Long-term outcome of combined catheter ablation and left atrial appendage closure in atrial fibrillation patients

Highlights

• The safety of the combined procedure of catheter ablation and left atrial appendage closure was acceptable.

• Despite a longer fluoroscopy time, the fluoroscopy-guided process had lower risks of respiratory depression and a shorter procedure time and required less workers than the transesophageal echocardiography-guided process.

• Long-term event rates of the combined procedure were low, including mortality, thromboembolic events, and major bleeding events.

Abstract

Background

The combined procedure of catheter ablation and left atrial appendage closure (LAAC) aims to simultaneously control the heart rhythm and reduce the risk of strokes in patients with atrial fibrillation (AF). The study aims to evaluate the procedural safety and long-term outcome of the combined procedure in a large patient cohort.

Methods

Clinical data of AF patients who underwent the combined procedure was retrospectively analyzed. Procedural and imaging follow-up parameters were compared between the transesophageal echocardiography-guided standard process and fluoroscopy-guided modified process, and between the single-seal WATCHMAN and dual-seal LACBES devices. Long-term outcomes included all-cause mortality, thromboembolic events, major bleeding, and recurrence of atrial tachyarrhythmias.

Results

A total of 1114 patients were included. The rates of procedure-related major complications were comparable between the standard and modified processes (3.7% vs. 2.2%, p = 0.219), except for a higher incidence of respiratory depression in standard process group (0.9% vs 0%, p = 0.037), and between WATCHMAN and LACBES devices (2.4% vs. 3.3%, p = 0.535). The follow-up imaging evaluation revealed a high rate of satisfactory seals (99.7%) and a low rate of device related thrombus (1.9%), which were similar between two process groups and devices. The follow-up of over 1960 patient-years revealed low rates of mortality, thromboembolism, and nonprocedural major bleeding (1.8, 3.2, and 0.9 per 100 patient-years, respectively). Recurrent atrial tachyarrhythmias was observed in 23.9% patients.

Conclusions

The results supported the safety and long-term efficacy of the combined procedure of catheter ablation and LAAC. Fluoroscopy-guided LAAC device implantation may be considered in experienced centers.

Introduction

Rhythm control and stroke prophylaxis have been recognized as two major approaches in the comprehensive management of atrial fibrillation (AF) [1,2]. Catheter ablation is recommended for symptomatic AF patients to restore sinus rhythm and improve quality of life [1,[3], [4], [5]]. The “local” therapy of left atrial appendage (LAA) closure (LAAC) recapitulates the benefits in stroke prevention observed not only in randomized trials comparing with warfarin and non-vitamin K antagonist oral anticoagulants (NOAC) [[6], [7], [8]], but also in real-world practices [9,10]. The combined procedure of the two left atrial intervention, i.e., catheter ablation and LAAC, has been proposed to simultaneously control the heart rhythm and reduce the risk of strokes. Despite remaining controversial, previous studies have reported the safety and effectiveness of this combined procedure, although in small cohorts [[11], [12], [13]].

As one of the largest electrophysiological centers in China, our center has performed the combined procedure of radiofrequency catheter ablation and LAAC since 2017. In real world scenarios, approaches have varied for both procedural phases, which has raised concerns about procedural safety and long-term effectiveness. During the ablation phase, comprehensive and highly individualized approaches were applied according to the temporal patterns of AF, severity of atrial substrate and discretion of physicians. These ablation strategies included pulmonary vein isolation (PVI), extra-PV trigger elimination, various linear ablations, complex fractionated atrial electrogram (CFAE) modification, vein of Marshall (VOM) ethanol infusion, ganglionated plexi ablation, and posterior wall BOX and LAA electrical isolation, etc. During the subsequent LAAC phase, anesthetic modes, modalities of intraprocedural imaging guidance, and device types also varied. In this study, we report promising results regarding procedural safety, post-procedural imaging follow-ups, and long-term outcomes in 1114 AF patients treated with the combined procedure. In addition, this study evaluates the feasibility and safety of fluoroscopy-guided LAAC device implantation without transesophageal echocardiography (TEE) guidance and results of the LAAC device developed based on the dual-seal mechanism.