Left Atrial Appendage Occlusion versus Oral Anticoagulation in Atrial Fibrillation: A Meta-Analysis of Randomized Trials

Babu, AD; Cameron, SJ; Gill, H; Gorantla, A; Bhanushali, K; Gowda, S; Kanj, M; Reed, GW; Krishnaswamy, A; Kapadia, S; Nanjundappa, A

doi:10.1016/j.jacadv.2026.103251

Left Atrial Appendage Occlusion versus Oral Anticoagulation in Atrial Fibrillation: A Meta-Analysis of Randomized Trials

JACC AdvPublished October 2026Randomized trials of left atrial appendage occlusion (LAAO) vs oral anticoagulation (OAC) in nonvalvular atrial fibrillation were pooled

Primary result · Ischemic strokeResultIncidence rate ratio 1.43 95% CI 1.07–1.91

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Authors' conclusion

LAAO significantly reduces nonprocedural major bleeding (TSA-confirmed) and clinically relevant nonmajor bleeding vs OAC. A trend toward higher ischemic stroke was not TSA-confirmed and was sensitive to trial exclusion; all-cause stroke and mortality were similar. These findings quantify the benefit-harm tradeoff central to LAAO decisions.

Study context

Population: Patients with nonvalvular atrial fibrillation in randomized trials of LAAO vs OAC
Participants: 7,004 patients6 trials

Comparison: LAAO vs OAC

Methodological detailsincidence rate ratios (IRRs) per patient-year, trial sequential analysis (TSA), Grading of Recommendations Assessment, Development, and Evaluation (GRADE)

Incidence rate ratios (IRRs) per patient-year
Trial sequential analysis (TSA)
Grading of Recommendations Assessment, Development, and Evaluation (GRADE)

Primary result

Ischemic stroke

Incidence rate ratio

1.43

95% CI 1.07–1.91

P = 0.01

Events by treatment group

LAAO

130

events

OAC

76

events

LAAOvs OAC

IRR 1.43 (95% CI 1.07–1.91); P = 0.01

As reported in the abstract

Further findings

Events

Outcome	LAAO	OAC	← Lower risk with LAAO ←→ Higher risk with LAAO →	IRR (95% CI)	P value
All-cause stroke	152	114	0.512	1.11 (0.86–1.43)	P = 0.43
All-cause mortality	403	368	0.512	0.93 (0.78–1.10)	P = 0.39
			0.512Incidence rate ratio (log scale)

Safety

Events

Outcome	LAAO	OAC	← Lower risk with LAAO ←→ Higher risk with LAAO →	IRR (95% CI)	P value
Nonprocedural major bleedingNumber needed to treat: 19; GRADE: high	194	232	0.20.5125	0.71 (0.55–0.91)	P = 0.01
Clinically relevant nonmajor bleedingNumber needed to treat: 15	145	303	0.20.5125	0.48 (0.39–0.58)	P < 0.001
			0.20.5125Incidence rate ratio (log scale)

Outcome	IRR	P value
Total major bleeding	0.91	P = 0.29

Original publication

Left Atrial Appendage Occlusion versus Oral Anticoagulation in Atrial Fibrillation: A Meta-Analysis of Randomized Trials. JACC Adv. Published October 2026. doi:10.1016/j.jacadv.2026.103251

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