clopidogrel) is used for six months postprocedure, as in the ASAP study, or for one to three months for patients at high risk of bleeding. As of September 2022, FDA labeling for patients with nonvalvular AF who undergo WATCHMAN FLX LAAO placement was expanded to include 45 days of oral anticoagulant therapy plus dual antiplatelet therapy. Data supportive of this approach were from an analysis of more than 17,000 patients from the NCDR-LAAO Registry, which demonstrated no significant difference in rates of major adverse events at 45 days postimplantation, whether patients were discharged from the hospital on dual antiplatelet therapy, a DOAC and aspirin, or warfarin and aspirin. https://www.uptodate.com/contents/atrial-fibrillation-left-atrial-appendage-occlusion/print 12/37 7/5/23, 9:05 AM Atrial fibrillation: Left atrial appendage occlusion - UpToDate Alternative anticoagulation strategies Alternative imaging-based strategy An alternative strategy was used in the nonrandomized, newer-generation WATCHMAN study (PINNACLE FLX), which confirmed device safety and efficacy [11]. This strategy included treatment with a DOAC through at least a 45-day follow-up, with apixaban or rivaroxaban strongly recommended. Patients were also prescribed concomitant low-dose (81 to 100 mg) aspirin. On evidence of adequate LAA seal (leak 5 mm) at the 45-day TEE evaluation, patients were directed to discontinue DOAC therapy and begin a dual antiplatelet therapy regimen of clopidogrel (75 mg) plus low-dose aspirin until six months postimplantation, followed by low-dose aspirin indefinitely. If a leak >5 mm was measured at the 45-day follow-up, patients continued DOAC plus aspirin and were reevaluated at six months postimplant. If there were no leaks >5 mm at the subsequent follow-up visit, patients could forego dual antiplatelet therapy and proceed straight to life-long low-dose aspirin. Postimplantation follow-up visits were required at 45 days and 6, 12, 18, and 24 months. Long-term, half-dose DOAC This regimen versus standard anticoagulation treatment was tested in a nonrandomized study of 555 patients post-WATCHMAN device implantation [33]. The primary endpoint was a composite of device-related thrombosis, thromboembolic events, and bleeding. After 13 months, device-related thrombosis occurred in 12 patients, all in the full-dose DOAC group (3 versus 0 percent). The risk of nonprocedural major bleeding was more favorable in the half-dose DOAC group (0.5 percent versus 4 percent). The rate of the primary composite endpoint was higher in the standard treatment group (10 versus 1 percent). Further randomized studies are needed before we can make recommendations about the long-term, half-DOAC anticoagulation strategy. Postprocedural imaging We obtain a transthoracic echocardiogram one day postprocedure to ensure there is no pericardial effusion. We also obtain a TEE between one and six months postprocedure to screen for or device-related thrombus (DRT), pericardial effusion, or a peridevice leak. DRT is present in approximately 2 to 5 percent of patients, depending on time of screening and device type, and is associated with risk of stroke or transient ischemic attack [16,20,34-36]. For patients with documented DRT, the optimal antithrombotic regimen is not known. Options for treatment of DRT include one of the following anticoagulants that may be combined with aspirin: DOAC (such as apixaban or rivaroxaban; avoid dabigatran) for 8 to 12 weeks, warfarin (target international https://www.uptodate.com/contents/atrial-fibrillation-left-atrial-appendage-occlusion/print 13/37 7/5/23, 9:05 AM Atrial fibrillation: Left atrial appendage occlusion - UpToDate normalized ratio 2 to 3) for 8 to 12 weeks, or low molecular weight heparin for two to four weeks [36]. It is important to check for any residual communication between the LA and LAA after device closure. In some cases, the presence of a leak will prompt shared decision- making discussions with patients regarding continued oral anticoagulation or closure of the leak with other devices such as a coil. It is uncertain if the size of the peridevice leak should guide further management, and prior data are mixed [37]. Previously, a peridevice leak of <5 mm was thought to be of little clinical significance (this amount of leak was arbitrarily used to define successful occlusion in device trials), whereas a leak 5 mm was an indication for continuing oral anticoagulation and/or additional endovascular procedure to close the residual leak (eg, with another percutaneous closure device or coils). Recent real-world, registry-based data suggest that small leaks may be associated with higher bleeding and thromboembolic risk [38]. (See 'Rationale and limitations' above.) A study of over 51,000 people in the National Cardiovascular