A new left atrial appendage isolation strategy for persistent atrial fibrillation requiring repeat ablation

The left atrial appendage (LAA) is a trigger for atrial fibrillation (AF) in nearly one-third of patients with persistent AF undergoing repeat ablation, and LAA isolation (LAAI) has been shown to improve arrhythmia outcomes. Previous studies of LAAI using an ostial approach without vein of Marshall ethanol ablation (VOM) resulted in variable rates of acute and durable LAAI and an elevated risk of stroke.

This study aimed to assess the feasibility and effect of LAAI using an anterior mitral isthmus line (AML) and posterior mitral isthmus line (PML), with adjunctive VOM, in patients with persistent AF undergoing repeat ablation.

We prospectively identified 23 patients undergoing repeat ablation for persistent AF in whom LAAI was intentionally performed via AML and PML ± VOM from 2023 to 2024. Patients were systematically remapped at the time of LAA occlusion to assess LAAI durability. Arrhythmia-free survival was assessed using Kaplan-Meier analysis.

The mean age was 72 years, 74% of patients were male, and 87% were white. VOM was successfully performed in 74% of cases, and LAAI was achieved acutely in all. The rate of durable LAAI was 61% and the arrhythmia recurrence rate was 61% at 1 year, with atrial tachycardia occurring more frequently than AF. There was no evidence of acute thrombus, and no strokes or transient ischemic attacks occurred.

LAAI using a linear approach of AML and PML with VOM is feasible and reproducible and results in a low rate of arrhythmia recurrences, most of which are self-limited.