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A Watchman and Ablation Combo? Everything You Never Thought to Ask

by Steve S. Ryan, PhD

The Watchman device closes off the Left Atrial Appendage (LAA), the source of most clots and A-Fib strokes.

The Watchman has been available in other countries since 2009, but only since 2015 in the US.

Research tells us that the Watchman device is not only as good as but is actually better for A-Fib patients than being on the blood thinner warfarin.  (See my post: Clinical Trials Results: Watchman Better Than a Lifetime on Warfarin)

Answers From Australia

A five-year study in Australia by Dr. Karen Phillips and her colleague, Dr. TW Walker, gives us ‘real world’ data and insights. Specifically, she studied combining the Watchman device with a catheter ablation for treating Atrial Fibrillation patients.

I’ve corresponded with Dr. Karen Phillips to help me answer your questions about the Watchman device.

“Can the Watchman be installed at the same time as my ablation?“

Yes.  Dr. Karen Phillips and several Electrophysiologists (EPs) in Europe have been doing this for over five years with no complications. She hasn’t seen any downside to doing the two procedures together. There’s very little, if any, experience in the US of combining a PVI with a Watchman device (US approved in 2015).

Should the Watchman be installed at the same time as my ablation?“

First answer: should the LAA be closed off? (Surgeons, unlike EPs, routinely remove the LAA in A-Fib surgery.) But the LAA isn’t a useless appendage and it has several functions. Younger people, especially the athletic, might be compromised by having their LAA closed off. (See LAA Important for Heart health.) There are many arguments for not routinely closing off the LAA in everyone.

Here are cases where closing off the LAA would be very beneficial:

Situation A: If you have other significant risk factors for stroke and after a successful PVI you would still need to be on life-long anticoagulation. But the Watchman usually replaces or fills this need for life-long anticoagulation. All of Dr. Phillips’ approximately 100 patients were able to stop taking anticoagulants.

Be advised that neither warfarin nor the Watchman absolutely guarantee that you will never have a stroke.

Situation B: Especially in the elderly, closing off the Left Atrial Appendage (LAA) can be done later in life when patients are less active and may not even notice or feel that their LAA is gone.

Situation C: Sometimes ablations don’t work or are only partially successful, particularly in cases of persistent A-Fib. But if the Watchman device is installed at the same time, the patient would still be protected from an A-Fib stroke.

Situation D: If an ablation is successful, there is a chance of recurrence of A-Fib. If A-Fib recurs, one is still protected from an A-Fib stroke by the Watchman device.

Situation E: If you anticipate that you will need or desire to have your Left Atrial Appendage (LAA) closed off, it would be easier, cheaper and less risky to have the Watchman installed at the same time as a your catheter ablation.

Situation F: Studies have shown that many patients prescribed anticoagulants don’t take them or don’t take them consistently. These patients are 4-5 times more at risk of an A-Fib stroke. The combined PVI/Watchman procedure would, if nothing else, protect them from an A-Fib stroke.

“Can I have a catheter ablation after I’ve had a Watchman device installed?”

Yes. But choose a more experienced operator. There are potential but unlikely risks.It will take more time and real world experience to see if these potential risks are indeed significant. What are the possible risks?

A post-mortem1 of a patient five months after having a combined PVI/Watchman procedure revealed normal heart wall tissue had grown over and almost completely covered the Watchman device.

Postential risk 1: Damage to the Watchman device. An inexperienced or less skilled operator can punch a hole through the Watchman device fabric.

But this is less likely to happen the longer the Watchman device has been installed. Heart tissue grows over the surface of the Watchman device within 28 days. A safe time frame is to wait 3 months before having your PVI.

Postential risk 2Dislodging the Watchman device. This is unlikely after three months.

Postential risk 3: Catheter entrapment―getting the catheter stuck in the Watchman device. Again, this is unlikely after three months.

“What if I develop A-Fib coming from the LAA? Would My Watchman interfere with ablating there?