Data LAAO Registry showed that small (>0 to 5 mm) leaks after LAAO were associated with a modestly higher incidence of thromboembolic and bleeding events, and large leaks (>5 mm) were not associated with adverse events, although higher proportions of these patients were maintained on anticoagulation. In this study, small leaks were common; 25.8 percent had small leaks and 0.7 percent had large leaks. A higher proportion of patients with large leaks were on warfarin at 45 days versus small or no leak (44.9 versus 34.4 and 32.4 percent, respectively). At 6 and 12 months, anticoagulant use decreased but remained more frequent in patients with large leaks. Thromboembolic and bleeding events were uncommon in all groups. However, compared with patients with no leak, those with small leaks had slightly higher odds of stroke/transient ischemic attack/systemic embolization (hazard ratio [HR] 1.15; 95% CI 1.03-1.29), major bleeding (HR 1.11; 95% CI, 1.03-1.12), and any major adverse events (HR 1.12; 95% CI 1.05-1.16). There were no significant differences in adverse events between patients with large leaks and patients with small or no leaks. After surgical occlusion Patients with no contraindication to anticoagulation These patients are treated with anticoagulation indefinitely. Long-term anticoagulation in patients with AF is discussed separately. (See 'Patients undergoing surgery' above and "Atrial fibrillation in adults: Use of oral anticoagulants".) https://www.uptodate.com/contents/atrial-fibrillation-left-atrial-appendage-occlusion/print 14/37 7/5/23, 9:05 AM Atrial fibrillation: Left atrial appendage occlusion - UpToDate Patients with a contraindication to long-term anticoagulation These patients are treated with anticoagulation (typically a DOAC) plus aspirin (81 to 325 mg daily) for six weeks to three months after the procedure, followed by TEE assessment of the completeness of occlusion. Patients with an absolute contraindication to oral anticoagulants instead receive dual antiplatelet therapy (once-daily aspirin 81 to 325 mg plus clopidogrel 75 mg) during the pre-TEE period of six weeks to three months. If the TEE demonstrates that the LAA is completely occluded and long-term anticoagulation is contraindicated, anticoagulation is discontinued, and aspirin is continued indefinitely. If any leak is present after surgical LAAO, oral anticoagulation should optimally be continued. This approach is supported by the results of an observational study of 72 patients undergoing surgical LAAO [39]. The study found that the risk of stroke or systolic embolism was higher in patients with incomplete LAA closure compared with those with complete closure (24 versus 2 percent during 44-month mean follow-up), despite similar rates of anticoagulation and recurrent AF. Among patients with incomplete closure, those with stroke or systemic embolism had smaller LAA neck diameters (2.8 versus 7.1 mm) than those without these adverse outcomes. DEVICE SAFETY AND COMPLICATIONS Percutaneous LAAO has become safer over time, possibly due to increased operator experience with the procedure and improvements in device iterations. Outcomes were compared between the 542 patients in the randomized study and 460 patients in the nonrandomized Continued Access Protocol registry who underwent WATCHMAN implantation after the randomized trial was completed [34]. A study done 10 years later showed a significant decline in the rate of procedure- or device-related safety events within seven days compared with those in the earlier randomized trial (3.7 versus 7.7 percent, respectively). In a large registry of over 38,000 WATCHMAN implantations, the procedural success rate was very high at 98.3 percent, which was even higher than reported in pivotal clinical trials such as PROTECT AF [40]. The complications of the LARIAT are described above. (See 'LARIAT system' above.) There are several potential complications that can arise from the procedure itself or that are due to the presence of the device in the LAA. Some of these complications can occur in the acute periprocedural period, whereas others occur over a longer time frame. Management of these complications is crucial and underscores the importance of aggressive patient follow-up using appropriate imaging to look for such complications. Furthermore, understanding factors that https://www.uptodate.com/contents/atrial-fibrillation-left-atrial-appendage-occlusion/print 15/37 7/5/23, 9:05 AM Atrial fibrillation: Left atrial appendage occlusion - UpToDate lead to increased risk of complications is also important in terms of patient counseling and shared decision-making. Complications of cardiac surgery are described in detail separately. (See "Postoperative complications among patients undergoing cardiac surgery".) In