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Peer-reviewedCC BY-NCAmerican heart journal plus : cardiology research and practice

Percutaneous left atrial appendage occlusion versus oral anticoagulation in atrial fibrillation: A pragmatic meta-analysis of randomized trials within the DOAC era.

  • Gabriel Moraes Kuniyoshi1
  • Rafael Zoppi Campane2
  • Nikita Patil3
  • Ana Clara Vitorino de Oliveira4
  • Beatriz Araújo5
  • Ricardo Ryoshim Kuniyoshi6,7,8
8 affiliations
  1. 1Department of Medicine, Escola Superior de Ciências da Santa Casa de Misericórdia de Vitória (EMESCAM), 2190 Nossa Senhora da Penha Avenue, Vitória, Brazil.
  2. 2Department of Medicine, Hospital Regional Hans Dieter Schimidt, 330 Xavier Arp Street, Joinville, Brazil.
  3. 3Hospitalist Department, Cape Fear Valley Health, 1638 Owen Drive, Fayetteville, NC, USA.
  4. 4Department of Medicine, Universidade Federal de Lavras, Trevo Rotatório Professor Edmir Sá Santos, Lavras, Brazil.
  5. 5Department of Medicine, Universidade Nove de Julho, 90 Dom Jaime de Barros Câmara Avenue, São Bernardo do Campo, Brazil.
  6. 6Department of Cardiac Arrhythmias, Centrocor, 60 Alfeu Alves Pereira Street, Vitória, Brazil.
  7. 7Department of Cardiac Arrhythmias, Vitória Apart Hospital, 591 Governador Mario Covas, Serra, Brazil.
  8. 8Department of Electrophysiology, Hospital Universitário Cassiano Antonio Moraes (HUCAM), Universidade Federal do Espírito Santo (UFES), 1355 Marechal Campos Avenue, Vitória, Brazil.
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Abstract

Background

Percutaneous left atrial appendage occlusion (LAAO) is an established alternative to oral anticoagulation (OAC). However, its safety and efficacy boundaries remain incompletely defined in dedicated comparisons against direct oral anticoagulants (DOACs).Objective

This study applied a pragmatic framework to evaluate the comparative efficacy and safety of LAAO versus OAC in a DOAC-predominant setting.Methods

PubMed, Embase, and Cochrane Library were searched for randomized controlled trials comparing LAAO with OAC, restricted to a DOAC-predominant comparator. Risk ratios (RR) with 95% confidence intervals (CI) were calculated via a Mantel-Haenszel random-effects model.Results

Four trials comprising 5890 patients were included (96.4% of controls assigned to DOACs). Overall stroke (RR 1.18, 95% CI 0.87-1.60; p = 0.28), systemic embolism (RR 1.09, 95% CI 0.29-4.08; p = 0.89), major bleeding (RR 0.98, 95% CI 0.81-1.19; p = 0.85), hemorrhagic stroke (RR 0.82, 95% CI 0.45-1.51; p = 0.53), and all-cause mortality (RR 1.00, 95% CI 0.85-1.17; p = 0.99) did not differ significantly. Ischemic stroke presented numerical asymmetry favoring OAC that approached statistical significance (RR 1.36, 95% CI 0.99-1.89; p = 0.06). Conversely, within available protocol-defined datasets, LAAO significantly reduced nonprocedural clinically relevant bleeding (RR 0.50, 95% CI 0.43-0.60; p < 0.01).Conclusions

In a pragmatic analysis of the DOAC era, randomized data show no statistically significant differences for hard individual endpoints, though broad confidence intervals reflect precision limits. A numerical asymmetry for ischemic stroke favored OAC, while LAAO reduced nonprocedural clinically relevant bleeding. Current evidence remains non-definitive, warranting shared clinical decision-making to balance individual thromboembolic risks against long-term bleeding susceptibility.

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Cite

BibTeXRIS
BibTeX
@article{kuniyoshi2026percutaneous,
  title = {{Percutaneous left atrial appendage occlusion versus oral anticoagulation in atrial fibrillation: A pragmatic meta-analysis of randomized trials within the DOAC era.}},
  author = {Gabriel Moraes Kuniyoshi and Rafael Zoppi Campane and Nikita Patil and Ana Clara Vitorino de Oliveira and Beatriz Araújo and Ricardo Ryoshim Kuniyoshi},
  journal = {American heart journal plus : cardiology research and practice},
  year = {2026},
  month = oct,
  doi = {10.1016/j.ahjo.2026.100942},
  url = {https://europepmc.org/article/MED/42898218},
  note = {CC BY-NC},
}
RIS
TY  - JOUR
TI  - Percutaneous left atrial appendage occlusion versus oral anticoagulation in atrial fibrillation: A pragmatic meta-analysis of randomized trials within the DOAC era.
AU  - Gabriel Moraes Kuniyoshi
AU  - Rafael Zoppi Campane
AU  - Nikita Patil
AU  - Ana Clara Vitorino de Oliveira
AU  - Beatriz Araújo
AU  - Ricardo Ryoshim Kuniyoshi
PY  - 2026
DA  - 2026/10/07
JO  - American heart journal plus : cardiology research and practice
DO  - 10.1016/j.ahjo.2026.100942
UR  - https://europepmc.org/article/MED/42898218
AB  - Background  Percutaneous left atrial appendage occlusion (LAAO) is an established alternative to oral anticoagulation (OAC). However, its safety and efficacy boundaries remain incompletely defined in dedicated comparisons against direct oral anticoagulants (DOACs).Objective  This study applied a pragmatic framework to evaluate the comparative efficacy and safety of LAAO versus OAC in a DOAC-predominant setting.Methods  PubMed, Embase, and Cochrane Library were searched for randomized controlled trials comparing LAAO with OAC, restricted to a DOAC-predominant comparator. Risk ratios (RR) with 95% confidence intervals (CI) were calculated via a Mantel-Haenszel random-effects model.Results  Four trials comprising 5890 patients were included (96.4% of controls assigned to DOACs). Overall stroke (RR 1.18, 95% CI 0.87-1.60; p = 0.28), systemic embolism (RR 1.09, 95% CI 0.29-4.08; p = 0.89), major bleeding (RR 0.98, 95% CI 0.81-1.19; p = 0.85), hemorrhagic stroke (RR 0.82, 95% CI 0.45-1.51; p = 0.53), and all-cause mortality (RR 1.00, 95% CI 0.85-1.17; p = 0.99) did not differ significantly. Ischemic stroke presented numerical asymmetry favoring OAC that approached statistical significance (RR 1.36, 95% CI 0.99-1.89; p = 0.06). Conversely, within available protocol-defined datasets, LAAO significantly reduced nonprocedural clinically relevant bleeding (RR 0.50, 95% CI 0.43-0.60; p < 0.01).Conclusions  In a pragmatic analysis of the DOAC era, randomized data show no statistically significant differences for hard individual endpoints, though broad confidence intervals reflect precision limits. A numerical asymmetry for ischemic stroke favored OAC, while LAAO reduced nonprocedural clinically relevant bleeding. Current evidence remains non-definitive, warranting shared clinical decision-making to balance individual thromboembolic risks against long-term bleeding susceptibility.
SN  - 2666-6022
ER  -