TEE Assessment for Watchman Device Patients
TEE surveillance after Watchman device placement should systematically evaluate for device-related thrombus, peridevice leak, device position and stability, and left atrial appendage sealing at 45 days and 1 year post-implantation. 1
Standard TEE Surveillance Protocol
Perform TEE at 45 days and 1 year after Watchman placement to evaluate for device-related complications before discontinuing anticoagulation. 1 This timing allows detection of both early and late complications, as device-related thrombus can develop in new patients between surveillance intervals who had no prior thrombus at 45 days. 2
Critical Assessment Components
Device-Related Thrombus (DRT)
- Systematically evaluate all device surfaces for thrombus using multiple TEE views, as DRT occurs in approximately 3.2-5.7% of patients at 45 days and may increase to 5.6% at 1 year. 3, 2
- Use five standardized echocardiographic criteria developed from the PROTECT-AF trial to diagnose DRT with high inter-observer agreement. 3
- Recognize that DRT carries significant clinical risk, with stroke, peripheral embolism, or cardiac/unexplained death occurring at 3.4 per 100 patient-years in affected patients. 3
Peridevice Leak (PDL)
- Assess for any peridevice leak using color Doppler from multiple views, as any leak (regardless of size) is associated with increased thromboembolism risk. 1
- Specifically measure leak size, noting that leaks >5 mm are considered significant and occur in approximately 15% of patients at 45 days, decreasing to 8.9% at 1 year. 2
- Effective left atrial appendage closure is defined as no leak or leak ≤5 mm, which should be achieved in >99% of properly deployed devices. 4
Device Position and Stability
- Verify device position relative to the left atrial appendage ostium, ensuring the device has not embolized or migrated. 5
- Assess device compression (recommended range 10-30%) to confirm appropriate sizing and seating. 4
- Evaluate for device impingement on surrounding structures, particularly the mitral valve, as catastrophic mitral regurgitation can occur with device dislodgement. 5
Left Atrial Appendage Sealing
- Document complete LAA sealing from multiple TEE views (typically mid-esophageal views at 0°, 45°, 90°, and 135°). 4
- Use 3D TEE when available to provide en face views of the device and LAA ostium for comprehensive assessment. 4
High-Risk Features Requiring Enhanced Surveillance
Certain patient characteristics warrant closer monitoring:
- Non-paroxysmal atrial fibrillation increases DRT risk (OR 1.90-2.24). 1
- Renal insufficiency substantially increases DRT risk (OR 4.02). 1
- History of TIA or stroke increases DRT risk (OR 2.31) and is significantly associated with complications at 1-year follow-up. 1, 2
- Deep device implantation (>10 mm from pulmonary vein limbus) increases DRT risk (OR 2.41). 1
Clinical Decision Points
Continue anticoagulation if DRT is detected at 45 days, as all cases in the EWOLUTION trial resolved with continued anticoagulation therapy. 2
Do not discontinue anticoagulation based solely on 45-day TEE results if high-risk features are present, as new DRT can develop between surveillance intervals in patients without prior thrombus. 2
Recognize that high-grade hypoattenuated thickening (a form of DRT) significantly increases stroke risk (HR 4.6), making detection critical for clinical decision-making. 1
Technical Considerations
TEE provides superior visualization compared to transthoracic echocardiography for posterior cardiac structures and device assessment, with higher spatial resolution essential for detecting small thrombi and leaks. 6
Intracardiac echocardiography from the left atrium can successfully guide Watchman FLX implantation and may serve as an alternative to TEE in select cases, though TEE remains the standard for surveillance imaging. 4
Ensure adequate sedation for TEE, as hemodynamic changes from sedation may affect valvular flow assessment, though this is less critical for device evaluation than for valvular assessment. 6