Percutaneous left atrial appendage closure in non-valvular atrial fibrillation with concomitant heart failure: a systematic review and meta-analysis of periprocedural and long-term outcomes

OBJECTIVE: Heart failure (HF) frequently coexists with non-valvular atrial fibrillation (NVAF) and may adversely affect outcomes after percutaneous left atrial appendage closure (LAAC). However, data on the safety and efficacy of LAAC in this high-risk subgroup remain inconsistent. METHODS: A comprehensive search of PubMed, Cochrane Library, ScienceDirect, Epistemonikos, and MedRxiv was conducted from inception to August 2025 for studies comparing outcomes of LAAC in NVAF patients with versus without HF. Random-effects meta-analyses were performed to estimate pooled odds ratios (ORs) for periprocedural outcomes, and hazard ratios (HRs) or ORs for long-term outcomes, with 95% confidence intervals (CIs). RESULT: Forty studies comprising 351,266 patients were included, with thirty-three contributing to quantitative synthesis. Compared with patients without HF, those with HF had higher odds of periprocedural major adverse events (OR 1.17, 95% CI 1.03-1.32), periprocedural mortality (OR 2.41, 95% CI 1.84-3.16), and major bleeding (OR 1.26, 95% CI 1.08-1.45). No significant differences were observed for periprocedural stroke or pericardial effusion. During long-term follow-up, HF was associated with increased all-cause mortality (HR 1.83, 95% CI 1.50-2.22), major adverse events (HR 1.21, 95% CI 1.00-1.46), and device-related thrombus (OR 1.45, 95% CI 1.17-1.79). Rates of long-term stroke, major bleeding, and peri-device leak were similar between groups. CONCLUSION: In NVAF patients undergoing LAAC, HF confers higher procedural risk and worse long-term survival, while protection against thromboembolism and major bleeding appears comparable. These findings underscore the need for careful patient selection, optimized procedural care, and individualized post-implant antithrombotic strategies.