Comparison of Extended Cryoballoon, Standard Cryoballoon, and Radiofrequency Catheter Ablation in Patients With Persistent AF

Abstract

Background: The performance of cryoballoon (CB) ablation compared with radiofrequency (RF) ablation has been demonstrated in patients with paroxysmal atrial fibrillation (AF). However, the role of CB ablation in patients with persistent AF has not been well established. Furthermore, the efficacy of additional posterior wall isolation following CB pulmonary vein (PV) isolation remains controversial.

Objectives: This study aimed to compare rhythm outcomes after extended CB, standard CB, and RF ablation in patients with persistent AF.

Methods: The authors conducted a multicenter, randomized, adjudicator-blinded trial comparing 3 approaches in patients with persistent AF: RF, standard CB (PV isolation only), and extended CB ablation (PV plus posterior wall isolation). The primary outcome was recurrence of atrial arrhythmia including AF or atrial tachycardia after a predefined blanking period (3 months), in the absence of antiarrhythmic drugs.

Results: A total of 288 patients were enrolled from 2 sites in South Korea. The mean age was 59.0 years; 12.8% were women; the mean left atrial diameter was 44.2 mm; and 37.2% had long-standing persistent AF. At 12 months, the primary outcome-freedom from atrial arrhythmia recurrence-was similar across the 3 groups (50.4% for RF ablation vs 47.3% for standard CB vs 44.8% for extended CB; P = 0.787). This trend remained consistent regardless of antiarrhythmic drug use (51.5% vs 50.0% vs 49.1%, respectively; P = 0.924) and whether patients underwent 1 or 2 procedures (57.9 vs 52.9% vs 52.2%, respectively; P = 0.945). No significant differences were observed in the rates of direct current cardioversion (9.6% vs 10.2% vs 4.2%; P = 0.236) or cardiovascular hospitalization (3.2% vs 0% vs 2.1%; P = 0.170). The incidence of major adverse events was also comparable among the groups (1.0% in all groups; P > 0.99).

Conclusions: In patients with persistent AF, CB ablation was found to be as effective as RF ablation. The addition of posterior wall isolation using CB ablation did not improve the rhythm outcomes compared with standard CB ablation. These findings do not support the routine use of posterior wall isolation with CB in patients with persistent AF. (Comparison Between Extended Cryoablation, Standard Cryoablation, and Radiofrequency Ablation [EXCAPE-AF]; NCT07034378; Comparison of Extended Cryoballoon Ablation, Standard Cryoballoon Ablation, and Radiofrequency Catheter Ablation in Patients With Persistent Atrial Fibrillation: A Multicenter, Randomized Controlled, Clinical Trial; KCT0005933).

Keywords: atrial fibrillation; catheter ablation; cryoballoon ablation; radiofrequency ablation; recurrence.