From the Guidelines
For device-related thrombus on a left atrial appendage occluder (LAAO), I strongly recommend continuing both anticoagulation and antiplatelet therapy to minimize the risk of stroke and ensure the best possible outcome in terms of morbidity, mortality, and quality of life. This approach is supported by the most recent and highest quality study available, which emphasizes the importance of anticoagulation and antiplatelet therapy in preventing thromboembolic events after LAAO procedures 1. The recommended regimen typically involves full-dose anticoagulation with a direct oral anticoagulant (DOAC) such as apixaban 5mg twice daily, rivaroxaban 20mg daily, or dabigatran 150mg twice daily, along with aspirin 81-100mg daily. Key considerations for this approach include:
- The high risk of stroke associated with device-related thrombus on LAAO devices, as highlighted in studies such as 1 and 1
- The importance of anticoagulation in dissolving existing thrombi and preventing further thrombus formation on the device surface
- The need for regular follow-up imaging with transesophageal echocardiography to monitor thrombus resolution and guide therapy duration
- The potential benefits of dual antiplatelet therapy (DAPT) with aspirin and clopidogrel for 1-6 months after LAAO, as suggested by some studies 1 Some important points to consider when making decisions about anticoagulation and antiplatelet therapy after LAAO include:
- The individual patient's risk of stroke and bleeding, as well as their overall health status and medical history
- The type of LAAO device used and the specific procedure performed
- The results of follow-up imaging studies, such as transesophageal echocardiography, which can help guide therapy duration and intensity Overall, the goal of continuing both anticoagulation and antiplatelet therapy after LAAO is to minimize the risk of stroke and ensure the best possible outcome for patients with device-related thrombus on LAAO devices.
From the Research
Device-Related Thrombus on LAAO
- The management of device-related thrombus on Left Atrial Appendage Occlusion (LAAO) involves the use of anticoagulant and antiplatelet agents 2, 3, 4, 5.
- A study published in 2019 found that device-related thrombus formation with the second-generation Amulet device was rare, occurring at a rate of 2.6%, and no patient experienced a device-related thromboembolic event during follow-up 2.
- The use of dual antiplatelet therapy (DAPT) is common in patients with LAAO, but the addition of oral anticoagulant therapy may be necessary in cases of device-related thrombus 2, 3.
- A meta-analysis published in 2022 found that device-related thrombus was associated with increased rates of ischemic events, including stroke and systemic embolism 5.
- The choice of oral anticoagulant did not impact bleeding rates in patients on triple antithrombotic therapy, but the use of prasugrel and a low baseline hemoglobin were associated with increased bleed rates 4.
Anticoagulant and Antiplatelet Therapy
- The combination of anticoagulant and antiplatelet therapy is more effective than antiplatelet therapy alone for the initial and long-term management of acute coronary syndromes, but increases the risk of bleeding 3.
- A study published in 2015 reported a case of embolic stroke during apixaban therapy for left atrial appendage thrombus, highlighting the need for monitoring for thromboembolic complications after the initiation of apixaban for the treatment of pre-existing LAA thrombus 6.
- The use of aspirin and clopidogrel is not as effective as oral anticoagulants in patients with atrial fibrillation, whereas the combination of aspirin and clopidogrel is more effective than oral anticoagulants in patients with coronary stents 3.