Left Atrial Appendage Occlusion and Its Role in Stroke Prevention

David Seiffge; Maurizio Paciaroni; Elias Auer; Jacqueline Saw; Michelle C. Johansen; Alexander P. Benz

doi:10.1161/strokeaha.124.043867

April 18, 2025Stroke

Left Atrial Appendage Occlusion and Its Role in Stroke Prevention

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Why the study?

Atrial fibrillation increases cardioembolic stroke risk, with the left atrial appendage being the main thrombus site, warranting a review of surgical and percutaneous LAAO approaches and evidence.

Does left atrial appendage occlusion prevent stroke in patients with atrial fibrillation?

Structured PICO

Does left atrial appendage occlusion prevent stroke in patients with atrial fibrillation?

P

Population

Patients with atrial fibrillation, particularly those with a history of intracranial hemorrhage, high risk of intracranial bleeding, or breakthrough stroke despite anticoagulation

I

Intervention

Surgical or percutaneous left atrial appendage occlusion (LAAO)

This review outlines the role of left atrial appendage occlusion for stroke prevention in atrial fibrillation, particularly for patients with high bleeding risk or breakthrough stroke.

Implication

Supports LAAO consideration in high-bleeding-risk AF or breakthrough stroke on anticoagulation; leaves open randomized confirmation of net benefit.

Abstract

Atrial fibrillation is a frequent cardiac arrhythmia and is associated with an increased risk of cardioembolic stroke. The left atrial appendage is a finger-like extension originating from the main body of the left atrium and the main location of thrombus formation in patients with atrial fibrillation. Surgical or percutaneous left atrial appendage occlusion (LAAO) aims at preventing clot formation in the left atrial appendage. Here, we describe available surgical and percutaneous approaches to achieve LAAO and discuss the available evidence for LAAO in patients with atrial fibrillation. We discuss LAAO and its role in stroke prevention in 2 frequent scenarios of cerebrovascular medicine: LAAO as a potential alternative to oral anticoagulation in patients with a history of intracranial hemorrhage or at high risk of intracranial bleeding, and LAAO as add-on therapy to direct oral anticoagulant therapy in patients with breakthrough stroke despite anticoagulation. Finally, we provide an outlook on currently ongoing trials that will provide further evidence in the next years.