Catheter ablation combined with left atrial appendage closure for non-valvular atrial fibrillation: A Single-Center Retrospective Study

Catheter ablation combined with left atrial appendage closure for non-valvular atrial fibrillation: A Single-Center Retrospective Study | Authorea try { document.documentElement.classList.add('js'); } catch (e) { } var _gaq = _gaq || []; _gaq.push(['_setAccount', 'G-8VDV14Y67G']); _gaq.push(['_trackPageview']); (function() { var ga = document.createElement('script'); ga.type = 'text/javascript'; ga.async = true; ga.src = ('https:' == document.location.protocol ? 'https://ssl' : 'http://www') + '.google-analytics.com/ga.js'; var s = document.getElementsByTagName('script')[0]; s.parentNode.insertBefore(ga, s); })(); Skip to main content Preprints Collections Wiley Open Research IET Open Research Ecological Society of Japan All Collections About About Authorea FAQs Contact Us Quick Search anywhere Search for preprint articles, keywords, etc. Search Search ADVANCED SEARCH SCROLL This is a preprint and has not been peer reviewed. Data may be preliminary. 18 March 2025 V1 Latest version Share on Catheter ablation combined with left atrial appendage closure for non-valvular atrial fibrillation: A Single-Center Retrospective Study Authors : Ying Zhang 0009-0009-7672-3364 , Ruixin Zhang , Peiliang Fang , Jingjing Fa 0000-0001-6933-3717 , Ke Wu , Aoli Chen , Jiaqi Jin , Jianfeng Huang , and Deyu Fu [email protected] Authors Info & Affiliations https://doi.org/10.22541/au.174226683.37751045/v1 179 views 113 downloads Contents Abstract Supplementary Material Information & Authors Metrics & Citations View Options References Figures Tables Media Share Abstract Background: Catheter ablation (CA) combined with left atrial appendage closure (LAAC) for non-valvular atrial fibrillation (NVAF) has become a hot topic in clinical research in recent years. Aims: This study aimed to investigated the safety and effect of CA combined with LAAC for NVAF. Methods: 150 patients diagnosed with NVAF who received CA combined with LAAC (combined group) in Shanghai Changhai Hospital from October 2020 to December 2021 were retrospectively included. Patients who underwent CA-Only (CA-only group, n=150) were selected using propensity score matching (PSM) in a 1:1 ratio. Results: At one-year follow-up, no significant differences in procedure-related complications（1.33% vs 1.33%,P=1.000）and the incidence of stroke（1.33% vs 1.33 %,P=1.000）were found. The success rate between the combined procedure and the CA-only procedure (persistent AF: 62.5% vs 68.8%, P =0.839; paroxysmal AF: 73.8% vs 76.2%, P =0.775) were similar. Furthermore, there was a significant difference in the incidence of heart failure with preserved ejection fraction (HFpEF) before and after procedure (combined group: 32% vs 18.67%,P=0.049; CA-only group: 18.7% vs 5.3%,P=0.024). Multivariate Logistic regression demonstrated longer short diameter of the LAA orifice (OR=1.196, P =0.049) might be a risk factor for residual leakage around the LAA occluder. Conclusion: The combined procedure was feasible, safe and effective in NVAF patients with a high risk for stroke. Longer short diameter of the LAA orifice might be a risk factor for leakage around the LAA occluder. Catheter ablation combined with left atrial appendage closure for non-valvular atrial fibrillation: A Single-Center Retrospective Study Short title: combined CA and LAAC for NVAF at high risk of stroke Ying Zhang a,b# ,Ruixin Zhang c# ,Peiliang Fang d# ,Jingjing Fa c ,Ke Wu a ,Aoli Chen a ,Jiaqi Jin a ,Jianfeng Huang c * and Deyu Fu b * a Putuo Hospital,Shanghai University of Traditional Chinese Medicine,Shanghai,China b Yueyang Hospital of Integrated Traditional Chinese and Western Medicine,Shanghai University of Traditional Chinese Medicine,Shanghai,China c Baoshan Branch,Ren Ji Hospital,School of Medicine,Shanghai Jiao Tong University,Shanghai, China d Department of Cardiology, Renji