Abstract 4368331: Direct Oral Anticoagulants versus Dual Antiplatelet Therapy After Left Atrial Appendage Closure: A Systematic Review and Meta-analysis

Background: Left atrial appendage closure (LAAC) has recently gained prominence as a pivotal intervention for managing atrial fibrillation (AF), particularly among patients contraindicated for prolonged anticoagulation therapy. However, there was a potential risk for device-related thrombosis (DRT) that could heighten the risk of thromboembolic complications following LAAC. Traditionally, dual-anti-platelet therapy (DAPT) is frequently prescribed following LAAC. However, emerging evidence suggests a more effective role for direct oral anticoagulants (DOACs) in reducing bleeding and DRT following LAAC. To date, no consensus has been reached on the optimal anticoagulation therapy after LAAC. Aim: We will conduct an extensive systematic review and meta-analysis comparing the safety and efficacy of DOACs and DAPTs for patients managed by LAAC. Methods: With strict adherence to PRISMA guidelines, we encompassed randomized controlled trials (RCTs) and observational studies comparing DOACs and DAPTs in patients who underwent LAAC. The primary endpoint was major bleeding. Secondary endpoints included DRT, stroke, and all-cause mortality. Upon employing a Dersomnian-laird random effect meta-analysis model, we utilized the odds ratio (OR) with a 95% confidence interval (CI) to pool the dichotomous outcomes. All the statistical analysis was carried out using STATA 18 BE. Results: 11 studies incorporating 25,089 patients managed by LAAC were included in this study. Pooled analysis revealed a significant reduction in the incidence of major bleeding within patients administrated DOAC compared to those administrated DAPT (RR = 0.67, 95% CI [0.50 to 0.90], p = 0.01). Similarly, DOACs were associated with a significantly lower risk of DRT (OR = 0.55, 95% CI [0.41 to 0.74], p = 0.001), all-cause mortality (OR = 0.70, 95% CI [0.60 to 0.82], p = 0.001), and stroke (OR = 0.66, 95% CI [0.48 to 0.92], p = 0.01). Conclusion: Our meta-analysis highlights the better efficacy of DOACs over DAPT in reducing the risk of DRT and stroke with a favorable bleeding profile. Further RCTs with higher sample sizes and longer follow-up periods are needed to optimize the post-LAAC antithrombotic approaches and guide clinical decision-making.