{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,17]],"date-time":"2026-07-17T04:05:48Z","timestamp":1784261148770,"version":"3.55.0"},"reference-count":49,"publisher":"MDPI AG","issue":"14","license":[{"start":{"date-parts":[[2026,7,16]],"date-time":"2026-07-16T00:00:00Z","timestamp":1784160000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JCM"],"abstract":"<jats:p>The left atrial appendage is well recognized as the site of thrombus formation in patients with atrial fibrillation. However, in patients who are either unsuitable for long-term oral anticoagulation or in whom this therapy is inefficient, left atrial occlusion has emerged as a mechanical strategy option to diminish stroke risk. Minimally invasive percutaneous and standalone surgical thoracoscopic techniques are appearing as viable options for left atrial appendage exclusion, each with distinct procedural risk profiles and characteristics, as well as evidence from trials or registers. We suggest that the choice between percutaneous and thoracoscopic left atrial appendage occlusion should be individualized, ideally within the multidisciplinary heart team, considering left atrial appendage anatomy, patient bleeding and thromboembolic risk profile, comorbidities, prior cardiac interventions, and institutional expertise and resources. We aim to present in this review the value of multimodality imaging in patient selection for minimally invasive left atrial appendage occlusion to minimize the possibility of complications, and to compare technical advancements and indications for percutaneous and standalone thoracoscopic left atrial appendage occlusion.<\/jats:p>","DOI":"10.3390\/jcm15145587","type":"journal-article","created":{"date-parts":[[2026,7,17]],"date-time":"2026-07-17T03:12:38Z","timestamp":1784257958000},"page":"5587","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Minimally Invasive Standalone Left Atrial Appendage Occlusion for Atrial Fibrillation: Procedural Approaches and Complications"],"prefix":"10.3390","volume":"15","author":[{"given":"Sandra","family":"Jaksic Jurinjak","sequence":"first","affiliation":[{"name":"Department of Cardiovascular Diseases, University Hospital Centre Zagreb, Kispaticeva 12, 10000 Zagreb, Croatia"},{"name":"School of Medicine, University of Zagreb, Salata 3, 10000 Zagreb, Croatia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4721-3236","authenticated-orcid":false,"given":"Vlatka","family":"Reskovic Luksic","sequence":"additional","affiliation":[{"name":"Department of Cardiovascular Diseases, University Hospital Centre Zagreb, Kispaticeva 12, 10000 Zagreb, Croatia"},{"name":"Algebra Bernays University, Gradiscanska 24, 10000 Zagreb, Croatia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4745-999X","authenticated-orcid":false,"given":"Tomislav","family":"Kopjar","sequence":"additional","affiliation":[{"name":"School of Medicine, University of Zagreb, Salata 3, 10000 Zagreb, Croatia"},{"name":"Department of Cardiac Surgery, University Hospital Centre Zagreb, Kispaticeva 12, 10000 Zagreb, Croatia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-5425-5840","authenticated-orcid":false,"given":"Vedran","family":"Velagic","sequence":"additional","affiliation":[{"name":"Department of Cardiovascular Diseases, University Hospital Centre Zagreb, Kispaticeva 12, 10000 Zagreb, Croatia"},{"name":"School of Medicine, University of Zagreb, Salata 3, 10000 Zagreb, Croatia"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2026,7,16]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"601","DOI":"10.1001\/jamacardio.2018.1176","article-title":"Association of Burden of Atrial Fibrillation with Risk of Ischemic Stroke in Adults with Paroxysmal Atrial Fibrillation: The KP-RHYTHM Study","volume":"3","author":"Go","year":"2018","journal-title":"JAMA Cardiol."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"353","DOI":"10.1056\/NEJMcp2023658","article-title":"Atrial Fibrillation","volume":"384","author":"Michaud","year":"2021","journal-title":"N. Engl. J. Med."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"i162","DOI":"10.1093\/eurheartjsupp\/suae088","article-title":"Subclinical atrial fibrillation\/atrial high-rate episodes: What significance and decision-making?","volume":"27","author":"Boriani","year":"2025","journal-title":"Eur. Heart J. Suppl."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"2N","DOI":"10.1016\/S0002-9149(98)00583-9","article-title":"Prevalence, Incidence, Prognosis, and Predisposing Conditions for Atrial Fibrillation: Population-Based Estimates","volume":"82","author":"Kannel","year":"1998","journal-title":"Am. J. Cardiol."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"3","DOI":"10.2174\/187152571201141201091848","article-title":"Novel oral anticoagulants in non-valvular atrial fibrillation","volume":"12","year":"2014","journal-title":"Cardiovasc. Hematol. Agents Med. Chem."