Long-Term Results of the Effectiveness of Cryoballoon and Radiofrequency Ablation in Patients with Atrial Fibrillation: Propensity Score Matching Analysis

Aim    To compare the long-term effectiveness of cryoballoon ablation (CBA) and radiofrequency ablation (RFA) in patients with atrial fibrillation (AF).
Material and methods    This retrospective single-site study included 597 patients with AF who had undergone CBA (n=241) or RFA (n=356) between 2016 and 2024. The study participants included 355 men (59.5%) and 242 women (40.5%) aged 58.4±10.8 years. The follow-up period was 13.0 [10.0; 27.5] months. The primary endpoint was late recurrence of AF (≥90 days after catheter ablation (CA)) confirmed by electrocardiography (ECG) or ECG Holter monitoring. To minimize confounding, the groups were compared by the propensity score matching (PSM, 234 pairs). The absence of AF recurrence was analyzed using Kaplan-Meier survival curves and group comparison with the log-rank test. Predictors for an increased risk of AF recurrence were identified by the univariate and multivariate Cox regression analysis. 
Results    With the use of PSM, late AF recurrence was found in 41 (17.5%) patients after CBA and in 85 (36.3%) after RFA (p<0.001). Thus, at 48 months after CA, AF recurrence was absent in 70% of patients in the CBA group and 53% patients in the RFA group; the difference between the groups was statistically significant (log-rank p=0.005). In the multivariate Cox analysis, independent predictors of AF recurrence were body mass index (BMI) (odds ratio (OR) 1.11; 95% confidence interval (CI) 1.05-1.18; p<0.001) and early AF recurrence within 90 days (OR 4.43; 95% CI 2.72-7.21; p<0.001). 
Conclusion    According to the study univariate analysis, CBA showed an advantage over RFA in terms of the efficacy in the long-term period. Body mass index and early AF recurrence were independent predictors of late AF recurrence after CA. 

1. Golukhova E.Z., Milievskaya E.B., Filatov A.G., Semenov V.Yu., Pryanishnikov V.V., Serguladze S.Yu. Arrhythmology – 2023. Heart rhythm and conduction disorders. -M.: A.N. Bakulev National Medical Research Center for Cardiovascular Surgery Ministry of Health of the Russian Federation; 2024. -212p.

2. Sellal J-M, Hammache N, Echivard M. La fibrillation atriale en 2025 : diagnostic et prise en charge. La Revue de Médecine Interne. 2025;S0248-8663(25)00078-5. [Epub ahead of print]. DOI: 10.1016/j.revmed.2025.02.010

3. Van Gelder IC, Rienstra M, Bunting KV, Casado-Arroyo R, Caso V, Crijns HJGM et al. 2024 ESC Guidelines for the management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS). European Heart Journal. 2024;45(36):3314–414. DOI: 10.1093/eurheartj/ehae176

4. Golukhova E.Z., Filatov A.G., Avanesyan G.A., Shvartz V.A., Shalov R.Z., Temirbulatov I.A. et al. Prospective randomized controlled trial “Comparative analysis of radiofrequency and cryoablation of the posterior wall of the left atrium in patients with persistent atrial fibrillation” in the Russian Federation (“PRIORITY-AF”): rationale, objectives and design. Creative Cardiology. 2024;18(3):317–27. [

5. Bocz B, Debreceni D, Jánosi K-F, Torma D, Kupo P. Comparison of Cryoballoon and Ablation Index-Guided Radiofrequency Ablation in Paroxysmal Atrial Fibrillation. Journal of Clinical Medicine. 2025;14(6):2119. DOI: 10.3390/jcm14062119

6. Kuck K-H, Brugada J, Fürnkranz A, Metzner A, Ouyang F, Chun KRJ et al. Cryoballoon or Radiofrequency Ablation for Paroxysmal Atrial Fibrillation. New England Journal of Medicine. 2016;374(23):2235– 45. DOI: 10.1056/NEJMoa1602014

7. Tomaiko E, Su WW. Comparing radiofrequency and cryoballoon technology for the ablation of atrial fibrillation. Current Opinion in Cardiology. 2019;34(1):1–5. DOI: 10.1097/HCO.0000000000000578

8. Li G, Zhao Y, Peng Z, Zhao Y. Risk factors for the recurrence of atrial fibrillation after catheter ablation: a meta-analysis. The Egyptian Heart Journal. 2025;77(1):9. DOI: 10.1186/s43044-025-00605-7

9. Erhard N, Metzner A, Fink T. Late arrhythmia recurrence after atrial fibrillation ablation: incidence, mechanisms and clinical implications. Herzschrittmachertherapie Elektrophysiologie. 2022;33(1):71– 6. DOI: 10.1007/s00399-021-00836-6

10. Ruxton GD. The unequal variance t-test is an underused alternative to Student’s t-test and the Mann–Whitney U test. Behavioral Ecology. 2006;17(4):688–90. DOI: 10.1093/beheco/ark016

11. Lumley T, Diehr P, Emerson S, Chen L. The Importance of the Normality Assumption in Large Public Health Data Sets. Annual Review of Public Health. 2002;23(1):151–69. DOI: 10.1146/annurev.publhealth. 23.100901.140546

12. Blanca M, Alarcón R, Arnau J, Bono R, Bendayan R. Non-normal data: Is ANOVA still a valid option? Psicothema. 2017;4(29):552–7. DOI: 10.7334/psicothema2016.383

13. PharmAdvisor. Addendum on Estimands and Sensitivity Analysis in Clinical Trials to the Guideline on Statistical Principles for Clinical Trials. 2019. Av. at: https://pharmadvisor.ru/document/tr3985/.

