"This book is incredibly complete and easy-to-understand for anybody. I certainly recommend it for patients who want to know more about atrial fibrillation than what they will learn from doctors...."

Pierre Jaïs, M.D. Professor of Cardiology, Haut-Lévêque Hospital, Bordeaux, France

"Dear Steve, I saw a patient this morning with your book [in hand] and highlights throughout. She loves it and finds it very useful to help her in dealing with atrial fibrillation."

Dr. Wilber Su Cavanaugh Heart Center, Phoenix, AZ

"Your book [Beat Your A-Fib] is the quintessential most important guide not only for the individual experiencing atrial fibrillation and his family, but also for primary physicians, and cardiologists."

Jane-Alexandra Krehbiel, nurse, blogger and author "Rational Preparedness: A Primer to Preparedness"


"Steve Ryan's summaries of the Boston A-Fib Symposium are terrific. Steve has the ability to synthesize and communicate accurately in clear and simple terms the essence of complex subjects. This is an exceptional skill and a great service to patients with atrial fibrillation."

Dr. Jeremy Ruskin of Mass. General Hospital and Harvard Medical School

"I love your [A-fib.com] website, Patti and Steve! An excellent resource for anybody seeking credible science on atrial fibrillation plus compelling real-life stories from others living with A-Fib. Congratulations…"

Carolyn Thomas, blogger and heart attack survivor; MyHeartSisters.org

"Steve, your website was so helpful. Thank you! After two ablations I am now A-fib free. You are a great help to a lot of people, keep up the good work."

Terry Traver, former A-Fib patient

"If you want to do some research on AF go to A-Fib.com by Steve Ryan, this site was a big help to me, and helped me be free of AF."

Roy Salmon Patient, A-Fib Free; pacemakerclub.com, Sept. 2013

blood thinners

The Watchman Device: My Top 5 Articles

You’re on a blood thinner for your increased stroke risk from A-Fib. But you hate it.

Is the monthly testing or diet restrictions a hassle? Is the increased risk of bleeding stressful?  Have you developed side effects, i.e., gastrointestinal problems or poor kidney function? Maybe you just don’t want a lifetime on meds.

Or, perhaps you’re unable to take a blood thinner for other medical reasons. What do you do?

WATCHMAN™ Occlusion Device: The Alternative to Blood Thinners

There is an alternative to taking blood thinners―closing off your Left Atrial Appendage (LAA) with the Watchman™, an occlusion device. The LAA, a small sack located at the top of your left atrium, is where 90-95% of A-Fib strokes originate.

Inserting the Watchman is a very low risk procedure that takes as little as 20 minutes to install. Afterward, you usually don’t need to be on a blood thinner.

Review these articles to learn more about the Watchman:

1. The Watchman™ Device: The Alternative to Blood Thinners

2. Clinical Trials Results: Watchman Better Than a Lifetime on Warfarin

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

4. Technology & Innovations: The Watchman Device 

5. Steve’s List of EPs Installing the Watchman Device

Bonus: Video about the Watchman

Video - Closure of the Left Atrial Appendage Technique

Click image for video.

Closure of the Left Atrial Appendage: The Watchman Device

Animation shows how the Watchman is inserted and positioned in the left atrial appendage (LAA) using a catheter; then how heart tissue grows over the Watchman, closing off the opening of the LAA trapping any blood clots. (1:04)

Are Anticoagulants and blood thinners the same thing? How do they thin the blood?

We’ve posted a new FAQ and answer under Drug Therapies and Medicines in our section:

Are Anticoagulants and blood thinners the same thing? How do they thin the blood?

Blood clots are usually good, such as when you get a scrape or cut.

Since A-Fib increases your risk of clots and stroke, blood thinners are prescribed to prevent or break up blood clots in your heart and blood vessels and thereby reduce your chance of an A-Fib-related stroke.

Although referred to as “blood thinners”, they don’t actually affect the “thickness” of your blood.

Anticoagulant Warfarin chemical diagram

Anticoagulant Warfarin

There are two main types: anticoagulants and antiplatelet agents.  They work differently to accomplish the same end effect.

Anticoagulants work chemically to lengthen the time it takes to form a blood clot.

Common anticoagulants include warfarin (Coumadin), Heparin and the NOACs such as apixaban (Eliquis).

Antiplatelet Aspirin

Antiplatelets prevent blood cells (platelets) from clumping together to form a clot.

Common antiplatelet medications include aspirin, ticlopidine (Ticlid) and clopidogrel (Plavix) .

Final answer: Yes, an anticoagulant is a blood thinner, but not all blood thinners are anticoagulants.

Note: To read about ‘clot buster’ drugs or treatments that could save you from a debilitating stroke, see my article: Your Nearest ‘Certified Stroke Center’ Could Save Your Life.

65 and Older: 99% Have Microbleeds—So Are Anticoagulants Risky?

In a  recent study, 99% of subjects aged 65 or older had evidence of microbleeds; and closer examination of the cranial MRI images revealed an increased number of detectable microbleeds (i.e., the closer they looked, the more microbleeds they found).

Microbleeds in the brain are thought to be a precursor of hemorrhagic stroke.

Cerebral microbleeds (MBs) are small chronic brain hemorrhages of the small vessels of the brain.

If Microbleeds Cause Hemorrhagic Stroke, Should I be on a Blood Thinner?

The fact that almost everyone 65 or older has microbleeds is astonishing and worrisome, particularly if you have A-Fib and have to take anticoagulants. Anticoagulants cause bleeding. That’s how they work.

In plain language, this study indicates that cerebral microbleeds lead to or cause hemorrhagic stroke. It’s not surprising then that some doctors are reluctant to prescribe heavy-duty anticoagulants to older A-Fib patients.

Being older and already having microbleeds only makes taking anticoagulants all the more worrisome.

Risks of Taking Anticoagulants (Blood Thinners)

Taking almost any prescription medication has trade-offs. Older A-Fib patients find themselves between a rock and a hard place.

In the case of anticoagulants, on one hand you get protection from having an A-Fib stroke (which often leads to death or severe disability), but on the other hand you have an increased risk of bleeding.

For those over 65 who already have microbleeds, … Continue reading this report…->

Beware: Women More Likely on Aspirin Inappropriately

Aspirin-rod-povray". Licensed under CC BY-SA 3.0 via Wikimedia Commons

Aspirin 3D model

I recently wrote about how aspirin is no longer recommended as first-line therapy to prevent A-Fib stroke. (See my posts: New A-Fib Guidelines: Ditch the Aspirin for Stroke Prevention; and More Than 1 in 10 Take Aspirin When They Shouldn’t)

In doing my research, I came across aspirin therapy studies that should be of interest to women.

