Left atrial roof ablation in patients with persistent atrial fibrillation using the second-generation cryoballoon: benefit or wasted time?

  • Malte Kuniss
  • Ersan AkkayaEmail author
  • Alexander Berkowitsch
  • Sergej Zaltsberg
  • Harald Greiss
  • Markus Rechner
  • Kay Weipert
  • Andreas Hain
  • Christian W. Hamm
  • Thomas Neumann
Original Paper



It is unknown whether left atrial (LA) roof ablation combined with pulmonary vein isolation (PVI) using a second-generation cryoballoon provides additional benefit beyond that of PVI alone in patients with persistent atrial fibrillation (AF). The aim of this study was to compare arrhythmia recurrence rates after PVI alone versus PVI plus LA roof ablation.

Methods and results

In this observational study, we analyzed 399 symptomatic patients with persistent AF treated with cryoballoon ablation. After univariate and multivariate analyses of the entire cohort, propensity score matching resulted in two groups of 86 patients each: (1) PVI plus LA roof ablation (PVI-plus group) and (2) PVI alone (PVI-only group). The primary endpoint was the first documented > 30-s arrhythmia recurrence after a 3-month blanking period. PVI was successful in all patients. A bidirectional conduction block across the LA roof was verified in 91.9% of patients in the PVI-plus group. During a median mid-term follow-up of 33 months, 21 patients (24.4%) in the PVI-plus group and 37 patients (43.0%) in the PVI-only group (P = 0.01) reached the primary endpoint. Multivariate analysis revealed AF history > 2 years (hazard ratio [HR] = 2.04, P < 0.01), LA area > 21 cm2 (HR = 2.36, P < 0.01), female sex (HR = 1.92, P = 0.02), and LA roof ablation (HR = 0.47, P < 0.01) as significant predictors of outcome.


We observed a significant difference in arrhythmia recurrence rates between the two groups. LA roof ablation is an effective adjuvant treatment option that shows improved outcome compared with PVI alone.

Graphic abstract


Left atrial roof ablation Mid-term outcome Persistent atrial fibrillation Roof line Second-generation cryoballoon 



There was no funding for this study.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.


