Comparative outcomes of combined left atrial appendage occlusion and catheter ablation versus isolated procedures in atrial fibrillation: a network meta-analysis

The left atrial appendage (LAA) is the primary source of thrombi in over 90% of patients with non-valvular atrial fibrillation (AF). Consequently, LAA occlusion (LAAO) has been shown to reduce stroke risk and decrease the need for oral anticoagulation (OAC), particularly in patients at high risk of bleeding. The combination of LAAO and catheter ablation (CA) may offer an effective strategy for both rhythm control and stroke prevention in AF patients. However, it remains unclear whether the benefits of the combined procedure outweigh the risks compared to isolated LAAO, CA alone, or CA combined with OAC.

The aim of this network meta-analysis is to compare the efficacy and safety of combining LAAO and CA versus LAAO alone, CA alone, or CA combined with OAC in patients with atrial fibrillation.

A systematic search was conducted across electronic databases (PubMed, Scopus, Web of Science, Embase, and Cochrane Library) up to February 2025 for studies involving adult patients with atrial fibrillation who underwent LAAO plus CA compared to isolated LAAO, CA alone, or CA combined with OAC. The analyzed outcomes included major bleeding, thromboembolic events, stroke, all-cause mortality, AF recurrence, and pericardial effusion. A random-effects network meta-analysis was performed to calculate odds ratios (ORs) with 95% confidence intervals (CIs) for the outcomes of interest.

The network meta-analysis included 23 studies comprising 46,161 patients. Among them, 22,824 patients underwent CA with LAAO, 3002 underwent LAAO alone, 18,857 underwent CA alone, and 1478 underwent CA combined with OAC. The combination of LAAO and CA was not associated with a higher rate of major bleeding or thromboembolic events compared to the three comparators. Interestingly, stroke rate, all-cause mortality, and AF recurrence were significantly lower in the CA-alone group compared to the combined procedure (OR: 0.69; 95% CI: 0.53–0.89; OR: 0.50; 95% CI: 0.43–0.59; and OR: 0.64; 95% CI: 0.49–0.83, respectively). In contrast, LAAO alone showed no significant difference compared to LAAO + CA for these outcomes. No significant differences were observed in the incidence of pericardial effusion, periprocedural complications, or vascular complications between the combined procedure and other interventions.

We conclude that the combination of LAAO and CA is not associated with an increased risk of adverse events compared to isolated procedures. However, CA alone was associated with a lower risk of stroke, all-cause mortality, and AF recurrence. Further randomized trials are needed to confirm these findings and inform guideline development.