Empirical cryoballoon-based left atrial appendage isolation followed by closure, including cases with LAA thrombosis, in patients with persistent atrial fibrillation and durable pulmonary vein isolation: Feasibility and long-term outcomes (CB LAAI + LAAC after durable PVI in persistent AF)

Tolga Han Efe; Ramin Ebrahimi; David Schaack; Lukas Urbanek; Stefano Bordignon; Boris Schmidt; Julian K R Chun; Shaojie Chen

doi:10.1016/j.hrthm.2025.12.004

Empirical cryoballoon-based left atrial appendage isolation followed by closure, including cases with LAA thrombosis, in patients with persistent atrial fibrillation and durable pulmonary vein isolation: Feasibility and long-term outcomes (CB LAAI + LAAC after durable PVI in persistent AF)

Heart Rhythm. 2025 Dec 5:S1547-5271(25)03137-6. doi: 10.1016/j.hrthm.2025.12.004. Online ahead of print.

Authors

Tolga Han Efe¹, Ramin Ebrahimi², David Schaack¹, Lukas Urbanek¹, Stefano Bordignon¹, Boris Schmidt¹, Julian K R Chun³, Shaojie Chen⁴

Affiliations

¹ Cardioangiologisches Centrum Bethanien (CCB), Kardiologie, Medizinische Klinik III, Agaplesion Markus Krankenhaus, Akademisches Lehrkrankenhaus der Goethe-Universität, Frankfurt am Main, Germany.
² Cardioangiologisches Centrum Bethanien (CCB), Kardiologie, Medizinische Klinik III, Agaplesion Markus Krankenhaus, Akademisches Lehrkrankenhaus der Goethe-Universität, Frankfurt am Main, Germany; Klinik Internal Medicine B (Cardiology, Angiology, Pneumology and Internal Intensive Care Medicine), University Medicine Greifswald, Greifswald, Germany.
³ Cardioangiologisches Centrum Bethanien (CCB), Kardiologie, Medizinische Klinik III, Agaplesion Markus Krankenhaus, Akademisches Lehrkrankenhaus der Goethe-Universität, Frankfurt am Main, Germany; Die Sektion Medizin, Universität zu Lübeck, Lübeck, Germany.
⁴ Cardioangiologisches Centrum Bethanien (CCB), Kardiologie, Medizinische Klinik III, Agaplesion Markus Krankenhaus, Akademisches Lehrkrankenhaus der Goethe-Universität, Frankfurt am Main, Germany; Rhythmology and Clinical Cardiac Electrophysiology, Klinik Internal Medicine B (Cardiology, Angiology, Pneumology and Internal Intensive Care Medicine), University Medicine Greifswald, Greifswald, Germany. Electronic address: drsjchen@126.com.

PMID: 41354227
DOI: 10.1016/j.hrthm.2025.12.004

Abstract

Background: Left atrial appendage isolation (LAAI) may improve rhythm outcomes in atrial fibrillation (AF) but raises concerns regarding safety and thromboembolic risk.

Objective: We evaluated the feasibility, safety, and long-term outcomes of cryoballoon (CB)-based-LAAI followed by left atrial appendage closure (LAAC).

Methods: In this observational cohort, 101 patients with recurrent persistent AF after durable pulmonary vein isolation underwent empirical CB-based LAAI. At 6 weeks, electrical reconnection was assessed, with repeat LAAI performed if indicated. Patients were subsequently scheduled for LAAC. Procedural characteristics, complications, and long-term outcomes, including arrhythmia recurrence and major adverse cardiac events, were assessed over 3 years.

Results: The median age was 69 years, 62% were male, and all had recurrent persistent AF. Durable LAAI was achieved in 81.2%; 19 patients underwent successful repeat isolation. LAAC was performed in 89 patients, with 100% implantation success. Periprocedural complications were infrequent: transient phrenic nerve palsy (2%), pericardial effusion (1%), groin hematoma (1%), and femoral pseudoaneurysm (1%). Distal LAA thrombus was detected in 10% but all underwent successful LAAC without embolic events. No periprocedural stroke, systemic embolism, or death occurred. At 3 years, freedom from atrial tachyarrhythmia was 73% at 1 year, 57% at 2 years, and 44% at 3 years. Major adverse cardiac events included ischemic stroke/transient ischemic attack (2%), major bleeding (2%), minor bleeding (2%), and all-cause mortality (3%). No device-related thrombus was observed.

Conclusion: Empirical CB LAAI followed by LAAC seems to be a feasible, safe, and effective strategy for patients with recurrent persistent AF after durable pulmonary vein isolation in an experienced center, offering a long-term therapeutic option for those at elevated thromboembolic and moderate bleeding risk.

Keywords: Atrial fibrillation; Catheter ablation; Cryoballoon; Left atrial appendage closure; Left atrial appendage isolation; Left atrial appendage thrombosis; Long term; Pulmonary vein isolation.