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BACKGROUND: Freezing rate of second-generation cryoballoon (CB) is a biophysical parameter thatcould assist pulmonary vein isolation. The aim of this study is to assess freezing rate (time to reach–30°C ([TT-30C]) as an early predictor of acute pulmonary vein isolation using the CB. METHODS: Biophysical data from CB freeze applications within a multicenter, nation-wide CB ablationregistry were gathered. Successful application (SA), was defined as achieving durable intraprocedural veinisolation. And SA with time to isolation under 60 s (SA-TTI<60) as achieving durable vein isolation inunder 60 s. Logistic regressions were performed and predictive models were built for the data set. RESULTS: 12,488 CB applications from 1,733 atrial fibrillation (AF) ablation procedures were includedwithin 27 centers from a Spanish CB AF ablation registry. SA was achieved in 6,349 of 9,178 (69.2%)total freeze applications, and SA-TTI<60 was obtained in 2,673 of 4,784 (55.9%) freezes where electrogrammonitoring was present. TT-30C was shorter in the SA group (33.4 ± 9.2 vs 39.3 ± 12.1 s;p < 0.001) and SA-TTI<60 group (31.8 ± 7.6 vs. 38.5 ± 11.5 s; p < 0.001). Also, a 10 s increase inTT-30C was associated with a 41% reduction in the odds for an SA (odds ratio [OR] 0.59; 95% confidenceinterval [CI] 0.56–0.63) and a 57% reduction in the odds for achieving SA-TTI<60 (OR 0.43;95% CI 0.39–0.49), when corrected for electrogram visualization, vein position, and application order. CONCLUSIONS: Time to reach –30°C is an early predictor of the quality of a CB application and can beused to guide the ablation procedure even in the absence of electrogram monitoring.

Background Pulsed-field ablation (PFA) has shown favourable data in terms of safety and procedural efficiency for pulmonary vein isolation (PVI). We sought to compare procedural and 1-year follow-up data of patients with paroxysmal atrial fibrillation (AF) undergoing PVI using PFA, cryoballoon ablation (CBA) and radiofrequency ablation (RFA). Methods Consecutive patients with paroxysmal AF undergoing a first PVI with PFA at our institution were included. For comparison, patients with paroxysmal AF undergoing a first PVI with CBA and RFA were selected using a 1:2:2 propensity score matching. The PFA group followed the standard 32-applications lesion-set protocol, the CBA group a time-to-effect plus 2-min strategy, and the RFA group the CLOSE protocol. Patients were followed with 7d-Holter ECGs 3, 6, and 12 months after ablation. The primary endpoint was recurrence of atrial tachyarrhythmia (ATa) following a blanking period of 3 months. Results A total of 200 patients were included (PFA n  = 40; CBA n  = 80; RFA n  = 80). Median procedure times were shortest with CBA (75 min) followed by PFA (94 min) and RFA (182 min ; p  < 0.001). Fluoroscopy dose was lowest with RFA (1.6Gycm 2 ) followed by PFA (5.0Gycm 2 ) and CBA (5.7Gycm 2 ; p  < 0.001). After a 1-year follow-up, freedom from ATa recurrence was 85.0% with PFA, 66.2% with CBA and 73.8% with RFA ( p  = 0.12 PFA vs. CBA; p  = 0.27 PFA vs. RFA). Conclusion In a propensity score matched analysis of patients with paroxysmal AF, freedom from any ATa 1 year after PVI using PFA was favourable and at least as good as for PVI with CBA or RFA. Graphical Abstract

Reflecting both the worldwide importance of AF, as well as the worldwide performance of AF ablation, this document is the result of a joint partnership between the HRS, EHRA, ECAS, the Asia Pacific Heart Rhythm Society (APHRS), and the Latin American Society of Cardiac Stimulation and Electrophysiology (Sociedad Latinoamericana de Estimulación Cardíaca y Electrofisiología [SOLAECE]). The purpose of this 2017 Consensus Statement is to provide a state-of-the-art review of the field of catheter and surgical ablation of AF and to report the findings of a writing group, convened by these five international societies. The writing group is composed of 60 experts representing 11 organizations: HRS, EHRA, ECAS, APHRS, SOLAECE, STS, ACC, American Heart Association (AHA), Canadian Heart Rhythm Society (CHRS), Japanese Heart Rhythm Society (JHRS), and Brazilian Society of Cardiac Arrhythmias (Sociedade Brasileira de Arritmias Cardíacas [SOBRAC]). Rather, the ultimate judgment regarding care of a particular patient must be made by the health care provider and the patient in light of all the circumstances presented by that patient.

