Left Atrial Appendage Closure: Past, Present, and Future

Abstract

Left atrial appendage closure (LAAC) has emerged as an important alternative strategy for stroke prevention in patients with non-valvular atrial fibrillation (NVAF), particularly when long-term oral anticoagulation (OAC) is contraindicated or poorly tolerated. Initially developed as a surgical technique based on ligation or excision of the left atrial appendage, LAAC has progressively shifted toward refined, minimally invasive transcatheter approaches. Randomized and observational data have established non-inferiority to warfarin, and non-inferiority compared with direct oral anticoagulants has also been suggested in selected high-risk cohorts and is currently under prospective evaluation in pivotal trials. At the same time, indications for LAAC are expanding beyond the classical high-bleeding-risk population, now encompassing patients undergoing atrial fibrillation (AF) ablation and those with only moderate thromboembolic risk but intolerance to OAC. Parallel advances in device design aimed at improving anatomical conformability, sealing performance, and surface biocompatibility seek to reduce peri-device leak (PDL), device-related thrombus (DRT), and bleeding and may allow for simplified or shortened post-procedural antithrombotic regimens. This narrative review summarizes the historical evolution of LAAC from surgical to contemporary transcatheter solutions, outlines key clinical evidence versus medical therapy, and discusses emerging implant-based and implant-free technologies. As evidence accumulates from ongoing randomized controlled trials, LAAC may transition from a niche intervention to a more widely adopted, guideline-supported component of AF management. However, broader implementation will depend on robust demonstration of long-term safety and efficacy, including clarification of PDL-, DRT-, and bleeding-related trade-offs, to define when LAAC can serve not only as an alternative to OAC but also as a tailored option for selected NVAF patients.