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

Wulamiding Kaisaier; Zixuan Xu; Min Ye; Zexuan Wu; Yugang Dong; Jiangui He; Chen Liu; Yili Chen; Gregory Y H Lip; Wengen Zhu

doi:10.1016/j.hrthm.2026.04.020

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

Heart Rhythm. 2026 Apr 17:S1547-5271(26)02270-8. doi: 10.1016/j.hrthm.2026.04.020. Online ahead of print.

Authors

Wulamiding Kaisaier¹, Zixuan Xu², Min Ye¹, Zexuan Wu¹, Yugang Dong¹, Jiangui He¹, Chen Liu³, Yili Chen⁴, Gregory Y H Lip⁵, Wengen Zhu⁶

Affiliations

¹ Department of Cardiology, the First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, PR China.
² Department of Emergency, the Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, PR China.
³ Department of Cardiology, the First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, PR China. Electronic address: chenyil7@mail.sysu.edu.cn.
⁴ Department of Cardiology, the First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, PR China. Electronic address: liuch75@mail.sysu.edu.cn.
⁵ Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark; Department of Cardiology, Lipidology and Internal Medicine with Intensive Coronary Care Unit, Medical University of Bialystok, Bialystok, Poland.
⁶ Department of Cardiology, the First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, PR China. Electronic address: zhuwg6@mail.sysu.edu.cn.

PMID: 42002016
DOI: 10.1016/j.hrthm.2026.04.020

Abstract

Background: 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).

Objective: 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.

Methods: 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.

Results: 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).

Conclusion: 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.

Keywords: Atrial fibrillation; Device-related thrombosis; Direct oral anticoagulants: Dual antiplatelet therapy; Left atrial appendage closure.