What are the post-procedure instructions for a patient after Watchman (Left Atrial Appendage Closure Device) implantation?

Post-Watchman Discharge Instructions

Sherry should receive dual antiplatelet therapy (aspirin plus clopidogrel) starting immediately after discharge, continue this for 45 days to 6 months, then transition to aspirin alone indefinitely. 1

Medication Regimen

Standard Post-Procedure Anticoagulation Protocol

• Aspirin plus clopidogrel (DAPT) for 45 days to 6 months post-implantation 1

  • This is the standard regimen for patients who cannot tolerate warfarin 1
  • After 6 months, transition to aspirin alone indefinitely 1

• Alternative regimen (if she can tolerate warfarin):

  • Warfarin (target INR 2.0-3.0) plus aspirin for at least 45 days 1
  • Then aspirin plus clopidogrel from 45 days to 6 months 1
  • Then aspirin alone indefinitely after 6 months 1

Important Medication Considerations

• Avoid combining multiple anticoagulants to reduce bleeding risk in this elderly population 2
• If she develops atrial fibrillation post-procedure, continue low-dose aspirin but avoid adding other antiplatelet agents if anticoagulation is required 2

Activity Restrictions

Immediate Post-Discharge (First Week)

• Avoid driving for at least 7 days to allow proper healing 3
• Keep the groin access site clean and dry for the first week 3
• Avoid submerging the incision in water (no baths, swimming) until completely healed 3

First 4-6 Weeks

• Avoid lifting objects heavier than 5-10 pounds during the healing period 3
• Limit strenuous activities during recovery 2
• Avoid activities with high injury risk or contact sports 2
• Most activities can be resumed within a few days, with full recovery within a few weeks 2

Follow-Up Schedule

Required Imaging Surveillance

• TEE at 45 days post-procedure to evaluate for device-related thrombus and peridevice leak before discontinuing anticoagulation 1
• TEE at 1 year post-procedure for continued surveillance 1
• These imaging studies are critical because device-related thrombus occurs in approximately 2.4-4% of patients 1, 4

Clinical Follow-Up Visits

• First follow-up at 45 days for device interrogation and TEE 1
• Follow-up at 6 months 2
• Follow-up at 1 year and annually thereafter 2

Warning Signs Requiring Immediate Medical Attention

Groin Access Site Complications

• Redness, swelling, warmth, or drainage from the incision site (signs of infection) 3
• Expanding hematoma or severe bruising at the groin 3

Cardiac Complications

• Sudden onset of chest pain, shortness of breath, or palpitations (possible pericardial effusion or tamponade, which occurs in approximately 1% of cases) 2, 4
• Sudden weakness, numbness, vision changes, or difficulty speaking (signs of stroke) 2
• Syncope or near-syncope (possible hemodynamic compromise) 2

Device-Related Concerns

• New onset atrial fibrillation or flutter (occurs in 1.8% of patients with persistent AF and 1.2% with transient AF) 2

Special Precautions

Electromagnetic Interference

• Carry device identification card at all times 2, 3
• The card should include device type and MRI information 2
• For future surgical procedures involving electrocautery: position the receiving plate so current does not pass through the device, use short intermittent bursts at lowest energy, consider bipolar electrocautery instead of monopolar 3

MRI Considerations

• MRI at 1.5T can be performed safely following manufacturer instructions for MRI-conditional devices 3
• Consultation required with ordering physician, cardiologist, radiologist, and device manufacturer before any MRI 3

Wound Care

• Monitor the groin incision daily for signs of infection 3
• Keep the site clean and dry until completely healed 3
• Report any concerning changes immediately 3

Risk Factors to Monitor

Sherry has specific risk factors that increase her complication risk:

• Age (69 years): elderly patients have higher bleeding risk with antiplatelet therapy 2
• Monitor for device-related thrombus risk factors: non-paroxysmal AF (OR 1.90-2.24), renal insufficiency (OR 4.02), history of TIA/stroke (OR 2.31) 1
• Deep device implantation (>10 mm from pulmonary vein limbus) increases thrombus risk (OR 2.41) 1

Expected Outcomes

• Stroke prevention: The Watchman device is non-inferior to warfarin for preventing stroke, systemic embolism, and cardiovascular death 1
• Hemorrhagic stroke risk: significantly lower compared to long-term warfarin (RR 0.09; 95% CI 0-0.45) 1
• Ischemic stroke rate: approximately 1.7% per year in patients with contraindications to anticoagulation 5
• Device-related thrombus: occurs in 2.4-4% of patients, which is associated with increased stroke risk (HR 4.6) if high-grade hypoattenuated thickening is detected 1, 4, 6

Common Pitfalls to Avoid

• Do not discontinue antiplatelet therapy prematurely before the 45-day TEE confirms adequate device position and absence of thrombus 1
• Do not skip the mandatory TEE surveillance at 45 days and 1 year, as any peridevice leak is associated with increased thromboembolism risk 1
• Do not combine multiple anticoagulants unnecessarily in this elderly patient to minimize bleeding risk 2