Advancing Concomitant Atrial Fibrillation Ablation and Left Atrial Appendage Closure: Imaging, Technique, and Best Practices for Procedural Success

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EP LAB DIGEST. 2026;26(11):11-12.

Interview by Jodie Elrod

In this interview, Yoel Vivas, MD, shares practical insights on performing concomitant atrial fibrillation (AF) ablation and left atrial appendage closure (LAAC), with a focus on procedural planning, imaging, and technique. He discusses key considerations for transseptal access, device sizing, ICE-guided workflows, and emerging technologies that may help improve procedural efficiency and outcomes.
 
As concomitant procedures become more common, how important is it for operators to develop proficiency in both ablation and LAAC, and what key competencies or procedural milestones should physicians achieve before routinely performing these cases? 
I think it is extremely important to be comfortable performing both an ablation for AF and occlusion of the LAA. Most operators have been performing ablations for a long period of time, even before LAAC came into the mainstream. Now that the 2 procedures can be performed concomitantly, I think that understanding the anatomy of the LAA and having the experience of performing several occlusion cases are important when you’re going to do them together. There are certain aspects of the procedures that are kind of different, but I believe that if you master ablations and occlusions, the transition to performing them concomitantly is not difficult at all.

What is different in your approach for the WATCHMAN™ LAAC device sizing in a concomitant procedure compared to a stand-alone case? 
In terms of sizing, I like to have a higher degree of compression. I always consider that, especially if I’m going to perform complex ablation along the ridge or the “saddle” area. I like to see compression of 20% to 25%. 

How does the potential of edema weigh into your decision to attempt a concomitant procedure? How does recent data from ALIGN-AF influence this decision? 
Acute tissue edema is a critical physiological response that directly affects procedural workflow and device selection during concomitant catheter ablation and LAAC. Operators must perform structural measurements prior to ablation (using preprocedural computed tomography (CT) or intraprocedural baseline transesophageal echocardiography [TEE]/intracardiac echocardiography [ICE]) to capture true baseline dimensions. We then measure the LAA orifice via left-sided ICE post-ablation.

In the ALIGN-AF trial, although minor LAA orifice edema occurred acutely in roughly 4.3% of patients, it did not significantly alter the physical structure or diameter of the appendage post-ablation. ALIGN-AF showed a low occurrence of edema after FARAWAVE ablation (94.1% no new LAA edema post-ablation), and high complete seal with WATCHMAN at 45 days (90.6% with 0-mm leak).

How has your approach to imaging evolved with the growth of concomitant procedures? Are there best practices you can share regarding efficient workflows with either ICE or TEE? 
I’ve been using left-sided 2D ICE for all my ablation procedures, even for simple pulmonary vein isolation (PVI) procedures, so I was very comfortable using it. Because of that, it was very easy to transition from stand-alone ablation to concomitant procedures using left-sided ICE. We also started adopting left-sided ICE early in our experience with LAAC. So, I think it’s extremely important that, if you decide to perform LAAC using ICE, you feel comfortable with the different views and with imaging different parts of the LA. Now, 100% of our cases are done with left-sided ICE. 

To ensure zero tolerance for peri-device leaks during LAAC without a dedicated cardiac imaging specialist, we have successfully implemented a fast, single-operator dual-imaging workflow under general anesthesia. Immediately following endotracheal intubation, the operator inserts a TEE probe and positions its tip cranial to the LAA under fluoroscopic guidance, allowing for rapid, immediate cross-checking alongside ICE deployment to confirm the absolute absence of leaks. Because this entire intraoperative process is managed solely by the primary operator, it is crucial to train our clinical sonographers to achieve ultra-accurate, highly precise LAA dimensions.

For physicians looking to expand their concomitant experience, what key imaging checkpoints, ICE techniques, or imaging views have the greatest impact on procedural efficiency, confidence, and decision-making—particularly during transseptal access, appendage evaluation, and device deployment/assessment? 
Regarding transseptal access, we always evaluate the anatomy of the LAA, including whether there is a posterior or anterior lobe or more straightforward anatomy. I believe that it’s easier to perform PVI whether you stick posterior, mid, or even anterior, but it’s more challenging to perform WATCHMAN closure if you have a bad transseptal. So, I think the operator needs to decide where to stick based on the anatomy of the LAA.

When we use ICE in the LA, we like to obtain comprehensive views of the appendage before we deploy. We will place the ICE catheter in the LSPV, mid-LA, and supramitral positions to obtain the analogs of what we call the 45°, 90°, and 120° views. It’s important to get measurements in all of these views because each view can give you different information.

