Classic case report: concomitant pulsed field ablation, cavotricuspid isthmus ablation and percutaneous left atrial appendage occlusion in a patient with prior intracranial haemorrhage

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 Cardiac CT then confirmed device seal without device-related thrombus, and all antithrombotic therapy was withdrawn.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.