When can Eliquis (apixaban) be discontinued after a left atrial appendage clip procedure in a patient with a history of atrial fibrillation?

Discontinuing Eliquis After Left Atrial Appendage Clip

Eliquis (apixaban) should generally be continued indefinitely after left atrial appendage clip placement, with the decision based on the patient's CHA₂DS₂-VASc score rather than the presence of the device, as there is insufficient evidence to support routine discontinuation of anticoagulation following left atrial appendage occlusion in patients with atrial fibrillation. 1

Initial Post-Procedure Anticoagulation Period

• At minimum, continue anticoagulation for at least 3 months after left atrial appendage ligation/excision, regardless of the patient's CHA₂DS₂-VASc risk score 1
• This 3-month period allows for endocardial healing and reduces the risk of thrombus formation on the thrombogenic surface created by the device and atrial manipulation 1
• The periprocedural period carries heightened stroke risk due to atrial stunning, stasis, and the thrombogenic milieu created by device implantation 1

Long-Term Anticoagulation Decision Algorithm

Step 1: Calculate CHA₂DS₂-VASc Score

• Congestive heart failure (1 point)
• Hypertension (1 point)
• Age ≥75 years (2 points)
• Diabetes (1 point)
• Prior stroke/TIA (2 points)
• Vascular disease (1 point)
• Age 65-74 years (1 point)
• Female sex (1 point) 2, 3

Step 2: Apply Evidence-Based Anticoagulation Criteria

• Males with CHA₂DS₂-VASc ≥2 or females with CHA₂DS₂-VASc ≥3: Continue anticoagulation indefinitely 2, 3
• Males with CHA₂DS₂-VASc = 1 or females with CHA₂DS₂-VASc = 2: Strongly consider continuing anticoagulation 3
• The presence of the left atrial appendage clip does NOT eliminate the need for anticoagulation based on stroke risk 1

Critical Evidence Against Routine Discontinuation

The ACC/AHA guidelines explicitly state: "There are insufficient data to support routine discontinuation of anticoagulation in patients with AF who are undergoing LA ligation/excision." 1

Key Supporting Evidence:

• Discontinuation of oral anticoagulation has been associated with late stroke, highlighting that the left atrial appendage is not the exclusive source of all thrombi in AF patients 1
• Surgical left atrial appendage occlusion can be incomplete, leaving residual thrombogenic potential 1
• The reduction in thromboembolism from left atrial appendage ligation/excision is less evident in patients who maintain anticoagulation, suggesting the device benefit is modest when anticoagulation continues 1
• In the GARFIELD-AF registry, discontinuation of oral anticoagulation for ≥7 consecutive days was associated with significantly higher risks of all-cause death (HR 1.62), stroke/systemic embolism (HR 2.21), and myocardial infarction (HR 1.85) 4

Alternative Approach: Device-Specific Considerations

If considering anticoagulation discontinuation after the initial 3-month period, the following must be verified:

• Confirm complete left atrial appendage occlusion via transesophageal echocardiography at 45 days and 6 months post-procedure 1
• Assess for device-related thrombus (DRT), which occurs more frequently when anticoagulation is discontinued prematurely 1
• Evaluate for residual peridevice leak that could serve as a nidus for thrombus formation 1

Post-Procedure Antiplatelet Regimen (If Anticoagulation Discontinued)

The consensus recommendation for patients who cannot continue anticoagulation:

• Dual antiplatelet therapy (DAPT) for 6 months after left atrial appendage closure 1
• Some studies suggest single antiplatelet therapy (SAPT) may be acceptable in high bleeding-risk patients, though evidence is limited 1

Common Pitfalls to Avoid

• Never discontinue anticoagulation solely because a left atrial appendage clip was placed – the decision must be based on stroke risk assessment 1, 2
• Do not assume the device eliminates stroke risk – strokes can originate from other cardiac sources beyond the left atrial appendage 1
• Avoid early discontinuation before 3 months – this period is critical for device endothelialization and healing 1
• Do not use bleeding risk scores to withhold anticoagulation in patients with high CHA₂DS₂-VASc scores 5
• Recognize that successful rhythm control (including ablation) does not eliminate stroke risk and is not a reason to discontinue anticoagulation 3

Special Consideration: Recent Trial Data

The 2024 OPTION trial demonstrated that left atrial appendage closure after AF ablation was associated with lower bleeding risk compared to continued anticoagulation, while maintaining noninferiority for stroke prevention 6. However, this trial specifically studied left atrial appendage closure as an alternative to anticoagulation, not as justification for discontinuing anticoagulation in patients who already have devices implanted and established stroke risk factors 6.