Key result
Percutaneous LAAO shows no difference in overall stroke compared with DOAC-predominant anticoagulation.
Why the study?
The safety and efficacy boundaries of percutaneous left atrial appendage occlusion compared with direct oral anticoagulants remain incompletely defined.
Does percutaneous left atrial appendage occlusion reduce thromboembolic and bleeding events compared to DOAC-predominant oral anticoagulation in patients with atrial fibrillation?
Meta-Analysis (n=5,890)
Does percutaneous left atrial appendage occlusion reduce thromboembolic and bleeding events compared to DOAC-predominant oral anticoagulation in patients with atrial fibrillation?
Relative Risk: 1.18 (95% CI 0.87–1.6)
p-value: p=0.28
In a DOAC-predominant era, LAAO shows no significant difference in hard clinical endpoints compared to OAC, though it may reduce nonprocedural clinically relevant bleeding at the potential cost of a numerically higher risk of ischemic stroke.
Background Percutaneous left atrial appendage occlusion (LAAO) is an established alternative to oral anticoagulation (OAC). However, its safety and efficacy boundaries remain incompletely defined in dedicated comparisons against direct oral anticoagulants (DOACs). Objective This study applied a pragmatic framework to evaluate the comparative efficacy and safety of LAAO versus OAC in a DOAC-predominant setting. Methods PubMed, Embase, and Cochrane Library were searched for randomized controlled trials comparing LAAO with OAC, restricted to a DOAC-predominant comparator. Risk ratios (RR) with 95% confidence intervals (CI) were calculated via a Mantel-Haenszel random-effects model. Results Four trials comprising 5890 patients were included (96.4% of controls assigned to DOACs). Overall stroke (RR 1.18, 95% CI 0.87–1.60; p = 0.28), systemic embolism (RR 1.09, 95% CI 0.29–4.08; p = 0.89), major bleeding (RR 0.98, 95% CI 0.81–1.19; p = 0.84), hemorrhagic stroke (RR 0.82, 95% CI 0.45–1.51; p = 0.53), and all-cause mortality (RR 1.00, 95% CI 0.85–1.17; p = 0.98) did not differ significantly. Ischemic stroke presented numerical asymmetry favoring OAC that approached statistical significance (RR 1.36, 95% CI 0.99–1.89; p = 0.06). Conversely, within available protocol-defined datasets, LAAO significantly reduced nonprocedural clinically relevant bleeding (RR 0.50, 95% CI 0.43–0.60; p < 0.01). Conclusions In a pragmatic analysis of the DOAC era, randomized data show no statistically significant differences for hard individual endpoints, though broad confidence intervals reflect precision limits. A numerical asymmetry for ischemic stroke favored OAC, while LAAO reduced nonprocedural clinically relevant bleeding. Current evidence remains non-definitive, warranting shared clinical decision-making to balance individual thromboembolic risks against long-term bleeding susceptibility.
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Kuniyoshi et al. (2026) conducted a meta-analysis in Atrial fibrillation (n=5,890). Percutaneous left atrial appendage occlusion (LAAO) vs. Oral anticoagulation (DOAC-predominant) was evaluated on Overall stroke (RR 1.18, 95% CI 0.87-1.60, p=0.28). Percutaneous left atrial appendage occlusion did not significantly differ from DOAC-predominant oral anticoagulation for overall stroke (RR 1.18; 95% CI 0.87-1.60; p=0.28).
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