SHM Converge Scientific Abstract ePoster Gallery-To Thin or Not to Thin a Watchman

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A 77-year-old woman with severe cardiac disease presented with weakness, melena, severe anemia (Hgb 6.5 g/dL), and markedly elevated INR (5) while taking chronic warfarin and aspirin. Her history included bioprosthetic aortic valve replacement, mitral valve repair, chronic atrial fibrillation treated with Maze ablation, and left atrial appendage closure with a WATCHMAN device.<br /><br />Endoscopy showed gastritis with recent bleeding. Review of her history revealed multiple prior GI bleeds and repeated supratherapeutic INRs, raising concern that the bleeding risk of ongoing anticoagulation outweighed benefit. Clinicians debated whether she still needed indefinite warfarin and/or antiplatelet therapy.<br /><br />The discussion emphasized current ACC/AHA guidance: warfarin is appropriate for the immediate post-operative period after valve surgery, but may be stopped later if no other indication exists. For atrial fibrillation, stroke prevention usually requires anticoagulation, but left atrial appendage closure with WATCHMAN is designed to reduce stroke risk by excluding the appendage, where most AF-related thrombi form. After the required post-procedure anticoagulation period, some patients can discontinue warfarin, especially if bleeding risk is high.<br /><br />Evidence from WATCHMAN studies shows reduced stroke risk, including in patients unable to tolerate long-term anticoagulation. However, WATCHMAN does not automatically eliminate the need for all antithrombotic therapy; many patients still require at least short-term anticoagulation and/or long-term single antiplatelet therapy.<br /><br />Conclusion: this patient had a clear indication for warfarin only during the early post-operative period after her cardiac procedures. Given her high bleeding risk and recurrent GI bleeding, warfarin could reasonably be discontinued afterward, while continuing lifelong single antiplatelet therapy with aspirin.

Asset Subtitle

Samantha Murray-Bainer

Meta Tag

Author List Samantha Murray-Bainer

Category Clinical Vignettes

Concept Warfarin

Concept Antithrombotic Therapy

Concept Atrial Fibrillation

Concept Left Atrial Appendage Closure

Concept Bioprosthetic Valve Replacement

Distinguished Non-Finalist

Presenter Organization University of Wisconsin School of Medicine & Public Health

Presenting Author Samantha Murray-Bainer

Track Adult

Keywords

warfarin

aspirin

gastrointestinal bleeding

atrial fibrillation

WATCHMAN device

left atrial appendage closure

bioprosthetic aortic valve

mitral valve repair

supratherapeutic INR

anticoagulation management

Warfarin

Antithrombotic Therapy

Atrial Fibrillation

Left Atrial Appendage Closure

Bioprosthetic Valve Replacement