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Post-LAAO Antithrombotic Protocol — EECC MCQ

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ModerateArrhythmia & ElectrophysiologyPost-LAAO Antithrombotic ProtocolEECC

A 72-year-old man with persistent AF is being considered for left atrial appendage occlusion (LAAO) as he has had 3 episodes of major GI bleeding on OAC. His CHA₂DS₂-VA score is 5. After LAAO device implantation, what antithrombotic regimen is needed post-procedure?

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Correct answer: B — Short-term dual antiplatelet therapy (DAPT: aspirin + clopidogrel) for 3-6 months to allow device endothelialisation, then aspirin monotherapy for a further 6 months, then potentially no antithrombotic therapy — protocols vary by device type and centre

After percutaneous LAAO (Watchman, Amulet devices), a period of antithrombotic therapy is needed to prevent device-related thrombus (DRT) during endothelialisation. Common protocols: (1) Watchman: DAPT (aspirin + clopidogrel) for 3-6 months → aspirin alone for 6-12 months → potentially no antithrombotic; OR OAC + aspirin for 45 days → OAC alone for 6 months → aspirin or nothing (varies by trial protocol); (2) Amulet: similar DAPT duration. The 2024 ESC AF Guidelines recommend: (1) TOE/CT at 3-6 months to confirm complete LAA closure and absence of DRT before stepping down therapy; (2) DRT occurs in ~3-5% of cases and requires anticoagulation; (3) the ultimate goal: no long-term antithrombotic therapy (the reason LAAO was chosen — bleeding intolerance). This patient's recurrent GI bleeding makes even short-term DAPT challenging — careful gastroenterology liaison is essential.

Reference: ESC (2024): AF Guidelines