Efficacy and Safety of Concomitant Catheter Ablation and Left Atrial Appendage Closure compared to Catheter Ablation only – A Systematic Review and Meta-Analysis

C. Friesacher (München)¹, T. Mews (München)¹, K.-L. Laugwitz (München)¹, M. Rattka (München)², I. M. Rattka (München)^1
1TUM Klinikum Rechts der Isar Klinik und Poliklinik für Innere Medizin I München, Deutschland; ²Technische Universität München Klinik für Kardiologie München, Deutschland

Background:
Atrial fibrillation (AF) carries substantial ischemic stroke risk originating predominantly from the left atrial appendage. Catheter ablation (CA) is the most effective rhythm-control strategy without thromboembolic risk reduction, while percutaneous left atrial appendage closure (LAAC) provides mechanical stroke prophylaxis. Combining both in a single “one-stop” procedure is increasingly performed, although clinical data on its rhythmic and periprocedural consequences remain scarce.

Objective:
Our systematic review and meta-analysis compared the efficacy and safety of combined CA+LAAC vs. CA-only in patients with AF. 

Methods:
We performed a PROSPERO-registered, PRISMA-compliant systematic review and meta-analysis, searching PubMed, Scopus, and Web of Science through June 2026 comparing CA+LAAC with CA-only. Two reviewers independently selected studies, extracted data, and assessed quality (NIH Quality Assessment Tool). The primary efficacy and safety outcomes were arrhythmia recurrence during follow-up and periprocedural pericardial effusion requiring drainage, respectively. Binary endpoints were pooled as Odds Ratios (OR) and continuous endpoints were pooled as mean differences (MD) using a random-effects model. Heterogeneity was reported as I².

Results:
Fifteen studies comprising 39,664 patients (19,700 CA+LAAC; 19,964 CA-only) were included, two of which were randomized trials and 13 were retrospective observational or registry-based cohorts. Median age was 66 years, 43% were female, and the pooled mean CHA₂DS₂-VASc-Score was 3.5. Arrhythmia recurrence was significantly more frequent after combined CA+LAAC evidenced by an OR of 1.56 (95% CI 1.11-2.19; I²=47%). Systemic thromboembolism (OR=0.66, 95% CI 0.37-1.21; I²=0%) and all-cause death (OR=1.01, 95% CI 0.60-1.70; I²=0%) did not show a significant difference. The primary safety outcome, periprocedural pericardial effusion requiring drainage, did not differ between groups (OR 0.96, 95% CI 0.22-4.17; I²=86%). Neither did periprocedural groin complications (OR 1.40, 95% CI 0.43-4.58; I²=0%) and periprocedural systemic thromboembolism (OR 0.48, 95% CI 0.08-2.98; I²= 72%). Total procedure time was significantly longer for the combined procedure, with an MD of +9.34 minutes (95% CI 0.63-18.05; I²=90%), while total fluoroscopy time was not (MD +2.81 min, 95% CI -0.88-6.51; I²=98%).

Conclusion:
In what is the largest meta-analysis to date comparing CA+LAAC with CA-only, the combined approach was associated with a significantly higher rate of arrhythmia recurrence. Neither the primary nor the secondary safety endpoints differed significantly between groups. These findings reinforce the prevailing assumption that combined CA+LAAC is safe relative to catheter ablation alone. Excess arrhythmia recurrence may be attributable to under-ablation in order to contain procedural time and safety constraints, mechanical irritation by the LAAC device, or residual confounding by a higher-risk combined-arm population. These findings warrant clarification in randomized controlled trials.