LAA Occluders for All Patients with Atrial Fibrillation - An Overreaching Statement

With great interest we read the article by Ghenzi et al. on “The evolving role of left atrial appendage (LAA) occlusion” published in the November 16th issue of Cardiovascular Medicine. However, the three conclusions drawn by the authors warrant some comments.

The conclusion that “LAA occlusion should be considered a first-line therapy for stroke prevention and discussed as a treatment option with all patients with atrial fibrillation” is daring. Based on the 2016 ESC Guidelines for the management of atrial fibrillation, LAA occlusion is currently considered a IIb (level of evidence C) indication in patients with atrial fibrillation, an indication for oral anticoagulation (OAC) and at the same time a clear contraindication for OAC. The data presented by the authors shows that in the patients undergoing LAA occlusion there were reasons for withholding OAC in the vast majority of cases, with a fair share (42.5%) of the patients having previous relevant bleeding. This means that the authors actually appear to use LAA occlusion in patients with an absolute or relative contraindication to OAC. Therefore, the statement that LAA occlusion should be considered a first-line therapy is not only not supported by current guidelines but also not backed by the presented data.

The conclusion that “LAA occlusion could be performed with a low complication rate” is at least debatable and depends on the “willingness-to-accept complications” threshold discussed with the patient. A major complication rate of 4.9% may be acceptable if there are no alternatives (i.e., in patients with a clear contraindication to OAC) but may be considered high when starting to use LAA occlusion as first-line therapy.

Finally, the conclusion that “LAA occlusion can be performed with high success rate” is supported by the presented data with a reported procedural success rate of 98.4%. A high procedural success rate may rightfully lower the threshold for performing a procedure, but, as Lord Henry Cohen of Birkenhead (1900–1977) once said: “The feasibility of an operation is not the best indication for its performance.”