Left atrial appendage occlusion devices: A contemporary approach to stroke prevention with a presentation of results in Serbia from 2014 to 2025

Introduction/Objective. Atrial fibrillation is the most common sustained cardiac arrhythmia and one of the most significant independent risk factors for ischemic stroke and systemic thromboembolism. In patients with non-valvular atrial fibrillation, the left atrial appendage (LAA) is the predominant site of intracardiac thrombus formation. This has led to the development of mechanical elimination of the thrombogenic substrate, i.e., percutaneous LAA occlusion (LAAO), as an alternative to long-term oral anticoagulant therapy in patients with contraindications to anticoagulation. Methods. The first LAAO device in Serbia was implanted on April 24, 2014, at BASICS+8, University Clinical Center of Serbia, by Prof. Dr. Milan A. Nedeljkovic and Prof. Dr. Branko Beleslin. LAAO device implantation is currently performed at four centers: University Clinical Center of Serbia, Institute for Cardiovascular Diseases of Vojvodina - Sremska Kamenica, and Bezanijska kosa University Clinical Center. Before LAAO implantation, either transesophageal echocardiography (TEE) or computed tomography is performed to determine the morphology of the LAA and confirm the absence of thrombus, which represents a contraindication to the procedure. The intervention is performed via femoral venous access under short-term analgosedation or general anesthesia, depending on the practice of the center, with fluoroscopic guidance and TEE monitoring. The key step is transseptal puncture to gain access to the left atrium and subsequently the LAA. TEE guidance is used to ensure precise puncture of the inferoposterior portion of the interatrial septum and facilitate positioning of the delivery system at the LAA ostium. Results. Between 2014 and 2025, a total of 30 LAAO devices were implanted at four centers in Serbia. With support from the Republic Health Insurance Fund, two devices were implanted at the University Clinical Center of Serbia in 2014, followed by one additional device in 2015. No data on the use of this method in cardiac catheterization laboratories in Serbia were available for the period from 2016 to 2022. In 2023, a total of six devices were implanted (four at Institute for Cardiovascular Diseases of Vojvodina - Sremska Kamenica and two at Dedinje Institute for Cardiovascular Diseases). In 2024, a total of 10 devices were implanted (six at Institute for Cardiovascular Diseases of Vojvodina - Sremska Kamenica, one at Dedinje Institute for Cardiovascular Diseases, and three at Bezanijska kosa University Clinical Center). In 2025, a total of 11 (five devices were implanted at Dedinje Institute for Cardiovascular Diseases) and six at Institute for Cardiovascular Diseases of Vojvodina - Sremska Kamenica. Conclusion. The use of percutaneous LAAO in Serbia demonstrates gradual development, from the initial sporadic application of the method at a single center to its expansion to multiple tertiary cardiology centers. Further development of LAAO in Serbia should be accompanied by the establishment of a national registry and standardized data collection.