Closure of the left ear canal

Percutaneous closure of the left atrial appendage is a procedure designed to reduce the risk of stroke and other embolisms in certain people with atrial fibrillation. It may be considered when there is a significant risk of embolism and maintaining long-term oral anticoagulation presents a clinical challenge or a significant risk.

What is left atrial appendage closure?

The left atrial appendage is a small extension of the left atrium, one of the upper chambers of the heart. In atrial fibrillation, a type of cardiac arrhythmia, the atria cease to contract in a co-ordinated manner and blood may flow more slowly within them, promoting the formation of clots.

If one of these clots breaks loose and reaches a cerebral artery, it can cause an ischaemic stroke. Percutaneous closure aims to reduce this risk by placing a device at the entrance to the appendage to isolate it from the bloodstream.

The implant is inserted via catheters, usually through a vein in the groin, and remains in place permanently. Over the following weeks and months, its surface is gradually covered by tissue, whilst its integration is monitored using imaging tests.

Indications for left atrial appendage closure

Percutaneous closure of the atrial appendage may be considered in people with atrial fibrillation and a significant risk of stroke, for whom maintaining long-term oral anticoagulation is particularly problematic. It may be particularly relevant where there is a history of severe haemorrhage, recurrent bleeding episodes where the cause cannot be adequately addressed, or other clinical circumstances that make it difficult to maintain anticoagulation safely.

The assessment also takes into account renal function, frailty, falls, tolerance to medication, associated conditions and the ability to adhere to treatment and follow-up appointments. The individual’s preferences form part of the decision once the benefits, limitations, risks and alternatives have been explained.

For most people with atrial fibrillation and a risk of embolism, oral anticoagulation remains the standard strategy for stroke prevention. Atrial appendage closure is reserved for selected situations where a different balance must be struck between protection against embolism and the risk of bleeding.

Patient selection and treatment planning

The decision to perform a percutaneous closure procedure begins with a comprehensive cardiological assessment. The team analyses the risk of embolism, any history of bleeding, factors that have made anticoagulation difficult, the patient’s general health, renal function and any associated conditions.

It is also important to ensure that the patient will be able to temporarily continue the antithrombotic treatment that is usually required after the procedure and attend follow-up appointments. Another essential factor is to have a precise understanding of the anatomy of the left atrial appendage, as its size and shape influence the choice of device and the implantation strategy.

Assessment of the left atrial appendage

Transoesophageal echocardiography allows the heart to be visualised using a probe inserted into the oesophagus, providing detailed images of the atrium and the left atrial appendage. It can be used to study its anatomy, measure its dimensions and rule out the presence of clots.

Cardiac computed tomography can provide additional three-dimensional information and help to plan the size and position of the implant. Depending on the case, one or both techniques may be used, alongside an electrocardiogram, blood tests and other assessments tailored to the clinical situation.

If the tests detect a thrombus within the atrial appendage, the team must reconsider the timing and strategy of the procedure before carrying out the implant.

Preparation for the procedure

Prior to the procedure, test results, cardiovascular history, bleeding risk and regular medication are reviewed. The management of anticoagulants and antiplatelet agents is planned specifically for each individual, as both their withdrawal and continued use can alter the balance between bleeding and clot formation.

These treatments must not be stopped or altered without medical advice. When the procedure requires general anaesthesia or deep sedation, the relevant anaesthetic assessment is also carried out and specific instructions are provided regarding fasting and medication.

How percutaneous atrial appendage closure is performed

The closure is performed in a suite equipped for image-guided interventional cardiac procedures. Depending on the characteristics of the case and the techniques used, general anaesthesia or deep sedation may be employed.

The specialist usually gains access to the vascular system via a vein in the groin and inserts a catheter, which is advanced to the right atrium. To reach the left atrium, a transseptal puncture is performed, a controlled manoeuvre that passes through the septum separating the two chambers.

