Application of local anaesthesia and cryosurgery for eyelid masses in dogs.

BACKGROUND: Eyelid mass removal and cryotherapy application using only local anaesthesia and restraint may benefit patients with high anaesthesia risks. OBJECTIVE: To evaluate and validate cryosurgery application using the CryoPen XL® on palpebral masses under local anaesthesia for patients not suitable for general anaesthesia. METHODS: Thirty patients underwent the procedure between November 2015 and April 2020. The procedure steps were as follows: skin preparation and local anaesthesia of the affected eyelid; debulking by resection and/or squeezing out the inspissated material; cryosurgery and post-operative care using topical medication, antibiotics and anti-inflammatory ointment. The medical records of the patients who underwent the operation were evaluated. Moreover, a telephonic survey with the pet owners was performed to determine recurrence, time to recurrence, survivability and side effects. RESULTS: Among the 30 owners, 29 responded to the survey. Ten (10/38, 26.3%) masses recurred with an average time to recurrence of 6.0 months. The estimated average depths for all, non-recurred, and recurred masses were 1.89, 1.88 and 1.90 mm, respectively. The average recurrence rate and time to recurrence were higher and earlier, respectively, than previously reported values. However, no patient presented intra- or post-operative complications. CONCLUSION: These findings suggest that local anaesthesia and cryosurgery using the CryoPen XL® can be used in patients with eyelid masses who are not suitable for general anaesthesia. Compared with the surgical eyelid mass removal and blepharoplasty procedure, the reported procedure is time- and cost-effective, with the additional benefit of not requiring general anaesthesia.

Cryosurgical ablation for treatment of rhinitis: A prospective multicenter study.

OBJECTIVE: To assess the efficacy and safety of cryoablation of the posterior nasal nerve (PNN) for treatment of chronic rhinitis. METHODS: This was a prospective single-arm trial of 98 adult patients at six U.S. centers with chronic allergic and nonallergic rhinitis. PNN cryoablation was performed in-office under local anesthesia using a handheld device. Patients discontinued use of intranasal ipratropium 3 days prior to treatment and throughout the study period. Reflective Total Nasal Symptom Score (rTNSS) was measured at pretreatment baseline and posttreatment at 1 month, 3 months, 6 months, and 9 months. The Rhinoconjunctivitis Quality of Life Questionnaire (RQLQ) was completed at pretreatment and 3 months posttreatment. Adverse effects and postprocedure medication usage were recorded. RESULTS: Ninety-eight procedures (100%) were successfully completed. rTNSS significantly improved over pretreatment baseline (6.1 ± 1.9) at 1 month (2.9 ± 1.9, P < 0.001), 3 months (3.0 ± 2.3, P < 0.001), 6 months (3.0 ± 2.1, P < 0.001), and 9 months (3.0 ± 2.4, P < 0.001) postprocedure. Nasal congestion and rhinorrhea subscores improved significantly at all time points (P < 0.001). Both allergic and nonallergic rhinitis subcohorts showed improvement (P < 0.001), with a comparable degree of improvement between groups. RQLQ significantly improved over pretreatment baseline (3.0 ± 1.0) at 3 months (1.5 ± 1.0, P < 0.001), and all RQLQ subdomains demonstrated improvement. Of 54 patients using intranasal medication at baseline, 19 (35.2%) were able to discontinue use. Twenty-nine adverse effects were reported, including headache, epistaxis, and sinusitis. CONCLUSION: Cryoablation of the PNN for chronic rhinitis is safe and can result in relief of nasal symptoms and improvements in quality of life. LEVEL OF EVIDENCE: 4 Laryngoscope, 130: 1877-1884, 2020.

Use of the cryoballoon to ablate pulmonary vein-dependent left atrial flutter.

New atrial flutter (AFL) that arises after pulmonary vein isolation (PVI) by catheter or surgical ablation can originate from reconnection of a pulmonary vein (PV). Reisolation of PVs with cryoballoon ablation (CBA) for treatment of peri-PV AFL after Maze or PVI has not previously been reported. The present case series describes use of CBA to treat post-PVI and post-Maze PV-dependent AFL. In these cases, CBA was used to reisolate the PVs and terminate AFL without requiring additional lesion sets for treatment of AFL.

The fourth cryoballoon generation with a shorter tip to facilitate real-time pulmonary vein potential recording: Feasibility and safety results.