According to Dr. Phillips’ experience, no. The Watchman is inserted inside the edges or mouth of the LAA. “…in practice we’ve seen no interaction with ablation and where the Watchman sits in the LAA.” If necessary, one can still ablate and electrically isolate the mouth of the LAA with the Watchman installed.

This may not be true of other occlusion devices. Currently no centers are doing the combined procedure with other devices than the Watchman.

“Do the ablation burns interfere with inserting the Watchman? Would they be better done separately?”

The ablation burns aren’t near enough to the LAA to affect its insertion.

“What if I’ve already had a Watchman? Would this prevent me from having an Ablation?”

No. Dr. Phillips has been doing PVIs on patients with installed Watchman devices with no problems. Dr. Phillips was able to use all standard mapping and ablation strategies in patients with a Watchman device. Because the Watchman device is situated inside the LAA, she was able to access the LAA mouth/opening to ablate and electrically isolate it. (Other occlusion devices do cover the mouth/opening of the LAA which might prevent isolation of the LAA.)

But Dr. Phillips does warn that, “left atrial catheter manipulation in the presence of an occlusion device should be undertaken only with extreme caution.”

What Patients Need to Know

Combination PVI and Watchman Will Become More Common: Currently in the US, unlike in Australia and Europe, no one is doing combination PVI and Watchman procedures. But I expect this will soon change.  The combination procedure is such a simple add-on that Master EPs will soon be doing it. If you would benefit from a combination procedure, you probably won’t have long to wait.

Catheter positioning the Watchman occlusion device at the mouth of the Left Atrial Appendage

Catheter positioning the Watchman occlusion device at the mouth of the Left Atrial Appendage

Will the Watchman be Routinely Combined with a PVI? One of the marketing points of surgical strategies for A-Fib was that the Left Atrial Appendage (LAA) was closed off or removed during the surgery. But this is now being done in catheter ablation combined with the Watchman device, and will certainly become a more common practice as EPs get more experienced with the Watchman.

But unlike with most surgical strategies, as a patient you will always have the option of retaining your LAA. It’s unlikely that the Watchman will ever be routinely inserted as part of a PVI (but I could be wrong).

Yes. You Can Have a PVI After a Watchman is Installed: Dr. Phillips’ research represents a major medical breakthrough for A-Fib patients. If you are diagnosed with A-Fib, you don’t have to spend months or years taking anticoagulants while waiting for a propitious time to have a PVI.

For Example: Let’s take the case of someone with silent (no-symptoms) A-Fib. Most EPs would be reluctant to do a PVI on someone with no A-Fib symptoms. But they would still prescribe anticoagulants to someone in silent A-Fib in order to prevent an A-Fib stroke. However, instead of having to take anticoagulants, you can instead opt for a Watchman device which works better than warfarin and certainly has less bad side effects.

It’s a short, relatively easy (though not risk-free), 20-30 minute procedure which can more easily be scheduled than a PVI. And as Dr. Philipps’ research shows, you can always have a PVI later.

Installing the Watchman device is probably safer and less risky in the long term than having to take a blood thinner like warfarin.

Dr. Karen Phillips

Dr Karen Phillips, Queensland, Australia

Dr Karen Phillips

I am indebted to Dr. Karen Phillips for her expert advice and support in writing this report. Her contact info:

Dr Karen Phillips, Arrhythmia Cardiologist / Cardiac Electrophysiologist, HeartCare Partners, Queensland, Australia. Website: http://www.heartcarepartners.com.au/
Email: kphillips(at)heartcarepartners.com.au
2015 Winner in the ‘100 Women of Influence Awards‘. 

If you find any errors on this page, email us. Y Last updated: Thursday, February 18, 2016

References for this article

 

References    (↵ returns to text)
  1. The death was a suicide. The coroner’s report did not implicate the combined PVI/Watchman procedure in the cause or circumstances of the suicide.

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