Persistent Atrial Fibrillation Using Arctic Front™ Cardiac Cryoablation System

Cryoablation of atrial fibrillation with Arctic FrontTM family of cryoballoons has radically altered the landscape of electrophysiology since its introduction just over a decade ago. We have seen the initially promising results in pulmonary vein isolation (PVI) for paroxysmal AF become highly reproducible as technological and procedural advances have been implemented, and cryoablation is routinely considered as equivalent in efficacy to radiofrequency ablation.1 As this efficacy and safety profile of the technique has been established, balloon cryoablation for pulmonary vein isolation (cryo-PVI) has become a first-line procedure for paroxysmal AF patients.2

Of course, the discovery that PVI alone provides an equivalent or better outcome than PVI plus empiric lines/fractionated electrogram ablation opened the door for cryo-PVI in patients with persistent AF, greatly expanding the patient base for whom this could be a useful treatment.3

The prospect of a highly reproducible procedure, with little intra-operator variability is greatly appealing: high throughput services could be configured, day case procedures established and consistent results expected. The simpler console and mapping system required for cryoablation has begun a democratisation of services. No longer must AF ablation be performed exclusively in large teaching hospitals, but satellite coronary labs can be easily converted to do this procedure.4

But as we expand the population of patients who would potentially be able to be treated with cryoablation, increasing the numbers of centres able to undertake the procedure, we must remain mindful of best practices and the continuing incremental improvements in operator techniques. Robust, rapid and safe isolation of the pulmonary veins remains the cornerstone of first line cryo-PVI for persistent AF ablation.5 The FDA just announced approval for indication expansion of the Cryoballoon to treat patients with drug refractory persistent AF. The Arctic Front family of Cardiac Cryoballoon catheters are the first devices approved for this indication by the FDA.6

We very much hope you enjoy the featured articles in this collection and find them useful in the delivery of treatment for your patients.


Dr Malcolm Finlay

The Persistent Atrial Fibrillation using Cryoballoon section is supported by Medtronic


Section advisor

Dr Malcolm Finlay, Consultant Cardiologist, Barts Heart Centre

Arctic Front Family of cryoballoons is the first FDA-approved ablation catheter for the treatment of Persistent AF in the US

Featured Articles Article icon

Predictive role of early recurrence of atrial fibrillation after cryoballoon ablation

Stabile G, Iacopino S, Verlato R, et al. Europace 2020;22:1798–1804.

High-density mapping in patients undergoing ablation of atrial fibrillation with the fourth-generation cryoballoon and the new spiral mapping catheter

Conte G, Soejima K, de Asmundis C, et al. Europace 2020;22:1653–8.

Procedural patterns and safety of atrial fibrillation ablation: findings from Get With The Guidelines-Atrial Fibrillation

Loring Z, Holmes DN, Matsouaka RA, et al. Circ Arrhythm Electrophysiol 2020;13:e007944.

Cryoballoon ablation of pulmonary veins for persistent atrial fibrillation: results from the multicenter STOP Persistent AF trial

Su WW, Reddy VY, Bhasin K, et al. Heart Rhythm 2020;17:1841–7.

Cryoballoon ablation as initial therapy for atrial fibrillation

Wazni OM, Dandamudi G, Sood N, et al. N Engl J Med 2021;384:316–24.

Cryoablation or drug therapy for initial treatment of atrial fibrillation

Andrade JG, Wells GA, Deyell MW, et al. N Engl J Med 2021;384:305–15.

Effect of Catheter Ablation vs Antiarrhythmic Medication on Quality of Life in Patients With Atrial Fibrillation: The CAPTAF Randomized Clinical Trial

Blomström-Lundqvist C, Gizurarson S, Schwieler J, et al. JAMA 2019;321;11:1059-1068.

Effect of Catheter Ablation vs Medical Therapy on Quality of Life Among Patients With Atrial Fibrillation: The CABANA Randomized Clinical Trial

Mark DB, Anstrom KJ, Sheng S, et al. JAMA 2019;321;13:1275-1285.

