Catheter-Based Left Atrial Appendage Closure vs Oral Anticoagulation in Patients With Atrial Fibrillation

Importance In patients with atrial fibrillation (AF), oral anticoagulation (OAC) is the gold standard for preventing ischemic stroke, at the expense of a higher risk of bleeding. Catheter-based left atrial appendage closure (LAAC) has been proposed as an alternative strategy to prevent stroke, but the efficacy and safety compared to OAC are uncertain. Objective To evaluate the efficacy and safety of catheter-based LAAC compared to OAC in patients with AF at high risk of stroke. Data Sources PubMed, Cochrane Central, and Web of Science were screened up to March 2026. The websites of leading cardiology societies, news outlets, and reference lists of each eligible study were also inspected. Study Selection Studies enrolling patients with AF randomly assigned to catheter-based LAAC or OAC and reporting at least 1 outcome of interest were included. Data Extraction and Synthesis Two investigators independently extracted data of interest and assessed data quality. Catheter-based LAAC vs OAC comparisons were pooled as incidence rate ratios (IRRs) using a frequentist random-effect model. Main Outcomes and Measures Primary and coprimary outcomes were long-term stroke and major bleeding. Secondary outcomes included the composite of cardiovascular death, stroke, or systemic embolism, all-cause death, the single components of the composite end point, ischemic stroke, hemorrhagic stroke, and nonprocedural major bleeding. Periprocedural events (ie, stroke, major bleeding, death, device embolization, and pericardial effusion) were also combined. Results Eight trials (7434 patients) were included in the meta-analysis. After a weighted mean follow-up of 37.9 months, no significant differences were detected for stroke (IRR, 1.08; 95% CI, 0.82-1.41) and major bleeding (IRR, 0.96; 95% CI, 0.81-1.14). However, catheter-based LAAC was associated with a higher risk of ischemic stroke (IRR, 1.34; 95% CI, 1.01-1.77) and a lower risk of nonprocedural major bleeding (IRR, 0.73; 95% CI, 0.58-0.92) compared with OAC. Periprocedural events per 1000 patients were 5 strokes, 9 episodes of bleeding, 1 death, 5 episodes of device embolization, and 9 pericardial effusions. Conclusions and Relevance In patients with AF, at long-term follow-up, transcatheter LAAC was associated with similar rates of any type of stroke and major bleeding compared with OAC, while increasing the risk of ischemic stroke and lowering the risk of nonprocedure-related major bleeding. These findings do not support the routine use of LAAC as a first-line strategy for stroke prevention in patients with AF at moderate to high risk of stroke.