Adjuvant cryoballoon ablation versus radiofrequency ablation for rotational and focal drivers in persistent atrial fibrillation

Background: Adjuvant radiofrequency ablation (RFA) of rotational and focal drivers did not seemingly to improve procedural outcomes in persistent atrial fibrillation (PeAF). We aimed to evaluate the role of adjuvant cryoballoon ablation (CBA)-based driver modulation in PeAF. Methods: In this retrospective cohort study, we enrolled 210 patients with PeAF who underwent pulmonary vein isolation (PVI) combined with left atrial roof (LAR) block and adjuvant driver modulation at our Atrial Fibrillation Center from January 1, 2020 to December 31, 2021. Using propensity-score matching (1:2) to control baseline differences, 45 patients accepted CBA and 88 patients accepted RFA were finally analyzed. Results: PVI and modulation of all targeted drivers were achieved in all patients. CBA had less LAR block than RFA (88.9% vs. 100%, P = 0.007). Over a mean follow-up of 13.1 ± 6.3 months, CBA experienced more symptom remission than RFA (91.1% vs. 76.1%, P = 0.036). The complication rate was 4.5%, with no death ( P = 0.678). In intention-to-treat analysis, CBA had comparable AF/AT-free survival with RFA (65.8% vs. 58.7%, P = 0.516). However, per-protocol analysis demonstrated improved AF/AT-free survival with CBA compared to RFA (77.2% vs. 59.6%; HR: 0.286, 95% CI: 0.085–0.97; P = 0.033). Conclusion: Cryoballoon allows for successful driver modulation. The role of adjuvant CBA-based driver modulation in PeAF remains uncertain.