Percutaneous left atrial appendage closure for stroke prevention in atrial fibrillation: who should receive it in current clinical practice?

PURPOSE OF REVIEW: Although oral anticoagulation (OAC) remains the cornerstone therapy for stroke prevention in atrial fibrillation, several limitations, such as noncompliance and bleeding, limit its effectiveness. Percutaneous left atrial appendage closure (pLAAC) has emerged as a promising therapy. We will review current and potential indications for pLAAC and knowledge gaps.

RECENT FINDINGS: Current guidelines recommend pLAAC for patients who have atrial fibrillation at moderate to high risk of stroke with a high risk of bleeding or who have a contraindication for OAC. pLAAC is being investigated as a potential therapeutic option for the following patient populations: end-stage renal disease, after atrial fibrillation ablation, and in combination with OAC in patients with a high risk of breakthrough stroke or in patients with prior stroke on OAC. The Left Atrial Appendage Occlusion Study IV (LAAOS-IV) ( n  = 4000) is a randomized trial that will determine the role of pLAAC and OAC compared to OAC alone in preventing ischemic stroke or systemic embolism.

SUMMARY: pLAAC has a growing role in patients with atrial fibrillation with moderate to high stroke risk and contraindication to OAC. Multiple randomized trials are currently underway in different patient populations, which may expand the role of pLAAC.