Hospital,School of Medicine, Shanghai Jiao Tong University, Shanghai, China # Both authors equally contributed to the study * Correspondence author Correspondence: Deyu Fu, Yueyang Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, China E-mail address: [email protected] Jianfeng Huang, E-mail address: [email protected] Statements and declarations Data availability statement: Raw data will be available by adequate request. Funding statement：Supported by the Innovation Fund for Science and Technology of Putuo District Health Commission, Shanghai (ptkwws202221).Supported by Baoshan Branch,Ren Ji Hospital,School of Medicine,Shanghai Jiao Tong University,Shanghai,China(2023-rbcxjj-011). • Conflict of interest disclosure: None • Ethics approval statement:Our research is based on a retrospective analysis of existing medical records and case data, which were generated during routine medical practice rather than being specifically collected for this study. • Patient consent statement:We fully recognize the importance of the rights and privacy of the study subjects. Throughout the research process, we have taken all reasonable measures to protect their privacy and ensure that the research results will not have any adverse effects on any individual. What’s new? 1. There was no difference in the incidence of procedure-related safety events and the success rate of ablation between the combined procedure (catheter ablation combined with left atrial appendage closure) and the catheter ablation (CA)-only procedure. 2. The combined procedure and CA-Only procedure could both reduce the incidence of HFpEF. 3. Longer short diameter of the left atrial appendage (LAA) orifice was a risk factor for leakage around the LAA occluder after combined procedure. Abstract Background: Catheter ablation (CA) combined with left atrial appendage closure (LAAC) for non-valvular atrial fibrillation (NVAF) has become a hot topic in clinical research in recent years. Aims: This study aimed to investigated the safety and effect of CA combined with LAAC for NVAF. Methods: 150 patients diagnosed with NVAF who received CA combined with LAAC (combined group) in Shanghai Changhai Hospital from October 2020 to December 2021 were retrospectively included. Patients who underwent CA-Only (CA-only group, n=150) were selected using propensity score matching (PSM) in a 1:1 ratio. Results: At one-year follow-up, no significant differences in procedure-related complications（1.33% vs 1.33%,P=1.000）and the incidence of stroke （1.33% vs 1.33 %,P=1.000）were found. The success rate between the combined procedure and the CA-only procedure (persistent AF: 62.5% vs 68.8%, P =0.839; paroxysmal AF: 73.8% vs 76.2%, P =0.775) were similar. Furthermore, there was a significant difference in the incidence of heart failure with preserved ejection fraction ( HFpEF ) before and after procedure (combined group: 32% vs 18.67%,P=0.049; CA-only group: 18.7% vs 5.3%,P=0.024). Multivariate Logistic regression demonstrated longer short diameter of the LAA orifice (OR=1.196, P =0.049) might be a risk factor for residual leakage around the LAA occluder. Conclusion: The combined procedure was feasible, safe and effective in NVAF patients with a high risk for stroke. Longer short diameter of the LAA orifice might be a risk factor for leakage around the LAA occluder. Keywords: Atrial fibrillation; Catheter ablation; Cardiac function; Left atrial appendage closure; Residual leakage around the occlude 1. Introduction According to the epidemiological study of atrial fibrillation (AF) conducted by Hu Daichi et al. in 13 provinces and cities in China, the age-adjusted prevalence rate of AF was 0.65%, and as high as 7.5% in people older than 80 years [1-2] . AF could reduce cardiac function, exercise tolerance, and increase the incidence of ischemic stroke as well as systemic thromboembolic events. Catheter ablation (CA) is the first-line treatment for symptomatic AF in selected