One-stop strategy for treatment of atrial fibrillation: feasibility and safety of combining catheter ablation and left atrial appendage closure in a single procedure
Atrial fibrillation (AF)—the most common persistent heart rhythm disorder—affects over 33 million people globally, doubling the risk of stroke and worsening quality of life for many. Two life-changing treatments exist: catheter ablation (to restore normal heart rhythm) and left atrial appendage closure (LAAC) (to block the heart’s small “pouch,” where 90% of AF-related blood clots form). But could combining these two procedures in one session—called a “one-stop” approach—be safer, more effective, and more convenient for patients? A 2020 study from Shanghai Jiao Tong University’s Xinhua Hospital set out to answer this question for Chinese AF patients—and the results offer hope.
Who Led the Study?
The research was conducted by Dr. Yi-Gang Li and colleagues from the Department of Cardiology at Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University—a leading cardiac care center in China. Their work, published in the Chinese Medical Journal, is one of the largest studies to evaluate one-stop AF treatment in a Chinese population.
The Problem: AF, Stroke, and Blood Thinners
AF causes the heart’s upper chambers to beat irregularly, allowing blood to pool in the left atrial appendage (LAA)—a finger-like structure in the heart. Pooled blood forms clots, which can travel to the brain and cause stroke. While catheter ablation fixes rhythm issues, it doesn’t eliminate stroke risk. Long-term blood thinners (oral anticoagulants, OACs) are the standard stroke prevention tool—but many patients can’t take them (due to bleeding risks) or refuse them (due to side effects).
LAAC solves this by sealing the LAA with a small implant (like the WATCHMAN device), stopping clots from forming. The one-stop strategy combines ablation and LAAC in a single procedure, sharing steps like vein access and heart mapping to reduce time, cost, and patient stress.
How the Study Worked
The team enrolled 178 consecutive Chinese patients with symptomatic, drug-resistant AF between March 2017 and September 2018. To qualify, patients:
- Had paroxysmal (short-term) or persistent (long-term) AF.
- Were 18–85 years old.
- Couldn’t take long-term OACs (due to bleeding risk) or refused them.
- Had no severe valve disease or hyperthyroidism.
Before the procedure:
- Patients stopped anti-arrhythmic and blood-thinning drugs (bridged with low-molecular-weight heparin).
- Imaging (echocardiography, CT scans) checked for LAA clots and measured heart structure.
During the one-stop procedure:
- Catheter ablation first: Doctors used 3D mapping systems (CARTO or ENSITE) to guide a thin catheter to the heart. They isolated the pulmonary veins (the main source of AF triggers) by creating small scars—stopping abnormal electrical signals. Success meant no more “pulmonary vein potential” (abnormal signals) and blocked pathways.
- LAAC next: Using the WATCHMAN device (a flexible, umbrella-shaped implant), doctors sealed the LAA. They used imaging (transesophageal echocardiography, TEE) to choose the right device size and ensure it fit securely (following the PASS principle: Position, Anchor, Size, Seal).
Afterward:
- Patients stayed in the hospital for ~5 days.
- They took OACs temporarily, switching to aspirin + clopidogrel if their LAA seal was good at 3 months.
Key Results: Safe and Effective
The one-stop approach worked well for most patients—with low complication rates:
Immediate Success
- Ablation: 98.9% (176/178) converted to normal sinus rhythm right away.
- LAAC: 100% achieved a “satisfactory seal” (leak <5mm), meaning no major clot risk from the LAA.
Complications
- Cardiac perforation: 4 patients (2.2%)—fixed with fluid drainage.
- Stroke: 1 patient (0.6%)—a woman, 84, who had a small cerebellar stroke 22 hours post-procedure (treated successfully).
- Minor issues: 6 patients (3.4%) had femoral vein problems (e.g., small aneurysms)—all resolved.
No deaths, device migrations, or major bleeding occurred.
Follow-Up: Long-Term Outcomes
The team tracked patients for 3 months (all) and 1 year (72 early-enrolled patients):
3 Months
- Rhythm: 86% (153/178) maintained normal sinus rhythm.
- LAAC seal: 100% still had a good seal (no leaks >5mm).
- Stroke: 1 more case—a 75-year-old woman with a history of LAA clots (she was on OACs, but her INR was unstable).
- Heart health: NT-proBNP (a marker for heart failure) dropped significantly, suggesting improved heart function.
1 Year
- Rhythm: 72% (52/72) stayed in normal rhythm.
- Stroke/clots: No new cases—even though most patients had stopped OACs.
- Device safety: No device-related clots or migrations.
Why This Matters for Chinese Patients
Previous one-stop studies included few Chinese patients. This research is unique because:
- Larger cohort: 178 patients (bigger than prior studies with 139 patients).
- Older, higher-risk patients: Average age 68.9 years (older than previous cohorts’ 64.1 years).
- Longer follow-up: 1 year (most studies stop at 30 days).
Notably, 78.1% of patients had a “cauliflower” shaped LAA—a morphology linked to the highest stroke risk. Western studies often report “chicken wing” as the most common LAA shape. Racial differences may explain this, but more research is needed.
Addressing Concerns
Critics worried combining procedures might:
- Increase complications: The study’s low complication rate (similar to separate procedures) puts this fear to rest.
- Mislead device sizing: Ablation can cause temporary heart swelling—could this lead to poor LAAC fit? No—all seals remained strong at follow-up.
- Raise costs: The one-stop approach cuts hospital stays by 3.5 days and saves ~20,000 RMB per patient compared to separate procedures.
Limitations to Consider
Like all studies, this one has gaps:
- Only WATCHMAN: Results apply only to this LAAC device (not others like Amplatzer).
- Single center: Findings need confirmation from multi-center studies.
- Short follow-up: Long-term outcomes (5+ years) are unknown.
Conclusion
For Chinese AF patients with high stroke risk who can’t or won’t take OACs, the one-stop approach is safe and feasible. It tackles both rhythm problems and stroke risk in one session—without adding extra risks. The study’s success in older, higher-risk patients makes it a promising option for millions of Chinese people living with AF.
The study was published in the Chinese Medical Journal in 2020 by Mu Chen, Zhi-Quan Wang, Qun-Shan Wang, Jian Sun, Peng-Pai Zhang, Xiang-Fei Feng, Wei Li, Ying Yu, Bo Liu, Bin-Feng Mo, Rui Zhang, Mei Yang, Chang-Qi Gong, Ming-Zhe Zhao, Yi-Chi Yu, Yan Zhao, Qiu-Fen Lu, and Yi-Gang Li. doi.org/10.1097/CM9.0000000000000855
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