Can Eliquis (apixaban) be stopped after an atrial appendage clip procedure?

Management of Anticoagulation After Left Atrial Appendage Occlusion

The safety of discontinuing oral anticoagulation after left atrial appendage occlusion remains uncertain, and current guidelines do not support routine discontinuation of anticoagulation therapy like apixaban (Eliquis) after atrial appendage clip procedures. 1

Current Evidence on Anticoagulation After LAA Occlusion

Guideline Recommendations

• The 2021 American Heart Association/American Stroke Association guidelines specifically identify the safety of discontinuing oral anticoagulation after surgical appendage closure as a knowledge gap 1
• The 2024 European Society of Cardiology guidelines state that percutaneous LAA occlusion may be considered in patients with AF and contraindications for long-term anticoagulant treatment (Class IIb recommendation) 1
• There is no high-quality evidence supporting routine discontinuation of anticoagulation after LAA occlusion

Post-Procedure Anticoagulation Protocol

Current regulatory approvals based on randomized controlled trials suggest:

• 45 days of vitamin K antagonist plus aspirin after implantation
• Followed by 6 months of dual antiplatelet therapy
• Then ongoing aspirin therapy 1

Risk Assessment for Anticoagulation Decisions

Factors That Influence Anticoagulation Management

1. Device Endothelialization

   • Complete endothelialization is expected to occur within 45 days but may be incomplete even after 1.5-2 years 2
   • Incomplete endothelialization can create a prothrombotic environment

2. Device-Related Thrombosis (DRT)

   • Risk of DRT varies with anticoagulation regimen
   • Higher rates of DRT have been observed with some DOACs compared to warfarin 3
   • DRT can lead to thromboembolic events

3. Peri-device Leaks

   • Presence of leaks may necessitate continued anticoagulation 4

Anticoagulation Options After LAA Occlusion

Standard Protocol (Based on Clinical Trials)

• 45 days of anticoagulation (traditionally warfarin)
• Followed by dual antiplatelet therapy for 6 months
• Then lifelong aspirin

Alternative Approaches (Limited Evidence)

• DOACs like rivaroxaban have been used in small studies with promising results 5
• Apixaban has been successfully used to treat device-related thrombus 6
• Low-dose dabigatran (110mg twice daily) showed higher DRT rates compared to warfarin (15.8% vs 2.2%) but lower bleeding rates 3

Monitoring After LAA Occlusion

Follow-up Schedule

• Transesophageal echocardiography (TEE) at:
  • 6 weeks post-procedure
  • 6 months post-procedure
  • 12 months post-procedure

What to Monitor

• Device position and stability
• Presence of device-related thrombus
• Peri-device leaks
• Signs of endothelialization

Clinical Decision Algorithm

1. Initial Post-Procedure Period (0-45 days)

   • Continue full anticoagulation with apixaban or warfarin

2. At 45-Day TEE Assessment

   • If complete seal and no DRT: Consider switching to dual antiplatelet therapy
   • If incomplete seal or DRT present: Continue anticoagulation

3. At 6-Month TEE Assessment

   • If complete seal and no DRT: Consider switching to single antiplatelet therapy
   • If incomplete seal or DRT present: Continue anticoagulation or dual antiplatelet therapy

4. Long-term Management

   • Annual reassessment of stroke and bleeding risk
   • Consider indefinite anticoagulation in high-risk patients

Important Caveats

• The efficacy of left atrial appendage closure compared with DOACs remains unknown 1
• Patients with contraindications to all oral anticoagulants have the most appropriate rationale for LAA occlusion 1
• The paradox is that post-procedure antithrombotic treatment may expose patients to bleeding risks similar to DOACs 1
• Incomplete device endothelialization can occur even years after implantation 2

In conclusion, while LAA occlusion devices aim to reduce the need for long-term anticoagulation, current evidence does not support routine discontinuation of apixaban after LAA occlusion procedures. The decision should be based on follow-up imaging confirming device position, absence of thrombus, and complete endothelialization, with careful consideration of the patient's individual stroke and bleeding risks.