Left Atrial Appendage Occlusion vs Direct Oral Anticoagulants for Atrial Fibrillation: Network Meta-Analyses
In brief
In 67,693 patients, appendage devices showed no advantage over blood thinners
Network analyses of 11 randomized trials found similar risks of stroke, systemic embolism or cardiovascular death, and major bleeding, with left atrial appendage occlusion devices compared with direct oral anticoagulants. The results do not establish that the treatments are interchangeable; further trials must clarify whether patients at high bleeding risk benefit more from occlusion.
- Journal
- JACC. Advances (Q1)
- Published
- 23 September 2026
- Study design
- Randomized controlled trial
- Evidence level
- Level 1, High (CEBM 1b)
- Authors
- Yuriko Hiruma, Tadao Aikawa, Iwanari Kawamura, Masao Iwagami, Polydoros Kampaktsis, Alexandros Briasoulis, et al.
- PMID
- 42777587
- DOI
- 10.1016/j.jacadv.2026.103269
Why clinicians should know about it
- Picked for Hematology (top studies of the week, 27 September 2026): LAAO vs DOACs for atrial fibrillation, cardiology
Abstract
BACKGROUND: Left atrial appendage occlusion (LAAO) is a treatment option to prevent thromboembolic events in patients with atrial fibrillation. However, it remains unclear whether LAAO offers superior efficacy and safety compared with oral anticoagulation for these patients. OBJECTIVES: This study aimed to assess the efficacy and safety of LAAO vs direct oral anticoagulants (DOACs). METHODS: We reviewed randomized controlled trials comparing oral anticoagulation and LAAO, using MEDLINE and CENTRAL. The primary outcome was a composite of stroke, systemic embolism, and cardiovascular death, whereas the safety outcome was major bleeding. Two network meta-analyses were conducted to assess LAAO vs DOAC, incorporating indirect comparisons: 1 comparing LAAO, DOACs, and vitamin K antagonist (3 arms), and the other comparing Watchman, Amulet, DOACs, and vitamin K antagonist (4 arms). RESULTS: A total of 67,693 patients from 11 randomized controlled trials were included, of whom 5,735 underwent LAAO. In the three-arm network meta-analysis, LAAO and DOACs demonstrated statistically similar risks for both the primary efficacy outcome (HR: 1.02; 95% CI: 0.88-1.19; I2 = 0%) and the safety outcome (HR: 0.98; 95% CI: 0.78-1.23; I2 = 70.5%). In the 4-arm network meta-analysis, both Amulet and Watchman were associated with similar risks of the primary outcome, comparable to those of DOACs, as well as the risk of major bleeding. CONCLUSIONS: LAAO devices did not demonstrate statistical superiority over DOACs in reducing thromboembolic events and major bleeding. Further trials are warranted to define patients for whom LAAO may offer the most significant benefit, such as those with high bleeding risk (CRD420251237886).
Abstract as published, via PubMed.
For healthcare professionals. The summary is generated by AI from the published abstract, and the evidence level is assigned automatically from the study design on the Oxford CEBM hierarchy. Neither is medical advice. Read the full paper before changing practice.