{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,3,2]],"date-time":"2026-03-02T20:12:38Z","timestamp":1772482358475,"version":"3.50.1"},"reference-count":43,"publisher":"Frontiers Media SA","license":[{"start":{"date-parts":[[2023,6,19]],"date-time":"2023-06-19T00:00:00Z","timestamp":1687132800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["frontiersin.org"],"crossmark-restriction":true},"short-container-title":["Front. Cardiovasc. Med."],"abstract":"<jats:sec><jats:title>Purpose<\/jats:title><jats:p>Pulmonary vein isolation (PVI) is the cornerstone of atrial fibrillation (AF) ablation in persistent AF (persAF), and cryoballoon PVI emerged as an initial ablation strategy. Symptomatic atrial arrhythmia recurrence following successful PVI in persAF is observed more frequently than in paroxysmal AF. Predictors for arrhythmia recurrence following cryoballoon PVI for persAF are not well described, and the role of left atrial appendage (LAA) anatomy is uncertain.<\/jats:p><\/jats:sec><jats:sec><jats:title>Methods<\/jats:title><jats:p>Patients with symptomatic persAF and pre-procedural cardiac computed tomography angiography (CCTA) images undergoing initial second-generation cryoballoon (CBG2) were enrolled. Left atrial (LA), pulmonary vein (PV) and LAA anatomical data were assessed. Clinical outcome and predictors for atrial arrhythmia recurrence were evaluated by univariate and multivariate regression analysis.<\/jats:p><\/jats:sec><jats:sec><jats:title>Results<\/jats:title><jats:p>From May 2012 to September 2016, 488 consecutive persAF patients underwent CBG2-PVI. CCTA with sufficient quality for measurements was available in 196 (60.4%) patients. Mean age was 65.7\u2009\u00b1\u20099.5 years. Freedom from arrhythmia was 58.2% after a median follow-up of 19 (13; 29) months. No major complications occurred. Independent predictors for arrhythmia recurrence were LAA volume (HR 1.082; 95% CI, 1.032 to 1.134; <jats:italic>p<\/jats:italic>\u2009=\u20090.001) and mitral regurgitation\u2009\u2265\u2009grade 2 (HR, 2.49; 95% CI 1.207 to 5.126; <jats:italic>p<\/jats:italic>\u2009=\u20090.013). LA volumes \u2265110.35\u2005ml [sensitivity: 0.81, specificity: 0.40, area under the curve (AUC)\u2009=\u20090.62] and LAA volumes \u22659.75\u2005ml (sensitivity: 0.56, specificity 0.70, AUC\u2009=\u20090.64) were associated with recurrence. LAA-morphology, classified as chicken-wing (21.9%), windsock (52.6%), cactus (10.2%) and cauliflower (15.3%), did not predict outcome (log-rank, <jats:italic>p<\/jats:italic>\u2009=\u20090.832).<\/jats:p><\/jats:sec><jats:sec><jats:title>Conclusion<\/jats:title><jats:p>LAA volume and mitral regurgitation were independent predictors for arrhythmia recurrence following cryoballoon ablation in persAF. LA volume was less predictive and correlated with LAA volume. LAA morphology did not predict the clinical outcome. To improve outcomes in persAF ablation, further studies should focus on treatment strategies for persAF patients with large LAA and mitral regurgitation.<\/jats:p><\/jats:sec>","DOI":"10.3389\/fcvm.2023.1190860","type":"journal-article","created":{"date-parts":[[2023,6,19]],"date-time":"2023-06-19T08:02:24Z","timestamp":1687161744000},"update-policy":"https:\/\/doi.org\/10.3389\/crossmark-policy","source":"Crossref","is-referenced-by-count":8,"title":["Left atrial appendage volume is an independent predictor of atrial arrhythmia recurrence following cryoballoon pulmonary vein isolation in persistent atrial