patients. Guidelines suggest for AF patients at high risk of stroke, anticoagulation therapy should be maintained even after successful postoperative conversion and sinus rhythm maintenance [3] . However, patients exposed to a high risk of stroke often had a relatively high bleeding risk score, and long-term oral anticoagulants increased the risk of bleeding. As an alternative treatment to oral anticoagulant drugs, left atrial appendage closure (LAAC) could safely and effectively prevent thromboembolic events [3] . AF can cause structural and functional changes in the heart, especially for left atrial enlargement. CA can reverse left atrial remodeling and reduce the increased left atrial diameter. In recent years, the safety of CA combined with LAAC (referred to as combined procedure) has been proven [4-8] . However, LAAC can increase the left atrial volume of patients in some studies [9-11] . Problems thus appear that how the diameter of the left atrium will change when CA and LAAC are combined, and whether this change will affect the success rate of AF ablation. To this end, the statistical method of propensity score matching (PSM) was used to investigate the effect of combined procedure on the ablation effect of AF in patients with a high risk for stroke. At the same time, the influence of combined procedure on left atrial remodeling was also discussed. 2.Methods 2.1 Studied Population In this study, non-valvular AF patients aged > 18 years and ≤90 years with a high risk of stroke (CHA2DS2-VASc score ≥2 in men and ≥3 in women) who received the combined procedure of CA and LAAC in Shanghai Changhai Hospital from October 2020 to December 2021 were retrospectively included as the combined group (n=150), including persistent AF (n=64) and paroxysmal AF (n=86). All participants were included based on the following indications for unsuitable long-term anticoagulant therapy: a clear history and/or tendency to bleed; allergy to anticoagulants; poor compliance with long-term oral anticoagulants; or increased blood risk (HAS-BLED score ≥3). During the same period of time, CA procedures were performed on 480 patients, including persistent AF (n=226) and paroxysmal AF (n=254) respectively. PSM was used to select controls to minimize potential confounding bias. Patients of the combined group were matched 1:1 to those who underwent CA alone (CA-only group). A total of 300 patients in both groups were included in the final analysis (Table 1). This retrospectively study was approved by the Ethics Committee of Changhai Hospital and complied with the Declaration of Helsinki. 2.2 Pre-procedural assessment All the procedures were performed by experienced operators having passed the learning curves of either CA or LAAC. Left atrial appendage (LAA) thrombus exclusion and size measurement were carried out by transesophageal echocardiography (TEE) before procedures on 30% (90/300) of patients. A cardiac computed tomography (CT) scan and 3-dimensional reconstruction of the left atrium were performed in advance to assist CA and/or LAAC for all patients. 2.3 Ablation procedure Under conscious sedation, a decapolar catheter was positioned in the coronary sinus, and two transseptal accesses were obtained through the right femoral vein. Mapping and ablation were performed under the guidance of CARTO (Biosense Webster, Diamond Bar, CA, USA) or EnSite (St. Jude Medical, St Paul, MN, USA) 3- dimensional electroanatomic mapping systems in addition to standard fluoroscopy. For patients with paroxysmal AF, standard pulmonary vein isolation (PVI) was performed, while for those with persistent AF, additional linear and/or complex fragmented atrial electrogram (CFAE) ablations were carried out according to the physician’s discretion. Sinus rhythm was restored by either ablation or electric cardioversion. 2.4 LAAC procedure All patients underwent successful LAA closure with the guidance of WATCHMAN. 