A meta-analysis of left atrial appendage closure for stroke prevention in atrial fibrillation—adding to the debate but elements remain unresolved

Managing the trade off between stroke risk and bleeding risk is a key challenge in patients with atrial fibrillation (AF). In 90% of patients with non-valvular AF and intracardiac thrombus, the left atrial appendage (LAA) is thought to be the location (1). The advent of devices to occlude the LAA therefore raised the possibility that stroke risk could be eliminated in this group of patients without the need for long term anticoagulation. However, since the first reports of percutaneous LAA closure with the PLAATO device were published in 2002, progress has been somewhat limited (2). Despite the initial optimism, concerns surrounding safety and efficacy have restricted the number of devices receiving FDA approval (3) and limited commissioning of this treatment in the United Kingdom (4). Guidelines for the management AF to date have varied their advice on this technology with European Guidelines giving LAA closure devices a “IIb” recommendation (usefulness/efficacy is less well established by evidence/opinion) and this only in patients who have a contraindication to warfarin (5). North American Guidelines do not currently recommend LAA closure at all (6). In some ways the caution in recommending this technology is understandable given the paucity of data to support their use.