Watchman indications

Following the encouraging news from irina1975, I have been looking in to Watchman for myself. So far it seems to me there is a good case for Watchman in young patients on AC particularly if they have a very active sporting lifestyle, and very elderly patients who are more at risk from AC generally, and thirdly anyone not tolerating AC for whatever reason.

The data seems less clear for the middle aged group. 5 year data looks encouraging even though Dr Mandrola has reservations.

Putting the data aside, the questions for me that crop up include

1. After my 2 ablations with a lot a LA remodelling , burning and freezing, I imagine that part of my stroke risk will not be removed by closing the LA appendage (LAA).

2. We are beginning to hear about AF being part of a systemic process, along with stroke. If true, then ablation, Watchman and other procedures may not remove the need for AC.

3. Many of us have had a go at the drug companies over DOACs and Statins, particularly in the matter of funding trials, could there be a similar doubt about Watchman?

My view right now is that I will wait for more follow up data. If my balance problems get worse, or if my CHADS2VASC2 score and HASBLED change, I will start to look in to whether there is a centre in the UK doing Watchman on the NHS.

If anyone else is considering or researching Watchman, I would be glad of your thoughts. Thank you

[BobD Volunteer]

I am one of the growing band who believe that ablation itself may contribute to stroke risk as per your question 1. I had hoped many years ago that successful ablation for me might mean cessation of anticoagulants but was soon persuaded otherwise.

Here in UK there is no general approval for the devices or procedures nor for the trans-thorasic LAA removal technique pioneered here by Dr Jonathan Hyde I believe. In fact there is a body of opinion that LAA is a useful bit of kit which should not be messed with. In order to have LAAO under NHS rules you need to be a special case who for whatever other reasons can not take A/Cs. NHS trials of the watchman device were terminated early a couple of years ago I understand.

[Hidden]

I slightly have the impression that LAAO has not gained any momentum in the UK recently unless for those who are unsuitable for anticoagulation.

I discussed it with my EP little over three years ago, when I was very unsettled on Warfarin and found the newer anticoagulants daunting. He poured quite cold water on my enthusiasm, saying it was not something he offered and in any case he felt I would not be eligible for it as an NHS patient in the UK.

Whilst I am now very happy indeed on Rivaroxaban, there's still that nagging feeling that anticoagulation takes one away from normality.

[seasider18 in reply to Hidden]

Cost is probably the main reason for not offering it. The Amplatzer trials at ten UK hospitals were successful but they put a two year moratorium on continuing due to the high cost of around £10K a procedure.

[Hidden]

Hi Oyster,

We had a very detailed presentation about the Watchman procedure by one of UK’s leading specialists at one of our Support Group meetings which aroused the interest of the majority of the audience. This arousal was soon thwarted when we were told it is unlikely to be performed here for all the reasons explained in BobD’s reply.

Hope to see you Saturday......

[Angie06]

Hi Oyster, I'm due to have a Watchman fitted next week on the NHS as I come into the special case category. Feeling a bit anxious at the moment as not much info on UK cases. Hopefully it will be successful and my stroke risk will decrease.

[seasider18 in reply to Angie06]

dailymail.co.uk/health/arti...

dailymail.co.uk/health/arti...

heartofaf.org/sites/default...

I had the other device the Amplatzer fitted last April and it was a simple procedure and my surgeon had at that time done over a hundred in trials and for NHS and private patients.

[Hidden in reply to seasider18]

Thanks for the last link. Very encouraging, but too soon to be sure, seems to be the take home message.

[Angie06 in reply to seasider18]

Hi Seasider, I've also just had an Amulet device fitted, one day post op, and wondered how you got on with yours? Did you have a TOE after 6wks and if so was it successful? Feeling anxious but too late to turn back now! 😀

[seasider18 in reply to Angie06]

Hi Angie,

Congratulations on going for it. Why did they change from the expected Watchman to the Amplatzer? The amplatzer has a bigger range of sizes. From my operation notes he tried one size but changed it for a bigger size.

I'm sure you will be pleased with the result. I had no problems with the wound or anything else and travelled home by taxi and train the next day.

I was amazed at the team in the theatre and counted eight of them. I asked about a TOE afterwards as I can gag when cleaning my teeth!. The Professor said 'That would be cruel an echocardiogram is all that I need' I had that four weeks later and the amulet was well positioned and he does not need to see me again. Though I have my two yearly echo coming up in August to check my 2012 replaced aortic valve.

I took clopidogrel for a month and a mini aspirin for six months.

[Angie06 in reply to seasider18]

Hi I only found out from reading the discharge form that I'd had the amulet not the Watchman so not sure why they changed it. I know that they had to use the smallest size of device so maybe the Watchman wasn't right. The Consultant/EP that I had before hand and I thought was doing the procedure had advised taking Clopidogrel and mini aspirin the same as you but after arriving home I've only got mini aspirin and they didn't give me any Clopidogrel which is a bit worrying as I'm not sure if they changed the plan or just forgot? I think I should give the EP that operated a ring as he wasn't the original consultant. All very worrying.

[Angie06 in reply to seasider18]

Hi again just wondered which hospital you went to for yours?

Angie

[MarkS]

The NHS Commissioning Board produced this report in 2013:

england.nhs.uk/commissionin...

The evidence summary concludes:

"The main RCT in this area fails to demonstrate that the LAA

occlusion device involved is better than the alternative therapies. The study design may mean that the device has worse outcomes than the usual therapy. Therefore the clinical effectiveness and the cost effectiveness are not established and there is the possibility of more harm than good to any patients receiving the device. "

[seasider18 in reply to MarkS]

After having the Amplatzer fitted last April in Brighton I only had to take clopidogrel for a month and aspirin for six months. There seems to be some debate on how long medication is needed. My only follow up was a echocardiogram after a month to see that the device was well positioned.

[Hidden in reply to seasider18]

I wonder if there is a case for regular echos, at say 6 monthly intervals, until the definitive trials come in.

[seasider18 in reply to Hidden]

I think that one Echo or TOE is enough to show that it has settled in.

As I had my aortic valve replaced in 2012 I I do get echocardiograms anyway. They are now down to two yearly and my next one is due in August so at least it will be viewed again.

[Hidden in reply to seasider18]

I was just wondering if ablation and LA scarring related thrombus, that BobD has talked about, could be picked up in this way.

[seasider18]

Bob might be able to tell you.