Volume 14, Issue 9, Pages 1319-1325 (September 2017) Verification of a novel atrial fibrillation cryoablation dosing algorithm guided by time-to- pulmonary vein isolation: Results from the Cryo-DOSING Study (Cryoballoon-ablation DOSING Based on the Assessment of Time-to-Effect and Pulmonary Vein Isolation Guidance)  Arash Aryana, MS, MD, FHRS, David N. Kenigsberg, MD, FHRS, Marcin Kowalski, MD, FHRS, Charles H. Koo, MD, Hae W. Lim, PhD, Padraig Gearoid O'Neill, MD, FHRS, Mark R. Bowers, MS, MD, Robert B. Hokanson, BA, Kenneth A. Ellenbogen, MD, FHRS  Heart Rhythm  Volume 14, Issue 9, Pages 1319-1325 (September 2017) DOI: 10.1016/j.hrthm.2017.06.020 Copyright © 2017 The Authors Terms and Conditions

Figure 1 The proposed cryoballoon ablation dosing protocol: The decision tree. Between 1 and 2 effective cryoapplications were delivered to each pulmonary vein (PV) during cryoablation of atrial fibrillation, based on the proposed dosing algorithm. A single cryoapplication was delivered to a PV if time-to-PV isolation (TT-PVI) measured ≤60 seconds (Route 1). The duration of this application consisted of TT-PVI + 2 minutes. If TT-PVI was >60 seconds but ≤90 seconds, then an additional (bonus) 2-minute application was delivered to the same PV (Route 2). However, if TT-PVI could not be achieved within 90 seconds, the cryoapplication was abandoned and the cryoballoon catheter repositioned to achieve a suitable TT-PVI. Lastly, if TT-PVI could not be measured at all, then an empiric 3-minute followed by a 2-minute cryoapplication was delivered to the PV (Route 3). It should be emphasized that PV isolation was always confirmed at the end of each arm of the algorithm by testing for entrance/exit block and after administration of intravenous adenosine. Heart Rhythm 2017 14, 1319-1325DOI: (10.1016/j.hrthm.2017.06.020) Copyright © 2017 The Authors Terms and Conditions

Figure 2 Kaplan-Meier estimates showing the cumulative freedom from all recurrent atrial arrhythmias after cryoballoon ablation of atrial fibrillation using the prespecified dosing protocol guided by time-to-pulmonary vein isolation (Cryo-AFDosing) vs the conventional, nonstandardized approach (Cryo-AFConventional). Freedom from all recurrent atrial arrhythmias did not differ between the 2 groups when compared by log-rank testing (P = .13). Heart Rhythm 2017 14, 1319-1325DOI: (10.1016/j.hrthm.2017.06.020) Copyright © 2017 The Authors Terms and Conditions