Stroke Prevention and Antithrombotic Strategies in Patients Undergoing Catheter Ablation for Atrial Fibrillation: A Systematic and Literature Review

Q: What are the key findings of this study?

Left atrial appendage closure was noninferior to oral anticoagulation for death, stroke, or systemic embolism after AF ablation (5.3% vs 5.8%; HR 0.91, 95% CI 0.59-1.39; P<0.001 for noninferiority).

Q: What is the clinical evidence from this study?

Study design: Systematic Review. Population: Atrial fibrillation undergoing catheter ablation (n=4717). Intervention: Left atrial appendage closure (WATCHMAN FLX) or uninterrupted/tailored antithrombotic strategies vs. Oral anticoagulation, interrupted warfarin with bridging, or aspirin. Primary outcome: Composite of all-cause death, stroke, or systemic embolism at 36 months (OPTION trial) (HR 0.91, 95% CI 0.59-1.39, p=<0.001 for noninferiority).

Q: What does this research mean for the field?

Left atrial appendage closure is noninferior to oral anticoagulation for death, stroke, or systemic embolism after catheter ablation for atrial fibrillation while significantly reducing non-procedural bleeding. Novelty: ClaimNovelty.SYNTHESIS. Consensus alignment: ConsensusAlignment.SUPPORTS_CONSENSUS.

Q: What question did this study set out to answer?

To evaluate the efficacy and safety of catheter ablation, oral anticoagulants, and left atrial appendage closure for thromboembolic prevention in patients with atrial fibrillation.

Zukhruf Zahoor; Shrikar Iragavarapu; Muhammad Nihal Moarij Azeem Malik; Shamal Basheer; Minahil Arshad; MAJD ALDIN OUDEH; Neeraj Joshi; Shubana Jaffar; Ahmed Ibrahim; Hager Elsayed Gouda Murad

doi:10.7759/cureus.119207

November 5, 2026CureusOpen Access

Stroke Prevention and Antithrombotic Strategies in Patients Undergoing Catheter Ablation for Atrial Fibrillation: A Systematic and Literature Review

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Key result

LAAC matches oral anticoagulation for major thromboembolic events and death after AF ablation.

HR 0.91
95% CI 0.59-1.39
P<0.001 for noninferiority
n=4,717

Why the study?

Contemporary evidence regarding stroke prevention in patients with AF is evolving with advances in catheter ablation, oral anticoagulation, and left atrial appendage closure, motivating a synthesis of comparative thromboembolic prevention and safety data.

Do contemporary periprocedural and post-ablation antithrombotic strategies and left atrial appendage closure reduce thromboembolic events and bleeding compared with standard antithrombotic regimens in patients with atrial fibrillation undergoing catheter ablation?

Key Points

To evaluate the efficacy and safety of catheter ablation, oral anticoagulants, and left atrial appendage closure for thromboembolic prevention in patients with atrial fibrillation.
Conducted a systematic review following PRISMA guidelines across PubMed, Embase, Scopus, and the Cochrane Library through June 2026.
Identified and qualitatively synthesized 4 randomized controlled trials encompassing 4,717 patients, using the Cochrane RoB 2 tool to assess bias.
Catheter ablation plus edoxaban did not significantly reduce composite death, stroke, systemic embolism, or heart failure versus edoxaban alone (18.0% vs. 18.0%; HR 1.11, 95% CI 0.62-2.01).
Uninterrupted warfarin significantly reduced periprocedural stroke or transient ischemic attack compared to interrupted warfarin with heparin bridging (0.25% vs. 4.9%; RR 0.051, 95% CI 0.012-0.211).
Left atrial appendage closure was noninferior to oral anticoagulation for death, stroke, or embolism (5.3% vs. 5.8%; HR 0.91, 95% CI 0.59-1.39) and significantly reduced non-procedural bleeding (8.5% vs. 18.1%; HR 0.44, 95% CI 0.33-0.59).

Study Design

Type

Systematic Review (n=4,717)

Blinding

Open-label

Randomization

Parallel-group across included RCTs

Multicenter

Yes

Structured PICO

Do contemporary periprocedural and post-ablation antithrombotic strategies and left atrial appendage closure reduce thromboembolic events and bleeding compared with standard antithrombotic regimens in patients with atrial fibrillation undergoing catheter ablation?

P

Population

4,717 adults across 4 randomized controlled trials with paroxysmal or persistent atrial fibrillation undergoing catheter ablation (mean ages 61.5 to 71.7 years, ~29% female), evaluating periprocedural and post-ablation stroke prevention strategies.

I

Intervention

Stroke-prevention and antithrombotic management strategies in the context of AF catheter ablation across four paradigms: 1) catheter ablation plus edoxaban (STABLED); 2) uninterrupted periprocedural warfarin (COMPARE); 3) post-ablation rivaroxaban in patients free of AF for >=1 year (OCEAN); and 4) left atrial appendage closure (LAAC) using WATCHMAN FLX concomitant with or following catheter ablation (OPTION).

C

Comparator

Clinically relevant antithrombotic comparator strategies across the four trials: 1) edoxaban alone (STABLED); 2) interrupted warfarin with low-molecular-weight heparin bridging (COMPARE); 3) aspirin in patients free of AF for >=1 year post-ablation (OCEAN); and 4) standard oral anticoagulation (OPTION).

