Left atrial appendage closure: therapeutic option or solution?

Abstract

Atrial fibrillation (AF) is the most common type of arrhythmia. AF increases the risk of thromboembolic complications including stroke. Stroke in patients with AF is more severe compared with patients with sinus rhythm. Long-term oral anticoagulant therapy (OAT) is widely used in a large population of patients with AF to prevent arterial thromboembolic events, such as stroke and systemic embolism. However, it is well established that OAT significantly increases the risk of bleeding. Percutaneous left atrial appendage closure (LAAC) is an option for stroke prophylaxis in patients with nonvalvular AF and high risk of bleeding. This paper provides an overview of recent studies that address the effectiveness and safety of LAAC using the Amplatzer Cardiac Plaque and Watchman Left Atrial Appendage System. LAAC provides a superior choice of treatment in patients with absolute contraindication of systemic OAT, in cases of refusal of systemic OAT by a patient, and as a complementary treatment to anticoagulation in patients with embolic events despite adequate OAT. LAAC should be also considered as a therapeutic option for patients with high thromboembolic risk and very high bleeding risk on the basis of individual risk/benefit evaluation for OAT vs. alternative methods of treatment. In general, LAAC becomes more attractive with increasing thromboembolic risk. There is a need for further studies to address the question of whether LAAC is actually the best method for preventing thromboembolism for patients with moderate/high thromboembolic risk and relatively low bleeding risk, to determine the optimum antithrombotic or antiplatelet therapy in patients who underwent LAAC, as well as to conduct direct comparative analysis of LAAC and the use of new oral anticoagulant drugs (NOAC).