Zero-Contrast Percutaneous Left Atrial Appendage Closure: A Large-Scale, Single-Center, Real-World Study

Left atrial appendage closure (LAAC) is a proven stroke prevention method for patients with non-valvular atrial fibrillation (AF) who are not suitable for long-term anticoagulation. However, the use of iodinated contrast agents during the procedure can increase the risk of acute kidney injury (AKI), especially in patients with chronic kidney disease (CKD). This study evaluates the safety and effectiveness of a zero-contrast LAAC technique using transesophageal echocardiography (TEE) and fluoroscopy.

In this retrospective study, 324 consecutive patients underwent zero-contrast LAAC between January 2014 and January 2025. All procedures were performed using TEE and fluoroscopy guidance without iodinated contrast agents. The primary safety endpoint was the composite of procedure-related major complications occurring within 7 days after the procedure. Secondary endpoints included the rate of procedural success.

The mean age was 74.1 ± 9.3 years. CKD was present in 25.6% of the population, including four patients (1.2%) with prior renal transplantation and 19 patients (5.9%) receiving maintenance hemodialysis. The median CHA₂DS₂-VASc and HAS-BLED scores were both 4.0. Primary endpoints were observed in 8 (2.46%) patients (all-cause mortality in 4 patients, device embolization in 2 patients, and major bleeding in 2 patients). The procedural success rate was 99.7%. Vascular access site complications were observed in 5 (1.5%) patients. Renal function assessment showed baseline serum creatinine levels of 1.24 ± 1.30 mg/dL and 1.26 ± 1.32 mg/dL at 24-48 h (p = 0.847). No cases of acute kidney injury (KDIGO criteria) occurred during the index hospitalization, and renal function remained stable in 83 patients (25.6%) with pre-existing CKD. Survival analysis stratified by CKD stages demonstrated significantly higher mortality rates with progressive renal dysfunction (p < 0.001).

Zero-contrast LAAC guided by TEE and fluoroscopy is a safe and effective alternative to contrast-enhanced LAAC, with particular advantages in patients with renal dysfunction. These findings support broader adoption of contrast-avoidance strategies in high-risk populations.