Targeted Superior Vena Cava Isolation Combined With Pulmonary Vein Isolation Versus Pulmonary Vein Isolation Alone Using Cryoballoon Ablation for Atrial Fibrillation.

BACKGROUND: The superior vena cava (SVC) is a common non-pulmonary vein (non-PV) trigger site in atrial fibrillation (AF), but its triggers are frequently underdetected without systematic mapping and provocation maneuvers. This study aimed to assess the temporal trend in SVC trigger detection rates and compare the efficacy and safety of cryoballoon-based targeted SVC isolation combined with pulmonary vein isolation (PVI) versus PVI alone. METHODS: A retrospective analysis was conducted on 990 consecutive patients who underwent cryoballoon ablation for AF between January 2020 and December 2024. Annual SVC trigger detection rates were assessed using the Cochran-Armitage trend test. After excluding redo cases and performing 1:1 propensity score matching, 55 matched pairs were compared in terms of procedural outcomes, complications, and 12-month freedom from atrial tachyarrhythmias. RESULTS: SVC trigger detection rates increased significantly over the study period, from 6.8% in 2020 to 21.3% in 2024 (P for trend = 0.023). After matching, the PVI + SVCI group showed significantly higher 12-month freedom from atrial tachyarrhythmias compared to the PVI-only group (90.9% vs. 76.4%, p = 0.037). Procedural time was modestly longer in the PVI + SVCI group (93 ± 26 min vs. 80 ± 20 min, p = 0.003), but fluoroscopy time (12 ± 5 min vs. 10 ± 4 min, p = 0.276) and complication rates (5.5% vs. 3.6%, p = 0.500) were comparable between groups, both with low overall complication rates. CONCLUSION: Cryoballoon-based targeted SVC isolation guided by systematic mapping and provocation maneuvers significantly enhances freedom from atrial tachyarrhythmias without compromising safety.