With the CHAMPION-AF trial, the field of catheter-based left atrial appendage closure (LAAC) enters a new phase. This large randomized study demonstrates that LAAC is not only an option for patients with contraindications to anticoagulation, but may also represent a valid alternative in patients who are otherwise eligible for DOAC therapy.
On this basis, the therapeutic paradigm begins to shift: LAAC is moving beyond its role as a “last resort” and is increasingly being considered earlier in the decision-making process as an active treatment strategy.
Noninferiority with Clinical Relevance
CHAMPION-AF demonstrated that LAAC is noninferior to DOAC therapy with respect to the composite endpoint of cardiovascular death, stroke, and systemic embolism at 3 years.
This noninferiority is clinically meaningful, as it was achieved in a population not specifically selected for LAAC, but rather in patients who were explicitly eligible for long-term anticoagulation. This addresses a key historical concern regarding the role of LAAC.
At the same time, absolute event rates were low in both groups, underscoring that LAAC may represent an effective stroke prevention strategy comparable to modern pharmacotherapy—at least in the mid-term (with 5-year data still pending).
The Key Advantage: Reduced Bleeding
Perhaps the most important clinical benefit of LAAC in CHAMPION-AF lies in the significant reduction in bleeding complications. The rate of non-procedural, clinically relevant bleeding was nearly halved.
This finding is particularly noteworthy given that the study population did not exhibit a pronounced high bleeding risk profile. This suggests that:
- the bleeding advantage of LAAC is not limited to high-risk patients but may extend to a broader patient population.
These findings are consistent with prior studies such as PRAGUE-17 and OPTION and further support the concept that LAAC may offer a safer long-term strategy with respect to bleeding complications.
High Procedural Safety
Another important aspect of CHAMPION-AF is the high procedural quality. Device implantation was successful in nearly all cases, and serious complications were rare.
- This reflects the progress made in recent years: Improved device technology, standardized imaging, and structured workflows have made LAAC a reproducible and safe procedure – particularly in experienced centers.
European Perspective: Controlled Expansion
From a European perspective, CHAMPION-AF primarily signals a controlled expansion of indications.
Current ESC guidelines position LAAC mainly in patients with contraindications to anticoagulation. While CHAMPION-AF is unlikely to immediately and fundamentally change this position, it may broaden it.
In particular, LAAC could be considered earlier in the following scenarios:
- patients with moderate stroke risk and expected long-term anticoagulation,
- patients with increasing bleeding risk over time,
- in the context of AF ablation (as supported by the OPTION trial),
- patients with limited adherence or preference against lifelong medication.
This reflects a shift from purely risk-based indication toward a more individualized treatment decision.
Patient Profiling as the Key
The central implication of CHAMPION-AF is not a broad expansion of LAAC indications, but rather a more precise application.
The key question moving forward is less:
“Is LAAC better than anticoagulation?”
and more:
“For which patient is LAAC the better strategy?”
Several factors need to be considered:
- individual bleeding risk over time,
- life expectancy and comorbidities,
- anatomical suitability,
- procedural risk,
- patient preference.
This is where European cardiology can leverage its strengths—through structured decision-making, heart team concepts, and high-level imaging expertise.
Conclusion
CHAMPION-AF represents an important step forward for LAAC:
LAAC is no longer limited to patients without alternatives, but is emerging as a genuine option within the therapeutic spectrum of stroke prevention.
The combination of comparable efficacy and reduced bleeding makes LAAC particularly attractive for patients in whom long-term anticoagulation is associated with increased risk or significant burden.
What does this mean from a European perspective?
- Not an uncritical expansion of indications for LAAC, but a revaluation of its role in clinical decision-making.
- The future does not lie in replacing anticoagulation, but in the individualized, patient-centered integration of LAAC into modern AF management.
About the author
Dr. Nina C. Wunderlich
Dr. Nina C. Wunderlich is an internationally recognized expert in the field of interventional imaging. Her work focuses on echocardiographic monitoring and imaging during cardiac catheterization procedures. She has published numerous scientific papers on this topic and is regarded as a renowned speaker and thought leader in this field. She also Governor elect of the German Chapter of the ACC.
Take-aways
- LAAC represents an evidence-based alternative to oral anticoagulation in selected patients.
- The main clinical advantage of LAAC is the long-term reduction in bleeding complications.
- Broad use as a first-line therapy is not justified at present—careful patient selection remains essential.
- The future lies in an individualized treatment approach (“patient profiling”) integrating clinical and procedural factors.
References
- Kar, S. Outcomes In Patients With Atrial Fibrillation Randomized To Receive Left Atrial Appendage Closure Or Oral Anticoagulation: Primary Results Of The CHAMPION-AF Clinical Trial. Late-Breaking Clinical Trials I. 31.03. New Orleans, ACC 2026.
- Doshi, S. K. et al. (2026). Left Atrial Appendage Closure or Anticoagulation for Atrial Fibrillation. New England Journal Of Medicine. https://doi.org/10.1056/nejmoa2517213.
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