Authors

• Vedran Velagić — University of Zagreb School of Medicine, University Hospital Centre Zagreb, Zagreb, Croatia — ORCID: 0000-0001-5425-5840
• Domagoj Kardum — University of Zagreb School of Medicine, University Hospital Centre Zagreb, Zagreb, Croatia — ORCID: 0000-0001-5202-4061
• Mislav Puljević — University of Zagreb School of Medicine, University Hospital Centre Zagreb, Zagreb, Croatia — ORCID: 0000-0003-1477-2581
• Borka Pezo-Nikolić — University of Zagreb School of Medicine, University Hospital Centre Zagreb, Zagreb, Croatia — ORCID: 0000-0002-0504-5238
• Martina Lovrić Benčić — University of Zagreb School of Medicine, University Hospital Centre Zagreb, Zagreb, Croatia — ORCID: 0000-0001-8446-6120
• Davor Puljević — University of Zagreb School of Medicine, University Hospital Centre Zagreb, Zagreb, Croatia — ORCID: 0000-0003-3603-2242
• Davor Miličić — University of Zagreb School of Medicine, University Hospital Centre Zagreb, Zagreb, Croatia — ORCID: 0000-0001-9101-1570

Keywords

atrial fibrillation, cryoballoon, anticoagulant therapy

DOI

Full Text

**Introduction**: Ablation of atrial fibrillation (AF) by cryoenergy preserves intact extracellular matrix and the endothelium of the left atrium and appears to be less thrombogenic than radiofrequency energy (1). Current guidelines recommend anticoagulant therapy (OAC) for a minimum of 8 weeks after ablation of AF (2). There are no published data on the safety of acetylsalicylic acid (ASA) as the only antithrombotic drug after cryoballoon ablation of pulmonary veins. **Patients and Methods:** We performed a retrospective analysis of patients with paroxysmal atrial fibrillation that underwent isolation of pulmonary veins (PVI) by second generation cryoballoon (CB-A) in our institution. All patients had CHADSVASc Score 0 and were followed for a minimum of 3 months after the procedure. None of the patients before ablation were taking OAC. After the procedure, introduction of oral anticoagulants or ASA was left to the discretion of the operator. The cryoballoon procedure itself was carried out under local anesthesia with sedation as described previously (3). **Results:** A total of 16 patients (15 men, average age 51.2±9.8) were analyzed who met the inclusion criteria. Eight patients (50%) after the procedure did not receive OAC (ASA group), while the other half received new oral anticoagulants (5; 31.2%) or a vitamin K antagonist (3; 18.8%) (OAC group). The two groups did not differ considering the relevant clinical and procedural characteristics. In both groups, there were no thromboembolic, nor hemorrhagic events peri- and post- procedurally. Considering the other complications, we noted only one permanent and one transient phrenic nerve paresis in the OAC group (12.5%). In the mean follow-up of 7.7±3.3 months, 2 patients (12.5%) had recurrent atrial arrhythmias after “blanking” period (both in the ASA group). **Conclusion:** Anticoagulant therapy is recommended universally after PVI, but other than protection from thromboembolic events, it increases the risk of bleeding (most often local vascular complications). This small pilot study suggests that the hemorrhagic complications might be avoided without compromising the safety in patients with low basic thromboembolic risk when using second generation cryoballoon. Larger studies are needed to confirm the above findings.

Literature

1. Ciconte G, Sieira-Moret J, Hacioglu E, Mugnai GDI, Giovanni G, Velagic V, et al. Single 3-Minute versus Double 4-Minute Freeze Strategy for Second-Generation Cryoballoon Ablation: A Single-Center Experience. J Cardiovasc Electrophysiol. 2016;27(7):796–803. https://doi.org/10.1111/jce.12986
2. Kirchhof P, Benussi S, Kotecha D, Ahlsson A, Atar D, Casadei B, et al. Authors/Task Force Members; Document Reviewers. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS: The Task Force for the 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 ESCEndorsed by the European Stroke Organisation (ESO). Europace. 2016 Aug 27;•••:euw295.; Epub ahead of print. https://doi.org/10.1093/europace/euw295
3. Sarabanda AV, Bunch TJ, Johnson SB, Mahapatra S, Milton MA, Leite LR, et al. Efficacy and safety of circumferential pulmonary vein isolation using a novel cryothermal balloon ablation system. J Am Coll Cardiol. 2005;46(10):1902–12. https://doi.org/10.1016/j.jacc.2005.07.046