Left atrial appendage occlusion in patients with atrial fibrillation and previous Intracranial Hemorrhage or Cerebral Amyloid Angiopathy: A systematic review and meta-analysis

Theodorοs Mavridis; Paraschos Archontakis‐Barakakis; Andreas Charidimou

doi:10.1177/17474930251360076

July 11, 2025International Journal of Stroke

Left atrial appendage occlusion in patients with atrial fibrillation and previous Intracranial Hemorrhage or Cerebral Amyloid Angiopathy: A systematic review and meta-analysis

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Why the study?

Patients with AF on OAC with prior ICrH or CAA have high recurrence risks, and while LAAO may be safe and feasible, data remain limited.

Does left atrial appendage occlusion prevent ischemic stroke and recurrent intracranial hemorrhage in patients with non-valvular atrial fibrillation and prior intracranial hemorrhage or cerebral amyloid angiopathy?

Structured PICO

Does left atrial appendage occlusion prevent ischemic stroke and recurrent intracranial hemorrhage in patients with non-valvular atrial fibrillation and prior intracranial hemorrhage or cerebral amyloid angiopathy?

P

Population

Patients with non-valvular atrial fibrillation and previous history of intracranial hemorrhage (ICrH) and/or cerebral amyloid angiopathy (CAA)

I

Intervention

Left atrial appendage occlusion (LAAO)

O

Outcome

Post-procedural ischemic stroke and recurrent ICrHhard clinical

Limitations

Poor quality of evidence
Limited data from small observational studies

Implication

LAAO may be a safe and effective alternative for stroke prevention in AF patients with prior intracranial hemorrhage or cerebral amyloid angiopathy, though current evidence is of poor quality.

Abstract

BACKGROUND: Patients with atrial fibrillation (AF) on oral anticoagulation (OAC) who have a history of intracranial hemorrhage (ICrH) or cerebral amyloid angiopathy (CAA) have an elevated risk of ICrH recurrence. Left atrial appendage occlusion (LAAO) has emerged as a potential alternative to OAC for stroke prevention in high-bleeding-risk AF patients. Small observational studies suggest that LAAO may be safe and feasible in patients with ICrH, when using single or dual antiplatelet therapy or short-term OAC post-procedure, though data remain limited. This systematic review and meta-analysis aims to consolidate evidence on the safety and efficacy of LAAO in patients with prior ICrH or CAA. METHODS: We conducted a systematic review and meta-analysis examining the safety and efficacy of LAAO in patients with non-valvular AF and prior ICrH and/or CAA. PubMed/MEDLINE and EMBASE (via Scopus) databases were systematically searched from inception until 29 February 2024. Eligible studies included randomized control trials, observational studies, and case series (⩾10 participants) reporting stroke events in patients with AF and previous history of ICrH and/or CAA undergoing LAAO. Pooled incidence rates (IRs) with corresponding 95% confidence intervals (CIs) were calculated for primary outcomes (post-procedural ischemic stroke and recurrent ICrH) and secondary outcomes. RESULTS: = 54%), respectively. In prespecified subgroup analyses of studies focusing on patients with intraparenchymal hemorrhage and/or CAA, pooled IRs for ischemic stroke, recurrent ICrH, and major hemorrhage IR of 4% (95% CI: 1-8%), 4% (95% CI: 0.4-10%) and 6% (95% CI: 3-12%), respectively. CONCLUSIONS: LAAO may be a safe and effective treatment for selected AF patients with a history of ICrH and/or CAA, but the quality of evidence is poor. Future randomized controlled trials are essential to validate LAAO's efficacy and long-term safety.