Silent veins during cryoballoon ablation of atrial fibrillation as a novel and independent predictor of long-term outcome: results from the Middelheim-PVI Registry 2

Background: The absence of pulmonary vein potential (PVP) recordings by the Achieve catheter occurs in 15% to 40% of the veins during cryoballoon ablation (CBA) of atrial fibrillation (AF). The long-term clinical implications of this absence of PVP during CBA are yet unknown. Aim: To determine whether the absence of PVP recording (silent vein) by the Achieve catheter is predictive of long-term clinical outcome. Methods and results: Out of 1,000 consecutive AF patients (mean age of 64 ± 10 years, 68% males) undergoing cryoballoon PVI (2017–2019) followed for 3 years, 803 had sufficient biophysical data for analysis. Primary outcome was clinical success, defined as freedom of documented AF without anti-arrhythmic drugs. At 3 years, clinical success was achieved in 65.3% of patients. Presence of PVP in all veins (no silent veins) was seen in 252 patients (31.4%), presence of 1 silent vein in 255 (31.8%), 2 silent veins in 159 (19.8%) and 3–4 in 137 (17.1%). Independent predictors of clinical success were persistent AF type (HR 2.05, 95%CI 1.57–2.68; p