Left atrial appendage occlusion: an alternative to anticoagulation in atrial fibrillation

Atrial fibrillation (AF) is the most common sustained arrhythmia. Global Burden of Disease estimates indicate that 52.6 million individuals were living with AF or atrial flutter in 2021, and one in three to one in five persons are expected to develop AF during their lifetime. AF is associated with an increased risk of stroke, systemic thromboembolism, and death. Oral anticoagulation (OAC) is the first-line strategy for preventing AF-associated embolism. However, embolic events still occur in 1%-4% of anticoagulated patients per year, major bleeding occurs in 2%-4% per year, and long-term adherence to direct oral anticoagulants (DOAC) is incomplete. Left atrial appendage occlusion (LAAO) was developed as a mechanical alternative to address these unmet needs. The evidence base has changed substantially over the last 2 years: three randomized controlled trials comparing LAAO with DOAC-OPTION, CHAMPION-AF, and CLOSURE-AF-have now reported. In this update, we summarize the pathophysiological rationale, the technical aspects of the procedure, and the totality of the randomized and observational evidence, including a 2026 meta-analysis of 5,890 randomized patients. Taken together, these data indicate that LAAO reduces non-procedure-related bleeding but does not decrease all-cause major bleeding, intracranial haemorrhage, or mortality, and may carry a higher risk of ischaemic stroke than DOAC. LAAO remains an established option for patients with contraindications to or intolerance of long-term OAC. In DOAC-eligible patients, it has become a randomized-tested alternative, but current evidence supports an individualized, shared decision rather than a universal offer. We outline the remaining controversies-patient selection, device-related thrombus, peri-device leak, post-procedural antithrombotic therapy, and the interpretation of observational data-and the trials designed to resolve them.