Cryoballoon ablation for atrial fibrillation

Adverse events in cryoballoon ablation for pulmonary vein isolation: Insight from the Food and Drug Administration Manufacturer and User Facility Device Experience

Background

Real-world clinical data on the adverse events related to the use of cryoballoon catheter for pulmonary vein isolation remains limited.

Objective

To report and describe the adverse events related to the use of Artic Front cryoballoon catheters (Arctic Front, Arctic Front Advance, and Arctic Front Advance Pro) reported in the Food and Drug Administration's (FDA) Manufacturers and User Defined Experience (MAUDE) database.

Methods

We reviewed all the adverse events reported to the FDA MAUDE database over a 10.7-year study period from January 01, 2011 to September 31, 2021. All events were independently reviewed by two physicians.

Results

During the study period, a total of 320 procedural-related adverse events reported in the MAUDE database were identified. The most common adverse event was transient or persistent phrenic nerve palsy (PNP), accounting for 48% of all events. This was followed by cardiac perforation (15%), pulmonary vein stenosis (8%), transient ischemic attack or stroke (6%), vascular injury (4%), transient or persistent ST-elevation myocardial infarction (3%), hemoptysis (2%), pericarditis (2%), and esophageal ulcer or fistula (1%). There were six reported intra-procedural death events as a result of cardiac perforation.

Conclusion

The two most common procedural adverse events associated with cryoballoon ablation were PNP and cardiac perforation. All cases of procedural mortality were due to cardiac perforation.

Clinical outcome of a single procedure cryoballoon ablation for the treatment of atrial fibrillation: A real-world multicenter experience in Portugal

BACKGROUND

Cryoballoon ablation (CBA) for pulmonary vein isolation (PVI) has been growing as an alternative technique, not only in patients with paroxysmal atrial fibrillation (PAF) but also in persistent atrial fibrillation (AF). Cryoballoon ablation has demonstrated encouraging acute and mid-term results. However, data on long-term follow-up of CB-based PVI are scarce.

OBJECTIVE

We sought to examine efficacy, safety, and long-term outcomes of CBA in PAF and persistent AF in four Portuguese centers.

METHODS

All patients that were treated with the cryoballoon catheter according to routine practices with a second-generation 28-mm CB in four centers were included. This was a retrospective, non-randomized analysis. Patients were followed-up for >12 months and freedom from atrial arrhythmias (AA) was evaluated at the end of follow-up.

RESULTS

Four hundred and six patients (57.7±12.4 years, 66% men) participated. AF was paroxysmal in 326 patients (80.2%) and persistent in 80 (19.7%). The mean procedure time duration was 107.7±50.9 min, and the fluoroscopy time was 19.5±9.7 min. Procedural/periprocedural complications occurred in 30 cases (7.3%), being transient phrenic nerve palsy the most frequent incident (2 out of 3 complications). Anatomic variations of the PV were present in 16.1% of cases. At a mean follow-up of 22.0±15.0 months, 310 patients (76.3%) remained in stable sinus rhythm, with at least one AF episode recurrence documented in 98 cases (24.1%). The recurrence rate was 20.5% in the PAF group and 37.8% in the persistent AF group.

CONCLUSION

In this multicenter experience, a single CBA procedure resulted in 75.9% freedom from AF at a 22-month follow-up. This technique was demonstrated to be a safe and effective option in experienced centers for the treatment of PAF and PersAF.

Second-generation cryoballoon versus contact force radiofrequency ablation for atrial fibrillation: an updated meta-analysis of evidence from randomized controlled trials

