A new clinical trial suggests that starting with left atrial appendage occlusion (LAAO) before catheter ablation (CA) leads to better long-term outcomes for patients with atrial fibrillation (AF) undergoing the combined procedure. The findings highlight the “occlusion-first” approach as a safer and more effective strategy compared to the traditional ablation-first method.
The multicenter COMBINATION trial included 202 patients with nonvalvular AF undergoing a combined LAAO and CA procedure. Participants were randomly assigned to either the occlusion-first or ablation-first group and followed for a median of 2.5 years to assess outcomes such as thromboembolic events, device-related thrombus (DRT), bleeding, rehospitalization, cardiovascular death, and freedom from atrial arrhythmias.
The occlusion-first group demonstrated significantly higher event-free survival for the composite primary endpoint (83.5% versus 71.1%; HR 0.53; P = 0.04). Patients in this group also had higher rates of long-term freedom from AF (77.3% versus 63.5%) and atrial tachyarrhythmia (70.1% versus. 55.7%). The ablation-first group experienced a higher incidence of chronic peridevice leaks (15.5% versus. 5.2%) and DRT (8.2% versus 1.0%).
Subgroup analyses revealed that male patients and those with higher CHA2DS2-VASc scores, a stroke risk assessment metric, benefited most from the occlusion-first approach. Both strategies achieved similar rates of acute procedural success and sinus rhythm restoration, but the occlusion-first method offered superior long-term efficacy and safety.
These results suggest that the occlusion-first strategy should be the preferred approach for patients undergoing combined LAAO and CA procedures, especially for those at higher risk of stroke or arrhythmia recurrence.
Reference
Du X et al. Strategy Optimization for a Combined Procedure in Patients With Atrial Fibrillation: The COMBINATION Randomized Clinical Trial. JAMA Netw Open. 2024;7(11):e2445084.
