Combined Left Atrial Appendage Closure and Pulmonary Vein Re‐Isolation in Very‐High Stroke‐Risk Patients

BACKGROUND: The optimal strategy remains undefined in non-valvular atrial fibrillation (NVAF) patients at very-high stroke risk who show no documented AF recurrence on routine follow-up after catheter ablation (CA) but cannot continue long-term anticoagulation. OBJECTIVE: To describe the feasibility, procedural safety, and clinical outcomes of a combined approach involving left atrial appendage closure (LAAC) with pulmonary vein (PV) remapping and re-isolation when reconnection was present in this selected real-world population. METHODS: In this prospective study, we enrolled NVAF patients with prior stroke who had no documented AF recurrence on routine surveillance after CA, but declined or were intolerant to long-term anticoagulation. All participants underwent LAAC with concurrent electrophysiological remapping/re-isolation of reconnected PVs. Primary endpoints included thromboembolic (TE) events, bleeding, all-cause mortality, and AF recurrences. Secondary endpoints covered periprocedural complications, peridevice leak (PDL), and device-related thrombus (DRT), evaluated via short-term imaging follow-up. RESULTS: 43 patients (median CHA2DS2-VASc score of 5.0 [IQR 4.0-6.0]) were included. The mean interval from CA to LAAC was 242.3 ± 175.7 days. Procedural success was 95.3%. Implanted devices included Watchman 2.5 (75.6%), Watchman FLX (9.8%), Watchman FLX Pro (2.4%) and LACBES (12.2%). One periprocedural tamponade occurred (2.4%). Over a median follow-up of 775 days, thromboembolic events occurred in 4.9% and bleeding in 9.8%. Device-related thrombus and peridevice leak were observed in 5.3% and 7.9%. PV reconnection was detected in 31.7% of patients, all successfully re-ablated, leading to 92.7% freedom from AF recurrence. CONCLUSION: In this selected single-center cohort, combined LAAC with PV remapping and re-isolation when indicated was feasible and associated with acceptable procedural outcomes. However, because of the single-arm design, small sample size, and intermittent rhythm surveillance, the incremental clinical benefit of this combined strategy requires confirmation in larger controlled studies.