Left Atrial Appendage Closure Versus Oral Anticoagulants in Atrial Fibrillation: A Systematic Review and Meta-Analysis

Background: Left atrial appendage (LAA) closure is an alternative to oral anticoagulants (OAC) for stroke prevention in atrial fibrillation (AF), but comparative evidence remains inconsistent. This study systematically evaluates the efficacy and safety of LAA closure versus OAC in AF patients. Methods: We systematically searched PubMed, EmBase, Cochrane Library, and Web of Science for randomized controlled trials (RCTs) and propensity score-matched (PSM) studies published up to 30 September 2025. Treatment effects were estimated using relative risks (RR) with 95% confidence intervals (CI), and a random-effects model was applied for all analyses. Results: Fifteen studies (17,116 AF patients) were included, comprising 4 RCTs, 3 prospective PSM studies, and 8 retrospective PSM studies. Compared with OAC, LAA closure significantly reduced the composite endpoint (RR: 0.79; 95% CI: 0.66–0.95; p = 0.010), all-cause mortality (RR: 0.58; 95% CI: 0.49–0.69; p < 0.001), and cardiovascular mortality (RR: 0.55; 95% CI: 0.44–0.67; p < 0.001). Risks of any stroke (RR: 1.06; 95% CI: 0.86–1.31; p = 0.555), ischemic stroke (RR: 1.00; 95% CI: 0.85–1.17; p = 0.972), hemorrhagic stroke (RR: 0.96; 95% CI: 0.54–1.70; p = 0.879), and major bleeding (RR: 0.84; 95% CI: 0.67–1.04; p = 0.112) were not significantly different between groups. Conclusions: In AF patients, LAA closure significantly reduces mortality and a composite clinical endpoint compared to OAC, with similar risks of stroke and major bleeding. It is a favorable alternative for patients unsuitable for long-term anticoagulation.