Recent Trials of Left Atrial Appendage Closure versus Oral Anticoagulants: An Optimistic View

Abstract: Thrombus formation in atrial fibrillation mostly occurs in the left atrial appendage (LAA). LAA closure (LAAC) seems logical to reduce thrombo-embolic AF-related stroke. Early device trials, which predominantly compared LAAC against oral anticoagulant (OAC) with warfarin, showing after 5 years less bleeding and possibly similar ischemic stroke rates with LAAC. New trials (CHAMPION-AF, OPTION, CLUSTER-AF and ASAP TOO) comparing LAAC versus direct OACs, or standard of care for the OAC-intolerant, have reported apparently discordant results, most probably related to the patient phenotype than LAAC itself. Recent meta-analyses, which include new trials have shown that overall, LAAC is followed by less clinically-relevant bleeding but more ischemic but not total strokes. Longer follow-up offsetting penalties related to the implant procedure, more expert implantation and reduced device-related thrombosis should increase the comparative value of LAAC. Meanwhile, LAAC offers therapeutic relief for OAC-intolerant patients or for those wh, understand the outcomes of LAAC and prefer device rather than medical therapy. A change in guideline recommendations should now be considered.