O

Outcome

Trial-specific primary efficacy outcomes: 1) Composite of stroke, systemic embolism, all-cause death, or heart failure (STABLED); 2) Periprocedural symptomatic stroke or transient ischemic attack (COMPARE); 3) Composite of clinical stroke, systemic embolism, or new covert embolic stroke (OCEAN); 4) Composite of all-cause death, stroke, or systemic embolism at 36 months (OPTION).composite

Main Result

Hazard Ratio: 0.91 (95% CI 0.59–1.39)

Absolute Event Rate: 5.3% vs 5.8%

p-value: p=<0.001 for noninferiority

This systematic review of four RCTs demonstrates that in patients undergoing AF catheter ablation, uninterrupted periprocedural anticoagulation is superior to interrupted bridging, while post-ablation LAAC offers non-inferior thromboembolic protection with lower non-procedural bleeding compared to oral anticoagulation.

Limitations

Limited evidence base with only four RCTs meeting eligibility criteria
Substantial clinical heterogeneity among included trials precluded quantitative meta-analysis
Open-label trial designs may have introduced performance or ascertainment bias
Relatively low incidence of thromboembolic events and major bleeding in some trials limited statistical power
Differences in baseline thromboembolic risk across trials may limit generalizability
Exclusion of non-English studies and head-to-head anticoagulant agent trials (such as RE-CIRCUIT and AXAFA-AFNET 5)
Because the included RCTs addressed different clinical questions and evaluated distinct interventions and comparators, the findings could not be quantitatively pooled.
Two included trials (COMPARE and OCEAN) were judged to have some concerns for risk of bias due to deviations from intended interventions and/or selection of the reported result.

Ask about this paper

Answers are grounded in this paper and cite their sources.

Implication

Supports LAA closure as alternative to oral anticoagulation after AF ablation; confirms noninferiority across 4 RCTs.

Abstract

Atrial fibrillation (AF) is the most frequently sustained cardiac arrhythmia and a major risk factor for ischemic stroke.Contemporary evidence is evolving regarding stroke prevention in patients with AF, particularly with advances in catheter ablation, oral anticoagulation, and left atrial appendage closure (LAAC).This systematic review synthesized comparative evidence evaluating these strategies for thromboembolic prevention and safety outcomes in patients with AF.A systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.PubMed, Embase, Scopus, and the Cochrane Library were searched from database inception through June 2026 for comparative studies evaluating catheter ablation, oral anticoagulation, and LAAC in patients with AF.Two reviewers independently screened studies and extracted data.Risk of bias was assessed using the Cochrane Risk of Bias 2 (RoB 2) tool for randomized controlled trials (RCTs).Studies reporting relevant efficacy and/or safety outcomes were included in the qualitative synthesis.Four RCTs involving 4,717 patients were included.In patients with recent ischemic stroke and nonvalvular AF, catheter ablation plus edoxaban did not significantly reduce the composite of stroke, systemic embolism, all-cause death, or heart failure compared with edoxaban alone (18.0% vs. 18.0%; heart rate (HR) 1.11, 95% confidence interval (CI) 0.62-2.01).Uninterrupted warfarin was associated with fewer periprocedural stroke or transient ischemic attacks than interrupted warfarin with low-molecular-weight heparin bridging (0.25% vs. 4.9%; relative risk (RR) 0.051, 95% CI 0.012-0.211).Following successful catheter ablation, rivaroxaban and aspirin showed no significant difference in the composite of clinical stroke, systemic embolism, or new covert embolic stroke (0.8% vs. 1.4%;RR 0.56, 95% CI 0.19-1.65),although clinically relevant nonmajor and overall bleeding were more frequent with rivaroxaban.In patients undergoing catheter ablation, LAAC was noninferior to oral anticoagulation for the composite of all-cause death, stroke, or systemic embolism (5.3% vs. 5.8%; HR 0.91, 95% CI 0.59-1.39)and significantly reduced non-procedural major or clinically relevant nonmajor bleeding (8.5% vs. 18.1%;HR 0.44, 95% CI 0.33-0.59).Contemporary evidence supports an individualized approach to stroke prevention in patients with AF undergoing catheter ablation.LAAC provides a non-inferior alternative to oral anticoagulation for thromboembolic outcomes while reducing non-procedural bleeding in appropriately selected patients.Periprocedural anticoagulation should favor uninterrupted therapy, while post-ablation antithrombotic treatment should be individualized according to thromboembolic and bleeding risk.

Discussion

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Cite This Study

Zahoor et al. (2026) conducted a systematic review in Atrial fibrillation undergoing catheter ablation (n=4,717). Left atrial appendage closure (WATCHMAN FLX) or uninterrupted/tailored antithrombotic strategies vs. Oral anticoagulation, interrupted warfarin with bridging, or aspirin was evaluated on Composite of all-cause death, stroke, or systemic embolism at 36 months (OPTION trial) (HR 0.91, 95% CI 0.59-1.39, p=<0.001 for noninferiority). Left atrial appendage closure was noninferior to oral anticoagulation for death, stroke, or systemic embolism after AF ablation (5.3% vs 5.8%; HR 0.91, 95% CI 0.59-1.39; P<0.001 for noninferiority).

synapsesocial.com/papers/6aefbd5d50d2071ffda4bd13 https://doi.org/10.7759/cureus.119207

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Stroke Prevention and Antithrombotic Strategies in Patients Undergoing Catheter Ablation for Atrial Fibrillation: A Systematic and Literature Review

Key Points

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

Stroke Prevention and Antithrombotic Strategies in Patients Undergoing Catheter Ablation for Atrial Fibrillation: A Systematic and Literature Review

Key Points

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

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