WASHINGTON—The Society for Cardiovascular Angiography & Interventions (SCAI) and the Heart Rhythm Society (HRS) have published the first rigorous, evidence-based, multisociety recommendations to guide the use of transcatheter left atrial appendage occlusion (LAAO) for stroke prevention in patients with non-valvular atrial fibrillation (NVAF).
The "2025 SCAI/HRS Clinical Practice Guidelines on Transcatheter Left Atrial Appendage Occlusion (LAAO) were published in JSCAI and Heart Rhythm Journal. An accompanying technical review provides a detailed analysis of the underlying evidence base, highlighting both the progress and ongoing knowledge gaps in the field.
"These guidelines represent a critical step toward ensuring that patients with NVAF receive high-quality, consistent care tailored to their individual needs and preferences. We based our recommendations on the best available evidence while acknowledging where evidence is limited and further research is needed," said Andrew M. Goldsweig , MD, MS, FSCAI, chair of the guideline writing group. "Furthermore, these guidelines reflect a truly collaborative effort between SCAI and HRS to address one of the most pressing clinical needs facing our specialties. They provide clinicians with clear, practical recommendations to guide evidence-based care and use of LAAO."
Addressing a critical clinical need
NVAF affects more than 12 million people in the United States and increases stroke risk fivefold. Oral anticoagulation (OAC) remains the standard of care for preventing stroke in NVAF, but more than one-third of patients cannot take long-term OAC due to bleeding risk, medication adherence challenges, cost, or personal preference. Transcatheter LAAO—a minimally invasive procedure that seals off the left atrial appendage, the source of most stroke-causing clots in NVAF—has emerged as an important alternative, with over 90,000 procedures performed annually in the United States.
Despite increasing adoption of LAAO, clinical practice has varied widely. Indications, imaging strategies, antithrombotic regimens, and management of complications such as peri-device leak (PDL) and device-related thrombus (DRT) differ significantly among centers and operators. Recognizing the need for standardized, evidence-based guidance, SCAI and HRS convened a multidisciplinary panel to develop these comprehensive guidelines. The panel was comprised of interventional cardiologists, electrophysiologists, cardiovascular imaging specialists, and methodological experts. A systematic review of more than 3,700 studies was conducted to evaluate evidence on eight key clinical questions.
Key recommendations
The guidelines provide specific recommendations for clinicians, patients, and policymakers. Among the key guidance:
- Patient selection: LAAO is suggested over no therapy for patients with NVAF and a contraindication to OAC, acknowledging that most patients would prefer to reduce stroke risk despite potential procedural risks. Either OAC or LAAO is appropriate for patients seeking stroke prevention when OAC is not absolutely contraindicated.
- Pre-procedural imaging: Pre-procedural imaging with transesophageal echocardiography (TEE) or cardiac computed tomography (CT) is preferred over no pre-procedural imaging, as pre-procedural imaging improves procedural planning and outcomes.
- Intra-procedural imaging: Either TEE or intracardiac echocardiography (ICE) can be used to guide the LAAO procedure, allowing flexibility to accommodate patient characteristics and institutional resources.
- Post-procedural antithrombotic therapy: Either OAC or dual antiplatelet therapy (DAPT) is reasonable following LAAO, with the choice individualized based on bleeding risk and patient preferences.
- Surveillance imaging: Post-procedural imaging with TEE or CT is suggested to detect complications such as PDL and DRT.
- Management of complications: Guidance is provided for the management of PDL and DRT, while acknowledging that optimal approaches remain uncertain, and further research is necessary.
The guidelines are intended to support shared decision-making between clinicians and patients, promote quality improvement initiatives, and inform policy and coverage decisions. The guidelines identify several critical research priorities, including:
- Optimal antithrombotic regimens following LAAO, particularly the role of single antiplatelet therapy (SAPT).
- Best practices for managing PDL and DRT.
- The utility of routine post-procedural imaging, including optimal timing and modality.
- The role of LAAO in broader NVAF populations beyond those with OAC contraindications.
"As transcatheter LAAO becomes more widely used, it's essential that care remains centered on each patient's unique needs," said Christopher R. Ellis , MD, FHRS, co-chair of the guideline writing group. "These guidelines reflect a true collaboration between specialties—providing a shared foundation for interventional cardiologists, electrophysiologists, imagers, and care teams to align around the best practices for stroke prevention, guided by both evidence and patient values."