Another Example of Gender Bias

One research study found that women were more likely than men to receive inappropriate aspirin therapy.

Another study spanning 15 years followed nearly 28,000 women taking aspirin for primary prevention of cardiovascular disease (CVD). The findings? For most women the benefits of aspirin did not outweigh the risks of bleeding complications.

The researchers concluded that aspirin “is ineffective or harmful in the majority of women with regard to the combined risk of cardiovascular disease, cancer, and major gastrointestinal bleeding.”

Like Other Blood Thinners, Aspirin is a Pharmaceutical Drug

It’s all too easy to take an aspirin―we don’t need a prescription to get it. But taking an aspirin isn’t like taking a vitamin. Aspirin is a pharmaceutical drug.

Discuss aspirin therapy with your doctor just as you’d do for any ‘by prescription’ blood thinner. (Take along a copy of my posts cited above.)

References for this article

Warn Family & Friends: 1 in 10 Take Aspirin When They Shouldn’t

I recently wrote about how aspirin is no longer recommended as first-line therapy to prevent A-Fib stroke. (See my AF Symposium report, AHA/ACC/HRS Treatment Guideline Changes.).

But it’s not just A-Fib patients who shouldn’t be on aspirin therapy for stroke prevention.

Data indicates more than 1 in 10 patients take aspirin when they shouldn’t.

Warn your family and friends who are taking daily aspirin for stroke risk: Maybe they shouldn’t be.
Aspirin-rod-povray". Licensed under CC BY-SA 3.0 via Wikimedia Commons

Aspirin 3D model

50 Million in the US Take Aspirin for Prevention of Cardiovascular Disease

The problem with routinely taking aspirin is an increased risk of bleeding complications. More than one-third of all adults in the U.S. are now taking aspirin for primary and secondary prevention of cardiovascular disease (CVD).

“Primary” means preventing a first event like a heart attack. “Secondary” means preventing a reoccurrence of an event, like a second stroke.

When is Aspirin Therapy Appropriate?

As a “primary” prevention, only patients with a moderate to high 10-year risk of cardiovascular disease and stroke should be on aspirin therapy (estimated using the ACC/AHA risk-prediction calculator or similar calculator).

Aspirin is recommended for “secondary” prevention.

Try the ACC/AHA Risk-Prediction Calculator for yourself but beware: 
Critics claim it overestimates CVD risk by 75-150% and could land you on lifelong statin therapy.

When is Aspirin Therapy Not Appropriate?

Aspirin is not appropriate for people who are at low risk—defined by their 10-year risk score. For these people, the risks of gastrointestinal bleeding and hemorrhagic strokes outweigh any potential benefit. “Among the more than 16,000 deaths each year linked to bleeding…, about one-third of these deaths occur in those who take low-dose (81-mg) aspirin.” The FDA in 2014 released a statement that warned against widespread use (of aspirin) in people of average risk.

Like Other Blood Thinners, Aspirin is a Pharmaceutical Drug

It’s all too easy to take an aspirin―we don’t need a prescription to get it. But taking an aspirin isn’t like taking a vitamin. Aspirin is a pharmaceutical drug.

Instead of routinely taking aspirin, you should discuss aspirin therapy with our doctor just as you’d do for any ‘by prescription’ blood thinner. (Take along a copy of this post.)

Note: Suddenly stopping daily aspirin therapy could have a rebound effect that may trigger a blood clot. If you have been taking daily aspirin therapy and want to stop, it’s important to talk to your doctor before making any changes.

References for this article


NEW FAQ: Can I Take CoQ10 With a Blood Thinners

Minerals and Supplements w border 125B at 96 res“Can I take the supplement CoQ10 while on Eliquis for Atrial Fibrillation? On your site it says CoQ10 could be helpful. But on my bottle of CoQ10, it says “do not take if you are on blood thinners”.”

Eliquis is a “single key activated factor,” while warfarin affects many different steps in the anticoagulant process. Vitamin K foods aren’t restricted with Eliquis. That might indicate that you could take CoQ10 with Eliquis. But Eliquis is so new we have little research to definitively say this.

To read Steve’s full answer, see FAQs Minerals & Supplements, Question 12: CoQ10 & Blood Thinners.

New Novel Anticoagulant Edoxaban: How Does it Compare to Other Blood Thinners?

Edoxaban label - Edoxaban marketed as Savaysa in North America

Edoxaban marketed as Savaysa in North America

FDA approved in January 2015, the anti-clotting drug edoxaban (brand names Savaysa and Lixiana) is the fourth novel anticoagulant (NOAC) developed as an alternative to the blood thinner warfarin (Coumadin). The others are apixaban (Eliquis), dabigatran (Pradaxa) and rivaroxaban (Xarelto).

Because edoxaban is so new, we don’t have much ‘real world’ data and can only look at the data from the clinical trial. Edoxaban is available by prescription in two dosages: 60 mg once daily and 30 mg once daily.

Prevention of stroke: The higher dose of edoxaban (60 mg once daily) was as good as and tended to be better than warfarin in preventing stroke. But the lower dose (30 mg once daily) wasn’t as effective as warfarin.

Stomach bleeding: All anticoagulants cause bleeding. That’s how they work. With the higher dose of edoxaban, bleeding from the stomach was greater than with warfarin. But with the lower dose of edoxaban, bleeding was lower than with warfarin.

Kidney clearance: Edoxaban is 35% cleared by the kidneys (as compared to 25% for apixaban [Eliquis] and 80% for dabigatran [Pradaxa]). This means if your kidneys are working well (creatine clearance greater than 95ml/min), you probably shouldn’t be taking edoxaban, because your kidneys are taking it out of your body too quickly. This puts you at greater a risk of stroke than those patients taking warfarin.

No Head-To-Head Clinical Tests

Unfortunately, there haven’t been any head-to-head clinical tests comparing edoxaban with the other novel anticoagulants (NOACs). In fact, drug manufacturers have only tested their products against the standard treatment of warfarin (Coumadin).

Safety Data for Edoxaban

Edoxaban is so new we don’t have a real-world safety score yet. But in the clinical trial, stomach bleeding was greater with the higher dose than warfarin. (The lower dose edoxaban is irrelevant because it didn’t work as well as warfarin.)

The Bottom Line for Edoxaban

The limited data about edoxaban in unimpressive. As you know, I’m not a medical doctor. So if you are seeking an alternative to warfarin, talk to your doctor. If I were you, I’d skip edoxaban for now and consider apixaban (Eliquis) instead.

To date, Eliquis is the only novel anticoagulant (NOAC) that can claim that survival improved with its use compared to warfarin. Eliquis was unique in that bleeding from other sites including the stomach, bowels, and bladder was less. Eliquis earned the best safety score from the FDA Adverse Event Reporting System compared to Pradaxa, Xarelto and warfarin. For more, see Warfarin vs. Pradaxa and the Other New Anticoagulants.