Background Damage to the sinus node (SN) has been described as a potential complication of superior vena cava (SVC) isolation. There have been reports of permanent SN injury requiring pacemaker implantation during isolation of the SVC. Hypothesis It is safe and effective to isolate SVC with the second‐generation 28‐mm cryoballoon by using a novel method. Methods Forty‐three patients (including six redo cases) with SVC‐related atrial fibrillation (AF) from a consecutive series of 650 patients who underwent cryoballoon ablation were included. After pulmonary vein isolation was achieved, if the SVC trigger was identified, the SVC was electrically isolated using the cryoballoon. First, the cryoballoon was inflated in the right atrium (RA) and advanced towards the SVC‐RA junction. After total occlusion was confirmed by dye injection with total retention of contrast in the SVC, the SVC‐RA junction was determined. Next, the cryoballoon was deflated, advanced into SVC, then reinflated, and pulled back gently. The equatorial band of the cryoballoon was then set slightly (4.32 ± 0.71 mm) above the SVC‐RA junction for isolation of the SVC. Results Real‐time SVC potential was observed in all patients during ablation. The mean time to isolation was 24.5 ± 10.7 s. The SVC was successfully isolated in all patients. The mean number of freeze cycles was 2.5 ± 1.4 per patient, and the mean ablation time was 99.8 ± 22.7 s. A transient phrenic nerve (PN) injury occurred in one patient (2.33%). There were no SN injuries. Freedom from AF rates at 6 and 12 months was 97.7% and 93.0%, respectively. Conclusions This novel method for SVC isolation using the cryoballoon is safe and feasible when the SVC driver during AF is determined and could avoid SN injury. PN function should still be carefully monitored during an SVC isolation procedure.

Background Absence of real-time pulmonary vein (PV) isolation (PVI) occurring in 15–40% of PVs during cryoballoon ablation (CBA) of atrial fibrillation (AF) raises doubt about adequate PVI.Aim of the present study is to determine whether real-time PVI during CBA is predictive of long-term clinical outcome and durability of PVI.MethodsEight hundred three AF patients (64 ± 10 years, 68% males) undergoing CBA were studied. The cohort was divided in 4 groups according to the number of PVs without real-time PVI: none (N = 252 [31.4%]), 1 (N = 255 [31.8%]), 2 (N = 159 [19.8%]), and 3–4 (N = 137 [17.1]).ResultsAt 3 years, 279 (34.7%) patients had recurrence of AF of which 188 underwent repeat ablation. A vein without real-time PVI was associated with AF recurrence (HR = 1.275; 95% CI 1.134–1.433; p < 0.01), independent of persistent AF type (HR = 2.075; 95% CI 1.584–2.738; p < 0.01), left atrial diameter (HR = 1.050; 95% CI 1.028–1.072; p < 0.01), and diagnosis-to-ablation time (HR = 1.002; 95% CI 1.000–1.005; p = 0.04). Highest success was achieved with present real-time PVI in all veins (77.4%), gradually decreasing per increasing number of absent real-time PVI: 66.3% for 1 vein, 58.5% for 2, and 48.9% for 3–4 veins (p < 0.001). At repeat ablation (N = 188), PV reconnection was seen in 99/430 (23.0%) versus 83/288 (28.8%) veins with and without real-time PVI, respectively (p = 0.08). Right inferior PVs (RIPVs) with real-time PVI were less reconnected than RIPVs without real-time PVI: 29.7% versus 43.7% (p = 0.047).ConclusionThe absence of real-time PVI during CBA independently predicts AF recurrence with a 30% gradual decrease in outcome per increase in veins without real-time PVI. Real-time PVI is particularly important for the RIPV to achieve durable PVI.

