Combined Left Atrial Appendage Closure and Pulmonary Vein Re-Isolation in Very-High Stroke-Risk Patients.

BACKGROUND

The optimal strategy remains undefined in non-valvular atrial fibrillation (NVAF) patients at very-high stroke risk who show no documented AF recurrence on routine follow-up after catheter ablation (CA) but cannot continue long-term anticoagulation.

OBJECTIVE

To describe the feasibility, procedural safety, and clinical outcomes of a combined approach involving left atrial appendage closure (LAAC) with pulmonary vein (PV) remapping and re-isolation when reconnection was present in this selected real-world population.

METHODS

In this prospective study, we enrolled NVAF patients with prior stroke who had no documented AF recurrence on routine surveillance after CA, but declined or were intolerant to long-term anticoagulation. All participants underwent LAAC with concurrent electrophysiological remapping/re-isolation of reconnected PVs. Primary endpoints included thromboembolic (TE) events, bleeding, all-cause mortality, and AF recurrences. Secondary endpoints covered periprocedural complications, peridevice leak (PDL), and device-related thrombus (DRT), evaluated via short-term imaging follow-up.

RESULTS

43 patients (median CHA2DS2-VASc score of 5.0 [IQR 4.0-6.0]) were included. The mean interval from CA to LAAC was 242.3 ± 175.7 days. Procedural success was 95.3%. Implanted devices included Watchman 2.5 (75.6%), Watchman FLX (9.8%), Watchman FLX Pro (2.4%) and LACBES (12.2%). One periprocedural tamponade occurred (2.4%). Over a median follow-up of 775 days, thromboembolic events occurred in 4.9% and bleeding in 9.8%. Device-related thrombus and peridevice leak were observed in 5.3% and 7.9%. PV reconnection was detected in 31.7% of patients, all successfully re-ablated, leading to 92.7% freedom from AF recurrence.

CONCLUSION

In this selected single-center cohort, combined LAAC with PV remapping and re-isolation when indicated was feasible and associated with acceptable procedural outcomes. However, because of the single-arm design, small sample size, and intermittent rhythm surveillance, the incremental clinical benefit of this combined strategy requires confirmation in larger controlled studies.