Impact of acute rhythm restoration strategy on atrial fibrillation recurrence after cryoballoon ablation: a real-world cohort study

Acute rhythm restoration after cryoballoon ablation may reflect underlying atrial substrate; however, its independent prognostic value for atrial fibrillation (AF) recurrence remains uncertain. To evaluate the association between acute rhythm restoration strategy and echocardiographic parameters with AF recurrence after cryoballoon ablation in a real-world cohort. This retrospective single-center cohort included 395 consecutive patients undergoing first-time cryoballoon ablation. AF recurrence was defined as any atrial tachyarrhythmia occurring after a 3-month blanking period. Multivariable logistic regression and Cox proportional hazards analyses were performed to assess independent predictors. During a median follow-up of 12 months, AF recurrence occurred in 23.9% of patients. In univariable analyses, successful sinus rhythm restoration after standard direct current cardioversion (DCCV) was associated with lower recurrence (p = 0.002); however, this association was not maintained after multivariable adjustment (OR 0.547, 95% CI 0.252–1.184, p = 0.126). Left atrial diameter (LAD) demonstrated a borderline association with AF recurrence (OR 1.064 per mm increase, 95% CI 0.997–1.137, p = 0.063) and showed moderate discriminative ability (AUC 0.692; optimal cut-off ≈43.5 mm). In multivariable Cox regression analysis, none of the examined variables were independently associated with time-to-recurrence. Acute cardioversion success was associated with recurrence in univariable analyses but was not independently predictive after multivariable adjustment. Left atrial diameter provided moderate but limited discrimination, supporting pragmatic risk stratification rather than a standalone predictor. These findings suggest that cardioversion success reflects the underlying atrial substrate rather than exerting a causal effect on long-term outcomes.