Reassuring but not convincing - another registry to support left atrial appendage closure but randomized data remains scarce

Left atrial appendage closure (LAAC) is considered an established therapy for patients with contraindications to long-term oral anticoagulation [1].As per study design, LAAC was initially deemed a true alternative to vitamin K antagonists [2,3].However, with the advent of direct oral anticoagulants (DOACs) and its compelling data from thousands of patients, interventional LAAC was pushed back to become a niche indication for patients with a high bleeding risk.Contemporary use and effectiveness were well described in two large-scale prospective registries mainly performed in Europe [4,5].In the present edition of the International Journal of Cardiology Heart & Vasculature, Philips and co-workers present on the Asian-Australian experience with Watchman™ for LAAC in 201 patients [6].The data documents the continuous effort of the researchers as well as the manufacturer to build evidence for LAAC.Outcome data were well in line with the European experience in the Ewolution registry reporting a high procedural success rate with few serious complications and an excellent device performance reflected by a high sealing rate.Moreover, the authors focused on a comparison between Asians and non-Asians without identifying any relevant differences for LAAC.This is of particular importance taking into consideration the increased risk for Asians to suffer from an intracerebral hemorrhage on oral anticoagulation with vitamin K antagonists as well as with dabigatran [7,8].It is striking to see the consistency of ischemic stroke/systemic embolism rate across all Watchman™ registries and studies ranging between 1.3 and 2% per year.Surprisingly, the annual major bleeding rate was low at 2.2%, in fact much lower as reported in the European experience being 2.7%/year after 2 years of follow-up [9].