Inside the First Same-Day Pulmonary Vein Isolation and Left Atrial Appendage Closure at BayCare Winter Haven

Insights From Ramez Morcos, MD, MBA

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EP LAB DIGEST. 2026;26(4). Online Only.

Interview by Jodie Elrod

In this interview, EP Lab Digest talks with Dr. Morcos about the successful completion of the first same-day pulmonary vein isolation (PVI) and left atrial appendage closure (LAAC) at BayCare Winter Haven Hospital in Winter Haven, Florida.

How are you currently selecting patients for same-day PVI + LAAC versus staging the procedures, and what factors most strongly influence that decision?

Right now, I see same-day PVI + LAAC as a selective strategy rather than something appropriate for every patient. The key question for me is whether the patient is truly an appropriate candidate for each procedure individually, and whether combining them adds meaningful value from a safety and patient-experience standpoint. In general, the best candidates are patients with symptomatic atrial fibrillation (AF) who are good ablation candidates and who also have a clear reason to pursue appendage closure, particularly when long-term anticoagulation is a concern. 

My interest in this began during fellowship, when I was involved in a research project looking at the combined same-day approach. That experience pushed me to think beyond “can we do it?” and more toward “when does it make sense to do it once, safely, for the patient?” That research made the concept feel very tangible and helped shape how I approach patient selection now.  

I still stage cases when the anatomy is less favorable, when I expect a more complex ablation, when the patient is frailer, or when combining both may add too much procedural time or unpredictability. Ultimately, the decision comes down to thoughtful patient selection. If a patient is well suited for both procedures and the workflow is favorable, there is a clear advantage to performing both procedures in a single session rather than bringing them back for a second invasive LA procedure.  

Do you see combined PVI + LAAC becoming standard of care for certain AF populations, or remaining center- and operator-dependent—and what additional data or experience is still needed to support broader adoption?

I think it is moving in that direction for selected patients, but for now it remains very center- and operator-dependent. It requires the right team, careful planning, and comfort performing both procedures in the same session. This is not just about technical success—it is about making the entire case efficient, organized, and reproducible.  

What excites me is that this is no longer just an idea. During fellowship, being involved in research in this area helped me appreciate the potential of the combined approach early on. Then, seeing that concept continue to evolve with newer evidence made it even more meaningful. My earlier national database work supported the feasibility and safety of the combined approach, and later the OPTION trial showed that LAAC after AF ablation reduced non-procedure-related major or clinically relevant nonmajor bleeding versus oral anticoagulation while remaining noninferior for death, stroke, or systemic embolism at 36 months. That progression from research to real-world practice is a big part of why this area is so exciting to me.  

I do think it may become a more established strategy for selected AF populations, especially for patients who have a clear reason to avoid long-term anticoagulation. However, we still need more prospective experience, more multicenter real-world data, and a better understanding of which patients benefit most from performing both procedures in a single setting rather than staging them.  

What were the biggest workflow challenges in coordinating PVI + LAAC in a single session, and what would you refine or optimize moving forward?

The biggest challenge is workflow. A combined case works best when it is approached as a single, coordinated LA procedure rather than 2 separate procedures performed on the same day. That means patient selection, imaging, transseptal strategy, sequencing, anesthesia, and team communication all have to align. We highlighted several important workflow details, including single transseptal access, doing PVI first, and maintaining good LAA coaxiality without changing the original transseptal axis. Those details are exactly what make these cases smoother and more reproducible.  

What I would continue to refine is the standardization around this approach: tighter pre-procedural planning, clearer same-day candidacy criteria, and a more predictable case pathway from start to finish. The more disciplined the workflow becomes, the more practical this strategy becomes in everyday EP practice.

From the patient perspective, this is where the combined approach becomes especially appealing. Patients value having both issues addressed in a single setting. They appreciate avoiding a second procedure, a second recovery, and another round of stress and logistics. That aspect is important to me. One of the most rewarding aspects of this has been seeing something that first sparked my interest as a fellowship research project evolve into a real option that patients genuinely value.  

References

1.     Morcos R, Al Taii H, Rubens M, et al. Hospital outcomes of patients receiving catheter ablation of atrial fibrillation, left atrial appendage closure, or both. J Interv Card Electrophysiol. 2023;66(4):913-921. doi:10.1007/s10840-022-01370-2

2.     Wazni OM, Saliba WI, Nair DG, et al. Left atrial appendage closure after ablation for atrial fibrillation. N Engl J Med. 2025;392(13):1277-1287. doi:10.1056/NEJMoa2408308