Left atrial appendage closure devices: a contemporary review of techniques, tips and tricks

Atrial fibrillation (AF) affects approximately 3%-5% of adults and is projected to double in prevalence by 2060, significantly increasing the burden of thromboembolic stroke. This risk is largely attributed to thrombus formation within the left atrial appendage (LAA), particularly in nonvalvular AF, where the LAA's trabeculated anatomy, diverse morphologies (e.g., chicken wing, windsock, cactus, cauliflower), and impaired contractility allows for blood stasis and thrombogenesis. As a result, the LAA has become a focus for stroke prevention strategies. This review demonstrates current evidence on LAA closure by discussing patient selection, anatomical feasibility, procedural workflow, imaging guidance (transesophageal echocardiography vs. intracardiac echocardiography), device platforms (Amplatzer Amulet, Watchman 2.5, Watchman FLX/FLX Pro), and complication profiles. P procedural success rates exceed 95%, with improving safety profiles. Nonetheless, adverse events such as pericardial effusion, device-related thrombus (DRT), peri-device leak (PDL), device embolization, and periprocedural stroke remain important considerations. Post-implant antithrombotic strategies are evolving beyond the traditional warfarin/aspirin → DAPT → SAPT pathway toward more individualized regimens, including simplified DOAC or antiplatelet-based approaches tailored to bleeding and thrombotic risk especially in complex scenarios like concurrent coronary stenting. Ongoing device innovations (e.g., FLX Pro, expanded size matrices, thromboresistant coatings), CT-led surveillance algorithms, and randomized studies of post-implant pharmacotherapy aim to reduce DRT/bleeding, harmonize follow-up, and expand indications. Collectively, these advances refine patient-centered LAA closure by aligning anatomic complexity, procedural technique, and pharmacology to improve stroke prevention and safety in AF.