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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𝘼𝙣𝙩𝙞𝙘𝙤𝙖𝙜𝙪𝙡𝙖𝙩𝙞𝙤𝙣 𝘼𝙛𝙩𝙚𝙧 𝙎𝙩𝙧𝙤𝙠𝙚

𝘼𝙣𝙩𝙞𝙘𝙤𝙖𝙜𝙪𝙡𝙖𝙩𝙞𝙤𝙣 𝘼𝙛𝙩𝙚𝙧 𝙎𝙩𝙧𝙤𝙠𝙚 in Patient with AF and acute IS/TIA European Heart Association Guideline recommends: • 1 days after TIA • 3 days after mild stroke • 6 days after moderate stroke • 12 days after severe stroke Early anticoagulation can decrease a risk of recurrent stroke and embolic events but may increase a risk of secondary hemorrhagic transformation of brain infarcts. The 1-3-6-12-day rule is a known consensus with graded increase in delay of anticoagulation between 1 and 12 days after onset of ischemic stroke or transient ischemic attack(TIA), according to neurological severity based on European expert opinions. However, this rule might be somewhat later than currently used in a real-world practical setting.

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