Feasibility, procedural efficiency, and early imaging outcomes of concomitant pulsed field ablation and left atrial appendage closure: a prospective single-centre study

AIMS: Concomitant pulsed field ablation (PFA) for atrial fibrillation (AF) with left atrial appendage closure (LAAC) offers a single-procedure approach for arrhythmia control and thromboembolic risk reduction. This study assessed the workflow, safety, and feasibility of combined PFA and LAAC in routine practice. METHODS AND RESULTS: We prospectively analysed patients undergoing zero-fluoroscopy PFA, with low fluoroscopy for LAAC. Pre-procedural planning used CT imaging and AI-based models for device selection and landing-zone assessment. A single transseptal puncture facilitated intracardiac echocardiography, PFA catheter, and LAAC sheath. A total of 209 patients were included (56% male; mean age 76.5 ± 7.8 years), with 59.3% paroxysmal AF, 40.7% persistent AF, and 50% de novo AF. The mean CHA2DS2-VASc score was 4.5. Mean procedure and left atrial dwell times were 57.3 ± 17 and 45.1 ± 13.6 min, respectively; fluoroscopy averaged 3.4 ± 0.8 min for LAAC. A single LAAC device was used in 94% of cases, achieving adequate seal in all. No pericardial effusion, phrenic nerve injury, kidney, or oesophageal injury occurred; two patients had minor groin bleeding. All were discharged same day on oral anticoagulation for 90 days. Follow-up CT (80%) or TEE (20%) at 111.6 ± 16.5 days showed no leaks >2 mm, a 4.7% small-leak rate, and two device-related thrombi without stroke, managed with extended anticoagulation. CONCLUSION: Combined PFA and LAAC is feasible and safe with favourable early outcomes. Multi-centre studies are warranted to confirm findings and standardize this workflow for broader clinical adoption.