Dr. Rick Henderson of AnMed Health Arrhythmia Specialists in Anderson, South Carolina, was recently the first in the region to offer the WATCHMAN Left Atrial Appendage Closure (Boston Scientific) implant. Learn more about his program here.
Tell us about your EP program at AnMed Health Arrhythmia Specialists. How many EP labs are there, and how many staff are on your team?
We have 2 full-time dedicated EP labs, an OR suite, and a hybrid room. There is currently 7 full-time staff, made up of certified techs and nurses. We’ve got a couple of openings as well.
How many atrial fibrillation (AF) cases do you see, on average?
For a community program, we’re pretty busy. We performed 200 AF ablations last year.
When did you start using the WATCHMAN? About how many patients have you implanted with the WATCHMAN so far?
We started implanting the WATCHMAN about six months ago. We’ve implanted the device in approximately 15 patients thus far.
Tell us about your first cases using the WATCHMAN. Why was it utilized in these instances? Who is the right WATCHMAN patient?
Some of the first patients we saw were at high risk for anticoagulation because of a prior bleeding event or had an exceptionally high risk of injury due to falls, lifestyle, or occupation. We saw some patients that were not candidates for the WATCHMAN because they were not candidates for short-term anticoagulation. Other patients that were referred to us had already had their left atrial appendage occluded in some way during open-heart surgery. Therefore, disseminating the indications and information into the medical community has been part of the challenge of getting our WATCHMAN program up and running.
Who is part of your WATCHMAN team during the implantation process? Do you utilize a collaborative approach?
Yes. In addition to myself, we have one interventional cardiologist who has been doing the echo portion of the procedure (he has not done any of the implants at this point). Early into the program, we implemented cardiothoracic surgery as backup in terms of outcomes and complications. We have an anesthesia team that is cardiovascular trained. Boston Scientific also sends their implanting team, so clinical support from industry has been fabulous. Our staff act as a technical backup.
How long does the implant procedure take?
We’ve seen a lot of variation. It can be as little as 35-40 minutes, but as long as about 2 hours.
What troubleshooting methods and tips for procedural success do you have for the WATCHMAN?
We have our patients come in a week or two prior to the procedure to get a preliminary transesophageal echocardiogram (TEE), to make sure that we’ve identified and defined the anatomy and ensure there is no appendage problem there that would be prohibitive on the day of the procedure. Several of our cases have been for patients that we have ablated in the past, so CAT scans with 3D reconstruction have been available, and that is obviously a good screening tool as well. The most important aspect, though, is working with the patient and their primary care physician to make sure that everything leading up to the procedure, including a mandated discussion with a non-implanting provider, has been done. The preauthorization process can be cumbersome and take quite a bit of office time, so we want to make sure all of our proverbial i’s are dotted and t’s are crossed before the day of the procedure.
How soon after WATCHMAN implant does the patient discontinue blood thinners?
From day 1 at implant, they are on warfarin for 6 weeks. At 6 weeks, we’ll bring the patient back for another comprehensive TEE, to make sure that there is still good position and seal of the closure device. At that point, warfarin is discontinued. Patients are then given aspirin and clopidogrel for 4 and a half months. After 6 months, it’s aspirin alone.
What other methods for left atrial appendage occlusion do you also use or were using previously?
We electively, and this was a decision that I independently made, were holding out for an FDA-approved closure device for stroke risk reduction. We have not used the LARIAT device (SentreHeart, Inc.). We were strongly looking into St. Jude Medical’s AMPLATZER Cardiac Plug (ACP) trial, and now that the trial will be resuming, we are very interested in that technology as well. From an anatomical standpoint, we found that there are some patients that simply aren’t suited for WATCHMAN that may be suited for the AMPLATZER Cardiac Plug. So we’re looking forward to when that trial resumes.
Why is the WATCHMAN a better alternative than blood thinners for treating AF?
Patients who have had complications on blood thinners are going to benefit the most. Patients with a high risk of bleeding due to their blood thinner will definitely benefit from the WATCHMAN as well. Regarding novel anticoagulants, we don’t have any prospective randomized data on appendage closure vs novel anticoagulants. Therefore, a discussion with the patient is needed, but that can be part of the pre-implant discussion with your patient.
Is there anything else you’d like to add?
As a medium-sized (~700-bed) institution in somewhat of a rural area in South Carolina, we’ve experienced some unique challenges in trying to get this novel technology introduced not only to the public but to the medical community as well. There has been a lot of legwork involved on our part in getting buy-in into the program and technology — it has been kind of a grassroots approach to simply disseminating that information. We’ve done a lot of seminars and talks about the WATCHMAN device and what it does, just to get that information out there. I suspect a lot of other community programs across the nation will be encountering some of the same challenges in getting their program off and running that we’ve had here in Anderson. It’s important not to give up, and to continue to get out there with that information and disseminate it in any way that’s appropriate. We’ve had a lot of success.
Disclosure: Dr. Henderson has no conflicts of interest to report regarding the content herein. Outside the submitted work, he reports receiving personal fees from Pfizer and Biosense Webster for lectures.