An observational analysis of device-related thrombus in patients with atrial fibrillation across different generations of Watchman devices

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Abstract Background LAAC devices have seen advancements in design, anchoring mechanisms, and deployment systems to reduce procedural complications over the years. Despite these improvements, device-related thrombus (DRT) continues to pose a significant postprocedural risk, contributing to higher morbidity. Objective To analyze the incidence, characteristics and outcomes of DRT in patients with AF across different generations of Watchman devices. Methods We analyzed data from a consecutive cohort of patients receiving Watchman device implants between 2016 and 2024. Follow-up TEEs were performed at ~4M and 1-year post-implantation to assess DRT incidence and timing. DRT events occurring within 6M of implantation were classified as early, while those occurring after 6M were categorized as late DRTs. Results Among 876 patients undergoing Watchman implantation, 468 (53.4%) received the 2.5 device, 308 (35.1%) the FLX device, and 100 (11.4%) the FLX Pro device. A documented DRT was seen in 27 patients (3.2%), of which 74% (20 of 27) occurred early. All patients with DRT were on some form of antithrombotic therapy at the time of diagnosis. Among these patients, 1 (10%) was on anticoagulation in those who received the 2.5 device, 2 (18.1%) were on anticoagulation in those who received the FLX device, and 1 (16.7%) was on anticoagulation in those who received the FLX Pro device. All other patients with DRT in these groups were on antiplatelet therapy. Baseline characteristics showed a mean age of 76.6 years, 40.7% males, and a mean CHA2DS2VASC score of 4.2. Most had non-paroxysmal AF (78.8%), vascular disease (52%), and hypertension (93%). Mean DRT size was 4.5 mm, and average follow-up for DRT was 214 days. Four patients (14.8%) experienced a cerebrovascular event, three had bleeding, and two had heart failure-related hospitalizations within one year. (Table) Conclusion Despite newer generation devices, incidence of DRT and the risk of associated complications remain significant, and clinicians may be falsely reassured into using lower doses of antithrombotic therapy. Careful consideration is crucial when selecting appropriate antithrombotic regimens.Table 1 Table 2

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