Work

The perspective of combining pulsed field ablation and left atrial appendage closure

Year: 2026

Type: review

Abstract: 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.

Source: EP Europace

DOI: 10.1093/europace/euag202