Pulmonary Vein Anatomy, Cooling Kinetics, and Recurrence After Cryoballoon Ablation for Atrial Fibrillation

Q: What are the key findings of this study?

Larger pulmonary vein ostial area lowered cryoballoon nadir temperature (β = -0.583°C per 50 mm2, p < 0.001), whereas left atrial volume index predicted 1-year recurrence (OR 1.659, p < 0.001).

Q: What is the clinical evidence from this study?

Study design: Cohort. Population: Symptomatic atrial fibrillation undergoing second-generation cryoballoon ablation (n=120). Intervention: Left atrial volume index (LAVI) and CT-derived pulmonary vein ostial area (OA) / ovality index (OI). Primary outcome: Post-blanking atrial arrhythmia recurrence between 3 and 12 months (per 10 mL/m2 increase in LAVI) (adjusted OR 1.659 per 10 mL/m2, 95% CI 1.250-2.201, p=<0.001).

Q: What does this research mean for the field?

Larger pulmonary vein ostial area is associated with modestly lower cryoballoon nadir temperatures, whereas left atrial volume index, rather than pulmonary vein anatomy, predicts 1-year atrial arrhythmia recurrence. Novelty: ClaimNovelty.CONFIRMATORY. Consensus alignment: ConsensusAlignment.NEUTRAL.

Q: What question did this study set out to answer?

Assess whether computed tomography-derived pulmonary vein ostial area and ovality index correlate with cooling kinetics during cryoballoon ablation and whether anatomical metrics associate with atrial fibrillation recurrence.

Kuo‐Ming Yang; Hsiang-Chiang Hsiao; Tung‐Chen Yeh; Chun‐Wang Chiou; Jeng‐Fung Hung; Cheng‐Hung Chiang

doi:10.1002/joa3.70511

November 2, 2026Journal of ArrhythmiaOpen Access

Pulmonary Vein Anatomy, Cooling Kinetics, and Recurrence After Cryoballoon Ablation for Atrial Fibrillation

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Key result

Higher LAVI is linked to ~66% higher odds of 1-year arrhythmia recurrence per 10 mL/m².

adjusted OR 1.659 per 10 mL/m2
95% CI 1.250-2.201
P<0.001
n=120

Figures

Graphical abstract published by Journal of Arrhythmia — Graphical abstract · Published by Journal of Arrhythmia · CC BY

Why the study?

Cryoballoon pulmonary vein isolation depends on balloon-to-ostium contact, motivating an assessment of whether CT-derived ostial area and ovality index are associated with cooling kinetics and arrhythmia recurrence after accounting for branch and within-patient clustering.

Are CT-derived pulmonary vein ostial area and ovality index associated with intraprocedural cryoballoon cooling kinetics and 1-year atrial arrhythmia recurrence in patients undergoing second-generation cryoballoon ablation for symptomatic atrial fibrillation?

Key Points

Assess whether computed tomography-derived pulmonary vein ostial area and ovality index correlate with cooling kinetics during cryoballoon ablation and whether anatomical metrics associate with atrial fibrillation recurrence.
Retrospectively analyzed 120 patients with symptomatic atrial fibrillation undergoing second-generation cryoballoon ablation, evaluating 476 pulmonary venous anatomical units.
Linear mixed-effects models adjusted for vein branch and within-patient clustering to examine cooling kinetics, while parsimonious logistic models evaluated arrhythmia recurrence after a 3-month blanking period over 12 months of follow-up.
Larger ostial area was associated with lower nadir temperature (β = −0.583°C per 50 mm²; 95% CI, −0.910 to −0.257; p < 0.001) and lower 1 min temperature (β = −0.441°C per 50 mm²; 95% CI, −0.764 to −0.118; p = 0.008), whereas ovality index showed no association with temperature outcomes.
Arrhythmia recurred in 23 of 120 patients (19.2%) between months 3 and 12, with left atrial volume index independently associated with recurrence (adjusted OR, 1.659 per 10 mL/m²; 95% CI, 1.250–2.201; p < 0.001), whereas persistent atrial fibrillation was not (adjusted OR, 1.827; 95% CI, 0.511–6.524; p = 0.354).

Study Design

Type

Cohort (n=120)

Multicenter

No

Structured PICO

Are CT-derived pulmonary vein ostial area and ovality index associated with intraprocedural cryoballoon cooling kinetics and 1-year atrial arrhythmia recurrence in patients undergoing second-generation cryoballoon ablation for symptomatic atrial fibrillation?

P

Population

120 adult patients (mean age 58.63 years, 16.67% female) with drug-refractory or intolerant symptomatic atrial fibrillation undergoing second-generation cryoballoon ablation at a single center in Taiwan, followed for 12 months.

E

Exposure

Pre-ablation 256-slice cardiac CT assessment of pulmonary vein ostial area (OA) and ovality index (OI), and left atrial volume index (LAVI), followed by pulmonary vein isolation using a 28 mm second-generation cryoballoon catheter (two cryoapplications of 120-180 s per vein when achievable).