Through this access point, the device – folded inside a catheter – is guided to the entrance of the left atrial appendage. Once in position, it is gradually deployed, and the team uses imaging to check that it fits the anatomy correctly, remains stable and achieves an adequate seal.

Transoesophageal echocardiography can be used to monitor the procedure in real time. The images help to guide the transseptal puncture, visualise the atrial appendage, check the position and stability of the device, and assess the seal before it is finally released.

If the result is unsatisfactory, the implant can be repositioned or replaced before it is released. Once the procedure is complete, the catheters are removed and the vascular access site in the groin is checked.

How you may feel after the procedure

The immediate experience depends on the type of anaesthesia or sedation used. In the hours following the procedure, you may experience tiredness, tenderness or a small bruise at the puncture site.

Where transoesophageal echocardiography has been used, there may also be mild discomfort or a sensation of irritation in the throat for a short time.

Benefits and aims of the treatment

The main aim of atrial appendage closure is to reduce the risk of a clot forming in this cavity and entering the bloodstream, causing a stroke or other embolism. When the device is correctly implanted and sealed, the atrial appendage is excluded from the main circulation.

In suitably selected patients, this approach may reduce the need for long-term oral anticoagulation – which may pose a significant bleeding risk or cannot be safely maintained. The protective effect, however, is not immediate, and it is usually necessary to continue antithrombotic treatment during the initial period.

The closure targets one of the main areas where thrombi can form in atrial fibrillation, but it does not eliminate all possible causes of stroke. It therefore remains important to manage blood pressure, diabetes, cholesterol, smoking and other cardiovascular risk factors.

Medication and follow-up after implantation

During the first few weeks or months, the surface of the device is gradually covered by tissue. Whilst this process is taking place, there may be a risk of a blood clot forming over the implant; therefore, it is usually necessary to continue with anticoagulant treatment, antiplatelet therapy or a combination of both on a temporary basis.

The treatment plan depends on the device, the risk of bleeding, the patient’s medical history and how they are progressing. There is no single regimen applicable to everyone, and medication must be continued for as long as advised by the medical team.

In the weeks or months that follow, a further imaging scan is carried out to check the position of the device, the degree of sealing and the absence of clots on its surface. Transoesophageal echocardiography or cardiac CT scans may be used for this follow-up.

The results of these tests help to determine how antithrombotic treatment should proceed. If significant leakage around the device or a thrombus on its surface is detected, it may be necessary to adjust or extend the medication and subsequently repeat the follow-up checks.

Risks and possible complications

Like any interventional cardiac procedure, percutaneous closure of the left atrial appendage may be associated with complications. The type and likelihood of these occurring depend on the individual’s characteristics, cardiac anatomy, the procedure performed and other clinical factors; therefore, the risk is assessed on a case-by-case basis prior to the procedure.

Some incidents are related to vascular access, such as pain, bruising or bleeding in the groin area. Complications may also arise in relation to blood vessels, contrast medium or anaesthesia.

Clinically relevant complications monitored by the team during and after the procedure include pericardial effusion, device displacement, thrombus formation on the implant or, in certain circumstances, an embolic event such as a stroke. Given their significance, it is essential to be aware of and monitor these complications, but their likelihood cannot be assessed in the same way for everyone.

Recovery after the procedure

After the procedure, your heart rate, blood pressure, neurological status and the area where the catheters were inserted are monitored. Many people remain in hospital until the following day, although the length of observation depends on your progress and any underlying conditions.

During the first few days, it is recommended that you take care of the access site in the groin and limit certain physical activities in accordance with the instructions provided. A return to normal activities takes place gradually and is tailored to the type of work, your general condition and your clinical progress.

Alternatives to left atrial appendage closure

Oral anticoagulation remains the standard strategy for preventing embolisms in most people with atrial fibrillation who are at risk of stroke. Where there are treatment-related issues, the assessment may include the possibility of addressing a cause of bleeding, changing the anticoagulant used, or adjusting other factors that increase the risk of bleeding.

