Beyond Echocardiography: The Evolving Role of Imaging in Left Atrial Appendage Closure in the Modern Era

Left atrial appendage closure (LAAC) has emerged as a crucial alternative for stroke prevention in patients with atrial fibrillation ineligible for long-term anticoagulation. While echocardiography, particularly transesophageal echocardiography (TEE), remains fundamental for procedural planning and guidance, the integration of multimodal imaging is increasingly shaping contemporary practice. This review explores the evolving landscape of imaging for LAAC, highlighting their complementary roles, technological advancements, and future directions in optimizing procedural outcomes. TEE is the standard imaging modality for LAAC, providing comprehensive anatomical and functional assessment across all procedural phases. However, advanced cardiac imaging techniques, including cardiac computed tomography (CCT) and cardiac magnetic resonance (CMR), are gaining prominence. CCT offers detailed anatomical characterization of the left atrial appendage (LAA) and surrounding structures, aiding in device sizing and excluding thrombus. CMR provides superior tissue characterization and can be an alternative when TEE is not feasible. Intracardiac echocardiography may be a valid alternative to TEE ti guide device deployment and assessment. This review critically evaluates the strengths and limitations of each imaging modality in the LAAC procedure, from pre-procedural planning and patient selection to intraprocedural guidance and post-procedural assessment for complications like device leaks and device-related thrombosis. The evolving role of three-dimensional imaging and potential future applications, such as artificial intelligence-assisted image analysis, are also considered. Understanding the complementary roles of these imaging modalities is crucial for optimizing patient care in the modern era of LAAC. LAAC has emerged as a crucial alternative for stroke prevention in patients with atrial fibrillation who are ineligible for long-term anticoagulation. While echocardiography remains the cornerstone of procedural planning and guidance, the expanding role of multimodal imaging is reshaping current practice. Advanced cardiac imaging techniques, including CCT and CMR, are increasingly integrated into patient selection, device sizing, and post-procedural assessment, enhancing safety and efficacy. This review explores the evolving landscape of imaging modalities in LAAC, highlighting their complementary roles, recent technological advances, and future directions in optimizing procedural outcomes.