The study was a single-center, observational, retrospective cohort study. Between January 2018 and February 2023, 5,542 consecutive patients with AF who underwent catheter ablation were screened at the West China Hospital of Sichuan University. The eligibility criteria included adults (≥18 years old) with at least one documented AF episode on 12-lead electrocardiography or Holter monitoring and the availability of preoperative transthoracic echocardiography (TTE) with tissue Doppler imaging (TDI) during sinus rhythm, resulting in 2,972 patients. Patients missing more than one scheduled postoperative TTE during sinus rhythm at 1, 3, 6, or 12 months were excluded, resulting in 256 patients. Finally, 182 patients with complete TDI data at all follow-up intervals were included in this study ( Figure 1 ).

Flowchart for assessing diastolic function. Flowchart of LV diastolic function assessment in hospitalized AF patients undergoing catheter ablation. AF = atrial fibrillation; e′ = septal early diastolic mitral annular velocity; E/A = ratio of early to late transmitral inflow; E/e′ = transmitral-to-annular velocity ratio; LAD = left atrial diameter; LAVI = left atrial volume index; LV = left ventricular; LVDD = left ventricular diastolic dysfunction; LVDDG = LVDD grade; TDI = tissue Doppler imaging; TTE = transthoracic echocardiography; TR = tricuspid regurgitation.

According to the 2025 Recommendations for Echocardiographic Assessment of LVDD supplemented with previous research, ^, patients were categorized into 3 groups based on 3 key screening parameters (septal e’ velocity, septal E/e’ ratio, and peak tricuspid regurgitation velocity) and left atrial volume index or left atrial diameter (LAD). These groups included Group A (normal diastolic function; patients with all normal screening variables), Group B (LVDD with normal left atrial pressure [LVDDG 1]; patients with reduced e’ only and an E/A ratio ≤0.8 or those with normal left atrial volume index or LAD during further assessment), and Group C (LVDD with increased left atrial pressure [LVDDG 2 or 3]; patients with abnormal average E/e’ ratio only or increased peak tricuspid regurgitation velocity or any 2 abnormal screening variables with abnormal left atrial volume index or LAD, and an E/A ratio ≥ 2 distinguished grade 3 from grade 2 dysfunction).

All procedures were performed under local anesthesia, and pulmonary vein isolation was performed via radiofrequency ablation or cryoablation. The following adjunctive ablation strategies were performed in a subset of the patients: posterior wall box isolation, left atrial roof line ablation, mitral and tricuspid isthmus line ablation, superior vena cava segmental ablation, complex fractionated atrial electrogram ablation, and coronary sinus ostial ablation. Transcatheter left atrial appendage closure was performed for thromboembolic risk reduction, if necessary.

Patients were followed up at 1-, 3-, 6-, and 12-month postablation for comprehensive TTE and electrocardiography to evaluate cardiac function, structure, and AF recurrence. Within 1 year after the procedure, AF recurrence was defined as recurrent AF, atrial flutter, or atrial tachycardia lasting ≥30 seconds after the 3-month blanking period, documented by electrocardiography or 24- or 72-hour Holter monitoring. Procedure-related complications and major adverse cardiovascular events were monitored at each follow-up visit through symptom assessment, physical examination, advanced imaging studies, and endoscopic evaluations when clinically indicated.

Postoperative changes in diastolic performance were quantified for each group through serial echocardiographic parameters and corresponding LVDDG measurements at preoperative and multiple postoperative intervals. Sustained LVDD improvement was defined as a ≥ 1-grade decrease in LVDDG documented at 2 or more follow-up visits up to the 6-month landmark, and this metric was used to examine the relationship between LVDD reversibility and subsequent AF recurrence.

LV structural remodeling was assessed by LV geometry based on relative wall thickness (RWT) and LV mass index (LVMI). Normal geometry was defined as RWT ≤0.42 and LVMI ≤95 g/m² for women and ≤115 g/m² for men. Concentric remodeling was defined as RWT >0.42 with normal LVMI, concentric hypertrophy as RWT >0.42 with increased LVMI, and eccentric hypertrophy as RWT ≤0.42 with increased LVMI. Reverse LV remodeling was evaluated by comparing the probability of remodeling patterns preoperatively and postoperatively.

Continuous variables are expressed as mean ± SD or median (interquartile range); group comparisons used analysis of variance or Kruskal–Wallis tests for continuous and χ² or Fisher’s exact tests for categorical variables. Echocardiographic data were analyzed using generalized estimating equations (GEE) with an unstructured working correlation matrix for repeated measures. Continuous outcomes were modeled with appropriate distributions, and binary outcomes with binomial logistic models. Given the exploratory nature of the study, multiplicity for repeated comparisons was handled using the least significant difference approach. AF recurrence was evaluated with Cox models and Kaplan–Meier curves. A prespecified 6-month landmark analysis assessed the association between sustained LVDD improvement and rhythm outcomes, excluding patients with recurrence before the landmark.

To assess representativeness of the analytic cohort, we randomly sampled (Excel RAND function) 150 patients from the overall excluded population and 150 from excluded patients who met the baseline sinus-rhythm echocardiography requirement, and compared their baseline characteristics with the included cohort.

To mitigate confounding effects, those unbalanced variables (variables with p < 0.05 at baseline) were incorporated as covariates into the GEE and Cox models.

Statistical significance was defined as a 2-sided p < 0.05. Analyses were performed using SPSS version 25.0 and R version 4.3.2.

A total of 182 patients were enrolled and stratified into 3 groups according to baseline LVDD stage: Group A with no LVDD, Group B with mild LVDD, and Group C with moderate–severe LVDD. Baseline clinical and echocardiographic characteristics are summarized in Table 1 . Baseline blood pressure and cardiovascular medications are summarized in Supplemental Table S1 . In a representativeness analysis ( Supplemental Table S2 ), the included cohort was broadly comparable to a random sample of excluded patients meeting the baseline sinus-rhythm echocardiography requirement, whereas differences versus the overall excluded population primarily reflected the study’s eligibility constraints. Compared with Group A, patients in Groups B and C were older. Group C also showed a higher proportion of women, a greater prevalence of hypertension, and mitral/tricuspid regurgitation. Mitral and tricuspid regurgitation were predominantly trace or mild in all groups, and moderate or more severe lesions were uncommon. Left ventricular ejection fraction (LVEF) was preserved overall and did not differ significantly among the 3 groups (p = 0.088).

All subjects underwent catheter ablation. The proportion with previous AF ablation history (repeat ablation) did not differ among the groups (p = 0.614). Ablation energy profiles and lesion sets (pulmonary vein isolation ± adjunctive ablation) showed no significant variations (p > 0.05). A subset of 26 patients (14.3%) underwent additional ablation for intraprocedurally mapped arrhythmogenic substrates, including atrial flutter, atrial tachycardia, atrioventricular nodal reentrant tachycardia, and atrioventricular reentrant tachycardia, with comparable distribution across the study groups. However, transcatheter left atrial appendage closure was more common in Group C than in Group A (30% vs 11%; p = 0.023).