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).

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.