Percutaneous left atrial appendage occlusion versus oral anticoagulation in atrial fibrillation: A pragmatic meta-analysis of randomized trials within the DOAC era.

Background: Percutaneous left atrial appendage occlusion (LAAO) is an established alternative to oral anticoagulation (OAC). However, its safety and efficacy boundaries remain incompletely defined in dedicated comparisons against direct oral anticoagulants (DOACs). Objective: This study applied a pragmatic framework to evaluate the comparative efficacy and safety of LAAO versus OAC in a DOAC-predominant setting. Methods: PubMed, Embase, and Cochrane Library were searched for randomized controlled trials comparing LAAO with OAC, restricted to a DOAC-predominant comparator. Risk ratios (RR) with 95% confidence intervals (CI) were calculated via a Mantel-Haenszel random-effects model. Results: Four trials comprising 5890 patients were included (96.4% of controls assigned to DOACs). Overall stroke (RR 1.18, 95% CI 0.87-1.60; Conclusions: In a pragmatic analysis of the DOAC era, randomized data show no statistically significant differences for hard individual endpoints, though broad confidence intervals reflect precision limits. A numerical asymmetry for ischemic stroke favored OAC, while LAAO reduced nonprocedural clinically relevant bleeding. Current evidence remains non-definitive, warranting shared clinical decision-making to balance individual thromboembolic risks against long-term bleeding susceptibility.