Key result
Surgical and percutaneous LAAO both reduce thromboembolic risk in AF, with neither approach proven superior.
Why the study?
Direct comparative evidence between surgical and percutaneous left atrial appendage occlusion in patients with non-valvular atrial fibrillation contraindicated to oral anticoagulation remains limited.
Does surgical or percutaneous left atrial appendage occlusion reduce thromboembolic risk in patients with non-valvular atrial fibrillation?
Does surgical or percutaneous left atrial appendage occlusion reduce thromboembolic risk in patients with non-valvular atrial fibrillation?
Both surgical and percutaneous LAAO reduce thromboembolic risk in non-valvular AF, but further studies are needed to directly compare them and address issues like residual LAA patency.
BACKGROUND: Left atrial appendage occlusion (LAAO) reduces thromboembolic risk in patients with atrial fibrillation (AF) who have contraindications to oral anticoagulation (OAC). LAAO can be performed surgically (S-LAAO) or percutaneously (pLAAO), but direct comparative evidence remains limited. METHODS: We conducted a contemporary narrative review of evidence for S-LAAO and pLAAO, emphasizing randomized controlled trials (RCTs) and systematic reviews (SRs), with and without meta-analyses. A focused PubMed/MEDLINE search evaluated procedural safety, thromboembolic outcomes, and completeness of LAA exclusion. Preprocedural, intraprocedural, and postprocedural imaging evidence was additionally assessed using guidelines, expert consensus statements, observational studies, and emerging clinical trials. RESULTS: RCTs and SRs support both S-LAAO and pLAAO for reducing thromboembolic events. S-LAAO reduces stroke and systemic embolism when performed during concomitant cardiac surgery, with the strongest evidence from LAAOS III. Evidence for isolated S-LAAO, including epicardial AtriClip closure, remains limited. pLAAO has been evaluated in multiple RCTs and SRs and has demonstrated noninferiority to OAC in selected populations. Incomplete LAA exclusion remains a concern with both approaches, manifesting as residual stumps after surgical closure and peri-device leaks after percutaneous implantation. TEE and cardiac CT remain key imaging modalities, while ICE, CMR, and DSA/fluoroscopy-guided techniques are increasingly investigated. CONCLUSION: Both S-LAAO and pLAAO effectively reduce thromboembolic risk; however, evidence does not establish superiority of one approach. Evidence is substantially greater for pLAAO, whereas S-LAAO is primarily studied during concomitant cardiac surgery. Direct comparative studies are needed. Future research should address residual LAA patency, postprocedural antithrombotic therapy, and emerging imaging strategies.
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Chestaro et al. (2026) conducted a review in Non-valvular atrial fibrillation. Surgical and percutaneous left atrial appendage occlusion (S-LAAO and pLAAO) vs. Oral anticoagulation or each other was evaluated. Both surgical and percutaneous left atrial appendage occlusion effectively reduce thromboembolic risk in atrial fibrillation, though evidence does not establish superiority of one approach.
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