Combined atrial fibrillation ablation and left atrial appendage closure: Indications and approaches

Atrial fibrillation (AF) is associated with an increased burden of cardiovascular complications. Early rhythm control has demonstrated promising benefits in this context. Oral anticoagulation has significantly improved overall survival in AF patients by reducing thromboembolic events. However, several comorbidities are linked to an elevated risk of hemorrhagic complications. Left atrial percutaneous appendage closure (LAPAC) is emerging as a promising therapeutic strategy in this subgroup of patients. Interventional cardiologists are increasingly exploring a combined approach involving simultaneous AF ablation and LAPAC to harness the benefits of both procedures and potentially reduce the length of in-hospital stay. According to current literature, the periprocedural safety of combined procedures appears comparable to that of each procedure performed separately, although it is associated with increased hospitalization costs. Notably, the appropriate anticoagulation/antiaggregant therapy regimen following combined procedures remains a subject of ongoing debate. A minimum of 8 weeks of oral anticoagulation is mandatory following AF ablation, irrespective of the patient’s stroke risk or the energy modality used. Conversely, LAPAC should be offered only to patients with contraindications to long-term oral anticoagulation. In the early post-discharge period, no significant differences are observed between combined and isolated procedures. Over long-term follow-up, device thrombosis may occur, with its incidence seemingly unaffected by combined procedures. However, peri-device leaks tend to increase over time in patients undergoing combined procedures, with ridge edema related to radiofrequency delivery considered the primary cause of this phenomenon. New emerging energies (such as pulsed-field ablation) require further evaluation to determine long-term outcomes. According to published position papers, the combined strategy of AF ablation and LAPAC may be a reasonable therapeutic option in selected patients.