Antithrombotic Therapy Management After Left Atrial Appendage Closure

Percutaneous left atrial appendage closure is increasingly used for stroke prevention in patients with atrial fibrillation, particularly when long-term oral anticoagulation (OAC) is unsuitable. Although postprocedural antithrombotic therapy is necessary to prevent device-related thrombosis (DRT), it may increase bleeding and attenuate the benefit of avoiding long-term OAC. Uncertainty over the optimal antithrombotic strategy persists, with available randomized trials being small and heterogeneous. Direct oral anticoagulant (DOAC) monotherapy and dual antiplatelet therapy (DAPT) are 2 common early strategies. In ANDES, DRT was numerically less frequent with DOAC than with DAPT (1.5% vs 4.1%). In ADALA, low-dose apixaban was associated with greater net benefit than DAPT (HR: 0.19; P = 0.02), although enrollment was prematurely stopped. A meta-analysis of randomized trials found significantly lower DRT with DOAC than with DAPT (risk ratio: 0.17). Current guidelines endorse regimens largely based on device-specific trial protocols or low-certainty evidence. During the initial postimplantation period, antithrombotic therapy should primarily aim to support device healing and prevent DRT, with treatment intensity tailored according to risk profile, concomitant indications, patient preferences, and the feasibility of imaging follow-up. Reassessment at 45 to 90 days should guide de-escalation once adequate device healing has been confirmed, with no fixed treatment stop date. In the absence of device-related complications, long-term OAC or DAPT should be continued only for concomitant indications, whereas continuation of single antiplatelet therapy or complete withdrawal of antithrombotic therapy should be individualized according to thrombotic and bleeding risk. Finally, definite or probable DRT generally warrants OAC, when feasible; in contrast, treatment decisions should not be based solely on the presence or size of a peridevice leak. This review critically appraises the available evidence and guideline recommendations and discusses how treatment intensity and duration may be tailored over time according to evolving thrombotic and bleeding risks.