Current methods of left atrial appendage closure: the non-pharmacological approach for stroke prevention in atrial fibrillation patients

Atrial fibrillation (AF) is a significant contributor to cardioembolic stroke, with the left atrial appendage (LAA) often being the principal source of thrombus. Given the substantial impact of stroke on patient quality of life, and its potential life-threatening nature, stroke prevention is paramount in the management of AF. Nonvitamin K oral anticoagulants (NOACs) or vitamin K antagonists are typically the first line of treatment to prevent strokes caused by AF. However, for patients unable to tolerate oral anticoagulants, alternatives such as percutaneous LAA closure (LAAC) or surgical LAAC might be considered. The most widely used percutaneous LAAC methods are the AMPLATZER Amulet and WATCHMAN devices. Registry studies have shown promising results for both devices, with low ischemic stroke rates in patients undergoing LAAC (Reddy in J Am Coll Cardiol 70(24):2964–75, 2017, Holmes in J Am Coll Cardiol 64(1):1–12, 2014). However, catheter-based LAAC has some limitations, such as a risk of device-related thrombus and the need for antithrombotic medication to facilitate device endothelialization Mesnier (Circ Cardiovasc Interv 16(5):e012812, 2023.). Surgical LAAC is being considered as a method that can complement the shortcomings of percutaneous LAAC. In the past, surgical LAAC was performed either by LAA resection or internal obliteration during open-heart surgery, but it was not widely used as a standalone treatment due to its high invasiveness. More recently, the development of a new clip device allows for LAAC via thoracoscopy, eliminating the need for cardiopulmonary bypass. Moreover, its safety and efficacy profiles surpass those of previous LAAC. The recent surgical LAAC devices have not only demonstrated high success rates but also shown low invasiveness. It becomes a feasible treatment alternative for non-valvular AF patients who experience NOAC failure or have a high bleeding risk with oral anticoagulants.