14F guide wire and pigtail catheters were advanced into the LAA following AF ablation. The size, depth, and shape of LAA was observed and recorded by angiogram under fluoroscopy guidance and TEE or ICE. The device was released after confirmation of an adequate position [no or minimal peridevice leakage (PDL) ≤ 3 mm by TEE/ICE] and a tug test. 2.5 Follow-Up All patients routinely received anticoagulation therapy for at least 3 months after the combined procedure. The anticoagulation regimen was usually either warfarin or novel OACs depending on the individual patient, Cardiac computed tomography angiography (CCTA) was performed 3-6 months after the combined procedure to assess device stability, LAA sealing and device-related thrombus (DRT). If the CCTA suggested PDL＜3mm or no DRT during follow-up, the patient was subsequently treated with dual antiplatelet therapy to the 6 th months after procedure, then oral aspirin or clopidogrel for long-term. Holter and echocardiography was routinely obtained at the 3,6 and12months outpatient clinic appointment for all patients. Freedom of AF, cardiac function, left ventricular ejection fraction (LVEF) and left atrial diameter (LAD) were compared between the combined group and CA-only group. Incidence of perioperative complications and thromboembolic events such as stroke, transient ischemic attack (TIA), and systemic embolism were observed during follow-up between the two groups. 2.6 Statistical Analysis Continuous variables were described as mean ± standard deviation (SD). Categorical variables were described as percentage (%). Kaplan–Meier estimate analyzed the freedom of atrial arrhythmia with p value achieved by the log-rank test. Multivariate logistics regression analysis was applied to determine the risk factors of the recurrence of atrial arrhythmias and residual leakage after left atrial appendage closure. All data were analyzed by SPSS 26.0, and P < 0.05 was considered statistically significant. 3.Results 3.1 Baseline data of subjects Baseline characteristics before and after propensity score matching are shown in Table 1. Compared with the combined group, patients in the CA-only group were younger (62.31±9.07&69.38±9.27, P < 0.001) and less likely to suffer from diabetes or cardiovascular/cerebrovascular disease. CHA2DS2-VASc and HAS-BLED scores of the combined group were both higher than those of the CA-only group. After propensity score matching, both groups with each of 150 subjects were matched. There were no significant differences in gender, age, AF type, ablation energy, smoking history, alcohol consumption, diabetes mellitus, cardiac structure and function between the CA-only group and the combined group after matching. Patients of the CA-only group were less likely to have cerebrovascular disease than that those of the combined group (P = 0.011). 3.2 Security events Safety event are presented in Table 2. There was one case of pericardial tamponade during the perioperative period in the combined group, and one of arteriovenous fistula in the CA-only group. No death, stroke, thromboembolism or surface thrombosis of air embolization instruments occurred in both groups during the perioperative period. The incidence of stroke was 1.33% (2/150 cases) in the combined group and 1.33 %(2/150) in the CA-only group (P=1.000). Compared with the incidence of thromboembolic events predicted by the CHA2DS2-VASc score, stroke events in the combined group was reduced by 42.3%. In the combined group, 2 patients died of lung cancer resection, while there were no deaths in the CA-only group. In addition, there was one case of brain glioma in the combined group and one of gastric malignant tumor in the CA-only group. Bleeding events are presented in Table 2. During oral anticoagulants, two cases of cerebral hemorrhage and eight cases of mild hemorrhage (four cases of subcutaneous congestion, two cases of hemoptysis, and two cases of gingival hemorrhage) occurred in the combined group. The mean HAS-BLED score before procedure was 1.85 in the combined group, compared with the corresponding HAS-BLED estimated annual incidence of major bleeding events of 1.9%, the incidence of major bleeding decreased by 31.6% in the CA-only group, and there were two cases of cerebral hemorrhage and four cases of mild bleeding events (two cases of subcutaneous congestion and two cases of gingival hemorrhage). 