BackgroundPatients with atrial fibrillation (AF) may benefit from undergoing concomitant interventions of left atrial catheter ablation and device occlusion of the left atrial appendage (LAA) as a two-pronged strategy for rhythm control and stroke prevention. We report on the outcome of combined procedures in a single center case series over a 5-year timeframe.MethodsNinety-eight patients with non-valvular AF and a mean CHA2DS2-VASc score 2.6±1.0 underwent either first time, or redo pulmonary vein isolation (PVI) procedures, followed by successful implant of a Watchman® device.ResultsAll procedures were generally uncomplicated with a mean case time of 213±40 min. Complete LAA occlusion was achieved at initial implant in 92 (94%) patients. Satisfactory LAA occlusion was achieved in 100% of patients at 12 months, with a complete LAA occlusion rate of 86%. All patients discontinued oral anticoagulation. Persistent late peri-device leaks were more frequently associated with device angulation or shoulder protrusion, and were associated with a significantly lower achieved device compression of 12±3% vs. 15±5% (p<0.01) than complete occlusion. One ischemic stroke was recorded over a mean follow-up time of 802±439 days. Twelve months׳ freedom from detectable AF was achieved in 77% of patients.ConclusionsCombined procedures of catheter ablation for AF and Watchman® LAA implant appear to be feasible and safe, with excellent rates of LAA occlusion achieved and an observed stroke rate of 0.5% per year during mid-term follow-up. Incomplete occlusion was associated with lower achieved device compression and was more frequently associated with suboptimal device position.

EVIDENCE-BASED PRACTICEG adolinium-based contrast agents (GBCAs) have been used clinically for decades and have an excellent safety record (1-3). Immediate hypersensitivity reactions to GB-CAs remain uncommon, estimated by meta-analysis to be approximately nine per 10 000 administrations, with severe reactions occurring in approximately five per 100 000 administrations (4). Limited studies have evaluated repeat GBCA administration in patients with a prior hypersensitivity reaction to a GBCA. The efficacy of corticosteroid premedication with or without antihistamines prior to repeat GBCA exposure remains unproven. Although commonly performed in clinical practice, the rationale for premedication prior to repeat GBCA administration is extrapolated from studies evaluating iodinated contrast media (5). Breakthrough reactions are immediate hypersensitivity reactions occurring despite appropriately dosed corticosteroid premedication. These reactions occur in up to one-third of patients in individual series that have studied GBCAs (6-8). Breakthrough reactions to GBCAs usually occur with the same severity as the original or index reaction, but escalation of breakthrough reaction severity to a GBCA has been reported (6-8). In patients with a prior severe hypersensitivity reaction to a GBCA, re-exposure to a GBCA (even with corticosteroid premedication) is contraindicated by the American College of Radiology (ACR) (9).

Left atrial catheter ablation therapy in the presence of an implanted Watchman® left atrial appendage occlusion device was efficacious and uncomplicated in our small single centre experience.

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