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.