Search Results (137)

Background: Ischemic cardiomyopathy (ICM) is characterized by heterogeneous structural remodeling that is not fully captured by conventional systolic metrics. How multidimensional structural echocardiographic information can improve pre-revascularization risk stratification remains unclear. Methods: In this retrospective study, 989 patients with ICM undergoing coronary angiography and revascularization were included in the derivation cohort, and 482 patients from an independent campus served as the validation cohort, with a median follow-up duration of 6.5 years. The primary endpoint was cardiovascular mortality. Eight routinely acquired pre-revascularization echocardiographic structural variables were analyzed. Unsupervised clustering identified structural clusters, and principal component analysis (PCA) was used to derive a structural risk score. Associations with cardiovascular mortality were assessed using the Cox proportional hazards model, and prognostic performance was evaluated by comparing individual echocardiographic predictors using Harrell’s C-index and time-dependent AUC analyses. Results: Three distinct structural clusters emerged, differing in chamber size, systolic function, pulmonary pressures, mitral regurgitation severity, and long-term cardiovascular mortality. The PCA-derived structural risk score, reflecting the dominant axis of remodeling and volume overload, showed association with cardiovascular mortality in the derivation cohort and remained independently predictive after multivariable adjustment. Compared with single echocardiographic parameters, both the structural clusters and the risk score demonstrated superior discriminative performance. In the validation cohort, the structural score again showed a consistent and independent association with cardiovascular mortality. Conclusions: Multidimensional structural echocardiographic assessment reveals clinically meaningful remodeling patterns and enables construction of a robust PCA-derived structural risk score. Both approaches provide prognostic information beyond individual echocardiographic measures and support more precise pre-revascularization risk stratification in patients with ICM. Full article

Objectives: Quantifying ventricular secondary mitral regurgitation (MR) remains challenging, and the prognostic value of echocardiographic parameters is uncertain. This study aimed to assess the concordance of parameters of MR severity and determine the added value of regurgitant fraction (RF) in predicting outcomes. Methods and results: We retrospectively analysed 186 patients with ventricular secondary MR who underwent echocardiography with MR assessment, evaluating effective regurgitant orifice area (EROA), regurgitant volume (RegVol) and RF. The primary endpoint was a composite of all-cause death or heart failure hospitalisation. Quantitative parameters of MR severity were frequently discordant. Using the guideline-recommended cut-offs for EROA (≥40 mm²), RegVol (≥60 mL) and RF (≥50%), severe MR was present in 5.4%, 3.3%, and 29.5% of patients, respectively. Both RF ≥ 50% and EROA ≥ 40 mm² were independently associated with clinical outcomes in multivariable Cox models. Combining RF and EROA provided incremental prognostic value over either parameter alone (p < 0.05). Kaplan–Meier curves showed that patients with EROA < 40 mm² and RF ≥ 50% had similar outcomes to those with EROA ≥ 40 mm² (p = 0.055), whereas patients with both EROA < 40 mm² and RF < 50% had significantly better outcomes (p = 0.002). Conclusions: Substantial discordance between quantitative parameters of severe MR was observed in ventricular secondary MR. RF is a strong, underutilised marker of MR severity, reflecting haemodynamic burden beyond EROA and RegVol. Patients with EROA < 40 mm² and RF > 50% had outcomes comparable to those who met the guideline-based threshold for severe MR, defined as EROA ≥ 40 mm². Our results demonstrate that routine RF assessment may enhance risk stratification and enable identification of a high-risk subgroup of patients with EROA < 40 mm². Full article

