Left Atrial Appendage Closure Linked to Higher Ischemic Stroke Risk

A systematic review and meta-analysis published online in JAMA Cardiology found that catheter-based left atrial appendage closure (LAAC) was associated with similar overall rates of stroke and major bleeding as oral anticoagulation (OAC) in patients with atrial fibrillation, but with differing risks for ischemic stroke and nonprocedural bleeding.

The analysis included 8 randomized clinical trials involving 7,434 patients with atrial fibrillation at high risk of stroke. Eligible studies randomly assigned participants to catheter-based LAAC or OAC and reported at least 1 outcome of interest. Two investigators independently extracted data and assessed data quality, and pooled comparisons using a frequentist random-effects model.

After a weighted mean follow-up of 37.9 months, investigators detected no significant difference in overall stroke between LAAC and OAC (incidence rate ratio [IRR], 1.08; 95% CI, 0.82-1.41). Major bleeding also did not differ significantly between groups (IRR, 0.96; 95% CI, 0.81-1.14).

However, LAAC was associated with a higher risk of ischemic stroke than OAC (IRR, 1.34; 95% CI, 1.01-1.77) and a lower risk of nonprocedural major bleeding (IRR, 0.73; 95% CI, 0.58-0.92). Per 1,000 patients undergoing LAAC, pooled periprocedural events included 5 strokes, 9 bleeding episodes, 1 death, 5 device embolizations, and 9 pericardial effusions.

The authors said the findings indicate trade-offs between ischemic and bleeding outcomes and do not support routine use of LAAC as a first-line stroke-prevention strategy for patients with atrial fibrillation at moderate to high stroke risk.

Source: Laudani C, Bujak K, Giacoppo D, et al. Catheter-based left atrial appendage closure vs oral anticoagulation in patients with atrial fibrillation: a systematic review and meta-analysis. JAMA Cardiol. Published online August 26, 2026. doi:10.1001/jamacardio.2026.2640