Effect of Catheter Ablation vs Antiarrhythmic Drug Therapy on Mortality, Stroke, Bleeding, and Cardiac Arrest Among Patients With Atrial Fibrillation: The CABANA Randomized Clinical Trial

Packer DL, Mark DB, Robb RA, et al. JAMA 2019;321;13:1261-1274.

Approaches to Catheter Ablation for Persistent Atrial Fibrillation

Verma A, Jiang C, Betts TR, et al. N Engl J Med 2015;372:1812-1822.

Cryoballoon or Radiofrequency Ablation for Paroxysmal Atrial Fibrillation

Kuck KH, Brugada J, Fürnkranz A, et al. N Engl J Med 2016;374:2235-2245.

Cryoballoon or Radiofrequency Ablation for Atrial Fibrillation Assessed by Continuous Monitoring: A Randomized Clinical Trial

Andrade JG, Champagne J, Dubuc M, et al. Circulation 2019;140;22:1779-1788.

Cryoballoon Ablation of Pulmonary Veins for Paroxysmal Atrial Fibrillation: First Results of the North American Arctic Front (STOP AF) Pivotal Trial

Packer DL, Kowal RC, Wheelan KR, et al. J Am Coll Cardiol 2013;61;16:1713-1723.

Point‐by‐Point Radiofrequency Ablation Versus the Cryoballoon or a Novel Combined Approach: A Randomized Trial Comparing 3 Methods of Pulmonary Vein Isolation for Paroxysmal Atrial Fibrillation (The Cryo Versus RF Trial)

Hunter RJ, Baker V, Finlay MC, et al. J Cardiovasc Electrophysiol 2015;26;12:1307-1314.

Cryoballoon Versus Open Irrigated Radiofrequency Ablation in Patients With Paroxysmal Atrial Fibrillation: The Prospective, Randomized, Controlled, Noninferiority FreezeAF Study

Luik A, Radzewitz A, Kieser M, et al. Circulation 2015;132;14:1311-1319.

Safety and efficacy outcomes of left atrial posterior wall isolation compared to pulmonary vein isolation and pulmonary vein isolation with linear ablation for the treatment of persistent atrial fibrillation

Sutter JS, Lokhnygina Y, Daubert JP, et al. Am Heart J 2020;220:89-96.

Quality of life after catheter and minimally invasive surgical ablation of paroxysmal and early persistent atrial fibrillation: results from the SCALAF trial

Buist TJ, Adiyaman A, Beukema RJ, et al. Clin Res Cardiol 2020;109;2:215-224.

Left atrial roof ablation in patients with persistent atrial fibrillation using the second-generation cryoballoon: benefit or wasted time?

Kuniss M, Akkaya E, Berkowitsch A, et al. Clin Res Cardiol 2019. [Epub ahead of print]

Catheter Ablation Versus Best Medical Therapy in Patients With Persistent Atrial Fibrillation and Congestive Heart Failure: The Randomized AMICA Trial

Kuck KH, Merkely B, Zahn R, et al. Circ Arrhythm Electrophysiol 2019;12;12:e007731.

Outcomes of cryoballoon or radiofrequency ablation in symptomatic paroxysmal or persistent atrial fibrillation

Hoffmann E, Straube F, Wegscheider K, et al. Europace 2019;21;9:1313-1324.

Long-term outcomes of cryoballoon-based left atrial appendage isolation in addition to pulmonary vein isolation in persistent atrial fibrillation

Yorgun H, Canpolat U, Okşul M, et al. Europace 2019;21;11:1653-1662.

12 Month Efficacy, Safety, Symptoms And Improved Quality Of Life Post Arctic Front Advance Cryoballoon Ablation In Persistent AF Patients

Calkins H, Su W, Bhasin K, et al. JACC 2020;75;11:270

Catheter ablation of atrial fibrillation: state-of-the-art techniques and future perspectives

Santangeli P, Di Biase L, Burkhardt DJ, et al. J Cardiovasc Med (Hagerstown) 2012;13;2:108-24.

