Abstract Body (Do not enter title and authors here): Background:
Left atrial appendage closure (LAAC) is increasingly used to reduce thromboembolic risk in patients with atrial fibrillation (AF) who are unsuitable for long-term anticoagulation. Despite procedural success, ischemic strokes still occur post-LAAC. Understanding contributing risk factors remains critical to improving patient outcomes.

Objectives:
To assess the incidence of ischemic stroke following LAAC and evaluate associated risk factors, including device-related thrombus (DRT), peri-device leak (PDL > 5 mm), patient-level factors such as the CHA₂DS₂-VASc score and left ventricular ejection fraction (LVEF), and post-procedural anticoagulation strategies.

Methods:
A systematic search of PubMed, Embase, and Cochrane Library was conducted for studies between January 2015 and May 2025. Observational studies and clinical trials reporting stroke outcomes after LAAC were included. Meta-analyses were performed using random-effects models to pool odds ratios (ORs) for stroke associated with risk factors. Heterogeneity and publication bias were evaluated using I² statistics and funnel plots.

Results:
Nineteen studies comprising 14,982 patients were included. The pooled incidence of ischemic stroke post-LAAC was 2.4% (range: 0.5%–4.4%) over a mean follow-up of 18 months. DRT was significantly associated with increased stroke risk (OR 5.08; 95% CI 3.47–7.44), as was peri-device leak (PDL) (OR 1.63; 95% CI 1.06–2.52). Patients with CHA₂DS₂-VASc scores ≥4 had higher stroke rates (OR: 1.7, 95% CI: 1.2–2.5), and those with reduced LVEF (<50%) were also at increased risk (OR: 1.6, 95% CI: 1.1–2.4). Although post-procedural anticoagulation regimens varied across studies, extended anticoagulation appeared to offer protective benefits in selected populations.

Conclusion:
Ischemic stroke can still occur after successful deployment of the LAAC device. DRT and PDL are strong predictors of stroke, which warrant continued anticoagulation. Patient-level factors, such as elevated CHA₂DS₂-VASc scores and reduced LVEF, are at risk of stroke after LAAC. Individualized anticoagulation and antiplatelet strategies, as well as routine post-procedure imaging, may continue to be used to mitigate these risks and improve long-term outcomes.