Safety of cardioversion without anticoagulation in patients' status post left atrial appendage occlusion: A systematic review and meta-analysis.

BACKGROUND

Direct current cardioversion (DCCV) is commonly used for rhythm control in atrial fibrillation (AF). Left atrial appendage occlusion (LAAO) provides stroke prevention in patients with contraindications to oral anticoagulation (OAC), but the safety of DCCV without periprocedural anticoagulation in this group remains uncertain.

OBJECTIVE

To evaluate the safety of performing DCCV without systemic anticoagulation in patients with prior LAAO.

METHODS

We conducted a systematic review and meta-analysis following PRISMA guidelines. PubMed, ScienceDirect, and the Cochrane Library were searched (January 2010-April 2025). Studies comparing outcomes of patients undergoing DCCV after LAAO, with versus without subsequent anticoagulation, were included. Primary outcomes were thromboembolic events and clinically significant bleeding. Odds ratios (ORs) were calculated using random-effects modeling, with heterogeneity assessed via I2 statistic.

RESULTS

Five observational studies (1697 DCCV procedures; 965 patients receiving post-DCCV anticoagulation) met inclusion criteria. Thromboembolic events occurred in 3.8 % of patients without OAC versus 1.6 % with OAC, with no statistically significant difference (OR 0.48; 95 % CI 0.16-1.43; p = 0.19; I2 = 17 %). Clinically significant bleeding occurred in 4.1 % without OAC and 4.0 % with OAC, also without significant difference (OR 1.22; 95 % CI 0.75-2.00; p = 0.42; I2 = 0 %). Pre-DCCV imaging protocols varied widely among studies.

CONCLUSIONS

In selected patients post-LAAO with no device-related thrombus or significant peri-device leak, DCCV without subsequent anticoagulation demonstrated low thromboembolic and bleeding risks. These findings, derived from limited observational data, require confirmation by randomized controlled trials.