Is anticoagulation therapy needed after Left Atrial Appendage (LAA) closure as part of Coronary Artery Bypass Grafting (CABG)?

From the Guidelines

Anticoagulation therapy is typically needed after Left Atrial Appendage (LAA) closure as part of Coronary Artery Bypass Grafting (CABG), but the regimen is usually less intensive than for atrial fibrillation patients without closure. The most recent and highest quality study, the 2024 ESC guidelines for the management of atrial fibrillation 1, suggests that surgical LAA closure should be considered as an adjunct therapy to prevent thromboembolism in addition to anticoagulation in patients with AF. Some key points to consider when deciding on anticoagulation therapy after LAA closure include:

• The LAAOS III trial showed that surgical occlusion or exclusion of the LAA can contribute to stroke prevention in patients with AF undergoing cardiac surgery 1.
• The need for post-procedure antithrombotic treatment exposes the patient to a bleeding risk that may be equivalent to that of DOACs 1.
• Regulatory approvals suggest the need for 45 days of VKA plus aspirin after implantation, followed by 6 months of DAPT in patients with no major peri-device leaks, and then ongoing aspirin 1.
• Observational studies have also supported the use of antiplatelet therapy without associated increases in device-related thrombosis or stroke 1. A common approach is to use dual antiplatelet therapy (DAPT) rather than full anticoagulation, which typically involves aspirin 81 mg daily indefinitely, combined with clopidogrel 75 mg daily for 1-3 months post-procedure. In some cases, particularly if the patient has other indications for anticoagulation, a short course (1-3 months) of oral anticoagulation with a direct oral anticoagulant (DOAC) like apixaban 5 mg twice daily or rivaroxaban 20 mg daily may be prescribed instead of or in addition to antiplatelet therapy 1. The exact duration and intensity of anticoagulation can vary based on individual patient factors, including bleeding risk and the presence of other indications for anticoagulation. Close follow-up and individualized decision-making are crucial in managing these patients post-operatively. It's worth noting that the 2012 focused update of the ESC guidelines for the management of atrial fibrillation 1 also discussed the need for antithrombotic therapy in AF patients, even after removal or closure of the LAA, but the more recent 2024 guidelines provide more up-to-date and relevant information on this topic.

From the Research

Anticoagulation Therapy after Left Atrial Appendage Closure

• The need for anticoagulation therapy after Left Atrial Appendage (LAA) closure as part of Coronary Artery Bypass Grafting (CABG) is a topic of ongoing research and debate 2, 3, 4, 5, 6.
• Studies have shown that antithrombotic therapy following interventional LAA closure is critical in balancing the risk of thromboembolism and bleeding during the endothelialization of the implanted devices 2.
• The most recent clinical trials suggest that for patients eligible for oral anticoagulation (OAC) and receiving a Watchman device, warfarin plus aspirin for 45 days followed by dual antiplatelet therapy (DAPT) for 6 months and a lifelong aspirin therapy may be the most effective approach 2.
• Alternatively, the Watchman was approved for 3 months of novel OAC (NOAC) therapy in conjunction with aspirin 2.
• Other studies have found that left atrial appendage closure is associated with a lower risk of non-procedure-related major or clinically relevant nonmajor bleeding than oral anticoagulation and is noninferior to oral anticoagulation with respect to a composite of death from any cause, stroke, or systemic embolism at 36 months 3.
• The cessation of oral anticoagulation following left atrial appendage surgery is a common clinical concern, and studies have shown that it may be safe to discontinue oral anticoagulation after surgical closure of the left atrial appendage in patients with a history of atrial fibrillation 4.
• Antithrombotic therapy after percutaneous left atrial appendage closure is still a topic of uncertainty, and there is a lack of randomized clinical trials comparing different antithrombotic agents after LAAC 5.
• Some studies have found that in highly selected patients at very high bleeding risk, discontinuation of any antithrombotic therapy after LAAC appears safe and feasible 6.

Specific Antithrombotic Regimens

• Dual antiplatelet therapy (DAPT) for 1-6 months has been used in the vast majority of cases after LAA closure 2.
• Single antiplatelet therapy using aspirin may be a viable option for short-term use 2.
• Novel OAC (NOAC) therapy in conjunction with aspirin has been approved for 3 months after Watchman device implantation 2.
• The optimal antithrombotic drug regimen following device implantation is still uncertain and requires further research 5.