From the Guidelines
Anticoagulation is typically still needed after atrial appendage ligation or clipping procedures for permanent atrial fibrillation. Even after successful left atrial appendage (LAA) closure with devices like the AtriClip, most patients should continue anticoagulation therapy with either a direct oral anticoagulant (DOAC) such as apixaban (5mg twice daily), rivaroxaban (20mg daily), or dabigatran (150mg twice daily), or warfarin (dose adjusted to maintain INR 2-3) 1. This recommendation stems from the fact that while LAA closure addresses one major source of thrombus formation, patients with permanent atrial fibrillation still have ongoing risk factors for stroke, including blood stasis in other parts of the atria and systemic hypercoagulability.
The decision to continue anticoagulation should be individualized based on the patient's CHA₂DS₂-VASc score, bleeding risk, and other comorbidities. Key considerations include:
- The patient's overall stroke risk
- The presence of other comorbid conditions that may influence the risk-benefit ratio of anticoagulation
- The specific details of the LAA closure procedure, including the device used and the confirmation of complete closure
In some specific cases where bleeding risk is exceptionally high, physicians might consider discontinuing anticoagulation after confirming complete LAA closure through imaging studies like transesophageal echocardiography, but this remains controversial and is not the standard approach for most patients with permanent atrial fibrillation 1. The most recent guidelines suggest that anticoagulation should be continued for at least 4 weeks after successful cardioversion to sinus rhythm, regardless of the baseline risk of stroke 1.
Ultimately, the management of anticoagulation in patients with permanent atrial fibrillation after LAA closure requires a nuanced approach, taking into account the latest evidence and individual patient factors 1.
From the Research
Anticoagulation after Atrial Ligation Clip for Permanent AFib
- The need for anticoagulation after atrial ligation clip for permanent atrial fibrillation (AFib) is a topic of ongoing research, with studies investigating the efficacy and safety of left atrial appendage (LAA) occlusion devices 2, 3, 4, 5, 6.
- A study published in 2020 found that epicardial standalone LAA clipping was a safe and efficient treatment for stroke prevention in patients with non-valvular AFib contraindicated for oral anticoagulation, with no ischemic stroke or hemorrhagic complications occurring during a mean follow-up of 16.4 months 4.
- Another study published in 2015 reported that LAA ligation with the Lariat device effectively closed the LAA and may be a beneficial approach to reduce the risk of embolic events in AF patients ineligible for oral anticoagulation therapy, with a composite endpoint event rate of 2.8% per year 3.
- A 2021 study observed the efficacy and safety of direct current cardioversion (DCCV) post-LAA occlusion in patients requiring DCCV, finding that DCCV was highly effective and no thrombo-embolic events were observed, regardless of the periprocedural anticoagulation or imaging strategy 5.
- A single-center study published in 2022 examined the safety and effectiveness of LAA occlusion with the AtriClip epicardial occlusion device, finding a successful closure rate of 96% and no postoperative thromboembolic events at the time of the study transesophageal echocardiography (TEE) 6.
Key Findings
- LAA occlusion devices, such as the AtriClip, can provide an excellent rate of successful closure of the LAA during surgical ablation procedures without device-related thrombus (DRT) 6.
- Epicardial standalone LAA clipping may be a safe and efficient treatment for stroke prevention in patients with non-valvular AFib contraindicated for oral anticoagulation 4.
- DCCV post-LAA occlusion is highly effective, with no thrombo-embolic events observed, regardless of the periprocedural anticoagulation or imaging strategy 5.