What are the recommendations for Dabigatran (Pradaxa) and aspirin after Watchman (Left Atrial Appendage Closure Device) placement?

From the Guidelines

After Watchman device placement, the recommended anticoagulation regimen typically involves a combination of anticoagulant and antiplatelet therapy, with dabigatran 110 mg twice daily considered in preference to dabigatran 150 mg twice daily for the duration of concomitant antiplatelet therapy, and aspirin should be discontinued after 1 month, as the risk of bleeding outweighs the benefits of continued use 1.

Key Considerations

• The initial anticoagulation regimen should involve a direct oral anticoagulant (DOAK) such as apixaban, rivaroxaban, or dabigatran for 45 days post-procedure.
• Dual antiplatelet therapy (DAPT) consisting of clopidogrel 75 mg daily and aspirin 81-325 mg daily should be used for an additional 4.5 months (until 6 months post-procedure) only if the patient has a high ischemic risk or other anatomical/procedural characteristics that outweigh the bleeding risk.
• After this period, patients should continue with a single antiplatelet agent, preferably clopidogrel, or be transitioned to a single anticoagulant, such as dabigatran, as the risk of bleeding increases with continued use of aspirin and clopidogrel 1.

Rationale

The regimen aims to prevent device-related thrombosis while allowing for proper endothelialization of the Watchman device. The initial DOAK therapy provides robust anticoagulation during the highest risk period for device-related thrombosis. The subsequent DAPT phase continues to offer protection while allowing the transition away from full anticoagulation. Long-term use of a single antiplatelet agent or anticoagulant helps maintain protection against thromboembolism while minimizing the risk of bleeding.

Patient-Specific Factors

It's essential to consider individual patient factors, such as bleeding risk or allergies, when adjusting the anticoagulation regimen. Regular follow-up, including imaging to assess device position and any peri-device flow, is crucial during this transition period. Patients should be educated about the importance of adherence to this medication regimen and the need to report any unusual bleeding or symptoms of stroke. The most recent guidelines from 2024 should be followed, as they provide the most up-to-date recommendations for antithrombotic therapy post-percutaneous coronary intervention in chronic coronary syndrome patients with an indication for oral anticoagulation 1.

From the Research

Recommendations for Dabigatran (Pradaxa) and Aspirin after Watchman (Left Atrial Appendage Closure Device) Placement

• The use of anticoagulants after WATCHMAN implantation in patients with high bleeding risks has been a source of debate 2.
• Warfarin and aspirin are given for 45 days after implantation. If TEE at 45 days shows minimal residual peri-device flow (≤ 5mm) and no device-related thrombus, warfarin is stopped. This is followed by aspirin and clopidogrel for six months, then aspirin indefinitely 2.
• Antithrombotic therapy with aspirin and clopidogrel for six months followed by daily aspirin indefinitely may be feasible for patients with an absolute contraindication to OAC 2.
• DOACs, such as dabigatran, are more convenient to use than warfarin, and limited evidence suggests that they are not inferior following implantation of the device 2, 3, 4.
• A short course of standard-dose rivaroxaban following Watchman LAAO is associated with low incidence of thrombotic complications and bleeding events, and might be a feasible alternative regimen 3.
• Short-term low-dose dabigatran (110 mg twice daily) could significantly decrease the risk of bleeding compared with warfarin at the expense of increased risk of DRT post-LAAO 4.
• WATCHMAN implantation followed by 6 months of anti-thrombotic therapy is safe in patients with a history of intracranial hemorrhage 5.
• Tailored antithrombotic treatment using even very reduced strategies such as SAPT or no therapy showed no significant differences regarding ischemic complications after LAA closure 6.

Dabigatran (Pradaxa) Specific Recommendations

• Short-term low-dose dabigatran (110 mg twice daily) should be used with caution for post-implant anticoagulation of LAAO due to increased risk of DRT 4.
• There is limited evidence on the feasibility and safety of dabigatran used after LAAO, and more research is needed to tailor the existing antithrombotic regimen to the needs of patients 2, 4.

Aspirin Specific Recommendations

• Aspirin is given for 45 days after implantation, and then continued indefinitely after the initial 6 months of dual antiplatelet therapy 2.
• Aspirin and clopidogrel for six months followed by daily aspirin indefinitely may be feasible for patients with an absolute contraindication to OAC 2.
• Single antiplatelet therapy (SAPT) with aspirin is a common antithrombotic strategy used in the long-term period after WATCHMAN implantation, with no significant differences found regarding ischemic complications 6.