fibrillation"],"prefix":"10.3389","volume":"10","author":[{"given":"J.","family":"Pongratz","sequence":"first","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"L.","family":"Riess","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"S.","family":"Hartl","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"B.","family":"Brueck","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"C.","family":"Tesche","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"U.","family":"Ebersberger","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"T.","family":"Helmberger","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"A.","family":"Crispin","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"M.","family":"Wankerl","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"U.","family":"Dorwarth","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"E.","family":"Hoffmann","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"F.","family":"Straube","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1965","published-online":{"date-parts":[[2023,6,19]]},"reference":[{"key":"B1","first-page":"257","article-title":"Atrial fibrillation: the most common arrhythmia","volume":"27","author":"Wyndham","year":"2000","journal-title":"Tex Heart Inst J"},{"key":"B2","doi-asserted-by":"publisher","first-page":"310","DOI":"10.2174\/157340312803760721","article-title":"Triggers and anatomical substrates in the genesis and perpetuation of atrial fibrillation","volume":"8","author":"Sanchez-Quintana","year":"2012","journal-title":"Curr Cardiol Rev"},{"key":"B3","doi-asserted-by":"publisher","first-page":"373","DOI":"10.1093\/eurheartj\/ehaa612","article-title":"2020 ESC guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European association for cardio-thoracic surgery (EACTS): the task force for the diagnosis and management of atrial fibrillation of the European society of cardiology (ESC) developed with the special contribution of the European heart rhythm association (EHRA) of the ESC","volume":"42","author":"Hindricks","year":"2021","journal-title":"Eur Heart J"},{"key":"B4","doi-asserted-by":"publisher","first-page":"182","DOI":"10.1007\/s00392-017-1171-5","article-title":"Second generation cryoballoon ablation for persistent atrial fibrillation: an updated meta-analysis","volume":"107","author":"Omran","year":"2018","journal-title":"Clin Res Cardiol"},{"key":"B5","doi-asserted-by":"publisher","first-page":"1","DOI":"10.1007\/s10840-017-0277-z","article-title":"2017 HRS\/EHRA\/ECAS\/APHRS\/SOLAECE expert consensus statement on catheter and surgical ablation of atrial fibrillation: executive summary","volume":"50","author":"Calkins","year":"2017","journal-title":"J Interv Card Electrophysiol"},{"key":"B6","doi-asserted-by":"publisher","first-page":"371","DOI":"10.1111\/jce.12603","article-title":"Electrophysiologic findings and long-term outcomes in patients undergoing third or more catheter ablation procedures for atrial fibrillation","volume":"26","author":"Lin","year":"2015","journal-title":"J Cardiovasc Electrophysiol"},{"key":"B7","doi-asserted-by":"publisher","first-page":"906","DOI":"10.1093\/europace\/euaa055","article-title":"Benefit of ultra-high-density mapping-guided radiofrequency reablation in pulmonary vein isolation non-responders after initial cryoballoon procedure","volume":"22","author":"Straube","year":"2020","journal-title":"Europace"},{"key":"B8","doi-asserted-by":"publisher","first-page":"1812","DOI":"10.1056\/NEJMoa1408288","article-title":"Approaches to catheter ablation for persistent atrial fibrillation","volume":"372","author":"Verma","year":"2015","journal-title":"N Engl J Med"},{"key":"B9","doi-asserted-by":"publisher","first-page":"916","DOI":"10.1111\/jce.14957","article-title":"Efficacy of LGE-MRI-guided fibrosis ablation versus conventional catheter ablation of atrial fibrillation: the DECAAF II trial: study design","volume":"32","author":"Marrouche","year":"2021","journal-title":"J Cardiovasc