Background and Objectives: Transcatheter edge-to-edge repair (TEER) has emerged as an effective treatment option for patients with severe mitral regurgitation who are at high surgical risk. However, clinical outcomes after TEER remain heterogeneous and are influenced not only by cardiac parameters but also by systemic comorbidities and multiorgan dysfunction. The albumin–bilirubin (ALBI) score, derived from serum albumin and bilirubin levels, has recently been proposed as a simple marker of hepatic dysfunction and cardio-hepatic interaction. This study aimed to evaluate the prognostic value of baseline ALBI score in predicting long-term mortality after TEER. Materials and Methods: In this single-center retrospective cohort study, 106 consecutive patients with symptomatic moderate-to-severe or severe mitral regurgitation who underwent TEER between January 2019 and December 2025 were included. Baseline ALBI score was calculated using pre-procedural serum albumin and bilirubin levels. Cox proportional hazards regression analysis was used to identify predictors of long-term mortality. Variable selection was performed using least absolute shrinkage and selection operator (LASSO) regression, followed by ridge-penalized multivariable Cox modeling to minimize overfitting. The incremental prognostic value of ALBI was assessed using concordance index (C-index) comparison between predictive models. Receiver operating characteristic (ROC) analysis and Kaplan–Meier survival analysis were also performed. Results: During a median follow-up of 17.9 months, 30 patients (28.3%) died. Higher baseline ALBI scores were significantly associated with increased mortality risk. In multivariable analysis, ALBI score (HR 3.35, 95% CI 1.46–7.71; p = 0.004), left atrial volume index (LAVI) (HR 1.02, 95% CI 1.01–1.03; p = 0.005), and log-transformed B-type natriuretic peptide (BNP) (HR 1.37, 95% CI 1.02–1.86; p = 0.039) remained independent predictors of mortality. Addition of the ALBI score improved model discrimination, increasing the C-index from 0.845 to 0.886. ROC analysis demonstrated good predictive performance of the ALBI score (area under the curve [AUC] = 0.877), with an optimal cut-off value of −1.67. Conclusions: Baseline ALBI score is independently associated with long-term mortality after TEER and may provide potential incremental prognostic information. However, the observed improvement is modest and should be interpreted cautiously. These findings support a potential role of ALBI as a complementary marker, which requires validation in larger prospective studies. Full article

Background: Right heart failure (HF) and tricuspid regurgitation (TR) are closely interrelated conditions, linked by a bidirectional and self-perpetuating pathophysiological relationship. Alterations in right-ventricular (RV) loading conditions, pulmonary vascular impedance, and ventriculo-arterial (VA) coupling play a central role in the development and progression of TR, which in turn exacerbates RV volume overload and end-organ dysfunction. Methods: This review provides a comprehensive overview of the pathophysiology of right HF and TR, focusing on the mechanisms underlying RV dysfunction, pressure–volume (PV) relationships, and pulmonary vascular load. We further examine the clinical implications of this interaction and summarize current strategies for risk stratification, with particular emphasis on disease-specific risk models. Results: TR emerges both as a consequence and a driver of RHF. Conditions such as pulmonary hypertension (PH) and left-sided heart disease promote annular dilation and leaflet tethering, leading to functional TR. Conversely, TR increases RV volume overload, worsening chamber dilation, reducing effective forward stroke volume (SV), and accelerating disease progression. This vicious cycle results in progressive RV impairment, impaired left-ventricular filling through ventricular interdependence, and systemic venous congestion affecting renal and hepatic function. Traditional risk scores fail to capture this complex pathophysiology. In this context, TRISCORE integrates clinical, biological, and echocardiographic (TTE) parameters reflecting RV dysfunction and systemic involvement, providing a more comprehensive assessment of disease severity and prognosis. Conclusions: TR should be considered not only a marker but also a key determinant of right HF progression. A multiparametric approach integrating pathophysiology and disease-specific risk stratification is essential to identifying the optimal therapeutic window and guiding clinical decision making. Full article