3.3 Recurrence of AF No difference was observed in the recurrence rate of atrial arrhythmia in both two groups（25.33% vs 28%， P =0.854. Kaplan-Meier estimate analysis (FIG. 1A and FIG. 1B) showed the combined procedure did not affect the survival without AF (Persistent AF: Log Rank P=0.84; Paroxysmal AF: Log Rank P=0.77). Univariate Logistic regression analysis found that age, AF type, duration of AF, CHA2DS2-VASc, HAS-BLED, BNP, LAV, LAD, smoking and drinking history had no statistical significance on the recurrence of AF in the combined group (Table 3). 3.4 Cardiac Function BNP and LVEF were used to assess the cardiac function, and the level of BNP in the CA-only group decreased compared with the preoperative value (P=0.028), and postoperative LVEF was also improved (P=0.025). In the combined group, only LVEF was improved compared with preoperative patients (P=0.032) (Table 4). There were 48 (32%) patients with heart failure in the combined group, in which 44 (29.3%) had HFpEF. After 12 months of follow-up, there were 28 (18.67%) patients with heart failure, in which 22 (14.67%) had HFpEF. While in the CA-only group, there were 28 (18.7%) patients with heart failure before procedure, in which 22 (14.67%) had HFpEF, and only 8 (5.3%) with HFpEF after procedure. The combined and CA-Only procedure can both reduced the incidence of heart failure (P= 0.049&0.024 respectively). 3.5 Remodeling of the left atrium LAD and LAV were used to evaluate the remodeling of the left atrium. In the CA-only group, LAD was reduced after ablation (P=0.002). However there were no significant changes in LAD and LAV in the combined group compared with those before procedure（ P =0.243； P =0.637） (Table 5). 3.6 Residual leakage around occluder In the combined group, 146 patients successfully underwent LAAC, 4 failed the closure, 130 completed CCTA follow-up, and 16 failed to complete the CCTA follow-up. Thrombosis on the surface of the occluder was not observed during the follow-up. Univariate Logistic regression analysis was performed on various factors such as AF type, ablation energy and duration of AF in the combined group, and the results indicated statistical significance in the short diameter of the LAA orifice . (Table 5) Multivariate logistic regression analysis of preoperative indexes showed that the short diameter of the LAA orifice (OR: 1.196, 95% CI: 1.001-1.429, P=0.049) was a risk factor affecting residual leakage around the left auricular occluder. (Table 5） 4.Discussion AF is the most common arrhythmia which is related to an increased risk of ischemic stroke. At present, catheter ablation has become a first-line treatment for the symptomatic AF in selected patients, but its effect on maintaining sinus rhythm decreases over time [12]. Therefore, the guidelines suggest for AF patients at high risk of stroke, anticoagulation therapy should be maintained even if the sinus rhythm is restored after CA [3] . LAAC has become an alternative to prevent stroke events in patients with nonvalvular AF [3, 13] . The safety and efficacy of LAAC combined with AF ablation in a single procedure have been discussed in some researches [14-16] . In the present study, the main findings include: (1) Combined procedure is as safe as ablation alone; (2) Combined procedure reduces the use of postoperative anticoagulant drugs without increasing the incidence of stroke; (3) Simultaneous LAAC does not affect the success rate of AF ablation; (4) Combined and CA-only procedure can significantly reduce the incidence of heart failure; (5) Combined procedure