Is Left Atrial Appendage Occlusion “Better” Than Direct Oral Anticoagulants in Very High-Risk Patients with Atrial Fibrillation?

While long-term anticoagulation has been the mainstay of therapy for thromboembolic prophylaxis in patients with nonvalvular atrial fibrillation (AF), left atrial appendage occlusion (LAAO) is now an alternative to oral anticoagulation (OAC) in select patients at high risk for bleeding and thromboembolic (TE) events. The recent 2023 ACC/AHA/ACCP/HRS AF guidelines give a Class 2a recommendation (LOE B-NR) for percutaneous LAAO in patients with AF at moderate to high risk of stroke (CHA2DS2-VASc score ≥2) who have a contraindication to long-term oral anticoagulation, with similar recommendations in the 2020 European Guidelines (Class 2b, LOE B).