Mitral valve prolapse represents the most common cause of primary mitral regurgitation in Western countries and has traditionally been viewed as a disorder driven by valvular incompetence and chronic volume overload. Within this paradigm, left ventricular enlargement was expected to correlate with regurgitant severity. However, patients with myxomatous bileaflet prolapse often exhibit left ventricular dilatation disproportionate to the degree of regurgitation, leading to the hypothesis of an intrinsic myocardial disease process. Cardiovascular magnetic resonance imaging has challenged this concept through the identification of doming volume, a previously unrecognized systolic blood compartment located between the mitral annular plane and the ventricular surface of prolapsing leaflets. This volume is mechanically coupled to ventricular contraction and contributes to total ventricular volume load independently of transvalvular regurgitation. Recognition of doming volume provides a physiological explanation for excessive ventricular remodeling observed in bileaflet prolapse and Barlow disease. Doming volume has important implications for imaging assessment. Its common exclusion from echocardiographic volumetric measurements may result in underestimation of left ventricular end-systolic volume, overestimation of ejection fraction, and underestimation of regurgitant burden, contributing to discordance between echocardiographic and cardiovascular magnetic resonance-derived measurements. Cardiovascular magnetic resonance enables comprehensive assessment, allowing accurate quantification of ventricular volumes, mitral regurgitation severity, doming volume, and myocardial tissue characteristics. Integration of doming volume into the evaluation of mitral valve prolapse improves physiological consistency between imaging findings and ventricular remodeling. However, further evidence is required before doming volume assessment can be incorporated into operative clinical indications or decision-making thresholds. Full article

Background: Risk stratification of patients with mitral regurgitation (MR), including both primary (degenerative) and secondary (functional) forms, remains challenging, particularly in asymptomatic or minimally symptomatic stages, as clinical assessment and resting echocardiography may underestimate disease severity and functional impairment. Exercise stress echocardiography (ESE) enables dynamic evaluation of regurgitation severity, ventricular performance, and cardiopulmonary response, potentially improving prognostic assessment. Methods: A systematic review was conducted according to PRISMA guidelines. PubMed, Scopus, and EMBASE were searched from inception to March 2026. Studies including adult patients with primary or secondary MR undergoing exercise-based stress echocardiography and reporting clinical outcomes were selected. Studies using exclusively pharmacological stress were excluded. Data were qualitatively synthesized, and continuous variables were summarized as weighted medians and interquartile ranges. In addition, emerging and non-conventional prognostic markers, including anatomical indices such as the modified Haller index (MHI), were explored to provide a more comprehensive risk stratification framework. Results: Nineteen studies were included, encompassing a heterogeneous population in terms of MR etiology, severity, and clinical presentation. During follow-up, a substantial proportion of patients experienced adverse events, including heart failure, mitral valve intervention, or death. Exercise-derived parameters consistently showed strong prognostic value. In particular, exercise-induced worsening of MR severity (increase in effective regurgitant orifice area and regurgitant volume), absence of contractile reserve, elevated filling pressures (E/e’), and exercise-induced pulmonary hypertension were associated with worse outcomes. Reduced functional capacity and impaired right ventricular–pulmonary arterial coupling provided additional prognostic information. Emerging markers, including chest wall configuration assessed by MHI, appeared to further refine risk stratification in selected patient subsets. In contrast, resting parameters were less consistently predictive. Conclusions: ESE provides incremental prognostic information in patients with MR by identifying dynamic abnormalities not evident at rest. Its integration into clinical evaluation, together with novel anatomical and functional markers, may improve risk stratification and support earlier identification of high-risk patients who could benefit from timely intervention. Further studies are needed to standardize methodologies and define clinically relevant thresholds. Full article

