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Left atrial appendage closure (LAAC) is a reasonable alternative to oral anticoagulation (OAC) in selected patients with atrial fibrillation (AF). We conducted an updated meta-analysis of randomized controlled trials comparing LAAC versus OAC in patients with AF. The primary efficacy endpoint was a composite of all stroke, systemic embolism, or cardiovascular/all-cause death. The primary safety endpoint was major bleeding. Secondary endpoints included net adverse clinical events, all-cause death, nonprocedure-related bleeding, and ischemic stroke. Reconstructed individual patient data meta-analysis using a 2-stage approach and study-level meta-analysis using random-effects models were performed. Six trials enrolling 7,004 patients randomized to LAAC (n = 3,681) or OAC (n = 3,323) were included. There were no significant differences between LAAC versus OAC for the primary efficacy endpoint (difference in restricted mean survival time [?RMST] -0.006 years, 95% confidence interval [CI] -0.027 to 0.015 years, p = 0.56) or primary safety endpoint (?RMST 0.004 years, 95% CI -0.025 to 0.034 years, p = 0.77) at 3 years. Nonprocedure-related bleeding was significantly lower with LAAC versus OAC (?RMST 0.162 years, 95% CI 0.104 to 0.220 years, p <0.001) with no difference in all-cause death (?RMST 0.029 years, 95% CI -0.031 to 0.089 years, p = 0.34). In a study-level meta-analysis, ischemic stroke was not significantly different with LAAC versus OAC (risk ratio 1.32, 95% CI 0.94 to 1.86, p = 0.09). In conclusion, the trade-off between a statistically significant lower risk of nonprocedure-related bleeding and a numerically, but not statistically, higher risk of ischemic stroke with LAAC versus OAC necessitates individualized risk assessment and shared decision-making for patients with AF at elevated risk of stroke.

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