{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,29]],"date-time":"2026-10-29T07:22:29Z","timestamp":1793258549856,"version":"4.5.0"},"reference-count":29,"publisher":"American Medical Association (AMA)","issue":"11","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JAMA Netw Open"],"abstract":"Importance<\/jats:title>The optimal strategy of combining left atrial appendage occlusion (LAAO) with catheter ablation (CA) in patients with atrial fibrillation (AF) during a single procedure remains unclear.<\/jats:p><\/jats:sec>Objective<\/jats:title>To determine the effects of ablation-first vs occlusion-first strategies on long-term clinical outcomes among patients with atrial fibrillation undergoing a combined LAAO and CA procedure.<\/jats:p><\/jats:sec>Design, Setting, and Participants<\/jats:title>The prospective, multicenter COMBINATION randomized clinical trial was conducted in 14 high-volume centers in China. Enrollment of patients with nonvalvular AF referred for the combined procedure began on July 24, 2020, and concluded on January 20, 2022.<\/jats:p><\/jats:sec>Interventions<\/jats:title>Patients were randomly assigned to either the ablation-first group or the occlusion-first group. Outcomes of LAAO using an occlusion device and CA using a contact force\u2013sensing catheter following different combination strategies during long-term follow-up were evaluated.<\/jats:p><\/jats:sec>Main Outcomes and Measures<\/jats:title>The primary end point was a composite of thromboembolic events including stroke or transient ischemic attack, device-related thrombus (DRT), clinically relevant bleeding, and cardiovascular rehospitalization or death. Freedom from AF or atrial tachyarrhythmia (ATA) after a single procedure without antiarrhythmic drugs, at both 1 year and long-term follow-up, was also evaluated.<\/jats:p><\/jats:sec>Results<\/jats:title>Of the 202 patients enrolled, 194 (96.0%) completed the trial (97 in the ablation-first group and 97 in the occlusion-first group). The mean (SD) age of the cohort was 67.3\u2009(9.2) years, and 110 patients (56.7%) were male. All procedures achieved acute successful LAAO and restoration of sinus rhythm, with similar incidences of periprocedural complications. Compared with the ablation-first group, the occlusion-first group exhibited significantly higher event-free survival of the primary end point (83.5% vs 71.1%; hazard ratio [HR], 0.53 [95% CI, 0.29-0.95]; log-rank P<\/jats:italic>\u2009=\u2009.04) during the median 2.5 (IQR, 2.3-2.8) years of follow-up. Subgroup analysis indicated that male patients and those with higher CHA2<\/jats:sub>DS2<\/jats:sub>-VASc scores (a composite of factors associated with stroke risk; higher scores indicate higher risk) were at lower risk of thromboembolic events. Rates of long-term freedom from AF (77.3% vs 63.5%; HR, 0.58 [95% CI, 0.34-0.97]; log-rank P<\/jats:italic>\u2009=\u2009.04) and from ATA (70.1% vs 55.7%; HR, 0.62 [95% CI, 0.39-0.99]; log-rank P<\/jats:italic>\u2009=\u2009.04) were higher in the occlusion-first group vs the ablation-first group. Additionally, a higher incidence of chronic peridevice leak (15 [15.5%] vs 5 [5.2%]; P<\/jats:italic>\u2009=\u2009.03) and DRT (8 [8.2%] vs 1 [1.0%]; P<\/jats:italic>\u2009=\u2009.04) was observed in the ablation-first group vs the occlusion-first group.<\/jats:p><\/jats:sec>Conclusions and Relevance<\/jats:title>In this randomized clinical trial, the occlusion-first approach was superior due to its higher event-free survival of the primary end point and long-term freedom from ATA. These findings suggest that the occlusion-first approach should be recommended for combined procedures with plug-like device implantation.<\/jats:p><\/jats:sec>Trial Registration<\/jats:title>Chinese Clinical Trial Registry Identifier: ChiCTR2000031486<\/jats:ext-link><\/jats:p><\/jats:sec>","DOI":"10.1001\/jamanetworkopen.2024.45084","type":"journal-article","created":{"date-parts":[[2024,11,15]],"date-time":"2024-11-15T16:31:28Z","timestamp":1731688288000},"page":"e2445084","source":"Crossref","is-referenced-by-count":21,"title":["Strategy Optimization for a Combined Procedure in Patients With Atrial Fibrillation"],"prefix":"10.1001","volume":"7","author":[{"given":"Xianfeng","family":"Du","sequence":"first","affiliation":[{"name":"Arrhythmia Center, The First Affiliated Hospital of Ningbo University, Ningbo First Hospital, Ningbo, China"},{"name":"Key Laboratory of Precision Medicine for Atherosclerotic Diseases of Zhejiang Province, Ningbo, 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