Background: The effective regurgitant orifice area to left ventricular end-diastolic volume (EROA/LVEDV) ratio has been proposed to distinguish proportionate from disproportionate functional mitral regurgitation and to guide patient selection for transcatheter edge-to-edge repair (TEER). Methods: We conducted a multicenter, retrospective cohort study of 221 patients undergoing TEER with the Mitraclip system. Preprocedural echocardiographic parameters, including EROA, LVEDV, diastolic indices, and chamber volumes, were systematically collected. The primary outcome indicative of symptom worsening was defined as Heart Failure Hospitalizations (HFH) requiring IV diuresis/death in the one year following clip placement. Association of the preprocedural EROA/LVEDV ratio and symptom worsening was assessed using multivariate regression models and ROC-AUC. Results: In the one-year follow-up, 87 patients (39.36%) had symptom worsening. In the multivariate regression analysis, preprocedural EROA/LVEDV ratio was associated with symptom worsening at one year (OR: 0.95 (0.92–0.97, p value < 0.01). In the ROC model, the pre-procedural EROA/LVEDV ratio had an AUC value of 0.74 (0.69–0.83), with a moderate value for predicting symptom worsening at one year. Conclusions: Results of the study proved that a lower pre-procedural EROA/LVEDV ratio had a significant association with symptom worsening, with the ratio proving to have a moderate value for predicting symptom worsening/death at one year. Full article

Quantitative assessment of mitral regurgitation (MR) in dogs with myxomatous mitral valve disease (MMVD) is influenced by the method used to estimate left ventricular volume. This study aimed to evaluate the impact of different left ventricular volume estimation methods on quantitative MR assessment, using the modified Simpson’s method of discs (Disc method) as a reference. Echocardiographic data from 167 dogs with MMVD and 19 healthy control dogs were analyzed. Regurgitant volume (RVol), body size-normalized RVol, and regurgitant fraction (RF) were calculated using diameter-based methods (Cube, Gibson, Meyer, and Teichholz) and compared with values obtained using the Disc method. All diameter-based methods showed significant positive correlations with the Disc method. However, Bland–Altman analyses demonstrated wide limits of agreement and systematic bias. Between-method discrepancies increased with advancing disease stage, with diameter-based methods tending to overestimate RVol and RF, particularly in dogs classified as American College of Veterinary Internal Medicine (ACVIM) stages B2 and C/D. Although relative trends in regurgitant indices were consistent across methods, substantial differences were observed in absolute values. These findings indicate that diameter-based methods are not interchangeable with the Disc method for absolute quantification of MR severity in dogs with MMVD, especially in advanced disease stages. Full article

Transoral endoscopic therapies in gastro-esophageal reflux disease (GERD) are increasingly performed in patients who do not respond to medical therapy or are not suitable for or willing to undergo long-term PPI therapy or surgery. Currently available effective techniques include reconstruction of the gastro-esophageal valve by transoral incisionless fundoplication (TIF) and tightening of the gastro-esophageal junction through scarring, obtained by mucosal resection or ablation. TIF may be accomplished by an EsophyX 2.0/Z, MUSE, or GERD-X device. An iatrogenic stricture of the cardia may be obtained using a procedure called anti-reflux mucosectomy (ARMS), which includes several technical variants, or through mucosal ablation (ARMA). TIF using EsophyX 2.0 has strong evidence of efficacy in patients with small hiatal hernias, irrespective of hernia reducibility, who experience high-volume reflux episodes and troublesome regurgitation despite PPI therapy. MUSE can be performed only in the presence of a spontaneously reducing hiatal hernia and is probably more effective than EsophyX in maintaining the reduced hernia over time. However, MUSE is no longer available in Western countries. GERD-X shows promising results but needs further confirmation of its efficacy over the long term. ARMS and ARMA are not indicated in the presence of hiatal hernias but have shown promising results in the short term and are less expensive than TIF. Appropriate patient selection and the possibility of proposing a tailored approach to different types of patients and clinical/anatomical conditions result in favorable outcomes in most GERD patients, especially considering their quality of life and independence from PPIs. In the last several years, transoral endoscopic therapies have been proposed, along with concomitant laparoscopic repair for large hiatal hernias (cTIF), for GERD occurring after esophageal peroral endoscopic myotomy (E-POEM), in obese patients before or after bariatric surgery, and in patients with Barrett’s esophagus. Full article

