[Interventional left atrial appendage occlusion : alternative to oral anticoagulation for stroke prevention in atrial...

Stroke prevention in patients with atrial fibrillation is one of the greatest challenges in modern cardiology. Interventional left atrial appendage occlusion is an alternative to oral anticoagulation in patients with non-valvular atrial fibrillation. This procedure is currently used mainly for patients with elevated risk for bleeding complications (HAS-BLED score ≥3) or other contraindications for oral anticoagulation. The novel anticoagulants dabigatran, rivaroxaban and apixaban carry a risk for major bleeding for 2-3% of patients per year. The indications for an interventional left atrial appendage closure are therefore not affected by these substances. Several devices have been developed for this purpose; however, currently only the WATCHMAN® and AMPLATZER® cardiac plug are used in the clinical routine in Germany. The WATCHMAN® device proved to be non-inferior to oral anticoagulation with warfarin in the PROTECT-AF trial in terms of safety and efficacy. These findings are supported by data from registries with up to 5 years follow-up. For the second device currently used in clinical practice, the AMPLATZER® cardiac plug, there is increasing data from registries suggesting comparable safety and efficacy. Both devices necessitate anticoagulation during the first 3-6 months after implantation until endothelialization is completed. Due to the anatomical complexity the implantation should be performed in experienced centers with reduction of the periprocedural risk to <1%. Thus, interventional left atrial appendage occlusion is a valid option to prevent stroke or other thromboembolic events in non-valvular atrial fibrillation especially for elderly patients or those with a history of bleeding complications.