Why the study?
Left atrial appendage closure has emerged as an alternative to oral anticoagulation for stroke prevention in atrial fibrillation, prompting an updated evaluation of cumulative randomized trial evidence on its long-term efficacy and safety.
Does left atrial appendage closure reduce thromboembolic, mortality, and bleeding outcomes compared with oral anticoagulation in patients with atrial fibrillation?
Meta-Analysis (n=7,004)
Randomized controlled trials
Does left atrial appendage closure reduce thromboembolic, mortality, and bleeding outcomes compared with oral anticoagulation in patients with atrial fibrillation?
In patients with atrial fibrillation, left atrial appendage closure provides a substantial reduction in non-procedural clinically relevant bleeding compared with oral anticoagulation, though a potential signal toward increased ischemic events warrants further investigation against contemporary DOAC therapy.
Reduces bleeding but raises ischemic risk with LAAC versus OAC; leaves open net benefit versus contemporary DOACs.
Left atrial appendage closure (LAAC) has emerged as an alternative to oral anticoagulation (OAC) for stroke prevention in patients with atrial fibrillation (AF), particularly among individuals at increased risk of bleeding. We performed an updated systematic review and meta-analysis of randomized controlled trials comparing the efficacy and safety of LAAC versus OAC in AF. PubMed, Embase, and Scopus were searched through May 2026. Risk ratios (RRs) with 95% confidence intervals (CIs) were pooled using a random-effects model, and trial sequential analysis (TSA) was conducted to evaluate the sufficiency of cumulative evidence. Six randomized trials involving 7,004 patients were included. Compared with OAC, LAAC demonstrated similar risks of stroke, systemic embolism, cardiovascular death, all-cause mortality, and transient ischemic attack. LAAC showed a nominally higher risk of ischemic stroke or systemic embolization (RR 1.36, 95% CI 1.04–1.79), although this finding was not robust to sensitivity analysis, with a borderline increase in ischemic stroke. In contrast, LAAC significantly reduced non-procedural clinically relevant bleeding (RR 0.49, 95% CI 0.42-0.58), while major bleeding and hemorrhagic stroke were comparable between groups. TSA confirmed sufficient evidence supporting the reduction in bleeding outcomes but indicated that current evidence remains insufficient to establish definitive conclusions regarding thromboembolic efficacy. Overall, LAAC was not associated with statistically significant differences in several thromboembolic and mortality outcomes compared with OAC, while providing a substantial reduction in non-procedural clinically relevant bleeding. However, the potential signal toward increased ischemic events warrants further investigation in adequately powered randomized trials, particularly against contemporary DOAC-based therapy.
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Farooq et al. (2026) conducted a meta-analysis in Atrial fibrillation (n=7,004). Left atrial appendage closure (LAAC) vs. Oral anticoagulation (OAC) was evaluated on Non-procedural clinically relevant bleeding (RR 0.49, 95% CI 0.42-0.58).
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