Simultaneous appendage ligation and atrial ablation – is it worth the risk?

Abstract

Electrical isolation of pulmonary veins remains the mainstay for the treatment of atrial fibrillation (AF). Optimal ablation lesion set in persistent AF and long-standing persistent AF remains unknown and failed to demonstrate superiority beyond stand-alone pulmonary vein isolation (PVI) [1]. Left atrial appendage (LAA) has been increasingly recognized as an important source of non-PV triggers and reentry [2,3]. Hence, electrical isolation of LAA as an adjunct to PVI may significantly decrease the recurrence of AF [4]. However, the procedural complexity, potential risk of perforation, significant (>50%) reconnection rates, and systemic thromboembolism after LAA isolation remain a critical concern [5e7]. Electrical isolation of LAA impairs its mechanical contractility e increases blood stasis and risk of thrombus formation (above and beyond stand-alone PVI with electrically intact LAA). This increases LAA thrombus risk and systemic embolization despite continued oral anticoagulation in some cases and demands uninterrupted oral anticoagulation, possibly occlusion for stroke protection despite successful AF rhythm control after an ablation. A strategy of sequential LAA ligation followed by PVI has shown to improve ablation outcomes, and a randomized control trial has recently been completed with results pending [8,9]. Sequential LAA ligation and ablation during two separate procedures has been the common strategy, however, simultaneous LAA ligation and ablation during the same procedure has not been studied. In this issue of Indian Pacing and Electrophysiology, Nentwich et al. report safety and long-term outcomes of concomitant AF ablationwith LAA ligationwith endoepicardial system (Lariat device) in a single procedure in a very small cohort [10]. Nine patients (mean age 67± 10 years, normal left ventricular systolic function, mean CHA2DS2VASc 4± 1.1 and HAS-BLED score 2.1± 0.78) with longstanding persistent AF underwent PVI and additional ablation (at operator discretion based on high-density bipolar voltage map) and concomitant Lariat device (LAA ligation) at high volume highly trained center in Europe. The study demonstrated 100% acute procedure success in LAA ligationwith no intraprocedural LAA flow on transesophageal echocardiogram. There were no major acute procedural complications. All patients received three months of oral anticoagulation and six weeks of colchicine. 33% (n1⁄4 3) patients experienced major complications e non-disabling stroke (deemed not procedure-related and with no flow across LAA at 14 weeks), dressler s syndrome, and pericardial tamponade (due to prolonged pericardial inflammation, requiring pericardiocentesis). At 12 months follow-up, a transesophageal echocardiogram demonstrated no flow across in LAA in all patients, with arrhythmia-free