(P198) SURGICAL OR PERCUTANEOUS LEFT ATRIAL APPENDAGE OCCLUSION IN PATIENTS WITH ATRIAL FIBRILLATION: A SYSTEMATIC REVIEW AND META-ANALYSIS OF RANDOMIZED TRIALS

Background:

Background: Guidelines recommend most patients with atrial fibrillation (AF) receive oral anticoagulation (OAC) to reduce their risk of stroke. However, OAC is limited by physician adherence to guidelines, patient compliance, and temporary interruptions. Therefore, occluding the left atrial appendage – the most common area of thrombus formation in AF – is an attractive alternative or adjunct to OAC in patients with AF. Aiming to summarize the evidence for the efficacy and safety of left atrial appendage occlusion (LAAO), we performed a systematic review and meta-analysis of randomized controlled trials evaluating LAAO.

METHODS AND RESULTS: We searched MEDLINE, EMBASE, Cochrane Library and trial for randomized controlled trials comparing either surgical or percutaneous LAAO to no occlusion. Outcomes of interest included ischemic stroke or systemic embolism, death, and bleeding. We pooled data using a fixed-effects model when LAAOS III (dominant trial) was included and used a random effects model otherwise. From 1417 references, 13 trials were included. Eight trials (total n=5734) evaluated surgical LAAO, of which 6 studied LAAO on top of OAC. Five trials (total n=1655) evaluated percutaneous LAAO; all of these evaluated LAAO against OAC. Nine trials were at low and 4 at unclear risk of bias using the Cochrane tool. In surgical trials, LAAO reduced the risk of ischemic stroke or systemic embolism with a relative risk (RR) 0.63, 95% confidence interval (CI) 0.51 to 0.78, I2=0%, but not the risk of death RR 1.00, 95%CI 0.90 to 1.11, I2 = 0%, or bleeding RR 0.93, 95%CI 0.79 to 1.10, I2 = 0%. In percutaneous trials, LAAO did not reduce the risk of ischemic stroke or systemic embolism RR 1.38, 95%CI 0.86 to 2.22, I2 = 0%, or bleeding RR 0.79, 95%CI 0.60 to 1.04, I2 = 44%. Percutaneous LAAO was associated with a reduction in death with RR 0.76, 95%CI 0.61 to 0.94, I2 = 0%.

Conclusion:

Conclusion: In patients with AF, surgical LAAO effectively prevents stroke; this benefit is incremental to oral anticoagulation. The benefit of percutaneous LAAO, which has been studied mostly in patients who are not taking OAC, remains uncertain.