Treatment strategies for prevention of cardioembolic stroke in atrial fibrillation

Stroke is the third leading cause of mortality and is one of the leading cause of disability in the world today. Although underused, anticoagulation with warfarin is still the treatment of choice for prevention of stroke in patients with AF, though hemorrhage is clearly increased in the anticoagulated patient. The substantial difficulties associated with warfarin use give reasons for the continuing challenge of decision making about antithrombotic therapy. They have led to a search for alternative approaches of stroke prophylaxis resulting in a strategy of mechanically sealing the left atrial appendage (LAA) and excluding it from the systemic circulation. A couple of years ago a percutaneous transcatheter transseptal approach to LAA occlusion has become feasible. Since then, valuable technical knowledge and a proof of concept emerged from clinical trials using three different systems. However, also the intervention bears a risk. Thus, identifying those patients who gain the most from either therapy is crucial which, in the first line, means to calculate the risk of stroke or bleeding. Unfortunately, patients with some defined comorbidities are at risk of both, cerebral embolism or hemorrhage. Whether this target group may benefit from LAA occlusion is a matter of this discussion.