Few patients undergoing implantation of the WATCHMAN left atrial appendage occlusion (LAAO) device receive post-discharge treatment consistent with the protocols studied in clinical trials, according to a study presented Nov. 13 during AHA 2020. The study, which used data from ACC’s LAAO Registry, looked at real-word patterns of post-procedural anticoagulation and antiplatelet therapy, as well as associated outcomes.

According to James V. Freeman, MD, FACC, et al., WATCHMAN clinical trials have used a post-procedure treatment and monitoring protocol that includes discharge on warfarin and aspirin for six weeks and then transesophageal echocardiogram-guided medication transitions. However, real-world applications are not well known.

Using LAAO Registry data from 34,592 patients undergoing WATCHMAN LAAO between 2016-2018, Freeman and colleagues calculated the proportion of those who were treated with the clinical trial protocol, while also evaluating the five most common medication strategies at discharge and rates of adverse events and 45 days and six months. 

Overall results found that the full post-procedure protocol studied in clinical trials was followed in only 10% of patients. The most common discharge treatment strategies were warfarin and aspirin (37.8%), warfarin only (19.4%), direct oral anticoagulant (DOAC) and aspirin (21.3%), DOAC only (16.6%), and dual antiplatelet therapy (DAPT) (7.9%). In most cases, baseline patient characteristics were generally similar across all five treatment groups, except for DAPT patients, who Freeman, et al., noted were older and had higher rates of prior bleeding.

In terms of adverse events and readmission, patients in the warfarin only and DOAC only groups had lower unadjusted rates of any adverse event and major adverse event compared with patients in the other groups during follow-up, largely due to lower rates of bleeding.

Based on the study findings, Freeman notes that discharge DOAC or DAPT may be reasonable alternatives to warfarin but cautioned that discharge aspirin when added to oral anticoagulants may increase the risk of adverse events. “These findings should inform future LAAO trials,” he said.

Clinical Topics: Anticoagulation Management, Arrhythmias and Clinical EP, Anticoagulation Management and Atrial Fibrillation, Atrial Fibrillation/Supraventricular Arrhythmias

Keywords: AHA Annual Scientific Sessions, AHA20, Atrial Appendage, Blood Coagulation, Blood Platelets, Anticoagulants, Atrial Fibrillation

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