Background: Patients with single-ventricle physiology represent a high-risk group for heart transplantation. Due to complex anatomical and physiological challenges, including multiple prior sternotomies, pulmonary artery abnormalities, and systemic consequences of altered circulation, they represent both a surgical and a clinical challenge. We aimed to analyze perioperative challenges, as well as early and long-term complications, in this specific group of patients. Methods: We performed a retrospective data analysis of a high-volume heart transplant center, focusing on patients with single-ventricle physiology who were scheduled for heart transplantation due to end-stage heart failure. We retrospectively analyzed the period from the beginning of the transplant program in November 1985 to the end of November 2024. Results: Among 1553 transplanted patients (adults and children), 29 were transplanted due to congenital heart disease (congenital valvular disease not included). In this group, nine patients were transplanted due to end-stage heart failure in the course of single-ventricle physiology. Age at transplantation ranged from 7 to 31 years (median, 17 years), and body weight ranged from 15 to 69 kg (median, 47.9 kg). All nine patients referred for heart transplantation presented with single-ventricle physiology. Their underlying congenital heart defects were heterogeneous and included hypoplastic left heart syndrome (HLHS), double-outlet left ventricle (DOLV), transposition of the great arteries (TGA) with associated ventricular septal defects (VSDs), atrial septal defects (ASDs), valvular abnormalities such as tricuspid and or pulmonary valve atresia or stenosis, systemic or atrioventricular valve regurgitation, and vascular abnormalities, including right-sided aortic arch, aortic coarctation, and pulmonary artery hypoplasia, stenosis, or occlusion, as well as associated pulmonary vascular abnormalities such as left pulmonary artery stenosis and MAPCAs. All patients had previously undergone staged palliative procedures, including Norwood, Hemi-Fontan, Fontan, bidirectional Glenn, modified Blalock–Taussig shunts, Bjork–Fontan, or pulmonary artery banding, often with repeated interventions such as balloon angioplasty, stent placement, or MAPCA closure. Extracardiac comorbidities were common and included coagulopathies, protein-losing enteropathy, hepatic dysfunction, and chronic venous insufficiency. Preoperative functional status was markedly impaired in all patients (NYHA III-IV, INTERMACS 3-4), with severely reduced exercise capacity and thrombotic events in several individuals. Perioperative transplant surgical strategies included femoral cannulation in four cases and standard aortic and caval cannulation in five cases. Pulmonary artery reconstruction was required in all patients. Extended donor pulmonary arteries were applied in eight cases, while a bifurcated Dacron prosthesis was utilized in one patient. Perioperative mortality was 33%, with three deaths attributed to bleeding and hemodynamic instability, while overall mortality was 44% including one late death unrelated to transplantation. Protein-losing enteropathy, although persistent in the immediate postoperative period, resolved in all surviving patients, underscoring the transformative impact of transplantation. Conclusions: These findings emphasize the importance of individualized surgical planning, extended donor pulmonary artery harvesting, and careful preoperative coordination. Heart transplantation remains a viable and life-extending option for selected single-ventricle patients, despite the significant technical and clinical challenges involved. Full article

Accurate quantification of mitral regurgitation (MR) is central to perioperative decision-making, yet the agreement and interchangeability of commonly used echocardiographic methods remain uncertain. This study evaluated quantitative MR parameters individually and within a multiparametric framework using three-dimensional (3D) vena contracta area (VCA) as an intraoperative reference. In this single-center retrospective analysis, intraoperative echocardiographic data from 85 patients undergoing mitral valve intervention between July 2024 and June 2025 were analyzed. Regurgitant volume (RVol) and regurgitant fraction (RF) were quantified using two-dimensional proximal isovelocity surface area (PISA), a 3D volumetric method, and a Doppler-based continuity equation. Agreement was assessed by Bland–Altman analysis, and categorical concordance was assessed by Cohen’s kappa for individual and multiparametric grading strategies. Agreement between individual quantitative methods was limited, with substantial bias and wide limits of agreement for both RVol and RF, resulting in poor-to-fair concordance for MR severity classification. Incorporation of RVol and RF into multiparametric grading strategies improved concordance. Compared with 3D VCA, multiparametric integration incorporating PISA-derived measures showed the best overall performance, with high accuracy and sensitivity and moderate specificity. These findings indicate limited interchangeability of standalone quantitative echocardiographic methods and support reporting the applied technique and using a multiparametric approach anchored to 3D VCA when cardiac magnetic resonance imaging is unavailable. Full article

