Pressure-Waveform Guidance for Pulmonary Vein Occlusion During Cryoballoon Ablation: Procedural Efficiency and Repeat-Procedure Findings from a Large Single-Center Cohort

Background/Objectives: The cryoballoon (CB) has simplified pulmonary vein isolation (PVI) for treating atrial fibrillation (AF). Vein occlusion is usually assessed utilizing contrast media which entails possible risks and increases fluoroscopy exposure. Pressure-guided assessment of occlusion has emerged as a potential alternative. The objective of this study is to compare procedural characteristics and repeat-procedure findings of pressure-guided and contrast-guided assessment of vein occlusion. Methods: From July 2018 to December 2023, 1166 patients (485 [41%] female, mean age 65 ± 10 years) with AF (64% paroxysmal) undergoing CB-PVI were enrolled at a single-center, 368 (32%) underwent a contrast-guided and 798 (68%) a pressure-guided approach. Results: Procedure duration (90 ± 20 vs. 93 ± 23 min) and ablation time (1342 ± 361 vs. 1368 ± 406 s) were similar in pressure- and contrast- guided groups, and the acute success rate of PVI was high in both groups. The pressure-guided approach had shorter X-ray times (5.7 ± 3.4 vs. 9.5 ± 4.8 min, p < 0.0001) and lower X-ray doses (82 ± 78.9 vs. 586 ± 546 cGy/cm2, p < 0.0001). In 112 redo-procedures for arrhythmia recurrence after CB-PVI, durable isolation of all veins was observed more often after pressure-guided procedures (28/56 [50%] vs. 13/56 [23%]); per-vein durability was also higher (174/224 [78%] vs. 150/224 [67%], p = 0.015). Conclusions: Pressure-waveform guidance during CB-PVI is a feasible alternative to contrast-guided occlusion assessment and was associated with substantially lower intraprocedural fluoroscopy exposure. Repeat-procedure findings suggest a possible durability signal, but this observation should be considered exploratory and confirmed in prospective studies.