INTRODUCTION: Time-to-isolation (TTI) guided ablation protocols have been developed to ensure durable pulmonary vein isolation (PVI) in cryoballoon ablation (CBA). The aim was to determine the feasibility and safety of the fourth generation cryoballoon (CBG4) with a shortened tip. METHODS AND RESULTS: Consecutive patients scheduled for initial atrial fibrillation (AF) ablation were prospectively included. PVI with the 28 mm CBG4 and the latest 20 mm spiral-mapping catheter (SMC) was performed. A total of 302 pulmonary veins (PVs) in 76 patients (64.8 ± 10.4 years, paroxysmal AF 49%) were treated with 617 applications. Left atrium (LA) time, fluoroscopy time, and dose-area product were 65.5 ± 19.2 minutes, 14.6 ± 5.6 minutes, and 1094 (738; 2097) cGy·cm2 , respectively. PVI in cryoballoon technique was achieved in 302 of 302 (100%) PVs. TTI was determined in 256 (84.8%) of PVs. The mean TTI was 45.3 ± 26.4 seconds. Single-shot isolation was achieved in 247 (82%) PVs. In 6 of 302 (2.0%) PV the SMC was changed to a stiff wire to isolate the PV because of instability, and in 17 of 302 (5.6%) of PVs, the 23 mm CB was used to isolate. No radiofrequency touch-up applications were applied. The mean nadir balloon temperature was -44.8°C ± 6.6°C. Balloon dislodgement during positioning occurred in 3 of 617 (0.5%) applications without complications. One PN palsy occurred which resolved until discharge. One patient suffered from the inflammatory syndrome. CONCLUSION: The CBG4 with a shorter distal tip seems to be safe and effective, and allows determining the TTI in 84.8% of PVs. In case of balloon instability, the exchange of the SMC to a stiff wire or, in small PV, the 23 mm cryoballoon facilitate PVI.

Dosing of the second-generation cryoballoon using acute time-to-pulmonary vein isolation as an indicator of durable ablation in a canine model.

BACKGROUND: Rigid time-based dosing protocol(s) currently used in the clinic for cryoballoon ablation of atrial fibrillation may be inadequate to guide the circumferential and transmural cryothermal energy transfer across the pulmonary vein (PV) and may result in injury to collateral tissues or electrical gaps between the PV and left atrium (LA). OBJECTIVE: A physiologic endpoint (e.g., acute time-to-PV isolation a.k.a. time-to-effect; TTE) may be effective in the determination of a transmural lesion formation and may allow for individualized ablation dosing across each PV. METHODS: Thirty PVs from 15 dogs were randomized into five dosing protocols, including (1) TTE + 60 s, (2) TTE + 90 s, (3) TTE + 120 s, (4) TTE + 150 s, and (5) 2 × 180 s. Ablations were conducted with a 23-mm second-generation cryoballoon, and TTE was assessed during a freeze by pacing from an inner balloon-lumen circular diagnostic catheter to a quadripolar diagnostic catheter in the coronary sinus. After ablation, animals were survived for 30 to 34 days, and repeat electrophysiology assessment of PV isolation was conducted after which animals were euthanized for gross anatomy and histological examination. RESULTS: At study termination, efficacy endpoint evaluations were based on maintenance of PV electrical isolation, gross anatomy assessment of PV lesions, and histological examination of PVs. Five efficacy endpoint failures were noted, including the following: 1 PV in the TTE + 90 sec group; 2 PVs in the TTE + 120 sec group; 1 PV in the TTE + 150 s group; and 1 PV in the 2 × 180 s group. Regarding safety, one phrenic nerve injury was observed in the 2 × 180 s cohort. No other complications were observed. CONCLUSIONS: In a canine model, effective PV isolation could be found even in the shortest duration dosing cohort (TTE + 60 s). One complication (phrenic nerve injury) was observed in the longest duration dosing group (2 × 180 s). Further studies will be required to correlate these results to a 28-mm cryoballoon (more commonly used in the cryoablation of a human LA); however, to date, this is the first reporting of a successful cryoablation using TTE + 60 s dosing (approximately 90 s total duration of freezing).

Atrial fibrillation ablation using cryoballoon technology: Recent advances and practical techniques.

