What question did this study set out to answer?

To review clinical trial evidence and real-world antithrombotic management strategies following interventional left atrial appendage occlusion in patients with non-valvular atrial fibrillation.

August 10, 2018Expert Review of Cardiovascular Therapy

Antithrombotic strategies after interventional left atrial appendage closure: an update

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Why the study?

What are the optimal antithrombotic strategies following interventional left atrial appendage occlusion in patients with non-valvular atrial fibrillation?

Key Points

To review clinical trial evidence and real-world antithrombotic management strategies following interventional left atrial appendage occlusion in patients with non-valvular atrial fibrillation.
Synthesized clinical trial protocols and real-world registry data evaluating antithrombotic regimens after left atrial appendage closure.
Assessed post-procedural regimens balancing thromboembolic risk and major bleeding during device endothelialization across different occluder devices.
Standard trial protocol for the Watchman device uses warfarin plus aspirin for 45 days, followed by dual antiplatelet therapy (DAPT) for 6 months and lifelong aspirin, with 3 months of novel oral anticoagulation plus aspirin approved as an alternative.
Real-world clinical practice predominantly employs DAPT for 1 to 6 months across most occlusion devices.
Evidence indicates that shorter-term DAPT (6 weeks) or single antiplatelet therapy with aspirin serves as a viable option to lower major bleeding complications.

Structured PICO

What are the optimal antithrombotic strategies following interventional left atrial appendage occlusion in patients with non-valvular atrial fibrillation?

Population

Patients with non-valvular atrial fibrillation undergoing interventional left atrial appendage occlusion (LAAO)

Intervention

Antithrombotic strategies following LAAO (including warfarin plus aspirin, dual antiplatelet therapy [DAPT], NOAC plus aspirin, or single antiplatelet therapy)

This review highlights that while standard post-LAAO antithrombotic regimens involve short-term anticoagulation or DAPT, real-world practice is shifting towards shorter DAPT or single antiplatelet therapy to minimize major bleeding risks.

Implication

Shorter DAPT or single antiplatelet therapy post-LAAO may reduce bleeding; leaves optimal regimen open for randomized trials.

Abstract

INTRODUCTION: Interventional left atrial appendage occlusion (LAAO) has emerged as a valid alternative to oral anticoagulation (OAC) therapy for the prevention of ischemic stroke and systemic embolism in patients with non-valvular atrial fibrillation (AF). Areas covered: Antithrombotic therapy following interventional LAAO is critical in balancing the risk of thromboembolism and bleeding during the endothelialization of the implanted devices. In this article, the most recent clinical trials are reviewed and the current real-world antithrombotic strategies following LAAO device implantation are discussed. Expert commentary: For patients eligible for OAC and receiving a Watchman device, the most solid scientific evidence exists for warfarin plus aspirin for 45 days followed by dual antiplatelet therapy (DAPT) for 6 months and a lifelong aspirin therapy. In real-world most patients are being treated with DAPT for 3-6 months. Alternatively, the Watchman was approved for 3 months of novel OAC (NOAC) therapy in conjunction with aspirin. For all other devices, DAPT for 1-6 months has been used in the vast majority of cases. Considering major bleeding as the predominant complication following LAAO, evidence suggests that short-term DAPT (6 weeks) or single antiplatelet therapy using aspirin may be a viable option.