Episodes of atrial fibrillation are frequently observed after a TAVI procedure most likely linked to the altered hemodynamic situation after the reduction of the transaortic gradient and with LV hypertrophy being present in almost all patients. This is associated with an increased risk of stroke during follow. In addition, many octogenarians with an increased bleeding risk receive a TAVI. LAA closure as part of the initial procedure may therefore be beneficial in selected patients in order to prevent fatal bleedings. This combination of procedures has been performed both in routine as well as in several live cases at various international meetings, i.e. at EuroPCR and TCT [1]. Aside from patient’s comfort of having only one procedure no particular benefit of combining both procedures could be demonstrated so far [2].

Most operators perform a TAVI procedure first by using a standard femoral access and then move on to occlude the LAA via a transvenous approach and transseptal puncture with the device they are most familiar with (Watchman or Amulet) thus avoiding prolonged procedure times. A TEE is not part of the TAVI procedure in many centers. Conscious sedation is sufficient for most TAVI procedures.

LAA closure can be performed through the femoral venous access that many centers use during a TAVI for the pacemaker lead or as a preventive measure if circulatory support is necessary. The TAVI prosthesis marks the aortic annulus which may serve as a landmark for transeptal puncture. LAA closure is performed following the usual standards. Post-implantation anticoagulation during the three months of device endothelialization may be done with either dual antiplatelet therapy or NOAC therapy-a therapeutic concept that is increasingly being used in this setting. NOAC’s appear to have the same bleeding risk as dual antiplatelet therapy but the advantage of a much shorter half-life (EWOLUTION). There is no indication for triple therapy in this setting.

Atrial fibrillation requiring stroke protection is also common in patients with mitral regurgitation. When a MitraClip implantation is chosen as therapeutic option to treat relevant mitral regurgitation in these patients, LAA closure during the same procedure seems to be attractive especially if an increased bleeding risk is present as the same access way can be used for the placement of both devices. However, there are two issues that question this approach: First, the implantation of a MitraClip usually leaves an increased gradient across the mitral valve behind that may increase the risk of thrombus formation in the free left atrial cavum rather than the LAA. Therefore the benefit of LAA closure in the setting of a MitraClip implantation may be limited. Secondly, for a MitraClip procedure the transseptal puncture site needs to be high above the mitral valve plane whereas LAA closure is easier with a low puncture site, particularly when an Amulet device is chosen [3] (around 4–4.5 cm vs. 3–4 cm above the mitral plane).