My Indication for Concomitant LAAO With Atrial Fibrillation Ablation: Insights From James Freeman, MD, MPH, MS

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Interview by Jodie Elrod

James Freeman, MD, MPH, MS, Professor of Medicine at the Yale School of Medicine, Director of the Cardiac Electrophysiology Laboratories for Yale New Haven Health, and Director of the Yale Atrial Fibrillation (AFib) Program, discusses his upcoming roundtable at the 2026 Western Atrial Fibrillation Symposium.

To begin, could you introduce yourself and briefly describe your clinical focus?

I am Jim Freeman, I am a cardiac electrophysiologist. I direct the EP program and AFib program at Yale. I do a lot of clinical work and research work on AFib, including both on the rhythm management side and in stroke prevention. 

Your upcoming roundtable centers on indications for concomitant left atrial appendage occlusion (LAAO) with AFib ablation. When considering concomitant LAAO at the time of AFib ablation, what are the key patient- and procedure-related factors that typically guide the decision-making process, and where do you see the greatest areas of debate or variation in practice?

The foundational question is whether the patient needs an indication for both procedures. The indications for AFib ablation have really broadened with a lot of the work that was done a few years ago looking at AFib ablation as first-line therapy compared to medical therapies. Between that and pulsed field ablation, we've seen a broad expansion of the use of AFib ablation for rhythm control. The indications for LAAO currently continue to be patients for whom long-term anticoagulation is problematic. They have some relative or absolute contraindication to anticoagulation. So, if we see a patient in clinic with AFib, we must be having both conversations. Irrespective of whether someone was referred for one or the other, we need to be asking about symptoms, symptomatology, and how is AFib impacting them from a symptom standpoint and impacting their overall health. From a stroke prevention standpoint, how are they doing on anticoagulation? Is anticoagulation a problem for them? Do they have bleeding issues? 

Having had that conversation, we decide if a patient meets the indication for both procedures. We have published 1 study and have 2 additional studies in development that will be published soon. All 3 examine whether patients who meet indications for both procedures should undergo them concurrently (as a concomitant procedure) or sequentially. A lot of the data seems to be pointing to the idea that there is really modest incremental risk for a concomitant procedure compared to either procedure alone. So, when procedures are done sequentially and a patient clearly meets the indication for both, on some level, we may be doing them a disservice by exposing them to the risks of anesthesia, 2 separate vascular accesses, and 2 transseptal punctures, when we could do everything once and accomplish both procedures in a similar time horizon with modest incremental risk over and above either procedure alone.

As you look ahead to Western AFib 2026, what are you most looking forward to discussing during this roundtable, and what do you hope attendees will take away from the conversation?

I'm very excited to talk about some of the science that we've done in this space and the opportunity to help educate the community about the risks and benefits of sequential versus concomitant procedures. I also look forward to discussing how we can change the conversation in the clinic to a more comprehensive approach to AFib—one that goes beyond focusing solely on rhythm management or stroke prevention in a single visit. We think holistically about the patient and how we can tackle those 2 key parts of AFib management in a single visit and potentially in a single procedure if patients meet indications for both. So, I'm excited about the opportunity to talk about changing how we think about AFib, how we discuss it, and how we approach that with patients in the clinic.

The transcripts have been edited for clarity and length.