The Assault on the Left Atrial Appendage in Perspective∗

For patients with atrial fibrillation (AF) inappropriate for or refractory to ablation or cardioversion, the choices have been austere: treat with anticoagulation or expose the patient to a 5-fold or greater risk of embolic events including stroke. Anticoagulation remains the standard of care and has been studied extensively in multiple level I trials, most recently as part of the introduction of a new-generation polypharmacy for nonvalvular AF. Anticoagulation nevertheless remains an iatrogenically induced disease with significant associated morbidity and mortality to which patients may be exposed for decades. Mechanical alternatives have been based on the assumption that the left atrial appendage (LAA) is the locus for virtually all clots in nonvalvular AF. Despite a general consensus that elimination of the LAA substantially reduces stroke risk, and decades of ad hoc surgical practice of primarily suturing or stapling the appendage shut, the evidence base is remarkably meager, in particular in the cardiac surgery literature, where only 1 prematurely abandoned and generally unsuccessful randomized pilot trial was reported .
Source: Journal of the American College of Cardiology - Category: Cardiology Authors: Tags: Mini-Focus: Left Atrial Closure in Atrial Fibrillation: Editorial Comment Source Type: research