptom and hospitalization burden: the RealiseAF Survey. Clin Cardiol. 2013;36:766\u0026ndash;74.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChen S, P\u0026uuml;rerfellner H, Meyer C, Acou WJ, Schratter A, Ling Z, et al. Rhythm control for patients with atrial fibrillation complicated with heart failure in the contemporary era of catheter ablation: a stratified pooled analysis of randomized data. Eur Heart J. 2020;41:2863\u0026ndash;73.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJoglar JA, Chung MK, Armbruster AL, Benjamin EJ, Chyou JY, Cronin EM, et al. 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. 2023. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.jacc.2023.08.017\u003c/span\u003e\u003cspan address=\"10.1016/j.jacc.2023.08.017\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePacker DL, Piccini JP, Monahan KH, Al-Khalidi HR, Silverstein AP, Noseworthy PA, et al. Ablation versus drug therapy for atrial fibrillation in heart failure: results from the CABANA trial. Circulation. 2021;143:1377\u0026ndash;90.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSiddiqui MU, Junarta J, Riley JM, Ahmed A, Pasha AK, Limbrick K, et al. Catheter ablation in patients with atrial fibrillation and heart failure with preserved ejection fraction: a systematic review and meta-analysis. J Arrhythm. 2022;38:981\u0026ndash;90.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKuck KH, Merkely B, Zahn R, Arentz T, Seidl K, Schl\u0026uuml;ter M, et al. Catheter ablation versus best medical therapy in patients with persistent atrial fibrillation and congestive heart failure: the randomized AMICA trial. Circ Arrhythm Electrophysiol. 2019;12:e007731.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePrabhu S, Taylor AJ, Costello BT, Kaye DM, McLellan AJA, Voskoboinik A, et al. Catheter ablation versus medical rate control in atrial fibrillation and systolic dysfunction: the CAMERA-MRI study. J Am Coll Cardiol. 2017;70:1949\u0026ndash;61.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePanchal G, Kwok CS, Morley-Davies A, Zachariah D, Phan T. A comparison of clinical outcomes following atrial fibrillation ablation for heart failure patients with preserved or reduced left ventricular function: A systematic review and meta-analysis. Indian Pacing Electrophysiol J. 2022;22:18\u0026ndash;23. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.ipej.2021.09.002\u003c/span\u003e\u003cspan address=\"10.1016/j.ipej.2021.09.002\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVecchio N, Ripa L, Orosco A, Tomas L, Mondrag\u0026oacute;n I, Acosta A, et al. Atrial fibrillation in heart failure patients with preserved or reduced ejection fraction. Prognostic significance of rhythm control strategy with catheter ablation. J Atr Fibrillation. 2019;11:2128.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKosiuk J, Van Belle Y, Bode K, Kornej J, Arya A, Rolf S, et al. Left ventricular diastolic dysfunction in atrial fibrillation: predictors and relation with symptom severity. J Cardiovasc Electrophysiol. 2012;23:1073\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKosiuk J, Breithardt OA, Bode K, Kornej J, Arya A, Piorkowski C, et al. The predictive value of echocardiographic parameters associated with left ventricular diastolic dysfunction on short- and long-term outcomes of catheter ablation of atrial fibrillation. Europace. 2014;16:1168\u0026ndash;74.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePrabhu S, Voskoboinik A, Kaye DM, Kistler PM. Atrial fibrillation and heart failure \u0026mdash; cause or effect? Heart Lung Circ. 2017;26:967\u0026ndash;74.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhao L, Wang WYS, Yang X. Anticoagulation in atrial fibrillation with heart failure. Heart Fail Rev. 2018;23:563\u0026ndash;71.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAldaas OM, Malladi CL, Mylavarapu PS, Lupercio F, Darden D, Han FT, et al. Comparison of outcomes after ablation of atrial fibrillation in patients with heart failure with preserved versus reduced ejection fraction. Am J Cardiol. 2020;136:62\u0026ndash;70.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRattka M, Pott A, K\u0026uuml;hberger A, Weinmann K, Scharnbeck D, Stephan T, et al. Restoration of sinus rhythm by pulmonary vein isolation improves heart failure with preserved ejection fraction in atrial fibrillation patients. Europace. 2020;22:1328\u0026ndash;36.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSugumar H, Nanayakkara S, Vizi D, Wright L, Chieng D, Leet A, et al. A prospective STudy using invAsive haemodynamic measurements foLLowing catheter ablation for AF and early HFpEF: STALL AF-HFpEF. Eur J Heart Fail. 2021;23:785\u0026ndash;96.