Left Atrial Appendage Closure vs Direct Oral Anticoagulants in Atrial Fibrillation: Meta-Analysis of Randomized Trials.

BACKGROUND

Left atrial appendage closure (LAAC) is a potential alternative to oral anticoagulation for stroke prevention in atrial fibrillation.

OBJECTIVES

We performed an updated meta-analysis of randomized controlled trials comparing LAAC with direct oral anticoagulants (DOACs) for efficacy and safety.

METHODS

We systematically searched from January 1, 2012, to April 3, 2026, for randomized controlled trials comparing percutaneous LAAC with DOACs in patients with atrial fibrillation. Using the longest available follow-up from each trial, we pooled efficacy and bleeding outcomes, including stroke, death, and intracranial hemorrhage (ICH), and pooled relative risks (RRs) with random-effects models.

RESULTS

Four randomized trials involving 5,890 patients were included, with 2,949 assigned to LAAC and 2,941 to DOAC therapy. The median follow-up ranged from 36 to 42 months. There were no significant differences in all stroke, hemorrhagic stroke, systemic embolism, all-cause death, or cardiovascular death. LAAC was associated with a numerically higher risk of ischemic stroke (RR: 1.36; 95% CI: 0.99-1.89; P = 0.06), which became significant (RR: 1.45; 95% CI: 1.03-2.06; P = 0.03) after exclusion of the OPTION trial. LAAC significantly reduced all nonmajor (RR: 0.53; 95% CI: 0.40-0.71; P < 0.0001) and nonprocedure-related major (RR: 0.79; 95% CI: 0.65-0.97; P = 0.02) and nonmajor bleeding (RR: 0.47; 95% CI: 0.39-0.57; P < 0.0001), whereas risks of all major bleeding (RR: 0.97; 95% CI: 0.81-1.17; P = 0.77) and ICH (RR 0.76; 95% CI: 0.45-1.26; P = 0.28) were similar.

CONCLUSIONS

Compared with DOACs, LAAC reduced nonprocedure-related major and nonmajor bleeding, potentially at the cost of an increased risk of ischemic stroke, without significant differences in major bleeding or ICH.