Left atrial appendage occlusion in patients with atrial fibrillation undergoing transcatheter aortic valve replacement: A meta-analysis

BACKGROUND Stroke prevention after transcatheter aortic valve replacement (TAVR) in patients with atrial fibrillation remains clinically challenging because thromboembolic risk must be balanced against substantial bleeding vulnerability. Left atrial appendage occlusion (LAAO) has been proposed as a nonpharmacologic alternative to long-term anticoagulation in selected patients, but its comparative role in the TAVR population remains insufficiently defined. METHODS We performed a systematic review and meta-analysis of comparative studies evaluating TAVR plus LAAO versus TAVR plus medical therapy in patients with atrial fibrillation. Randomized trials and observational comparative cohorts were eligible. The primary outcome was stroke, transient ischemic attack, or systemic embolism. Secondary outcomes were major bleeding and all-cause mortality. Random-effects odds ratios (ORs) with 95% confidence intervals (CIs) were pooled. RESULTS Four studies comprising 652 patients were included, of whom 289 underwent TAVR plus LAAO and 363 received TAVR plus medical therapy. The evidence base included two randomized trials and two observational studies, with LAAO performed either concomitantly with TAVR or in a staged manner shortly thereafter. TAVR plus LAAO was not associated with a significant reduction in stroke/transient ischemic attack/systemic embolism compared with medical therapy (OR 0.83, 95% CI 0.40-1.74). There were also no significant differences in major bleeding (OR 1.10, 95% CI 0.68-1.77) or all-cause mortality (OR 0.93, 95% CI 0.62-1.40). CONCLUSIONS In the currently available comparative evidence, adding LAAO to TAVR was associated with similar thromboembolic, bleeding, and mortality outcomes compared with medical therapy. These findings do not support routine LAAO for all patients with atrial fibrillation undergoing TAVR, but they leave room for selective use in carefully chosen patients in whom long-term anticoagulation is undesirable.