Leonardo Knijnik

Background: Landmark randomized controlled trials (RCTs) comparing left atrial appendage occlusion (LAAO) against direct oral anticoagulants (DOACs) are individually underpowered for small but clinically meaningful differences. We performed a pooled meta‐analysis to provide more precise efficacy and safety data. Methods: Utilizing random‐effects models, we pooled data from 5890 patients across four landmark RCTs (PRAGUE‐17, CLOSURE‐AF, OPTION, and CHAMPION‐AF) at their longest follow‐up. Results: There were no significant differences between LAAO and antithrombotics in cardiovascular mortality (5.3% vs. 4.8%, p = 0.33), all‐cause stroke (3.3% vs. 2.8%, p = 0.31), systemic embolism (0.2% vs. 0.1%, p = 0.68), or major bleeding (6.6% vs. 6.8%, p = 0.85). Non‐procedural bleeding was significantly lower with LAAO (9.2% vs. 16.7%; RR 0.55; 95% CI 0.47–0.64; p < 0.0001), though there was a numerical trend toward more ischemic stroke events (2.7% vs. 2.0%; RR 1.35; 95% CI 0.97–1.88; p = 0.08). Conclusion: LAAO offers similar overall efficacy and safety to modern antithrombotics. It represents a clinical trade‐off: accepting a known upfront procedural risk for a robust, long‐term reduction in non‐procedural bleeding, potentially at the cost of a slight numerical increase in ischemic stroke.