Perspective:

LAAO is an increasingly common procedure to reduce stroke and systemic embolism risk for patients with nonvalvular atrial fibrillation, particularly those at high risk for anticoagulant-related bleeding. While the initial studies required warfarin therapy for 45 days after LAAO, the Food and Drug Administration has since approved the use of either warfarin plus aspirin or DAPT therapy for 45 days post-implantation in the WATCHMAN FLX device. While limited by a retrospective design, this large and well-conducted study provides reassurance to clinicians that both an OAC plus aspirin and DAPT approach post WATCHMAN FLX LAAO provide similar clinical outcomes across a composite of thrombotic and hemorrhagic complications.

Perhaps even more helpful is that the DAPT strategy was associated with fewer bleeding events than the DOAC plus aspirin strategy, suggesting that this may be particularly useful for patients with a history of OAC-related bleeding. Of note, this analysis did not look at the use of DOAC monotherapy (either full-dose or half-dose), which has been shown to have low rates of both bleeding and device-related thrombosis in the prior version of the WATCHMAN device. Nonetheless, clinicians can feel comfortable using a variety of different antithrombotic strategies for patients undergoing WATCHMAN FLX LAAO and to tailor these strategies to individual patient risks.