Cronin Edmond M, Filby Steven, Field Michael E, Huded Chetan, Indik Julia H, Sharma Abhishek, Armah Chelsea, Firestone Scott, Fix Angela M, Senerth Emily, Morgan Rebecca L, Falck-Ytter Yngve
Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania.
University Hospitals Cleveland Medical Center, Cleveland, Ohio.
Heart Rhythm. 2025 Aug 5. doi: 10.1016/j.hrthm.2025.05.049.
Nonvalvular atrial fibrillation (NVAF) is associated with an increased risk of stroke due to thrombus formation in the left atrial appendage, where over 90% of thrombi originate. While oral anticoagulation (OAC) is the standard therapy for stroke prevention, many patients cannot tolerate long-term OAC due to bleeding risks. Percutaneous left atrial appendage occlusion (LAAO) has emerged as an alternative strategy. Despite its rapid adoption, substantial variability exists in clinical practice regarding patient selection, imaging techniques, procedural guidance, and postprocedural management. This systematic review aims to collect and synthesize evidence to inform the development of new Society for Cardiovascular Angiography & Interventions and the Heart Rhythm Society guidelines on LAAO.
We searched PubMed, Embase, and Cochrane Library from inception through January 5, 2024, for studies of the percutaneous LAAO procedure. Eligible studies were conducted in adults with NVAF undergoing LAAO, or with peridevice leak or device-related thrombus after an occlusion procedure. Studies of surgical LAAO, double device or combined procedures, and devices that are not currently marketed in the United States were excluded. Data were extracted from studies in duplicate and summarized using meta-analysis and narrative synthesis. Risk of bias (RoB) was assessed using the RoB in nonrandomized studies of interventions tool, and version 2 of the Cochrane RoB tool for randomized trials (RoB 2.0). Overall certainty of evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation approach.
Our search identified 3769 titles and abstracts, of which 27 studies met eligibility criteria and contributed data to the analysis. Data were abstracted to address outcomes of LAAO for stroke prevention in patients with NVAF, in comparison to OAC, no therapy, and across various approaches including preprocedure imaging, intraprocedure guidance, and postprocedure antithrombotic regimens.
Left atrial appendage occlusion is an effective alternative to OAC for stroke prevention in NVAF patients with bleeding risks, but uncertainties remain regarding imaging strategies and postprocedural management.
非瓣膜性心房颤动（NVAF）与左心耳血栓形成导致的中风风险增加相关，超过90%的血栓起源于此。虽然口服抗凝药（OAC）是预防中风的标准疗法，但许多患者由于出血风险无法耐受长期OAC。经皮左心耳封堵术（LAAO）已成为一种替代策略。尽管其应用迅速，但在临床实践中，关于患者选择、成像技术、手术指导和术后管理仍存在很大差异。本系统评价旨在收集和综合证据，为心血管造影和介入学会及心律学会关于LAAO的新指南制定提供参考。
我们检索了从创刊至2024年1月5日的PubMed、Embase和Cochrane图书馆，以查找经皮LAAO手术的研究。符合条件的研究是在接受LAAO的NVAF成年患者中进行的，或在封堵术后出现装置周围渗漏或装置相关血栓的患者中进行的。排除手术LAAO、双装置或联合手术以及目前在美国未上市的装置的研究。数据从研究中进行双份提取，并使用荟萃分析和叙述性综合进行总结。使用干预措施非随机研究中的偏倚风险（RoB）工具以及Cochrane随机试验偏倚风险工具第2版（RoB 2.0）评估偏倚风险。使用推荐分级评估、制定和评价方法评估证据的总体确定性。
我们的检索确定了3769个标题和摘要，其中27项研究符合纳入标准并为分析提供了数据。提取数据以探讨LAAO预防NVAF患者中风的结果，与OAC、不进行治疗以及包括术前成像、术中指导和术后抗栓方案在内的各种方法进行比较。
对于有出血风险的NVAF患者，左心耳封堵术是预防中风的一种有效替代OAC的方法，但在成像策略和术后管理方面仍存在不确定性。