Catheter ablation has been recommended for patients with symptomatic atrial fibrillation (AF), with pulmonary vein isolation being the cornerstone of the ablation procedure. Newly developed technologies, such as cryoballoon ablation with a second-generation cryoballoon (CB2) and the contact force radiofrequency (CF-RF) ablation, have been introduced in recent years to overcome the shortcomings of the widely used RF ablation approach. However, high-quality results comparing CB2 and CF-RF remain controversial. Thus, we conducted this meta-analysis to assess the efficacy and safety between CB2 and CF-RF using evidence from randomized controlled trials (RCTs). Databases including Embase, PubMed, the Cochrane Library, and ClinicalTrials.gov were systematically searched from their date of inception to January 2021. Only RCTs that met the inclusion criteria were included for analysis. The primary outcome of interest was freedom from atrial tachyarrhythmia (AT) during follow-up. Secondary outcomes included procedure-related complications, procedure time and fluoroscopy time. Six RCTs with a total of 987 patients were finally enrolled. No significant differences were found between CB2 and CF-RF in terms of freedom from AT (relative risk [RR] = 1.03, 95% confidence interval [CI] 0.92-1.14, p = 0.616) or total procedural-related complications (RR = 1.25, 95% CI 0.69-2.27, p = 0.457). CB2 treatment was associated with a significantly higher risk of phrenic nerve palsy (PNP) than CF-RF (RR = 4.93, 95% CI 1.12-21.73, p = 0.035). The occurrences of pericardial effusion/tamponade and vascular complications were comparable between the CB2 and CF-RF treatments (RR = 0.41, p = 0.398; RR = 0.82, p = 0.632). In addition, CB2 treatment had a significantly shorter procedure time than CF-RF (weighted mean difference [WMD] = - 20.75 min, 95% CI - 25.44 ~ - 16.05 min, P < 0.001), whereas no difference was found in terms of fluoroscopy time (WMD = 4.63 min, p = 0.179). CB2 and CF-RF treatment are comparable for AF patients regarding freedom from AT and procedure-related complications. Compared to CF-RF, CB2 treatment was associated with a shorter procedure time but a higher incidence of PNP. Further large-scale studies are warranted to compare these two techniques and provide an up-to-date recommendation.

Comparative efficacy and safety of catheter ablation interventions for atrial fibrillation: comprehensive network meta-analysis of randomized controlled trials

PURPOSE

Point-by-point radiofrequency (RF) ablation has been the cornerstone of pulmonary vein isolation (PVI) for patients with atrial fibrillation (AF); however, it remains a complex and time-consuming procedure. Many novel AF catheter ablation (CA) techniques have been introduced, but whether they represent valuable alternatives remains controversial. Thus, we conducted a network meta-analysis to comprehensively evaluate the efficacy and safety of different CA interventions.

METHODS

We systematically searched several databases (Embase, PubMed, the Cochrane Library, and ClinicalTrials.gov ) from inception to March, 2020. The primary outcomes of interest were freedom from atrial tachyarrhythmia (AT) and procedure-related complications; secondary outcomes included procedure time and fluoroscopy time.

RESULTS

Finally, 33 randomized controlled trials (RCTs) with a total of 4801 patients were enrolled. No significant differences were found among the different interventions in terms of primary efficacy or safety outcomes. PVAC was most likely to have the shortest procedure time (Prbest = 61.5%) and nMARQ the shortest fluoroscopy time (Prbest = 60.6%); compared with conventional irrigated RF (IRF) ablation, cryoballoon ablation (CBA) showed comparable clinical efficacy and safety; CBA with second-generation CB (CB2) had a significantly shorter procedure time than IRF with contact force technology (CF-IRF) (WMD = - 20.75; p = 0.00).

CONCLUSION

There is insufficient evidence to suggest that one CA technique is superior to another. However, PVAC may be associated with a shorter procedural duration, and the CB2 catheters also seemed to reduce the procedure time compared with that of CF-IRF. Further large-scale studies are warranted to compare the available CA techniques and provide an up-to-date optimum recommendation.

Short and Intermediate Term Outcomes of the Convergent Procedure: Initial Experience in a Tertiary Referral Center

PURPOSE

The Convergent procedure is a hybrid, multidisciplinary treatment for symptomatic atrial fibrillation (AF) consisting of minimally invasive surgical epicardial ablation and percutaneous/catheter endocardial ablation. We investigated outcomes following introduction of the Convergent procedure at our institution.

METHODS

Retrospective study examining single-center outcomes. Demographic, procedural, and post-procedural variables were collected with follow-up data obtained at 3, 6, and 12 months.

RESULTS

In all, 36 patients with paroxysmal (11%) or persistent/long-standing persistent (89%) AF underwent the Convergent procedure. 36% also underwent concomitant left atrial appendage (LAA) exclusion by thoracoscopic placement of an epicardial clip. Mean age 60.6 ± 8.0 years with mean arrhythmia burden of 3.9 ± 2.7 years. All patients had failed prior attempts at medical management, 81% had failed prior cardioversion, and 17% had failed prior catheter ablation. Convergent was performed successfully in all patients with no peri-procedural deaths or major complications. At 3 and 12 months, 77.8% and 77.3% of patients, respectively, were free from symptomatic arrhythmia. 65.8% were off anti-arrhythmic medication at 12 months.

