Restraint before routine: Left atrial appendage clipping beyond atrial fibrillation

Surgical left atrial appendage (LAA) exclusion has transitioned from a disease-specific therapy for atrial fibrillation (AF) to an increasingly routine adjunct during cardiac surgery, including in patients who present in sinus rhythm. This shift has occurred not through definitive evidence, but through a convergence of technical feasibility, biologic plausibility, and expanding clinical momentum. Contemporary studies in non-AF populations have largely focused on risk-enriched cohorts and suggest a possible reduction in late cerebrovascular events, yet these findings remain heterogeneous and context-dependent. At the same time, real-world data highlight a consistent early clinical burden, including postoperative AF, anticoagulation exposure, and variability in downstream management. The central issue is therefore not simply one of efficacy or safety, but of sequencing and definition: a preventive intervention has entered routine use before its net clinical value and care pathway have been clearly established. In this setting, prophylactic LAA exclusion in sinus rhythm should not be viewed as a settled extension of surgical practice, but as an evolving strategy that warrants selectivity, transparency, and disciplined evaluation.