First Reported Concomitant Pulsed-Field Ablation and Left Atrial Appendage Occlusion in a Patient With Prior Atrial...

Transseptal access in patients with prior atrial septal defect (ASD) closure devices is technically challenging, particularly when large-bore sheaths are required. We report a 59-year-old woman with longstanding persistent atrial fibrillation (AF) and prior ASD closure who underwent concomitant pulsed-field ablation (PFA) and left atrial appendage (LAA) occlusion. Preprocedural cardiac computed tomography identified a narrow (~5 mm) inferior native septal window. A multimodality imaging approach incorporating intracardiac echocardiography, transesophageal echocardiography, fluoroscopy, and CT integration enabled precise inferior transseptal puncture directed toward the LAA. This strategy allowed safe delivery of large sheaths and optimal coaxial alignment for Watchman implantation. Pulmonary vein isolation, posterior wall isolation, and cavotricuspid isthmus ablation were performed, followed by successful LAA occlusion without residual leak. To our knowledge, this is the first reported case of concomitant PFA and LAA occlusion performed through a single transseptal access in a patient with a prior ASD closure device. A focused multi-database literature search identified no previously reported case of this specific combination.