Cost-Effectiveness of Left Atrial Appendage Occlusion

The idea that mechanical intervention to close the left atrial appendage (LAA) might reduce complications from atrial fibrillation (AF) is at least 70 years old. Early attempts to test this idea in humans with surgical ligation were abandoned after only a few years for 2 reasons. First, proponents soon realized that they had no way to choose the candidates believed most likely to benefit without the ability to image the LAA preoperatively. Second, interest was rapidly growing in what appeared a much more promising new therapy, chronic oral anticoagulation. Fast forward about a half century. Transesophageal echocardiography provides excellent imaging data about the LAA, clinical risk scores are used to guide therapy, and major research efforts are underway to develop an effective pharmacological alternative to warfarin, which doctors really do not like using and patients really do not like taking. At the same time, some in the field think a better approach still might be to occlude the LAA, thereby eliminating the need for lifetime anticoagulation altogether.