How is defibrillation performed in patients with a Watchman (Left Atrial Appendage Closure) device?

Defibrillation in Patients with Watchman Left Atrial Appendage Closure Device

Standard defibrillation protocols should be followed in patients with Watchman devices, with electrode pad placement at least 8 cm away from the implanted device to minimize the risk of device damage or malfunction.

Understanding the Watchman Device

The Watchman device is a percutaneously implanted left atrial appendage (LAA) closure device used for stroke prevention in patients with atrial fibrillation. It consists of a self-expanding nitinol cage with a polyethylene membrane that occludes the LAA to prevent thrombus formation and embolization 1.

Defibrillation Approach

Pad Placement

• Anteroposterior or anterolateral positions are acceptable for patients with implanted cardiac devices 1
• Position pads/paddles at least 8 cm away from the Watchman device to prevent potential damage or interference 1
• Avoid placing defibrillation pads directly over the device, but do not delay defibrillation if optimal pad placement would cause delays 1

Energy Settings

• Use standard energy settings as you would for patients without Watchman devices
• No energy modifications are required specifically for patients with LAA closure devices

Additional Considerations

• Remove any transdermal medication patches and wipe the area before attaching electrode pads 1
• If the patient is wet or diaphoretic, briskly wipe the chest before attaching electrode pads 1
• For excessive chest hair, consider rapid shaving in the pad area if it would not delay defibrillation 1

Post-Defibrillation Management

After successful defibrillation:

1. Perform a post-procedure transthoracic echocardiogram to assess for device position and integrity
2. Consider transesophageal echocardiography if there are concerns about device dislodgement or damage
3. Continue the patient's antithrombotic regimen as previously prescribed

Potential Complications

While there is limited specific literature on defibrillation in patients with Watchman devices, general concerns with defibrillation near implanted cardiac devices include:

• Potential for device dislodgement (though rare with properly positioned defibrillation pads)
• Possible damage to the device electronics or structure
• Transient sensing abnormalities

Clinical Pearls

• Do not delay defibrillation in life-threatening arrhythmias due to concerns about the Watchman device
• The benefits of prompt defibrillation outweigh the theoretical risks to the device
• Follow-up imaging after defibrillation may be reasonable to confirm device position and integrity
• Watchman devices are designed to withstand standard external defibrillation when proper pad placement is used

The presence of a Watchman device should not significantly alter the approach to emergency defibrillation, as the primary goal remains restoration of a perfusing rhythm to preserve life.