Impact of the autonomic nervous system on long-term-recurrence- free-survival following second generation cryoballoon ablation for persistent atrial fibrillation

Denise Guckel (Bad Oeynhausen)1, M. El Hamriti (Bad Oeynhausen)1, T. Fink (Bad Oeynhausen)1, V. Sciacca (Bad Oeynhausen)1, G. Imnadze (Bad Oeynhausen)1, M. Braun (Bad Oeynhausen)1, M. Khalaph (Bad Oeynhausen)1, K. Isgandarova (Bad Oeynhausen)1, P. Sommer (Bad Oeynhausen)1, C. Sohns (Bad Oeynhausen)1, G. Nölker (Unna)2

1Herz- und Diabeteszentrum NRW Klinik für Elektrophysiologie/ Rhythmologie Bad Oeynhausen, Deutschland; 2Christliches Klinikum Unna-Mitte Innere Klinik II / Kardiologie Unna, Deutschland



Cryoballon (CB)-guided pulmonary vein isolation (PVI) is an accepted treatment option for atrial fibrillation (AF). The cardiac autonomic nervous system (ANS) plays a crucial role in the regulation of AF.


The aim of this observational study was to analyze the impact of vagal reactions (VRs), as a surrogate parameter for ANS modulation, on the long-term outcome of CB-ablation in patients with persistent AF (PERS AF).



Data from consecutive PERS AF patients treated with a CB-guided PVI for symptomatic drug refractory AF between 2013-2023 were analyzed. VRs were defined as bradycardia < 40 beats/min, asystole or higher-degree atrioventricular block. All patients were continuously followed up in our outpatient clinic. AF-recurrence was defined as AF lasting > 30 seconds beyond a 3-month blanking period.



A total of 250 consecutive patients (mean age 63.9 ± 10.0 years, 70% male) were included. VRs were recorded in 61 patients (24%). The mean follow-up duration amounted to 84±14 months. Within this observation period 101 patients (40%) developed AF recurrence a mean of 1.75 ± 0.80 times. Re-ablation procedures were performed in 61 patients (60%) a mean of 1.28 ± 0.55 times. Reconnected PVs were documented in 41 cases (67%). An additional substrate modification was performed in 34 procedures (42%). Patients with procedure associated VRs presented with a significantly higher estimated AF-free survival rate compared to those without (log-rank p-value=0.016) (Figure 1). Multivariate analyses revealed the days to first AF- recurrence following primary CB-ablation as an independent predictor for AF-free survival (CI 0.841-0.928, HR, 0.883, p<0.01).



CB-ablation procedure associated VRs are associated with a favorable long-term outcome in PERS AF. Early AF-recurrence following CB-ablation seems to be predictive for a worse long-term-outcome. Further studies are required to verify our initial findings.

Figure 1 Kaplan Meier plot on long-term AF-free survival.


AF, atrial fibrillation; VR, vagal reaction; a p-value ≤ 0.05 indicates statistical significance.
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