From the Guidelines
Concomitant catheter ablation and Watchman (Left Atrial Appendage Closure) device implantation can be safely performed together in appropriate patients with atrial fibrillation, offering a single procedure and recovery period, and reducing overall healthcare utilization and patient burden. This combined approach is reasonable for patients who need both rhythm control (ablation) and stroke prevention but have contraindications to long-term anticoagulation 1. After the procedure, patients typically require anticoagulation with warfarin for 45 days until device endothelialization occurs, followed by dual antiplatelet therapy (aspirin 81mg daily plus clopidogrel 75mg daily) for 4.5 months, and then lifelong aspirin 81mg daily. The post-procedure protocol includes transesophageal echocardiography at 45 days to confirm proper Watchman placement and seal before transitioning from anticoagulation to antiplatelet therapy.
Some key considerations for this combined approach include:
- Patient selection should consider factors such as left atrial size, thrombus risk, anticoagulation contraindications, and overall procedural risk 1
- Close follow-up with both electrophysiology and cardiology is essential to monitor rhythm control and device function 1
- The procedure may slightly increase procedural time, radiation exposure, and potential for complications compared to staged procedures 1
- The Watchman device has been compared with warfarin in patients with AF, and a meta-analysis demonstrated that patients receiving the device had significantly fewer hemorrhagic strokes than did those receiving warfarin, but there was an increase in ischemic strokes in the device group 1
Overall, the decision to perform concomitant catheter ablation and Watchman device implantation should be individualized based on patient-specific factors and made in consultation with a multidisciplinary team of electrophysiologists, cardiologists, and other relevant specialists.
From the Research
Implications of Concurrent Catheter Ablation and Watchman Device Implantation
The implications of concurrent catheter ablation and Watchman (Left Atrial Appendage Closure) device implantation can be understood through several key points:
- Feasibility and Safety: Studies have shown that combined procedures of catheter ablation for atrial fibrillation and Watchman LAA implant are feasible and safe, with excellent rates of LAA occlusion achieved 2, 3, 4.
- Stroke Prevention: The Watchman device has been found to be at least as effective as warfarin in preventing stroke (all-causes) and death (all-causes) 5.
- Reduction of Thromboembolic Events: Catheter ablation has been shown to decrease the risk of stroke and transient ischemic attack events, and combining it with Watchman implantation may further reduce the incidence of stroke in high-risk patients 5.
- Mid-term Outcomes: Mid-term outcomes of concomitant left atrial appendage closure and catheter ablation have been found to be safe, with a low rate of complications and a high rate of complete sealing 6.
- Potential Benefits: The combined procedure may enable patients to undergo implantation of the Watchman device without subsequent warfarin treatment, presenting an avenue of treatment previously unavailable to patients ineligible for warfarin treatment due to recurrent bleeding or other warfarin-associated problems 5.
Key Findings
Some key findings from the studies include:
- A 30-day serious adverse event rate of 8.7% and a device and/or procedure-related serious adverse event rate of 1.4% 3.
- A mean case time of 213±40 min and a complete LAA occlusion rate of 94% at initial implant 2.
- A 12-month freedom from detectable AF of 77% and an observed stroke rate of 0.5% per year during mid-term follow-up 2.
- A mid-term outcome of 36% atrial arrhythmia relapse and 91.8% complete sealing, with two transient ischemic attacks and one ischemic stroke under an off-oral anticoagulant situation 6.