Electrophysiol"},{"key":"B10","doi-asserted-by":"publisher","first-page":"20","DOI":"10.1093\/eurheartj\/ehw260","article-title":"Catheter ablation in patients with persistent atrial fibrillation","volume":"38","author":"Kirchhof","year":"2017","journal-title":"Eur Heart J"},{"key":"B11","doi-asserted-by":"publisher","DOI":"10.1161\/JAHA.118.009294","article-title":"Causes and predictors of readmission in patients with atrial fibrillation undergoing catheter ablation: a national population-based cohort study","volume":"7","author":"Arora","year":"2018","journal-title":"J Am Heart Assoc"},{"key":"B12","doi-asserted-by":"publisher","first-page":"16678","DOI":"10.1038\/s41598-017-16938-6","article-title":"Predictors of atrial fibrillation recurrence after catheter ablation: data from the German ablation registry","volume":"7","author":"Sultan","year":"2017","journal-title":"Sci Rep"},{"key":"B13","doi-asserted-by":"publisher","first-page":"313","DOI":"10.1111\/pace.13600","article-title":"Atrial fibrillation history impact on catheter ablation outcome. Findings from the ESC-EHRA atrial fibrillation ablation long-term registry","volume":"42","author":"Stabile","year":"2019","journal-title":"Pacing Clin Electrophysiol"},{"key":"B14","doi-asserted-by":"publisher","first-page":"109","DOI":"10.1161\/CIRCULATIONAHA.109.928903","article-title":"Left atrial appendage: an underrecognized trigger site of atrial fibrillation","volume":"122","author":"Di Biase","year":"2010","journal-title":"Circulation"},{"key":"B15","doi-asserted-by":"publisher","first-page":"1853","DOI":"10.1016\/j.hrthm.2011.07.013","article-title":"Localized reentry within the left atrial appendage: arrhythmogenic role in patients undergoing ablation of persistent atrial fibrillation","volume":"8","author":"Hocini","year":"2011","journal-title":"Heart Rhythm"},{"key":"B16","doi-asserted-by":"publisher","first-page":"601","DOI":"10.1080\/14779072.2017.1355237","article-title":"Persistent atrial fibrillation vs paroxysmal atrial fibrillation: differences in management","volume":"15","author":"Margulescu","year":"2017","journal-title":"Expert Rev Cardiovasc Ther"},{"key":"B17","doi-asserted-by":"publisher","first-page":"1636","DOI":"10.1002\/clc.23743","article-title":"Cardiac computed tomography angiography-derived analysis of left atrial appendage morphology and left atrial dimensions for the prediction of atrial fibrillation recurrence after pulmonary vein isolation","volume":"44","author":"Straube","year":"2021","journal-title":"Clin Cardiol"},{"key":"B18","doi-asserted-by":"publisher","first-page":"1434","DOI":"10.1093\/europace\/euu162","article-title":"Differences of two cryoballoon generations: insights from the prospective multicentre, multinational FREEZE cohort substudy","volume":"16","author":"Straube","year":"2014","journal-title":"Europace"},{"key":"B19","doi-asserted-by":"publisher","first-page":"492","DOI":"10.1016\/j.jjcc.2016.02.007","article-title":"Cryoballoon ablation for persistent atrial fibrillation\u2014large single-center experience","volume":"68","author":"Straube","year":"2016","journal-title":"J Cardiol"},{"key":"B20","doi-asserted-by":"publisher","first-page":"973","DOI":"10.1111\/j.1540-8167.2010.01814.x","article-title":"Left atrial appendage studied by computed tomography to help planning for appendage closure device placement","volume":"21","author":"Wang","year":"2010","journal-title":"J Cardiovasc Electrophysiol"},{"key":"B21","doi-asserted-by":"publisher","first-page":"921","DOI":"10.1016\/j.hrthm.2013.01.036","article-title":"Anatomical characteristics of the left atrial appendage in cardiogenic stroke with low CHADS2 scores","volume":"10","author":"Kimura","year":"2013","journal-title":"Heart Rhythm"},{"key":"B22","doi-asserted-by":"publisher","first-page":"273","DOI":"10.1002\/clc.23748","article-title":"Left