One-Stop Strategy for Treatment of Atrial Fibrillation: Feasibility and Safety of Combining Catheter Ablation and Left Atrial Appendage Closure in a Single Procedure
Introduction
Atrial fibrillation (AF) is a common cardiac arrhythmia associated with increased risks of stroke, heart failure, and mortality. Catheter ablation has emerged as an effective treatment for restoring sinus rhythm and improving quality of life in patients with AF. However, AF ablation alone has limited long-term preventive effects on stroke and systemic embolism, necessitating post-ablation anticoagulation in patients with high stroke risks. Unfortunately, many patients cannot tolerate long-term oral anticoagulation (OAC) due to high bleeding risks or personal preferences. In such cases, left atrial appendage closure (LAAC) has become an acceptable non-pharmacologic approach for stroke prevention in non-valvular AF patients.
The concept of combining catheter ablation for AF and LAAC in a single procedure, known as the “one-stop” strategy, has gained increasing attention. This approach is based on shared operative techniques, including femoral venous catheterization, trans-septal puncture, and perioperative management. While previous studies have reported promising results, limited data exists on the Chinese population. This study aimed to evaluate the feasibility and safety of the one-stop procedure in Chinese AF patients.
Methods
This prospective study enrolled 178 consecutive Chinese patients with symptomatic drug-refractory AF who underwent the combined procedure of AF ablation and LAAC with the WATCHMAN device between March 2017 and September 2018. Inclusion criteria included: (1) paroxysmal or persistent AF with electrocardiogram evidence; (2) age between 18 and 85 years; (3) contraindications or unwillingness to receive long-term OACs; and (4) signed informed consent. Patients with severe valvular heart diseases and hyperthyroidism were excluded.
The one-stop procedure involved successive catheter ablation of AF followed by LAAC. Pulmonary vein isolation (PVI) was performed in all patients, with additional linear ablation if deemed necessary by the operator. The CARTO or ENSITE electro-anatomical mapping systems were used for left atrial reconstruction and guidance of AF ablation, employing near-zero fluoroscopy approaches. LAAC was performed using the WATCHMAN device, with device size selection based on LAA angiography. The device was released only if the PASS (Position-Anchor-Size-Seal) principle was fulfilled.
Patients were followed up at 3 months post-procedure, with additional 1-year follow-up for earlier-enrolled subjects. Follow-up assessments included Holter monitoring, electrocardiogram, N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels, transthoracic echocardiography (TTE), and transesophageal echocardiography (TEE) or cardiac CT for detection of peri-device leak and device-related thrombus.
Results
The study population consisted of 178 AF patients (94 males, 84 females) with a mean age of 68.9 ± 8.1 years. The mean CHA2DS2-VASc score was 3.3 ± 1.5, and the mean HAS-BLED score was 1.6 ± 1.0. Persistent AF was present in 50.6% of patients. Prior to admission, 43.8% of patients were on anticoagulation, 20.2% on antiplatelet therapy, and 36.0% were not on any antithrombotic medication.
Procedural success was achieved in all patients, with immediate conversion to sinus rhythm in 176 patients (98.9%). Satisfactory LAA seal (residual leak <5 mm) was achieved in all patients, with a median of one device used per procedure. The most frequently selected device size was 27 mm (34.8%), and the most common LAA morphology was cauliflower (78.1%).
Perioperative complications included one stroke (0.6%) and four cardiac perforations (2.2%), all of which were managed appropriately. No peri-procedural coronary air embolism, device embolization, or death occurred.
At 3-month follow-up, sinus rhythm was maintained in 153 patients (86.0%). TEE found no major peri-device leaks (>5 mm) and eight minimal residual leaks (<5 mm). One stroke and one delayed cardiac tamponade occurred during this period. No device-related thrombus or prominent device migration was observed.
For the 72 patients who completed 1-year follow-up, sinus rhythm was maintained in 52 patients (72.2%). Redo ablation was performed in six patients with uncontrolled recurrent AF. One gastrointestinal bleeding event occurred on aspirin therapy. No stroke or other procedure-related complications were observed during the 1-year follow-up.
Cardiac remodeling was assessed through NT-proBNP levels and echocardiographic parameters. NT-proBNP levels were significantly reduced at both 3-month and 1-year follow-up compared to baseline. However, no significant differences were observed in echocardiographic parameters, including left ventricular ejection fraction, left atrial diameter, and left ventricular end-diastolic and end-systolic diameters.
Discussion
The one-stop strategy of combining catheter ablation and LAAC in a single procedure was successfully and safely performed in this Chinese AF patient population. The low complication rates and high success rates were comparable to those reported in previous studies, suggesting no additional peri-procedural risks induced by the combined strategy.
The timing of the procedures, with LAAC performed after catheter ablation, was chosen to avoid potential challenges in catheter manipulation and tissue contact near the device. This sequence also ensures access to arrhythmogenic foci within or at the base of the LAA. While some studies have reported similar outcomes regardless of the order of procedures, performing ablation prior to LAAC is recommended based on the current evidence.
The predominant LAA morphology in this Chinese population was cauliflower type (78.1%), which contrasts with findings from Western populations where chicken wing type is more common. This difference may be attributed to racial variations or selection bias and warrants further investigation.
The one-stop strategy offers several potential advantages, including reduced hospitalization costs and shorter hospital stays compared to performing the procedures separately. It may be particularly beneficial for AF patients at high stroke risks who are intolerant or unwilling to receive long-term anticoagulation.
Limitations of this study include the use of only the WATCHMAN device, the single-center observational design, and the lack of long-term follow-up data. Future studies should address these limitations and provide more comprehensive evidence on the effectiveness and safety of the one-stop strategy.
Conclusion
The one-stop strategy of combining catheter ablation and LAAC for AF treatment is feasible and safe in the Chinese population. This approach offers a comprehensive treatment option for AF patients who are at high stroke risks and intolerant or unwilling to receive long-term anticoagulation. The procedure demonstrates favorable short- and intermediate-term outcomes, with low complication rates and high success rates. Further research is needed to evaluate long-term outcomes and compare the one-stop strategy with separate procedures.
doi.org/10.1097/CM9.0000000000000855
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