Recommendation for NHSScotland

Left atrial appendage occlusion (LAAO) may be offered to patients with non-valvular atrial fibrillation deemed to be at high risk of ischaemic stroke, who have absolute contraindications to oral anticoagulation with warfarin and direct oral anticoagulants. Prior to undergoing the LAAO procedure, an individual patient risk assessment must be carried out by a multidisciplinary team. The potential future benefits of LAAO, the risks associated with the procedure, and the need for long-term antiplatelet therapy, should be discussed with each patient prior to making a treatment decision.

LAAO procedure volume per centre should be maximised to support optimal patient outcomes and ensure clinical experience is achieved and retained.

NHSScotland is required to consider the Scottish Health Technologies Group (SHTG) advice.

What were we asked to look at?

We were asked us to provide advice on the use of LAAO in patients with atrial fibrillation and contraindications to oral anticoagulation.

Why is this important?

Patients with atrial fibrillation have a substantially increased risk of ischaemic stroke compared with the general population. The standard of care for ischaemic stroke prevention in patients with atrial fibrillation is long-term anticoagulant therapy with warfarin or a direct oral anticoagulant (apixaban, dabigatran, edoxaban, or rivaroxaban). However, some patients with atrial fibrillation have contraindications to oral anticoagulation, meaning they cannot receive this treatment and hence remain at increased risk of having an ischaemic stroke. LAAO involves inserting a device designed to block the left atrial appendage of the heart where many of the blood clots that lead to ischaemic stroke in atrial fibrillation patients are thought to form. LAAO may therefore be an option for patients with atrial fibrillation and contraindications to oral anticoagulation.

Referred by

The National Advisory Committee for Heart Disease