Timing is Everything: Antithrombotic Strategies and Imaging Surveillance in the LAAO Journey - 2025 Quality Summit Presentation (Non-CE)-Timing is Everything: Antithrombotic Strategies and Imaging Surveillance in the LAAO Journey

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Video Summary

Dr. Vic Jagadeesan from West Virginia University discussed left atrial appendage occlusion (LAO) focused on antithrombotic strategies, imaging, and surveillance. LAO aims to prevent stroke in atrial fibrillation patients who cannot tolerate anticoagulation, as over 90% of AF-related strokes originate in the left atrial appendage. The procedure uses nitinol-based devices like the Watchman and Amulet, implanted via ultrasound and X-ray guidance. Antithrombotic therapy post-implantation balances preventing device-related thrombus (DRT) and bleeding risk. Initial clot risk arises due to the device's foreign surface, requiring intra-procedural heparinization, followed by endothelialization over months. Patient and implant factors influence DRT risk, including age, heart function, kidney disease, appendage anatomy, and implant technique.<br /><br />Historically, post-LAO treatment involved warfarin plus aspirin, evolving to dual antiplatelet therapy (DAPT) or low-dose DOACs. Emerging small studies suggest potential for low-dose NOACs or monotherapy to reduce bleeding without increasing clot risk, though data is limited. Imaging via TEE and intracardiac echocardiography (ICE) guides procedural success, implant placement, and post-procedural surveillance for leaks and thrombus. ICE with moderate sedation is increasingly favored over TEE with general anesthesia, improving patient comfort and efficiency. Surveillance imaging typically occurs at 45-60 days post-implant to assess seal and thrombus presence. Management of DRT remains uncertain, with anticoagulation reinitiation based on clinical judgment. Ongoing trials aim to refine optimal antithrombotic regimens and surveillance protocols to enhance LAO patient care.

Keywords

Intravascular Imaging

Percutaneous Coronary Intervention

IVUS

OCT

Cardiovascular Care

Plaque Assessment

Stent Placement

Regulatory Challenges

Coronary CT Angiography

Left atrial appendage occlusion

Antithrombotic strategies

Atrial fibrillation stroke prevention

Nitinol-based devices

Watchman device

Dual antiplatelet therapy

Intracardiac echocardiography

Device-related thrombus

Post-implantation surveillance