Who Is WATCHMAN For?
Major Bleeding Risk
Frank has health problems resulting from a fall that put him at risk for major bleeding
- Age: 80
- Involved Grandfather
- NVAF, Congestive Heart Failure, Hypertension, Diabetes
- CHA2DS2-VASc score: 5
- HAS-BLED score: 2
- Although patient is suitable for warfarin, he is currently taking 15 mg rivaroxaban daily
Frank has a history of recurrent falls, resulting in both a broken hip and cerebral contusion after falling on separate occasions. His physician believes his medical condition places him at high risk of major bleeding secondary to trauma*
Frank's physician determined he is a potential candidate for a WATCHMAN Implant
Case description for educational purposes; not a real patient case.
*Some studies of patients with a history of falls, or at risk for falls and head trauma, have shown that the benefits of anticoagulation therapy to reduce the risk of stroke outweigh the risk of major, life-threatening bleeding. An individualized benefit and risk assessment should be made in such patients2‑4
Difficulty Maintaining INR Range
Catherine has challenges with medication costs and being adequately controlled on OACs
- Age: 68
- Retired, Volunteer
- NVAF, Hypertension, Vascular Disease
- CHA2DS2-VASc score: 4
- HAS-BLED score: 3
- Currently taking 5 mg warfarin and 100 mg of aspirin daily
Catherine is unable to comply with regular INR monitoring due to her proximity to the clinic and cannot afford novel oral anticoagulant (NOAC) medication
Catherine's physician determined she is a potential candidate for a WATCHMAN Implant
Lifestyle Creates Potential Bleed Risk
Gwen's lifestyle may elevate the risk of major bleeding
- Age: 65
- Home Health Aide
- NVAF, Diabetes
- CHA2DS2-VASc score: 3
- HAS-BLED score: 3
- Although patient is suitable for warfarin, she is currently taking 150 mg dabigatran twice daily
Gwen's physician determined her active lifestyle, which includes horseback riding, places her at risk of major bleeding secondary to trauma
Gwen's physician determined she is a potential candidate for a WATCHMAN Implant
Occupation Elevates Bleed Risk
The combination of John working as a commercial fisherman and his warfarin regimen prompt concerns about bleeding risks
- Age: 55
- Commercial Fisherman
- NVAF, Hypertension, Diabetes
- CHA2DS2-VASc score: 2
- HAS-BLED score: 2
- Currently taking 5 mg warfarin daily
John's physician feels that his work as a fisherman puts him at risk of major bleeding secondary to trauma.
John's physician determined he is a potential candidate for a WATCHMAN Implant
- Blackshear JL, Odell JA. Appendage obliteration to reduce stroke in cardiac surgical patients with atrial fibrillation. Ann Thorac Surg. 1996;61(2):755-759. 2. American Geriatrics Society/British Geriatrics Society Clinical Practice Guideline for Prevention of Falls in Older Persons. J Am Geriat Soc. 2011;59(1):148-157. http://www.americangeriatrics.org/files/documents/health_care_pros/JAGS.Falls.Guidelines.pdf. 3. Sellers MB, Newby LK. Atrial fibrillation, anticoagulation, fall risk, and outcomes in elderly patients. Am Heart J. 2011;161(2):241-246. 4. Donzé J, Clair C, Hug B, et al. Risk of falls and major bleeds in patients on oral anticoagulation therapy. Am J Med. 2012;125(8):773-778.
WATCHMAN Left Atrial Appendage Closure Device with Delivery System and WATCHMAN Access System
INDICATIONS FOR USE
The WATCHMAN Device is indicated to reduce the risk of thromboembolism from the left atrial appendage in patients with non-valvular atrial fibrillation who:
- Are at increased risk for stroke and systemic embolism based on CHADS2 or CHA2DS2-VASc scores and are recommended for anticoagulation therapy;
- Are deemed by their physicians to be suitable for warfarin; and
- Have an appropriate rationale to seek a non-pharmacologic alternative to warfarin, taking into account the safety and effectiveness of the device compared to warfarin.
The WATCHMAN Access System is intended to provide vascular and transseptal access for all WATCHMAN Left Atrial Appendage Closure Devices with Delivery Systems.
Do not use the WATCHMAN Device if:
- Intracardiac thrombus is visualized by echocardiographic imaging.
