Impact of left atrial appendage closure on long-term stroke risk in atrial fibrillation: an umbrella review.

Left atrial appendage closure (LAAC) is an alternative to oral anticoagulation (OAC) for stroke prevention in atrial fibrillation (AF). While efficacy is established for follow-up periods up to 5 years, longer-term (>5 years) stroke outcomes remain underexplored, particularly across diverse AF populations and LAAC approaches (percutaneous and surgical). This paper synthesizes systematic reviews and meta-analyses evaluating the impact of LAAC on stroke risk in AF patients, focusing on ischemic and hemorrhagic stroke, device-specific outcomes, antithrombotic regimens, and valvular vs. non-valvular AF differences. We searched PubMed, Embase, Scopus, Cochrane Library, and Web of Science for systematic reviews and meta-analyses on LAAC and stroke outcomes in AF, following Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 guidelines. Included reviews reported stroke outcomes. Data were extracted on study characteristics, stroke outcomes, complications (e.g., device-related thrombosis), and subgroups. Quality was assessed using AMSTAR-2. Narrative synthesis was performed. Ten reviews (over 50 000 patients) were included, with follow-ups up to 5 years. LAAC reduced hemorrhagic stroke [e.g., hazard ratio 0.22, 95% confidence interval (CI) 0.08-0.61] and was non-inferior to OAC for all-cause stroke (OR 0.71, 95% CI 0.51-1.00). Surgical LAAC in valvular AF reduced stroke risk (Relative Risk (RR) 0.87, 95% CI 0.84-0.91). Complications like peri-device leaks increased ischemic stroke risk in non-valvular AF. No reviews reported >5-year stroke data. AMSTAR-2 ratings were moderate to high. LAAC effectively reduces hemorrhagic stroke risk in AF, with comparable all-cause stroke prevention to OAC up to 5 years. Longer-term (>5 years) data and valvular AF outcomes are limited, warranting further research.