Atrial fibrillation (AF) affects 1-2% of the population, and its prevalence is estimated to double in the next 50 years as the population ages. AF results in impaired patients' life quality, deteriorated cardiac function, and even increased mortality. Antiarrhythmic drugs frequently fail to restore sinus rhythm. Catheter ablation is a valuable treatment approach for AF, even as a first-line therapy strategy in selected patients. Effective electrical pulmonary vein isolation (PVI) is the cornerstone of all AF ablation strategies. Use of radiofrequency (RF) catheter in combination of a three-dimensional electroanatomical mapping system is the most established ablation approach. However, catheter ablation of AF is challenging even sometimes for experienced operators. To facilitate catheter ablation of AF without compromising the durability of the pulmonary vein isolation, "single shot" ablation devices have been developed; of them, cryoballoon ablation, is by far the most widely investigated. In this report, we review the current knowledge of AF and discuss the recent evidence in catheter ablation of AF, particularly cryoballoon ablation. Moreover, we review relevant data from the literature as well as our own experience and summarize the key procedural practical techniques in PVI using cryoballoon technology, aiming to shorten the learning curve of the ablation technique and to contribute further to reduction of the disease burden.

Influence of energy source on early atrial fibrillation recurrences: a comparison of cryoballoon vs. radiofrequency current energy ablation with the endpoint of unexcitability in pulmonary vein isolation.

Introduction: Comparative data of early recurrence rates of atrial fibrillation (ERAF) following second-generation cryoballoon (CB-G2) and radiofrequency current (RFC) ablation for pulmonary vein isolation (PVI) in paroxysmal AF (PAF) are rare. We randomized PAF patients into either PVI with CB-G2 (group 1) or PVI with a combined RFC-approach applying contact force (CF) with the endpoint of unexcitability (group 2) to investigate ERAF. Methods and results: In group 1 (n = 30), CB-G2-PVI was performed. After CF-PVI in group 2 (n = 30), bipolar pacing on the ablation line and additional ablation until unexcitability was conducted. Follow-up included 48 h of in-hospital monitoring followed by 5-day Holter ECGs 1, 2, 3, 6, 12 months postablation to evaluate ERAF. Acute PVI was reached in 100% of group 2 and in 99% of group 1. Shorter procedure durations (98.0 ± 21.9 vs. 114.3 ± 18.7 min, P < 0.05) but extended fluoroscopy times (15.4 ± 3.9 vs. 10.0 ± 4.3 min, P < 0.05) were found in the CB-G2 group. Ten non-severe complications occurred (6 vs. 4 in group 1 and 2, P = 0.73). In group 2, five patients suffered from ERAF vs. seven patients in group 1 (P = 0.67). The time until the occurrence of ERAF was shorter in group 2 (1 day (q1-q3: 1-4.5)) when compared with group 1 (22 (q1-q3: 6-54) days, P = 0.025). Conclusion: ERAF rates were equal among groups; however, they occurred earlier in the initial phase after RFC ablation when compared with CB-G2. PVI utilizing cryoablation is associated with shorter procedure durations but extended fluoroscopy time while being similarly secure.

Pulmonary vein re-mapping after cryoballoon ablation for atrial fibrillation.

Aims: Establishment of pulmonary vein isolation (PVI) during cryoballoon (CB) ablation is generally confirmed by use of an octapolar inner-lumen mapping catheter (Achieve®). The aim of this study is to evaluate the residual PV potential (PVP) using the conventional circular catheter after CB-PVI. Methods and results: A total of 105 consecutive patients (418 PVs) with paroxysmal AF who underwent the initial CB-PVI were prospectively included in this study. Of those, 305 (73%) PVs with real-time recordings of PVP elimination by Achieve® catheter during successful PVI were included. After isolation of all 4 PVs, PV antral remapping by conventional circular mapping catheter was performed. After CB-PVI, residual PVP was detected in 4.3% (13/305) of PVs (1.2% of left-superior PV, 2.5% of left-inferior PV, none of right-superior PV, and 20% of right-inferior PV). Almost 60% of residual PV potential was located around the bottom portion of the right-inferior PV. In PVs with residual potential, PV trunk was shorter (12.7 ± 5.7 mm vs. 18.7 ± 7.9, P = 0.001), minimal balloon temperature was higher (-46.6 ± 5.9 °C vs. -50.9 ± 8.2, P = 0.02), and balloon warming time was shorter (35.6 ± 17.8 s vs. 50.0 ± 22.8, P = 0.006) than those without. All residual potentials were eliminated by additional touch up ablation. After the initial ablation procedure, 1-year AF-free rate was 79.5%. Conclusion: PV remapping after CB-PVI revealed residual antral PVP in 4.3% of PVs and in 20% of RIPVs in particular. The Achieve® catheter sometimes fails to detect complete PV antral isolation.

