Left atrial appendage occlusion versus oral anticoagulation for stroke prevention in atrial fibrillation: A meta-analysis of randomized controlled trials

Abstract:

Randomised controlled trials comparing percutaneous left atrial appendage occlusion (LAAO) with oral anticoagulation (OAC) for stroke prevention in atrial fibrillation (AF) have reported mixed results. We conducted a systematic review and meta-analysis of randomised controlled trials comparing LAAO with OAC in patients with non-valvular AF. Prespecified outcomes included the composite of stroke, systemic embolism, or cardiovascular death; ischaemic, haemorrhagic, disabling, non-disabling, and all stroke; cardiovascular and all-cause mortality; non-procedural and total major bleeding; and pericardial effusion or tamponade. Random-effects models were used to pool log-transformed hazard ratios (HRs) with 95% confidence intervals (CIs). Six trials comprising 7004 patients were included. LAAO was not associated with a significant difference in the composite outcome of stroke, systemic embolism, or cardiovascular death compared with OAC (HR, 1.00; 95% CI, 0.83–1.21; I ² = 30.8%). LAAO was associated with a higher risk of ischaemic stroke (HR, 1.44; 95% CI, 1.06–1.95; I ² = 0%) and a lower risk of non-procedural major bleeding (HR, 0.55; 95% CI, 0.40–0.74), whereas total major bleeding did not differ significantly between groups (HR, 0.94; 95% CI, 0.79–1.11). Exploratory Bayesian analyses showed a high posterior probability of harm for ischaemic stroke and strong support for a reduction in non-procedural major bleeding. LAAO therefore demonstrated similar overall composite efficacy to OAC but was associated with increased ischaemic stroke and reduced non-procedural major bleeding, without a significant difference in total major bleeding. These competing effects should be explicitly considered during shared decision-making.