2026 AF Symposium

Live Case Transmission—Combining Pulmonary Vein Ablation with Installation of Watchman Device (Concomitant Ablation)

Concomitant ablation, combining Pulmonary Vein Ablation with installing a Watchman occlusion device in the Left Atrial Appendage (LAA) in one procedure was once considered innovative or somewhat unusual. Well, it’s no longer so. Instead, at many A-Fib centers it’s a standardized or normal practice. At this year’s AF Symposium, I counted 9 sessions and/or cases dealing with concomitant ablation.

Dr. David Weisman

Dr. David Weisman (Jupiter Medical Center Physicians Group, Jupiter, FL) gave a practical live case transmission of how he performs a concomitant ablation, “Concomitant PVI and LAA Closure Using Nuvision 4D ICE.”

Patient A-Fib History: Very Symptomatic, Multiple Falls

His patient was a 76-year-old woman with very symptomatic paroxysmal A-Fib who had failed multiple antiarrhythmic drug therapies. She was on amiodarone but still had A-Fib episodes. She had suffered multiple physical falls and used an assisted walking device. She has had orthopedic injuries including a recent rib fracture. She had hypertension, sleep apnea and obesity. Otherwise, her labs were normal.

The HAS-BLED score estimates 1-year major bleeding risk for A-Fib patients on anticoagulation; a score of 3 or higher indicating high risk.

Her CHA2DS2-VASc score was 4, her HAS-BLED score was 2. In her case, Dr. Weisman was looking for an alternative to oral anticoagulation.

That is why they were now doing a left atrial appendage closure (LAAC) with a Watchman device in the same procedure as the catheter ablation.

ICE Ultrasound Catheter for Ablation

Stock image from Nuvision 4D Intracardiac Echocardiography (ICE)

When the AF Symposium attendees joined the live transmission from Dr. Weisman’s EP lab in Florida, he had already completed isolating three of the four pulmonary veins (PVs) and was in the process of working on the left upper PV.

He used a Nuvision 4D Intracardiac Echocardiography (ICE) ultrasound catheter (Johnson & Johnson Med Tech) which has a 360-degree rotating tip. It produces multi-planar visualization in color and 4D imaging with 90° by 90° views. The 4D color images seemed remarkably vivid and seemed to greatly facilitate the ablation.

4D color imaging (4D Flow MRI): A sophisticated, real-time diagnostic technique that adds the dimension of time to 3D ultrasound images, creating a “live-motion” video of the heart and internal structures.

Installing the Watchman After the Pulmonary Vein Isolation

Before every concomitant ablation, Dr. Weisman said he makes a CT Scan (Computed Tomography) to pre-image the Left Atrial Appendage (LAA) to guide his procedure.

When Dr. Weisman finished the Pulmonary Vein Isolation (PVI), he simply changed the catheter sheaths to install the Watchman occlusion device in the Left Atrial Appendage. He used a deflectable sheath to manipulate and position the ICE catheter in the left atrium.

Dr. Weisman stated that one of the advantages of using 4D Nuvision visualization was no need for fluoroscopy, except for special circumstances.

Sizing the Watchman

The patient’s LAA had a chicken wing anatomy. After measuring the LAA, he installed a 24mm Watchman.

There was a lot of discussion on the size among the Symposium participants. Some recommended oversizing it to 27mm for better compression.

Dr. Weisman achieved 15–18% compression with the 24mm Watchman. After installing, he checked for leaks using color flow doppler. There were none.

Typical Patient Follow–Up

This patient will be followed up for 45 days. Typically, after 6–12 weeks a transesophageal echocardiogram (TEE) is performed. (Longer follow up times with some patients were often not possible because many do not reside full-time near Dr. Weisman’s practice in Florida.)

About 4D Color Imaging

Dr. Weisman said that 4D color imaging with the Echocardiography (ICE) was more cost effective than a transesophageal echocardiogram (TEE), and that procedure times were shorter. Efficiency was better, and less experience was required.

Editor’s Comments

Perfect Candidate for Concomitant Ablation: Dr. Weisman couldn’t have picked a better candidate for a Concomitant Ablation. She obviously needed a PVI to stop her A-Fib and get her back into normal sinus rhythm. And her frequent falling made her at risk of major bleeding due to taking anticoagulants. The Watchman addressed this. A Concomitant Ablation handled both issues in one procedure.

Stock image ACUSON AcuNav Volume 4D ICE Catheter

4-D Color Imaging Huge Improvement: 4D color imaging seems a striking improvement over current visualization systems. The images seem to jump out at you and are remarkably vivid.

In addition, they will probably reduce or eliminate the need for fluoroscopy, thereby eliminating the need for operators to wear those heavy lead vests during ablations.

Concomitant Ablation Easy to Do: It seemed relatively easy for Dr. Weisman to move from doing a PVI to installing a Watchman occlusion device. Aside from switching sheaths, the Watchman procedure was the same as when performed separately.

What This Means For Patients: Concomitant Ablation, combining a PVI with installation of a Watchman, is feasible, practical, and here to stay.

Don’t Settle for Less. If your doctor wants you to do two separate procedures, get a second opinion to ask about getting them done at the same time.

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