Left atrial appendage occlusion in atrial fibrillation: contemporary techniques, clinical outcomes, and future directions

Abstract

Left atrial appendage occlusion (LAAO) is an important strategy for stroke prevention in patients with non-valvular atrial fibrillation (AF) who have contraindications to long-term oral anticoagulation. We differentiate this review from existing literature by integrating recent controversial trial data and device-specific outcomes. Advances in technology and imaging have transformed LAAO into a widely adopted percutaneous therapy. Large trials and registries demonstrate LAAO’s non-inferiority to oral anticoagulants. For example, the PRAGUE-17 trial (N=402) found LAAO non-inferior to direct oral anticoagulants, while PROTECT-AF and PREVAIL 5-year data (N=1114) showed significant reductions in hemorrhagic stroke. The surgical LAAOS III trial (N=4811) demonstrated a 33% longterm reduction in stroke or systemic embolism. Major complications have declined; the SURPASS registry (N=16,446) demonstrated a 0.51% incidence of pericardial effusion for the WATCHMAN FLX. In the Amulet IDE trial, pericardial effusion occurred in 2.4% of Amulet patients versus 1.2% of WATCHMAN patients. Recent 2026 NEJM trials (CHAMPION-AF and CLOSURE-AF) reached opposite conclusions in different populations, remaining a central controversy. Emerging technologies like artificial intelligence-guided planning, which accurately predicted device size in 72.7% of cases, and low-thrombogenic devices continue to improve safety. This review summarizes contemporary techniques, imaging, complications, outcomes, and future directions.