Integrated Atrial Flutter/Fibrillation Ablation, Left Atrial Appendage Occlusion, and Atrial Septal Defect Closure in a Post-Extracorporeal Membrane Oxygenation Heart Failure Patient

A one-stop strategy combining atrial fibrillation (AF) ablation and left atrial appendage occlusion (LAAO) has emerged as a feasible approach in selected high-risk patients. However, the integration of AF ablation, LAAO, and transcatheter closure of a large atrial septal defect (ASD) in a single session remains rarely described, particularly in patients with advanced heart failure (HF), recent critical illness, and limited tolerance to oral anticoagulation. A 73-year-old male with hypertension, chronic kidney disease, and acute decompensated HF developed severe urosepsis requiring veno-venous extracorporeal membrane oxygenation. Evaluation revealed a large secundum ASD with significant left-to-right shunting, biatrial enlargement, and right ventricular dysfunction. His course was complicated by recurrent AF and atypical atrial flutter (AFL), acute ischemic stroke, high bleeding risk and difficulty maintaining stable anticoagulation. After stabilization, a staged approach was considered; however, a single-session strategy was selected to avoid repeated anesthesia and prolonged ASD-related right-sided volume overload. Targeted flutter ablation and pulmonary vein isolation were performed first to stabilize rhythm, followed by left atrial appendage occlusion using the same left atrial access. Finally, transcatheter ASD closure was completed to reduce right-sided volume overload. Transient post-closure pulmonary congestion resolved with medical therapy. At 1 year, he remained in sinus rhythm without recurrent stroke, bleeding, or heart failure hospitalization. In carefully selected high-risk patients, a single-session strategy integrating AFL/AF ablation, LAAO, and ASD closure may be feasible, but its procedural benefits should be balanced against the risk of post-closure pulmonary congestion and the potential advantages of staged treatment.