Outcomes of percutaneous left atrial appendage occlusion in patients with cardiac amyloidosis and atrial fibrillation
A H Almakadma, O Alqassab, P Khan, M Abomohsen, A E Mohamed, E Habib, R IbrahimAbstract
Background/introduction
Patients with cardiac amyloidosis (CA) frequently develop atrial fibrillation (AF) due to atrial infiltration and remodeling. both conditions increase thromboembolic risk, while amyloid-related vascular fragility and anticoagulation increase bleeding risk, complicating long-term therapy. Left atrial appendage occlusion (LAAO) is an established alternative to anticoagulation in selected AF populations; however, patients with CA were underrepresented in major trials, and outcome data remain limited. We present the first meta-analysis of outcomes of LAAO for AF in CA patients.
Purpose
To systematically evaluate the safety and efficacy of LAAO in patients with CA and AF compared with non-CA patients undergoing LAAO.
Methods
Pubmed, embase, cochrane databases, and clinicaltrials.gov were searched from january 2000 to january 2026 for studies reporting outcomes of LAAO in adult patients with CA and AF with a non-CA comparator. Studies with ≥180 days follow-up were included. Primary outcomes were all-cause mortality and ischemic stroke; secondary outcomes were major bleeding and hospitalization. Pooled analyses were performed using the inverse variance method within a random-effects model to calculate incidence rate ratios (IRR) with 95% confidence intervals (CI). IRR was used as it accounts for differences in follow-up duration across different studies. The Hartung-Knapp-Sidik-Jonkman adjustment was applied to account for the small number of included studies. Sensitivity analyses included subgroup analysis and leave-one-out sensitivity analysis to assess robustness.
Results
Four observational studies comprising 67,302 patients (852 CA and 66,450 non-CA) met inclusion criteria. compared with non-CA patients, CA patients undergoing LAAO had no statistically significant difference in all-cause mortality (IRR 1.65, 95% CI 0.62–4.39), ischemic stroke (IRR 2.15, 95% CI 0.82–5.65), major bleeding (IRR 1.14, 95% CI 0.42–3.13), or hospitalization (IRR 0.91, 95% CI 0.65–1.28). Confidence intervals were wide and crossed unity. Sensitivity analyses showed pooled estimates were influenced by large datasets, with heterogeneity for selected outcomes indicating limited robustness and highlighting the hypothesis-generating nature of these findings.
Conclusion
In pooled observational data, LAAO in patients with CA and AF appears feasible, with outcomes comparable to non-CA populations despite elevated baseline risk. These findings support consideration of LAAO in carefully selected CA patients unsuitable for long-term anticoagulation. Prospective multicenter studies with standardized antithrombotic strategies and amyloid subtype–specific analyses (AL vs ATTR) are needed to better define patient selection and long-term efficacy.Forest Plots of Outcomes