atrial appendage size is a marker of atrial fibrillation recurrence after radiofrequency catheter ablation in patients with persistent atrial fibrillation","volume":"45","author":"Simon","year":"2022","journal-title":"Clin Cardiol"},{"key":"B23","doi-asserted-by":"publisher","first-page":"165","DOI":"10.1007\/s10840-017-0256-4","article-title":"Left atrial appendage volume as a new predictor of atrial fibrillation recurrence after catheter ablation","volume":"49","author":"Pinto Teixeira","year":"2017","journal-title":"J Interv Card Electrophysiol"},{"key":"B24","doi-asserted-by":"publisher","first-page":"33","DOI":"10.1093\/europace\/eux013","article-title":"Left atrial volume predicts atrial fibrillation recurrence after radiofrequency ablation: a meta-analysis","volume":"20","author":"Njoku","year":"2018","journal-title":"Europace"},{"key":"B25","doi-asserted-by":"publisher","first-page":"369","DOI":"10.1161\/CIRCEP.109.924985","article-title":"Association of left atrial endothelin-1 with atrial rhythm, size, and fibrosis in patients with structural heart disease","volume":"3","author":"Mayyas","year":"2010","journal-title":"Circ Arrhythm Electrophysiol"},{"key":"B26","first-page":"142","article-title":"The role of rotors in atrial fibrillation","volume":"7","author":"Krummen","year":"2015","journal-title":"J Thorac Dis"},{"key":"B27","doi-asserted-by":"publisher","first-page":"1251","DOI":"10.1016\/j.jcmg.2014.08.009","article-title":"The left atrial appendage: anatomy, function, and noninvasive evaluation","volume":"7","author":"Beigel","year":"2014","journal-title":"JACC Cardiovasc Imaging"},{"key":"B28","doi-asserted-by":"publisher","first-page":"95","DOI":"10.1016\/S1054-8807(00)00030-2","article-title":"Structural remodeling of the left atrial appendage in patients with chronic non-valvular atrial fibrillation: implications for thrombus formation, systemic embolism, and assessment by transesophageal echocardiography","volume":"9","author":"Shirani","year":"2000","journal-title":"Cardiovasc Pathol"},{"key":"B29","doi-asserted-by":"publisher","first-page":"21","DOI":"10.1016\/j.jacep.2019.08.012","article-title":"Incidence of left atrial appendage triggers in patients with atrial fibrillation undergoing catheter ablation","volume":"6","author":"Al Rawahi","year":"2020","journal-title":"JACC Clin Electrophysiol"},{"key":"B30","doi-asserted-by":"publisher","first-page":"1929","DOI":"10.1016\/j.jacc.2016.07.770","article-title":"Left atrial appendage isolation in patients with longstanding persistent AF undergoing catheter ablation: belief trial","volume":"68","author":"Di Biase","year":"2016","journal-title":"J Am Coll Cardiol"},{"key":"B31","doi-asserted-by":"publisher","first-page":"1127","DOI":"10.1093\/europace\/eur098","article-title":"The impact of mitral regurgitation on patients undergoing catheter ablation of atrial fibrillation","volume":"13","author":"Gertz","year":"2011","journal-title":"Europace"},{"key":"B32","doi-asserted-by":"publisher","first-page":"29","DOI":"10.1161\/01.CIR.27.1.29","article-title":"The syndrome of severe mitral regurgitation with normal left atrial pressure","volume":"27","author":"Braunwald","year":"1963","journal-title":"Circulation"},{"key":"B33","doi-asserted-by":"publisher","first-page":"467","DOI":"10.4065\/76.5.467","article-title":"Left atrial volume: important risk marker of incident atrial fibrillation in 1655 older men and women","volume":"76","author":"Tsang","year":"2001","journal-title":"Mayo Clin Proc"},{"key":"B34","doi-asserted-by":"publisher","first-page":"832","DOI":"10.1016\/j.amjcard.2005.05.031","article-title":"Usefulness of left atrial volume in predicting first congestive heart failure in patients > or=65 years of age with