Background Pulmonary vein isolation (PVI) has become the cornerstone treatment of atrial fibrillation (AF). While in cryoablation cell damage is caused by thermal effects, lately, pulsed field ablation (PFA) has been established as a novel non-thermal tissue-specific ablation modality for PVI. However, data comparing outcomes of patients undergoing either PFA or cryoballoon ablation (CBA) for primary PVI are sparse. Methods Consecutive patients with AF undergoing PVI by either CBA or PFA were included in the analysis. The primary outcome was the time to AF/AT recurrence. For secondary outcomes, clinical and periprocedural parameters were compared. Results In total, outcomes of 141 AF patients treated by PFA (94 patients) or CBA (47 patients) were compared. After 365 days, 70% of patients in the PFA group and 61% of patients in the CBA group were free from AF/AT ( HR 1.35, 95% CI 0.60–3.00; p = 0.470). No deaths occurred. While symptoms alleviated in both groups, only after PFA, we observed significant improvement of left atrial volume index (PFA group baseline: 40 [31;62] ml/m 2 , PFA group follow-up: 35 [29;49] ml/m 2 ; p = 0.015), NT-pro BNP levels (PFA group baseline: 1106 ± 2479 pg/ml, PFA group follow-up: 1033 ± 1742 pg/ml; p = 0.048), and left ventricular ejection fraction (LVEF) (PFA group baseline: 55 [48;60] %, PFA group follow-up: 58 [54;63] %; p = 0.006). PVI by PFA was the only independent predictor of LVEF improvement. Conclusion In our study, we show that CBA and PFA for PVI are of similar efficacy when it comes to AF recurrence. However, our findings suggest that PFA rather than CBA might induce left atrial reverse remodeling thereby contributing to left ventricular systolic function.

The impact of cryoballoon ablation (CBA) for atrial fibrillation (AF) in patients with enlarged left atrium (E-LA) has not been sufficiently clarified. A total of 306 patients underwent an initial CBA for paroxysmal AF between February 2017 and March 2022 in our hospital. These patients were categorized into 2 groups according to the preprocedural left atrium (LA) diameter (LAD): E-LA group with LAD ≥40 mm and normal LA (N-LA) group with LAD <40 mm. We compared late recurrence (LR, defined as a recurrence of atrial tachyarrhythmia more than 3 months after the ablation) between the 2 groups. In addition, we made a further classification of the E-LA group into a severely E-LA (SE-LA) group with LAD ≥50 mm and mildly enlarged LA (ME-LA) group with LAD <50 mm and compared LR in the SE-LA, ME-LA, and N-LA groups. In the patients who experienced a second ablation procedure owing to LR, subsequent recurrences were also evaluated. After initial CBA, there was no significant difference in recurrence-free survival between E-LA and N-LA groups (p = 0.447). In contrast, the SE-LA group showed the lowest incidence of recurrence-free survival in the SE-LA, ME-LA, and N-LA groups (p = 0.012). However, when we analyzed recurrences after the ablation including second ablation procedure, there were no significant differences in recurrence-free survival among these 3 groups (p = 0.103). In conclusion, patients with paroxysmal AF with enlarged LA showed favorable outcomes compared with those with N-LA after CBA.

