06 Jul 2026
Editorial - The Essentials of left atrial appendage closure
Philippe Garot introduces this special report, which brings together leading experts to review the latest evidence, practical considerations and future directions in LAAC.
Stroke remains one of the most devastating complications of atrial fibrillation (AF) and a major cause of death and disability worldwide. Although direct oral anticoagulants (DOACs) have revolutionised stroke prevention and remain the standard of care for most patients, important unmet needs persist. Bleeding complications, treatment interruption, poor long-term adherence, renal dysfunction and ischemic stroke despite anticoagulation continue to challenge clinicians in daily practice. As the prevalence of AF continues to increase, so does the need for complementary strategies that provide durable protection while addressing these limitations.
Over the past two decades, left atrial appendage closure (LAAC) has evolved from an innovative concept into an established therapy supported by robust clinical evidence. Initially developed for patients with contraindications to long-term anticoagulation, LAAC has matured alongside major advances in device technology, imaging, procedural techniques and operator experience. Contemporary implantation is now associated with a high success rate and a very low incidence of major procedural complications, making LAAC one of the most refined procedures in structural heart intervention.
More importantly, the questions facing the field have fundamentally changed. We are no longer asking whether LAAC works. Landmark randomised trials have already demonstrated that it is an effective strategy for stroke prevention in appropriately selected patients. Instead, the current challenges are to identify the patients who derive the greatest benefit, define the optimal timing of intervention, simplify post-procedural antithrombotic therapy and determine how LAAC should be integrated into the broader management of atrial fibrillation.
This Essentials series reflects this new era.
- Jens-Erik Nielsen-Kudsk revisits the evidence that has shaped the field, from the pioneering PROTECT-AF and PREVAIL studies to the contemporary randomised trials OPTION and CHAMPION-AF, which have considerably expanded the evidence supporting LAAC.
- Tom De Potter discusses the implications of CHAMPION-AF for clinical practice and the questions that remain unanswered before broader implementation.
- Martin Bergmann focuses on one of the most important aspects of contemporary practice (patient selection) and reviews the different clinical scenarios in which LAAC may offer the greatest benefit, including patients with high bleeding risk, those undergoing AF ablation, patients with breakthrough stroke despite anticoagulation and other emerging indications.
- Looking toward the future, Marek Grygier presents the ongoing randomised studies, including SIMPLAAFY, CATALYST and LAAOS-IV, which will further define the role of LAAC by addressing post-implant antithrombotic therapy, comparison with contemporary anticoagulation and the potential role of LAAC as an adjunct rather than an alternative to oral anticoagulation.
- In an exclusive interview, Saibal Kar, a global pioneer and one of the leading investigators of the CHAMPION-AF trial, shares his perspective following this landmark trial, explaining why these results represent a pivotal moment for the field, how they are likely to influence clinical practice, and offering his vision of the next era of left atrial appendage closure.
- Finally, Ole De Backer illustrates how contemporary LAAC is performed through a state-of-the-art clinical case, highlighting how advances in CT planning, intracardiac echocardiography, transseptal technologies and next-generation delivery systems have simplified the procedure while improving precision and procedural safety.
Perhaps the greatest evolution has not been technological, but conceptual. LAAC is no longer viewed simply as a device implanted to replace anticoagulation. It has become part of a comprehensive strategy for stroke prevention that integrates clinical assessment, multimodality imaging, procedural excellence and individualised post-procedural management. Increasingly, treatment decisions rely on shared decision-making, balancing thromboembolic risk, bleeding risk, life expectancy, patient preference and anticipated adherence to long-term medical therapy.
The next few years promise to be equally transformative. Ongoing randomised trials will refine indications, clarify optimal pharmacological management after implantation and determine whether LAAC should be considered not only as an alternative to oral anticoagulation but also as a complementary therapy in selected high-risk populations. At the same time, continued advances in imaging, device design and procedural planning will further improve safety, reproducibility and long-term outcomes.
Few fields in interventional cardiology have evolved as rapidly as left atrial appendage closure. The challenge today is no longer to demonstrate that the procedure is feasible or effective, but to define how it can be used most appropriately for each individual patient. Through this Essentials series, internationally recognised experts provide a practical and evidence-based overview of the current state of the art and offer their perspective on where the field is heading. We hope these articles will help clinicians translate an expanding body of evidence into better decisions and, ultimately, better care for patients with atrial fibrillation.
