Percutaneous left atrial appendage occlusion versus oral anticoagulation in patients with atrial fibrillation: a systematic review and meta-analysis

Introduction and objectives: Percutaneous left atrial appendage occlusion (LAAO) has emerged as an alternative to oral anticoagulants (OACs) in patients with atrial fibrillation (AF). However, up-to-date comparisons are lacking. We performed a systematic review and meta-analysis of randomized clinical trials comparing percutaneous LAAO with OACs (either a vitamin K antagonist or a direct oral anticoagulant) in patients with AF. Methods: MEDLINE and EMBASE were searched from inception through March 29, 2026. The primary outcome was all-cause death. Coprimary outcomes were stroke and any bleeding. Secondary outcomes included a composite of ischemic events, systemic embolism, cardiovascular death, ischemic stroke, hemorrhagic stroke, and nonprocedural bleeding. Random-effects meta-analyses were performed using IRRs with 95%CIs. Subgroup and meta-regression analyses were conducted. Results: Seven randomized trials including 7353 patients were analyzed. There were no significant differences between LAAO and OAC in terms of all-cause death (IRR, 0.95; 95%CI, 0.81-1.10), stroke (IRR, 1.00; 95%CI, 0.72-1.39), or any bleeding (IRR, 0.84; 95%CI, 0.64-1.08). LAAO reduced nonprocedural bleeding (IRR, 0.56; 95%CI, 0.45-0.71), but was associated with a numerically higher risk of ischemic stroke (IRR, 1.28; 95%CI, 1.00-1.66). There was a significant interaction between LAAO and the type of OAC regimen in terms of all-cause death ( P interaction = .02). Conclusions: In patients with AF eligible for OACs, there were no significant differences in clinical efficacy between LAAO and OAC, whereas LAAO was associated with a significant reduction in nonprocedural bleeding events. The observed trend toward an increased risk of ischemic stroke requires further investigation.