Cryoballoon Versus Radiofrequency Ablation for Persistent Atrial Fibrillation: Meta-Analysis of Randomized Trials

Pulmonary vein isolation (PVI) alone achieves modest arrhythmia freedom in persistent atrial fibrillation (PeAF). Cryoballoon ablation (CBA) offers a single-shot alternative to radiofrequency ablation (RFA) that streamlines procedural workflow. We aimed to quantify the clinical efficacy, procedural efficiency, and safety of CBA versus RFA through a meta-analysis of randomized controlled trials (RCTs).

Systematic review of PubMed, Embase, and Scopus identified 5 RCTs enrolling 1,091 patients (515 CBA, 576 RFA). The primary endpoint was 12-month freedom from any atrial arrhythmia, with isolated AF, and atrial tachycardia/flutter evaluated as secondary endpoints. Random-effects models generated relative risks (RRs) and mean differences (MDs) with 95% confidence intervals (CI). Time-to-event data were pooled using a generic inverse-variance approach to derive hazard ratios (HR). CBA and RFA demonstrated equivalent freedom from any arrhythmia (RR 0.97, 95% CI 0.81-1.15; p = 0.71). Time-to-event analysis corroborated a comparable recurrence hazard (HR 0.91, 95% CI 0.67-1.24; p = 0.56; I² = 0%). Repeat ablation rates were identical (RR 0.93; p = 0.50). CBA significantly reduced procedural time (MD -45.37 min; p < 0.0001), while major complications were comparable (1.5% vs. 2.7%; p = 0.18). Trial sequential analysis indicated that further randomization is unlikely to demonstrate superiority.

In PeAF, CBA and RFA achieve equivalent 12-month arrhythmia-free survival and comparable repeat-ablation rates, while CBA confers a highly significant reduction in procedural time. However, reliance on 12-month follow-up and heterogeneous rhythm surveillance protocols may limit assessments of true long-term durability.