Cryoballoon ablation of paroxysmal atrial fibrillation: bigger is better and simpler is better

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Abstract
Pulmonary vein isolation (PVI) is the mainstay of catheter ablation for atrial fibrillation. In an effort to overcome the shortcomings of drawing a continuous line around the pulmonary vein (PV) ostia by point-by-point focal radiofrequency catheter ablation, research in the interventional electrophysiology field currently focuses on developing new energy sources and catheter designs to achieve PVI safer, faster, and with equal efficacy as compared with the conventional radiofrequency approach. In that respect, balloon-based catheter ablation systems are particularly promising because they allow for a ‘single shot’ PVI by placing the balloon at the PV ostium and ablating circumferentially around the PV ostia with a single energy application. Balloon-based catheter systems using various energy sources (cryothermal energy, non-focused ultrasound, highly focused ultrasound, laser, radiofrequency) have been developed or are currently under investigation.1 With regard to safety aspects, cryothermal energy may have advantages over other energy sources since both human and experimental animal data have demonstrated that the risk for PV stenosis,2 atrio-oesophageal fistulae,3 and thrombus formation4 is extremely low to absent with application of cryothermal energy.