FAQs A-Fib Drug Therapy: Can I get off blood thinners all together?

 FAQs A-Fib Drug Therapy: How to get off Coumadin?

Drug Therapies for Atrial Fibrillation, A-Fib, Afib

20. “Is there a way to get off blood thinners all together? I hate taking Coumadin. I know I’m at risk of an A-Fib stroke.”

To get off blood thinners all together you must solve the underlying reason why you’re on the drug in the first place.

You must cure your Atrial Fibrillation and address any other contributing issues that puts you at risk of clots and stroke. For example, if you have undiagnosed sleep apnea, your EP will want you tested and put on an appropriate treatment. The same is true if you have heart valve disease, high blood pressure, diabetes or are severely overweight.

You may need to change doctors, too. You want an electrophysiologist (EP) who specializes in heart rhythm problems and Atrial Fibrillation in particular. Seek an EP whom you are comfortable with, someone who will partner with you to seek your cure. For help, see “Finding the Right Doctor.”

Your EP will evaluate you and your Atrial Fibrillation and other conditions impacting your health. You may discuss a catheter ablation procedure. Or if you have other heart problems or you don’t qualify for an ablation, you may look at the Cox maze or Mini-maze, or a Hybrid Surgery/Ablation procedure.

Caution: It’s important to understand that you should not stop taking Coumadin without the guidance of your doctor or a health care professional.

Return to FAQ Drug Therapies

FAQs A-Fib Ablations: Blood Thinner Post-Ablation?

 FAQs A-Fib Ablations: Blood Thinner Post-Ablation? 

Catheter Ablation

Catheter Ablation

15. “After my successful Pulmonary Vein Ablation, do I still need to be on blood thinners like Coumadin or aspirin?”

You may still have a high CHADS2 stroke risk score or other factors that make it necessary for you to stay on blood thinners.

But if you no longer have A-Fib, you are no longer in danger of having an A-Fib stroke. So, in most cases, you don’t need to be on blood thinners.

A recent observational study involving nearly 38,000 patients found that the stroke risk of patients who had a successful catheter ablation was similar to patients with no history of A-Fib. When you are in sinus rhythm, your stroke risk is basically the same as a normal heart-healthy person.

However, there is no medication or treatment that would absolutely guarantee one would never get a stroke, even for people in normal sinus rhythm.

“Anticoagulant treatment for people with A-Fib ranks as one of the highest-risk treatments in older Americans.
∼Thomas J. Moore, MD

Because you’ve been cured of A-Fib and are A-Fib free, the places in your heart where A-Fib normally develops have been ablated and isolated. Taking anticoagulants because you might develop A-Fib is like taking out your appendix because at some future date you might develop appendicitis (frowned upon these days). As Dr. John Mandrola says, “And if there is no A-Fib, there is no benefit from anticoagulation.”

A study in 2010 indicates that anticoagulants, like warfarin, can be stopped 3-6 months after a successful Pulmonary Vein Ablation (Isolation).

Silent A-Fib May Appear Post-Ablation

However, though feeling cured of your A-Fib, you may still be experiencing ‘silent A-Fib’ (A-Fib with no symptoms) which can be dangerous.

But doctors today are very good at spotting silent A-Fib and have a wide variety of monitoring devices (such as the Zio patch which you wear like a Band-Aid for two weeks). These monitoring devices would capture any silent A-Fib episodes you may have and alert your doctor that you may still need to be on anticoagulants. If you’re worried about being in silent A-Fib, ask your doctor for more extensive monitoring. Short episodes of silent A-Fib in general aren’t likely to cause a clot.

Danger of Taking Anticoagulants

No one should be on anticoagulants unless there is a real risk of stroke. Anticoagulants have their own risks and dangers.

Anticoagulants are not like taking vitamins (contrary to the impression given by the recent TV advertisements for the new anticoagulants, NOACs).

No one should be on anticoagulants unless there is a real risk of stroke. Anticoagulants have their own risks and dangers. No one wants to be on blood thinners like warfarin (Coumadin). You bruise easily, cuts take a long time to stop bleeding, you can’t participate in any contact sports or any activities like mountain climbing, bike riding, etc.

If taking the newer anticoagulants (NOACs) and you’re in an accident, you risk bleeding to death, because there is currently no practical way to reverse the anticlotting effect.

(Added October 26, 2015: The FDA granted “accelerated approval” to Praxbind®, a reversal agent (antidote) to Pradaxa®. Praxbind is given intravenously to patients who have uncontrolled bleeding or require emergency surgery.)

Even a low dose like a baby aspirin (81 mg) can cause bleeding and intestinal problems.

When taking anticoagulants, there is an increased risk of developing a hemorrhagic stroke and gastrointestinal bleeding. And anticoagulants often have other bad side effects, make one feel sick, and diminish one’s quality of life. “Anticoagulant treatment for people with A-Fib ranks as one of the highest-risk treatments in older Americans, according to Thomas J. Moore, senior scientist at the Institute for Safe Medication Practices. “More than 15% of older patients treated for A-Fib with blood thinners for 1 year have bleeding.”

Even a low dose like a baby aspirin (81 mg) can cause bleeding and intestinal problems.

Whether you should be on anticoagulants after a successful catheter ablation is a judgment call for you and your doctor.

August 2015 Update: Aspirin is No Longer Recommended as First-Line Therapy

Aspirin is no longer recommended as first-line therapy for Atrial Fibrillation patients according to the 2014 AHA/ACC/HRS Treatment Guidelines for Atrial Fibrillation. Though not a new finding, it should be noted that aspirin has been downgraded to class 2B drug.

A similar directive is included in the 2012 European ESC guidelines for the Management of Atrial Fibrillation: aspirin is not recommended as first-line therapy for patients with a CHA2DS2-VASc score of 1.

Aspirin is not appropriate for people who are at low risk of cardiovascular disease and stroke. For these people, the risks of gastrointestinal bleeding and hemorrhagic strokes outweigh any potential benefit.

Aspirin also causes stomach ulcers in 13% of those using it. And these ulcers usually develop without any warning symptoms. Many of these ulcers will cause a serious stomach bleed at some point. Also, taking low-dose aspirin on a regular basis more than doubles your risk of developing wet macular degeneration. On the positive side, people regularly taking low-dose aspirin have a significantly lower chance of getting cancer.

When is aspirin appropriate? Aspirin is recommended for “secondary” prevention of cardiovascular disease such as to prevent a reoccurrence of a stroke or heart attack.

