Left atrial appendage closure vs oral anticoagulation for stroke prevention in atrial fibrillation: Long-term outcomes from 4 randomized trials
Wulamiding Kaisaier, Zixuan Xu, Linjuan Guo, Yugang Dong, Yili Chen, Gregory Y. H. Lip, Wengen Zhu
Abstract
BACKGROUND: Left atrial appendage closure (LAAC) is primarily indicated for stroke prevention in patients with atrial fibrillation (AF) who have contraindications to long-term oral anticoagulants (OACs). However, the long-term comparative benefits of LAAC vs OACs in the broader AF population remain unclear. OBJECTIVE: To study aimed to assess the long-term efficacy and safety of LAAC compared with OACs in patients with AF, we conducted a meta-analysis of randomized controlled trials (RCTs). METHODS: We systematically searched PubMed, Embase, and Cochrane Library for eligible RCTs. Risk ratios (RRs) with 95% confidence intervals (CIs) were calculated using fixed-effects models. RESULTS: Four RCTs involving 3116 patients with AF (1736 assigned to LAAC and 1380 to OACs) and follow-up durations ranging from 36 to 49.6 months were included. Compared with OACs, LAAC was associated with reduced risks of all-cause death (RR = 0.78; 95% CI: 0.64-0.95) and cardiovascular or unexplained death (RR = 0.69; 95% CI: 0.51-0.94). There were no significant differences between the 2 groups in stroke or systemic embolism, ischemic stroke, or systemic embolism, and non-cardiovascular death. LAAC was associated with significantly lower risk of hemorrhagic stroke (RR = 0.34; 95% CI: 0.16-0.76) and non-procedural clinically relevant bleeding (RR = 0.49; 95% CI: 0.40-0.61). Major bleeding (including procedural and non-procedural) risk did not differ significantly between groups. CONCLUSION: In this meta-analysis of RCTs, LAAC was associated with significantly lower risks of all-cause and cardiovascular death, hemorrhagic stroke, and non-procedural clinically relevant bleeding compared with OACs, without increasing the risk of thromboembolic events or major bleeding. These findings support the consideration of LAAC as an alternative to OAC in selected patients with AF.