In people who require heart surgery for another reason, surgical closure of the atrial appendage may be considered during the same procedure. Atrial fibrillation ablation, on the other hand, has a different aim: to treat the arrhythmia and help control the heart rhythm.

Although ablation may improve heart rhythm, the strategy for preventing stroke continues to be determined based on individual risk and is not automatically altered by the outcome of the procedure.

Signs requiring medical assessment

After discharge, you should seek medical assessment if you experience persistent bleeding or a rapid increase in bruising in the groin area. Severe chest pain, significant breathing difficulties, severe dizziness, loss of consciousness or a sudden deterioration in your general condition also require medical attention.

The sudden onset of weakness in one side of the body, slurred speech, loss of vision or other neurological symptoms may indicate a stroke and requires urgent medical attention. Fever, progressive redness or discharge from the puncture site should also be reported to the healthcare team.

Specialists involved

Percutaneous closure of the left atrial appendage requires coordination across various areas of cardiology, from the initial assessment through to follow-up checks. The process involves the assessment of atrial fibrillation and embolic risk, imaging to characterise the atrial appendage, and the performance of the interventional procedure.

At the Publio Cordón Memorial Hospital, the Haemodynamics and Interventional Cardiology Unit is directly responsible for carrying out the implant. It specialises in percutaneous cardiovascular procedures and structural heart disease, and works within a coordinated model alongside other cardiology units to plan and perform complex interventions.

The Electrophysiology and Arrhythmias Unit is involved in the assessment of atrial fibrillation and helps to integrate atrial appendage closure into the overall strategy for treating arrhythmias and preventing their complications. The hospital’s Cardiology department comprises this unit alongside the Haemodynamics and Advanced Cardiac Imaging units.

The Advanced Cardiac Imaging Unit plays a key role at various stages of the process. Prior to the procedure, imaging techniques enable the precise assessment of the atrial appendage’s anatomy, the evaluation of any potential thrombi, and the provision of information to select and plan the implant. The unit is equipped with advanced echocardiography and cardiac tomography and is involved in the planning of complex interventional procedures.

During closure, transoesophageal echocardiography provides real-time support to the interventional team. It allows visualisation of cardiac structures during transseptal puncture, guides the positioning of the device and verifies its stability and the degree of sealing before the procedure is completed. Following implantation, cardiac imaging is again used in follow-up checks to confirm the device’s position, assess any potential leaks and rule out the formation of thrombi on the device.

These units form part of the Cardiology Department and work in a coordinated manner. This organisation allows for the integration of diagnosis and risk assessment → planning using imaging → device implantation → verification of the result → subsequent follow-up within a single care pathway.

When the procedure requires general anaesthesia or advanced sedation, the Department of Anaesthetology and Resuscitation is involved in the pre-procedure assessment and in anaesthetic management during the procedure.

In certain situations, other specialities may be involved, depending on the patient’s history of bleeding, kidney disease, previous neurological episodes or other associated conditions. The specific team is tailored to each individual’s clinical needs and the decisions required during follow-up.

Medical information for general guidance

This information sheet aims to help you understand what percutaneous closure of the left atrial appendage involves, why it may be considered for certain people with atrial fibrillation, how the procedure is carried out, and what medication and follow-up checks are required after the implant. It also explains the main benefits, risks and alternatives.

At the Publio Cordón Memorial Hospital, we believe it is important for medical information to be accurate, understandable and useful in guiding each person through their journey of care. Our specialists devote part of their work to explaining conditions, tests and treatment options in an accessible way, helping patients and their families to better understand each stage and to participate with greater confidence in decisions about their health. This commitment to knowledge and public outreach is also part of our commitment to .

The information in this factsheet describes the general principles of left atrial appendage closure. The indication must be assessed on a case-by-case basis, taking into account the risk of stroke, history and causes of bleeding, the possibility of continuing anticoagulation therapy, cardiac anatomy, associated conditions, and the patient’s ability to adhere to treatment and attend follow-up appointments.