AHA Scientific Sessions 2026 Abstract · Nov 2, 2026
Comparative Efficacy and Safety of Left Atrial Appendage Closure Devices and Oral Anticoagulation Strategies for Stroke Prevention in Atrial Fibrillation
By Salih MS, Towfig MF, Ahmed M et al.
Background: Left atrial appendage closure (LAAC) and oral anticoagulation (OAC) are established options for stroke prevention in nonvalvular atrial fibrillation, but comparative evidence across contemporary LAAC devices and OAC strategies remains limited. Hypothesis: We evaluated whether percutaneous LAAC devices, surgical LAAC, direct oral anticoagulants (DOACs), vitamin K antagonists (VKAs), or no anticoagulation differ in efficacy or safety for stroke prevention in adults with nonvalvular atrial fibrillation. Methods: PubMed, Scopus, Web of Science, and Cochrane CENTRAL were searched from inception through March 30, 2026. Randomized controlled trials comparing LAAC devices, DOACs, VKAs, or no anticoagulation were eligible for network meta-analysis; single-arm studies were summarized descriptively for safety. Primary outcomes were stroke/systemic embolism and major bleeding. Frequentist random-effects network meta-analysis was performed using netmeta in R. Results: Twenty studies, including 18 randomized controlled trials and 2 single-arm registries, enrolled 71,802 participants. For stroke/systemic embolism, 11 trials contributed to the network. No intervention differed significantly from DOACs or from each other. Compared with DOACs, point estimates were RR 0.83 (95% CI, 0.18-3.74) for Amplatzer Amulet and RR 1.01 (95% CI, 0.27-3.85) for Watchman FLX; however, precision was low, and heterogeneity was severe (I ² =98.6%). For major bleeding, 8 trials contributed to the network. Watchman FLX was associated with lower major bleeding than DOACs (RR 0.65; 95% CI, 0.46-0.90), whereas VKAs were associated with higher major bleeding than DOACs (RR 1.28; 95% CI, 1.06-1.55). Conclusion: In randomized evidence synthesized by network meta-analysis, contemporary LAAC devices did not show a statistically significant difference in stroke/systemic embolism compared with DOACs, but estimates were imprecise and limited by extreme heterogeneity. Watchman FLX was associated with lower major bleeding than DOACs. LAAC may be a reasonable alternative for selected patients at increased bleeding risk, while individualized decision-making remains essential.