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"955","DOI":"10.1016\/j.mayocp.2023.12.005","article-title":"Surgical Coronary Revascularization in Patients with Underlying Atrial Fibrillation: State-of-the-Art Review","volume":"99","author":"Kurasz","year":"2024","journal-title":"Mayo Clin. Proc."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"373","DOI":"10.1093\/eurheartj\/ehaa612","article-title":"2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS): The Task Force for the diagnosis and management of atrial fibrillation of the European Society of Cardiology (ESC) Developed with the special contribution of the European Heart Rhythm Association (EHRA) of the ESC","volume":"42","author":"Hindricks","year":"2021","journal-title":"Eur. Heart J."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"3314","DOI":"10.1093\/eurheartj\/ehae176","article-title":"2024 ESC Guidelines for the management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS)","volume":"45","author":"Rienstra","year":"2024","journal-title":"Eur. Heart J."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"139","DOI":"10.1136\/heartjnl-2016-309782","article-title":"Efficacy and safety of left atrial appendage closure versus medical treatment in atrial fibrillation: A network meta-analysis from randomised trials","volume":"103","author":"Sahay","year":"2017","journal-title":"Heart"},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"100941","DOI":"10.1016\/j.ijcha.2021.100941","article-title":"Impact of Operato\u0155s Experience on Peri-Procedural Outcomes with Watchman FLX: Insights from the FLX-SPA Registry","volume":"38","author":"Molina","year":"2022","journal-title":"IJC Heart Vasc."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"2465","DOI":"10.1093\/eurheartj\/ehv730","article-title":"Implant success and safety of left atrial appendage closure with the WATCHMAN device: Peri-procedural outcomes from the EWOLUTION registry","volume":"37","author":"Boersma","year":"2016","journal-title":"Eur. Heart J."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"109","DOI":"10.1016\/j.jacc.2023.08.017","article-title":"2023 ACC\/AHA\/ACCP\/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology\/American Heart Association Joint Committee on Clinical Practice Guidelines","volume":"83","author":"Joglar","year":"2024","journal-title":"JACC"},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"4229","DOI":"10.1093\/eurheartj\/ehac244","article-title":"2022 ESC Guidelines on cardio-oncology developed in collaboration with the European Hematology Association (EHA), the European Society for Therapeutic Radiology and Oncology (ESTRO) and the International Cardio-Oncology Society (IC-OS): Developed by the task force on cardio-oncology of the European Society of Cardiology (ESC)","volume":"43","author":"Lyon","year":"2022","journal-title":"Eur. Heart J."},{"key":"ref_14","unstructured":"Amplatzer, T.M., and Amulet, T.M. (2025, June 25). Left Atrial Appendage Occluder Instructions for Use, Available online: https:\/\/www.accessdata.fda.gov\/cdrh_docs\/pdf20\/P200049C.pdf."},{"key":"ref_15","doi-asserted-by":"crossref","unstructured":"Korhonen, M., Muuronen, A., Arponen, O., Mustonen, P., Hedman, M., Jakala, P., Vanninen, R., and Taina, M. (2015). Left atrial appendage morphology in patients with suspected cardiogenic stroke without known atrial fibrillation. PLoS ONE, 10.","DOI":"10.1371\/journal.pone.0118822"},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"e1","DOI":"10.1016\/j.hrthm.2023.01.007","article-title":"SCAI\/HRS expert consensus statement on transcatheter left atrial appendage closure","volume":"20","author":"Saw","year":"2023","journal-title":"Heart Rhythm"},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"364","DOI":"10.1080\/24748706.2019.1643957","article-title":"Imaging for Percutaneous Left Atrial Appendage Closure: A Contemporary Review","volume":"3","author":"Ramchand","year":"2019","journal-title":"Struct. Heart"},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"1236","DOI":"10.1007\/s00330-020-07172-2","article-title":"Diagnosis of left atrial appendage thrombus in patients with atrial fibrillation: Delayed contrast-enhanced cardiac CT","volume":"31","author":"Spagnolo","year":"2021","journal-title":"Eur. Radiol."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"117","DOI":"10.1002\/clc.23956","article-title":"Clinical efficacy and safety comparison of Watchman device versus ACP\/Amulet device for percutaneous left atrial appendage closure in patients with nonvalvular atrial fibrillation: A study-level meta-analysis of clinical trials","volume":"46","author":"Bing","year":"2023","journal-title":"Clin. Cardiol."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"26841","DOI":"10.31083\/RCM26841","article-title":"Surgical Methods and Devices for Atrial Fibrillation","volume":"26","author":"Yu","year":"2025","journal-title":"Rev. Cardiovasc. Med."