Two randomized studies evaluated the WATCHMAN (Atritech, Inc) device vs warfarin: the Watchman Left Atrial Appendage System for Embolic Protection in Patients with Atrial Fibrillation (PROTECT AF) and the Evaluation of the WATCHMAN LAA Closure Device in Patients With Atrial Fibrillation Versus Long Term Warfarin Therapy (PREVAIL AF).446-452 In the PROTECT AF trial, the ef cacy of LAA closure with the device met the pre-speci ed criteria for non-inferiority vs warfarin, but the rate of adverse safety events in the intervention group was 4.4% with evidence of harmful periprocedural complications (pericardial effusion and procedure-related ischemic stroke). For acute complications, a learning curve appeared to be present, with serious pericardial effusions (requiring drainage) in 7.1% of the rst 3 implant patients at each site compared with 4.4% of subsequent patients.453 The serious complication rate of about 7% has been reported also for rst- or second-generation Amplatzer A recent systematic review network meta-analysis on the use of OACs and the Watchman device showed that the use of VKA, NOAC, and the Watchman device signi cantly reduce the risk of any stroke and systemic embolism as compared with placebo/control (Watchman device OR, 0.35; 95% CI, Data on the use of the WATCHMAN device in patients with contraindications to anticoagulation are very limited, and DAPT is needed for at least 6 weeks after the procedure, potentially exposing the patient to increased risk of bleeding.453 The Lariat device is based on an epicardial snare that requires positioning using a percutaneous approach to the epicardium through a pericardial access and in combination a percutaneous endocardial approach. In inexperienced operators, incomplete occlusion of the LAA after LARIAT ligation was relatively common (20% of cases) and was associated with risk of No randomized controlled study comparing this device with oral anticoagulation is currently available. 