Laurent Fauchier, Mathieu Nasarre, Bertrand Pierre, Arnaud Bisson, Gregory Y H Lip
In contemporary practice after LAAO, reduced-dose DOAC therapy was associated with more favourable outcomes than DAPT but showed no clear advantage over SAPT, supporting simplified and individualised post-implantation antithrombotic strategies.
BACKGROUND: The optimal antithrombotic therapy after left atrial appendage occlusion (LAAO) in patients with atrial fibrillation (AF) remains uncertain. Reduced-dose direct oral anticoagulation (DOAC) is increasingly used in clinical practice as an alternative to antiplatelet-based strategies, but comparative outcome data are limited.
AIMS: We sought to compare the clinical outcomes associated with low-dose DOAC therapy versus dual antiplatelet therapy (DAPT) or single antiplatelet therapy (SAPT) after LAAO.
METHODS: Using the TriNetX Global Network, we identified adult patients with AF who underwent percutaneous LAAO between 2010 and 2025. Three parallel propensity score-matched analyses were conducted: reduced-dose DOAC versus DAPT, SAPT versus DAPT, and reduced-dose DOAC versus SAPT. Outcomes included all-cause death, thromboembolic events, device-related thrombosis, bleeding events, and net clinical benefit (NCB).
RESULTS: After matching, 1,773 patients were included in each group for the reduced-dose DOAC versus DAPT comparison (mean follow-up 1.4±1.0 years). Reduced-dose DOAC was associated with lower risks of all-cause death (hazard ratio [HR] 0.79, 95% confidence interval [CI]: 0.65-0.96) and major bleeding (HR 0.87, 95% CI: 0.77-0.98), with no significant differences in ischaemic stroke, thromboembolism, or device-related thrombosis. NCB favoured reduced-dose DOAC (HR 0.87, 95% CI: 0.78-0.96). SAPT was also associated with fewer bleeding events and favourable outcomes compared with DAPT. In the reduced-dose DOAC versus SAPT comparison (1,582 matched patients per group), reduced-dose DOAC showed estimates compatible with a slightly higher risk of major bleeding compared with SAPT (HR 1.14, 95% CI: 1.00-1.30; p=0.06), while mortality, thromboembolic outcomes, and NCB did not differ significantly.
CONCLUSIONS: In contemporary practice after LAAO, reduced-dose DOAC therapy was associated with more favourable outcomes than DAPT but showed no clear advantage over SAPT, supporting simplified and individualised post-implantation antithrombotic strategies.