CONCLUSIONS

The Convergent procedure is safe and has good short- and intermediate-term clinical success rates. This unique hybrid approach combines strengths of surgical and catheter ablation and should be part of any comprehensive AF treatment program.

The Role of Echocardiography in Determining the Method of Ablation for the Treatment of Paroxysmal Atrial Fibrillation: A Literature Review

Atrial fibrillation is the most common cardiac arrhythmia, affecting approximately 1 out of every 250 people. It is associated with thrombus formation in the left atrium, decreased cardiac output, and deterioration of the myocardium. There are multiple treatments available for paroxysmal atrial fibrillation. This literature review will assess the benefits, risks, and complications associated with radiofrequency ablation and cryoablation, which utilize heat and freezing mechanisms, respectively. The review will also assess the role of echocardiography in determining which treatment, if any, is appropriate for atrial fibrillation.

Comparison of the Incidences of Complications After Second-Generation Cryoballoon Ablation of Atrial Fibrillation Using Vitamin K Antagonists Versus Novel Oral Anticoagulants

Data evaluating the impact of the periprocedural administration of novel oral anticoagulants (NOACs) on complications in the setting of pulmonary vein (PV) isolation using cryoballoon (CB) is limited. In the present study, our aim was to analyze procedural characteristics and incidence of complications in those patients who underwent CB ablation for atrial fibrillation and the impact of NOACs on adverse events compared with vitamin K antagonists (VKAs). Consecutive patients with drug resistant atrial fibrillation who underwent PV isolation by CB as index procedure were retrospectively included in our analysis. In group I, 290 of 454 patients (63.9%) received VKAs (warfarin: n = 222 and acenocoumarol: n = 68), and in group II, 164 of 454 patients (36.1%) were treated with NOACs (rivaroxaban: n = 71; dabigatran: n = 60; and apixaban: n = 33). Age was significantly higher in the group II (62.8 ± 9.7 vs 58.6 ± 11.3; p <0.001). During the study period, 454 consecutive patients (male 71%, age 60.1 ± 10.9 years) were enrolled. Major complications occurred in 9 patients (2.0%): peripheral vascular complications were observed in 6 patients (1.3% per procedure), persistent phrenic nerve palsy occurred in 2 (0.4%), and transient ischemic attacks in 1 (0.2%). In both groups, the incidence of major complications was similar (group I [VKAs]: 7 patients [2.4%] vs group II [NOACs]: 2 patients [1.2%]; p = 0.5). In conclusion, CB ablation is a safe procedure for PV isolation and is associated with low complication rates. The incidence of adverse events in PV isolation using the second-generation CB with the periprocedural administration of NOACs is not significantly different than VKA treatment.

Cryoballoon versus Radiofrequency Ablation for Atrial Fibrillation: A Meta-analysis of 16 Clinical Trials

Introduction: We aimed to study the procedural characteristics, efficacy and safety of cryoballoon ablation (CBA) versus radiofrequency ablation (RFA) for catheter ablation of paroxysmal atrial fibrillation (AF). Methods: A systematic literature search was performed using PubMed, EMBASE, Web of Science, and Cochrane Central Register of Controlled Trials to clinical trials comparing CBA and RFA for AF. Outcomes were evaluated for efficacy, procedure characteristics and safety. For each study, odd ratio (OR) and 95% confidence intervals (CIs) were calculated for endpoints for both approaches. Results: We analyzed a total of 9,957 participants (3,369 in the CBA and 6,588 in RFA group) enrolled in 16 clinical trials. No significant difference was observed between CBA and RFA with regards to freedom from atrial arrhythmia at 12-months, recurrent atrial arrhythmias or repeat catheter ablation. CBA group had a significantly higher transient phrenic nerve injury (OR 14.19, 95% CI: 6.92-29.10; p<0.001) and persistent phrenic nerve injury (OR 4.62, 95% CI: 1.97-10.81; p<0.001); and a significantly lower pericardial effusion/cardiac tamponade (OR 0.43, 95% CI: 0.26-0.72; p=0.001), and groin site complications (OR 0.60, 95% CI: 0.38-0.93; p=0.02). No significant difference was observed in overall complications, stroke/thromboembolic events, major bleeding, and minor bleeding. Conclusion: CBA was non-inferior to RFA for catheter ablation of paroxysmal AF. RF ablation was associated with a higher groin complications and pericardial effusion/cardiac tamponade, whereas CBA was associated with higher rates of transient and persistent phrenic nerve injury.