patients undergoing percutaneous LAAO, these complications have been described: Death and cardiac arrest Death and cardiac arrest are infrequent complications of WATCHMAN procedures. Among 38,158 patients who underwent LAAO in the National Cardiovascular Data LAAO Registry, in-hospital, procedural-related death occurred in 0.19 percent and cardiac arrest in 0.24 percent of patients [40]. Vascular The majority of periprocedural complications are vascular (ie, resulting femoral vein puncture). The incidence of such complications is infrequent with adoption of newer techniques to access the femoral vein and to stop bleeding after the procedure. Complications that may arise due to the transseptal puncture itself can also be minimized with ultrasound-guided puncture. Among 38,158 people who underwent LAAO in the National Cardiovascular Data LAAO Registry, the prevalence of a major vascular complication was 0.15 percent [40]. Pericardial effusion The LA and LAA are thin walled; thus, manipulation of transseptal equipment, large-bore sheaths, and devices can traumatize the wall, resulting in pericardial effusion. The incidence of pericardial effusion has declined over time, with improved operator skills; in the earlier PROTECT-AF study of WATCHMAN devices, the incidence of pericardial effusion requiring intervention was 4.3 percent [34], whereas in the more recent WATCHMAN clinical trials and registries, the pooled incidence of cardiac tamponade was about 1.3 percent [41,42]. In a report from the National Cardiovascular Data LAAO Registry, among 65,355 patients, 881 (1.3 percent) developed procedural pericardial effusions, percutaneous drainage was performed in 1.18 percent, and cardiac surgery was performed in 0.27 percent of the study population [42]. Pericardial effusion not requiring intervention was reported in 669 patients (1.02 percent). Signs and symptoms of a pericardial effusion and tamponade are discussed separately. (See "Diagnosis and treatment of pericardial effusion", section on 'Clinical presentation'.) Periprocedure stroke Peridevice leaks (also called device-related leaks), air embolism, and device-related thrombus can lead to near-term stroke. Anticoagulation and antiplatelet therapy after the procedure are discussed above. (See 'Postprocedure management' above.) https://www.uptodate.com/contents/atrial-fibrillation-left-atrial-appendage-occlusion/print 16/37 7/5/23, 9:05 AM Atrial fibrillation: Left atrial appendage occlusion - UpToDate In the National Cardiovascular Data LAAO registry, in-hospital ischemic stroke was documented in 0.12 and hemorrhagic stroke in 0.01 percent of patients, respectively [40]. Most events were related to air embolism from inadequate device prepping. Fewer complications are due to thromboembolism from preexisting or de-novo equipment- related LAA thrombus. Air embolism cerebral circulation can cause a transient ischemic attack or stroke. Once a thrombus is detected, additional heparin should be administered, and thrombus aspiration via a large sheath may be attempted. The procedure should be completed expeditiously with either deployment of the device or removal of the sheath/device from the LA. Full neurological assessment should be performed when the patient awakes from general anesthesia, and emergent stroke team consultation is required if the patient has neurological deficits. Device embolization Device embolization is a rare but serious complication of LAAO. With the legacy WATCHMAN device, the reported incidence was 0.24 percent in clinical trials [41], with an even lower incidence reported in the real-world National Cardiovascular Data LAAO registry at 0.07 percent [40]. Most embolizations do not cause symptoms; however, palpitations, heart failure, hypotension, and cardiac arrest had been reported. The first-line strategy for management is percutaneous retrieval of the embolized device. Device erosion This complication is very rare (occurring in <1 percent or patients) but can be devastating. Long-term follow-up with appropriate imaging (ie, a transesophageal echocardiogram [TEE] between one and six months postprocedure) to look for new pericardial effusion is important to screen for this complication [43]. The following issues regarding LAAO adverse events and hospital readmission are also important to recognize: Greater adverse events in females Females have a higher risk of in-hospital adverse events after LAAO [44]. In the National Cardiovascular Data Registry, 49,000 patients (41 percent female) underwent LAAO between 2016 and 2017. Females were more likely than males to experience any adverse event (6 versus 4 percent), including a pericardial effusion requiring drainage (1.2 versus 0.5 percent) or major bleeding (1.7 versus 0.8 percent). Also, female patients were more likely