References for this Article

Return to FAQ Catheters

FAQs A-Fib Treatments: Catheter Ablation Procedures

Catheter ablation illustration at A-Fib.com

Catheter ablation

Atrial Fibrillation patients seeking a cure and relief from their symptoms often have many questions about catheter ablation procedures. Here are answers to the most frequently asked questions by patients and their families. (Click on the question to jump to the answer)

1. “I have a defective Mitral Valve? Is it causing my A-Fib? Should I have my Mitral Valve fixed first before I have a PVA?

2. “With the recent improvements in Pulmonary Vein ablation techniques, should I wait for a better technique? I’m getting by with my Atrial Fibrillation.”

3. “Are there different types of “Pulmonary Vein Ablation”? Are they different from “Pulmonary Vein Isolation?

4. I’’ve heard of Cryo (freezing) catheters for PVA(I) ablations. Are they good or better than the RF (Radio Frequency) catheters for ablations?

5. “How dangerous is a Pulmonary Vein Ablation procedure? What are my risks?

6. “During the ablation procedure A-Fib doctors actually burn within the heart with RF energy. How does this burning and scarring affect how the heart functions? Should athletes, for example, be concerned that their heart won’t function as well after an ablation?

7. “How dangerous is the fluoroscopy radiation during an ablation? I know I need a Pulmonary Vein Ablation (Isolation) procedure to stop my A-Fib—A-Fib destroys my life. I can’t work or exercise, and live in fear of the next attack. Antiarrhythmic meds cause me bad side effects. But I’m worried about being exposed to radiation during the ablation.

8. “I have serious heart problems and chronic heart disease along with Atrial Fibrillation. Would a Pulmonary Vein Ablation help me? Should I get one?

9. “What is an enlarged heart? Does it cause A-Fib?. I was told I can’t have a Pulmonary Vein Ablation (Isolation) procedure because I have an enlarged heart. Why is that?”

10. “I am 82 years old. Am I too old to have a successful Pulmonary Vein Ablation? What doctors or medical centers perform PVAs on patients my age?

11. “Since my PVI, I have been A-Fib free with no symptoms for 32 months. What do you think my chances of staying A-Fib free are?”

12. “How long before you know a Pulmonary Vein Ablation procedure is a success? I just had a PVA(I). I’ve got bruising on my leg, my chest hurts, and I have a fever at night. I still don’t feel quite right. Is this normal?”

13. I want to read exactly what was done during my Pulmonary Vein Ablation. Where can I get the specifics? What records are kept?

14. “What is the typical length of a catheter ablation today versus when you had your catheter ablation in 1998 in Bordeaux, France? What makes it possible?

15. “After my successful Pulmonary Vein Ablation, do I still need to be on blood thinners like Coumadin or aspirin?

16. “I’ve had a successful ablation. For protection against potential stroke risk if my A-Fib re-occurs, which if better—81 mg baby aspirin or 325 mg?

17. Since my ablation, my A-Fib feels worse and is more frequent than before, though I do seem to be improving each week. My doctor said I shouldn’t worry, that this is normal. Is my ablation a failure?

18. “I love to exercise and I’m having a PVA. Everything I read says ‘You can resume normal activity in a few days.’ Can I return to what’s ‘normal’ exercise for me?

19. I have Chronic Atrial Fibrillation (the heart remains in A-Fib all the time). Am I a candidate for a Pulmonary Vein Ablation? Will it cure me? What are my chances of being cured compared to someone with Paroxysmal (occasional) A-Fib?

20. “I’m 80 and have been in Chronic (persistent/permanent) A-Fib for 3 years. I actually feel somewhat better now than when I had occasional (Paroxysmal) A-Fib. Is it worth trying to get an ablation?

21.“Will an ablation take care of both A-Fib and Flutter? Does one cause the other? Which comes first A-Fib or Flutter?

22. Are there other areas besides the pulmonary veins with the potential to turn into A-Fib hot spots? I had a successful catheter ablation and feel great. Could they eventually be turned on and put me back into A-Fib

23. “During an ablation, how much danger is there of developing a clot? What are the odds? How can these clots be prevented?

24. “I was told that I will have to take an anticoagulant for about 2-3 months after my ablation. After all, if fibrillation episodes are reduced or eliminated after an ablation, shouldn’t there be even less need for a prescription anticoagulant rather than more?

25. “I’m six months post CryoBalloon ablation and very pleased. But my resting heart rate remains higher in the low 80s. Why? I’ve been told it’s not a problem. I’m 64 and exercise okay, but I’ve had to drop interval training.”

26. “I’ve heard good things about the French Bordeaux group. Didn’t Prof. Michel Häissaguerre invent catheter ablation for A-Fib? Where can I get more info about them? How much does it cost to go there?

27. “I’m a life-long runner. I recently got intermittent A-Fib. Does ablation (whether RF or Cryo) affect the heart’s blood pumping output potential because of the destruction of cardiac tissue? And if so, how much? One doc said it does.

Last updated: Thursday, September 8, 2016

Return to FAQs

FAQs A-Fib Treatments: Medicines and Drug Therapies

FAQs A-Fib Treatments: Medicines and Drug Therapies

Drug Therapies for Atrial Fibrillation, A-Fib, Afib

Drug Therapies for Atrial Fibrillation

Atrial Fibrillation patients often search for unbiased information and guidance about medicines and drug therapy treatments. These are answers to the most frequently asked questions by patients and their families. (Click on the question to jump to the answer.)

1. Which medications are best to control my Atrial Fibrillation?” “I have a heart condition. What medications work best for me?

2. “Is the “Pill-In-The-Pocket” treatment a cure for A-Fib? When should it be used?”

3. “I take atenolol, a beta-blocker. Will it stop my A-Fib.”

4. I’ve been on amiodarone for over a year. It works for me and keeps me out of A-Fib. But I’m worried about the toxic side effects. What should I do?”

5. Should everyone who has A-Fib be on a blood thinner like warfarin (Coumadin)?”

6. Which is the better anticoagulant to prevent stroke—warfarin (Coumadin) or aspirin?

7. What’s the difference between warfarin and Coumadin?

8. I’m on warfarin. Can I also take aspirin, since it works differently than warfarin? Wouldn’t that give me more protection from an A-Fib (ischemic) stroke?

9. “What are my chances of getting an A-Fib stroke?

10. “I’m worried about having to take the blood thinner warfarin (brand name Coumadin). If I cut myself, do I risk bleeding to death?

11. “I am on Coumadin (warfarin) to thin my blood and prevent A-Fib blood clots. Do I now need to avoid foods with Vitamin K which would interfere with the blood thinning effects of Coumadin?” UPDATED

12. “The A-Fib.com web site claims that an A-Fib stroke is often worse than other causes of stroke. Why is that? If a clot causes a stroke, what difference does it make if it comes from A-Fib or other causes? Isn’t the damage the same?

