Catheter ablation for atrial fibrillation in patients with left atrial appendage closure devices.

Abstract

In this issue of HeartRhythm, Heeger et al present an interesting observational study of the feasibility of left atrial catheter ablation for the treatment of atrial fibrillation (AF) in patients with previous left atrial appendage (LAA) occlusion devices. As the authors point out, given the proximity of the mechanical device and ablation targets around the left pulmonary veins, ablation may conceivably be less successful and/or unsafe. The data they present are important (particularly because it includes a cautionary tale), well in keeping with this group’s history of excellent clinical research. Describing what we do from day to day is important, as the delivery of care is ever more complex and the combinations of therapies more intricate. Observational research provides a monitoring strategy for unintended consequences, which occur even after robust preclinical and clinical product development. This study involves 8 patients (mean age 69 8 years) with previous implantation of LAA occlusion devices (Watchman in 7 patients and Amplatzer in 1 patient) for standard indications: a high HAS-BLED score in 4 patients and previous severe anticoagulation associated bleeding (not further described) in 4 patients. All LAA occlusion procedures were performed by the Hamburg investigators and were successful, without implant complications. Standard postprocedure guideline-directed management of anticoagulation was prescribed. At a mean duration of 201 days after LAA occlusion (range 41–756 days), catheter ablation for the treatment of symptomatic drug refractory AF was performed; this represented a repeat procedure for 2 patients. A transesophageal echocardiogram (TEE) was performed in all patients, documenting optimal positioning of the occlusion device before the ablation procedure. Periprocedural anticoagulation was prescribed according to the institution’s usual care (bridging warfarin, reduced-dose target specific oral anticoagulant treatment after ablation, and heparin dosed to activated clotting time (ACT) 4 250 seconds during left