From the Guidelines
Anticoagulation can be discontinued after a Watchman procedure, but this occurs in a specific, staged process rather than immediately after implantation, with the most recent guidelines suggesting a transition to aspirin alone indefinitely after 6 months, as supported by the 2024 ESC guidelines for the management of atrial fibrillation 1.
Overview of the Process
The process typically involves a structured medication regimen, starting with warfarin (Coumadin) plus aspirin 81mg daily for 45 days post-procedure.
- This is followed by dual antiplatelet therapy (clopidogrel 75mg daily plus aspirin 81-325mg daily) for another 4.5 months if a transesophageal echocardiogram (TEE) confirms proper device placement and adequate left atrial appendage (LAA) closure with minimal leakage (<5mm).
- After 6 months total, patients usually transition to aspirin alone indefinitely.
Rationale and Evidence
This gradual transition allows time for the device to endothelialize (become covered with tissue), which prevents blood clots from forming in the LAA, as noted in the 2021 guideline for the prevention of stroke in patients with stroke and transient ischemic attack 1.
- Some patients with higher bleeding risks may follow alternative protocols, starting with dual antiplatelet therapy instead of warfarin.
- The decision to discontinue anticoagulation should always be made by the cardiologist managing the Watchman device, as individual patient factors may require protocol adjustments, with consideration of the latest evidence from the 2024 ESC guidelines 1.
Considerations and Recommendations
It is essential to consider the procedural risk associated with the Watchman procedure, including stroke, major bleeding, device-related thrombus, pericardial effusion, vascular complications, and death, as highlighted in the 2024 ESC guidelines 1.
- Voluntary registries and national registries report varying peri-procedural risk rates, emphasizing the need for careful patient selection and management.
- Device-related thrombi and peri-device leaks are potential complications that require follow-up screening, as noted in the 2024 ESC guidelines 1.
From the Research
Anticoagulation Discontinuation after Watchman Procedure
- The decision to discontinue anticoagulation after a Watchman procedure is complex and depends on various factors, including the patient's bleeding risk and the presence of device-related thrombosis 2.
- According to a study published in the American Journal of Cardiovascular Disease, anticoagulation can be discontinued after 45 days if transesophageal echocardiography (TEE) shows minimal residual peri-device flow (≤ 5mm) and no device-related thrombus 2.
- In patients with an absolute contraindication to oral anticoagulation, antithrombotic therapy with aspirin and clopidogrel for six months followed by daily aspirin indefinitely may be feasible 2.
- A case report published in Medicine demonstrated the successful treatment of device-related thrombus with a short course of apixaban, followed by dual antiplatelet therapy and eventually lifelong aspirin 3.
- The choice of oral anticoagulant does not appear to impact bleeding rates in patients on triple antithrombotic therapy, but the use of prasugrel and a low baseline hemoglobin are associated with increased bleed rates 4.
Cost-Effectiveness and Comparison with Other Treatments
- A cost-effectiveness analysis published in Europace found that left atrial appendage closure with the Watchman device is a cost-effective and cost-saving solution for stroke risk reduction in patients with non-valvular atrial fibrillation who are at risk for stroke but have contraindications to warfarin 5.
- A network meta-analysis published in the International Journal of Cardiology compared the Watchman device with new oral anticoagulants in patients with atrial fibrillation and found no significant differences in outcomes between the two treatments, although there was a trend toward higher rates of ischemic stroke with the Watchman device 6.