Abstract
<title>Abstract</title> <p> <bold>Background:</bold> Patients with atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI) represent a high-risk population requiring complex antithrombotic management. Left atrial appendage closure (LAAC) is increasingly used for stroke prevention in AF patients with contraindications to long-term oral anticoagulation. However, evidence guiding post-LAAC antithrombotic strategies in patients with recent or concomitant PCI remains limited, as highlighted by the 2025 SCAI/HRS guidelines which identified key knowledge gaps regarding single antiplatelet therapy (SAPT) and management in complex populations. <bold>Aim:</bold> To systematically review and, where possible, meta-analyse the current evidence on antithrombotic management strategies and clinical/imaging outcomes following LAAC in AF patients who have undergone or require PCI. <bold>Methods:</bold> A systematic literature search was conducted in PubMed/MEDLINE, Embase, Cochrane Library, and Web of Science from January 2015 to June 2026 following PRISMA guidelines. Observational studies, registries, and randomised trials reporting antithrombotic regimens and outcomes (bleeding, thromboembolism, peri-device leak [PDL], device-related thrombus [DRT]) in AF patients undergoing LAAC with PCI history were included. Quality assessment used ROBINS-I and Cochrane RoB 2 tools. Narrative synthesis and random-effects meta-analysis were performed where appropriate. <bold>Results:</bold> Eleven studies (9 observational registries/cohorts and 2 post-hoc analyses) comprising 4,872 patients were included. Significant heterogeneity existed in post-LAAC antithrombotic regimens. Dual antiplatelet therapy (DAPT) or oral anticoagulation (OAC) plus single antiplatelet therapy were most commonly reported. Pooled incidence of major bleeding ranged from 6.8% to 14.2% depending on regimen, with lower rates observed in DOAC-based strategies in recent studies. DRT incidence was 1.2–3.8% and significant PDL (>3mm) occurred in 4.1–9.7% of patients. Data specific to the PCI subgroup were limited; no randomised controlled trials directly compared regimens in this population. The 2025 SCAI/HRS recommendation for OAC or DAPT post-LAAC was supported by observational data, while SAPT remains a knowledge gap. <bold>Conclusion:</bold> Current evidence supports individualised antithrombotic therapy after LAAC in AF-PCI patients, with a trend toward DOAC-based regimens to balance bleeding and thrombotic risk. High-quality randomised data are urgently needed. This review underscores the need for dedicated prospective studies and informs clinical decision-making and future guideline development in interventional cardiology. </p>