Filling the Void: The Past, Present, and Future of Left Atrial Appendage Occlusion

Left atrial appendage occlusion (LAAO) has emerged as an alternative strategy to oral anticoagulation (OAC) to mitigate the risk of thromboembolic events in patients with atrial fibrillation (AF). Endovascular LAAO devices were first developed in the early 2000s for patients with relative and absolute contraindications to OAC. Four randomized controlled trials have demonstrated the safety and efficacy of LAAO procedures, and two LAAO devices have been approved and are commercially available in the United States. Procedural complications, especially pericardial effusion, as well as subsequent peri‑device leak and device-related thrombosis have decreased over time due to improved device design and implantation techniques. Many aspects of the LAAO technology continue to evolve. Intracardiac echocardiography (ICE) is used increasingly and offers distinct advantages and disadvantages compared to transesophageal echocardiography (TEE) for procedural guidance. The role of universal post-procedure surveillance imaging remains unclear. Post-LAAO antithrombotic therapy has shifted from short-term anticoagulation to immediate dual antiplatelet therapy, with ongoing research exploring the feasibility of single antiplatelet therapy. Novel devices with improved design and technology are currently undergoing clinical trials. Additionally, the patient population eligible for LAAO may significantly increase in the coming years, as ongoing trials are evaluating the effectiveness of LAAO devices in a broader population of patients with AF. In conclusion, the history, current state, and active research related to LAAO are summarized in this review article.