to have a hospital stay >1 day (16 versus 12 percent) or experience death (adjusted odds ratio 2.01; 95% CI 1.31-3.09), although death was rare and absolute differences minimal (0.3 versus 0.1 percent). Female patients in this study were older than male patients but less likely to have diabetes and heart failure. High readmission Among 14,000 patients with LAAO in the Nationwide Inpatient Sample between 2016 and 2017, the 30-day readmission rate was 9.4 percent [45]. Of these, 12 https://www.uptodate.com/contents/atrial-fibrillation-left-atrial-appendage-occlusion/print 17/37 7/5/23, 9:05 AM Atrial fibrillation: Left atrial appendage occlusion - UpToDate percent of readmissions were attributable to gastrointestinal bleeding. Risk factors for readmission included drug abuse ( odds ratio 4.1; 95% CI 1.34-12.54) and anemia (OR 1.88; 95% CI 1.12-3.18). RECOMMENDATIONS OF OTHER GROUPS The LAAOS III trial on surgical LAAO was completed after major society guidelines were published, so this evidence was not incorporated in those guidelines. (See 'Patients undergoing surgery' above.) A consensus statement from the European Heart Rhythm Association and the European Association of Percutaneous Cardiovascular Interventions published in 2020 states that LAAO is acceptable in patients with a contraindication to oral anticoagulation or those who are unwilling or unable to take oral anticoagulation [46]. The United States Food and Drug Administration (FDA) approval is somewhat more liberal than the European Society of Cardiology guideline for patients eligible for oral anticoagulation and has other indications for nonpharmacologic therapy (eg, lifestyle indications, labile international normalized ratio). The 2019 focused update of the 2014 American Heart Association/American College of Cardiology/Heart Rhythm Society guideline for the management of patients with AF makes a weak recommendation for surgical excision of LAA at the time of cardiac surgery [47,48]. In addition, it states that percutaneous LAAO may be considered in patients with AF at increased risk of stroke who have contraindications to long-term anticoagulation. SOCIETY GUIDELINE LINKS Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Atrial fibrillation" and "Society guideline links: Arrhythmias in adults".) SUMMARY AND RECOMMENDATIONS Rationale and limitations Among patients with atrial fibrillation (AF), thrombus in the left atrial appendage (LAA) is the primary source for thromboemboli. This is the rationale for excluding the appendage in selected patients. (See 'Rationale and limitations' above.) https://www.uptodate.com/contents/atrial-fibrillation-left-atrial-appendage-occlusion/print 18/37 7/5/23, 9:05 AM Atrial fibrillation: Left atrial appendage occlusion - UpToDate However, thrombogenesis in patients with AF may not be limited to the LA, and the procedure does not always result in complete occlusion of the LAA. Indications Patients not undergoing cardiac surgery For patients with AF with an indication for anticoagulation (based upon risk of stroke and other systemic thromboembolism ( table 1)) but who have a contraindication to long-term anticoagulation, we suggest a percutaneous LAA occlusion (LAAO) procedure (Grade 2B). Among these devices, we prefer the WATCHMAN. (See 'Patients not undergoing cardiac surgery' above and 'WATCHMAN device' above.) This approach does not apply to patients with an indication for anticoagulation other than AF (eg, an implanted mechanical valve). (See "Atrial fibrillation in adults: Selection of candidates for anticoagulation".) Patients with AF and a CHA DS -VASc score of at least 2 ( 2 table 1) who are 2 undergoing cardiac surgery for another indication For such patients, if there is no contraindication to long-term anticoagulation, we recommend concomitant surgical LAAO. (Grade 1B) (See 'Patients undergoing surgery' above.) For such patients, if there is a contraindication to long-term anticoagulation, we suggest concomitant surgical LAAO (Grade 2C). (See 'Patients undergoing surgery' above.) Preprocedure planning Specific LAA measurements can be useful for LAA closure planning; these can be obtained by transesophageal echocardiogram (TEE), cardiac computed tomography angiography, or cardiac magnetic resonance imaging. If cardiac imaging shows an LA/LAA thrombus, the LAAO procedure is contraindicated. (See 'Preprocedure planning' above.) Percutaneous devices The WATCHMAN device is the most commonly implanted percutaneous LAAO device and has the most robust data to support its use ( table 3). (See 'Percutaneous devices' above.) Surgical devices Types of surgical closure include stapler occlusion, amputation and suture, and epicardial device closure ( table 2). (See 'Surgical LAA closure' above.) Postprocedure management After percutaneous