Left Atrial Appendage Occlusion vs Anticoagulation Following Atrial Fibrillation Ablation: A Propensity-Matched Comparative Outcomes Study

Background: Anticoagulation remains the standard of care following catheter ablation for atrial fibrillation (AF). However, the role of left atrial appendage occlusion (LAAO) as an alternative stroke prevention strategy in this context is not well established. Objective: To compare clinical outcomes between patients undergoing LAAO within 3 months after AF ablation versus those receiving long-term anticoagulation following AF ablation in a large, real-world cohort. Methods: We queried the TriNetX U.S. Collaborative Network, comprising de-identified electronic health record data from over 60 health systems. Using data from 2010-2025, we conducted a propensity-matched analysis of two cohorts of adult patients who underwent catheter ablation for atrial fibrillation and were subsequently treated with either LAAO without oral anticoagulation or oral anticoagulation alone. Propensity score matching (1:1) was performed based on demographics and clinical comorbidities. Outcomes were assessed at 1 year, 3 years, and 5 years. Primary outcomes included all-cause mortality, stroke events, and major bleeding events. Cox proportional hazards models were used to calculate hazard ratios (HRs) and p-values. Results: After propensity matching, the two cohorts each had 2,060 patients. Baseline characteristics were well-balanced post-matching: mean age was 71.4 ± 8.2 vs 71.4 ± 11.6 years (p=0.787), 36.8% were female in both cohorts (p=1.0), with similar rates of ischemic heart disease (51.9% vs 51.9%, p=0.975), hyperlipidemia (70.6% vs 69.5%, p=0.454), and baseline antiplatelet use (48.6% vs 48.3%, p=0.852). LAAO was associated with reduced all-cause mortality and major bleeding events at 5 years compared to oral anticoagulation alone, with no significant difference in stroke incidence among both groups. (Figures 1). Conclusion: In this large, multicenter propensity-matched cohort, LAAO following AF ablation was associated with lower risks of all-cause mortality and major bleeding events compared to anticoagulation. These findings suggest LAAO may offer a favorable long-term alternative for select post-ablation patients.