Combined use of cryoballoon and focal open-irrigation radiofrequency ablation for treatment of persistent atrial fibrillation: Results from a pilot study

Background: Pulmonary vein isolation (PVI) achieved using a cryoballoon has been shown to be safe and effective. This treatment modality has limited effectiveness for treatment of persistent atrial fibrillation (AF). Objective: The purpose of this study was to evaluate a combined approach using a cryoballoon for treatment of PVI and focal radiofrequency (RF) left atrial substrate ablation for treatment of persistent AF. Methods: Twenty-two consecutive patients with persistent AF were included in the study. PVI initially was performed with a cryoballoon. Left atrial complex fractionated atrial electrograms (CFAEs) then were ablated using an RF catheter. Finally, linear ablations using the RF catheter were performed. Results: Eighty-three PVs, including five with left common ostia, were targeted and isolated (100%). Seventy-seven (94%) of 82 PVs targeted with the cryoballoon were isolated, and 5 (6%) required use of RF energy to complete isolation. A mean of 9.7 ± 2.6 cryoablation applications per patient was needed to achieve PVI. Median time required for cryoablation per vein was 600 seconds, and mean number of balloon applications per vein was 2.5 ± 1.0. In 19 (86%) patients in whom AF persisted after PVI, CFAE areas were ablated using the RF catheter. Two cases of transient phrenic nerve paralysis occurred. After a single procedure and mean follow-up of 6.0 ± 2.9 months, 86.4% of patients were AF-free without antiarrhythmic drugs. Conclusion: A combined approach of cryoablation and RF ablation for treatment of persistent AF is feasible and is associated with a favorable short-term outcome.