Comparison of 6-mm Versus 8-mm-Tip Cryoablation Catheter for the Treatment of Atrioventricular Nodal Reentrant Tachycardia in Children: A Prospective Study.

Due to its safety profile, cryoablation (Cryo) for atrioventricular nodal reentrant tachycardia (AVNRT) is more commonly preferred over radiofrequency (RF) ablation in children in recent years. Recent studies demonstrated high long-term success rates comparable to radiofrequency ablation. The aim of this prospective study was to compare the efficacy and safety of an 8-mm-tip versus 6-mm-tip Cryo catheter in the treatment of AVNRT in children. A total of 125 consecutive patients over 10 years of age with AVNRT were included. EnSite system (St. JudeMedical, St Paul, MN, USA) was used to reduce or eliminate fluoroscopy. The acute procedural success was 100% in both groups. The prodecure duration for the 8-mm-tip group was shorter (151.6 ± 63.2 vs. 126.6 ± 36.7 min, p < 0.01, respectively). Fluoroscopy was used in only 7 patients. The mean follow-up duration was 14.6 ± 8.4 months (median 13.5 months, min. 3 months and max. 27 months). The recurrence rate for AVNRT was also comparable between the two groups (6-mm tip: 9.6 vs. 8-mm tip: 8%). Cryo of AVNRT is a safe and effective procedure with comparable acute and mid-term follow-up success rates using 6-mm and 8-mm-tip catheters in children. In addition, procedure duration is shorter with an 8-mm-tip Cryo catheter.

Pulmonary Vein Stenosis After Second-Generation Cryoballoon Ablation.

BACKGROUND: Pulmonary vein stenosis (PVST) can occur after first-generation cryoballoon ablation. This study aimed to evaluate the incidence, severity, and characteristics of PVST after second-generation cryoballoon ablation. METHODS: In total, 103 patients underwent PV isolation of paroxysmal atrial fibrillation using second-generation cryoballoons with a single big-balloon 3-minute freeze technique. Cardiac enhanced multidetector computed tomography (MDCT) was performed both before and a median of 6.0 (4.0-8.0) months after the procedure in all. PVST was classified as follows: minimal (<25%), mild (25-50%), moderate (50-70%), or severe (>70%). RESULTS: In total, 406 PVs were analyzed. MDCT demonstrated PV stenosis in 10(2.5%) PVs among 8(7.8%) patients. In detail, minimal and mild PVSTs were observed in 6 and 4 PVs, respectively. PVST occurred in the left superior (LSPV), left inferior, and right superior PVs in 6, 1, and 3 PVs, respectively. No stenosis was observed in 15 PVs with active balloon deflations during freezing. All PVSTs had concentric patterns except for 2 PVs with minimal stenosis. Balloon deformities were observed during freezing of 2 PVs with mild stenosis. When the PVST was defined as a >25% decreased diameter, the incidence was 0.98% (4/406; including 3 LSPVs). PVST did not progress further during the follow-up period. CONCLUSIONS: Although the incidence of PVST was low, it could occur even if a single big-balloon short freeze technique was applied. The risk of PV stenosis significantly differed among the 4 PVs, and reaching balloon temperatures of -60 °C and active balloon deflations during freezing were not associated with any PV stenosis.

Characterization of Electrical Reconnection Following Pulmonary Vein Isolation Using First- and Second-Generation Cryoballoon.

BACKGROUND: Second-generation cryoballoon (CB-2) is associated with improved outcomes for pulmonary vein isolation (PVI) compared to first generation (CB-1). However, data regarding the predictors of pulmonary vein (PV) electrical reconnection are limited. In this study, we aimed to characterize the predilection sites and predictors of reconnection in patients with recurrent atrial tachyarrhythmia (ATa) after PVI using CB-1 and CB-2. METHODS: A total of 59 patients (mean age: 62 ± 11 years and 66% male) with recurrent ATa after previous CB-PVI, using either a 28-mm CB-1 or CB-2, underwent repeat ablation. PV reisolation was performed by irrigated radiofrequency ablation using three-dimensional electroanatomical mapping systems. RESULTS: Electrical PV reconnection was detected in 10 of 11 (91%) of CB-1 patients compared to 41 of 48 (85%) of CB-2 patients. Time to redo procedure after index CB-1 was 8.9 ± 10.2 months and 11.2 ± 7.0 months in CB-2. Bonus freeze was applied in all patients with CB-1 and 41% of the patients with CB-2. Superior quadrants of both superior PVs and inferior quadrants of the both inferior PVs exhibited higher predilection for conduction compared to other quadrants (P < 0.001). Multivariate binary logistic analysis revealed that right inferior PV (RIPV; odds ratio [OR]: 1.52, 95% confidence interval [CI]: 1.09-2.13, P = 0.014) and minimum temperature (OR: 1.09, 95% CI: 1.03-1.15, P = 0.004) were the independent predictors of electrical reconnection after CB-2 ablation. CONCLUSION: Conduction gaps after CB-1 and CB-2 were higher in inferior PVs compared to superior PVs. The RIPV and minimum CB temperature were independent predictors of PV electrical reconnection after CB-2.

