Left Atrial Appendage Closure: Between Imaging Precision and Uncertain Clinical Benefit

Left atrial appendage closure has emerged as an established nonpharmacological strategy for stroke prevention in selected patients with atrial fibrillation, particularly those in whom long-term oral anticoagulation is problematic. Its contemporary role, however, is defined by a central tension between procedural precision and clinical uncertainty. Advances in multimodality imaging, including transesophageal echocardiography, cardiac computed tomography, three-dimensional echocardiography, fusion imaging, and emerging computational tools, now allow highly accurate assessment of left atrial appendage anatomy, device sizing, intraprocedural guidance, and postprocedural surveillance. These techniques are essential to minimize peri-device leak, device-related thrombus, and other procedure-related complications in a structure characterized by marked interindividual variability. At the same time, the randomized evidence base remains nuanced. Early warfarin-era trials established the feasibility of LAAC, whereas contemporary comparisons with direct oral anticoagulants and best available medical therapy have yielded more heterogeneous results, reflecting differences in patient selection, comparator regimens, and endpoint design. Taken together, the available data support LAAC as a reasonable option in carefully selected patients at elevated bleeding risk or with limited tolerance for chronic anticoagulation, but not as a universal substitute for oral anticoagulant therapy. Future progress will depend on more refined phenotyping, standardized imaging pathways, and longer-term comparative data to better define which patients derive the greatest net clinical benefit from LAAC.