Abstract
Introduction: Pulmonary vein isolation (PVI) is the cornerstone of catheter ablation for paroxysmal atrial fibrillation (AF), but the optimal ablation strategy for persistent AF (PsAF) remains controversial. Hypothesis: The purpose of this study was to investigate whether combined-energy cryoballoon (CB) PVI and radiofrequency (RF) left atrial posterior wall isolation (LAPWI) at index ablation of PsAF yields higher success than PVI alone. Methods: Patients with persistent AF (n = 186) who underwent catheter ablation between 2016 and 2019 at a single large academic medical center were retrospectively reviewed. Patients with congenital heart disease or prior left atrial ablation or surgery were excluded. Combined-energy ablation (n=92) consisted of CB antral PVI followed by RF roof and floor lines to achieve LAPWI, along with isolation inside the box as needed. The control group had PVI only (n=94) with either CB (n=57) or RF (n=37). The primary endpoint was 12-, 24-, and 36-month freedom from any documented atrial tachyarrhythmia over 30 seconds after a 90-day blanking period following catheter ablation, compared by Kaplan-Meier analysis. Secondary endpoints included AF burden, procedural parameters, and complications. Results: The primary endpoint of 12-month freedom from any atrial tachyarrhythmia was higher for the combined-energy group vs the control group (79.1% vs 58.2%, p = 0.009). This improvement was sustained at 24 months (63.0% vs 45.8%) and at 36 months (60.3% vs 43.1%) and remained significant after adjustment for clinical covariates (adjusted HR 0.45, 95% confidence interval 0.22-0.95; p = 0.03). There was no significant difference in procedure time or complication rates, however fluoroscopy time was shorter with combined-energy ablation (p<.001). Conclusions: In this single center experience, combined-energy CB-PVI and RF-LAPWI was associated with reduced AF recurrence compared to PVI with a single energy source.
Published Version
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