The ANDES (Antithrombotic Therapy After Left Atrial Appendage Closure: Direct Oral Anticoagulants vs Dual Antiplatelet Therapy) trial results demonstrated that, in patients with nonvalvular atrial fibrillation who underwent left atrial appendage closure (LAAC), short-term direct oral anticoagulant (DOAC) therapy provided similar protection from device-related thrombosis (DRT) as did dual antiplatelet therapy (DAPT), but with fewer bleeding complications and an improved composite safety profile.¹

In this multicenter study, 510 patients (35% women; mean age 77 years) were randomly assigned to receive either DOAC or DAPT (aspirin plus clopidogrel) for 60 days after LAAC. Among 399 patients who underwent transesophageal echocardiogram, DRT occurred in 1.5% of in the DOAC group and in 4.1% in the DAPT group (95% confidence interval, -6% to 0.6%; p = 0.11); the composite safety endpoint (all-cause death, stroke, bleeding, and DRT) significantly favored DOAC (22.5% vs. 34.9%; p = 0.003), driven primarily by fewer bleeding events.

Investigator-selected, standard-dose DOACs were permitted in the study protocol. This approach was in contrast to prior trials such as the ADALA (Low-Dose Direct Oral Anticoagulation vs Dual Antiplatelet Therapy After Left Atrial Appendage Occlusion) trial, which evaluated low-dose apixaban (2.5 mg twice daily) and found a lower rate of DRT and a better composite safety profile despite early termination and limited sample size due to slow patient recruitment during the coronavirus disease 2019 pandemic.² The results from two recent meta-analyses reinforced the safety signal favoring DOAC-based strategies after LAAC, although these findings should be interpreted with caution given limited existing trial numbers.^3,4

The ANDES trial had several limitations, including low statistical power for the primary endpoint, a short follow-up period of 60 days, an open-label design, and no prespecified DOAC agent or dosing regimen. Within these constraints, the findings support DOAC therapy as a safe and effective short-term strategy following LAAC while underscoring the need for long-term, agent-specific studies to further guide postprocedural management.

References

1. Rodés-Cabau J, Nombela-Franco L, Cruz-Gonzalez I, et al. Short-term anticoagulation versus dual antiplatelet therapy for preventing device thrombosis following left atrial appendage closure: the ANDES randomized clinical trial. Circulation. 2025;152(25):1759-1768. doi:10.1161/CIRCULATIONAHA.125.077469
2. Freixa X, Cruz-González I, Cepas-Guillén P, et al. Low-dose direct oral anticoagulation vs dual antiplatelet therapy after left atrial appendage occlusion: the ADALA randomized clinical trial. JAMA Cardiol. 2024;9(10):922-926. doi:10.1001/jamacardio.2024.2335
3. Ibrahim A, Shalabi L, Zreigh S, et al. Comparative efficacy and safety of low-dose direct oral anticoagulants versus dual antiplatelet therapy following left atrial appendage occlusion in patients with nonvalvular atrial fibrillation: a systematic review and meta-analysis. Catheter Cardiovasc Interv. 2025;105(6):1311-1319. doi:10.1002/ccd.31461
4. Lima NA, Filho FWPA, Mendes BX, Neto VLM, d'Avila ALB. Reduced direct oral anticoagulant dose vs dual antiplatelet therapy after left atrial appendage closure in patients with nonvalvular atrial fibrillation: a systematic review and meta-analysis. Heart Rhythm. 2025;22(4):979-986. doi:10.1016/j.hrthm.2024.11.035