Watchman™ Left Atrial Appendage Occlusion

What is the Watchman Procedure?

The Watchman left atrial appendage occlusion procedure is used to treat atrial fibrillation with the Watchman device. The Watchman device—an umbrella-shaped plug, which prevents blood from flowing in and out of the left atrial appendage—is designed for patients who are at-risk for stroke due to the presence of atrial fibrillation but who are also at high risk for bleeding events or complications due to chronic anticoagulation.

The Watchman procedure takes about an hour to perform. Patients are usually kept in the hospital for one night.

How the Procedure Works

A small tube, or sheath, is inserted into a vein in the patient’s leg. Through this tube, the Watchman left atrial appendage closure device is advanced into the left upper chamber of the heart and into the left atrial appendage.

The Watchman procedure is done under x-ray and ultrasound imaging guidance, which ensures that the device is securely positioned and that it effectively prevents blood flow in and out of the appendage.

Patients do receive general anesthesia for the procedure.

What Condition Does the Watchman Procedure Treat?

The Watchman procedure treats atrial fibrillation, or a-fib. Atrial fibrillation is a common heart rhythm problem which becomes more prevalent in patients over the age of 65, especially in patients who have hypertension, diabetes, sleep apnea, and/or other heart diseases.

In many patients, atrial fibrillation is a major risk factor for stroke because this rhythm prevents the upper chambers of the heart from contracting normally and circulating blood normally. When blood pools in the upper chambers of the heart, it can form clots, which can break loose and cause stroke. It is estimated that 90% of the clots that form in atrial fibrillation are located in a blind outpouching in the left upper chamber of heart called the left atrial appendage.
Blood thinners, with warfarin, or one of the newer medications (e.g. Eliquis, Xarelto Pradaxa) are the therapy of choice to prevent stroke in most patients with atrial fibrillation. Aspirin is not an effective alternative to blood thinners for stroke prevention in atrial fibrillation.
However, for many reasons, patients may not be good candidates for long-term use of blood thinners. Recurrent bleeds, history of major bleeding problems, frequent falls, or difficulty maintaining stable Coumadin levels are common reasons that patients are unable to tolerate blood thinners.
In patients who cannot take blood thinners, or who are at high risk of bleeding problems with blood thinners the Watchman device may be a good alternative. This umbrella-shaped plug can be placed into the left atrial appendage through a small tube, and can seal off the left atrial appendage, thus keeping blood clots from forming in this part of the heart. It has been shown to be as effective as warfarin at preventing stroke in patients who have atrial fibrillation that is not related to heart valve disease.
Once the watchman device completely closes the appendage (which usually takes 6 weeks) patients can come off Coumadin for life.

How to Prepare

Prior to the procedure, patients are evaluated in the Structural Heart Clinic, where the procedure can be discussed in detail, and patients can meet the implanting physicians. Patients can expect several tests:

All patients should undergo transesophageal echocardiogram (TEE): This is an ultrasound of the heart that is performed under light sedation. It is similar to endoscopy. After receiving sedation, patients swallow a small tube with an ultrasound tip, which allows detailed imaging of the left atrial appendage. This test is used to help select the appropriately sized device and to ensure that there is no blood clot in the heart from the atrial fibrillation.
Most patients also will undergo CT scan of the heart with contrast, which allows for precise 3-dimensional evaluation of the left atrial appendage. This also helps in the selection of the appropriately sized device.
Patients will meet with the anesthesia team for a preanesthesia testing visit (PAT).

After the Watchman Procedure

After the procedure, most patients stay in the hospital for one night.

For six weeks following the Watchman implantation, patients still need to be on aspirin and Coumadin. After six weeks, another transesophageal echo is performed, and if the device is well healed, patients can stop taking Coumadin. Patients go on a combination of aspirin and clopidogrel for a total of six months post procedure, and then they can be on low-dose aspirin alone.