Cryoballoon ablation for atrial fibrillation (AF) carries a non-negligible 1-year recurrence risk, and existing risk models often omit electrocardiographic and echocardiographic features. We aimed to develop and internally validate an AF recurrence prediction model that integrates the PR interval and echocardiographic measures—left atrial dimension (LAD) and left atrial appendage flow velocity (LAAFV)—with clinical characteristics. In this single-center retrospective cohort of 757 patients who underwent first-time cryoballoon ablation (2017–2023), participants were randomly divided into training (70%) and validation (30%) sets. Candidate predictors were selected via least absolute shrinkage and selection operator (LASSO) and random forest. Model performance was evaluated at prespecified 12- and 24-month horizons with time-dependent receiver operating characteristic (ROC) curves, calibration, decision curve analysis, and Kaplan–Meier estimates. Fiveindependently associated predictors were identified: female sex, persistent AF, prolonged PR interval, increased LAD, and reduced LAAFV. A multivariable Cox proportional hazards model was used to construct the nomogram. Head-to-head benchmarking against APPLE, SUCCESS, PAT2C2H, HATCH, BASE-AF2, and CHA₂DS₂-VASc was performed within the same participants via two-sided paired DeLong tests with Holm correction. The nomogram showed strong discrimination (AUC 0.81 and 0.83 in training; 0.82 and 0.80 in validation at 12 and 24 months, respectively) and outperformed all comparators at both horizons (Holm-adjusted P < 0.01). Risk stratification separated the low-, intermediate-, and high-risk groups, with 24-month recurrence-free survival rates of approximately 80%, 45%, and 20%, respectively. By combining structural and functional atrial parameters with clinical features, this tool enhances the prediction of AF recurrence after cryoballoon ablation and may inform individualized postablation management. Prospective multicenter external validation is warranted.

The impact of the P-wave morphology on clinical outcomes postcatheter ablation (post-CA) and recurrent arrhythmia characteristics or electrophysiologic findings in patients with paroxysmal atrial fibrillation (PAF) remains unclear. Patients with PAF who underwent cryoballoon ablation were enrolled. In 12-lead electrocardiography recorded within 1 month before CA, the P-wave duration (Pd) and P-wave vector magnitude (Pvm) (square root of the sum of the squared P-wave amplitude in leads II, V6, and one-half of the P-wave amplitude in V2) were measured and divided into 2 groups: patients with high and low Pd/Pvm based on a statistically calculated cut-off value. We evaluated the incidence of late recurrence of atrial fibrillation (LRAF), myocardial injury (high-sensitive troponin I), and the electrophysiologic findings in repeat ablation sessions. This study included 269 patients with PAF. The median follow-up duration was 697 days. The cut-off value of the Pd/Pvm for predicting LRAF was 740.7 ms/mV (area under the curve = 0.81, sensitivity = 58.2%, and specificity = 89.6%). Multivariable Cox proportional hazards analysis showed that high Pd/Pvm (>740.7 ms/mV) was significantly associated with LRAF (p <0.001). The high-sensitive troponin I level was significantly lower, and the ratio of DR-FLASH score >3 was significantly higher in those with high than low Pd/Pvm (p = 0.044 and p = 0.002, respectively). In the repeat ablation sessions, the Pd/Pvm in patients with atrial tachycardia-induced or spontaneously occurring during the repeat CA sessions was significantly higher than in those without (p = 0.009). There was a significant difference between the Pd/Pvm and low-voltage area (p <0.001). In conclusion, the Pd/Pvm is significantly associated with LRAF after cryoballoon ablation in patients with PAF and predicts left atrial low-voltage areas and atrial tachycardia inducibility.

Atrial fibrillation (AF) is a common arrhythmia often treated with cryoballoon ablation. The impact of Metabolic-associated fatty liver disease (MASLD), a condition newly defined by a fatty liver index ≥ 60, on AF recurrence post-ablation is unclear. We analyzed 303 patients undergoing cryoballoon ablation for AF. Cox proportional hazards models were used to assess the relationship between MASLD and AF recurrence. Paroxysmal atrial fibrillation was present in 61.1% of patients and 63% were male. Among the patients, 23.4% had MASLD. These patients exhibited larger left atrial diameter and left ventricular end-diastolic dimension. During a median follow-up of 14 months, AF recurrence was more frequent in MASLD patients (45.1% vs. 20.7%). MASLD independently predicted AF recurrence (HR, 2.24 [95% CI 1.35–3.74], P  = 0.002), alongside persistent AF, longer AF duration, and larger left atrial diameter. MASLD consistently demonstrated a significant association with an increased risk of AF recurrence in both paroxysmal (HR, 2.38 [95% CI, 1.08–5.23], P  = 0.031) and persistent AF (HR, 2.55 [95% CI, 1.23–5.26], P  = 0.011). MASLD significantly increases the risk of AF recurrence after cryoballoon ablation, highlighting the importance of supporting targeted interventions of MASLD in the periprocedural management of AF.