13. “I just had an Electrical Cardioversion. My doctor wants me to stay on Coumadin for at least one month. Why is that required? They mentioned something about a “stunned atrium.” What is that?

14. Are natural blood thinners for blood clot treatment as good as prescription blood thinners like warfarin?”

15. “How long do I have to be in A-Fib before I develop a clot and have a stroke?

16. I have to be on aspirin for stroke prevention. Which is better—the low-dose baby aspirin (81 mg) or a high dose (325 mg)? Should I take the immediate-release (uncoated) or the enteric-coated aspirin?

17. I don’t want to be on blood thinners for the rest of my life. I’ve had a successful catheter ablation and am no longer in A-Fib. But my doctor says I need to be on a blood thinner. I’ve been told that, even after a successful catheter ablation, I could still have “silent” A-Fib—A-Fib episodes that I’m not aware of.  Is there anything I can do to get off of blood thinners?

18. “My last cardiologist had me on Pradaxa. My new cardiologist wants me to switch to Eliquis. Is Eliquis easier to deal with if bleeding occurs?

19. “My doctor told me about the Tikosyn drug option that I want to consider in getting rid of my 5-month-old persistent A-Fib. That seems like something that should be discussed on your web site.

20. “I hate taking Coumadin. Is there a way to get off blood thinners all together? I know I’m at risk of an A-Fib stroke.”

21. “I”ve read about a new anticoagulant, edoxaban, as an alternative to warfarin (Coumadin) for reducing risk of stroke. For A-Fib patients, how does it compare to warfarin? Should I consider edoxaban instead of the other NOACs?

22. “Do you have information about Hormone Replacement Therapy (HRT) and if it might help or hinder my atrial fibrillation?

23. Are Anticoagulants and blood thinners the same thing? How do they thin the blood?

24. I have A-Fib, and my heart doctor wants me to take Xarelto 15 mg. I am concerned about the side effects which can involve death. What else can I do?

25. “Is the antiarrhythmic drug Multaq [dronedarone] safer than taking amiodarone? How does it compare to other antiarrhythmic drugs?”

Last updated: Wednesday, May 25, 2016

Back to FAQs by Patients with Atrial Fibrillation

FAQs A-Fib Drug Therapy: Post Ablation Blood Thinner?

 FAQs A-Fib Drug Therapy: Post PVI Blood Thinners

Drug Therapies for Atrial Fibrillation, A-Fib, Afib

17. “I’ve had a successful catheter ablation and am no longer in A-Fib. But my doctor says I need to be on a blood thinner because I could still have “silent” A-Fib—A-Fib episodes that I’m not aware of. Is there anything I can do to get off of blood thinners?”

If you’re no longer in A-Fib, you’re also no longer in danger of having an A-Fib stroke. But you can have a “normal” stroke: i.e., a stroke that doesn’t originate from being in A-Fib. That’s probably what your doctor is worried about.

“Silent” A-Fib isn’t as much a problem as in the past. Today’s A-Fib catheter ablation doctors follow their patients for long periods of time after a successful catheter ablation and use an extensive array of monitoring devices to tell if a patient is in “silent” A-Fib. (See: A Primer: Ambulatory Heart Rhythm Monitors) It’s unlikely you’d experience a long period of silent A-Fib without your doctor being aware, though doctors and monitoring devices aren’t infallible.

Most doctors say you don’t need to worry about short A-Fib episodes. Conventional wisdom says it takes 24-48 hours of being in A-Fib for a clot to form. Though some doctors think it takes as little as 5 1/2 hours of being in A-Fib for a clot to develop.

Don’t be hesitant about getting a second opinion if you’re worried about having to be on an anticoagulant. Anticoagulants increase the risk of bleeding disorders. In addition to bleeding, Pradaxa can cause stomach upset or burning, and stomach pain. According to Dr. David Graham of the FDA, “Coumadin (the most commonly prescribed anticoagulant) provides a benefit, but it is also responsible for probably more deaths than any single drug currently marketed.” No one should be on blood thinners unless there’s a real risk of stroke. (See my article: Women in A-Fib Not at Greater Risk of Stroke!)

(Be advised that no anticoagulant regimen or procedure will absolutely guarantee you will never have a stroke. Even warfarin [Coumadin] only reduces the risk of stroke by 55% to 65% in A-Fib patients.)

No one wants to be on blood thinners. You bruise easily, cuts take a long time to stop bleeding, you can’t participate in any contact sports or any activities like mountain climbing, bike riding, etc. If in an accident, you risk bleeding to death, because there is currently no practical way to reverse the anticlotting effect of the newer anticoagulants. When taking anticoagulants, there is an increased risk of developing a hemorrhagic stroke and gastrointestinal bleeding. And anticoagulants often have other bad side effects, make one feel sick, and diminish one’s quality of life.

(Added October 26, 2015:
The FDA granted “accelerated approval” to Praxbind®, a reversal agent (antidote) to Pradaxa®. Praxbind is given intravenously to patients who have uncontrolled bleeding or require emergency surgery.)

Alternatives to Anticoagulants

Here are some alternatives to taking anticoagulants (discuss with your doctor before making any changes in your treatment plan):

•  “Pill-In-The-Pocket”: Katharine had a successful catheter ablation several months ago. She emailed me that she now carries rivaroxiban (Xarelto) with her wherever she goes, though she’s never had to use it.

Rivaroxiban is a newer fast-acting anticoagulant which Katharine would use if she felt she was having an A-Fib episode. If Katharine were in an A-Fib episode, the rivaroxiban would work to prevent a clot from forming. No clinical trials have been done using this strategy, but it makes sense.

This “Pill-In-The-Pocket” approach means Katharine doesn’t have to risk taking heavy-duty anticoagulants for long periods of time or for the rest of her life. (Katharine hasn’t had any A-Fib episodes since her successful catheter ablation. But she’s happy to have rivaroxiban with her just in case.) See also: Treatments/Drug Therapies.

Be advised that this web site is not recommending or suggesting that you quit taking prescription blood thinners.

•  “Natural” Blood Thinners: Do your own research, then discuss this option with your doctor. There are several informative articles about Natural Blood Thinners at LIVESTRONG.COM and an extensive article, “Blood Thinners and Nutritional Supplement” by Dr. Lam on his website. See also Question #14 above.

•  Left Atrial Appendage (LAA) Occlusion Devices: The theory behind these devices which close off the opening of the Left Atrial Appendage is that 90%-95% of A-Fib clots come from the LAA. See Technical Innovation/The Watchman Device and Technical Innovations/The Lariat II.