can affect the left atrium reverse remodeling after CA; (6) A longer short diameter of the LAA orifice indicates greater possibility of residual leakage after LAAC. 4.1 Safety The most common complications of interventional treatment of AF include pericardial effusion and arteriovenous fistula. According to previous studies, the incidence of complications of combined procedure ranges from 3.1% to 20.0% [4-6] .Our present study showed that incidence of stroke and major bleeding events was 1.33% and 1.33% in the combined group. The predicted annual incidence of thromboembolic events was 4.6% based on the CHA2DS2-VASc score, and compared with the predicted incidence of stroke events based on corresponding CHA2DS2-VASc score, the incidence of stroke events and major bleeding in the combined group was reduced by 42.3%&31.6% respectively. The success rate of occluder implantation was 97.3%, except for one case of pericardial tamponade. Utilization rate of anticoagulants decreased from 100% to 10.7% after LAAC, and the occurrence of thrombotic events was still effectively prevented. 4.2 Success rate of AF ablation CA can maintain sinus rhythm for a long time and improve the prognosis of patients [17, 18] . The question is whether similar conclusions can be reached by combined procedure. To this end, the recurrence rate of postoperative atrial arrhythmias and the survival time curve without AF were hereby compared between the combined group and the CA-only group. No difference in the success rate of AF ablation between the two groups was observed, indicating that simultaneous LAAC was acceptable. 4.3 Cardiac function In this study, BNP and cardiac ultrasonic cardiogram were used to evaluate the cardiac function of patients. Increase LVEF was found in both groups. In the CA-only group, BNP level decreased before and after procedure, while in the combined group, BNP level did not change significantly before and after procedure, only with an increasing trend. Natriuretic peptide in patients with AF mainly comes from the left atrium, especially from LAA. Implantation of the LAA occluder provides continuous pressure on the LAA, promoting the production of natriuretic peptide [19] , which resulted to higher BNP level after combined procedure. In addition, in the combined group, 48 patients with heart failure before decreased to 28 one year later, and in the CA-only group, 28 with heart failure before decreased to 8 one year later. In conclusion, combined and CA-only procedure can both improve the cardiac function of patients and reduce the incidence of heart failure. 4.4 Left atrial remodeling Ablation could actively improve the left atrial remodeling in patients with AF, the BNP and LAD were alleviated compared with those before ablation. LAV also presented a trend of remission, which was consistent with previous research results [20, 21] . However, compared with the CA-only group, the left atrial remodeling after AF ablation was not significant in the combined group. Some studies [11] indicated LAV increase after LAAC, which had opposite effects on the volume of left atrium comparing to ablation alone. After combined procedure, there was no significant change in LAD and LAV compared with preoperative procedure, and the BNP level even tends to increase. In the CA-only group, the LAD and BNP levels at baseline were improved and LAV showed a trend of improvement, indicating that LAAC might have a negative impact on the reverse remodeling effect of CA. This result might be related to the effect on the mechanical function of the left atrium after occluder implantation. Under sinus rhythm, the LAA undergoes two filling and empting processes in one cardiac cycle [22] ,which not only reduces the volume load of the left atrium, but also plays a role in assisting the filling of the left ventricle. The implantation of the LAA occluder interfered with the changes in this cycle, thus leading to the enlargement of the left atrial diameter. 