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"1251","DOI":"10.1016\/j.jcmg.2014.08.009","article-title":"The left atrial appendage: Anatomy, function, and noninvasive evaluation","volume":"7","author":"Beigel","year":"2014","journal-title":"JACC Cardiovasc. Imaging"},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"548","DOI":"10.1093\/icvts\/ivab334","article-title":"Standalone epicardial left atrial appendage exclusion for thromboembolism prevention in atrial fibrillation","volume":"34","author":"Cartledge","year":"2022","journal-title":"Interact. Cardiovasc. Thorac. Surg."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"771","DOI":"10.1016\/j.hrthm.2024.01.046","article-title":"Minimally invasive epicardial surgical left atrial appendage exclusion for atrial fibrillation patients at high risk for stroke and for bleeding","volume":"21","author":"Rose","year":"2024","journal-title":"Heart Rhythm"},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"541","DOI":"10.1177\/1556984520960116","article-title":"Stand-Alone Thoracoscopic Left Atrial Appendage Closure in Nonvalvular Atrial Fibrillation Patients at High Bleeding Risk","volume":"15","author":"Franciulli","year":"2020","journal-title":"Innovations"},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"e71","DOI":"10.1016\/j.athoracsur.2018.07.046","article-title":"Totally Thoracoscopic Closure of the Left Atrial Appendage","volume":"107","author":"Ramlawi","year":"2019","journal-title":"Ann. Thorac. Surg."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"655","DOI":"10.1093\/icvts\/ivz156","article-title":"Outcomes of left atrial appendage occlusion using the AtriClip device: A systematic review","volume":"29","author":"Toale","year":"2019","journal-title":"Interact. Cardiovasc. Thorac. Surg."},{"key":"ref_27","doi-asserted-by":"crossref","unstructured":"\u015awi\u0119czkowski, M., D\u0105browski, E.J., Muszy\u0144ski, P., Pogorzelski, P., Jemielita, P., Dudzik, J.M., Januszko, T., Duzinkiewicz, M., and Poludniewski, M. (2024). A Comprehensive Review of Percutaneous and Surgical Left Atrial Appendage Occlusion. J. Cardiovasc. Dev. Dis., 11.","DOI":"10.3390\/jcdd11080234"},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"2081","DOI":"10.1056\/NEJMoa2101897","article-title":"Left Atrial Appendage Occlusion during Cardiac Surgery to Prevent Stroke","volume":"384","author":"Whitlock","year":"2021","journal-title":"N. Engl. J. Med."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"1269","DOI":"10.1016\/j.jtcvs.2009.06.033","article-title":"Left atrial appendage clip occlusion: Early clinical results","volume":"139","author":"Salzberg","year":"2010","journal-title":"J. Thorac. Cardiovasc. Surg."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"1075","DOI":"10.1016\/j.jtcvs.2016.06.009","article-title":"A randomized, prospective pilot comparison of 3 atrial appendage elimination techniques: Internal ligation, stapled excision, and surgical excision","volume":"152","author":"Lee","year":"2016","journal-title":"J. Thorac. Cardiovasc. Surg."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"534","DOI":"10.1016\/S0140-6736(09)61343-X","article-title":"Percutaneous closure of the left atrial appendage versus warfarin therapy for prevention of stroke in patients with atrial fibrillation: A randomized non-inferiority trial","volume":"374","author":"Holmes","year":"2009","journal-title":"Lancet"},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1016\/j.jacc.2014.04.029","article-title":"Prospective randomized evaluation of the Watchman Left Atrial Appendage Closure device in patients with atrial fibrillation versus long-term warfarin therapy: The PREVAIL trial","volume":"64","author":"Holmes","year":"2014","journal-title":"J. Am. Coll. Cardiol."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"2551","DOI":"10.1016\/j.jacc.2013.03.035","article-title":"Left atrial appendage closure with the Watchman device in patients with a contraindication for oral anticoagulation: The ASAP study","volume":"61","author":"Reddy","year":"2013","journal-title":"J. Am. Coll. Cardiol."},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"1543","DOI":"10.1161\/CIRCULATIONAHA.121.057063","article-title":"Amplatzer Amulet Left Atrial Appendage Occluder versus Watchman Device for Stroke Prophylaxis (Amulet IDE): A randomized, controlled trial","volume":"144","author":"Lakkireddy","year":"2021","journal-title":"Circulation"},{"key":"ref_35","first-page":"101290","article-title":"Steerable Delivery Sheath for Left Atrial Appendage Closure in Patients with Severely Enlarged Left Atria","volume":"3","author":"Amabile","year":"2024","journal-title":"J. Soc. Cardiovasc. Angiogr. Interv."