Catheter ablation for atrial fibrillation (AF) has become the mainstay of interventional treatment of AF and primarily aims at the elimination of AF triggers, which are myocardial muscle extensions (“sleeves”) covering the outside of the pulmonary veins (PV) [1-3]. AF ablation has been mainly performed with the use of radiofrequency (RF) energy creating continuous circumferential lesions by point-by-point ablation. Given the difficulties associated with creating contiguous curvilinear lesions with focal ablation, this technique is challenging and highly dependent on operator dexterity. Therefore, efforts have been directed towards the development of balloon-based systems potentially offering a simpler and less operator dependent means of achieving PV isolation (PVI) by creating a continuous circumferential lesion set with a limited number of energy applications. While such a balloon-based system using cryothermal energy – the cryoballoon (Arctic Front, Medtronic, Minneapolis, MN) – has been commercially used in Europe since 2005 it has only recently received Food and Drug Administration (FDA) approval for the treatment of paroxysmal AF in the United States based on the STOP-AF trial (Sustained Treatment of Paroxysmal Atrial Fibrillation) [4].

Apart from the efficacy of a novel treatment modality, it is of importance to determine its safety in order to determine the risk-to-benefit profile of a specific procedure. “New” intervention related complications were identified since the beginning of AF ablation using RF energy, such as development of PV stenosis or atrio-esophageal fistula. Although complication rates of cryoballoon ablation of AF have been reported to be similar when compared to radiofrequency ablation (RFA), specific energy and device related complications are probable.

The aim of this article is to review the role of cryoballoon ablation in patients with paroxysmal AF with an emphasis on practical technical aspects, but also limitations and pitfalls based on our clinical experience.