closure https://www.uptodate.com/contents/atrial-fibrillation-left-atrial-appendage-occlusion/print 19/37 7/5/23, 9:05 AM Atrial fibrillation: Left atrial appendage occlusion - UpToDate We treat with short-term antithrombotic therapy (anticoagulant and antiplatelet therapy) after placement of the device. Patients with an absolute contraindication to oral anticoagulants instead receive dual antiplatelet therapy postprocedure. We obtain a TEE between one and six months postprocedure. Device-related thrombus and/or peridevice leak 5 mm may be indications for continued anticoagulation. (See 'After percutaneous closure' above.) After surgical occlusion Patients with a contraindication to long-term anticoagulation These patients are treated with short-term anticoagulation (typically a DOAC) plus aspirin for six weeks to three months after the surgery, followed by TEE assessment of the completeness of occlusion. Patients with an absolute contraindication to oral anticoagulants instead receive dual antiplatelet therapy during the pre-TEE period of six weeks to three months. If the TEE demonstrates that the LAA is completely occluded and long-term anticoagulation is contraindicated, only aspirin is continued indefinitely. If any leak is present postsurgical LAAO, oral anticoagulation should be continued. (See 'After surgical occlusion' above.) Patients with no contraindication to anticoagulation These patients are treated with anticoagulation indefinitely regardless of whether a rhythm control intervention is performed. (See 'Patients undergoing surgery' above.) Complications These are rare but include pericardial effusion/tamponade, vascular injury, device erosion or embolization, stroke, death, and cardiac arrest. (See 'Device safety and complications' above.) ACKNOWLEDGMENT The UpToDate editorial staff acknowledges Alan Cheng, MD, who contributed to earlier versions of this topic review. Use of UpToDate is subject to the Terms of Use. REFERENCES https://www.uptodate.com/contents/atrial-fibrillation-left-atrial-appendage-occlusion/print 20/37 7/5/23, 9:05 AM Atrial fibrillation: Left atrial appendage occlusion - UpToDate 1. Blackshear JL, Odell JA. Appendage obliteration to reduce stroke in cardiac surgical patients with atrial fibrillation. Ann Thorac Surg 1996; 61:755. 2. Viles-Gonzalez JF, Kar S, Douglas P, et al. The clinical impact of incomplete left atrial appendage closure with the Watchman Device in patients with atrial fibrillation: a PROTECT AF (Percutaneous Closure of the Left Atrial Appendage Versus Warfarin Therapy for Prevention of Stroke in Patients With Atrial Fibrillation) substudy. J Am Coll Cardiol 2012; 59:923. 3. Turagam MK, Osmancik P, Neuzil P, et al. Left Atrial Appendage Closure Versus Oral Anticoagulants in Atrial Fibrillation: A Meta-Analysis of Randomized Trials. J Am Coll Cardiol 2020; 76:2795. 4. Whitlock RP, Belley-Cote EP, Paparella D, et al. Left Atrial Appendage Occlusion during Cardiac Surgery to Prevent Stroke. N Engl J Med 2021; 384:2081. 5. Friedman DJ, Piccini JP, Wang T, et al. Association Between Left Atrial Appendage Occlusion and Readmission for Thromboembolism Among Patients With Atrial Fibrillation Undergoing Concomitant Cardiac Surgery. JAMA 2018; 319:365. 6. Yao X, Gersh BJ, Holmes DR Jr, et al. Association of Surgical Left Atrial Appendage Occlusion With Subsequent Stroke and Mortality Among Patients Undergoing Cardiac Surgery. JAMA 2018; 319:2116. 7. Melduni RM, Schaff HV, Lee HC, et al. Impact of Left Atrial Appendage Closure During Cardiac Surgery on the Occurrence of Early Postoperative Atrial Fibrillation, Stroke, and Mortality: A Propensity Score-Matched Analysis of 10 633 Patients. Circulation 2017; 135:366. 8. Wang Y, Di Biase L, Horton RP, et al. Left atrial appendage studied by computed tomography to help planning for appendage closure device placement. J Cardiovasc Electrophysiol 2010; 21:973. 9. Husain Z, Safavi-Naeini P, Rasekh A, et al. Anesthetic Management of Patients Undergoing Percutaneous Endocardial and Epicardial Left Atrial Appendage Occlusion. Semin Cardiothorac Vasc Anesth 2017; 21:291. 10. Lip GY, Dagres N, Proclemer A, et al. Left atrial appendage occlusion for stroke prevention in atrial fibrillation in Europe: results of the European Heart Rhythm Association survey. Europace 2013; 15:141. 11. Kar S, Doshi SK, Sadhu A, et al. Primary Outcome Evaluation of a Next-Generation Left Atrial Appendage Closure Device: Results From the PINNACLE FLX Trial. Circulation 2021; 143:1754. https://www.uptodate.com/contents/atrial-fibrillation-left-atrial-appendage-occlusion/print 21/37 7/5/23, 9:05 AM Atrial fibrillation: Left atrial appendage occlusion - UpToDate 12. Alli O, Doshi S, Kar S, et al. Quality of life assessment in the randomized PROTECT AF (Percutaneous Closure of the Left Atrial Appendage Versus Warfarin Therapy for Prevention of Stroke in Patients With Atrial Fibrillation) trial of patients at risk for stroke with nonvalvular atrial fibrillation. J Am Coll Cardiol 2013; 61:1790. 