Air Embolism During Cryoballoon Ablation for Atrial Fibrillation Under Different Respiratory Management Strategies

BACKGROUND: Coronary air embolism is a rare but potentially fatal complication during catheter ablation for atrial fibrillation (AF). Use of large-bore sheaths, such as those required for balloon-based catheter ablation, in the setting of unstable respiratory control may increase the risk. METHODS: We retrospectively evaluated consecutive patients who underwent first-time cryoballoon ablation (CBA) for AF from January 2017 to December 2024. Patients were divided into two groups according to respiratory management strategy: adaptive servo-ventilation (ASV, n = 266) and laryngeal mask with mechanical ventilation (LM, n = 225). The incidence of complications was compared, with a primary focus on air embolism. RESULTS: A total of 491 patients (median age 68 years, 71.3% male) were included. Coronary air embolism occurred in 5 patients (1.9%) in the ASV group and in none of the patients in the LM group (absolute risk difference, 1.9%; 95% CI, -0.1% to 4.3%; p = 0.066). In one patient with coronary air embolism, brain MRI performed on the day of the procedure incidentally revealed an asymptomatic acute cerebral embolic lesion. Other complications included two cases of cardiac tamponade in the ASV group and two cases of transient phrenic nerve palsy in the LM group. CONCLUSIONS: Coronary air embolism was numerically less frequent in patients undergoing cryoballoon ablation with laryngeal mask ventilation than in those managed with ASV, although the difference did not reach statistical significance. Further prospective studies are warranted to clarify the potential role of respiratory management in procedural safety.