Left Atrial Appendage and Closure: Who, When, and How

Area of Science:

• Cardiology
• Neurology
• Medical Devices

Background:

• Nonvalvular atrial fibrillation (NVAF) significantly increases stroke risk, particularly in the elderly.
• The left atrial appendage is the source of thrombus in 90% of NVAF-related strokes.
• Oral anticoagulants are effective but underutilized (40-50%) due to contraindications and bleeding risks.

Purpose of the Study:

• To evaluate the efficacy and safety of left atrial appendage occlusion (LAAO) devices for stroke prevention in NVAF patients.
• To compare outcomes of LAAO devices versus standard care or anticoagulation.

Main Methods:

• Meta-analysis of 2 randomized clinical trials and 2 registries.
• Inclusion of patients with NVAF at increased stroke risk, suitable for anticoagulation but with concerns about its risk/benefit ratio.
• Device used: FDA-approved Watchman device for LAAO.

Main Results:

• Significant reduction in hemorrhagic strokes (HR 0.22, P=0.004) and cardiovascular/unexplained death (HR 0.48, P=0.004) in the device group.
• No significant difference in ischemic strokes when periprocedural events were excluded.
• Significant reduction in nonprocedural bleeding (HR 0.51, P=0.006) with the device compared to control.

Conclusions:

• LAAO devices are a viable option for stroke prevention in select NVAF patients, especially those with contraindications or concerns regarding oral anticoagulation.
• Further research is needed to define optimal patient selection and compare LAAO devices with novel oral anticoagulants.