Comparison of the Efficacy and Safety of Percutaneous Left Atrial Appendage Closure Versus Direct Oral Anticoagulants and Vitamin K Antagonists in Patients With Permanent Atrial Fibrillation and High Risk of Adverse Events: A Literature Review

Abstract

Introduction and purpose
Atrial fibrillation (AF) is the most common sustained supraventricular arrhythmia and a major cause of ischemic stroke and systemic thromboembolism. In non-valvular AF, most thrombi originate in the left atrial appendage (LAA). Oral anticoagulation with vitamin K antagonists (VKAs) or direct oral anticoagulants (DOACs) remains the cornerstone of stroke prevention; however, long-term therapy may be limited by bleeding risk and adherence challenges. Percutaneous left atrial appendage closure (LAAC) has emerged as an anatomy-based alternative. This review aimed to compare the efficacy and safety of LAAC with DOACs and VKAs in patients with permanent AF at high risk of adverse events.

Material and methods
A qualitative literature review was conducted using PubMed, Embase, Cochrane Library, and Web of Science. Randomized controlled trials, meta-analyses, pooled analyses, and large cohort or registry studies published between 2015 and 2025 were included. Outcomes of interest included ischemic stroke, systemic embolism, major bleeding, mortality, and procedure-related complications.

Results
Across randomized trials and observational studies, LAAC, DOACs, and VKAs demonstrated comparable efficacy in preventing ischemic stroke and systemic embolism. Randomized data confirmed the non-inferiority of LAAC compared with warfarin and DOAC therapy. Safety profiles differed: DOACs showed lower rates of major bleeding than VKAs, whereas LAAC presented higher early procedural risk but fewer late bleeding events.

Conclusions
LAAC provides stroke prevention efficacy comparable to oral anticoagulation and may offer long-term safety advantages in selected high-risk patients. Individualized treatment strategies remain essential in permanent AF.