Cryoablation for the Treatment of Drug Refractory Symptomatic Atrial Fibrillation: A Regional Medical Center Experience

INTRODUCTION

PVI is an effective, guideline-based treatment for drug refractory symptomatic AF. Balloon cryoablation has been shown to be a safe and effective method for PVI. In the STOP-AF trial, data was produced from practitioners performing PVI with significant experience at high volume centers. This study evaluates the effectiveness and safety of treating symptomatic, drug refractory AF with PVI via cryoablation after implementation in a regional medical center.

METHOD

This represents a retrospective analysis of outcomes after cryoablation treatment for AF in 71 patients over 354.7 +/- 164.4 days. Reported and recorded episodes of AF were categorized into a representative percent of AF "burden" for each 90 day period. Primary effectiveness and safety end points paralleled those of the STOP-AF trial.

RESULTS

Patients undergoing cryoablation had a 91% reduction of AF burden at 6 months following the procedure with an event-free survival rate of 45.5 % at a mean follow up of 12 months. The mean burden reduction was 3.21% per quarter. Anti-arrhythmic and anticoagulant medication use was reduced by 14.3% and 26.8% respectively. Significant complications included one report of pulmonary vein stenosis, one report of pseudoaneurysm and 5.5% of patients had transient pericarditis or pericardial effusion following the procedure.

CONCLUSION

The results of this study were comparable to those of the high volume multi-center STOP-AF trial. PVI via cryoablation is a safe and effective alternative treatment of drug refractory symptomatic AF in the setting of a regional medical center.

Femoral venous pressure waveform as indicator of phrenic nerve injury in the setting of second-generation cryoballoon ablation

AIMS

Femoral venous pressure waveform (VPW) analysis has been recently described as a novel method to assess phrenic nerve function during atrial fibrillation ablation procedures by means of the cryoballoon technique. In this study, we sought to evaluate the feasibility and effectiveness of this technique, with respect to the incidence of phrenic nerve injury (PNI), in comparison with the traditional abdominal palpation technique alone.

METHODS

Consecutive patients undergoing second-generation cryoballoon ablation (CB-A) from June 2014 to June 2015 were retrospectively analyzed. Diagnosis of PNI was made if any reduced motility or paralysis of the hemidiaphragm was detected on fluoroscopy.

RESULTS

During the study period, a total of 350 consecutive patients (man 67%, age 57.2 ± 12.9 years) were enrolled (200 using traditional phrenic nerve assessment and 150 using VPW monitoring). The incidence of PNI in the overall population was 8.0% (28/350); of these, eight were impending PNI (2.3%), 14 transient (4.0%), and six persistent (1.7%). Patients having undergone CB-A with traditional assessment experienced 18 phrenic nerve palsies (9.0%) vs two in 'VPW monitoring' group (1.3%; P = 0.002). Specifically, the former presented 12 transient (6.0%) and six persistent (3.0%) phrenic nerve palsies, and the latter exhibited two transient (1.3%; P = 0.03) and no persistent (0%; P = 0.04) phrenic nerve palsies.

CONCLUSION

In conclusion, this novel method assessing the VPW for predicting PNI is inexpensive, easily available, with reproducible measurements, and appears to be more effective than traditional assessment methods.

Vagal Reactions during Cryoballoon-Based Pulmonary Vein Isolation: A Clue for Autonomic Nervous System Modulation?

Although paroxysmal atrial fibrillation (AF) is known to be initiated by rapid firing of pulmonary veins (PV) and non-PV triggers, the crucial role of cardiac autonomic nervous system (ANS) in the initiation and maintenance of AF has long been appreciated in both experimental and clinical studies. The cardiac intrinsic ANS is composed of ganglionated plexi (GPs), located close to the left atrium-pulmonary vein junctions and a vast network of interconnecting neurons. Ablation strategies aiming for complete PV isolation (PVI) remain the cornerstone of AF ablation procedures. However, several observational studies and few randomized studies have suggested that GP ablation, as an adjunctive strategy, might achieve better clinical outcomes in patients undergoing radiofrequency-based PVI for both paroxysmal and nonparoxysmal AF. In these patients, vagal reactions (VR) such as vagally mediated bradycardia or asystole are thought to reflect intrinsic cardiac ANS modulation and/or denervation. Vagal reactions occurring during cryoballoon- (CB-) based PVI have been previously reported; however, little is known on resulting ANS modulation and/or prevalence and significance of vagal reactions during PVI with the CB technique. We conducted a review of prevalence, putative mechanisms, and significance of VR during CB-based PVI.

