Watchman_Procedure.jpg

Diagnosed with non-valvular atrial fibrillation and prescribed lifelong warfarin? Well, despair not, for there is a relief from continual use of this drug. It is the Watchman Device.

This is a permanent implant and effectively reduces your risk of having a stroke without any bleeding risk that is associated with long-term warfarin use. The Watchman Device also helps in eliminating diet restrictions and the need for regular blood tests related to warfarin use.

Similar to Mitraclip for mitral regurgitation or TAVR for aortic stenosis, the Watchman procedure is also a type of structural heart procedure.

The WatchmanDevice and Reduced Stroke Risk

The Watchman device is a small implant that is placed in the heart to decrease the chances of a person with atrial fibrillation (AFib) developing a stroke.

A human heart has a small sac present on the top left side called the left atrial appendage. In AFib patients, this sac quivers and has stagnant blood present, which can result in the formation of clots, known as left appendage clots.

These clots can get dislodged and travel to the brain, which can result in you having a stroke. Doctors believe that AFib is one of the primary causes of strokes in patients, and appendage clots are the prime suspect.

Implantation of the Watchman Device into the left atrial appendage helps in closing off the appendage and preventing the formation of clots.

Who is Eligible

Historically, AFib patients were prescribed warfarin, a blood thinner, to reduce the clot formation. However, most of the AFib patients cannot tolerate warfarin.

They can develop complications like bleeding issues, increased risk of falling, intolerance to medication, and also lifestyle issues. The Watchman Device is an ideal alternative for such patients.

An Ideal Watchman Device Candidate

For a person to be considered a suitable candidate for Watchman Device implantation, they should meet the following criteria.

Increased stroke risk

Doctors use a scoring system called CHADS2 or CHA2DS2-VASc for determining whether a patient is at increased risk for developing a stroke. The CHADS2 score is.
  • Congestive heart failure – 1 point
  • Hypertension – 1 point
  • Age ≥ 75 – 1 point
  • Diabetes – 1 point
  • Stroke – 2 points
If a patient scores 2 or 3 points in a CHADS2 scoring system, then they are at a higher risk of developing stroke and need to be treated conventionally with blood thinners.

Deemed ideal candidate by their doctor for warfarin

The second criterion for a patient to be deemed a perfect warfarin candidate is an ability to tolerate the medication for 45 days after undergoing a procedure and endothelialization process.

You also have to take another blood thinner Plavix for six months or more.

Appropriate rationale for seeking non-pharmacologic warfarin alternative

There has to be an appropriate rationale for the doctor to prescribe a non-pharmacologic alternative such as Watchman Device to a patient.

The first line of defense for AFib patients who have a high risk for stroke is blood thinners such as warfarin. The Watchman Device is recommended to only those who are deemed unsuitable for the use of blood thinners in the long term.

Some examples of a person suitable for Watchman Device include patients at risk of bleeding due to several reasons, at increased fall risk, or patients with a lifestyle that is incompatible for daily blood thinners.

Regardless of the reason, there should appropriate rationale for using The Watchman Device.

The Watchman Procedure

The goal of this procedure is to close left atrial appendage, where clots are formed, which can result in strokes in AFib patients. The paragraphs below explain the Watchman procedure.

A minimally invasive procedure, the Watchman Device procedure utilizes the vessels present in the leg. The patient is anesthetized, and the leg vessel is accessed by the surgeon with the help of wire and needle.

Once access is obtained, a tube is passed right up to the right chamber. This tube is passed from the right chamber to the left by creating a hole in the inter-atrial septum, also called a transseptal puncture.

Once the transseptal hole is created, a tube which will deliver the device is then placed into the left atrial appendage. A pigtail catheter is used for positioning the tube. The use of a pigtail catheter minimizes the damage to the surrounding heart structures.

The Watchman Device is advanced through the tube. When the tube is in place, it is slowly pulled backward. The Watchman Device is then released and takes its final shape at the appendageal mouth.

The surgeon does numerous checks, including a tug test, to ensure that the device is firmly secure. The device which is attached to the delivery cord is then slowly detached by unscrewing it from the cord. The device is once again checked for stability.

Once the device has been placed, over the next few weeks to months, the body, through endothelialization, covers the device with a natural lining. This ensures that the device is stable lifelong. It also ensures the prevention of clot formation.

The video of the Watchman Device procedure can be viewed here


Appendage Type

The Watchman Device helps in covering and eliminating the appendage, thereby reducing the risk of clots.

There are three types of appendages:
  • Broccoli
  • Chicken-wing
  • Windsock.
While they may sound funny, but the name accurately describes appendageal shape.

The easiest appendage to close is the windsock type since one can deliver the device quickly. The chicken-wing can sometimes be very difficult and sometimes very straightforward. The most challenging type of appendage to close is the broccoli type.

Despite the difficulties, the success rate of Watchman Device in all three types is very high.

How Long Will The Device Last

The Watchman Device has been placed in countless thousands of AFib patients over the past decade, and data regarding the device longevity is being accumulated.

Since the device undergoes an endothelialization process, it ideally should last lifelong.

Advantages of Watchman Device

The most significant advantage of the Watchman Device is that the patients can stop the use of strong blood thinners within 45 days of undergoing the procedure.

This helps in avoiding daily medicines, which can result in substantial cost savings over a lifetime.

Risks of Watchman Device

Like any other procedure, even the Watchman Device also has specific risks associated with it, namely

Damage to vessels in the leg

Since the procedure is done through the leg vessels, there is a small chance of injury or damage to the vessels. However, any damage to this can be rectified quickly.

Risk of infection

The chances of the infection are high during the initial post-surgery phase, and the patient should be administered appropriate antibiotics. Theoretically, the chances of infection are high at the entry site or the device itself, which is extremely rare.

Damage to structures of the heart

The heart structures are thin, and the chances of it suffering any tear or pericardial effusion are high during any heart procedure. In some instances, emergency surgery might be required, or a drain is placed to rectify the damage.

Device embolization

If the Watchman Device is not seated correctly, then theoretically, it could come loose and float till it gets entangled in a heart structure. Retrieving the device might require major surgery.

However, there is an extensive checklist to ensure the device is safely placed.

In Conclusion

The Watchman Device is a device that can help an AFIB switch off from the lifelong requirement on being on a blood thinner. You should consult your doctor and the cardiologist to see if you are suitable for this procedure.