Left Atrial Appendage Occlusion vs Direct Oral Anticoagulants for Atrial Fibrillation

Q: What is the clinical evidence from this study?

Study design: Meta-Analysis. Population: Atrial Fibrillation (n=67693). Intervention: Left atrial appendage occlusion (LAAO) vs. Direct oral anticoagulants (DOACs). Primary outcome: composite of stroke, systemic embolism, and cardiovascular death (HR 1.02, 95% CI 0.88-1.19).

Yuriko Hiruma; Tadao Aikawa; Iwanari Kawamura; Masao Iwagami; Polydoros Kampaktsis; Alexandros Briasoulis; Ali Fatehi Hassanabad; Kaveh Hosseini; Pier Pasquale Leone; Leandro N. Slipczuk; Jose Wiley; Eric Secemsky; Roger J. Laham; Toshiki Kuno

doi:10.1016/j.jacadv.2026.103269

September 23, 2026JACC AdvancesOpen Access

Left Atrial Appendage Occlusion vs Direct Oral Anticoagulants for Atrial Fibrillation

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Key result

Left atrial appendage occlusion did not demonstrate statistical superiority over DOACs for stroke, systemic embolism, and cardiovascular death (HR 1.02; 95% CI 0.88-1.19).

Figures

Graphical abstract published by JACC Advances — Graphical abstract · Published by JACC Advances · CC BY-NC-ND

Why the study?

It remains unclear whether left atrial appendage occlusion offers superior efficacy and safety compared with oral anticoagulation in patients with atrial fibrillation.

Does left atrial appendage occlusion reduce the composite of stroke, systemic embolism, and cardiovascular death compared to direct oral anticoagulants in patients with atrial fibrillation?

Key Points

To assess the comparative efficacy and safety of left atrial appendage occlusion versus direct oral anticoagulants in patients with atrial fibrillation.
Conducted a systematic review and two network meta-analyses of randomized controlled trials identified through MEDLINE and CENTRAL.
Evaluated 67,693 patients across 11 randomized controlled trials, of whom 5,735 underwent left atrial appendage occlusion.
Assessed a primary composite efficacy endpoint (stroke, systemic embolism, and cardiovascular death) and a safety endpoint (major bleeding) across multi-arm device and anticoagulant regimens.
In the three-arm network meta-analysis, left atrial appendage occlusion showed a similar risk for the primary efficacy outcome compared to direct oral anticoagulants (HR: 1.02; 95% CI: 0.88–1.19).
Left atrial appendage occlusion devices did not demonstrate statistical superiority over direct oral anticoagulants in lowering rates of thromboembolic events or major bleeding.

Study Design

Type

Meta-Analysis (n=67,693)

Structured PICO

Does left atrial appendage occlusion reduce the composite of stroke, systemic embolism, and cardiovascular death compared to direct oral anticoagulants in patients with atrial fibrillation?

P

Population

67,693 patients with atrial fibrillation from 11 randomized controlled trials comparing oral anticoagulation and LAAO.

I

Intervention

Left atrial appendage occlusion (LAAO) devices (including Watchman and Amulet)

C

Comparator

Direct oral anticoagulants (DOACs) and vitamin K antagonists

O

Outcome

Composite of stroke, systemic embolism, and cardiovascular deathcomposite

Main Result

Hazard Ratio: 1.02 (95% CI 0.88–1.19)

Implication

Left atrial appendage occlusion does not demonstrate statistical superiority over direct oral anticoagulants for preventing thromboembolic events or major bleeding in patients with atrial fibrillation.

Abstract

BACKGROUND: Left atrial appendage occlusion (LAAO) is a treatment option to prevent thromboembolic events in patients with atrial fibrillation. However, it remains unclear whether LAAO offers superior efficacy and safety compared with oral anticoagulation for these patients. OBJECTIVES: This study aimed to assess the efficacy and safety of LAAO vs direct oral anticoagulants (DOACs). METHODS: We reviewed randomized controlled trials comparing oral anticoagulation and LAAO, using MEDLINE and CENTRAL. The primary outcome was a composite of stroke, systemic embolism, and cardiovascular death, whereas the safety outcome was major bleeding. Two network meta-analyses were conducted to assess LAAO vs DOAC, incorporating indirect comparisons: 1 comparing LAAO, DOACs, and vitamin K antagonist (3 arms), and the other comparing Watchman, Amulet, DOACs, and vitamin K antagonist (4 arms). RESULTS: A total of 67,693 patients from 11 randomized controlled trials were included, of whom 5,735 underwent LAAO. In the three-arm network meta-analysis, LAAO and DOACs demonstrated statistically similar risks for both the primary efficacy outcome (HR: 1.02; 95% CI: 0.88-1.19; I CONCLUSIONS: LAAO devices did not demonstrate statistical superiority over DOACs in reducing thromboembolic events and major bleeding. Further trials are warranted to define patients for whom LAAO may offer the most significant benefit, such as those with high bleeding risk (CRD420251237886).

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Cite This Study

Hiruma et al. (2026) conducted a meta-analysis in Atrial Fibrillation (n=67,693). Left atrial appendage occlusion (LAAO) vs. Direct oral anticoagulants (DOACs) was evaluated on composite of stroke, systemic embolism, and cardiovascular death (HR 1.02, 95% CI 0.88-1.19). Left atrial appendage occlusion did not demonstrate statistical superiority over DOACs for stroke, systemic embolism, and cardiovascular death (HR 1.02; 95% CI 0.88-1.19).

synapsesocial.com/papers/6ab61350406bf401c146a36d https://doi.org/10.1016/j.jacadv.2026.103269