Initial experience and treatment of atrial fibrillation using a novel irrigated multielectrode catheter: Results from a prospective two-center study

BACKGROUND

PV electrical isolation has become the cornerstone of catheter ablation for the treatment of atrial fibrillation (AF). Several strategies have been proposed to achieve this goal. The aim of this study was to assess the efficacy and safety of AF ablation using a new circular irrigated multielectrode ablation catheter designed to achieve single-delivery pulmonary vein (PV) isolation.

METHODS

Thirty-five patients with drug refractory paroxysmal AF and normal ejection fraction from two centers were prospectively enrolled in this study. All patients underwent PV isolation with an nMARQ circular irrigated multielectrode ablation catheter guided by an electroanatomic mapping system. Magnetic resonance imaging was performed to exclude PV stenosis.

RESULTS

PV isolation was achieved in 138 of 140 (98.57%) targeted veins. The mean procedure time was 79.5 min (SD 39.3 min). During a mean follow up of 16.8±2.8 months, 27 of 35 (77.2%) patients were free of AF. No PV narrowing was observed. One case of pericardial effusion due to perforation of the left atrial free wall during catheter manipulation did occur.

CONCLUSIONS

PV isolation with a circular irrigated multielectrode ablation catheter is a feasible technique with a high acute success rate. The majority of patients remained asymptomatic during the midterm follow-up period. PV stenosis was not detected. While only a single serious adverse event occurred, this technique׳s safety profile should be tested in larger studies.

Balloon-based pulmonary vein isolation for the treatment of paroxysmal atrial fibrillation (cryoballoon and laserballoon)

Electrical isolation of the pulmonary veins still remains one of the major objectives during catheter ablation of atrial fibrillation. In patients with paroxysmal atrial fibrillation, balloon-based technologies hold great promise to simplify the approach to successful pulmonary vein isolation. While the cryoballoon represents the only true 'single-shot' technology, the laserballoon allows real-time endoscopic visualization of the pulmonary vein antrum during energy delivery. Either technology aims at complete electrical isolation, requiring continuous transmural lesion sets encircling the pulmonary veins. Strategies to confirm and to improve upon the efficacy of pulmonary vein isolation are the key to acute and long-term clinical success and will be reviewed in this article.

CoolLoop® First: A First In Man Study To Test A Novel Circular Cryoablation System In Paroxysmal Atrial Fibrillation

INTRODUCTION

Pulmonary vein (PV) isolation is the mainstay of catheter treatment of paroxysmal atrial fibrillation (AF). The CoolLoop® cryoablation catheter (AFreeze® GmbH; Innsbruck, Austria) was developed to create wide and complete circular lesions around the PVs. In this study we evaluated feasibility and safety of this novel ablation system in humans.

METHODS

10 patients (6M/4F; 57.6±7.6y) with paroxysmal AF were included in 2 referral centers. The CoolLoop® catheter was positioned at each PV antrum using a steerable transseptal sheath. Subsequently, 2-6 double-freezes over 5min were performed at each vein and PV-isolation was assessed thereafter using a circular mapping catheter. During cryoablation of the right PVs, pacing was used to monitor phrenic nerve function.

RESULTS

The CoolLoop® catheter could be successfully positioned at each PV. A mean of 5.6±1.8 cryoablations were performed in the LSPV, 5.2±1.6 in the LIPV, 6.3±2.5 in the RSPV and 5.4±1.6 in the RIPV, respectively. Mean procedure time was 251±60min and mean fluoroscopy time was 44.0±13.2min. 6 / 10 LSPV, 6 / 10 LIPV, 5 / 10 RSPV and 6 / 10 RIPV could be isolated exclusively using the novel cryoablation system. One patient developed groin hematoma and a brief episode of ST-elevation due to air embolism was observed in another subject. No other clinical complications occurred during 3 months of follow up.

CONCLUSIONS

PV-isolation for paroxysmal atrial fibrillation using the CoolLoop® catheter is feasible and appears safe. Clinical long term efficacy still needs to be evaluated and will be compared with established catheters used for AF ablation.

