Guidelines from Leading Societies for Transcatheter Left Atrial Appendage Occlusion in Stroke Prevention

The Society for Cardiovascular Angiography & Interventions (SCAI) and the Heart Rhythm Society (HRS) have jointly issued comprehensive, evidence-based recommendations to optimize the use of transcatheter left atrial appendage occlusion (LAAO) for preventing stroke in patients with non-valvular atrial fibrillation (NVAF). These guidelines represent the first multisociety effort to provide standardized clinical guidance, aiming to improve patient outcomes through uniformity and rigor.

Published in the 2025 issue of the Journal of the Society for Cardiovascular Angiography & Interventions and Heart Rhythm Journal, the guidelines also include a technical review that critically analyzes current evidence and highlights emerging research gaps. Dr. Andrew M. Goldsweig, chair of the guideline panel, emphasized that these recommendations are designed to facilitate high-quality, individualized care pathways for patients at risk.

NVAF is a significant health concern, impacting over 12 million Americans and increasing stroke risk fivefold. While oral anticoagulation remains the primary preventive measure, many patients cannot tolerate long-term anticoagulants due to bleeding risks, compliance issues, costs, or personal choices. In these cases, LAAO, a minimally invasive procedure that seals off the left atrial appendage—the main source of embolic clots—is an important alternative that has seen over 90,000 procedures annually in the U.S.

Despite the growth in LAAO procedures, practice variability remains high, especially regarding candidate selection, imaging techniques, antithrombotic strategies post-procedure, and complication management such as peri-device leak (PDL) or device-related thrombus (DRT). To address this inconsistency, a multidisciplinary panel comprising interventional cardiologists, electrophysiologists, imaging specialists, and methodological experts conducted a systematic review of more than 3,700 studies covering eight key clinical questions.

Key highlights of the guidelines include:

• Patient Selection: LAAO is recommended over no therapy for NVAF patients who cannot take oral anticoagulants. For others, a shared decision-making approach considers both anticoagulation and LAAO based on individual risk profiles.
• Pre-Procedural Imaging: The use of transesophageal echocardiography (TEE) or cardiac CT is preferred to improve procedural planning and outcomes.
• Intra-Procedural Guidance: Both TEE and intracardiac echocardiography (ICE) are viable options depending on resources and patient circumstances.
• Post-Procedural Therapy: Dual antiplatelet therapy or oral anticoagulants may be used based on bleeding risk and patient preferences.
• Follow-Up Imaging: Post-procedure TEE or CT scans are recommended to monitor for complications like PDL or DRT.
• Handling Complications: Guidance is provided for managing issues such as PDL and DRT, though optimal treatment approaches require further research.

These guidelines aim to support clinician-patient discussions, quality improvement efforts, and policymaking. They also outline critical research avenues, including optimal antithrombotic regimens, management of post-procedural leaks and thrombi, ideal imaging timing and modalities, and expanding LAAO to broader NVAF populations.

Dr. Christopher R. Ellis, co-chair of the guideline group, underscored the importance of personalized care and multidisciplinary collaboration to enhance stroke prevention strategies in NVAF patients. These recommendations serve as a shared foundation for cardiologists, electrophysiologists, imagers, and other care teams committed to evidence-based, patient-centered treatment.