**5. Indications and current recommendation**

Indication for LAAO occlusion procedure is similar to standard indication of OAC in patients with AF. The need of OAC is justified by stroke risk factors that are summarized in the clinical risk-factor-based on established CHA2DS2-VASc score [Congestive heart failure, Hypertension, Age, Diabetes mellitus, Stroke, Vascular disease, and Sex category (female)]. However, when initiation of OAC strategy, individual potential risk of bleeding also needs to be assessed (**Table 1**).


*CKD-EPI = Chronic Kidney Disease Epidemiology Collaboration; CrCl = creatinine clearance; cTnT-hs = high-sensitivity troponin T; CYP = cytochrome P; GDF-15 = growth differentiation factor-15; INR = international normalized ratio; NSAID = non-steroidal anti-inflammatory drug; OAC = oral anticoagulant; SBP = systolic blood pressure; TTR = time in therapeutic range; VKA = vitamin K antagonist.*

#### **Table 1.**

*Risk factors for bleeding with OAC and antiplatelet therapy (ESC guidelines 2020) [1].*


#### **Table 2.**

*Current recommendation for percutaneous LAAO.*

There are few absolute contraindications that potentially prevent some patients to have OAC as stroke prevention therapies. These include active major bleeding with unidentified and untreated source, comorbidities [e.g., severe anemia (Hb<80 g/L) or thrombocytopenia (<50 platelets/microliter)], or a high-risk bleeding episode such as intracranial hemorrhage. In such cases, non-drug options such as LAAO should be considered. Based on current existing guidelines, the recommendations of LAAO as stroke prevention option are:

#### **5.1 Percutaneous approaches**

Currently available recommendation for percutaneous LAAO is described in **Table 2**. According to 2020 ESC guidelines for Atrial Fibrillation, recommendations for antithrombotic therapy after LAAO are mentioned in **Table 3** [1].

#### **5.2 Surgical approaches**

**Table 4** shows current available recommendation for surgical LAA excision/occlusion approach.


*ACP = Amplatzer Cardiac Plug; INR = international normalized ratio; LAA = Left atrial appendage; OAC = Oral anticoagulation; TOE = Transesophageal Echocardiography.*

#### **Table 3.**

*Anti-thrombotic recommendation after LAAO.*


*ACC = American College of Cardiology; AF = atrial fibrillation; AHA = American Heart association; ESC = European Society of Cardiology; HRS = Heart Rhythm Society; LA = Left atrium; LAA = Left atrial appendage; NR = Nonrandomized; NVAF = Non-valvular atrial fibrillation; VAF = Valvular atrial fibrillation.*

#### **Table 4.**

*Current recommendation for surgical LAAO.*
