{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,6,11]],"date-time":"2026-06-11T18:03:28Z","timestamp":1781201008880,"version":"3.54.1"},"reference-count":24,"publisher":"MDPI AG","issue":"3","license":[{"start":{"date-parts":[[2026,3,19]],"date-time":"2026-03-19T00:00:00Z","timestamp":1773878400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"name":"National Research Foundation of Korea (NRF) grant funded by the Korea government","award":["NRF-2021R1G1A1095709"],"award-info":[{"award-number":["NRF-2021R1G1A1095709"]}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Life"],"abstract":"<jats:p>Background: Atrial fibrillation (AF) frequently develops in patients with atrial flutter (AFL), even after successful cavotricuspid isthmus (CTI) ablation. Identifying simple clinical markers for early detection is crucial. Diagonal earlobe crease (ELC), also known as Frank\u2019s sign, has been proposed as a marker of aging and cardiovascular risk. This study investigates the association between ELC and the risk of new-onset AF following CTI ablation in patients with AFL. Methods: We conducted a retrospective cohort study of 292 patients without a prior history of AF who underwent CTI ablation for typical AFL between 2015 and 2024. The presence of ELC was assessed at baseline CTI ablation. The primary outcome was the occurrence of new-onset AF during follow-up, stratified according to the presence of ELC. The median follow-up duration was 49 months, with a minimum follow-up of 6 months. Results: Among the 292 patients, 72 (24.7%) exhibited ELC. Patients with ELC were older (59 \u00b1 11 years vs. 55 \u00b1 14 years, p = 0.05). During the follow-up period, new-onset AF occurred in 31 patients with ELC (43.1%) and 65 patients without ELC (29.5%) (p = 0.03). Kaplan\u2013Meier analysis demonstrated that the occurrence of AF was significantly higher in the ELC group than in the non-ELC group (log-rank test, p = 0.013). Multivariate analysis revealed that ELC was independently associated with an increased risk of AF (hazard ratio 1.67, 95% confidence interval 1.03\u20132.72, p = 0.039). Conclusions: The presence of ELC is associated with a higher risk of new-onset AF following CTI ablation in patients with AFL. ELC may serve as a simple, non-invasive clinical marker to identify patients who may benefit from closer rhythm surveillance after AFL ablation.<\/jats:p>","DOI":"10.3390\/life16030508","type":"journal-article","created":{"date-parts":[[2026,3,19]],"date-time":"2026-03-19T11:50:36Z","timestamp":1773921036000},"page":"508","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":1,"title":["Diagonal Earlobe Crease and the Risk of New-Onset Atrial Fibrillation After Cavotricuspid Isthmus Ablation in Patients with Typical Atrial Flutter"],"prefix":"10.3390","volume":"16","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-5482-4441","authenticated-orcid":false,"given":"Moo-Nyun","family":"Jin","sequence":"first","affiliation":[{"name":"Department of Cardiology, Incheon Sejong Hospital, Incheon 21080, Republic of Korea"},{"name":"Department of Internal Medicine, Ewha Womans University College of Medicine, Seoul 07985, Republic of Korea"},{"name":"Jinsim Heart Rhythm Laboratory, Seoul 05553, Republic of Korea"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-7816-0106","authenticated-orcid":false,"given":"Young Ju","family":"Kim","sequence":"additional","affiliation":[{"name":"Department of Cardiology, Catholic Kwandong University International St. Mary\u2019s Hospital, Incheon 22711, Republic of Korea"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Changho","family":"Song","sequence":"additional","affiliation":[{"name":"Division of Cardiology, BHS Hanseo Hospital, Busan 48253, Republic of Korea"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2026,3,19]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"55","DOI":"10.15420\/aer.2017:5:2","article-title":"Atrial Flutter, Typical and Atypical: A Review","volume":"6","year":"2017","journal-title":"Arrhythmia Electrophysiol. Rev."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"236","DOI":"10.3349\/ymj.2018.59.2.236","article-title":"CHA2DS2-VASc Score in the Prediction of Ischemic Stroke in Patients after Radiofrequency Catheter Ablation of Typical Atrial Flutter","volume":"59","author":"Jin","year":"2018","journal-title":"Yonsei. Med. J."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"393","DOI":"10.1161\/CIRCEP.109.871665","article-title":"Long-term outcomes after catheter ablation of cavo-tricuspid isthmus dependent atrial flutter: A meta-analysis","volume":"2","author":"Schubert","year":"2009","journal-title":"Circ. Arrhythmia Electrophysiol."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"e007197","DOI":"10.1161\/CIRCEP.119.007197","article-title":"Atrial Fibrillation Catheter Ablation Improves 1-Year Follow-Up Cognitive Function, Especially in Patients With Impaired Cognitive Function","volume":"12","author":"Jin","year":"2019","journal-title":"Circ. Arrhythmia Electrophysiol."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"euad343","DOI":"10.1093\/europace\/euad343","article-title":"Navigating the risk of atrial fibrillation after successful ablation of lone typical atrial flutter","volume":"26","author":"Dixit","year":"2024","journal-title":"Europace"},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"327","DOI":"10.1056\/NEJM197308092890622","article-title":"Aural sign of coronary-artery disease","volume":"289","author":"Frank","year":"1973","journal-title":"N. Engl. J. Med."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"92","DOI":"10.1161\/CIRCULATIONAHA.114.009738","article-title":"Bilateral earlobe creases and coronary artery disease","volume":"130","author":"Qamar","year":"2014","journal-title":"Circulation"},{"key":"ref_8","first-page":"739","article-title":"Diagonal earlobe crease in newborn infants and in children","volume":"20","author":"Merlob","year":"1981","journal-title":"Clin. Pediatr."