Innappropriate Sinus Tachycardia After Superior Vena Cava Isolation In Addition To Pulmonary Veins Isolatin Of Paroxysmal Atrial Fibrillation Cryoballoon Ablation

We report a case of persistent inappropriate sinus tachycardia (IST) after pulmonary vein and superior vena cava (SVC) isolation with cryoballoon ablation for paroxysmal atrial fibrillation (PAF). After the cryoballoon ablation (CBA) procedure, the patient presented with sinus tachycardia of 105 beats/minute. The patient was successfully treated with metoprolol and ivabradine therapy.

Conjoined Inferior Pulmonary Veins during Pulmonary Vein Isolation: Prevalence and Novel Approach for Pulmonary Vein Isolation with Cryoballoon

Cardiac resynchronization therapy is an established treatment modality in heart failure. Though non-response is a serious issue. To address this issue, a good understanding of the electrical activation during left bundle branch block, biventricular, as well as right- and left ventricular pacing is needed. This way by interpreting the 12-lead electrocardiogram, possible reasons for suboptimal treatment can be identified and addressed. This article reviews the literature on QRS morphology in cardiac resynchronization therapy and its meaning in optimization of therapy.

Comparison of pulmonary vein isolation using cryoballoon versus conventional radiofrequency for paroxysmal atrial fibrillation

The aim of this study was to compare the results of pulmonary vein isolation using conventional irrigated radiofrequency (RF) approach versus the cryoballoon (CB) ablation. From January 2008 to December 2011, a total of 426 patients with drug-resistant symptomatic paroxysmal atrial fibrillation underwent pulmonary vein isolation as the index procedure by conventional manual RF or CB ablation at our center. A final population of 396 patients was considered for analysis and divided into 2 groups: conventional RF ablation (n = 260) and CB ablation (n = 136). At a mean follow-up of 23 ± 13 months (median 27, range 4 to 68), the success rate for RF ablation group was 57.3% (149 patients) and was 63.2% (86 patients) for cryoablation group (p = 0.25). Procedural times were significantly shorter in the cryoablation group (192 ± 49 vs 112 ± 58 minutes, p <0.000001) but not fluoroscopy times (36 ± 14 vs 31 ± 17 minutes, p = 0.45). No clinical predictors were found to predict atrial fibrillation recurrences. Complication rates were similar in both groups except for phrenic nerve palsy that was uniquely observed in the CB group (8.1%, p <0.00001). All phrenic nerve palsies resolved during follow-up. In conclusion, on a medium-term follow-up, conventional point-by-point RF ablation and CB ablation showed similar success rates. Procedural times were significantly shorter in the CB approach. The most frequent complication during CB procedures was phrenic nerve palsy, which occurred in 8.1% of patients and resolved in all during the follow-up period.

Comparing Safety and Efficacy of Irrigated Radiofrequency Catheter Ablation Versus Combined Cryoballoon and Catheter Ablation for Persistent Atrial Fibrillation

Background: Catheter and cryoballoon ablation are established treatments for atrial fibrillation. Frequently, substrate modification of the left atrium is performed in patients with persistent AF or evidence of left atrial adverse remodeling. We compared one year outcomes of AF ablation with substrate modification utilizing radiofrequency catheter ablation (RFA) compared to a combination of cryoballoon ablation with radiofrequency catheter ablation (HAFA). Methods: Ablation for persistent AF was performed using stand-alone catheter ablation (RFA group, n=31) or cryoballoon for pulmonary vein isolation with RFA catheter ablation for substrate modification (HAFA group, n=21) and procedural and clinical outcomes were analyzed. Pulmonary vein isolation and LA substrate modification including creation of left atrial ablation lines and/or CFAEs was performed in all patients. Patients were followed for up to one year. A three- month blinding window was applied for analysis. Results: Clinical characteristics were similar between groups. Total procedure (244.15±64.7 vs 235.5±54.6, p=0.6) and fluoroscopy time (37±15.4 vs 29.5±15.7, p=0.96) were not different between the HAFA and RFA groups, respectively. Periprocedural complications were similar among groups. AF free survival was not significantly different between Conclusions: Combined cryoballoon and catheter ablation for LA substrate modification (HAFA) has similar safety and efficacy compared to stand-alone catheter ablation for persistent AF. Recurrent atrial flutter is more frequently observed after cryoballoon ablation for persistent AF.