Indications of left atrial appendage (LAA) device closure

Indications of left atrial appendage (LAA) device closure:

Patients with non-valvular atrial fibrillation who have an increased risk of stroke (CHA₂DS₂-VASc score ≥2 in men or ≥3 in women) and are not suitable for long-term oral anticoagulation.

Absolute contraindication to long-term oral anticoagulants: History of major or life-threatening bleeding (e.g., intracranial hemorrhage). Active bleeding disorder or high-risk bleeding lesion. Severe thrombocytopenia or advanced liver disease with coagulopathy.

Relative contraindication or intolerance to oral anticoagulation: Recurrent clinically significant bleeding while on adequate anticoagulation. Poor tolerance or allergy to anticoagulants. Inability to maintain stable INR on warfarin. Poor adherence or inability to take long-term anticoagulant therapy.

High bleeding risk despite indication for anticoagulation: HAS-BLED score ≥3 with anticipated long-term bleeding risk. Elderly patients with frequent falls or frailty where bleeding risk outweighs benefit of anticoagulation.

Patients requiring stroke prevention where anticoagulation is undesirable: Those needing long-term dual antiplatelet therapy (e.g., recent coronary stenting) with high bleeding risk. Patients with previous gastrointestinal bleeding where recurrence risk is high.

Recurrent thromboembolic events despite adequate anticoagulation: Ischemic stroke or systemic embolism occurring while on therapeutic oral anticoagulation, after excluding non-cardiac causes.

Guideline-based summary: LAA device closure is reasonable in patients with non-valvular atrial fibrillation, increased stroke risk, and contraindication to long-term oral anticoagulation, when performed in experienced centers after shared decision-making.

Key exclusions to remember: Mechanical heart valves. Moderate to severe rheumatic mitral stenosis. Presence of active LAA thrombus at the time of procedure.

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