Impact of pre-existing left atrial appendage occluder on catheter ablation of atrial fibrillation

Jien‐Jiun Chen; Fu‐Chun Chiu; Sheng‐Nan Chang; Hsiao‐Liang Cheng; Pang‐Shuo Huang; Cho‐Kai Wu; Yi‐Chih Wang; Juey‐Jen Hwang; Chia‐Ti Tsai

doi:10.1136/heartjnl-2022-321934

February 7, 2023Heart

Impact of pre-existing left atrial appendage occluder on catheter ablation of atrial fibrillation

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Why the study?

Patients with drug-refractory AF and pre-existing LAAO devices may require PVI, but the impact of pre-existing LAAO on AF substrates and PVI outcomes remained unknown.

Does a pre-existing left atrial appendage occluder impact the feasibility, safety, and outcomes of pulmonary vein isolation in patients with drug-refractory atrial fibrillation?

Structured PICO

Does a pre-existing left atrial appendage occluder impact the feasibility, safety, and outcomes of pulmonary vein isolation in patients with drug-refractory atrial fibrillation?

P

Population

189 patients with drug-refractory atrial fibrillation (AF) undergoing pulmonary vein isolation (PVI), including 65 with a pre-existing left atrial appendage occluder (LAAO) and 124 without LAAO.

I

Intervention

Pulmonary vein isolation (PVI) in the presence of a pre-existing left atrial appendage occluder (LAAO)

C

Comparator

Pulmonary vein isolation (PVI) in patients without a pre-existing LAAO

O

Outcome

Feasibility of PVI, procedural stroke, and AF recurrence rate at 1 yearhard clinical

Pulmonary vein isolation is feasible in patients with a pre-existing LAAO, yielding similar 1-year AF recurrence rates as those without LAAO, although the device may modulate left atrial substrate and complicate left-sided isolation.

Implication

PVI feasible with pre-existing LAAO; leaves open substrate effects and needs randomized safety data.

Abstract

Background Patients with drug-refractory atrial fibrillation (AF) and pre-existing left atrial appendage occluder (LAAO) device may need pulmonary vein isolation (PVI). In this pioneer study, we investigated the impact of pre-existing LAAO on AF substrates and outcomes of PVI. Methods From our AF registry, 65 drug-refractory patients with LAAO (72.1±11.4 years old; CHA 2 DS 2 -VASc score 3.7±2.1) were included for PVI. A balanced control group with 124 patients without LAAO receiving PVI (70.9±10.2 years old, CHA 2 DS 2 -VASc 3.6±1.9) were included for comparison. Results We found PVI is feasible in patients with AF with pre-existing LAAO without new peridevice leak. Two patients with LAAO and one without LAAO had stroke during the procedure (2/65 vs 1/124, p=0.272). Complete isolation of left-sided PVs might not be achieved if the device covered the ridge joining the left atrial (LA) appendage to the body of LA. Local electrogram could be detected over LAAO and there was propagation of conduction over the occluder either under sinus rhythm or under atrial arrhythmia. LAAO might modulate LA substrate and induce peridevice fibrosis, peridevice LA flutter and complex fractionate atrial electrogram. The AF recurrent rate at 1 year was similar between the two groups (9.2% vs 8.8%). Conclusions This pioneer study first showed impacts of LAAO on LA substrate and PVI procedure.