Left atrial appendage occlusion was superior to oral anticoagulation for stroke or systemic embolism prevention in patients with atrial fibrillation and ESRD (RR 0.74; 95% CI 0.64-0.86; p=0.0001).
Meta-Analysis (n=22,512)
Does left atrial appendage occlusion reduce stroke/systemic embolism and major bleeding compared to oral anticoagulation in adults with atrial fibrillation and end-stage renal disease?
In patients with atrial fibrillation and end-stage renal disease, left atrial appendage occlusion is associated with superior stroke prevention and reduced major bleeding compared to oral anticoagulation.
Effect estimate: RR 0.74 (95% CI 0.64-0.86)
p-value: p=0.0001
Abstract Background and aims Atrial fibrillation is common in patients with end-stage renal disease (ESRD), however, the optimal stroke prevention modality is unclear. This meta-analysis compares left atrial appendage occlusion (LAAO) to oral anticoagulation (OAC) in stroke prevention and associated bleeding and mortality rates in ESRD adults. Methods A systematic search of major databases was conducted up to December 2025. Analysis was performed using the generic inverse variance method with a random-effects model on RevMan software. Results The analysis incorporated 22, 512 patients. LAAO displayed a significantly lower risk of stroke/systemic embolism Relative Risk (RR): 0. 74; 95% Confidence interval (CI): 0. 64, 0. 86; I² = 0%; p= 0. 0001, and study-defined Major bleeding RR: 0. 73, 95% CI: 0. 57, 0. 93; I² = 80%; p= 0. 01. Notably, subgroup analysis revealed significantly higher reduction in major bleeding in studies with patients predominantly on warfarin RR: 0. 59, 95% CI: 0. 52, 0. 67; I² = 0%; p 0. 00001 compared to studies with patients predominantly on direct oral anticoagulants RR: 0. 88, 95% CI: 0. 77, 0. 99; I² = 0%; p= 0. 04 (p-value for subgroup differences 0. 0001). However, there was no significant difference between the interventions in all-cause mortality RR: 0. 8, 95% CI: 0. 59, 1. 07 or cardiovascular deaths RR: 0. 95, 95% CI: 0. 82, 1. 11. Conclusions LAAO is associated with superior stroke prevention compared to OAC in patients with ESRD. While LAAO reduces bleeding risk compared to both warfarin and DOACs, the benefit is most pronounced against warfarin. Future randomized controlled trials comparing LAAO to DOACs and warfarin are recommended. Conflict of interest Zeyad Bady: nothing to disclose, Mahmoud Refaey: nothing to disclose, Ahmed Talkhan: nothing to disclose, Abdullah Al Kahil: nothing to disclose, Ahmed Nasreldein: nothing to disclose.
Bady et al. (2026) conducted a meta-analysis in Atrial fibrillation and end-stage renal disease (n=22,512). Left atrial appendage occlusion (LAAO) vs. Oral anticoagulation (OAC) was evaluated on Stroke/systemic embolism (RR 0.74, 95% CI 0.64-0.86, p=0.0001). Left atrial appendage occlusion was superior to oral anticoagulation for stroke or systemic embolism prevention in patients with atrial fibrillation and ESRD (RR 0.74; 95% CI 0.64-0.86; p=0.0001).