Combined catheter ablation for atrial fibrillation and Watchman® left atrial appendage occlusion procedures: Five‐year experience

Abstract

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.

Optimal combination strategy of left atrial appendage closure plus catheter ablation in a single procedure in patients with nonvalvular atrial fibrillation

“…The Watchman device did not interfere with a repeat ablation. Similar experience had been reported in other single‐ and multicenter studies . The 5‐year outcomes of combination therapy (LAAC with the Watchman device and CA for AF) also indicated the long‐term efficacy and safety .…”

“…Magnetic resonance imaging assessment of the LAA in an 8‐patient study indicated nonsignificant increase and decrease of LAA diameters and area within 48 hours of and 3 months post‐AF ablation, providing reassurance for concomitant AF CA and LAAC . In fact, the ablation‐first strategy was adopted in several combination studies with implantation of Watchman devices . However, acute and subacute radiofrequency tissue injury presenting as edema in this region might be a deterrent, causing peridevice leak.…”

“…In the ablation‐first group, LAAC was performed immediately after the ablation phase and TEE reevaluation as previously described …”

“…Patients with contraindications for chronic oral anticoagulation (OAC) could also benefit from LAAC . Recently, the efficacy and safety of the concomitant therapy of CA for AF symptom relief and LAAC for stroke prevention in a single procedure have been assessed . The advantages of the combined procedures are measurable; however, the optimal combination strategy has not been discussed.…”

Termination of anticoagulation therapy at 45 days after concomitant atrial fibrillation catheter ablation and left atrial appendage occlusion resulting in device-related thrombosis and stroke

“…Recently, some centers have begun to perform concomitant catheter ablation and WATCHMAN LAA occlusion 3, 4, 5, 6. This strategy has the benefit of providing treatment for symptomatic AF as well as stroke prevention without the need for long-term anticoagulation.…”