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVerma A, Kalman JM, Callans DJ. Treatment of patients with atrial fibrillation and heart failure with reduced ejection fraction. Circulation. 2017;135:1547\u0026ndash;63.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMarrouche NF, Brachmann J, Andresen D, Siebels J, Boersma L, Jordaens L, et al. Catheter ablation for atrial fibrillation with heart failure. N Engl J Med. 2018;378:417\u0026ndash;27.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJones DG, Haldar SK, Hussain W, Sharma R, Francis DP, Rahman-Haley SL, et al. A randomized trial to assess catheter ablation versus rate control in the management of persistent atrial fibrillation in heart failure. J Am Coll Cardiol. 2013;61:1894\u0026ndash;903.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Atrial fibrillation, Catheter ablation, Heart failure with preserved ejection fraction, Outcomes","lastPublishedDoi":"10.21203/rs.3.rs-3935654/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3935654/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eIn patients with heart failure with reduced ejection fraction, catheter ablation for atrial fibrillation is a useful alternative to drug-induced rhythm control. However, the efficacy of this procedure in patients with heart failure (HF) with preserved ejection fraction (HFpEF) is unclear. Therefore, this study aimed to assess the outcomes of the radiofrequency catheter ablation procedure for atrial fibrillation in patients with HFpEF.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThe retrospective cohort study included 144 patients with a left ventricular ejection fraction\u0026thinsp;\u0026ge;\u0026thinsp;50% who underwent catheter ablation for atrial fibrillation for the first time. We compared clinical outcomes, including freedom from atrial arrhythmia recurrence at 12 months, symptom severity decrease measured using the European Heart Rhythm Association (EHRA) score, and all-cause hospitalizations between patients with HFpEF and those without HF.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eAmong the 144 patients, 43 (29.9%) had HFpEF and 101 (70.1%) did not have HF. At the 12-month follow-up, significant difference was found in the recurrence rate of atrial arrhythmia between the two groups (41.9%, HFpEF group vs. 13.9%, non-HF group; P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Nonetheless, no significant difference was noted in the decrease in symptom severity, evaluated using the reduction in EHRA scores, between the two groups (-1.30\u0026thinsp;\u0026plusmn;\u0026thinsp;0.60 vs. -1.42\u0026thinsp;\u0026plusmn;\u0026thinsp;0.55; P\u0026thinsp;=\u0026thinsp;0.273). Similarly, no significant difference was observed in all-cause hospitalizations between the two groups (9.3% vs. 4.0%; P\u0026thinsp;=\u0026thinsp;0.239). After adjusting for HFpEF, atrial fibrillation type, age group (age\u0026thinsp;\u0026ge;\u0026thinsp;75 vs. \u0026lt;75 years), atrial fibrillation duration, chronic obstructive pulmonary disease, and left atrial diameter, a significant association was noted between HFpEF and increased probability of atrial fibrillation recurrence (hazard ratio: 2.56; 95% confidence interval: 1.17\u0026ndash;5.61; P\u0026thinsp;=\u0026thinsp;0.018).\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eDespite the significantly lower incidence of arrhythmia-free survival within 12 months of follow-up in patients with HFpEF than in those without HF, catheter ablation for atrial fibrillation significantly reduced symptom severity. The study findings suggest catheter ablation as a potential treatment alternative for atrial fibrillation in patients with HFpEF.\u003c/p\u003e","manuscriptTitle":"Catheter ablation as a potential treatment alternative for atrial fibrillation among patients with heart failure with preserved ejection fraction: a retrospective cohort study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-02-16 17:37:25","doi":"10.21203/rs.3.rs-3935654/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"83eed9fa-763d-4a14-bbff-2cc41b664f60","owner":[],"postedDate":"February 16th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-05-13T06:42:58+00:00","versionOfRecord":[],"versionCreatedAt":"2024-02-16 17:37:25","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3935654","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3935654","identity":"rs-3935654","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}