Tom De Potter

Pulsed field ablation (PFA) and left atrial appendage closure (LAAC) are increasingly discussed as complementary strategies in atrial fibrillation (AF) care, addressing rhythm control and long-term thromboembolic risk. The rationale is attractive, but the current evidence base is uneven. Randomized evidence for LAAC around AF ablation is strongest for thermal-ablation-era workflows, particularly the OPTION trial, which showed lower non-procedure-related major or clinically relevant non-major bleeding with LAAC than with oral anticoagulation (OAC) and non-inferiority for death, stroke, or systemic embolism. Dedicated PFA-specific evidence remains limited to feasibility studies and early observational experience, and no trial has demonstrated that combined ablation-LAAC procedures are clinically superior when the ablation component is performed with PFA rather than radiofrequency or cryoballoon ablation. In parallel, OAC-withdrawal trials after apparently successful ablation, including OCEAN and ALONE-AF, have reported low thromboembolic event rates in selected lower-risk populations, whereas CLOSURE-AF cautions against simple extrapolation of LAAC benefit to older, frailer patients at high stroke and bleeding risk. This review therefore positions combined PFA-LAAC as a potential option for carefully selected patients rather than an established routine strategy. We summarize procedural workflow, patient selection, trial populations, device-platform considerations, reimbursement and organizational issues, and the main uncertainties that should guide future prospective studies.

Aims: Patients with left atrial appendage (LAAO) devices are increasingly referred for atrial fibrillation (AF) ablation, yet anticoagulation strategies remain uncertain. The goal of this study was to evaluate the safety and efficacy of catheter ablation for AF in patients with pre-existing LAAO devices and to describe patterns in anticoagulation management after ablation in this unique population. Methods and results: We collected data from 14 centres worldwide on patients with prior LAAO devices undergoing AF ablation. Each site provided clinical characteristics, procedural details, and information on complications and arrhythmia outcomes. Data were aggregated and analysed centrally to evaluate procedural safety, efficacy, and variability in management strategies. A total of 198 patients (age 70 years, 37% female, 42% paroxysmal AF) with prior LAAO were included. Ablation was performed a median of 271 days after LAAO. After ablation, 84% of patients were on oral anticoagulation (OAC), most commonly for 2–3 months. Bleeding complications on OAC occurred in 6.7% of patients at a median of 20 (13, 70) days after ablation. Stroke or TIA occurred in five patients (2.6% of cases) within the follow-up period with two occurrences (1% of cases) the day after ablation. There were two cases of new or worsened peri-device leak after ablation. Conclusion: In a large, international registry of patients undergoing catheter ablation for AF with pre-existing LAAO devices, ablation was feasible, and device related complications were rare. Despite higher bleeding risk in an LAAO population, 84% of patients with prior LAAO tolerated short-term OAC post-ablation with bleeding events at expected rates for this population.

Aims: Atrial fibrillation (AF) ablation by pulmonary vein isolation (PVI) and left atrial appendage closure (LAAC) are increasingly performed as standalone procedures. Given that PVI and LAAC share the same access route, a combined approach of pulsed field ablation (PFA)-based PVI and LAAC might be beneficial. The COCONUT study focused on safety, efficacy, and outcomes combining PVI by PFA with LAAC in one procedure. Methods: This is a retrospective, multinational registry study. The primary endpoints were the following: (1) primary safety endpoint: serious adverse events; and (2) primary efficacy endpoint: success of PVI and LAA closure defined as the ability to isolate all pulmonary veins and the successful closure of the LAA. For secondary endpoints, peri-procedural data and follow-up data were collected. Results: A total of 155 patients from 22 centres of nine European countries were treated by concomitant pentaspline catheter PFA-based PVI and LAAC. The mean CHA2DS2-VA score was 3.1 ± 1.4. The primary efficacy endpoint was achieved at 97.4% with successful PVI at 100% and successful LAAC in 151/155 patients (97.4%). The primary safety endpoint was observed in 3/155 patients (1.9%). Transoesophageal echocardiography and/or CCTA 67 ± 26 days after the procedure showed no device embolization and no device-related thrombus, 24/151 (15.9%) patients showed peri-device gaps of 5 mm have been observed in 3/151 (2.0%). Among 137/155 patients with available arrhythmia, a follow-up >6 months at 78.1% showed sinus rhythm. Conclusion: In this large multicentre study, concomitant PFA-based AF ablation and LAA closure proved to be feasible, effective, and safe and overall procedure duration was short.

Aims: Atrial fibrillation (AF) is highly prevalent among cardiac amyloidosis (CA) patients and contributes significantly to their morbidity and mortality. Evidence regarding AF ablation efficacy and safety in CA patients remains limited. The aim of our study is to evaluate baseline characteristics, clinical course and outcomes of AF ablation in a series of patients with transthyretin (ATTR) or light-chain (AL) CA from a multicentre international registry. Methods and results: Patients with CA who underwent AF ablation were included. Co-primary endpoints were: (i) atrial arrhythmia (AA) recurrence; (ii) a composite endpoint of all-cause mortality and heart failure hospitalization (HFH). 109 patients (mean age 72.4 ± 7.4 years, females 17.4%, persistent AF 64.2%, ATTR 78%, AL 22%) were included. Radiofrequency, cryo-balloon and pulsed-field ablation were performed in 67%, 15% and 18% of patients, respectively; 49.5% received pulmonary vein isolation plus additional ablations. Low voltage zones were documented in 34 out of 44 patients undergoing electro-anatomical mapping (77.3%). During a median follow-up of 22.7 months, 63 patients (58.3%) experienced AA recurrence (32.4% persistent AF recurrence), with no significant differences between CA subtypes (ATTR 59.5% vs. AL 54.2%, log-rank P = 0.55). The composite endpoint of HFH and all-cause death occurred in 27 patients (25%). Recurrence of persistent AF was associated with three-fold higher risk (OR 2.9, P = 0.02) of the composite endpoint. Conclusion: CA patients undergoing AF ablation present high prevalence of persistent AF. Freedom from AA after AF ablation is achieved in 42% of patients after a two-year follow-up. Patients with persistent AF recurrence have a three-fold higher risk of HFH and death.

Same-day discharge (SDD) following electrophysiology (EP) and cardiac implantable electronic device (CIED) procedures has emerged as a contemporary care model driven by improvements in procedural safety, efficiency, and healthcare resource constraints. Despite growing evidence supporting its safety in selected patients, adoption of SDD across Europe remains heterogeneous. This clinical consensus statement, developed by the European Heart Rhythm Association (EHRA) of the ESC in collaboration with the Association of Cardiovascular Nursing & Allied Professions (ACNAP) of the ESC, provides an evidence-based and practice-oriented framework for the implementation of SDD pathways after EP and CIED interventions. Based on a structured review of contemporary trials, registries, and expert consensus, the document addresses patient selection, peri-procedural management, early complication surveillance, discharge criteria, and post-discharge follow-up. Procedure-specific considerations are provided for catheter ablation and device implantation. This consensus aims to harmonize clinical practice, reduce variability in care, and support the safe and sustainable expansion of SDD across diverse European healthcare systems.