Ablation of persistent atrial fibrillation: Challenges and solutions

Terricabras M, Piccini JP and Verma A. J Cardiovasc Electrophysiol 2019. [Epub ahead of print].

2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart R

January CT, Wann LS, Calkins H, et al. J Am Coll Cardiol 2019;74;1:104-132.

Cryoablation for persistent atrial fibrillation: less may be more… sometimes!

Hussein AA and Wazni OM. Europace 2020;22;3:333-334.

The rationale for isolation of the left atrial pulmonary venous component to control atrial fibrillation: A review article

Elbatran AI, Anderson RH, Mori S and Saba MM. Heart Rhythm 2019;16;9:1392-1398.

The Hot and the Cold: Radiofrequency Versus Cryoballoon Ablation for Atrial Fibrillation

Ang R, Domenichini G, Finlay MC, et al. Curr Cardiol Rep 2015;17;9:631.

Catheter ablation in patients with persistent atrial fibrillation

Kirchhof P and Calkins H. European Heart Journal 2017;38;1:20-26.

Rhythm Control in AF: Have We Reached the Last Frontier?

Dan, GA. European Cardiology Review 2019;14;2:77-81.

Complications of Cryoballoon Pulmonary Vein Isolation

Miyazaki, S and Tada, H. Arrhythmia & Electrophysiology Review 2019;8;1:60-64.

Long-term Outcome of Pulmonary Vein Isolation Versus Amiodarone Therapy in Patients with Coexistent Persistent AF and Congestive Heart Failure

Faggioni M, Della Rocca DG, Mohanty S, et al. Cardiac Failure Review 2020;6:e04.

High-Resolution Mapping In Patients With Persistent AF

Andronache M, Drca N and Viola G. Arrhythmia & Electrophysiology Review 2019;8(2):111-5.

Predictors of Recurrence of AF in Patients After Radiofrequency Ablation

Garvanski I, Simova I, Angelkov L and Matveev M. European Cardiology Review 2019;14(3):165-8.

Understanding AF Mechanisms Through Computational Modelling And Simulations

Aronis KN, Ali RL, Liang JA, et al. Arrhythmia & Electrophysiology Review 2019;8(3):210-9.

Individualised Approaches for Catheter Ablation of AF: Patient Selection and Procedural Endpoints

Johner N, Namdar M and Shah DC. Arrhythmia & Electrophysiology Review 2019;8(3):184-90.

  • 1Hoffmann E, et al. EP Europace 2019, doi:10.1093/europace/euz155.;KuckKH, et al. EuropeanHeart Journal 2016, doi:10.1093/eurheartj/ehw285.
  • 2KirchhofP, et al., ESC 2016 AF guidelines, EHJ 2016.;Calkins H, et al. HeartRhythm2017 May 12.
  • 3Verma A, et al. N Engl J Med 2015;372:1812-1822.
  • 4ProvidenciaR, et al. EP Europace 2017, doi:10.1093/europace/euw080.; MonnickendamG, et al. Operations Research for Health Care 2018,; Velagi?V, et al. Journal of Cardiovascular Medicine 2017, doi:10.2459/JCM.0000000000000493.
  • 5Kirchhof P, et al. ESC 2016 AF guidelines, EHJ 2016.; Calkins H, et al. Heart Rhythm2017 May 12.; Boveda S, et al. JACC Clin Electrophysiol2018,; Su W, et al. Heart Rhythm 2020,
  • 6Su W, et al. Heart Rhythm 2020,


The content on this site is for information purposes only and is not a substitute for professional medical advice. The views and opinions expressed in the content on this site does not necessarily reflect or represent the views and opinions of Radcliffe Cardiology or Medtronic. See the device manual for information regarding the instructions for use, the implant procedure, indications, contraindications, warnings, precautions, and potential adverse events. For further information, contact your local Medtronic representative and/or consult the Medtronic website at