Classic case report: concomitant pulsed field ablation, cavotricuspid isthmus ablation and percutaneous left atrial appendage occlusion in a patient with prior intracranial haemorrhage.
- 1Barts Heart Centre, St Bartholomew's Hospital, W Smithfield, London EC1A 7BE, United Kingdom.
Abstract
Background
Concomitant atrial fibrillation (AF) ablation and percutaneous left atrial appendage occlusion (pLAAO) offers single-procedure rhythm control and stroke prevention in patients unable to tolerate long-term oral anticoagulation. Patients with prior intracranial haemorrhage (ICH) from suspected cerebral amyloid angiopathy (CAA) have among the strongest contraindications to anticoagulation yet are absent from randomized trials of concomitant procedures, and combining pulsed field ablation (PFA) with pLAAO introduces energy-specific considerations.Case summary
A 66-year-old woman with persistent AF, cavotricuspid isthmus-dependent atrial flutter and a CHA₂DS₂-VA score of 3 had been off anticoagulation for 2 years after an ICH. Brain magnetic resonance imaging showed microhaemorrhages and siderosis suggestive of CAA. Through a single transseptal puncture, four-vein PFA was performed first to avoid electrical interaction with the nitinol pLAAO frame, followed by WATCHMAN FLX deployment under transoesophageal echocardiographic and computed tomography (CT)-fluoroscopy guidance and radiofrequency cavotricuspid isthmus ablation. She received edoxaban without aspirin for three months. Cardiac CT then confirmed device seal without device-related thrombus, and all antithrombotic therapy was withdrawn.Discussion
Randomized trials show that anticoagulation after ICH prevents ischaemic stroke at the cost of a marked increase in recurrent haemorrhage, and lobar or CAA-related haemorrhage carries the least favourable balance. Concomitant ablation and pLAAO delivers rhythm control and stroke prevention with one transseptal access and one time-limited exposure to anticoagulation. Combining PFA with pLAAO requires sizing the occluder before ablation, because PFA induces acute pulmonary ridge oedema, and completing pulmonary vein isolation before deployment to avoid arcing against the nitinol frame.
Related
- Temporal Trends and Demographic Disparities in Percutaneous Left Atrial Appendage Occlusion Utilization in the United States, 2016-2022
- Effects of percutaneous kyphoplasty with concomitant postural reduction in the treatment of acute osteoporotic vertebral compression fractures
- Efanesoctocog Alfa for the Management of a Life-Threatening Intracranial Haemorrhage in Mild Haemophilia A: A Case Report.
- Percutaneous Closure of a Left Atrial Pseudoaneurysm After Left Atrial Appendage Closure
- Intracranial Haemorrhage and Haemorrhagic Stroke in Patients with Atrial Fibrillation on Edoxaban in ETNA-AF-Europe
BibTeX
@article{muthalaly2026classic,
title = {{Classic case report: concomitant pulsed field ablation, cavotricuspid isthmus ablation and percutaneous left atrial appendage occlusion in a patient with prior intracranial haemorrhage.}},
author = {Rahul G Muthalaly and Sara El-Saadany and Richard Ang and Mehul B Dhinoja and Mark J Earley},
journal = {European heart journal. Case reports},
year = {2026},
month = oct,
doi = {10.1093/ehjcr/ytag742},
url = {https://europepmc.org/article/MED/42923769},
note = {CC BY},
}
RIS
TY - JOUR
TI - Classic case report: concomitant pulsed field ablation, cavotricuspid isthmus ablation and percutaneous left atrial appendage occlusion in a patient with prior intracranial haemorrhage.
AU - Rahul G Muthalaly
AU - Sara El-Saadany
AU - Richard Ang
AU - Mehul B Dhinoja
AU - Mark J Earley
PY - 2026
DA - 2026/10/07
JO - European heart journal. Case reports
DO - 10.1093/ehjcr/ytag742
UR - https://europepmc.org/article/MED/42923769
AB - Background Concomitant atrial fibrillation (AF) ablation and percutaneous left atrial appendage occlusion (pLAAO) offers single-procedure rhythm control and stroke prevention in patients unable to tolerate long-term oral anticoagulation. Patients with prior intracranial haemorrhage (ICH) from suspected cerebral amyloid angiopathy (CAA) have among the strongest contraindications to anticoagulation yet are absent from randomized trials of concomitant procedures, and combining pulsed field ablation (PFA) with pLAAO introduces energy-specific considerations.Case summary A 66-year-old woman with persistent AF, cavotricuspid isthmus-dependent atrial flutter and a CHA₂DS₂-VA score of 3 had been off anticoagulation for 2 years after an ICH. Brain magnetic resonance imaging showed microhaemorrhages and siderosis suggestive of CAA. Through a single transseptal puncture, four-vein PFA was performed first to avoid electrical interaction with the nitinol pLAAO frame, followed by WATCHMAN FLX deployment under transoesophageal echocardiographic and computed tomography (CT)-fluoroscopy guidance and radiofrequency cavotricuspid isthmus ablation. She received edoxaban without aspirin for three months. Cardiac CT then confirmed device seal without device-related thrombus, and all antithrombotic therapy was withdrawn.Discussion Randomized trials show that anticoagulation after ICH prevents ischaemic stroke at the cost of a marked increase in recurrent haemorrhage, and lobar or CAA-related haemorrhage carries the least favourable balance. Concomitant ablation and pLAAO delivers rhythm control and stroke prevention with one transseptal access and one time-limited exposure to anticoagulation. Combining PFA with pLAAO requires sizing the occluder before ablation, because PFA induces acute pulmonary ridge oedema, and completing pulmonary vein isolation before deployment to avoid arcing against the nitinol frame.
SN - 2514-2119
ER -