Abstract 11235: Left Atrial Appendage Closure versus Oral Anticoagulation in Patients with Atrial Fibrillation: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Background: Atrial fibrillation (AF) is associated with an increased risk of stroke and systemic thromboembolism. Although left atrial appendage closure (LAAC) is an established alternative for patients unsuitable for long-term anticoagulation, its role in patients who remain eligible for anticoagulation remains uncertain. Recent randomized controlled trials (RCTs) have reported conflicting results. Therefore, we performed an updated systematic review and meta-analysis of five RCTs comparing LAAC with anticoagulation in this population. Methods: PubMed, Embase, and Cochrane databases were systematically searched through April 2026. A random-effects model was used to calculate risk ratios (RRs) with 95% confidence intervals (CIs). Statistical analyses were conducted using Review Manager software, version 5.4.1. Results: Five RCTs comprising 5,404 patients were included, with a mean follow-up of 3.4 years. Among trials reporting CHA 2 DS 2 -VASc scores, the weighted mean score was approximately 4.0, consistent with a population at moderate-to-high thromboembolic risk. Compared with anticoagulation, LAAC was associated with significantly lower risks of clinically relevant non-major bleeding (CRNMB) (RR 0.51, 95% CI 0.41-0.64; p < 0.001; I 2 = 0%) and non-procedure related bleeding (RR 0.59, 95% CI 0.49-0.71; p < 0.001; I 2 = 0%), but a higher risk of ischemic stroke (RR 1.48, 95% CI 1.09-2.02; p = 0.01; I 2 = 0%). No significant differences were observed in cardiovascular mortality (RR 0.88, 95% CI 0.62-1.26; p = 0.49; I 2 = 58%), all-cause stroke (RR 1.10, 95% CI 0.81-1.50; p = 0.55; I 2 = 25%), systemic embolism (RR 1.22, 95% CI 0.34-4.38; p = 0.76; I 2 = 0%), or major bleeding (RR 0.98, 95% CI 0.80-1.19; p = 0.82; I 2 = 0%). In subgroup analyses by anticoagulation strategy, LAAC was associated with a lower risk of all-cause mortality (RR 0.76, 95% CI 0.58-0.99; p = 0.05; I 2 = 0%) and hemorrhagic stroke (RR 0.21, 95% CI 0.07-0.58; p = 0.003; I 2 = 0%) compared with warfarin. Conclusions: Among anticoagulation-eligible patients with AF, LAAC showed similar risks of cardiovascular mortality, all-cause stroke, systemic embolism and major bleeding compared with anticoagulation, but was associated with significantly lower clinically relevant non-major and non-procedure related bleeding and a higher risk of ischemic stroke. These findings highlight the need for individualized selection of LAAC versus continued anticoagulation based on thromboembolic and bleeding risk.