Left atrial appendage closure: Current status, unresolved issues, and future perspectives

Left atrial appendage closure (LAAC) is an established therapy for stroke prevention in patients with nonvalvular atrial fibrillation (AF) who cannot tolerate long-term oral anticoagulation (OAC). In Japan, LAAC was introduced in 2019 and has been performed in more than 10,000 cases a0s of 2025. Although indications remain limited to high-risk patients with OAC contraindications, procedural volume continues to rise. This review outlines the current status, remaining challenges, and future perspectives of LAAC, with emphasis on the WATCHMAN device. The WATCHMAN FLX and FLX Pro have enhanced procedural safety, sealing efficacy, and anatomical adaptability. Large clinical trials and registries have confirmed stroke prevention efficacy comparable to OAC with fewer hemorrhagic complications. However, device-related thrombus (DRT) and peri-device leak (PDL) remain major concerns, underscoring the need to optimize postprocedural antithrombotic therapy. The Amulet device provides superior ostial sealing through its dual-disk design but is technically more complex and associated with higher procedural complication rates. Intracardiac echocardiography (ICE) has emerged as a less invasive alternative to transesophageal echocardiography, reducing anesthesia requirements and enabling same-session LAAC with AF ablation. The development of pulsed field ablation (PFA) further improves the feasibility of such integrated approaches. Future priorities include risk stratification for DRT, individualized antithrombotic strategies, and broader indications encompassing OAC-resistant embolic stroke and other high-risk populations. With advancing technology, ICE-guided, minimally invasive workflows and integrated ablation-occlusion procedures are expected to establish LAAC as a key component of comprehensive AF management.