4.5 Residual leakage around the occluder Some studies have suggested that residual leakage may be related to the morphology of LAA, the compression ratio of occlusive device, occlusive endothelization insufficiency, and the incongruity of myocardial remodeling of LAA. Herein, it was found that longer short diameter of the LAA might be prone to residual leakage. Patients without residual leakage shunt usually had a smaller LAA opening width [23] . Certain compression ratio of 20% or higher would contribute to reducing the incidence of residual shunt [25, 26] . At present, there is no clear clinical research conclusion on the relationship between residual leakage shunt devices of occluder and stroke events. It is of great significance to explore the incomplete blocking mechanism of different occluder devices for guiding clinical treatment. Therefore, individualized anticoagulation should be developed for patients with residual shunt. 5 . Limitations There are still certain limitations in the present study. The structure and function of the left atrium awaits more precise evaluation metrics. In addition, the sample size was insufficient, and further studies with larger samples are needed. Author Contribution Ying Zhang: concept/design, data collection, data analysis/interpretation, drafting of manuscript. Jianfeng Huang and Ruixin Zhang: data collection, drafting of manuscript. Jingjing Fa, Ke Wu, Aoli Chen and Jiaqi Jin: data collection, critical revision. Deyu Fu: concept/design, data collection, drafting of manuscript, critical revision. Acknowledgments We acknowledge Dr. Mingzhu Wang for his technical assistance. References 1. Roth GA, Mensah GA, Johnson CO, et al. Global burden of cardiovascular diseases and risk factors, 1990-2019: update from the GBD 2019 study. J Am Coll Cardiol. 2021;76(25):2982-3021. doi: 10.1016/j.jacc.2021.02.039. 2. Guo Y, Tian Y, Wang H, Si Q, Wang Y, Lip GYH. Prevalence, incidence, and lifetime risk of atrial fibrillation in China: new insights into the global burden of atrial fibrillation. Chest. 2015;147(1): 109-119.doi:10.1378/chest.14-0321 3. Reddy VY, Sievert H, Halperin J, et al. 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J Am Coll Cardiol. 2017;69(3):253-261. doi:10.1016/j.jacc.2016.10.010 Tables Table 1 Baseline data of the patients in the combined procedure group and the CA-only group before and after matching Baseline characteristics combined procedure group(n=150) Unmatched control group (480) Matched control group（150） P1 P2 Age(years) 69.38±9.27 62.31±9.07 66.90±8.67 ＜0.001 0.055 Gender male 92 317 86 0.579 1 female 58 163 64 CHA2DS2-VASc score 3.32±1.27 1.83±1.45 3.12±1.53 ＜0.001 0.110 HAS-BLED score 1.85±0.83 1.08±0.96 1.62±0.96 ＜0.001 0.27 AF Type Paroxysmal AF 86 254 86 0.421 1 Persistent AF 64 226 64 Ablation energy RFA 54 120 54 0.15 1 CRA 96 360 96 Smoking (n, %) 28 26 26 0.162 1 Drinking(n, %) 28 60 20 0.504 0.303 Diabetes(n, %) 48 72 36 0.001 0.363 Hypertension (n, %) 110 284 114 0.085 0.851 CCVd Cardiovasculardisease 46 70 42 0.008 0.855 Cerebrovasculardisease 48 28 20 ＜0.001 0.011 Carotid plaque 74 142 54 0.46 0.980 BNP/NT-proBNP（pg/ml） 211±237 160±227 179±293 0.124 0.468 LVEF（%） 60.57±8.91 61.36±6.94 61.34±4.96 0.385 0.305 LAV（ml） 65.34±22.61 66.37±23.84 67.02±24.45 0.946 LAD (cm) 3.98±0.57 3.96±0.51 3.97±0.50 0.677 LAA morphology Cauliflower type 4 28 10 - - Chickenwing type 46 226 54 - - Anti-Chickenwing type 0 28 10 - - Bag type 94 290 66 - - Cactus type 2 18 6 - - Depth of LAA（cm） 3.77±0.75 3.60±7.90 3.58±0.70 0.107 0.121 Long diameter of LAA（cm） 2.65±0.63 2.580±5.57 2.74±0.65 0.356 0.440 Short diameter of LAA（cm） 1.98±0.51 1.91±4.86 1.96±0.47 0.273 0.351 Table 2 Two groups of safety events Complications Combined group CA-only group P Stroke 2 2 1.000 cerebral hemorrhage 2 2 1.000 Death 2 0 - Pericardial tamponade 2 0 - Arteriovenous fistula 0 2 - Bleeding site 10(6.7%) 6(4.0%) 1.000 cerebral hemorrhage 2 2 hemoptysis 