Left Atrial Appendage Occlusion Versus Oral Anticoagulation in Atrial Fibrillation: A Comprehensive Evidence Synthesis.

BACKGROUND: Oral anticoagulation (OAC) remains the cornerstone of stroke prevention in atrial fibrillation (AF) but is limited by bleeding risk. Left atrial appendage occlusion (LAAO) devices offer an alternative; however, recent randomized trials have reported inconsistent efficacy compared with OAC. METHODS: We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) comparing LAAO with OAC through April 1, 2026, using MEDLINE, EMBASE, and Cochrane CENTRAL. Eligible studies enrolled adults (≥18 years) with AF randomized to LAAO or OAC. Primary and secondary outcomes were pooled as risk ratios (RR) with 95% confidence intervals (CIs). Individual patient-level data (IPD) were reconstructed from published Kaplan-Meier curves for time-to-event sensitivity analyses. RESULTS: Six RCTs (n = 7,004; mean age 72 years; CHA2DS2‑VASc 3.9; HAS‑BLED 1.7; mean follow-up 38 months) were included. LAAO showed no significant difference in ischemic stroke (RR 1.20, 95% CI 0.82-1.76), major bleeding (RR 0.77, 95% CI 0.50-1.17), or all-cause mortality (RR 0.96, 95% CI 0.82-1.13) compared with OAC. Hemorrhagic stroke risk was significantly lower with LAAO (RR 0.53, 95% CI 0.30-0.93). Reconstructed IPD demonstrated similar stroke and bleeding risks (HR 1.24 and 0.84, respectively) but lower all-cause mortality with LAAO (HR 0.70, 95% CI 0.52-0.95). CONCLUSION: LAAO provides comparable ischemic stroke prevention and major bleeding outcomes to OAC and reduces hemorrhagic stroke risk. Reconstructed IPD analyses suggest a possible mortality benefit that warrants further investigation. Future studies using contemporary devices and post-ablation populations are needed to refine patient selection and further characterize the comparative clinical outcomes of LAAO and OAC in AF patients.