Level of Skill Required

The FIRE and ICE investigators noted that the “complexity” of RF mapping has “restricted ablation therapy for AF to specialized centers,” thereby limiting its availability.10

Indeed, point-by-point RF has a more extensive learning curve because it is highly technical and requires great skill and proficiency, Dr Calkins observed. Although use of cryoablation is also highly technical, the learning curve is shorter. This may allow smaller centers without extensive prior experience with point-by-point-RF ablation to rapidly become proficient.

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Indications for RF and Cryoablation

At present, both types of ablation are approved by the FDA only for treatment of drug-refractory paroxysmal AF, Dr Calkins noted. However, he added, both technologies are also frequently used to treat patients with persistent early AF. This practice is common in Europe and in the United States.13-15 

Further trials are underway to establish this approach and obtain regulatory approval, and FIRE and ICE investigators recently presented a secondary analysis at the 2016 Cardiotism-EHRA Europace meeting in Nice, France. The analysis included demographic characterizations of atrial arrhythmia recurrence and re-ablation, quality of life assessment, and other device-related adverse events.16


Despite advances in both RF and cryoablation, only approximately two- thirds of patients in each group were free from recurrent AF and other atrial arrhythmias in the FIRE and ICE trial.10

“There are still missing pieces we have not figured out,” Dr Simons said. Further research is needed to increase the efficacy of both procedures.


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  3. Calkins H, Kuck KH, Cappato R, et al; on behalf of the Heart Rhythm Society Task Force on Catheter and Surgical Ablation of Atrial Fibrillation. 2012 HRS/EHRA/ECAS expert consensus statement on catheter and surgical ablation of atrial fibrillation: recommendations for patient selection, procedural techniques, patient management and follow-up, definitions, end points, and research trial design: a report of the Heart Rhythm Society (HRS) Task Force on Catheter and Surgical Ablation of Atrial Fibrillation. Developed in partnership with the European Heart Rhythm Association (EHRA), a registered branch of the European Society of Cardiology (ESC) and the European Cardiac Arrhythmia Society (ECAS); and in collaboration with the American College of Cardiology (ACC), American Heart Association (AHA), the Asia Pacific Heart Rhythm Society (APHRS), and the Society of Thoracic Surgeons (STS). Endorsed by the governing bodies of the American College of Cardiology Foundation, the American Heart Association, the European Cardiac Arrhythmia Society, the European Heart Rhythm Association, the Society of Thoracic Surgeons, the Asia Pacific Heart Rhythm Society, and the Heart Rhythm Society. Heart Rhythm. 2012 Apr;9(4):632-696. doi: 10.1016/j.hrthm.2011.12.016.
  4. Packer DL, Kowal RC, Wheelan KR, et al. Cryoballoon ablation of pulmonary veins for paroxysmal atrial fibrillation: first results of the North American Arctic Front (STOP AF) pivotal trial. J Am Coll Cardiol. 2013;61(16):1713-1723. doi: 10.1016/j.jacc.2012.11.064.
  5. Mandell J, Amico F, Parekh S, Snow J, Germano J, Cohen TJ. Early experience with the cryablation balloon procedure for the treatment of atrial fibrillation by an experienced radiofrequency catheter ablation center. J Invasive Cardiol. 2013;25(6):288-292. 
  6. Luik A, Radzewitz A, Kieser M, et al. Cryoballoon vs open irrigated radiofrequency ablation in patients with paroxysmal atrial fibrillation: the prospective, randomized, controlled, noninferiority FreezeAF study. Circulation. 2015;132(14):1311-1319.
  7. Aryana A, Singh SM, Kowalski M, et al. Acute and long-term outcomes of catheter ablation of atrial fibrillation using the second-generation cryoballoon vs open-irrigated radiofrequency: a multicenter experience. J Cardiovasc Electrophysiol. 2015;26(8):832-839. doi: 10.1111/jce.12695.
  8. Wasserlauf J, Pelchovitz DJ, Rhyner J, et al. Cryoballoon vs radiofrequency catheter ablation for paroxysmal atrial fibrillation. Pacing Clin Electrophysiol. 2015;38(4):483-489.
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  10. Kuck KH, Brugada J, Fürnkranz A, et al; on behalf of the FIRE and ICE Investigators. Cryoballoon or radiofrequency ablation for paroxysmal atrial fibrillation. N Engl J Med. 2016;374(23):2235-2245. doi: 10.1056/NEJMoa1602014.  
  11. DeVille JB, Svinarich JT, Dan D, et al. Comparison of resource utilization of pulmonary vein isolation: cryoablation vs RF ablation with 3-dimensional mapping in the Value PVI Study. J Invasive Cardiol. 2014;26(6):268-272.
  12. Haldar S, Wong T. Contact force sensing for atrial fibrillation ablation. European Society of Cardiology Council for Cardiology Practice. https://www.escardio.org/Guidelines-&-Education/Journals-and-publications/ESC-journals-family/E-journal-of-Cardiology-Practice/Volume-11/Contact-force-sensing-for-atrial-fibrillation-ablation. May 6, 2013.
  13. Dagres N, Bongiorni MG, Larsen TB, et al; on behalf of the Scientific Initiatives Committee, European Heart Rhythm Association.  Current ablation techniques for persistent atrial fibrillation: results of the European Heart Rhythm Association Survey. Europace. 2015;17(10):1596-1600. doi: 10.1093/europace/euv323.
  14. Magnani S, Muser D, Chik W, Santangeli P. Adjunct ablation strategies for persistent atrial fibrillation—beyond pulmonary vein isolation. J Thorac Dis. 2015;7(2):178–184. doi: 10.3978/j.issn.2072-1439.2015.01.25.
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  16. Kuck KH, Brugada J, Fürnkranz A, et al; on behalf of the FIRE and ICE Investigators. The FIRE and ICE trial: looking beyond the primary efficacy and safety end points [abstract]. Presented at Cardiotism-EHRA Europace 2016; June 8-11, 2016; Nice, France.

51 (12.8%)

51 (12.8%)


2 (0.5%)

2 (0.5%)