  1. 1.
    Neumann T, Vogt J, Schumacher B, Dorszewski A, Kuniss M, Neuser H, Kurzidim K, Berkowitsch A, Koller M, Heintze J, Scholz U, Wetzel U, Schneider MA, Horstkotte D, Hamm CW, Pitschner HF (2008) Circumferential pulmonary vein isolation with the cryoballoon technique results from a prospective 3-center study. J Am Coll Cardiol 52:273–278. CrossRefPubMedGoogle Scholar
  2. 2.
    Heeger CH, Wissner E, Knöll M, Knoop B, Reissmann B, Mathew S, Sohns C, Lemes C, Maurer T, Santoro F, Riedl J, Inaba O, Fink T, Rottner L, Wohlmuth P, Goldmann B, Ouyang F, Kuck KH, Metzner A (2017) Three-year clinical outcome after 2nd-generation cryoballoon-based pulmonary vein isolation for the treatment of paroxysmal and persistent atrial fibrillation—A 2-center experience. Circ J 81:974–980. Epub 2017 Mar 24 CrossRefPubMedGoogle Scholar
  3. 3.
    Oakes RS, Badger TJ, Kholmovski EG, Akoum N, Burgon NS, Fish EN, Blauer JJE, Rao SN, DiBella EVR, Segerson NM, Daccarett M, Windfelder J, McGann CJ, Parker D, MacLeod RS, Marrouche NF (2009) Detection and quantification of left atrial structural remodeling with delayed-enhancement magnetic resonance imaging in patients with atrial fibrillation. Circulation 119:1758–1767CrossRefGoogle Scholar
  4. 4.
    Marrouche NF, Wilber D, Hindricks G, Jais P, Akoum N, Marchlinski F, Kholmovski E, Burgon N, Hu N, Mont L, Deneke T, Duytschaever M, Neumann T, Mansour M, Mahnkopf C, Herweg B, Daoud E, Wissner E, Bansmann P, Brachmann J (2014) Association of atrial tissue fibrosis identified by delayed enhancement MRI and atrial fibrillation catheter ablation: the DECAAF study. JAMA 311:498–506. CrossRefPubMedGoogle Scholar
  5. 5.
    Willems S, Klemm H, Rostock T, Brandstrup B, Ventura R, Steven D, Risius T, Lutomsky B, Meinertz T (2006) Substrate modification combined with pulmonary vein isolation improves outcome of catheter ablation in patients with persistent atrial fibrillation: a prospective randomized comparison. Eur Heart J 27:2871–2878 Epub 2006 Jun 16 CrossRefGoogle Scholar
  6. 6.
    Kuniss M, Greiß H, Pajitnev D, Akkaya E, Deubner N, Hain A, Bodammer L, Berkowitsch A, Chierchia GB, Hamm CW, Neumann T (2016) Cryoballoon ablation of persistent atrial fibrillation: feasibility and safety of left atrial roof ablation with generation of conduction block in addition to antral pulmonary vein isolation. Europace. CrossRefPubMedPubMedCentralGoogle Scholar
  7. 7.
    Lang RM, Bierig M, Devereux RB, Flachskampf FA, Foster E, Pellikka PA, Picard MH, Roman MJ, Seward J, Shanewise JS, Solomon SD, Spencer KT, Sutton MS, Stewart WJ (2005) Chamber Quantification Writing Group; American Society of Echocardiography’s Guidelines and Standards Committee; European Association of Echocardiography. Recommendations for chamber quantification: a report from the American Society of Echocardiography’s Guidelines and Standards Committee and the Chamber Quantification Writing Group, developed in conjunction with the European Association of Echocardiography, a branch of the European Society of Cardiology. J Am Soc Echocardiogr 18:1440–1463CrossRefGoogle Scholar
  8. 8.
    Akkaya E, Berkowitsch A, Zaltsberg S, Deubner N, Greiss H, Hain A, Hamm CW, Sperzel J, Neumann T, Kuniss M (2017) Safety and feasibility of percutaneous skin closure using purse-string suture compared with compression bandage after pulmonary vein isolation. J Cardiovasc Electrophysiol 28:1048–1057. Epub 2017 Aug 30 CrossRefPubMedPubMedCentralGoogle Scholar
  9. 9.
    Calkins H, Hindricks G, Cappato R, Kim YH, Saad EB, Aguinaga L, Akar JG, Badhwar V, Brugada J, Camm J, Chen PS, Chen SA, Chung MK, Cosedis Nielsen J, Curtis AB, Davies DW, Day JD, d’Avila A, Natasja de Groot NMS, Di Biase L, Duytschaever M, Edgerton JR, Ellenbogen KA, Ellinor PT, Ernst S, Fenelon G, Gerstenfeld EP, Haines DE, Haissaguerre M, Helm RH, Hylek E, Jackman WM, Jalife J, Kalman JM, Kautzner J, Kottkamp H, Kuck KH, Kumagai K, Lee R, Lewalter T, Lindsay BD, Macle L, Mansour M, Marchlinski FE, Michaud GF, Nakagawa H, Natale A, Nattel S, Okumura K, Packer D, Pokushalov E, Reynolds MR, Sanders P, Scanavacca M, Schilling R, Tondo C, Tsao HM, Verma A, Wilber DJ, Yamane T (2017) Document Reviewers. 2017 HRS/EHRA/ECAS/APHRS/SOLAECE expert consensus statement on catheter and surgical ablation of atrial fibrillation. Europace 2018(20):e1–e160. CrossRefGoogle Scholar
  10. 10.
    Sainani KL (2012) Propensity scores: uses and limitations. PM R 4:693–697. CrossRefPubMedPubMedCentralGoogle Scholar
  11. 11.
    Tscholl V, Lsharaf AK, Lin T, Bellmann B, Biewener S, Nagel P, Suhail S, Lenz K, Landmesser U, Roser M, Rillig A (2016) Two years outcome in patients with persistent atrial fibrillation after pulmonary vein isolation using the second-generation 28-mm cryoballoon. Heart Rhythm 13:1817–1822. CrossRefPubMedPubMedCentralGoogle Scholar
