Long‐Term Progression to Permanent Atrial Fibrillation After Cryoballoon Pulmonary Vein Isolation: Insights From the Multicenter 1STOP Project

Abstract

ABSTRACT Background Atrial fibrillation (AF) often progresses from paroxysmal to persistent forms, culminating in permanent AF, a transition associated with increased risks of stroke, heart failure, and hospitalization. Cryoballoon pulmonary vein isolation (CB‐PVI) is an established rhythm‐control strategy; however, long‐term data on AF progression following ablation remain limited. This study aimed to assess the incidence of progression to permanent AF after CB‐PVI and to identify clinical predictors of such progression to guide patient management. Methods We analyzed 1330 consecutive patients enrolled in the prospective, multicenter 1STOP registry who underwent CB‐PVI between 2012 and 2018 across 13 Italian centers, with ≥ 5 years of follow‐up. Baseline clinical, echocardiographic, and procedural characteristics were prospectively collected. Results During a median follow‐up of 81 months, 93 patients (7.0%) progressed to permanent AF. Independent predictors of progression included baseline persistent AF (HR ≈ 2.2, p < 0.001), need for cardioversion during index procedure (HR ≈ 2.2, p = 0.001), and older age (HR 1.05 per year, p < 0.001). Patients progressing to permanent AF had larger left atrium dimensions, higher CHA 2 DS 2 ‐VA scores, and a greater burden of comorbidities. Among patients experiencing AF recurrence, those undergoing repeat ablation had lower rates of progression compared to those without reintervention (11.0% vs. 17.6%). Conclusion In this large multicenter cohort, long‐term progression to permanent AF after CB‐PVI was relatively uncommon (7%). Baseline AF type, age, and intra‐procedural cardioversion independently predicted progression. Early rhythm‐control strategies and individualized risk stratification may help delay the transition to permanent AF and improve long‐term rhythm outcomes.