O

Outcome

Intraprocedural cryokinetic outcomes (nadir temperature, temperature at 1 min, and time to isolation [TTI]) and 1-year post-blanking atrial arrhythmia recurrence (documented AF, atrial flutter, or atrial tachycardia lasting ≥ 30 s between 3 and 12 months after ablation).surrogate

Main Result

Odds Ratio: 1.659 (95% CI 1.25–2.201)

p-value: p=<0.001

In patients undergoing cryoballoon ablation for atrial fibrillation, CT-derived pulmonary vein ostial area modestly influences intraprocedural cooling temperatures without predicting 1-year recurrence, whereas left atrial volume index is strongly associated with arrhythmia recurrence.

Limitations

Retrospective single-center analysis with a moderate sample size (n = 120)
Potential residual confounding by unmeasured procedural factors such as occlusion grade, sheath position, balloon alignment, freeze duration, and operator technique
Ostial area was estimated from CT-derived diameters using an elliptical formula and cannot fully represent irregular 3D ostial geometry
Time to isolation (TTI) analysis was limited to an available-case sample where real-time PV potentials were visible
Recurrence modeling was restricted by a small number of outcome events (23 events)
Repeat invasive mapping was not performed systematically in patients with recurrence
Follow-up relied on scheduled visits and intermittent 12-lead ECG monitoring, which may underestimate asymptomatic recurrence
Retrospective single-center analysis with a moderate sample size
OA was estimated from CT-derived diameters using an elliptical formula and cannot fully represent irregular ostial geometry or dynamic contact surface
TTI could only be analyzed when real-time PV potentials were visible (available-case sample of 361 units)
Recurrence modeling was limited by only 23 outcome events, restricting multivariable analyses to parsimonious models
Repeat invasive mapping was not performed systematically in patients with recurrence, and follow-up relied on scheduled visits and intermittent rhythm monitoring which may underestimate asymptomatic recurrence

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Implication

Ostial area may inform procedural expectations without altering technique; leaves open left atrial volume index for recurrence risk stratification.

Abstract

Background Cryoballoon pulmonary vein isolation depends on balloon‐to‐ostium contact. We assessed whether computed tomography‐derived pulmonary vein ostial area (OA) and ovality index (OI) were associated with cooling after accounting for pulmonary vein (PV) branch and within‐patient clustering, and whether PV anatomy was associated with recurrence. Methods We retrospectively studied 120 patients with symptomatic atrial fibrillation undergoing second‐generation cryoballoon ablation. Vein‐level associations with nadir temperature, 1 min temperature, and time to isolation were assessed using linear mixed‐effects models with a patient random intercept and PV branch as a fixed effect; generalized estimating equations served as sensitivity analyses. Given 23 post‐blanking recurrences, logistic models were limited to left atrial volume index (LAVI) and one clinically selected covariate, with Firth‐penalized regression as a sensitivity analysis. Results All patients achieved acute PV isolation. Larger OA was associated with lower nadir temperature ( β = −0.583°C per 50 mm 2 ; 95% CI, −0.910 to −0.257; p < 0.001) and 1 min temperature ( β = −0.441°C per 50 mm 2 ; 95% CI, −0.764 to −0.118; p = 0.008) after branch and clustering adjustment. OI was not associated with either temperature outcome. Twenty‐three patients (19.2%) developed recurrent atrial arrhythmia. LAVI was associated with recurrence (adjusted OR, 1.659 per 10 mL/m 2 ; 95% CI, 1.250–2.201; p < 0.001), whereas persistent AF was not. Conclusions OA showed a modest association with cryoballoon temperatures but should not be used as a stand‐alone prognostic marker. LAVI remained associated with recurrence in parsimonious patient‐level analyses.

Discussion

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Cite This Study

Yang et al. (2026) conducted a cohort in Symptomatic atrial fibrillation undergoing second-generation cryoballoon ablation (n=120). Left atrial volume index (LAVI) and CT-derived pulmonary vein ostial area (OA) / ovality index (OI) was evaluated on Post-blanking atrial arrhythmia recurrence between 3 and 12 months (per 10 mL/m2 increase in LAVI) (adjusted OR 1.659 per 10 mL/m2, 95% CI 1.250-2.201, p=<0.001). Larger pulmonary vein ostial area lowered cryoballoon nadir temperature (β = -0.583°C per 50 mm2, p < 0.001), whereas left atrial volume index predicted 1-year recurrence (OR 1.659, p < 0.001).

synapsesocial.com/papers/6aebc8ba3e63ca1b6c315e0e https://doi.org/10.1002/joa3.70511

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Pulmonary Vein Anatomy, Cooling Kinetics, and Recurrence After Cryoballoon Ablation for Atrial Fibrillation

Figures

Key Points

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

Pulmonary Vein Anatomy, Cooling Kinetics, and Recurrence After Cryoballoon Ablation for Atrial Fibrillation

Figures

Key Points

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

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