Clinical practice in left atrial appendage closure with focus on antithrombotic therapy: results from a European Heart Rhythm Association survey

Background

In contrast to pulmonary vein isolation—where procedural workflows and peri-procedural management have become increasingly standardized—LAAC procedures still lack such uniformity. This applies in particular, to the optimal post-procedural antithrombotic strategy. Therefore, the Scientific Initiatives Committee (SIC) of the European Heart Rhythm Association (EHRA) conducted a survey to capture current practice patterns regarding these different aspects, with a specific focus on antithrombotic strategies following LAAC.

Methods

A structured online questionnaire was developed in the Scientific Initiatives Committee (SIC) and distributed through the European Heart Rhythm Association (EHRA) network and social media. A total of 140 physicians from more than 20 countries participated in the survey. The questionnaire addressed operator background, procedural setting, and antithrombotic regimens at discharge and follow-up.

Results

Most respondents were electrophysiologists (67.4%; 93/138), with nearly half working in university hospitals (44.9%; 62/138). The majority of centers reported an annual procedural volume of 1–20 LAAC procedures (42.8%).

The most common indication for LAAC was a history of major bleeding (64.0% indications). The Watchman FLX (67.4%) and Amulet (66.3%) were the most frequently available devices. Transesophageal echocardiography (TEE) was the preferred imaging modality both pre-procedurally (68.4%) and intra-procedurally (91.9%) and intracardiac echocardiography (ICE) was used by 15.2%. Hospital stay was typically brief (most commonly one night; 58.6%), and late cardiac tamponade was rarely observed (19.4% ever observed, >80% never experienced). Follow-up imaging was performed in most centers (85.9%) after a mean of 10.5 weeks after implantation.

In patients undergoing LAAC for bleeding or high bleeding risk, the most frequent discharge regimen was dual antiplatelet therapy (DAPT; 47.9%), typically followed by transition to single antiplatelet therapy (SAPT) after TEE follow-up imaging. In contrast, when LAAC was performed for stroke prevention, direct oral anticoagulation (DOAC) was the preferred regimen at discharge (41.1%; 39/95) and was most commonly (51.2%; 49/95) continued without further adjustment. In cases where treatment was modified, a switch to SAPT was the most frequent adjustment (28.9%; 13/45).

Furthermore, peri-device leaks ≥5 mm prompted modification of the antithrombotic regimen in 43.3% of respondents, and 55.8% would consider interventional closure, most commonly using a vascular plug.

Conclusion

This EHRA survey reveals substantial diversity in post-LAAC antithrombotic management, despite of a high level of procedural consistency. While DAPT and SAPT dominate in bleeding-related indications, DOAC-based strategies remain common in stroke-risk patients. The findings highlight the urgent need for harmonized, evidence-based guidance on antithrombotic therapy following LAAC.