Atrial fibrillation is an irregular heart rhythm that can allow blood to pool and form clots inside the heart. These clots may travel to the brain and cause a stroke. Blood-thinning medicine remains the main stroke-prevention treatment for many patients. However, research such as the PRAGUE-17 trial has shown that left atrial appendage closure may be an alternative for carefully selected high-risk patients. It should not be treated as a routine replacement for anticoagulation in everyone with atrial fibrillation.
The left atrial appendage is a small pouch connected to the upper-left chamber of the heart. In people with non-valvular atrial fibrillation, many clots associated with the rhythm begin in this pouch.
Closing the appendage can reduce the chance that a clot formed there will enter the bloodstream.
How stroke risk is assessed
Not every person with atrial fibrillation has the same risk. Clinicians consider factors such as:
- Age
- Previous stroke or transient ischaemic attack
- Heart failure
- High blood pressure
- Diabetes
- Vascular disease
- Sex
- Other medical conditions
Bleeding risk is also assessed. A high bleeding-risk score does not automatically mean blood-thinning medicine should be stopped. It helps the clinician identify problems that can be corrected and plan safer treatment.
Why anticoagulant medicine is commonly used
Direct oral anticoagulants and warfarin reduce the blood’s ability to form harmful clots.
These medicines can be highly effective, but they also increase bleeding risk. Correct dosing, kidney-function monitoring, medicine interactions, and adherence are important.
A patient should not stop an anticoagulant because of bruising or fear of bleeding without speaking to the prescribing clinician. Suddenly stopping treatment may increase stroke risk.
What is LAAO?
LAAO stands for left atrial appendage occlusion. During the procedure, a device is guided through a vein to the heart and positioned to seal the opening of the appendage.
The procedure is usually performed with imaging guidance. Patients are monitored afterward and may need short-term anticoagulant or antiplatelet treatment while the device heals into place.
Heart Valve Experts provides an overview of LAAO, including evaluation, device placement, possible benefits, risks, and follow-up.
Who may be considered for LAAO?
A specialist may discuss LAAO when a patient:
- Has non-valvular atrial fibrillation
- Has a meaningful risk of stroke
- Has a serious reason why long-term anticoagulation is unsuitable
- Has experienced major bleeding
- Faces a particularly difficult balance between clotting and bleeding risk
- Has suitable appendage anatomy
- Understands that the procedure has its own risks
A previous minor nosebleed or fear of medicine is not automatically enough to justify the procedure.
The reason anticoagulation is unsuitable should be carefully reviewed. Sometimes changing the medicine, dose, or another interacting treatment may solve the problem.
What assessment is needed?
Assessment may include:
- ECG or rhythm monitoring
- Echocardiography
- Transoesophageal echocardiography
- CT imaging
- Kidney-function tests
- Review of previous bleeding
- Review of stroke history
- Detailed medicine assessment
The team must also rule out a clot already present in the appendage before placing a closure device.
What are the possible risks?
Possible risks include bleeding, damage to a blood vessel, fluid around the heart, stroke, device movement, incomplete closure, infection, or a clot forming on the device.
Follow-up imaging is important to confirm the device position and check for leakage or clot.
Patients who wish to understand the procedure can review information about left atrial appendage occlusion before discussing their individual stroke and bleeding risks with a specialist.
Questions to ask the heart team
- What is my estimated stroke risk?
- Why is anticoagulation unsuitable for me?
- Could another anticoagulant be used?
- Is my appendage anatomy suitable?
- What medicine will I need after LAAO?
- What imaging follow-up is required?
- What are the main risks in my case?
- What happens if the device does not seal completely?
Call emergency services for sudden facial weakness, arm weakness, difficulty speaking, sudden vision loss, severe imbalance, or a sudden severe headache.
This article is intended for general education and does not replace personalised cardiology or stroke-prevention advice.