Left Atrial Appendage Occlusion Devices: Are We Isolating the Right Population?

Atrial fibrillation (AF) affects more than 37 million persons worldwide contributing to significant morbidity and mortality. 1 Lippi G Sanchis-Gomar F Cervellin G. Global epidemiology of atrial fibrillation: an increasing epidemic and public health challenge. Int J Stroke. 2021; 16: 217-221 Crossref PubMed Scopus (383) Google Scholar Stroke prevention with vitamin K antagonists (VKAs) or non-VKA oral anticoagulants remains the mainstay of therapy in patients with AF because of the reduction of all-cause mortality in randomized clinical trials when compared with placebo. VKAs are necessary for those patients with valvular AF but carry a higher risk of stroke, intracranial hemorrhage, and mortality when compared with non-VKA oral anticoagulants. 2 Hicks T Stewart F Eisinga A. NOACs versus warfarin for stroke prevention in patients with AF: a systematic review and meta-analysis. Open Heart. 2016; 3e000279 Crossref PubMed Google Scholar Bleeding risk can limit the use of oral anticoagulants in some patients leaving them at increased risk for stroke. Left atrial appendage occlusion (LAAO) procedures have emerged as a safe alternative to long-term anticoagulation in patients with nonvalvular AF. LAAO can be performed by surgical or transcatheter approach. In patients who underwent cardiac surgery, left atrial appendage closure has been associated with a decreased risk of stroke at 30 days follow-up. 3 Friedman DJ Piccini JP Wang T Zheng J Malaisrie SC Holmes DR Suri RM Mack MJ Badhwar V Jacobs JP Gaca JG Chow SC Peterson ED Brennan JM. Association between left atrial appendage occlusion and readmission for thromboembolism among patients with atrial fibrillation undergoing concomitant cardiac surgery. JAMA. 2018; 319: 365-374 Crossref PubMed Scopus (112) Google Scholar In patients who did not undergo cardiac surgery, commercially available transcatheter devices have been approved for use in patients with nonvalvular AF and were not inferior to dose-adjusted warfarin for stroke prevention. 4 Fountain RB Holmes DR Chandrasekaran K Packer D Asirvatham S Van Tassel R Turi Z. The PROTECT AF (WATCHMAN Left Atrial Appendage System for Embolic PROTECTion in Patients with atrial fibrillation) trial. Am Heart J. 2006; 151: 956-961 Crossref PubMed Scopus (181) Google Scholar Long-term outcomes for LAAO from trials find a very low incidence of ischemic stroke (1.0 per 100 patient year) but a high overall mortality (>50%) in LAAO device recipients at 10 years follow-up. 5 Mesnier J Cruz-González I Peral V Nombela-Franco L Freixa X Laffond AE Mas-Lladó C McInerney A Regueiro A O'Hara G Rodés-Cabau J Ten-year outcomes following percutaneous left atrial appendage closure in patients with atrial fibrillation and absolute or relative contraindications to chronic anticoagulation. Circ Cardiovasc Interv. 2021; 14e010821 Crossref PubMed Scopus (4) Google Scholar A high overall mortality in this group emphasizes the need for appropriate patient selection.