From the Guidelines
After Watchman device placement, the recommended anticoagulation and antiplatelet regimen is as follows: DOAC (e.g., apixaban 5mg twice daily or rivaroxaban 20mg once daily) plus aspirin 81mg daily for the first 45 days, followed by DAPT (clopidogrel 75mg daily and aspirin 81mg daily) from day 46 to 6 months, and then aspirin 81mg daily indefinitely, as supported by the 2024 ESC guidelines for the management of atrial fibrillation 1.
Rationale for the Recommendation
The recommended regimen is based on the latest guidelines and evidence, which suggest that surgical left atrial appendage occlusion can contribute to stroke prevention in patients with atrial fibrillation (AF) undergoing cardiac surgery 1. The LAAOS III trial demonstrated a significant reduction in ischemic stroke or systemic embolism with LAA occlusion compared to no occlusion (HR, 0.67; 95% CI, 0.53–0.85; P = .001) 1.
Anticoagulation and Antiplatelet Regimen
The initial 45-day period with DOAC plus aspirin provides potent antithrombotic protection during the highest risk period, while the subsequent DAPT regimen allows continued protection with a lower bleeding risk. Long-term aspirin use helps prevent device-related thrombus formation and reduces overall cardiovascular risk.
Key Considerations
- Patients should undergo transesophageal echocardiography at 45 days to ensure proper device placement and absence of peri-device leak before transitioning to DAPT.
- Regular follow-ups are essential to monitor for any complications and ensure adherence to the medication regimen.
- The patient's bleeding risk should be assessed, and the regimen adjusted if necessary.
Evidence Summary
The 2024 ESC guidelines for the management of atrial fibrillation provide the most recent and highest-quality evidence for the recommended anticoagulation and antiplatelet regimen after Watchman device placement 1. Observational studies have also supported the use of antiplatelet therapy without associated increases in device-related thrombosis or stroke. However, it is essential to note that the evidence is still evolving, and ongoing trials are expected to provide more insight into the optimal anticoagulation and antiplatelet regimen after LAAO implantation.
From the Research
Recommendations for Direct Oral Anticoagulants (DOAC) and Dual Antiplatelet Therapy (DAPT) after Watchman 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 are more convenient to use than warfarin, and limited evidence suggests that they are not inferior following implantation of the device 2, 3.
- 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.
- DAPT is a safe alternative to OAC for patients undergoing WATCHMAN implantation, with similarly low rates of complications such as stroke and device-associated thrombosis (DAT) in both groups 4.
Dual Antiplatelet Therapy (DAPT) after Watchman Placement
- DAPT poses as a potential alternative to patients who have a contraindication to OAC use 4.
- The DAPT cohort did have a higher number of gastrointestinal (GI) bleeding but this was not significant in the analysis 4.
- 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.
Direct Oral Anticoagulants (DOAC) after Watchman Placement
- DOACs such as dabigatran, apixaban, and rivaroxaban are considered for stroke prevention in patients with atrial fibrillation (AF) 5.
- Limited evidence suggests that DOACs are not inferior following implantation of the device 2, 3.
- 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.