Left atrial appendage occlusion: are we targeting the right patients?

The prevalence of non-valvular atrial fibrillation (NVAF) continues to rise at rates that exceed anticipated projections. The heightened stroke risk and common intolerance of anticoagulation in NVAF patients have catalysed the advent of left atrial appendage occlusion (LAAO). Following the first-in-human LAAO procedure in 2002, two LAAO devices − WATCHMAN (Boston Scientific) and Amplatzer Amulet (Abbott) − received European conformity (CE) marking in Europe in 2005 and 2008 and U.S. Food and Drug Administration (FDA) approval in the USA in 2015 and 2019, respectively. Recently, LAAO literature and volumes have surged, showcasing field progress as well as sparking debates on its appropriate use and best practices.

As organisational structure shapes behaviour, clinical practices in adopting new technology frequently follow guidelines established by professional societies. Current US and European guidelines assign a class IIb recommendation for LAAO in high-risk NVAF patients who have contraindications to long-term anticoagulation. Embedded in these guidelines are (1) the limited literature guiding LAAO use, and (2) the necessity to forecast ischaemic and bleeding risks when assessing a patient’s candidacy for LAAO. In the USA, healthcare payers mandate...