What is the role of a Watchman (Left Atrial Appendage Closure Device) for atrial fibrillation (Afib)?

From the Guidelines

The Watchman device is a recommended option for patients with atrial fibrillation (AFib) who are at high risk for stroke but cannot take long-term blood thinners, as it has been shown to be as effective as warfarin for stroke prevention while reducing bleeding risks over time 1.

Key Points

• The Watchman device is a small, parachute-shaped implant placed in the left atrial appendage (LAA) of the heart, where most stroke-causing blood clots form in AFib patients.
• The procedure is minimally invasive, performed under general anesthesia, and typically takes about an hour.
• After implantation, patients usually stay in the hospital overnight and initially need to take blood thinners (often warfarin) for about 45 days until the device becomes fully incorporated into the heart tissue.
• Then patients transition to dual antiplatelet therapy (aspirin plus clopidogrel) for another 4.5 months, and finally to aspirin alone indefinitely.
• Clinical trials have shown that the Watchman device reduces the risk of hemorrhagic strokes compared to warfarin, but may increase the risk of ischemic strokes, although this difference is not significant when periprocedural events are excluded 1.

Patient Selection

• The Watchman device is generally reserved for patients with contraindications to long-term anticoagulation therapy, such as those with a high risk of bleeding or poor drug tolerance or adherence.
• Patients should have a CHADS2 score ≥2 or a CHA2DS2-VASc score ≥3 to be considered for the device.
• The procedure requires specific heart anatomy, and patients should be deemed suitable for anticoagulation and a period of periprocedural anticoagulation.

Ongoing Research

• There is increasing experience outside the United States with LAA closure in oral anticoagulation–ineligible patients using an antiplatelet regimen only, and this is the focus of an ongoing RCT 1.
• Further research is needed to determine the optimal patient selection and periprocedural antithrombotic regimen for the Watchman device.

From the Research

Role of Watchman (Left Atrial Appendage Closure Device) for Atrial Fibrillation (Afib)

The Watchman device is a left atrial appendage closure device used for stroke prevention in patients with non-valvular atrial fibrillation (NVAF) [ 2, 3,4,5,6 ].

Key Findings

• The Watchman device has been shown to be non-inferior to anticoagulation with warfarin for a combined endpoint in patients with NVAF 3.
• Left atrial appendage occlusion with the Watchman device can be safely performed without a warfarin transition and is a reasonable alternative for patients at high risk for stroke but with contraindications to systemic oral anticoagulation 4.
• The annual rates for ischemic stroke and other thromboembolic events were low, ranging from 0.8% to 2.2% 2, 5.
• Major bleeding during follow-up occurred at an annual rate of 1.1% to 1.3% 2, 5.

Device Implantation and Follow-up

• Device implantation was successful in 95.5% to 100% of procedures 2, 5.
• The rate of major procedural complications was low, ranging from 2.2% to 3.6% 2, 5.
• Follow-up data showed that left atrial appendage occlusion is a safe and effective stroke prevention therapy in high-risk NVAF cohorts, both at implantation and over longer follow-up periods 2, 5.

Indications and Patient Selection

• The Watchman device is indicated for patients with NVAF who are at high risk for stroke and have contraindications to oral anticoagulants 2, 4.
• Patient selection should be based on individual risk assessment, including CHA2DS2-VASc and HAS-BLED scores 2, 5.