SCAI/HRS Clinical Practice Guidelines on Transcatheter Left Atrial Appendage Occlusion-SCAI/HRS Clinical Practice Guidelines on Transcatheter Left Atrial Appendage Occlusion

Video Transcription

Video Summary

The webinar, hosted by the Society for Cardiovascular Angiography and Interventions (SCAI) and the Heart Rhythm Society (HRS), reviewed the 2025 clinical practice guidelines on transcatheter left atrial appendage occlusion (LAAO) for stroke prevention in non-valvular atrial fibrillation (AF). Christopher Ellis outlined the two-year guideline development process: a multidisciplinary panel, formal PICO questions, systematic evidence review using GRADE and an evidence-to-decision framework, and consensus voting. Most recommendations are <em>conditional</em> due to limited data, though a focused update is planned as major trials (e.g., CHAMPION-AF, CATALYST, CLOSURE-AF) emerge.

Key recommendations discussed included: LAAO is suggested over no therapy for AF patients with contraindications to anticoagulation (very low certainty). For patients eligible for stroke prevention, either oral anticoagulation (OAC) or LAAO may be chosen, as randomized trials show broadly similar outcomes (moderate certainty). Conditional guidance addresses pre-procedure imaging (CT or TEE), intraprocedural imaging (TEE or ICE), post-implant antithrombotic therapy (OAC or dual antiplatelet therapy), and follow-up imaging. Knowledge gaps remain for single antiplatelet therapy, peridevice leak (PDL) management, and optimal duration of anticoagulation for device-related thrombus (DRT).

Three cases illustrated guideline application: (1) ICE-guided Watchman implantation in a patient with cerebral microhemorrhages, highlighting procedural flexibility and post-implant DAPT with 45–90 day imaging. (2) DRT detected on follow-up TEE in a complex hematologic patient, managed with anticoagulation until resolution. (3) A challenging anatomy without pre-imaging led to significant PDL requiring later plug closure, emphasizing the value of pre-procedure planning and the uncertainty around PDL thresholds and treatment.

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Keywords

transcatheter left atrial appendage occlusion

LAAO

non-valvular atrial fibrillation

stroke prevention

2025 clinical practice guidelines

Society for Cardiovascular Angiography and Interventions

Heart Rhythm Society

oral anticoagulation

device-related thrombus

peridevice leak