Left atrial appendage occlusion in combination procedures - better together?

Introduction Left atrial appendage occlusion (LAAO) has been increasingly adopted as a strategy to prevent stroke in patients (pts) with atrial fibrillation (AF). In some situations, it may be conducted in combination with another cardiac procedure. Real-world data for this approach is limited. Purpose To evaluate the safety and efficacy of combining LAAO with other cardiac procedures (cLAAO). Methods Single-center retrospective study included consecutive pts who underwent LAAO from 2009 to early December 2024, either as an isolated procedure (iLAAO) or in combination with another cardiac intervention. Groups were adjusted for CHA2DS2-VASc and HAS-BLED scores. Safety was defined as any acute complication and freedom from bleeding events during follow-up (FUP). Efficacy was assessed by freedom from thromboembolic events. Kaplan-Meier survival analysis was used for comparison outcomes. Results Among 215 pts undergoing LAAO, 46 underwent cLAAO (57% male, age 75±20 years, mean CHA2DS2-VASc 2.6±1.2, HAS-BLED 3.16±1). Indication for LAAO was similar in both groups - high bleeding risk/OAC intolerance in 80%, followed by ischemic events despite OAC in 10%. LAAO was combined with TAVI (37%), AF ablation (33%), and percutaneous mitral interventions (22%) and was the initial procedure in only 3 cases. Implanted devices were Watchman (56%), Watchman Flx (35%), and Amulet (9%). Acute complications were more frequent with cLAAO. There were 4 cases of cardiac tamponade (3 with Watchman first gen devices and 1 with the Amulet device), 3 of which in cLAAO. All tamponades were promptly managed percutaneously and occurred during the early years of LAAO (before May 2015). There was one case of major vascular complication in cLAAO and 3 cases of minor vascular complications in iLAAO. 51% of pts were discharged on dual antiplatelet therapy, 28% on NOACs, 14% on VKAs with aspirin, and 7% on aspirin alone, similar between groups. Over a mean FUP of 4 years, hemorrhagic and ischemic event rates were comparable (cLAAO:8(%) vs iLAAO:23(%) Long rank p=0.8, cLAAO:3(%) vs iLAAO: 2(%) Long rank p=0.9) in both groups. Conclusion Combining LAAO with another cardiac was associated with increased intra-procedural complication rates, but only in the first years of the technique and with first generation devices. Regarding long term outcomes, cLAAO had similar safety and efficacy when compared with iLAAO. cLAAO should be performed by experienced operators in high-volume centers, in order to ensure low complication rates.