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. 2021 Nov 8;14(21):2353-2364.
doi: 10.1016/j.jcin.2021.07.031. Epub 2021 Oct 13.

Half-Dose Direct Oral Anticoagulation Versus Standard Antithrombotic Therapy After Left Atrial Appendage Occlusion

Domenico G Della Rocca  1 , Michele Magnocavallo  2 , Luigi Di Biase  3 , Sanghamitra Mohanty  4 , Chintan Trivedi  4 , Nicola Tarantino  5 , Carola Gianni  4 , Carlo Lavalle  6 , Christoffel Johannes Van Niekerk  7 , Jorge Romero  5 , David F Briceño  5 , Mohamed Bassiouny  4 , Amin Al-Ahmad  4 , J David Burkhardt  4 , Veronica N Natale  8 , G Joseph Gallinghouse  4 , Armando Del Prete  9 , Giovanni B Forleo  10 , Javier Sanchez  4 , Dhanunjaya Lakkireddy  11 , Rodney P Horton  4 , Douglas N Gibson  7 , Andrea Natale  12
Affiliations
Free article

Half-Dose Direct Oral Anticoagulation Versus Standard Antithrombotic Therapy After Left Atrial Appendage Occlusion

Domenico G Della Rocca et al. JACC Cardiovasc Interv. .
Free article

Abstract

Objectives: This study evaluated the long-term efficacy of a standard antithrombotic strategy versus half-dose direct oral anticoagulation (DOAC) after Watchman implantation.

Background: No consensus currently exists on the selection of the most effective antithrombotic strategy to prevent device-related thrombosis (DRT) in patients undergoing endocardial left atrial appendage closure.

Methods: After successful left atrial appendage closure, consecutive patients were prescribed a standard antithrombotic strategy (SAT) or long-term half-dose DOAC (hdDOAC). The primary composite endpoint was DRT and thromboembolic (TE) and bleeding events.

Results: Overall, 555 patients (mean age 75 ± 8 years, 63% male; median CHA2DS2-VASc [congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, prior stroke or transient ischemic attack or thromboembolism, vascular disease, age 65-74 years, sex category] score 4 [interquartile range (IQR): 3-6]; median HAS-BLED [hypertension, abnormal renal or liver function, stroke, bleeding, labile international normalized ratio, elderly, drugs or alcohol] score 3 [IQR: 2-4]) were included. Patients were categorized into 2 groups (SAT: n = 357 vs hdDOAC: n = 198). Baseline clinical characteristics were similar between groups. The median follow-up duration was 13 months (IQR: 12-15 months). DRT occurred in 12 (2.1%) patients, all in the SAT group (3.4% vs 0.0%; log-rank P = 0.009). The risk of nonprocedural major bleeding was significantly more favorable in the hdDOAC group (0.5% vs. 3.9%; log-rank P = 0.018). The rate of the primary composite endpoint of DRT and TE and major bleeding events was 9.5% in SAT patients and 1.0% in hdDOAC patients (HR: 9.8; 95% CI: 2.3-40.7; P = 0.002).

Conclusions: After successful Watchman implantation, long-term half-dose DOAC significantly reduced the risk of the composite endpoint of DRT and TE and major bleeding events compared with a standard, antiplatelet-based, antithrombotic therapy.

Keywords: Watchman; antiplatelet therapy; aspirin; left atrial appendage; oral anticoagulation; stroke; thromboembolism.

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Conflict of interest statement

Funding Support and Author Disclosures Dr Di Biase has served as a consultant for Biosense Webster, Boston Scientific, Stereotaxis, and St. Jude Medical; and has received speaker honoraria from Medtronic, Atricure, EPiEP, and Biotronik. Dr Burkhardt has served as a consultant for Biosense Webster and Stereotaxis. Dr Gibson has served as a consultant for Biosense Webster, Boston Scientific and Abbott. Dr Natale has received speaker honoraria from Boston Scientific, Biosense Webster, St. Jude Medical, Biotronik, and Medtronic; and has served as a consultant for Biosense Webster, St. Jude Medical, and Janssen. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.

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