14. Rasch D, Kubinger KD, Moder K. The two-sample t test: pre-testing its assumptions does not pay off. Statistical Papers. 2011;52(1):219– 31. DOI: 10.1007/s00362-009-0224-x

15. Rochon J, Kieser M. A closer look at the effect of preliminary goodness- of-fit testing for normality for the one-sample t-test. British Journal of Mathematical and Statistical Psychology. 2011;64(3):410–26. DOI: 10.1348/2044-8317.002003

16. Rochon J, Gondan M, Kieser M. To test or not to test: Preliminary assessment of normality when comparing two independent samBMC Medical Research Methodology. 2012;12(1):81. DOI: 10.1186/1471-2288-12-81

17. Schoder V, Himmelmann A, Wilhelm KP. Preliminary testing for normality: some statistical aspects of a common concept. Clinical and Experimental Dermatology. 2006;31(6):757–61. DOI: 10.1111/j.1365-2230.2006.02206.x

18. Mörtsell D, Arbelo E, Dagres N, Brugada J, Laroche C, Trines SA et al. Cryoballoon vs. radiofrequency ablation for atrial fibrillation: a study of outcome and safety based on the ESC-EHRA atrial fibrillation ablation long-term registry and the Swedish catheter ablation registry. EP Europace. 2019;21(4):581–9. DOI: 10.1093/europace/euy239

19. Ravi V, Poudyal A, Pulipati P, Larsen T, Krishnan K, Trohman RG et al. A systematic review and meta-analysis comparing second-generation cryoballoon and contact force radiofrequency ablation for initial ablation of paroxysmal and persistent atrial fibrillation. Journal of Cardiovascular Electrophysiology. 2020;31(10):2559–71. DOI: 10.1111/jce.14676

20. Dretzke J, Chuchu N, Agarwal R, Herd C, Chua W, Fabritz L et al. Predicting recurrent atrial fibrillation after catheter ablation: a systematic review of prognostic models. EP Europace. 2020;22(5):748–60. DOI: 10.1093/europace/euaa041

21. Fortuni F, Casula M, Sanzo A, Angelini F, Cornara S, Somaschini A et al. Meta-Analysis Comparing Cryoballoon Versus Radiofrequency as First Ablation Procedure for Atrial Fibrillation. The American Journal of Cardiology. 2020;125(8):1170–9. DOI: 10.1016/j.amjcard. 2020.01.016

22. Liu F, Song T, Hu Q, Zhu X, Zhao H, Tan Z et al. Body mass index and atrial fibrillation recurrence post ablation: A systematic review and dose-response meta-analysis. Frontiers in Cardiovascular Medicine. 2023;9:999845. DOI: 10.3389/fcvm.2022.999845

23. Mohanty S, Della Rocca DG, Gianni C, Trivedi C, Mayedo AQ, Mac-Donald B et al. Predictors of recurrent atrial fibrillation following catheter ablation. Expert Review of Cardiovascular Therapy. 2021;19(3):237–46. DOI: 10.1080/14779072.2021.1892490

24. Saksena S, Ken-Opurum J, McKindley DS, Preblick R, Rashkin J, Aldaas OM et al. Arrhythmia Recurrence and Rhythm Control Strategies After Catheter Ablation of Newly Diagnosed Atrial Fibrillation (ARRC-AF Study). JACC: Clinical Electrophysiology. 2025;11(4):763–75. DOI: 10.1016/j.jacep.2024.11.020

25. Takami A, Miake J, Kato M, Ogura K, Okamura A, Tomomori T et al. Impact of BMI and Type of Ablation Procedure on Atrial Fibrillation Recurrence in Japanese Patients. Journal of Asian Pacific Society of Cardiology. 2022;1:e15. DOI: 10.15420/japsc.2021.27

26. Novikov I.A., Novikov P.S., Mironov N.Yu., Layovich L.Yu., Malkina T.A., Shariya M.A. et al. Potential risk factors of atrial fibrillation recurrence after cryoballoon ablation. Kardiologiia. 2022;62(6):23– 9.

27. Ukita K, Egami Y, Kawanami S, Sugae H, Kawamura A, Nakamura H et al. Impact of very early recurrence of atrial fibrillation after cryoballoon ablation. Pacing and Clinical Electrophysiology. 2022;45(11):1323–9. DOI: 10.1111/pace.14583

28. Ukita K, Egami Y, Nohara H, Kawanami S, Kawamura A, Yasumoto K et al. Predictors of late recurrence after second catheter ablation for persistent atrial fibrillation. Heart Rhythm. 2024;S1547-5271(24)03514-8. [Epub ahead of print]. DOI: 10.1016/j. hrthm.2024.10.053

29. Avanesyan G.A., Filatov A.G., Shalov R.Z. Anatomical and functional remodeling of the left atrium in patients with paroxysmal and persistent atrial fibrillation after cryoballoon isolation of pulmonary vein orifices. Creative Cardiology. 2024;18(1):59–72.

30. Golukhova E.Z., Gromova O.I., Bulaeva N.I., Arakelyan M.G. Mechanisms of Arrhythmogenesis and Risk Factors for Thromboembolic Events in Patients with Atrial Fibrillation without Concomitant Coronary and Valvular Heart Disease. Annals of the Russian academy of medical sciences. 2020;75(5):523–31.

31. Abgaryan A.A., Berdibekov B.Sh., Aleksandrova S.A., Ivanova Z.Z., Bulaeva N.I., Tarasova K.A. et al. Prognostic role of left atrial fibrosis assessment using magnetic resonance imaging in patients with atrial fibrillation after catheter pulmonary vein isolation. Creative Cardiology. 2024;18(1):92–103.