Left Atrial Appendage Closure or Anticoagulation for Atrial Fibrillation.

Summary

In a 3,000-patient international randomized trial of anticoagulation-eligible atrial fibrillation, device-based left atrial appendage closure was noninferior to NOACs for cardiovascular death, stroke, or systemic embolism at 3 years and superior for reducing non–procedure-related bleeding. These findings expand the potential role of LAA closure beyond patients intolerant to anticoagulation.

Key Findings

• In 3,000 randomized AF patients eligible for anticoagulation, LAA closure was noninferior to NOACs for the composite of cardiovascular death, stroke, or systemic embolism at 3 years.
• LAA closure was superior to NOAC therapy for the safety endpoint of non–procedure-related bleeding.
• Randomization achieved balanced baseline characteristics (mean age 71.7 years; 31.9% women).

Clinical Implications

LAA closure may be considered as an alternative to long-term NOAC therapy in AF patients eligible for anticoagulation, particularly for those at elevated bleeding risk or with adherence concerns, pending guideline updates and shared decision-making.

Limitations

• Abstract text truncation limits access to detailed subgroup and procedural complication data
• Longer-term durability beyond 3 years and device-specific complications require continued follow-up

Future Directions

Define patient subgroups with net clinical benefit, evaluate cost-effectiveness, and integrate LAA closure into shared decision-making frameworks and guideline updates.