Shortening of freezing cycles provides equal outcome to standard ablation procedure using second-generation 28 mm cryoballoon after 15-month follow-up.

AIMS: Complications such as thermal oesophageal lesions, phrenic nerve injury, and pulmonary haemorrhage were found in cryoballoon (CB) ablation. Whether shortening of freezing times translates into equal efficacy rate and outcome is unknown. The aim of this study was to test the hypothesis that a single freeze cycle per pulmonary vein (PV) without dormant conduction during adenosine infusion is equally effective to standard CB procedure with a bonus freeze after documented PV isolation (PVI). METHODS AND RESULTS: In 53 patients with drug-refractory atrial fibrillation (AF) demonstrating PVI after a single 240 s freeze cycle without PV activity during adenosine no additional bonus freeze was applied (study group). In 139 patients, PVI was performed using a bonus freeze (240 s) after documented PVI (control group). Primary endpoint was recurrence of AF. Secondary endpoint was the assessment of quality of life (QoL-score from 1 to 6, being 1 the best and 6 the worst). Follow-up (FU) was performed at 3, 6, and 12 months. Freedom from symptomatic AF during a mean FU of 458 ± 107 days was achieved in 43 (81%) patients in the study group and in 110 (79%) control patients (P = ns). The QoL-score improved equally in both groups (4.8 ± 0.9 to 2.1 ± 0.7, P < 0.05 and 4.7 ± 0.6 to 2.2 ± 0.6, P < 0.05). Procedure duration (79 ± 14 vs. 98 ± 16 min, P < 0.01) was shorter in the study group. Complication rate was similar in both groups. CONCLUSION: Shortening of freezing times to 4 min per PV without residual dormant PV conduction after adenosine provocation is equally effective to the standard CB ablation protocol using a bonus freeze.

Male Body Contouring.

Men are increasingly turning to dermatologists and plastic surgeons to request procedures that correct or enhance physical features. With the advent of this emerging new patient population, alterations in preexisting aesthetic techniques, gender-specific uses of existing devices and overall approaches need to be revisited and adapted to obtain results that are suitable for the male patient. Recently, body contouring has become one of the most sought out procedures by men. Although the majority of clinical studies involving body contouring esthetics are performed with female patients, gains from such studies can be extrapolated to men. Body contouring can be broadly classified as non-invasive or invasive, depending on the modality used. Non-invasive contouring is most frequently performed with devices that target subcutaneous adipose with focused electrical or thermal energy, including low-level laser, cryolipolysis, ultrasonography, and radiofrequency. Invasive body contouring modalities useful for male body contouring include liposuction, pectoral and abdominal wall etching, jawline fillers, synthetic deoxycholic acid injections, and solid silicone implants. The purpose of this review is to bring attention to the unique aspects, strategies, and modalities used in aesthetic body contouring for the male patient.

Durability of Pulmonary Vein Isolation with Cryoballoon Ablation: Results from the Sustained PV Isolation with Arctic Front Advance (SUPIR) Study.

