Use of Direct Oral Anticoagulation Therapy Following Implantation of the Watchman Left Atrial Appendage Occlusion Device

Abstract

ABSTRACT Background: Previously, the standard of care following left atrial appendage occlusion (LAAO) with the Watchman device (Boston Scientific) was 45 days of warfarin and aspirin followed by dual antiplatelet therapy (DAPT) for a total of 6 months and lifelong aspirin thereafter. The recommendation has recently been updated to include post-implantation oral anticoagulation, but there remains a lack of data supporting the use of direct oral anticoagulation (DOAC) therapy. Methods: This was a single-center retrospective analysis of patients undergoing LAAO between 2016 to 2019. Transesophageal echocardiogram (TEE) was conducted at 45 days post implantation. We reported outcomes for patients receiving warfarin with aspirin, DOAC with aspirin, and DOAC alone. Device thrombosis, device leak, transient ischemic attack (TIA)/stroke, major bleeding, and death were evaluated at 45 days and 1 year follow-up. Results: In total, 213 patients were evaluated, where 61 received warfarin/ASA, 81 received DOAC/ASA, and 71 received DOAC alone. At 45 days follow-up TEE, device thrombus was visualized in 2 (3.3%) patients on warfarin/ASA, one (1.2%) patient on DOAC/ASA, and 4 (5.6%) patients on DOAC (P = 0.34). Rates of device leak at 45 days were similar between the groups, from 7.0% to 8.3% (P > 0.99). Major bleeding event rates were similar at 45 days (P = 0.86) and 1 year (P = 0.50). There were no TIA/strokes at both 45 days and 1 year follow-up. At 45 days, one patient on warfarin/ASA died. Conclusion: The use of DOAC with and without aspirin has safety and efficacy outcomes post Watchman implantation similar to outcomes of warfarin and aspirin. Abbreviations: LAAO: left atrial appendage occlusion; DRT: device-related thrombosis; DAPT: dual antiplatelet therapy; DOAC: direct oral anticoagulant; CVA: cerebrovascular accident (i.e., transient ischemic attack [TIA] and stroke); CAD: coronary artery disease; ASA: aspirin; TEE: transesophageal echocardiogram; GI: gastrointestinal