Discussion
To the best of our knowledge, we report the first experience of combined AF PFA and LAA closure with cerebral protection system use in a patient at high risk of cardioembolic stroke, thus showing that the procedure is feasible.
In several PFA studies with 1-year follow-up (IMPULSE [NCT03700385], PEFCAT [NCT03714178], and PEFCAT II [NCT04170621]), only one patient experienced a TIA post ablation, and there were no strokes3. Although PFA is a safe procedure relatively to thromboembolic risk, some patients have an especially high-risk profile in addition to the intrinsic one of the catheter ablation and LAA closure combined procedures11,12.
The presented patient had relapsing strokes/TIAs despite appropriate OAC therapy, and an intense smoke effect was demonstrated in LAA and LA at TEE, prompting us to use the cerebral protection system (SENTINELTM); at the end of procedure, there was evidence of small debris in the system. Whether the use of the cerebral protection system during AF catheter ablation is useful has not been proven yet, and we need to wait for the completion of an ongoing trial (NCT04685317) to solve this issue.
Our preliminary experience seems to suggest that combined AF PFA and LAA is feasible and may allow rapid completion of the procedure, similar to what was previously shown with cryoablation13. Whether the use of PFA may be preferable to cryoablation in terms of procedural time, risk of complications, and long-term efficacy deserves further study.