Left atrial appendage occlusion versus oral anticoagulation for stroke prevention in atrial fibrillation: A meta-analysis of randomized controlled trials

Randomised controlled trials comparing percutaneous left atrial appendage occlusion (LAAO) with oral anticoagulation (OAC) for stroke prevention in atrial fibrillation (AF) have reported mixed results. We conducted a systematic review and meta-analysis of randomised controlled trials comparing LAAO with OAC in patients with non-valvular AF. Prespecified outcomes included the composite of stroke, systemic embolism, or cardiovascular death; ischaemic, haemorrhagic, disabling, non-disabling, and all stroke; cardiovascular and all-cause mortality; non-procedural and total major bleeding; and pericardial effusion or tamponade. Random-effects models were used to pool log-transformed hazard ratios (HRs) with 95% confidence intervals (CIs). Six trials comprising 7004 patients were included. LAAO was not associated with a significant difference in the composite outcome of stroke, systemic embolism, or cardiovascular death compared with OAC (HR, 1.00; 95% CI, 0.83–1.21; I 2 = 30.8%). LAAO was associated with a higher risk of ischaemic stroke (HR, 1.44; 95% CI, 1.06–1.95; I 2 = 0%) and a lower risk of non-procedural major bleeding (HR, 0.55; 95% CI, 0.40–0.74), whereas total major bleeding did not differ significantly between groups (HR, 0.94; 95% CI, 0.79–1.11). Exploratory Bayesian analyses showed a high posterior probability of harm for ischaemic stroke and strong support for a reduction in non-procedural major bleeding. LAAO therefore demonstrated similar overall composite efficacy to OAC but was associated with increased ischaemic stroke and reduced non-procedural major bleeding, without a significant difference in total major bleeding. These competing effects should be explicitly considered during shared decision-making.