References for this article

Return to FAQ Drug Therapies

Last updated: Wednesday, May 18, 2016

FAQs A-Fib Drug Therapy: Blood Thinner Warfarin

 FAQs A-Fib Drug Therapy: Warfarin 

Drug Therapies for Atrial Fibrillation, A-Fib, Afib

5. “Should everyone who has A-Fib be on a blood thinner like warfarin (Coumadin)?”

Not necessarily. The biggest danger of A-Fib is the increased risk of stroke, because your heart isn’t pumping out properly.

A blood thinner is used to help protect you from stroke. Your doctor will evaluate your risk of an A-Fib related stroke. If you are young, athletic and in overall good health, your doctor may rate your risk of stroke as low and not put you on a blood thinner.

See, also, the FAQ question Which is the better anticoagulant to prevent stroke?”

Return to FAQ Drug Therapies

A-Fib and Stroke: A Woman’s Perspective

A-Fib and Stroke: Women Under-Diagnosed & Under-Treated:
A Woman’s Perspective

By Lynn Haye

Clot blocking vein

Stroke prevention is the primary focus for all people with A-Fib; men and women, young and old – regardless of the type of A-Fib. Patients with A-Fib have a 5-fold increased risk of stroke. This risk factor increases steeply with age (1.5% at ages 50-59 to 23.5% at ages 80-89)1 In addition, since A-Fib is often asymptomatic and may go clinically undetected, the stroke risk attributed to A-Fib may be substantially underestimated.

The National Stroke Association estimates that at least 1 in 6 strokes are actually caused by A-Fib and that A-Fib strokes are more debilitating with higher rates of mortality. However, three out of four A-Fib strokes can be prevented in patients who have been diagnosed with A-Fib and are receiving appropriate treatment.2

  Her A-Fib Stroke Risk

Recent publications have highlighted the gender differences in stroke risk.3,4 Women have a higher lifetime risk of stroke from all causes, and this is probably related to both life expectancy and treatment variables. The question of female sex as a separate risk factor for stroke in A-Fib is a bit more complicated.

There are two stroke risk tools currently used by physicians to predict risk in A-Fib patients; CHADS2 in the US and the newer CHA2DS2-VASc in Europe.5  The newer tool adds an independent risk factor for female sex and lowers the age range to 65 for risk. (To read more about CHADS2 and CHA2DS2-VASc see our article: The CHADS2 Stroke-Risk Grading System.) This development puts younger women with A-Fib into consideration for anticoagulation medication. Because of the increased risk for bleeding on these medications, there is concern about putting more and younger patients on them.  Anticoagulants are not like taking vitamins. No one should be on anticoagulants unless there is a real risk of stroke.

A recent Danish study 6 found that while female sex increased stroke risk by 20% in A-Fib patients older than 75, it did not do so in female A-Fib patients age 65-74.  This suggests no increased risk for younger women, while older women remain at risk due to age. The current UK protocol in the GARFIELD study 7may answer this difference as they are evaluating the significance of female sex as an independent risk factor for A-Fib stroke in younger patients, age 65-74.


As with other cardiovascular disorders, women with arrhythmias in the US have been under-treated and under-referred.  This less aggressive and/or less effective treatment for A-Fib may put women at higher risk for stroke overall.  Studies have shown that women with A-Fib have been less likely to receive anticoagulation and ablation procedures compared to men, although their treatment benefits are comparable.4

  Elaine’s Stroke

Let’s take the example of Elaine, a college-educated professional who marries at age 25 to Bob, a 32-year-old accountant. They both lead busy but fulfilling lives and have two wonderful children. Elaine is naturally protected from a stroke during her child-bearing years by her menstrual cycle. The blood she loses every month thins her blood and makes her less susceptible to forming clots and having a stroke. But once Elaine enters menopause and no longer has her menstrual cycle, all too soon her risk of stroke becomes the same as her husband, Bob.

Bob unfortunately passes away at age 76 leaving Elaine a widow at age 69. (Women in the US live an average of five years longer than men.) As Elaine ages she becomes more limited in her physical activities. Her blood becomes thicker and less viscous. Clots can more easily form in her heart, especially in the Left Atrial Appendage (where 90-95% of A-Fib clots form). She may develop A-Fib which is more likely to happen as people get older. At age 81 Elaine has an A-Fib stroke.

Unfortunately this scenario is an all too common for women.

  Preventing Her A-Fib Stroke

Is there anything women can do to reduce their risk of stroke? Some things come to mind:

Recognize Important Signs

If you haven’t been formally diagnosed with A-Fib, be sure to take seriously signs such as palpitations, shortness of breath, fatigue, dizziness, chest pain and fainting.  These signs may be significant, not just moods or the result of an ‘off’ day.  Check your pulse for any irregularity – it’s the rhythm not the rate that should concern you here.  Remember, A-Fib stroke may be avoided with early diagnosis and treatment.

See an Electrophysiologist (EP)

If you are newly diagnosed, have you followed up with a cardiologist or, better still, an electrophysiologist (EP)?  EPs see arrhythmias all the time and are usually more current on treatment options.  Sometimes it feels just ‘too’ serious or inappropriate to contact a ‘heart’ specialist, but it’s really more comforting when you are in the care of someone who regularly treats A-Fib.

If you need help locating an electrophysiologist in your area, check the provider list on this web site.

Be Aware—We Women Communicate Differently

Most women agree that we tend to communicate differently!  Contrary to some popular opinion, we often hesitate to complain or report symptoms – even when we know we should.  Some women still see heart problems as ‘masculine’ and can feel awkward presenting cardiac symptoms, particularly to a male physician. Just watch the comedic video by Elizabeth Banks at the American Heart Association website for a very insightful rendition of how we can minimize symptoms (AHA, Go Red for Women, “Just a Little Heart Attack”). It’s painfully funny….

Prepare for Your Electrophysiologist (EP) Appointment

Your physician may have limited time, so be prepared before going in for your appointment. It helps to take a list of questions or concerns to help you stay focused and make the best use of your time.  This also demonstrates the level of seriousness and concern that you bring to the session.

Importance of Blood Thinners for Women

Anticoagulation therapy is so basic to stroke prevention in A-Fib that any woman diagnosed with non-valvular A-Fib should make sure to discuss this with her physician at her first appointment.  But ‘Blood thinners’ carry the risk of bleeding, so your physician may check your risk on the HAS-BLED score.8 before prescribing blood thinners for you.

The newer, novel anticoagulants such as Pradaxa and Xarelto can make adherence easier for women. This is because the lack of dietary restrictions suits the diet of the typically ‘dieting’ woman.  However, the new, novel anticoagulants do not yet have reversal agents and should be used with caution. The other option, warfarin, requires frequent blood monitoring, and women are often very reluctant to add more required tasks to their already busy schedules.  There is a procedure for those who cannot tolerate anticoagulation medication. This procedure involves closing off the left atrial appendage and involves a more detailed and complex risk-benefit analysis.

