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Peer-reviewedCC BY 4.0Journal of the Society for Cardiovascular Angiography & Interventions

Percutaneous Left Atrial Appendage Occlusion Versus Oral Anticoagulation in Atrial Fibrillation: A Systematic Review and Bayesian Meta-analysis

  • Amar Rai1,2
  • Abhinav Kandala3
  • Harroop Bola2
  • James Schurr4
  • Mandeep Singh5
  • Yousif Ahmad6
  • Alexander Fanaroff4
  • Ray Hu4
  • Nitin Malik4
  • David S. Frankel4
  • Timothy Markman4
  • Saman Nazarian4
3 more authors
  • Jay Giri4
  • Tayyab Shah4
  • Ashwin Nathan4
6 affiliations
  1. 1Department of Internal Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
  2. 2Faculty of Medicine, Imperial College London, London, United Kingdom
  3. 3Faculty of Medicine, University College London, London, United Kingdom
  4. 4Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
  5. 5Department of Medicine, University of Rochester Medical Center, Rochester, New York
  6. 6Division of Cardiology, University of California San Francisco, San Francisco, California
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Abstract

Background: Conflicting randomized trial results have generated uncertainty regarding percutaneous left atrial appendage occlusion (LAAO) vs oral anticoagulation (OAC) for stroke prevention in atrial fibrillation (AF). Thus, the objective of this study is to estimate the posterior probability that LAAO confers clinically meaningful excess ischemic stroke risk relative to OAC.

Methods: A Bayesian hierarchical meta-analysis was performed of RCT comparing LAAO with OAC in nonvalvular AF. The primary outcome was ischemic stroke, analyzed using Bayesian random-effects Poisson regression under a vague (primary), skeptical, and enthusiastic prior specification.

Results: Six RCT (7004 patients, +18,000 patient-years) were included. Ischemic stroke incidence rate ratio (IRR) was 1.34 (95% credible interval [CrI], 0.91-1.97; P [IRR > 1.0] = 94%). The probability of exceeding 0.5 and 1.0 excess events/100 patient-years was 12% and 0.5%, respectively. The effect on any-stroke was smaller (IRR, 1.09; 95% CrI, 0.76-1.56; P [IRR > 1.0] = 70%; P [absolute rate difference >0.5%/y] = 4.7%), because of a reduction in hemorrhagic stroke (IRR, 0.55; 95% CrI, 0.23-1.18; P [IRR < 1.0] = 94.5%). The decrease in hemorrhagic stroke was attenuated among trials using direct oral anticoagulants for medical management (IRR, 0.80; 95% CrI, 0.33-1.75).

Conclusions: In AF, there is a high posterior probability that LAAO is associated with a higher rate of any-stroke, driven by an increase in ischemic stroke relative to OAC. However, the 95% CrI for ischemic stroke crossed unity, and the estimated absolute excess is small. This possible excess must be weighed against a substantial reduction in the risk of hemorrhagic stroke.

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Cite

BibTeXRIS
BibTeX
@article{rai2026percutaneous,
  title = {{Percutaneous Left Atrial Appendage Occlusion Versus Oral Anticoagulation in Atrial Fibrillation: A Systematic Review and Bayesian Meta-analysis}},
  author = {Amar Rai and Abhinav Kandala and Harroop Bola and James Schurr and Mandeep Singh and Yousif Ahmad and Alexander Fanaroff and Ray Hu and Nitin Malik and David S. Frankel and Timothy Markman and Saman Nazarian and Jay Giri and Tayyab Shah and Ashwin Nathan},
  journal = {Journal of the Society for Cardiovascular Angiography \& Interventions},
  year = {2026},
  month = sep,
  doi = {10.1016/j.jscai.2026.105625},
  url = {https://doi.org/10.1016/j.jscai.2026.105625},
  note = {CC BY 4.0},
}
RIS
TY  - JOUR
TI  - Percutaneous Left Atrial Appendage Occlusion Versus Oral Anticoagulation in Atrial Fibrillation: A Systematic Review and Bayesian Meta-analysis
AU  - Amar Rai
AU  - Abhinav Kandala
AU  - Harroop Bola
AU  - James Schurr
AU  - Mandeep Singh
AU  - Yousif Ahmad
AU  - Alexander Fanaroff
AU  - Ray Hu
AU  - Nitin Malik
AU  - David S. Frankel
AU  - Timothy Markman
AU  - Saman Nazarian
AU  - Jay Giri
AU  - Tayyab Shah
AU  - Ashwin Nathan
PY  - 2026
DA  - 2026/09/10
JO  - Journal of the Society for Cardiovascular Angiography & Interventions
DO  - 10.1016/j.jscai.2026.105625
UR  - https://doi.org/10.1016/j.jscai.2026.105625
AB  - Background: Conflicting randomized trial results have generated uncertainty regarding percutaneous left atrial appendage occlusion (LAAO) vs oral anticoagulation (OAC) for stroke prevention in atrial fibrillation (AF). Thus, the objective of this study is to estimate the posterior probability that LAAO confers clinically meaningful excess ischemic stroke risk relative to OAC.  Methods: A Bayesian hierarchical meta-analysis was performed of RCT comparing LAAO with OAC in nonvalvular AF. The primary outcome was ischemic stroke, analyzed using Bayesian random-effects Poisson regression under a vague (primary), skeptical, and enthusiastic prior specification.  Results: Six RCT (7004 patients, +18,000 patient-years) were included. Ischemic stroke incidence rate ratio (IRR) was 1.34 (95% credible interval [CrI], 0.91-1.97; P [IRR > 1.0] = 94%). The probability of exceeding 0.5 and 1.0 excess events/100 patient-years was 12% and 0.5%, respectively. The effect on any-stroke was smaller (IRR, 1.09; 95% CrI, 0.76-1.56; P [IRR > 1.0] = 70%; P [absolute rate difference >0.5%/y] = 4.7%), because of a reduction in hemorrhagic stroke (IRR, 0.55; 95% CrI, 0.23-1.18; P [IRR < 1.0] = 94.5%). The decrease in hemorrhagic stroke was attenuated among trials using direct oral anticoagulants for medical management (IRR, 0.80; 95% CrI, 0.33-1.75).  Conclusions: In AF, there is a high posterior probability that LAAO is associated with a higher rate of any-stroke, driven by an increase in ischemic stroke relative to OAC. However, the 95% CrI for ischemic stroke crossed unity, and the estimated absolute excess is small. This possible excess must be weighed against a substantial reduction in the risk of hemorrhagic stroke.
SN  - 2772-9303
ER  -