Percutaneous left atrial appendage occlusion in the current practice.

Abstract

Oral anticoagulation (OAC) is the standard of care for stroke prevention in atrial fibrillation (AF) but is associated with a substantial risk of bleeding complications and is dependent on optimal patient´s compliance. In patients with non-valvular AF, the left atrial appendage is the source of thrombi that may cause stroke in up to 91-95% of cases. Thus, percutaneous left atrial appendage occlusion (LAAO) is increasingly being performed as an alternative to OAC for stroke prophylaxis in patients at increased bleeding risk. Current evidence supporting LAAO derives from three randomized controlled trials: 2 performed with the Watchman in patients suitable for short-term OAC and a more recent trial comparing LAAO with Amulet and Watchman versus long-term OAC with direct oral anticoagulants (DOACs). In addition, numerous real-life registries have reported favorable outcomes with Watchman, ACP and Amulet devices in patients at higher bleeding risk and/or formal contraindications for short-term OAC, employing less intensive antithrombotic regimes after LAAO. Furthermore, there is growing evidence on newer devices with distinct features that might be of value for specific subgroups of patients. However, there remain several unresolved issues including optimal patient and device selection, individual tailoring of post-procedural antithrombotic therapy and management of periprocedural complications such as device-related thrombus and residual peri-device leaks. Finally, the relative benefit of LAAO versus DOACs should be further assessed across the spectrum of patient candidacy for DOACs, over extended follow-up periods. In this article, we review the body of evidence supporting LAAO with currently available devices.