Direct oral anticoagulants vs dual antiplatelet therapy following left atrial appendage closure in atrial fibrillation

Percutaneous left atrial appendage closure (LAAC) is an established alternative to oral anticoagulants for preventing thromboembolic events for selected patients with atrial fibrillation (AF). However, optimal post-procedural antithrombotic therapy remains uncertain, particularly regarding the use of direct oral anticoagulants (DOACs) vs dual antiplatelet therapy (DAPT).

This meta-analysis aimed to compare the efficacy and safety outcomes of DOACs vs DAPT in the early post-implant period following LAAC in patients with AF.

We systematically searched PubMed and Embase until November 2025 to identify randomized controlled trials (RCTs) that compared DOACs with DAPT after LAAC. Efficacy outcomes included device-related thrombosis (DRT), stroke, and all-cause mortality, whereas safety outcomes encompassed major and minor bleeding. Pooled effect estimates were calculated as odds ratios (ORs) with 95% confidence intervals (CIs). Where appropriate, fixed- or random-effects models were applied according to between-study heterogeneity.

3 RCTs (ADRIFT, ADALA, ANDES) involving 704 patients (mean age 75.8-78.4 years; 65% males) were included, with 368 assigned to DOAC and 336 to DAPT. Baseline thromboembolic and bleeding risk were high (mean CHA₂DS₂-VASc 4.0-4.7; mean HAS-BLED 3.5-3.8). Clinical outcomes were evaluated at 2-3 months. Compared with DAPT, DOACs were associated with significantly lower risks of DRT (OR = 0.16; 95% CI: 0.05-0.57), major bleeding (OR = 0.46; 95% CI: 0.26-0.81) and minor bleeding (OR = 0.59; 95% CI: 0.38-0.92). No significant differences were observed in stroke (OR = 0.46; 95% CI: 0.07-3.13) and all-cause mortality (OR = 0.60; 95% CI: 0.23-1.54).

In randomized trials of patients with AF undergoing LAAC, short-term DOAC-based regimens were associated with lower rates of DRT and fewer bleeding events than DAPT, without differences in stroke or mortality. These findings support DOACs as a favorable short-term antithrombotic option after LAAC in selected patients.