Chronic pulmonary regurgitation (PR) after the repair of tetralogy of Fallot (TOF) and other right ventricular outflow tract (RVOT) interventions leads to progressive right ventricular (RV) dilatation, altered ventricular–ventricular interaction, and an increased risk of arrhythmia and heart failure. Pulmonary valve replacement (PVR), whether surgical or transcatheter, effectively eliminates or reduces PR and is associated with short- and mid-term improvement in RV size, symptoms, and electrocardiographic markers. However, the optimal timing of intervention remains unresolved: operating late can result in irreversible myocardial damage and arrhythmogenic substrates, whereas operating early can lead to repeated reinterventions, the impact of which on hard outcomes is uncertain. This review summarizes contemporary evidence on ventricular remodelling after PVR, focusing on cardiovascular magnetic resonance (CMR) and echocardiographic markers, and critically appraises proposed criteria for timing PVR. Classic CMR-derived thresholds (RV end-diastolic volume index [RVEDVi] 150–170 mL/m², RV end-systolic volume index [RVESVi] 80–90 mL/m²) and QRS duration cut-offs are discussed alongside emerging markers of risk, including the RV mass-to-volume ratio, diffuse myocardial fibrosis (extracellular volume fraction), strain imaging, and diastolic dysfunction. Meta-analyses show consistent reverse remodelling and symptomatic benefit after PVR, but no conclusive survival benefit has been demonstrated, and data on arrhythmic outcomes remain conflicting. Key gaps include (i) the lack of prospective randomized or carefully matched comparative studies of “early” versus “deferred” PVR; (ii) limited understanding of how myocardial fibrosis, RV hypertrophy, and diastolic dysfunction interact with volume load and timing to influence long-term outcomes; (iii) under-representation of adult and older adult TOF cohorts; and (iv) insufficient integration of multiparametric risk scores and machine-learning approaches into clinical decision-making. Future research should prioritize multicentre longitudinal cohorts with standardized imaging, electrophysiological and clinical endpoints, incorporate advanced imaging techniques (e.g., strain, 3D late gadolinium enhancement, and T1 mapping), and explore precision-medicine strategies to individualize PVR timing. Full article

Endotracheal intubation in cats carries risks; supraglottic airway devices (SADs) offer a less invasive alternative. This prospective clinical study evaluated the V-gel^® advanced in cats undergoing ovariohysterectomy, with the primary aim of intra-anaesthetic gas leakage; secondary aims were ease of placement, complications, and the effect of device re-use. Spirometric inspired/expired tidal volumes were recorded under predefined ventilatory settings; leakage was calculated and analysed. Of 52 cats enrolled, 47 were analysed. Leakage occurred in 13% during spontaneous breathing and rose to 41.8% with Continuous Positive Airway Pressure (CPAP) 5 cmH₂O; by contrast, controlled mechanical ventilation showed lower leakage, with the smallest values at Peak Inspiratory Pressure (PIP) of 12 cmH₂O and 16 cmH₂O (2.1% and 6.5%, respectively). Re-used devices leaked less than new ones (p = 0.003). Placement by students was straightforward after adequate depth was achieved. Complications included mild regurgitant material in three cats and pulmonary aspiration in two (one euthanised, one discharged after supportive care). The V-gel^® advanced enabled rapid airway management with leakage influenced by ventilation mode, airway pressure, and device re-use. Findings support cautious use during spontaneous breathing or CPAP, attention to fasting and fresh-gas flows, and further controlled comparisons with prior V-gel^® models and endotracheal intubation. Full article