Know the Symptoms of Stroke!

•  Sudden numbness or weakness of face, arm, leg—especially on one side of the body.
•  Sudden confusion, trouble speaking or understanding
•  Sudden trouble seeing in one or both eyes
•  Sudden trouble walking, dizziness, loss of balance or coordination
•  Sudden severe headache with no known cause

And the Other Symptoms Unique to women!

•  Sudden face and limb pain
•  Sudden hiccups
•  Sudden nausea
•  Sudden general weakness
•  Sudden chest pain
•  Sudden shortness of breath
•  Sudden palpitations

Call your emergency service (dial 911 in the US or 999 in the UK) if you have any of these symptoms, and make sure that your family and friends know that time is critical with stroke.  Everyone should know the simple test to act F.A.S.T.

F = FACE  Ask the person to smile. Does one side of the face droop?

A= ARMS  Ask the person to raise both arms. Does one arm drift down?

S= SPEECH  Ask the person to repeat a simple phrase. Is their speech slurred or strange?

T= TIME  If you observe any of these signs, call 911 immediately. 2

  Aim to be A-Fib Free

Probably the best thing to know about A-Fib stroke prevention is to not have A-Fib!  As Steve Ryan points out so well in his book, “Beat Your A-Fib”, the best preventive for A-Fib stroke is get rid of your A-Fib, to ‘Beat Your A-Fib’.

(posted October 2013)

Prevent an A-Fib stroke—first ‘treat’—then ‘beat’ your A-Fib!

Photo of Lynn Haye, PhD

Lynn Haye, PhD

LYNN HAYE, Ph.D.  is a clinical psychologist and former A-Fib patient. She studies and writes about current trends in the treatment and diagnosis of atrial fibrillation and has a special interest in women’s health issues. Dr. Haye and her family live in Orange County, CA.

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Return to Index of Articles: Research and Innovations

Last updated: Saturday, August 15, 2015

References    (↵ returns to text)

  1.  American Heart Association, Heart disease and stroke statistics 2013 update. www.heart.org
  2.  National Stroke Association www.stroke.org
  3. True Hills, M., ‘Gender Matters: Why Afib is More Fatal for Women’ EP Lab Digest 2013. www.eplabdigest.com/articles/Gender-Matters-Why-Afib-More-Fatal-Women
  4. Curtis, A.B., Narasimha, D., ‘Arrhythmias in Women’ Clinical Cardiology, 2012 Mar; 36(3)   www.ncbi.nlm.nih.gov/pubmed/22389121
  5. www.mdcalc.com/cha2ds2-vasc-score-for-atrial-fibrillation-stroke-risk/
  6. Mikkelsen, A., et al, ‘Female gender increases stroke risk in AF patients aged greater than 75 years by 20%’ European Society of Cardiology. 2012 www.escardio.org
  7. An international longitudinal registry of patients with atrial fibrillation at risk of stroke (GARFIELD): the UK protocol. 2013 www.biomedcentral.com
  8. Curtis, A.B., Narasimha, D., ‘Arrhythmias in Women’ Clinical Cardiology, 2012 Mar; 36(3) www.ncbi.nlm.nih.gov/pubmed/22389121
  9. www.mdcalc.com/has-bled-score-for-major-bleeding-risk/
  10. National Stroke Association www.stroke.org

Role of the Left Atrial Appendage & Removal Issues

Left Atrial Appendage heart illustration; Source: Boston Scientific Inc. educational brochure

The Role of the Left Atrial Appendage (LAA) & Removal Issues

By Steve S. Ryan, PhD

In the first trimester or two of our time in the womb, The Left Atrial Appendage (LAA) was originally our left atrium (LA). When the final real Left Atrium (LA) formed gradually from the conjunction and evolutionary development of the four pulmonary veins, the actual LA chamber grew and ballooned out, pushing the smaller remnant LA up to the left top of the Left Atrium where it became became known as the Left Atrial Appendage (LAA) with its own functions and behaviors.

But as we age and as heart disease/A-Fib, etc. start to set in, the LAA can turn into “the most lethal, no longer essential appendage in the human anatomy.” (Thanks to Shannon Dickson for these insights about the LAA.)

One considered advantage of the Mini-Maze operations is that the Left Atrial Appendage (LAA) is closed or cut off. Most A-Fib blood clots which cause stroke come from the Left Atrial Appendage. By closing off the LAA, most but not all risk of stroke is eliminated even if you are still in A-Fib.

Failure to Completely Close Off the LAA is Common

However, in a study by Surgeon s, “both suture exclusion and stapler exclusion had extraordinarily low success rates. In fact, none of the patients with stapler exclusion had successful closure…This study presents clear evidence of the inadequacy of these techniques.”1

According to Dr. Marc Gillinov of the Cleveland Clinic, staplers “can be hard to apply to the appendage and tend to leave a little cul-de-sac and also cause bleeding and tearing, so they are not particularly safe or effective.”2

However, the AtriClip device (FDA approved June, 2010) makes it much easier for surgeons to close off the LAA during open heart surgery. The surgeon positions the rectangular-shaped device around the LAA and then closes it like a clamp. Blood no longer flows into and out of the Left Atrial Appendage.3 

AtriCure has developed a version of the AtriClip which can be used in Mini-Maze surgery.

Should the LAA be routinely cut out, stapled shut or closed off in all A-Fib patients?

Some question the need or benefit of removing the Left Atrial Appendage (LAA) if someone is no longer in A-Fib.

The rationale for closing off the LAA is that, in case the operation fails which happens occasionally, the patient is still protected from having an A-Fib stroke. 90%-95% of A-Fib strokes come from clots which originate in the LAA. In A-Fib, blood stagnates in the LAA and clots tend to form.

Another important consideration, even if a person is no longer in A-Fib, is that closing off the LAA may still prevent a stroke. The LAA is where most clots originate. If a surgeon is already working on the heart, why not close off the LAA and reduce the patient’s chance of having a future stroke? (If a surgeon didn’t close off the LAA, they could be sued if a patient later had a stroke, even if the patient was no longer in A-Fib.) Life (no stroke) is more important for most people than a possible reduced exercise intolerance.

In the future even people without A-Fib may have their Left Atrial Appendage closed off if it prevents or reduces the risk of a stroke. This may become a way to prevent stroke in older people, particularly women, who are more at risk of stroke as we age. There are currently a variety of devices, surgical and non-surgical, which can do this. LAA closure may become an important new way to reduce strokes, particularly in the elderly.

