Table 1.

Appropriate Selection of Percutaneous Approaches for Left Atrial Appendage Closure

Device/Method	Advantages	Limitations
Transseptal device placement	Transseptal technique widely available Available in the setting of previous cardiac surgery Validated as noninferior to warfarin for stroke prevention (Watchman)	Need for procedural and short term anticoagulation and/or antithrombotic regimen until endothelialization occurs Foreign body left in central circulation (small risk of embolization, erosion, dislodgement) Device must be sized to match LAA Previous atrial septal defect closure may preclude transseptal delivery
Epicardial	No foreign body left behind No need for procedural anticoagulation because no contact with central circulation and no transseptal puncture (which exposes blood to tissue factor) Adjustable size loop to accommodate variable LAA shape/morphology without need for sizing Pericardial control facilitates management of effusion should one develop	Human experience not yet reported Previous cardiac surgery limits pericardial access and maneuverability Epicardial access techniques less widely available than transseptal puncture
Hybrid	No foreign body left behind Pericardial control facilitates management of effusion should one develop	Need for both transseptal and epicardial access with risks of both, and delivery failure if cannot achieve both Superiorly directed LAA, multiple lobes and pectus excavatum may preclude use

From Friedman, J Cardiovasc Electrophysiol 2011; 22 (10): 1184 – 91, with permission.