Left Atrial Appendage Occlusion Versus Lifelong Anticoagulation: Framing a Genuinely Preference-Sensitive Decision
DOI:
https://doi.org/10.5281/zenodo.22305502Keywords:
Left atrial appendage occlusion, Atrial fibrillation, Anticoagulation, Direct oral anticoagulants, Shared decision making, Stroke preventionAbstract
Percutaneous left atrial appendage occlusion (LAAO) was developed on a simple premise: in non-valvular atrial fibrillation,
the great majority of atrial thrombi form in the left atrial appendage, so mechanically sealing it might substitute for lifelong
oral anticoagulation. Fifteen years of randomized trials have shown LAAO to be non-inferior to warfarin for stroke
prevention, with a durable reduction in hemorrhagic stroke and post-procedural bleeding, and procedural safety has
improved considerably across successive device generations and operator experience. What has been missing until very
recently was a well-powered, direct comparison against modern direct oral anticoagulant (DOAC) therapy in a general
atrial-fibrillation population, rather than against warfarin or in a bleeding-risk-enriched subgroup. Two such trials reported
topline results within days of each other in March 2026: CHAMPION-AF, an industry-funded trial using a single modern
device, met noninferiority and showed markedly less non-procedural bleeding with LAAO than DOAC therapy;
CLOSURE-AF, a publicly funded, multi-device, European trial in an older and more bleeding-prone population, did not meet
noninferiority and reported a higher cardiovascular death rate with LAAO. Reconciling these results requires attention to
funding source, device protocol, and population selection rather than treating either as definitive. Current guidelines already
draw a sharper distinction than headline device comparisons suggest: LAAO carries a stronger recommendation for patients
with a genuine contraindication to long-term anticoagulation than for patients who could take a DOAC but would prefer not
to. This review sets out that fifteen-year evidence base, the specific and still-relevant risk of device-related thrombus, and the
case for framing the LAAO-versus-anticoagulation choice through structured shared decision-making rather than as a
question with one correct default answer.
References
Blackshear JL, Odell JA. "Appendage obliteration to reduce stroke in cardiac surgical patients with atrial fibrillation". Ann Thorac Surg 61(1996):755-759.
Joglar JA, Chung MK, Armbruster AL, et al. "2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation". Circulation 149(2024):e1-e156.
Ruff CT, Giugliano RP, Braunwald E, et al. "Comparison of the efficacy and safety of new oral anticoagulants with warfarin in patients with atrial fibrillation: a meta-analysis of randomised trials". Lancet 383(2014):955-962.
Holmes DR, Reddy VY, Turi ZG, et al. "Percutaneous closure of the left atrial appendage versus warfarin therapy for prevention of stroke in patients with atrial fibrillation: a randomised non-inferiority trial". Lancet 374(2009):534-542.
Holmes DR Jr, Kar S, Price MJ, et al. "Prospective randomized evaluation of the Watchman Left Atrial Appendage Closure device in patients with atrial fibrillation versus long-term warfarin therapy: the PREVAIL trial". J Am Coll Cardiol 64(2014):1-12.
Reddy VY, Doshi SK, Kar S, et al. "5-Year Outcomes After Left Atrial Appendage Closure: From the PREVAIL and PROTECT AF Trials". J Am Coll Cardiol 70(2017):2964-2975.
Osmancik P, Herman D, Neuzil P, et al. "Left Atrial Appendage Closure Versus Direct Oral Anticoagulants in High-Risk Patients With Atrial Fibrillation". J Am Coll Cardiol 75(2020):3122-3135.
Osmancik P, Herman D, Neuzil P, et al. "4-Year Outcomes After Left Atrial Appendage Closure Versus Nonwarfarin Oral Anticoagulation for Atrial Fibrillation". J Am Coll Cardiol 79(2022):1-14.
Lakkireddy D, Thaler D, Ellis CR, et al. "Amplatzer Amulet Left Atrial Appendage Occluder Versus Watchman Device for Stroke Prophylaxis (Amulet IDE): A Randomized Controlled Trial". Circulation 144(2021):1543-1552.
Doshi SK, Kar S, Nair DG, et al. "Left Atrial Appendage Closure or Anticoagulation for Atrial Fibrillation". N Engl J Med (2026); published online 28 March 2026.
Landmesser U, Skurk C, Kirchhof P, et al. "Left Atrial Appendage Closure or Medical Therapy in Atrial Fibrillation". N Engl J Med (2026); published online 18 March 2026.
Wazni OM, Saliba WI, Nair DG, et al. "Left Atrial Appendage Closure after Ablation for Atrial Fibrillation". N Engl J Med (2024); published online 16 November 2024.
Freeman JV, Varosy P, Price MJ, et al. "The NCDR Left Atrial Appendage Occlusion Registry". J Am Coll Cardiol 75(2020):1503-1518.
Dukkipati SR, Kar S, Holmes DR, et al. "Device-Related Thrombus After Left Atrial Appendage Closure: Incidence, Predictors, and Outcomes". Circulation 138(2018):874-885.
Omerovic E, Redfors B. "CHAMPION-AF and CLOSURE-AF: reconciling contrasting results". Eur Heart J (2026); editorial.
Task Force for the Management of Atrial Fibrillation of the European Society of Cardiology. "2024 ESC Guidelines for the management of atrial fibrillation". Eur Heart J 45(2024):3314-3414.
Elwyn G, Frosch D, Thomson R, et al. "Shared Decision Making: A Model for Clinical Practice". J Gen Intern Med 27(2012):1361-1367.
Lip GYH, Nieuwlaat R, Pisters R, Lane DA, Crijns HJGM. "Refining Clinical Risk Stratification for Predicting Stroke and Thromboembolism in Atrial Fibrillation Using a Novel Risk Factor-Based Approach: The Euro Heart Survey on Atrial Fibrillation". Chest 137(2010):263-272.
Reddy VY, Doshi SK, Sievert H, et al. "Percutaneous Left Atrial Appendage Closure vs Warfarin for Atrial Fibrillation: A Randomized Clinical Trial". JAMA 312(2014):1988-1998.