13. Holmes DR Jr, Kar S, Price MJ, et al. Prospective randomized evaluation of the Watchman Left Atrial Appendage Closure device in patients with atrial fibrillation versus long-term warfarin therapy: the PREVAIL trial. J Am Coll Cardiol 2014; 64:1. 14. Reddy VY, Doshi SK, Kar S, et al. 5-Year Outcomes After Left Atrial Appendage Closure: From the PREVAIL and PROTECT AF Trials. J Am Coll Cardiol 2017; 70:2964. 15. Holmes DR, Reddy VY, Turi ZG, et al. Percutaneous closure of the left atrial appendage versus warfarin therapy for prevention of stroke in patients with atrial fibrillation: a randomised non-inferiority trial. Lancet 2009; 374:534. 16. Reddy VY, M bius-Winkler S, Miller MA, et al. Left atrial appendage closure with the Watchman device in patients with a contraindication for oral anticoagulation: the ASAP study (ASA Plavix Feasibility Study With Watchman Left Atrial Appendage Closure Technology). J Am Coll Cardiol 2013; 61:2551. 17. Boersma LV, Schmidt B, Betts TR, et al. Implant success and safety of left atrial appendage closure with the WATCHMAN device: peri-procedural outcomes from the EWOLUTION registry. Eur Heart J 2016; 37:2465. 18. Boersma LV, Ince H, Kische S, et al. Efficacy and safety of left atrial appendage closure with WATCHMAN in patients with or without contraindication to oral anticoagulation: 1-Year follow-up outcome data of the EWOLUTION trial. Heart Rhythm 2017; 14:1302. 19. Meier B, Palacios I, Windecker S, et al. Transcatheter left atrial appendage occlusion with Amplatzer devices to obviate anticoagulation in patients with atrial fibrillation. Catheter Cardiovasc Interv 2003; 60:417. 20. Landmesser U, Schmidt B, Nielsen-Kudsk JE, et al. Left atrial appendage occlusion with the AMPLATZER Amulet device: periprocedural and early clinical/echocardiographic data from a global prospective observational study. EuroIntervention 2017; 13:867. 21. Lakkireddy D, Thaler D, Ellis CR, et al. Amplatzer Amulet Left Atrial Appendage Occluder Versus Watchman Device for Stroke Prophylaxis (Amulet IDE): A Randomized, Controlled Trial. Circulation 2021; 144:1543. 22. Bartus K, Bednarek J, Myc J, et al. Feasibility of closed-chest ligation of the left atrial appendage in humans. Heart Rhythm 2011; 8:188. 23. Lee RJ, Bartus K, Yakubov SJ. Catheter-based left atrial appendage (LAA) ligation for the prevention of embolic events arising from the LAA: initial experience in a canine model. Circ https://www.uptodate.com/contents/atrial-fibrillation-left-atrial-appendage-occlusion/print 22/37 7/5/23, 9:05 AM Atrial fibrillation: Left atrial appendage occlusion - UpToDate Cardiovasc Interv 2010; 3:224. 24. Shetty R, Leitner JP, Zhang M. Percutaneous catheter-based left atrial appendage ligation and management of periprocedural left atrial appendage perforation with the LARIAT suture delivery system. J Invasive Cardiol 2012; 24:E289. 25. Bartus K, Han FT, Bednarek J, et al. Percutaneous left atrial appendage suture ligation using the LARIAT device in patients with atrial fibrillation: initial clinical experience. J Am Coll Cardiol 2013; 62:108. 26. Massumi A, Chelu MG, Nazeri A, et al. Initial experience with a novel percutaneous left atrial appendage exclusion device in patients with atrial fibrillation, increased stroke risk, and contraindications to anticoagulation. Am J Cardiol 2013; 111:869. 27. Late-Breaking Science Abstracts and Featured Science Abstracts From the American Heart Association's Scientific Sessions 2021 and Late-Breaking Abstracts in Resuscitation Science From the Resuscitation Science Symposium 2021. Circulation 2021; 144:e564. 28. Garc a-Fern ndez MA, P rez-David E, Quiles J, et al. Role of left atrial appendage obliteration in stroke reduction in patients with mitral valve prosthesis: a transesophageal echocardiographic study. J Am Coll Cardiol 2003; 42:1253. 29. Katz ES, Tsiamtsiouris T, Applebaum RM, et al. Surgical left atrial appendage ligation is frequently incomplete: a transesophageal echocardiograhic study. J Am Coll Cardiol 2000; 36:468. 30. Kanderian AS, Gillinov AM, Pettersson GB, et al. Success of surgical left atrial appendage closure: assessment by transesophageal echocardiography. J Am Coll Cardiol 2008; 52:924. 31. Ostermayer SH, Reisman M, Kramer PH, et al. Percutaneous left atrial appendage transcatheter occlusion (PLAATO system) to prevent stroke in high-risk patients with non- rheumatic atrial fibrillation: results from the international multi-center feasibility trials. J Am Coll Cardiol 2005; 46:9. 