What is your opinion on concomitant atrial fibrillation ablation with left atrial appendage occlusion?

Highlights

• Implanting a left atrial appendage occlusion device upfront concedes defeat before the atrial fibrillation ablation has been performed.
• Upcoming trials may show that anticoagulation is not needed in patients with no AF recurrence, making concomitant LAAO unnecessary.
• The decision to implant a LAAO device should be deferred until after the ablation, specifically for select patients unable to take anticoagulation.

Expert Insights

A Cautious Approach to Concomitant LAAO

The strategy of performing left atrial appendage occlusion (LAAO) at the time of atrial fibrillation (AF) ablation is a topic of ongoing clinical discussion. This approach aims to provide a comprehensive, single-procedure solution for both rhythm control and stroke prevention. However, some electrophysiologists advocate for a more staged and patient-selective approach, questioning the upfront necessity of LAAO in all ablation candidates.

Questioning the Default Strategy

Dr. William Sauer, a specialist in cardiac electrophysiology, puts forth a strong argument against the routine concomitant procedure. He contends that implanting an LAAO device during an index ablation is tantamount to "conceding defeat up front." This perspective is rooted in the principle that a successful ablation may obviate the need for long-term anticoagulation, thereby making a simultaneously implanted LAAO device unnecessary for a subset of patients. The decision to occlude the appendage at the time of ablation presupposes that AF will recur or that the patient will require indefinite anticoagulation regardless of the ablation outcome.

"By implanting a left atrial appendage occlusion device (LAAO), we are conceding defeat up front." Dr. William Sauer

The Role of Emerging Evidence

Dr. Sauer points to emerging clinical trial data to support a more conservative, sequential strategy. He highlights that trials such as ALONE-AF, and likely the upcoming OCEAN trial, are positioned to demonstrate that anticoagulation may not be required for patients who show no evidence of AF recurrence following a successful ablation. This potential outcome challenges the fundamental rationale for performing a prophylactic LAAO in this population, suggesting that the primary indication for the device—stroke risk from AF—may be eliminated by the ablation itself.

A Proposed Sequential Pathway

Based on this clinical reasoning, Dr. Sauer recommends a more patient-centered, sequential treatment pathway. The initial focus should be on the success of the AF ablation. Following the procedure, patients should be monitored for AF recurrence. Only after assessing the long-term outcome of the ablation should LAAO be considered. In his view, the appropriate indication for LAAO in the post-ablation patient is reserved for a select group: those who are subsequently found to be unable to tolerate necessary anticoagulation, either due to AF recurrence or other clinical factors. This approach avoids an unnecessary intervention in patients who achieve long-term sinus rhythm.

"WE should wait for the results of the procedure and then consider implantation of LAAO devices in select patients who are unable to take anticoagulation." Dr. William Sauer