[Percutaneous exclusion of the left atrial appendage: perspectives]

With its high prevalence and well-known thromboembolic risk, atrial fibrillation (AF) is a crucial component of the 2010-2014 actions plan, ongoing in France to reduce the annual incidence of stroke. The stroke risk is stratified well with the CHA(2)DS(2)-VASc score. With the current guidelines, most patients with AF should be on oral anticoagulant regimen, a treatment recognized as effective but whose bleeding risks limit its use. In clinical practice, warfarin is often not prescribed in patients with high risk of stroke. Thus, the exploration of new ways in preventing thromboembolic events in patients with AF is needed. Beside new more convenient anticoagulant agents, the exclusion of the left atrial appendage recognized as main source of thrombi, may be an alternative in patients with both high risk of thrombotic and haemorrhagic events. Surgical experience showed that the results depend on the quality of the exclusion. For over the past 10 years, several percutaneous exclusion systems of the left atrial appendage have been developed. A randomized study (PROTECT AF) demonstrated the non-inferiority of the percutaneous exclusion in comparison with the warfarin. However, the place of this interventional therapy remains to be clarified, particularly the definition of the target population. This often multidisciplinary approach will have to be accompanied by a reduction of periprocedural complications, increase in rate of complete occlusion, and enough long clinical follow-up to assess the efficiency of this strategy.