Functions of the Left Atrial Appendage

Some question the need or benefit of removing the Left Atrial Appendage (LAA) if someone is no longer in A-Fib. For a patient made A-Fib free, would their heart function better or more normally if they still had their LAA?

The LAA functions like a reservoir or decompression chamber or a surge tank on a hot water heater to prevent surges of blood in the left atrium when the mitral valve is closed.4Without it there is increased pressure on the pulmonary veins and left atrium which might possibly lead to heart problems later.


Cutting out or stapling shut the LAA also reduces the amount of blood pumped by the heart and may result in exercise intolerance for people with an active life style. (In dogs the LAA provides 17.2% volume of blood pumped.5) This is usually not a problem for patients with Persistent (Chronic) A-Fib, whose LAA has stopped contracting along with the fibrillating atrium. Cutting out or stapling shut the LAA won’t affect their cardiac output. But this may not be the case for patients with Paroxysmal A-Fib who still have large amounts of normal rhythm and whose LAA still functions normally.

But would a non-functioning LAA return to normal when someone with, for example, longstanding persistent (Chronic) A-Fib becomes A-Fib free?

The author isn’t aware of any surgeons (or EPs) who do pre- and post-LAA closure measurements of exercise ability, heart pumping function, etc. with and without the LAA.

(When doctors do a TEE [Transesophageal Echocardiogram] of the LAA of someone in A-Fib, the LAA doesn’t move at all and blood does not move. Doctors refer to this as “SMOKE” which is shorthand for Spontaneous Echo Contrast. The blood not moving looks like smoke inside the LAA.)

The LAA also has a high concentration of Atrial Natriuretic Factor (ANF) granules which help to reduce blood pressure.6Some preliminary research indicates that when the LAA is closed or cut off, the Right Atrial Appendage produces more ANF to compensate for the lost of the LAA.

Editor’s comment: If you are thinking of having a Cox Maze or Mini-Maze, discuss removing the LAA with the surgeon. Ask if they close off the Left Atrial Appendage and with what: sutures, stapler or the AtriClip.

Posted June 2013

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Return to Index of Articles: Maze, Mini-Maze, Convergent, LAA Closure Surgeries

Last updated: Sunday, February 15, 2015

References    (↵ returns to text)

  1. Damiano, Jr., RJ. “What Is the Best Way to Surgically Eliminate the Left Atrial Appendage?” Journal of the American College of Cardiology 2008, Sept. 9; Vol. 52, No. 11:930-1.
  2. AtriCure’s AtriClip system receives FDA 510(k) clearance (press release). June 14, 2010. 
  3. AtriCure’s AtriClip system receives FDA 510(k) clearance (press release). June 14, 2010.
  4. Al-Saady, N M, et al.  Left atrial appendage: structure, function, and role in thromboembolism
  5. Hondo T. et al. “The Role of the left atrial appendage. A volume loading study in open-chest dogs.” Jpn Heart J 1995 Mar;36(2):225-34.  http://www.ncbi.nlm.nih.gov/pubmed/7596042
  6. Atrial natriuretic peptide. Wikipedia.org. Last accessed April 13, 2014, URL: http://en.wikipedia.org/wiki/Atrial_natriuretic_peptide.

Watchman Occlusion Device – Blood Thinners Alternative

The Watchman device placed in opening to the Left Atrial Appendage

Illustration: The Watchman device placed in opening to the Left Atrial Appendage

The Watchman™ Device: The Alternative to Blood Thinners

By Steve S. Ryan, PhD, updated March 2015

Do you hate having to take Coumadin or other blood thinners? Hate the side effects? Or are you allergic to them? A replacement to taking blood thinners is the Watchman, an occlusion device.

The theory behind the WATCHMAN™ LAA closure technology is that most A-Fib clots originate in the Left Atrial Appendage (LAA). The Watchman closes off the LAA where 90-95% of A-Fib strokes come from. It’s a very low risk procedure that takes as little as 20 minutes to install. Afterward, you would usually not need to be on blood thinners.

Boston Scientific's WATCHMAN™ LAA closure technology

Boston Scientific’s WATCHMAN™ LAA closure technology

How It Works

The Watchman device comes in multiple sizes from 21mm to 33mm to accommodate the different sizes of LAAs. Once a patient’s Left Atrial Appendage is measured, a wide-sheathed catheter with a spline is used to insert the Watchman device which has a self-expanding Nitinol (a special metal) open-ended circular frame.

The atrial surface of this frame is covered with a thin, permeable 160 μm (micron) pore filter made of polyester material (Polyethylene Terephthalate known as Dacron or PET). This filter allows blood to pass through while stopping clots. Little hooks or anchors called fixation barbs at the middle of the device make sure it is attached firmly to the LAA wall.

Before the catheter is removed (which fixes the Watchman in place), contrast agents are used to make sure the Watchman is stable and entirely closes off the LAA opening. Over time heart tissue grows over the polyester (PET) material so that it completely closes off the LAA with smooth heart tissue similar to other heart surfaces.

In this Occlusion image, heart tissue has completely covered the Watchman device after only nine months. 

Anatomical View of the WATCHMAN Device in the LAA 9 months after implantation.

Patients on Coumadin continue to take it for six weeks after the Watchman device is inserted. They are then examined using a TEE (Transesophageal Echocardiogram) to make sure there is complete closure of the LAA. At that time they are taken off of Coumadin and put on a different type of blood thinner called clopidogrel (Plavix) until six months after the implant procedure. 

Think of the Watchman as a replacement for blood thinners; both reduce but do not totally eliminate the risk of stroke. The stroke risk is reduced to that of a person with a normal heart.

Even while you are waiting for or trying to decide on having a Pulmonary Vein Ablation, you can have the Watchman inserted and reduce your stroke risk to that of a person without A-Fib.

The Future

Just as closing off the LAA is standard practice in the Cox Maze/Mini-Maze operations, in the future, the Watchman device could become part of most catheter ablation procedures. If included with the ablation procedure, the Watchman would protect the patient from blood clots even if the catheter ablation procedure was unsuccessful. The Watchman device may become standard therapy for anyone at risk of a stroke, not just for people with A-Fib.

For a list of US doctors installing the Watchman device, go to Steve’s Lists/Doctors Installing the Watchman Device.

Update: The U.S. Food and Drug Administration (FDA) approved Boston Scientific’s WATCHMAN™ LAA closure technology for use in the U.S. on March 13, 2015. It has been available internationally since 2009. The FDA approval of the WATCHMAN device is based on the clinical program which consists of numerous studies, with more than 2,400 patients and nearly 6,000 patient-years of follow-up. The Watchman device will be available first at U.S. centers where it has been used in clinical studies. 
Reference for this Article

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