From the Guidelines
The cornerstone treatment for atrial fibrillation after Watchman device implantation is a structured anticoagulation and antiplatelet regimen, typically consisting of warfarin (target INR 2.0-3.0) plus aspirin (81-100 mg daily) for 45 days post-procedure, followed by dual antiplatelet therapy with clopidogrel (75 mg daily) and aspirin (81-100 mg daily) until 6 months post-implantation, and then aspirin monotherapy (81-100 mg daily) indefinitely 1. This approach is based on the most recent and highest quality study available, which demonstrated the efficacy and safety of this regimen in preventing stroke and systemic embolism in patients with atrial fibrillation after Watchman device implantation. Key considerations in the management of atrial fibrillation after Watchman device implantation include:
- The use of anticoagulation therapy to prevent thrombus formation and promote endothelialization of the device
- The selection of patients who are suitable for Watchman device implantation, including those with a CHADS2 score ≥2 or a CHA2DS2-VASc score ≥3 1
- The monitoring of patients for device-related complications and the adjustment of anticoagulation therapy as needed
- The consideration of individual bleeding risk and the modification of anticoagulation protocols accordingly, with some centers using direct oral anticoagulants instead of warfarin in the initial phase. Overall, the goal of treatment is to prevent stroke and systemic embolism while minimizing the risk of bleeding complications, and to promote proper healing and endothelialization of the Watchman device.
From the Research
Cornerstone Treatment for Atrial Fibrillation Post-Watchman Device Implantation
The cornerstone treatment for atrial fibrillation post-Watchman device implantation involves anticoagulation and antiplatelet therapy to prevent stroke and systemic embolization.
- The initial treatment typically includes warfarin and aspirin for 45 days after implantation 2.
- After 45 days, a transesophageal echocardiography (TEE) is performed to assess residual peridevice flow and possible device-related thrombosis (DRT) formation 3, 2.
- If the TEE shows minimal residual peri-device flow (≤ 5mm) and no device-related thrombus, warfarin is stopped, and aspirin and clopidogrel are given for six months, followed by aspirin indefinitely 2.
- For patients with an absolute contraindication to oral anticoagulation, antithrombotic therapy with aspirin and clopidogrel for six months, followed by daily aspirin indefinitely, may be feasible 2.
- Direct oral anticoagulants (DOACs) are also being considered as an alternative to warfarin, with limited evidence suggesting they are not inferior following implantation of the device 3, 2.
Anticoagulation Strategies
Different anticoagulation strategies are being used post-Watchman device implantation, including:
- Warfarin followed by antiplatelet treatment 2, 4
- DOACs as a substitute for warfarin 3, 2
- Dual antiplatelet therapy (DAPT) for patients with absolute contraindications to oral anticoagulants (OACs)/DOACs 3
- Low molecular weight heparin (LMWH) and OAC for DRT treatment if detected 3
Complications and Risks
The Watchman device implantation is associated with various risks and complications, including: