Do you give aspirin (acetylsalicylic acid) after a Watchman procedure?

Antiplatelet Therapy After Watchman Device Implantation

After Watchman device implantation, patients should receive aspirin (81-100mg daily) indefinitely as part of the standard post-procedural antithrombotic regimen. 1

Standard Post-Watchman Antithrombotic Protocol

The evidence-based protocol for antithrombotic therapy following Watchman implantation follows this sequence:

1. Initial 45 days post-implantation:

   • Warfarin (target INR 2.0-3.0) plus aspirin (81-100mg daily) 1
   • Alternative: DOACs may be used instead of warfarin based on emerging evidence 2

2. Day 45 to 6 months (after TEE confirmation of device sealing):

   • Discontinue warfarin if TEE shows:
     • Adequate LAA closure
     • Minimal residual peri-device flow (≤5mm)
     • No device-related thrombus
   • Continue with dual antiplatelet therapy:
     • Aspirin (81-100mg daily)
     • Clopidogrel (75mg daily) 1, 2

3. After 6 months:

   • Discontinue clopidogrel
   • Continue aspirin (81-100mg daily) indefinitely 1, 2

Special Considerations

Patients with High Bleeding Risk

• For patients with absolute contraindications to oral anticoagulation:
  • Consider dual antiplatelet therapy (aspirin plus clopidogrel) for the first 6 months, followed by aspirin alone indefinitely 2, 3
  • This approach has been shown to be safe even in patients with prior intracranial hemorrhage 3

Device-Related Thrombus Management

• If device-related thrombus is detected:
  • Consider short-term anticoagulation with a DOAC (e.g., apixaban)
  • Evidence shows successful resolution of thrombus with this approach 4
  • After thrombus resolution, resume standard antiplatelet therapy 4

Long-Term Outcomes

Recent evidence suggests that the Watchman device may provide comparable or better outcomes than DOACs for stroke prevention in high-risk patients:

• A 5-year retrospective cohort study showed that Watchman was associated with:
  • Lower rates of major bleeding events
  • Lower rates of ischemic strokes
  • Lower rates of TIAs
  • No significant difference in hemorrhagic strokes 5

Important Caveats

• The antithrombotic regimen may need adjustment based on individual patient factors, but aspirin remains a cornerstone of therapy
• Regular follow-up with TEE is essential to monitor for device-related complications
• Patients with mechanical heart valves require different management approaches
• The procedural risk of device implantation should be weighed against the benefits of reducing long-term anticoagulation 6

Conclusion

Aspirin therapy is a critical component of post-Watchman management, initially combined with warfarin or a DOAC for 45 days, then with clopidogrel for an additional 4.5 months, and then continued indefinitely as monotherapy to prevent device-related thrombosis while minimizing bleeding risk.