The Closing Argument for Surgical Left Atrial Appendage Occlusion

This editorial advocates for surgical occlusion of the left atrial appendage (LAA) during cardiac surgery in patients with atrial fibrillation (AF) and elevated stroke risk (CHA₂DS₂-VASc ≥2). It contrasts the robust evidence supporting oral anticoagulation with the weaker data for percutaneous LAA occlusion, noting limited guideline recommendations and FDA approval that implies controversial therapeutic equivalence. The author critiques the risks, cost, and equivocal benefit of percutaneous approaches. In contrast, the LAAOS III trial offers strong data: a 33% reduction in ischemic stroke/systemic embolism over 3.8 years with surgical LAA occlusion added to standard care, with minimal procedural risk and no increase in bleeding, MI, or mortality. The editorial proposes upgrading guidelines to recommend surgical LAA occlusion at time of cardiac surgery for AF patients with CHA₂DS₂-VASc ≥2. It emphasizes continued anticoagulation post-op and highlights unanswered questions around its use in patients unable to receive anticoagulation or with lower CHA₂DS₂-VASc scores.

This editorial advocates for surgical occlusion of the left atrial appendage (LAA) during cardiac surgery in patients with atrial fibrillation (AF) and elevated stroke risk (CHA₂DS₂-VASc ≥2). It contrasts the robust evidence supporting oral anticoagulation with the weaker data for percutaneous LAA occlusion, noting limited guideline recommendations and FDA approval that implies controversial therapeutic equivalence. The author critiques the risks, cost, and equivocal benefit of percutaneous approaches. In contrast, the LAAOS III trial offers strong data: a 33% reduction in ischemic stroke/systemic embolism over 3.8 years with surgical LAA occlusion added to standard care, with minimal procedural risk and no increase in bleeding, MI, or mortality. The editorial proposes upgrading guidelines to recommend surgical LAA occlusion at time of cardiac surgery for AF patients with CHA₂DS₂-VASc ≥2. It emphasizes continued anticoagulation post-op and highlights unanswered questions around its use in patients unable to receive anticoagulation or with lower CHA₂DS₂-VASc scores.