32. Ohtsuka T, Ninomiya M, Nonaka T, et al. Thoracoscopic stand-alone left atrial appendectomy for thromboembolism prevention in nonvalvular atrial fibrillation. J Am Coll Cardiol 2013; 62:103. 33. Della Rocca DG, Magnocavallo M, Di Biase L, et al. Half-Dose Direct Oral Anticoagulation Versus Standard Antithrombotic Therapy After Left Atrial Appendage Occlusion. JACC Cardiovasc Interv 2021; 14:2353. 34. Reddy VY, Holmes D, Doshi SK, et al. Safety of percutaneous left atrial appendage closure: results from the Watchman Left Atrial Appendage System for Embolic Protection in Patients with AF (PROTECT AF) clinical trial and the Continued Access Registry. Circulation 2011; 123:417. https://www.uptodate.com/contents/atrial-fibrillation-left-atrial-appendage-occlusion/print 23/37 7/5/23, 9:05 AM Atrial fibrillation: Left atrial appendage occlusion - UpToDate 35. Bergmann MW, Ince H, Kische S, et al. Real-world safety and efficacy of WATCHMAN LAA closure at one year in patients on dual antiplatelet therapy: results of the DAPT subgroup from the EWOLUTION all-comers study. EuroIntervention 2018; 13:2003. 36. Saw J, Nielsen-Kudsk JE, Bergmann M, et al. Antithrombotic Therapy and Device-Related Thrombosis Following Endovascular Left Atrial Appendage Closure. JACC Cardiovasc Interv 2019; 12:1067. 37. Gabriels JK, Liu CF. Peri-Device Leak After Left Atrial Appendage Occlusion: Minding the Gap. JACC Clin Electrophysiol 2022; 8:779. 38. Alkhouli M, Du C, Killu A, et al. Clinical Impact of Residual Leaks Following Left Atrial Appendage Occlusion: Insights From the NCDR LAAO Registry. JACC Clin Electrophysiol 2022; 8:766. 39. Aryana A, Singh SK, Singh SM, et al. Association between incomplete surgical ligation of left atrial appendage and stroke and systemic embolization. Heart Rhythm 2015; 12:1431. 40. Freeman JV, Varosy P, Price MJ, et al. The NCDR Left Atrial Appendage Occlusion Registry. J Am Coll Cardiol 2020; 75:1503. 41. Reddy VY, Gibson DN, Kar S, et al. Post-Approval U.S. Experience With Left Atrial Appendage Closure for Stroke Prevention in Atrial Fibrillation. J Am Coll Cardiol 2017; 69:253. 42. Price MJ, Valderr bano M, Zimmerman S, et al. Periprocedural Pericardial Effusion Complicating Transcatheter Left Atrial Appendage Occlusion: A Report From the NCDR LAAO Registry. Circ Cardiovasc Interv 2022; 15:e011718. 43. Wilkins B, Fukutomi M, De Backer O, S ndergaard L. Left Atrial Appendage Closure: Prevention and Management of Periprocedural and Postprocedural Complications. Card Electrophysiol Clin 2020; 12:67. 44. Darden D, Duong T, Du C, et al. Sex Differences in Procedural Outcomes Among Patients Undergoing Left Atrial Appendage Occlusion: Insights From the NCDR LAAO Registry. JAMA Cardiol 2021; 6:1275. 45. Pasupula DK, Munir MB, Bhat AG, et al. Outcomes and predictors of readmission after implantation of a percutaneous left atrial appendage occlusion device in the United States: A propensity score-matched analysis from The National Readmission Database. J Cardiovasc Electrophysiol 2021; 32:2961. 46. Glikson M, Wolff R, Hindricks G, et al. EHRA/EAPCI expert consensus statement on catheter- based left atrial appendage occlusion - an update. EuroIntervention 2020; 15:1133. 47. January CT, Wann LS, Alpert JS, et al. 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American https://www.uptodate.com/contents/atrial-fibrillation-left-atrial-appendage-occlusion/print 24/37 7/5/23, 9:05 AM Atrial fibrillation: Left atrial appendage occlusion - UpToDate Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol 2014; 64:e1. 48. January CT, Wann LS, Calkins H, et al. 2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society in Collaboration With the Society of Thoracic Surgeons. Circulation 2019; 140:e125. Topic 928 Version 61.0 https://www.uptodate.com/contents/atrial-fibrillation-left-atrial-appendage-occlusion/print 25/37 7/5/23, 9:05 AM Atrial fibrillation: Left atrial appendage occlusion - UpToDate GRAPHICS Comparison of the CHADS and CHA DS -VASc risk stratification scores for 2 patients with nonvalvular AF 2 2 Definition and scores for CHADS and Stroke risk stratification with the 2 CHA DS -VASc CHADS and CHA DS -VASc scores 2 2 2 2 2 Unadjusted ischemic stroke rate [1] CHADS acronym Score CHADS acronym 2 2 (% per year) Congestive HF 1 0 0.6 Hypertension 1 1 3.0 Age 75 years 1 2 4.2 Diabetes mellitus 1 3 7.1 Stroke/TIA/TE 2 4 11.1 Maximum score 6 5 12.5 6 13.0 Unadjusted ischemic stroke rate CHA DS -VASc 2 2 [2] CHA DS -VASc acronym Score 2 2 acronym (% per year) Congestive HF 1 0 0.2 Hypertension 1 1 0.6 Age 75 years 2 2 2.2 Diabetes mellitus 1 3 3.2 Stroke/TIA/TE 2 4 4.8 Vascular disease (prior MI, PAD, or 1 5 7.2 aortic plaque) Age 65 to 74 years 1 6 9.7 Sex category (ie, female sex) 1 7 11.2 Maximum score 9 8 10.8 9 12.2 AF: atrial fibrillation; CHADS : Congestive heart failure, Hypertension, Age 75 