For deployment, we particularly like the supramitral view. I believe that, for most operators, getting used to the supramitral view is extremely important because it helps delineate the anatomy and avoid implants that are too deep or shallow. Once you deploy, it’s important to confirm in all the views, just as you would with TEE, that you don’t have a large shoulder or any leaks and that the axis of the device is aligned with the axis of the appendage.

What other best practices have you found to be helpful while adopting ICE for concomitant procedures (ie, pre-planning, standard protocol when using ICE, ensure continual training on ICE)? 

It has been easier for us in our lab because we use ICE for all of our left-sided procedures. I think that if somebody wants to make that transition, it’s easier to start by doing straightforward PVIs with left-sided ICE, get used to the anatomy of the PVs and the LAA, and then, once they are comfortable with that, they can move to performing concomitant procedures with ICE. 

For the standard non-angulated LAA morphology, an infero-mid transseptal puncture is ideal. For the reverse chicken-wing LAA, inferior but mid-to-anterior may be preferred. For cranial or highly superior LAA, a very low stick may be needed.

We started by combining ICE and TEE. So, for the first 5 to 10 cases, TEE helped validate our experience with ICE. It was important to have somebody help us with the TEE to confirm that we were getting good measurements and to ensure there were no leaks during these procedures.

How do you handle complex scenarios that might occur during a concomitant procedure? (eg, right-sided flutter, focal ablation, etc)? 
Accurately characterizing the AF type prior to the procedure is crucial for mapping out an efficient combined ablation and LAAC strategy. Because our core LA ablation strategy is entirely unmodified by the LAAC device implantation, any necessary LA substrate modification proceeds immediately after PVI, with the LAA occlusion performed at the end of the LA phase. However, special scenarios dictate our workflow sequence: in patients with prior ablations where unintentional LAA isolation occurs, we must be fully committed to LAAC. Furthermore, if the case requires right atrial (RA) mapping and ablation—either due to extensive prior LA ablation or the emergence of typical atrial flutter (AFL) post-PVI—we routinely deploy the LAAC device first to secure the LA before transitioning to the right side to complete the procedure.

How do steerable sheaths such as TruSteer™ influence navigation and delivery during concomitant ablation and LAAC procedures? 
It’s extremely important in cases of complex anatomy where you have additional lobes and need to deploy the device in certain ways that would otherwise be impossible without that extra reach and flexibility. Especially for anterior or chicken-wing anatomies, it can be very helpful. 

Using a deflective sheath can be more forgiving of a suboptimal transseptal puncture. It can help if you went a little bit anterior or posterior with your approach. So, I think it overcomes some of these limitations. It has been extremely valuable in our practice to use these sheaths.

What benefits do you see with using FARAPULSE™ PFA (Boston Scientific) and WATCHMAN together in a concomitant procedure? 
I think that it’s very advantageous because FARAPULSE has a good track record as a safe technology with low complication rates. That aligns very well with the track record of the WATCHMAN device. WATCHMAN is a very safe device with a low rate of major adverse events, such as tamponade or perforation. 

The intra-LAA design of the WATCHMAN device ensures that the device sits flush with or distal to the appendage ostium. This minimizes the exposure of metal and fabric into the LA body. Because the WATCHMAN device remains contained inside the LAA cavity, it preserves anatomical access, allowing electrophysiologists to safely perform future catheter ablations for rhythm control without hitting or damaging the implant. 

So, I believe that for physicians who want to get into the concomitant space, WATCHMAN is the preferred device due to its low complication rate compared with other devices on the market. 

Additionally, FARAPULSE + WATCHMAN is the only combination of PFA and LAAC for concomitant procedures with real-world data (ALIGN-AF).

What new technologies are you most excited about that will further enhance your concomitant procedures? 
I’m very excited about the FARAFLEX™ catheter (Boston Scientific). I believe that it will allow us to target areas in a different way. I think that FARAWAVE™ (Boston Scientific) is an excellent tool, but it still has a larger footprint compared with something like FARAFLEX. So, I’m excited to see the clinical data and what that is going to bring us in the future. 

While I have not yet used the ACUNAV Luxera 4D ICE catheter (distributed by Boston Scientific), its potential for right-sided ICE guidance could make it an attractive option for a broad range of operators provided it shows optimal views of both the LAA and the PVs. 

The transcripts were edited for clarity and length.

Disclosures: Dr Vivas has completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. He reports consulting fees from Boston Scientific and Abbott.  

This content was published with support from Boston Scientific.

SH-2608204-AA