Challenges and solutions for optimizing outcomes in patients undergoing surgical left atrial appendage closure

Left atrial appendage closure (LAAC) during cardiac surgery is a pivotal strategy for stroke prevention in atrial fibrillation (AF), gaining recognition in guidelines (Class I AHA 2023, Class IIa ESC 2024). This review identifies critical challenges and proposes solutions for optimizing outcomes. Challenges 1) Patient Selection: Significant controversy exists regarding extending LAAC to high-stroke-risk patients without documented AF ;(CHA₂DS₂-VASc ≥2), where 50% of post-cardiac surgery strokes occur, creating an evidence-practice gap. Conflicting meta-analyses exist (Baudo et al. vs. Kowalewski et al.). 2) Technique Standardization: Marked heterogeneity in surgical techniques (suture, excision, stapling) and lack of standardized protocols lead to highly variable success rates (0%-100%), unlike standardized clipping (AtriClip®; > 93% success). 3)Post-procedural Management: Unresolved debates persist on optimal post-surgical antithrombotic regimens and the standalone efficacy of LAAC vs. anticoagulation. Solutions 1) Ongoing RCTs (LeAAPS, LAA-CLOSURE, LAACS-2) aim to define LAAC efficacy in non-AF populations. 2) Implement evidence-based standardized operating procedures (SOPs) for each technique, prioritizing validated clipping devices. Promote unified imaging criteria (transesophageal echocardiography(TEE) intra-operation, Cardiac Computed Tomography Angiography(CCTA) follow-up) per AHA 2023 guidelines. 3) The LAA-CLIP trial is evaluating thoracoscopic clipping vs. DOACs, potentially supporting anticoagulation simplification post-LAAC. Addressing these challenges through standardization and targeted trials is crucial for maximizing LAAC efficacy.