years, Diabetes mellitus, prior Stroke or TIA or thromboembolism (doubled); CHA DS -VASc: Congestive heart failure, Hypertension, Age 75 years (doubled), Diabetes mellitus, prior Stroke or TIA or thromboembolism 2 2 2 https://www.uptodate.com/contents/atrial-fibrillation-left-atrial-appendage-occlusion/print 26/37 7/5/23, 9:05 AM Atrial fibrillation: Left atrial appendage occlusion - UpToDate (doubled), Vascular disease, Age 65 to 74 years, Sex category; HF: heart failure; TIA: transient ischemic attack; TE: thromboembolism; MI: myocardial infarction; PAD: peripheral artery disease. [3] These unadjusted (not adjusted for possible use of aspirin) stroke rates were published in 2012 . Actual rates of stroke in contemporary cohorts might vary from these estimates. References: 1. Gage BF, Waterman AD, Shannon W, et al. Validation of clinical classi cation schemes for predicting stroke: results from the National Registry of Atrial Fibrillation. JAMA 2001; 285:2864. 2. Lip GYH, Nieuwlaat R, Pisters R, et al. Re ning clinical risk strati cation for predicting stroke and thromboembolism in atrial brillation using a novel risk factor-based approach: the euro heart survey on atrial brillation. Chest 2010; 137:263. 3. Friberg L, Rosenqvist M, Lip GY. Evaluation of risk strati cation schemes for ischaemic stroke and bleeding in 182 678 patients with atrial brillation: the Swedish Atrial Fibrillation cohort study. Eur Heart J 2012; 33:1500. Original table and unadjusted ischemic stroke rates, as noted above, have been modi ed for this publication. January CT, Wann LS, Alpert JS, et al. 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol 2014; 64:e1. Table used with the permission of Elsevier Inc. All rights reserved. Graphic 94752 Version 14.0 https://www.uptodate.com/contents/atrial-fibrillation-left-atrial-appendage-occlusion/print 27/37 7/5/23, 9:05 AM Atrial fibrillation: Left atrial appendage occlusion - UpToDate Endovascular left atrial appendage closure devices Device name Company Design Device sizes (mm) WATCHMAN* Boston Scientific Single-lobe occluder 21, 24, 27, 30, 33 with nitinol frame, PET membrane, 10 fixation anchors. WATCHMAN FLX* Boston Scientific Single-lobe occluder with nitinol frame, PET 20, 24, 27, 31, 35 membrane, 12 fixation anchors. Amplatzer Cardiac Plug (ACP) Abbott Lobe and disc (polyester mesh in 16, 18, 20, 22, 24, 26, 28, 30 both) nitinol mesh construct. Stabilizing wires. Amulet* Abbott Similar design as Amplatzer Cardiac Plug, but wider lobe and disc and more stabilizing wires. 16, 18, 20, 22, 25, 28, 31, 34 WaveCrest Coherex Medical Single-lobe occluder. 22, 27, 32 Nitinol frame, polyurethane foam, ePTFE membrane, retractable anchors. Occlutech LAA Occluder Occlutech Single-lobe occluder. Nitinol wire mesh, 15, 18, 21, 24, 27, 30, 33, 36, 39 stabilizing loops, nanomaterial covering. Lambre Lifetech Lobe and disc nitinol 16 to 36 frame. PET membrane. Distal barbs anchors. PET: polyethylene terephthalate; ePTFE: polytetrafluoroethylene; LAA: left atrial appendage; FDA: United States Food and Drug Administration; CE: conformit Europ enne (French for "European conformity"). FDA approved. CE mark refers to any product that may be freely traded in any part of Europe (ie, European Union) economic area. https://www.uptodate.com/contents/atrial-fibrillation-left-atrial-appendage-occlusion/print 28/37 7/5/23, 9:05 AM Atrial fibrillation: Left atrial appendage occlusion - UpToDate Graphic 140267 Version 1.0 https://www.uptodate.com/contents/atrial-fibrillation-left-atrial-appendage-occlusion/print 29/37 7/5/23, 9:05 AM Atrial fibrillation: Left atrial appendage occlusion - UpToDate WATCHMAN implant (A) Watchman left atrial appendage (LAA) closure technology. (B) Watchman LAA closure technology in anatomical position. Reproduced from: Jain AK, Gallagher S. Technology and guidelines Percutaneous occlusion of the left atrial appendage in non-valvular atrial brillation for the prevention of thromboembolism: NICE guidance. Heart 2011; 97:762, with permission from BMJ Publishing Group Ltd. Graphic 61636 Version 5.0 https://www.uptodate.com/contents/atrial-fibrillation-left-atrial-appendage-occlusion/print 30/37 7/5/23, 9:05 AM Atrial fibrillation: Left atrial appendage occlusion - UpToDate Epicardial percutaneous or surgical left atrial appendage closure devices Device name Company Design Device sizes (mm) LARIAT* SentreHeart Endocardial and LAA sizes up to 40 epicardial percutaneous access width, 20 height, 70 length required. Magnetically assisted snaring of LAA. AtriClip* AtriCure Surgical/thoracotomy approach. Parallel clip 35, 40, 45, 50 with polyester mesh. TigerPaw II* Marquet Surgical approach. Compliant soft silicone fastener. LAA: left atrial appendage; CE: conformit Europ enne (French for "European conformity").