Pulsed Field Versus Radiofrequency Ablation in Concomitant Pulmonary Vein Isolation and LAA Occlusion: Impact on Peridevice Leak and Procedural Efficiency

BACKGROUND: Concomitant pulmonary vein isolation (PVI) and left atrial appendage occlusion (LAAO) is increasingly performed in patients with atrial fibrillation (AF) at elevated thromboembolic risk. Radiofrequency ablation (RFA) has been the conventional approach, but pulsed field ablation (PFA) may reduce tissue edema, procedural duration, and peridevice leak (PDL). OBJECTIVE: To compare safety, efficacy, and PDL rates between PFA + LAAO and RFA + LAAO. METHODS: In this single-center, retrospective study, 175 consecutive patients undergoing LAAO with or without concomitant PVI between September 2021 and May 2025 were included: RFA + LAAO (n = 61), PFA + LAAO (n = 39), and LAAO-only (n = 75). Procedural data, device characteristics, and complications were collected. The primary endpoint was PDL at 45-day follow-up transesophageal echocardiography (TEE). Secondary endpoints included procedure duration, vascular and esophageal complications, device-related thrombosis, and arrhythmia recurrence. RESULTS: Baseline characteristics were generally balanced, although RFA + LAAO patients were younger. No large PDL (> 5 mm) was observed. At 45 days, small PDL (≤ 5 mm) was significantly higher in RFA + LAAO (23%) vs. PFA + LAAO (5.1%) and LAAO-only (9.3%; p = 0.015). Mean procedure duration was shorter with PFA + LAAO (67.1 ± 10.4 min) compared with RFA + LAAO (99.6 ± 12.8 min; p < 0.001). Major complications and device-related thrombosis were rare. Minor complications and AF recurrence were comparable across groups. CONCLUSIONS: Concomitant PFA + LAAO is associated with lower PDL incidence and shorter procedural times compared with RFA + LAAO, without compromising safety.