  12. 12.
    Verma A, Jiang CY, Betts TR, Chen J, Deisenhofer I, Mantovan R, Macle L, Morillo CA, Haverkamp W, Weerasooriya R, Albenque JP, Nardi S, Menardi E, Novak P, Sanders P (2015) STAR AF II investigators. Approaches to catheter ablation for persistent atrial fibrillation. N Engl J Med 372:1812–1822CrossRefGoogle Scholar
  13. 13.
    Ciconte G, Baltogiannis G, de Asmundis C, Sieira J, Conte G, Di Giovanni G, Saitoh Y, Irfan G, Mugnai G, Hunuk B, Chierchia GB, Brugada P (2015) Circumferential pulmonary vein isolation as index procedure for persistent atrial fibrillation: a comparison between radiofrequency catheter ablation and second-generation cryoballoon ablation. Europace 17:559–565. CrossRefPubMedPubMedCentralGoogle Scholar
  14. 14.
    Wynn GJ, Das M, Bonnett LJ, Panikker S, Wong T, Gupta D (2014) Efficacy of catheter ablation for persistent atrial fibrillation: a systematic review and meta-analysis of evidence from randomized and nonrandomized controlled trials. Circ Arrhythm Electrophysiol 7:841–852. CrossRefPubMedPubMedCentralGoogle Scholar
  15. 15.
    Reddy VY, Shah D, Kautzner J, Schmidt B, Saoudi N, Herrera C, Jaïs P, Hindricks G, Peichl P, Yulzari A, Lambert H, Neuzil P, Natale A, Kuck KH (2012) The relationship between contact force and clinical outcome during radiofrequency catheter ablation of atrial fibrillation in the TOCCATA study. Heart Rhythm 9:1789–1795. CrossRefPubMedPubMedCentralGoogle Scholar
  16. 16.
    Su WW, Alzubaidi M, Tseng R, Jebaily N, Lin YJ, Wang PJ (2016) Novel usage of the cryoballoon catheter to achieve large area atrial substrate modification in persistent and long-standing persistent atrial fibrillation. J Interv Card Electrophysiol 46:275–285. CrossRefPubMedPubMedCentralGoogle Scholar
  17. 17.
    Sawhney N, Anousheh R, Chen W, Feld GK (2010) Circumferential pulmonary vein ablation with additional linear ablation results in an increased incidence of left atrial flutter compared with segmental pulmonary vein isolation as an initial approach to ablation of paroxysmal atrial fibrillation. Circ Arrhythm Electrophysiol 3:242–248. CrossRefGoogle Scholar
  18. 18.
    Suenari K, Chen YC, Kao YH, Cheng CC, Lin YK, Chen YJ, Chen SA (2011) Discrepant electrophysiological characteristics and calcium homeostasis of left atrial anterior and posterior myocytes. Basic Res Cardiol 106:65–74. Epub 2010 Nov 12 CrossRefPubMedPubMedCentralGoogle Scholar
  19. 19.
    Aryana A, Baker JH, Espinosa Ginic MA, Pujara DK, Bowers MR, O’Neill PG, Ellenbogen KA, Di Biase L, d’Avila A, Natale A (2018) Posterior wall isolation using the cryoballoon in conjunction with pulmonary vein ablation is superior to pulmonary vein isolation alone in patients with persistent atrial fibrillation: a multicenter experience. Heart Rhythm 15:1121–1129. CrossRefPubMedPubMedCentralGoogle Scholar
  20. 20.
    Kenigsberg DN, Martin N, Lim HW, Kowalski M, Ellenbogen KA (2015) Quantification of the cryoablation zone demarcated by pre- and postprocedural electroanatomic mapping in patients with atrial fibrillation using the 28-mm second-generation cryoballoon. Heart Rhythm 12:283–290. CrossRefPubMedGoogle Scholar
  21. 21.
    Segerson NM, Daccarett M, Badger TJ, Shabaan A, Akoum N, Fish EN, Rao S, Burgon NS, Adjei-Poku Y, Kholmovski E, Vijayakumar S, DiBella EV, MacLeod RS, Marrouche NF (2010) Magnetic resonance imaging-confirmed ablative debulking of the left atrial posterior wall and septum for treatment of persistent atrial fibrillation: rationale and initial experience. J Cardiovasc Electrophysiol 21:126–132. Epub 2009 Oct 5 CrossRefPubMedPubMedCentralGoogle Scholar
  22. 22.
    John RM, Kapur S, Ellenbogen KA, Koneru JN (2017) Atrioesophageal fistula formation with cryoballoon ablation is most commonly related to the left inferior pulmonary vein. Heart Rhythm 14:184–189. Epub 2016 Oct 18 CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Authors and Affiliations

  • Malte Kuniss
    • 2
  • Ersan Akkaya
    • 2
    Email author
  • Alexander Berkowitsch
    • 1
  • Sergej Zaltsberg
    • 1
  • Harald Greiss
    • 1
  • Markus Rechner
    • 3
  • Kay Weipert
    • 1
  • Andreas Hain
    • 1
  • Christian W. Hamm
    • 4
  • Thomas Neumann
    • 1
  1. 1.Department of CardiologyKerckhoff Heart CenterBad NauheimGermany
  2. 2.Department of Cardiology and ElectrophysiologyJung Stilling Hospital SiegenSiegenGermany
  3. 3.Department of CardiologyBundeswehrkrankenhausKoblenzGermany
  4. 4.Medical Clinic IJustus-Liebig UniversityGiessenGermany

Personalised recommendations