Characterization of atrial flutter after pulmonary vein isolation by cryoballoon ablation



Pulmonary vein isolation (PVI) by cryoballoon ablation (CBA) has emerged as a commonly used technique for the treatment of atrial fibrillation. We sought to explore the incidence, risk factors for, and characterization of post-CBA-PVI atrial flutter.


We analyzed a prospective registry of patients who underwent CBA-PVI at a single institution. We included patients with more than 3 months of follow-up data and excluded those with a history of cavotricuspid isthmus (CTI) ablation. Locations of post-CBA-PVI atrial flutters were determined by analysis of intracardiac electrograms and electroanatomic maps.


There were 556 patients included in the analysis. The mean age was 61.0 ± 10.6 years, 67.4% were male, the number of failed anti-arrhythmic medication trials was 1.2 ± 0.8, and the duration of atrial fibrillation pre-CBA was 54.3 ± 69.1 months. The 28-mm second-generation cryoballoon was used almost exclusively. Over a median follow-up time of 22.7 ± 17.9 months, 25 (4.5%) patients developed post-CBA-PVI atrial flutter after the 3-month blanking period. Of those 25 patients, 15 (60%) underwent subsequent ablation to eliminate the atrial flutter circuit, with 60% being CTI-dependent and the remainder left-sided (p value not significant). Risk factors for the development of atrial flutter included NYHA class ≥ 2 (OR 5.02, p < 0.001), presence of baseline bundle branch block (OR 4.33, p = 0.006), and left ventricular ejection fraction < 50% (OR 3.36, p = 0.007).


The rate of post-CBA-PVI atrial flutter is low after the blanking period even with medium-term follow-up. The origin of atrial flutter is equally divided between the right and left atria.

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Author information




JRBConcept/design, data analysis/interpretation, drafting article.

RKConcept/design, critical revision of article.

CLD, GP, AABData collection, critical revision of article.

AT, JW, ABC, RA, SK, AL, NVData acquisition, approval of article.

BPKConcept/design, critical revision of article.

RSPConcept/design, data analysis/interpretation, drafting article, critical revision of article.

Corresponding author

Correspondence to Rod S. Passman.

Ethics declarations

The institutional review board at Northwestern University approved the study protocol.

Conflict of interest

Bradley P. Knight receives honoraria for consulting and speaking for Medtronic Inc. Rod S. Passman receives research support, consulting fees, and speaker fees from Medtronic; royalties from UpToDate; and research support from Pfizer and Kardia. Northwestern University receives fellowship support from Medtronic, Inc.

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Baman, J.R., Kaplan, R.M., Diaz, C.L. et al. Characterization of atrial flutter after pulmonary vein isolation by cryoballoon ablation. J Interv Card Electrophysiol 57, 233–240 (2020).

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  • Atrial fibrillation
  • Atrial flutter
  • Pulmonary vein isolation
  • Cryoballoon
  • Ablation