title: Left atrial appendage occlusion for stroke prevention in patients with atrial fibrillation: a systematic review and network meta-analysis of randomized controlled trials.
abstract: BACKGROUND
  Atrial fibrillation (AF) is one of the leading causes of stroke. Risks associated with oral anticoagulation (OAC) limit adherence to recommended therapy. Left atrial appendage (LAA) occlusion is a treatment alternative in patients with AF. We performed a network meta-analysis (NMA) of randomized trials evaluating the efficacy of LAA occlusion compared with oral anticoagulant, antiplatelet, and placebo for stroke prevention. We also assessed the impact of LAA occlusion on mortality, major bleeding, and operative time.
  
  
  METHODS
  We searched MEDLINE, EMBASE, PubMed, and Cochrane Library for randomized trials comparing percutaneous or surgical LAA occlusion with standard of care in AF patients.
  
  
  RESULTS
  Conventional meta-analysis found no difference between groups for stroke (5 trials, 1285 patients;RR 0.78, 95% CI 0.47-1.29), and a significant reduction in mortality (5 trials, 1285 patients; RR 0.71, 95% CI 0.51-0.99) favouring LAA occlusion. NMA demonstrated a trend towards reduction in stroke (OR 0.84, 95% CrI 0.47-1.55) and mortality (OR 0.69, 95% CrI 0.44-1.10) for LAA occlusion versus warfarin, but no statistically significant effect. Statistical ranking curves placed LAA occlusion as the most efficacious treatment on the outcomes of stroke and mortality when compared to warfarin, aspirin, or placebo. No significant differences between groups were seen in major bleeding or operative time for surgical trials. The overall quality of the evidence was low as assessed by GRADE.
  
  
  CONCLUSIONS
  LAA occlusion appears to preserve the benefits of OAC therapy for stroke prevention in patients with AF, but the current evidence is of low quality.
authors.affiliation: Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada.|Division of Cardiac Surgery, McMaster University, Hamilton, ON, Canada.
authors.forename: Hasib
authors.initials: H
authors.lastname: Hanif
authors.affiliation: Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada.
authors.forename: Emilie P
authors.initials: EP
authors.lastname: Belley-Cote
authors.affiliation: Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada.|Division of Cardiac Surgery, McMaster University, Hamilton, ON, Canada.
authors.forename: Abdullah
authors.initials: A
authors.lastname: Alotaibi
authors.affiliation: Division of Cardiac Surgery, McMaster University, Hamilton, ON, Canada.
authors.forename: Nazari
authors.initials: N
authors.lastname: Dvirnik
authors.affiliation: Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada.
authors.forename: Binod
authors.initials: B
authors.lastname: Neupane
authors.affiliation: Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada.
authors.forename: Joseph
authors.initials: J
authors.lastname: Beyene
authors.affiliation: Department of Medicine, McMaster University, Hamilton, ON, Canada.|Population Health Research Institute, Hamilton, ON, Canada.
authors.forename: John W
authors.initials: JW
authors.lastname: Eikelboom
authors.affiliation: Division of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic College of Medicine, Mayo Clinic and Mayo Foundation, Rochester, MN, USA.
authors.forename: David
authors.initials: D
authors.lastname: Holmes
authors.affiliation: Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada - Richard.Whitlock@phri.ca.|Division of Cardiac Surgery, McMaster University, Hamilton, ON, Canada.|Population Health Research Institute, Hamilton, ON, Canada.
authors.forename: Richard P
authors.initials: RP
authors.lastname: Whitlock
mesh_terms: D000925:Anticoagulants / Q000009:adverse effects / Q000627:therapeutic use; D020517:Atrial Appendage / Q000601:surgery*; D001281:Atrial Fibrillation / Q000150:complications* / Q000401:mortality / Q000601:surgery*; D006470:Hemorrhage / Q000139:chemically induced; D061646:Operative Time; D016032:Randomized Controlled Trials as Topic; D020521:Stroke / Q000401:mortality / Q000517:prevention & control*
chemical_list: D000925:Anticoagulants