well-preserved left ventricular systolic function","volume":"96","author":"Takemoto","year":"2005","journal-title":"Am J Cardiol"},{"key":"B35","doi-asserted-by":"publisher","first-page":"835","DOI":"10.1161\/01.CIR.92.4.835","article-title":"Left atrial size and the risk of stroke and death. The framingham heart study","volume":"92","author":"Benjamin","year":"1995","journal-title":"Circulation"},{"key":"B36","doi-asserted-by":"publisher","first-page":"1615","DOI":"10.1016\/j.amjcard.2010.07.038","article-title":"Atrial substrate properties and outcome of catheter ablation in patients with paroxysmal atrial fibrillation associated with diabetes mellitus or impaired fasting glucose","volume":"106","author":"Chao","year":"2010","journal-title":"Am J Cardiol"},{"key":"B37","doi-asserted-by":"publisher","first-page":"3","DOI":"10.1016\/j.jjcc.2016.07.008","article-title":"Impaired renal function is associated with recurrence after cryoballoon catheter ablation for paroxysmal atrial fibrillation: a potential effect of non-pulmonary vein foci","volume":"69","author":"Yanagisawa","year":"2017","journal-title":"J Cardiol"},{"key":"B38","doi-asserted-by":"publisher","first-page":"145","DOI":"10.1111\/jebm.12313","article-title":"Effect of obstructive sleep apnea and its treatment of atrial fibrillation recurrence after radiofrequency catheter ablation: a meta-analysis","volume":"11","author":"Congrete","year":"2018","journal-title":"J Evid Based Med"},{"key":"B39","doi-asserted-by":"publisher","first-page":"1343","DOI":"10.1093\/europace\/euv419","article-title":"Outcomes after cryoablation vs. Radiofrequency in patients with paroxysmal atrial fibrillation: impact of pulmonary veins anatomy","volume":"18","author":"Khoueiry","year":"2016","journal-title":"Europace"},{"key":"B40","doi-asserted-by":"publisher","first-page":"531","DOI":"10.1016\/j.jacc.2012.04.032","article-title":"Does the left atrial appendage morphology correlate with the risk of stroke in patients with atrial fibrillation? Results from a multicenter study","volume":"60","author":"Di Biase","year":"2012","journal-title":"J Am Coll Cardiol"},{"key":"B41","doi-asserted-by":"publisher","first-page":"105","DOI":"10.1016\/j.jcct.2019.01.011","article-title":"Impact of anatomical features of the left atrial appendage on outcomes after cryoablation for atrial fibrillation","volume":"13","author":"Kocyigit","year":"2019","journal-title":"J Cardiovasc Comput Tomogr"},{"key":"B42","doi-asserted-by":"publisher","first-page":"584","DOI":"10.1007\/s11886-012-0293-7","article-title":"Preprocedural imaging for patients with atrial fibrillation and heart failure","volume":"14","author":"Thai","year":"2012","journal-title":"Curr Cardiol Rep"},{"key":"B43","doi-asserted-by":"publisher","first-page":"e008707","DOI":"10.1161\/CIRCEP.120.008707","article-title":"Magnetic resonance imaging-guided fibrosis ablation for the treatment of atrial fibrillation: the ALICIA trial","volume":"13","author":"Bisbal","year":"2020","journal-title":"Circ Arrhythm Electrophysiol"}],"container-title":["Frontiers in Cardiovascular Medicine"],"original-title":[],"link":[{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fcvm.2023.1190860\/full","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2023,6,19]],"date-time":"2023-06-19T08:02:30Z","timestamp":1687161750000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fcvm.2023.1190860\/full"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2023,6,19]]},"references-count":43,"alternative-id":["10.3389\/fcvm.2023.1190860"],"URL":"https:\/\/doi.org\/10.3389\/fcvm.2023.1190860","relation":{},"ISSN":["2297-055X"],"issn-type":[{"value":"2297-055X","type":"electronic"}],"subject":[],"published":{"date-parts":[[2023,6,19]]},"article-number":"1190860"}}