2 0 subcutaneous congestion 4 2 gingival hemorrhage 2 2 Leak[ (%)] 24 - - ＜1mm 6（4%） - - 1~3mm 14（8%） - - ＞3mm 4（4%） - - Table 3 Logistic regression analysis of the recurrence of AF in the combined group B S.E. Walds P Exp（B）(95%CI) AF Type 0.375 0.526 0.507 0.476 1.455(0.519,4.078) Age(years) -0.035 0.031 1.292 0.256 0.966(0.910,1.025) Gender 0.130 0.526 0.061 0.805 1.138 (0.406,3.192) duration of AF 0.075 0.048 2.445 0.118 1.078 (0.981,1.185) CHA2DS2-VASc -0.427 0.225 3.589 0.058 0.653 (0.420,1.015) HAS-BLED -0.540 0.345 2.452 0.117 0.583 (0.297,1.146) BNP（pg/ml） 0.000 0.001 0.001 0.981 1.000 (0.998,1.002) LAD (cm) 0.131 0.465 0.079 0.779 1.140 (0.458,2.838) LAV (ml) 0.008 0.012 0.403 0.526 1.008(0.984,1.032) Smoking -0.253 0.718 0.124 0.724 0.776(0.190,3.169) Drinking 0.223 0.668 0.112 0.738 1.250(0.338,4.627) Table 4 Cardiac function before and after procedure in the combined and the CA-only group Cardiac Function Combined group CA-only group Before surgery after surgery P Before surgery after surgery P LVEF（%） 61.53±6.05 62.95±5.07 0.032 61.34±4.96 63.02±4.76 0.025 BNP（pg/ml） 160±139 281±461 0.098 177±294 114±144 0.028 LAD(cm) 3.96±0.53 3.90±0.49 0.243 3.98±0.50 3.82±0.53 0.002 LAV(ml) 67.51±20.76 66.12±23.70 0.637 59.61±20.50 58.40±20.23 0.245 Table 5 Logistic regression analysis of residual leakage around the left auricular occluder Univariate Logistic regression analysis Multivariate logistic regression analysis OR (95%CI) β p OR (95%CI) β P AF Type 1.389(0.385,5.013) 0.329 0.616 ablation energy 0.563(0.133,2.387) -0.575 0.435 duration of AF 0.918 (0.736,1.145) -0.085 0.449 CHA2DS2-VASc 1.010 (0.625,1.631 0.010 0.968 HAS-BLED 0.908 (0.414,1.995) -0.096 0.811 BNP（pg/ml） 1.001 (0.999,1.004) 0.001 0.341 0.999(0.996,1.003) -0.001 0.730 LAD (cm) 1.022 (0.252,4.145) 0.021 0.976 0.169(0.019,1.494) -1.777 0.110 LAV (ml) 1.033 (0.996,1.071) 0.032 0.082 1.057(0.998,1.119) 0.055 0.060 Depth of LAA 1.008(0.915,1.111) 0.008 0.868 Long diameter of LAA(cm) 1.117(0.996,1.254) 0.111 0.058 Short diameter of LAA (cm) 1.174(1.015,1.358) 0.160 0.031 1.196(1.001,1.429) 0.179 0.049 Figure Legends FIG. 1 Kaplan-Meier estimate analysis for the survival without AF. A. Persistent AF: Log Rank P=0.88; B. Paroxysmal AF: Log Rank P=0.77 Supplementary Material File (figure_1.jifaj_14.docx) Download 144.73 KB Information & Authors Information Version history V1 Version 1 18 March 2025 Copyright This work is licensed under a Non Exclusive No Reuse License. Keywords basic: cardiac fibrillation/defibrillation clinical: catheter ablation – atrial fibrillation clinical: implantable devices – atrial fibrillation Authors Affiliations Ying Zhang 0009-0009-7672-3364 Shanghai PuTuo District Center Hospital View all articles by this author Ruixin Zhang Shanghai Jiao Tong University School of Medicine Affiliated Renji Hospital Baoshan Branch View all articles by this author Peiliang Fang Shanghai Jiao Tong University School of Medicine Affiliated Renji Hospital View all articles by this author Jingjing Fa 0000-0001-6933-3717 Shanghai Jiao Tong University School of Medicine Affiliated Renji Hospital Baoshan Branch View all articles by this author Ke Wu Shanghai PuTuo District Center Hospital View all articles by this author Aoli Chen Shanghai PuTuo District Center Hospital View all articles by this author Jiaqi Jin Shanghai PuTuo District Center Hospital View all articles by this author Jianfeng Huang Shanghai Jiao Tong University School of Medicine Affiliated Renji Hospital Baoshan Branch View all articles by this author Deyu Fu [email protected] Shanghai University of Traditional Chinese Medicine Yueyang Hospital of Integrated Traditional Chinese and Western Medicine View all articles by this author Metrics & Citations Metrics Article Usage 179 views 113 downloads .FvxKWukQNSOunydq8rnd { width: 100px; } Citations Download citation Ying Zhang, Ruixin Zhang, Peiliang Fang, et al. 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