2023 AF Symposium

Ablation Combines with LAA Closure in One Procedure

Walid Saliba, MD

Dr. Walid Saliba of the Cleveland Clinic Foundation in Cleveland, OH, discussed an innovative treatment for A-Fib patients―combining A-Fib ablation with the insertion of a Left Atrial Appendage (LAA) occlusion device in a combined procedure. (This treatment strategy is currently in use in many countries overseas, but isn’t yet common practice in the U.S.)

Patient Selection

Dr. Saliba explained how patient selection is important in this combined procedure.

The idea patient with atrial fibrillation needing an ablation would also have a high risk of stroke but couldn’t tolerate anticoagulants because of a high risk of bleeding.

Advantages of Combining PVI with LAA Closure

While these two procedures (A-Fib ablation and LAA closure) are typically done separately, combining them in one procedure has many potential advantages. Both procedures:

• require access from the groin to the left atrium

• initiating oral anticoagulation around the time of the procedure

Dr. Saliba made the following points:

1.Combining these two procedures reduces the risk of complications. (For example, one only has to make a transseptal puncture once rather than at two different times.)

2. Patients prefer only having to have one procedure rather than the hassle of going to the hospital twice for two different steps.

3. Combining these two procedures reduces the potential risk of bleeding.

Reimbursement Problem in U.S.

Dr. Saliba described how in the beginning (2015) it was difficult to be reimbursed for combining two different procedures at the same time. But eventually he was able to convince the powers that be that this was good for certain patients and actually saved the hospital money.

Source of A-Fib Recurrences

Dr. Natale and Dr. Saliba discussed that many A-Fib recurrences come from the Left Atrial Appendage. Inserting an LAA occlusion device when performing an ablation might prevent the mapping and ablating of non-PV triggers in or around the LAA. (This is less of a problem with the Watchman than with the Amulet device which actually masks off the LAA area with a metal disc.)

High Success, Low Complication

Dr. Saliba and his colleagues at the Cleveland Clinic have performed this combined procedure on more than 240 patients with one-year follow-up. Their success rate is high with low complications. Patients stayed in the hospital for a day.  Over 95% of their patients are eventually off of anticoagulants.

Half of their patients received the original Watchman, while the other half got the Watchman FlX. Leaks around the Watchman were only around 2.2% and were less than 2mm. At 90 days leaks were around 25% with less than 3mm. Dr. Saliba hasn’t noticed any problems with LAA remodeling, pressure, or scarring of the Left Atrium wall.

OPTION Trial Revelations to Come

The OPTION Trial is a clinical study of patients with non-valvular A-Fib. It compares outcomes of a combined ablation + LAA occlusion procedure versus catheter ablation alone followed with anticoagulation.

Specifically, the study is to determine if the WATCHMAN FLX occlusion device placed at the time of the ablation is a reasonable alternative to continuation of oral anticoagulation following catheter ablation. The results of this trial will be available in 2024.

Editor’s Comments

Combining PVI with LAA Closure Medical Breakthrough! Combining a catheter ablation for A-Fib (PVI) with the insertion of a Watchman occlusion device seems a major improvement for patients, as well as reducing or eliminating a major source of worry for electrophysiologists (EPs).

One day, hopefully soon, everyone getting a catheter ablation will also have an occlusion device inserted in one procedure.

Free from Most Stroke Risk: Inserting a Watchman device to close off the LAA has become a relatively simple and fast process. Combining it with a PVI doesn’t add much time to the ablation procedure. And Dr. Saliba’s research demonstrated that it works!

The Left Atrial Appendage (LAA) is where most clots and strokes come from in patients with non valvular A-Fib. Patients getting a catheter ablation generally leave the hospital A-Fib free.

Nevertheless, they are still considered at some risk of stroke. Current guidelines dictate continuation of stroke prevention with oral anticoagulation despite a successful ablation. Having the LAA closure device offers protection against stroke without the ongoing bleeding issues of oral anticoagulation.

Patients Would Choose/Prefer This Combination Procedure: If you offered the average A-Fib patient the chance to be protected from a stroke at the same time they are made A-Fib free by a catheter ablation, most patients would choose the combination procedure.

They would only have to be hospitalized once and wouldn’t have to return weeks later to have their LAA closed off, as is common practice in the U.S. today.

They would have better peace of mind and quality of life knowing they are largely protected from having an A-Fib stroke.

And their doctor wouldn’t have to worry about them going off their anticoagulant and developing a clot in their LAA.

If you find any errors on this page, email us. Y Last updated: Thursday, May 11, 2023

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