Left Atrial Appendage Occlusion: Where are We Going?

Prevention of ischemic stroke is one of the most important issues in patients with atrial fibrillation (AF). Currently, most patients are managed satisfactorily with oral anticoagulant (OAC) therapy. The remaining patients, who cannot tolerate long-term systemic OAC or who have an excess thrombotic burden that cannot be adequately controlled by OAC alone, require local anti-thrombotic therapy such as left atrial appendage (LAA) mechanical exclusion, either by surgical excision or percutaneous closure device implantation. Since the first percutaneous left atrial appendage occlusion (LAAO) device implantation was performed in 2001, there have been numerous unanswered questions, which might be clarified only after additional experience in this field. Although an enormous number of non-valvular atrial fibrillation (NVAF) patients require thrombo-prophylactic management, which can be either systemic or local management, LAAO has not yet been widely adopted as an alternative to anticoagulant therapy because of the extraordinarily diverse anatomical variation within the LAA as well as the complexity of clinical situations (i.e. relative / absolute contraindication to anticoagulant, high bleeding risk with or without prior major bleeding events, recurrent stroke during proper secondary prevention, comorbidities that increase the bleeding risk or thrombotic risk, and are accompanied by a compromised life expectancy, such as malignancy). The preliminary answer to the question regarding the meaningful destination of LAAO has been carefully discussed in this article. Can LAAO replace OAC?