Background/Objectives: The objective of this study was to characterize echocardiographic characteristics comparing patients accepted or deemed unsuitable for transcatheter mitral valve interventions. Methods: We performed a retrospective analysis of 293 patients with severe mitral regurgitation evaluated for mitral transcatheter edge-to-edge repair (M-TEER) or transcatheter mitral valve replacement (TMVR), if patients were primarily identified as unsuitable candidates for M-TEER, at our institution between 2018 and 2023. All patients underwent transthoracic and transesophageal echocardiography, and mitral valve quantification (MVQ) analysis was performed. Feasibility was determined by an interdisciplinary Heart Team based on quantitative data and semi-quantitative echocardiographic parameters, including mean pressure gradient, regurgitation volumes, and morphological aspects alongside clinical assessment. Patient characteristics were evaluated using clinical records and echocardiographic data. Results: We screened 195 patients for M-TEER, 168 of which were accepted for the procedure. M-TEER-rejected patients presented with higher regurgitation volumes and higher transmitral pressure gradients than those accepted to undergo M-TEER. We then screened 104 patients for TMVR, and 27 were approved for the procedure. Patients rejected for TMVR presented with lower tenting volume, area, and height and had smaller ventricular diameters. Further, mitral valve area appears to be an important parameter in determining MR treatment strategy. Conclusions: The majority of MR patients screened for transcatheter intervention were suitable for M-TEER. However, elevated MPG and more pronounced billowing were the main factors associated with M-TEER exclusion. Conversely, the only morphological parameter associated with TMVR refusal was small left ventricular size. Importantly, the multimorbidity of patients and level of critical illness did not prohibit TMVR. Full article

Background/Objectives: For many years, catheter ablation (CA) has been a cornerstone in atrial fibrillation (AF) rhythm control therapy; however, recurrence remains common. Multiple parameters have been proposed to quantify AF arrhythmogenic substrate, yet reliable predictors of long-term outcomes are lacking. To assess the value of non-invasive amplified P-wave duration (PWD), echocardiographic parameters, biomarkers, and electroanatomical mapping (EAM) were used in predicting left atrial (LA) fibrosis and arrhythmia recurrence after CA. Methods: We included 196 patients undergoing first CA for paroxysmal or persistent AF. Amplified 12-lead ECG PWD parameters [Pmax, Pmin and left atrial P-wave (LAP)], echocardiographic parameters, and biomarkers were assessed pre-procedure. We measured low-voltage areas (LVA, 0.2–0.5 mV) on high-density voltage EAM during sinus rhythm as a surrogate of fibrosis. Freedom from arrhythmia was evaluated at 6 and 12 months. Results: Patients with LVA on EAM had prolonged Pmax (148 vs. 135 ms, p < 0.0001), Pmin (111 vs. 101.5 ms, p = 0.0001), LAP (73.5 vs. 55.5 ms, p < 0.0001), larger LA diameter (p = 0.0002), area (p = 0.0365) and volume (p = 0.004), higher E/E’ (p = 0.0007) and E/A ratios (p = 0.037), more mitral regurgitation (p = 0.0315), and higher pro-BNP levels (p = 0.0094). Univariate analysis showed 12-month recurrence rates higher with greater Pmax, Pmin, LAP, LVA presence and extent; however, in multivariate analysis, only P-wave parameters remained independently associated with recurrence. Conclusions: Prolonged PWD parameters strongly reflect LA substrate (Pmax, Pmin) and independently predict post-ablation AF recurrence (Pmax, Pmin, and LAP). LA size, diastolic dysfunction, and mitral regurgitation were associated with LA fibrosis, while pro-BNP was associated with both fibrosis and arrhythmia recurrence. Integrating these simple, non-invasive markers into a multimodal assessment alongside EAM could improve pre-procedural risk stratification and guide individualized ablation strategies. Full article