INTRODUCTION: Pulmonary vein (PV) reconnection remains the most important cause of AF recurrence after AF ablation. The second-generation cryoballoon catheter's ability to achieve durable PV isolation was assessed in a prospective nonrandomized clinical trial. METHODS AND RESULTS: PV isolation was performed by 4-minute ablations. Following verification of electrical isolation by a multielectrode mapping catheter, 1 additional lesion per PV was applied. Esophageal temperatures were monitored and all patients underwent postprocedure esophageal endoscopy. All patients underwent a second PV remapping procedure at ∼3 months to assess for PVI durability. Eighty-four (100%) veins were acutely isolated using only the 28 mm cryoballoon in 21 consecutive PAF patients with 2.2 ± 0.6 cryoapplications per vein, with the majority (83%) occurring after a single freeze. One patient presented with hematemesis and an esophageal ulceration that was treated conservatively; there were no episodes of esophageal fistula or phrenic nerve palsy. At 3.4 (2.9-4.1) months postablation, 68/75 veins (91%) remained electrically isolated; all PVs remained durably isolated in 79% of patients. Two patients accounted for 5 of 7 reconducting veins. The most common site for reconnection was the inferior aspect of the RIPV (3/7 reconnections). Reconnected veins had poorer occlusion at the index ablation procedure than veins that maintained chronic isolation (occlusion grade 2.9 ± 0.7 vs. 3.4 ± 0.7, P = 0.001). Clinical AF recurrence was detected in 2 patients (11%) at follow-up. CONCLUSIONS: The improved thermodynamic characteristics of the second-generation cryoballoon led to a high rate of both single-shot PVI and chronic lesion durability. This high rate of durable PV isolation is anticipated to translate to improved clinical outcome.

High rate of durable pulmonary vein isolation after second-generation cryoballoon ablation: analysis of repeat procedures.

AIMS: Pulmonary vein isolation (PVI) using the first-generation cryoballoon (CB1) was characterized by a high rate of recovered pulmonary vein (PV) conduction along with a typical conduction gap pattern in patients with recurrent atrial tachyarrhythmia (ATa). Second generation (CB2) enables more uniform freezing. However, the rate of chronic PVI and PV conduction gap pattern is unknown. METHODS AND RESULTS: All patients with ATa recurrence undergoing a second procedure after CB2 or (historical) CB1 PVI (28 mm) were enrolled. In all patients, a left atrial three-dimensional electronatomic reconstruction was performed. The rates of chronic PVI and localization of PV conduction gaps were determined and compared between CB1 and CB2. Antral PV re-isolation was performed using irrigated-tip radiofrequency current energy ablation. Of 206 patients (CB2), 18 patients underwent the repeat procedure after 192 (75:245) days. In 6 of 18 (33%) patients, all PVs were electrically isolated whereas in the remaining 12 patients (66%) at least one PV demonstrated PV reconduction. Of 71 PVs [1 left common PV (LCPV)], 55 PVs (77%) were chronically isolated. The right superior PV (RSPV) was characterized by the lowest rate of chronic PVI (RSPV: 56%, LSPV: 76%, RIPV: 83%, LIPV: 94%, LCPV: 100%). Compared with CB1, CB2 ablation resulted in a significantly higher rate of chronic PVI (CB2: 77% vs. CB1: 32%; P < 0.0001) with the greatest improvement along both inferior PVs. CONCLUSION: Second-generation cryoballoon atrial fibrillation ablation is associated with a high rate of durable PVI in patients with ATa recurrence. The RSPV represents the PV with the greatest risk for left atrium-pulmonary vein reconnection.

Quantification of the cryoablation zone demarcated by pre- and postprocedural electroanatomic mapping in patients with atrial fibrillation using the 28-mm second-generation cryoballoon.

BACKGROUND: There are 2 Food and Drug Administration-approved catheters (ThermoCool RF and Arctic Front Advance cryoballoon) for the treatment of drug refractory and symptomatic paroxysmal atrial fibrillation. Each tool is used to ablate the area surrounding the pulmonary veins (PVs). However, no study has described and quantified the ablated surface area after the application of cryoablation lesions with the second-generation cryoballoon. OBJECTIVE: The purpose of this study was to determine the area of ablation during cryoballoon PV isolation. METHODS: Preprocedural computed tomography angiography of the left atrium (LA) was conducted in 43 patients to accurately determine spatial chamber dimensions. Before and after the ablation procedure, a detailed 3-dimensional electroanatomic map of the LA was created and merged onto the computed tomography angiogram to improve the accuracy of the data recordings. RESULTS: The posterior LA wall had a mean surface area of 31.1 (±1.6 SEM) cm(2). Left- and right-sided antral PV surface areas of cryoballoon ablation were not statistically different (P = .935), which were 11.4 (±0.8 SEM) and 11.3 (±0.8 SEM) cm(2), respectively. In total, 27% of the posterior LA wall remained unablated, electrically functional, and homogeneous with regard to voltage conductivity. This ablation strategy resulted in 95.3% freedom from atrial fibrillation at 6 months. CONCLUSION: The area of the posterior LA wall ablation with the cryoballoon catheter is wide and antral, and the resulting posterior LA wall debulking could be a part of the cryoballoon efficacy beyond discrete PV isolation.