Key result
Late recurrent device-related thrombosis can occur after Watchman FLX despite guideline-directed therapy.
Why the study?
Device-related thrombosis following left atrial appendage closure carries a threefold increase in embolic events and remains a therapeutic challenge, even with the newer Watchman FLX occluder.
Case Report (n=1)
Recurrent device-related thrombosis can occur late after Watchman FLX implantation despite initial resolution, highlighting the need for vigilant surveillance and tailored antithrombotic management.
Answers are grounded in this paper and cite their sources.
May warrant extended surveillance after Watchman FLX; case report leaves open optimal long-term antithrombotic strategies.
Background: Left atrial appendage closure (LAAC) effectively lowers stroke risk in atrial-fibrillation (AF) patients who cannot tolerate long-term anticoagulation. Device-related thrombosis (DRT), although infrequent, carries a threefold increase in subsequent embolic events and remains a therapeutic challenge, even with the newer Watchman FLX occluder. Case summary: -VASc = 5; HAS-BLED = 2) underwent LAAC with a 30 mm Watchman FLX after bleeding-limited warfarin use. She was prescribed dual antiplatelet therapy (DAPT) post-procedure. Eight weeks later, cardiac CT detected a device-surface thrombus; warfarin (INR 2.5-3.0) achieved complete resolution by 7 months. Despite continued anticoagulation, repeat CT at 22 months revealed a larger thrombus. Transesophageal echocardiography confirmed recurrent DRT. Discussion: This case underscores multifactorial DRT pathogenesis: patient-specific hypercoagulability (age, persistent AF, PAI-1 variant), anatomic factors (large LAA, 30 mm device), and premature INR reduction. Current evidence indicates that early hypoattenuation thickening on cardiac CT, peri-device leak, and suboptimal antithrombotic regimens are associated with DRT. Emerging data support CT-based surveillance, individualized anticoagulation-potentially favoring direct oral anticoagulants (DOACs)-and next-generation, endothelialization-oriented device designs. Conclusion: Recurrent, large-burden DRT can occur late after Watchman FLX implantation despite initial thrombus resolution and guideline-directed therapy. Optimal management requires (1) vigilant, multimodality imaging follow-up; (2) stringent, patient-tailored anticoagulation with real-time INR or DOAC level assessment; (3) consideration of genetic or laboratory markers of thrombophilia; and (4) advances in device bioengineering to accelerate endothelial healing. Further studies should refine risk-stratified antithrombotic strategies and validate imaging biomarkers to pre-empt DRT in high-risk LAAC recipients.
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Yu et al. (2025) conducted a case report in Device-related thrombosis after left atrial appendage closure (n=1). Watchman FLX implantation was evaluated on Recurrent device-related thrombosis. Recurrent, large-burden device-related thrombosis can occur late after Watchman FLX implantation despite initial thrombus resolution and guideline-directed therapy.
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