The WATCHMAN Device Review: A new era for stroke prophylaxis

Abstract

Atrial fibrillation (AF) is a major risk factor for ischemic stroke, accounting for more than 37 million cases worldwide. In AF, the left atrial appendage (LAA) is the most common site of thrombus formation, and its ligation/closure with the WATCHMAN device is a good alternative to long-term oral anticoagulation, especially in patients with contraindications to warfarin. However, the implantation procedure is associated with various risks and complications. A short-term anticoagulant and antithrombotic administration are essential after implantation. However, no consensus has been reached on the optimal regimen. The WATCHMAN device is non-inferior to warfarin and is a safe alternative for the prevention of stroke and systemic embolization related to non-valvular atrial fibrillation (NVAF). Important procedure-related complications include pericardial effusion (PE), device embolization, procedure-related ischemic stroke, and device-related thrombosis (DRT) formation. It is essential to optimize post-implantation therapy according to individual patient bleeding risk, DRT formation, and contraindication to direct oral anticoagulants (DOACs). Recent studies have also shown that DOACs are a convenient and non-inferior substitute for warfarin. Furthermore, patients with absolute contraindications to OACs/DOACs can only be managed with dual antiplatelet therapy (DAPT). Transesophageal echocardiography (TEE) should be used to assess residual peridevice flow and possible DRT formation at days 45 and 12 months. Low molecular weight heparin (LMWH) and OAC are excellent choices for DRT treatment if detected. This review summarizes the most important complications of the WATCHMAN device in the existing literature and discusses various anticoagulation strategies and challenges post-implementation.

A Rare Case of Left Main Coronary Artery Coronary Sinus Fistula in an 85-Year-Old Female

“…The patient was referred to the structural heart clinic for evaluation of left atrial appendage closure through a WATCHMAN device. This minimally invasive procedure is non-inferior to warfarin and is a safe alternative for the prevention of stroke and systemic embolization related to non-valvular atrial fibrillation in settings where anticoagulation is contraindicated [ 4 ]. The transesophageal echocardiograms (TEE) revealed a dilated left main coronary artery with a large anomalous vascular structure, which was suspected to be branching from the left main coronary artery but ultimately could not be identified.…”

Evaluating the effectiveness of echocardiographic guidance in diminishing postoperative wound complications for left atrial appendage closure: A clinical retrospective study

“…TEE provides detailed visualization of the LAA, facilitating accurate device placement, minimizing procedural duration and potentially reducing the risk of complications associated with device misplacement, such as pericardial effusion or device-related thrombus formation. 9,10 The hypothesis that echocardiographic guidance could also play a role in reducing surgical site complications is grounded in the premise that more precise procedural execution might lead to less tissue trauma and, consequently, more favourable wound healing outcomes. This retrospective analysis, therefore, delves into the relationship between the use of echocardiographic guidance in LAA closure procedures and the incidence of postoperative surgical site wound complications.…”

“…Echocardiographic guidance, particularly transoesophageal echocardiography (TEE), has emerged as a vital tool in LAA closure procedures. TEE provides detailed visualization of the LAA, facilitating accurate device placement, minimizing procedural duration and potentially reducing the risk of complications associated with device misplacement, such as pericardial effusion or device‐related thrombus formation 9,10 . The hypothesis that echocardiographic guidance could also play a role in reducing surgical site complications is grounded in the premise that more precise procedural execution might lead to less tissue trauma and, consequently, more favourable wound healing outcomes.…”