},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"1277","DOI":"10.1056\/NEJMoa2408308","article-title":"Left Atrial Appendage Closure after Ablation for Atrial Fibrillation","volume":"392","author":"Wazni","year":"2025","journal-title":"N. Engl. J. Med."},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"1503","DOI":"10.1016\/j.jacc.2019.12.040","article-title":"The NCDR Left Atrial Appendage Occlusion Registry","volume":"75","author":"Freeman","year":"2020","journal-title":"J. Am. Coll. Cardiol."},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"171","DOI":"10.1111\/j.1540-8175.2008.00794.x","article-title":"Evaluation of left atrial appendage functions according to different etiologies of atrial fibrillation with a tissue Doppler imaging technique by using transesophageal echocardiography","volume":"26","author":"Sahin","year":"2009","journal-title":"Echocardiography"},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"472","DOI":"10.1016\/j.jcmg.2015.02.002","article-title":"Percutaneous interventions for left atrial appendage exclusion: Options, assessment, and imaging using 2D and 3D echocardiography","volume":"8","author":"Wunderlich","year":"2015","journal-title":"JACC Cardiovasc. Imaging"},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"25","DOI":"10.1007\/s00392-024-02492-5","article-title":"Echocardiographic assessment of left atrial appendage morphology and function\u2014An expert proposal by the German Working Group of Cardiovascular Ultrasound","volume":"114","author":"Hagendorff","year":"2025","journal-title":"Clin. Res. Cardiol."},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"e013750","DOI":"10.1161\/CIRCINTERVENTIONS.123.013750","article-title":"Outcomes with the WATCHMAN FLX in Everyday Clinical Practice from the NCDR Left Atrial Appendage Occlusion Registry","volume":"17","author":"Kapadia","year":"2024","journal-title":"Circ. Cardiovasc. Interv."},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"R65","DOI":"10.1530\/ERP-18-0083","article-title":"Left atrial spontaneous echo contrast: Relationship with clinical and echocardiographic parameters","volume":"6","author":"Ito","year":"2019","journal-title":"Echo Res. Pract."},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"e1048","DOI":"10.1016\/j.hrthm.2025.05.048","article-title":"2025 SCAI\/HRS clinical practice guidelines on transcatheter left atrial appendage occlusion","volume":"22","author":"Goldsweig","year":"2025","journal-title":"Heart Rhythm"},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"86","DOI":"10.1016\/j.ahj.2025.04.015","article-title":"Rationale and design of the anticoagulant therapy after left atrial appendage closure (ATLAAC) trial","volume":"287","author":"Gosvig","year":"2025","journal-title":"Am. Heart J."},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"955","DOI":"10.1007\/s00392-025-02697-2","article-title":"Comparison of left atrial appendage occlusion with medical treatment for non-valvular atrial fibrillation: Systematic review, network and reconstructed individual patient data meta-analysis","volume":"115","author":"Lerman","year":"2026","journal-title":"Clin. Res. Cardiol."},{"key":"ref_46","doi-asserted-by":"crossref","first-page":"270","DOI":"10.1007\/s12181-025-00750-y","article-title":"DGK-Positionspapier zum Umgang mit Device-detektiertem Vorhofflimmern (DDAF)","volume":"19","author":"Birkemeyer","year":"2025","journal-title":"Kardiologie"},{"key":"ref_47","first-page":"1042","article-title":"Reply: Introducing the Fourth Left Atrial Appendage Occlusion Study","volume":"11","author":"Garg","year":"2025","journal-title":"J. Am. Coll. Cardiol. EP"},{"key":"ref_48","doi-asserted-by":"crossref","first-page":"391","DOI":"10.1016\/j.case.2023.05.009","article-title":"Left Atrial Appendage Tilt-Up-and-Turn-Left Maneuver: A Novel Three-Dimensional Transesophageal Echocardiography Imaging Maneuver to Characterize the Left Atrial Appendage and to Improve Transcatheter Closure Guidance","volume":"7","author":"Hayes","year":"2023","journal-title":"CASE"},{"key":"ref_49","doi-asserted-by":"crossref","first-page":"28189","DOI":"10.31083\/RCM28189","article-title":"Intracardiac Echocardiography to Guide Left Atrial Appendage Occlusion: An Update","volume":"26","author":"Brankovic","year":"2025","journal-title":"Rev. Cardiovasc. Med."}],"container-title":["Journal of Clinical Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2077-0383\/15\/14\/5587\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,7,17]],"date-time":"2026-07-17T03:48:45Z","timestamp":1784260125000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2077-0383\/15\/14\/5587"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,7,16]]},"references-count":49,"journal-issue":{"issue":"14","published-online":{"date-parts":[[2026,7]]}},"alternative-id":["jcm15145587"],"URL":"https:\/\/doi.org\/10.3390\/jcm15145587","relation":{},"ISSN":["2077-0383"],"issn-type":[{"value":"2077-0383","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,7,16]]}}}