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"274","DOI":"10.1253\/circj.CJ-08-0267","article-title":"Diagonal earlobe crease are associated with shorter telomere in male Japanese patients with metabolic syndrome","volume":"73","author":"Higuchi","year":"2009","journal-title":"Circ. J."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"347","DOI":"10.1016\/j.jjcc.2015.06.002","article-title":"The association of circulating inflammatory and oxidative stress biomarker levels with diagonal earlobe crease in patients with atherosclerotic diseases","volume":"67","author":"Koyama","year":"2016","journal-title":"J. Cardiol."},{"key":"ref_11","doi-asserted-by":"crossref","unstructured":"Deng, Y., Liu, F., Yang, X., and Xia, Y. (2021). The Key Role of Uric Acid in Oxidative Stress, Inflammation, Fibrosis, Apoptosis, and Immunity in the Pathogenesis of Atrial Fibrillation. Front. Cardiovasc. Med., 8.","DOI":"10.3389\/fcvm.2021.641136"},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"495","DOI":"10.1253\/circj.CJ-15-0138","article-title":"Role of inflammation in atrial fibrillation pathophysiology and management","volume":"79","author":"Harada","year":"2015","journal-title":"Circ. J."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"55","DOI":"10.1016\/j.ccl.2008.09.010","article-title":"Diagnosis and management of typical atrial flutter","volume":"27","author":"Sawhney","year":"2009","journal-title":"Cardiol. Clin."},{"key":"ref_14","doi-asserted-by":"crossref","unstructured":"Jin, M.N., Song, C., and Kim, Y.J. (2024). Association of Diagonal Earlobe Crease with Risk of Atrial Fibrillation in Stable Patients with Coronary Artery Disease. J. Clin. Med., 13.","DOI":"10.3390\/jcm13185643"},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"3314","DOI":"10.1093\/eurheartj\/ehae176","article-title":"2024 ESC Guidelines for the management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS)","volume":"45","author":"Rienstra","year":"2024","journal-title":"Eur. Heart J."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"1273","DOI":"10.1056\/NEJMoa2206916","article-title":"Global Effect of Modifiable Risk Factors on Cardiovascular Disease and Mortality","volume":"389","author":"Magnussen","year":"2023","journal-title":"N. Engl. J. Med."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"716","DOI":"10.1016\/j.mayocp.2021.10.003","article-title":"Association of Physical Activity with Primary Cardiac Arrest Risk in the General Population: A Nationwide Cohort Study of the Dose-Response Relationship","volume":"97","author":"Jin","year":"2022","journal-title":"Mayo Clin Proc."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"e1","DOI":"10.1161\/CIR.0000000000001193","article-title":"2023 ACC\/AHA\/ACCP\/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology\/American Heart Association Joint Committee on Clinical Practice Guidelines","volume":"149","author":"Joglar","year":"2024","journal-title":"Circulation"},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"1331","DOI":"10.1016\/j.jacep.2019.07.016","article-title":"Development and Validation of a Prediction Model for Atrial Fibrillation Using Electronic Health Records","volume":"5","author":"Hulme","year":"2019","journal-title":"JACC Clin. Electrophysiol."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"990","DOI":"10.1161\/CIRCULATIONAHA.113.001696","article-title":"Visible age-related signs and risk of ischemic heart disease in the general population: A prospective cohort study","volume":"129","author":"Christoffersen","year":"2014","journal-title":"Circulation"},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"euae204","DOI":"10.1093\/europace\/euae204","article-title":"Atrial cardiomyopathy revisited-evolution of a concept: A clinical consensus statement of the European Heart Rhythm Association (EHRA) of the ESC, the Heart Rhythm Society (HRS), the Asian Pacific Heart Rhythm Society (APHRS), and the Latin American Heart Rhythm Society (LAHRS)","volume":"26","author":"Goette","year":"2024","journal-title":"Europace"},{"key":"ref_22","doi-asserted-by":"crossref","unstructured":"Wei, N., Zhang, R., Zhu, Z., Li, R., Yu, Q., Wang, Q., Xu, C., Ma, M., Mu, S., and Liu, F. (2021). Adropin and Irisin Deficiencies Are Associated with Presence of Diagonal Earlobe Crease in CAD Patients. Front. Cardiovasc. Med., 8.","DOI":"10.3389\/fcvm.2021.719763"},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"682","DOI":"10.1016\/j.jacep.2016.03.014","article-title":"Incidence of Atrial Fibrillation After Atrial Flutter Ablation","volume":"2","author":"Maskoun","year":"2016","journal-title":"JACC Clin. Electrophysiol."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"488","DOI":"10.1016\/j.cjco.2022.02.001","article-title":"Rhythm-Monitoring Strategy and Arrhythmia Recurrence in Atrial Fibrillation Ablation Trials: A Systematic Review","volume":"4","author":"Unni","year":"2022","journal-title":"CJC Open"}],"container-title":["Life"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2075-1729\/16\/3\/508\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,3,19]],"date-time":"2026-03-19T12:08:28Z","timestamp":1773922108000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2075-1729\/16\/3\/508"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,3,19]]},"references-count":24,"journal-issue":{"issue":"3","published-online":{"date-parts":[[2026,3]]}},"alternative-id":["life16030508"],"URL":"https:\/\/doi.org\/10.3390\/life16030508","relation":{},"ISSN":["2075-1729"],"issn-type":[{"value":"2075-1729","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,3,19]]}}}