- An atrial septal defect repair or closure device or a patent foramen ovale repair or closure device is present.
- The LAA anatomy will not accommodate a device. See Table 46 in the DFU.
- Any of the customary contraindications for other percutaneous catheterization procedures (e.g., patient size too small to accommodate TEE probe or required catheters) or conditions (e.g., active infection, bleeding disorder) are present.
- There are contraindications to the use of warfarin, aspirin, or clopidogrel.
- The patient has a known hypersensitivity to any portion of the device material or the individual components (see Device Description section) such that the use of the WATCHMAN Device is contraindicated.
- Device selection should be based on accurate LAA measurements obtained using fluoro and ultrasound guidance (TEE recommended) in multiple angles (e.g., 0°, 45°, 90°, 135°).
- Do not release the WATCHMAN Device from the core wire if the device does not meet all release criteria.
- If thrombus is observed on the device, warfarin therapy is recommended until resolution of thrombus is demonstrated by TEE.
- The potential for device embolization exists with cardioversion <30 days following device implantation. Verify device position post-cardioversion during this period.
- Administer appropriate endocarditis prophylaxis for 6 months following device implantation. The decision to continue endocarditis prophylaxis beyond 6 months is at physician discretion.
- For single use only. Do not reuse, reprocess, or resterilize.
- The safety and effectiveness (and benefit-risk profile) of the WATCHMAN Device has not been established in patients for whom long-term anticoagulation is determined to be contraindicated.
- The LAA is a thin-walled structure. Use caution when accessing the LAA and deploying the device.
- Use caution when introducing the WATCHMAN Access System to prevent damage to cardiac structures.
- Use caution when introducing the Delivery System to prevent damage to cardiac structures.
- To prevent damage to the Delivery Catheter or device, do not allow the WATCHMAN Device to protrude beyond the distal tip of the Delivery Catheter when inserting the Delivery System into the Access Sheath.
- If using a power injector, the maximum pressure should not exceed 100 psi.
- In view of the concerns that were raised by the RE-ALIGN1 study of dabigatran in the presence of prosthetic mechanical heart valves, caution should be used when prescribing oral anticoagulants other than warfarin in patients treated with the WATCHMAN Device. The WATCHMAN Device has only been evaluated with the use of warfarin post-device implantation.
Potential adverse events (in alphabetical order) which may be associated with the use of a left atrial appendage closure device or implantation procedure include but are not limited to:Air embolism, Airway trauma, Allergic reaction to contrast media/medications or device materials, Altered mental status, Anemia requiring transfusion, Anesthesia risks, Angina, Anoxic encephalopathy, Arrhythmias, Atrial septal defect, AV fistula, Bruising, hematoma or seroma, Cardiac perforation, Chest pain/discomfort, Confusion post procedure, Congestive heart failure, Contrast related nephropathy, Cranial bleed, Decreased hemoglobin, Deep vein thrombosis, Death, Device embolism, Device fracture, Device thrombosis, Edema, Excessive bleeding, Fever, Groin pain, Groin puncture bleed, Hematuria, Hemoptysis, Hypotension, Hypoxia, Improper wound healing, Inability to reposition, recapture, or retrieve the device, Infection/pneumonia, Interatrial septum thrombus, Intratracheal bleeding, Major bleeding requiring transfusion, Misplacement of the device/improper seal of the appendage/movement of device from appendage wall, Myocardia erosion, Nausea, Oral bleeding, Pericardial effusion/tamponade, Pleural effusion, Prolonged bleeding from a laceration, Pseudoaneurysm, Pulmonary edema, Renal failure, Respiratory insufficiency/failure, Surgical removal of the device, Stroke – Ischemic, Stroke – Hemorrhagic, Systemic embolism, TEE complications (throat pain, bleeding, esophageal trauma), Thrombocytopenia, Thrombosis, Transient ischemic attack (TIA), Valvular damage, Vasovagal reactions. There may be other potential adverse events that are unforeseen at this time.
CAUTION: Federal law (USA) restricts this device to sale by or on the order of a physician. Rx only. Prior to use, please see the complete “Directions for Use” for more information on Indications, Contraindications, Warnings, Precautions, Adverse Events, and Operator’s Instructions.
1. Eikelboom JW, Connolly SJ, Brueckmann M, et al. N Engl J Med 2013;369:1206-14.