When should a Transesophageal Echocardiogram (TEE) be checked after Watchman placement?

TEE Surveillance After Watchman Placement

A transesophageal echocardiogram (TEE) should be performed at 45 days and 1 year after Watchman left atrial appendage occlusion device placement to evaluate for device-related thrombus and peridevice leak before discontinuing anticoagulation. 1, 2

Standard TEE Surveillance Protocol

• The standard protocol for TEE surveillance after Watchman placement includes:

  • First TEE at 45 days post-implantation 3, 4
  • Second TEE at 1 year post-implantation 5, 2

• The 45-day TEE is crucial for:

  • Assessing for device-related thrombus (DRT) 3
  • Evaluating for peridevice leak (PDL) (≤5mm is considered acceptable) 4
  • Making decisions about anticoagulation discontinuation 4

• If the 45-day TEE shows:

  • No significant PDL (≤5mm)
  • No DRT
  • Then warfarin can be discontinued and replaced with dual antiplatelet therapy (aspirin and clopidogrel) for 6 months, followed by aspirin indefinitely 4

Rationale for TEE Timing

• The 45-day timepoint is critical as it represents when anticoagulation is typically discontinued in the standard protocol 4, 6
• The 1-year follow-up is important because:
  • New DRT can develop after discontinuation of more intensive antithrombotic therapy 5
  • Studies show that 5.6% of patients may develop DRT at 1 year, even without prior thrombus at 45 days 5
  • The incidence of DRT may actually increase from 45 days to 1 year in some patient populations 5

Emerging Alternative Approaches

• Some centers are exploring a 4-month initial TEE instead of the 45-day TEE based on:
  • Evidence that DRT is most likely to occur after instituting aspirin monotherapy 6
  • Studies showing no ischemic strokes between 45 days and 4 months with this approach 6
  • DRT detection rate of 2.4% at 4 months in one study of 530 patients 6

Risk Factors for Device-Related Complications

• Factors associated with increased risk of DRT include:
  • Non-paroxysmal atrial fibrillation (OR 1.90–2.24) 1
  • Renal insufficiency (OR 4.02) 1
  • History of TIA or stroke (OR 2.31) 1, 5
  • Deep device implantation (>10 mm from pulmonary vein limbus; OR 2.41) 1
  • Larger device size 3
  • Discontinuation of anticoagulant/antiplatelet therapy 3

Management of Complications Detected on TEE

• If DRT is detected at any surveillance TEE:

  • Reinitiate or continue oral anticoagulation 3, 2
  • Complete resolution of thrombus can typically be achieved with warfarin therapy 3
  • Low molecular weight heparin is an alternative option 2
  • Repeat TEE should be performed to confirm thrombus resolution 3

• If significant PDL is detected:

  • PDL rates range from 15% at 45 days to 8.9% at 1 year 5
  • Any peridevice leak detected by TEE, regardless of size, is associated with increased risk of thromboembolism 1
  • Management typically involves continued clinical monitoring rather than intervention 5

Special Considerations

• Patients with high bleeding risk may require modified antithrombotic regimens:

  • DAPT alone (aspirin and clopidogrel) for 6 months followed by aspirin indefinitely may be considered 4
  • These patients still require the standard TEE surveillance protocol 4, 2

• Patients with history of prior TIA or thromboembolism:

  • May benefit from extended surveillance beyond 1 year 5
  • Have significantly higher association with DRT or PDL at 1 year 5

Clinical Implications

• The detection of high-grade hypoattenuated thickening (a form of DRT) is significantly associated with increased stroke risk (HR 4.6) 1
• No change in surveillance protocol is typically needed for PDL, but DRT requires continued anticoagulation 5
• All patients with DRT at 45 days in studies had resolution with continued anticoagulation 3