From the Guidelines
Patients who have undergone a Watchman procedure should take a Direct Oral Anticoagulant (DOAC) for 45 days, followed by dual antiplatelet therapy with aspirin and a P2Y12 receptor inhibitor, such as clopidogrel, for 6 months, and then aspirin indefinitely. The recommended anticoagulation regimen post-Watchman procedure is designed to balance the risk of thrombus formation with the risk of bleeding complications.
- The initial 45-day course of DOAC, such as apixaban, rivaroxaban, or dabigatran, at standard dosing, provides robust anticoagulation during the highest risk period for thrombus formation 1.
- After 45 days, dual antiplatelet therapy with clopidogrel 75 mg daily plus aspirin 81-100 mg daily is typically initiated until 6 months post-procedure, as this regimen has been shown to prevent device-related thrombus formation while minimizing bleeding risk 1.
- The choice of antiplatelet therapy may be modified based on individual patient factors, such as bleeding risk, prior anticoagulation tolerance, and specific institutional protocols.
- A follow-up transesophageal echocardiogram is typically performed at 45 days to confirm proper device placement and absence of peridevice leaks before transitioning from DOAC to dual antiplatelet therapy.
- The use of aspirin 81-100 mg daily indefinitely after 6 months is recommended to maintain long-term protection against thrombotic events, as the risk of bleeding complications is lower with aspirin monotherapy compared to dual antiplatelet therapy 1.
From the Research
Post-Watchman Procedure Anticoagulation Therapy
The recommended duration of Direct Oral Anticoagulant (DOAC) and Aspirin (Acetylsalicylic Acid (ASA)) therapy post-Watchman procedure is as follows:
- Initially, warfarin and aspirin are given for 45 days after implantation 2
- If transesophageal echocardiography (TEE) at 45 days shows minimal residual peri-device flow (≤ 5mm) and no device-related thrombus, warfarin is stopped 2
- This is followed by aspirin and clopidogrel for six months, then aspirin indefinitely 2
- For patients with high bleeding risks, antithrombotic therapy with aspirin and clopidogrel for six months followed by daily aspirin indefinitely may be feasible 2
- The use of DOACs is more convenient than warfarin, and limited evidence suggests that they are not inferior following implantation of the device 2, 3, 4
- Half-dose DOAC has been shown to reduce the risk of device-related thrombosis and major bleeding events compared to standard antithrombotic therapy 3
Duration of DOAC and ASA Therapy
- The exact duration of DOAC and ASA therapy post-Watchman procedure is not well established, but studies suggest that DOAC can be used for a shorter duration than warfarin 3, 4
- One study found that half-dose DOAC for a median follow-up duration of 13 months was effective in reducing the risk of device-related thrombosis and major bleeding events 3
- Another study found that DOAC was associated with reductions in major bleeding and all bleeding compared to warfarin at mid-term follow-up (mean follow-up of 1.5-12 months) 4