- Hey, I'm Dr. Morales.
I'm a board-certified cardiologist
as well as electrophysiologist,
and I have treated 1,000s of patients
with atrial fibrillation.
In this video, I'm going to discuss the Watchman procedure
which is an excellent alternative option
for stroke risk reduction
for a lot of patients with atrial fibrillation.
I'm gonna discuss what it does, how it helps,
as well as the procedure itself
so you can kind of help figure out
if this is a good option for you as well.
If you like this video,
you wanna check out more videos
that I've made on atrial fibrillation,
check out my page underneath this video here as well.
Also, click that subscribe button
so you can be up-to-date on the rest of my videos as well.
So let's talk about atrial fibrillation
as well as the Watchman procedure.
I'm gonna talk about stroke risk reduction,
why does AFib cause risk of stroke,
Why medications are usually needed,
and ultimately talk about the Watchman procedure
and how it can be an excellent alternative
for a lot of people who have atrial fibrillation.
Atrial fibrillation is the most common heart arrhythmia
worldwide affecting over 5 million people
in the United States and over 30 million people
across the globe.
And it significantly increases a person's risk of stroke.
In general, somebody with atrial fibrillation
has a five-times higher risk of stroke
than people who do not have atrial fibrillation.
But it can be very individualized.
Not everybody has the same risk of stroke.
Somebody who is younger may have not as high risk of stroke
as somebody who is older or has other health problems.
The most common risk factor scoring system
is called a CHADSVASc Risk Score.
That really helps your doctor decide
what is your individual risk for stroke.
So if you need to learn more about stroke risk reduction,
check out some links underneath this video
if you wanna understand a little bit more
about how your individual risk of stroke pertains
or affects your own treatment strategy.
But why does atrial fibrillation increase risk of stroke?
Well, atrial fibrillation, as I always tell people,
comes from the atria,
which are the top portions of a person's heart.
Top portions of the patient's heart,
instead of beating and contracting in unison,
like a normal heartbeat does, it's just kind of quivering.
It's just going so fast and so erratic,
it's not pumping that blood very well,
and blood tends to become stagnant
when any people have atrial fibrillation.
That can eventually lead to clots
and increase risk of stroke.
But the main risk of stroke actually comes
in a very specific area of the heart.
In an area of the heart,
and specifically in the left upper chamber of the heart,
there's a little pocket in the left side of the heart,
called the appendage.
Kind of like a cul-de-sac, a little blind alley,
a little pocket off to the left side of the heart.
And that's where blood tends to become very stagnant
when people are in atrial fibrillation.
It just doesn't move,
doesn't circulate as well in that pocket area.
And that's where most blood clots form.
Some studies in the past have noticed that over 90%
of blood clots that form in atrial fibrillation are formed
in that little pocket area right there,
called the left atrial appendage.
So that's really where the main risk of strokes comes from.
People get a blood clot, it develops usually in that area.
Then, it goes to the person's brain
and it can lead to a risk of stroke.
So how do you prevent that?
How do you reduce that risk of having
that blood clot inside of your heart?
For many, many years,
the main treatment is with blood-thinning medication.
Blood-thinning medication significantly reduces risk
of blood clots in that area in that left atrial appendage
and significantly reduces risk of stroke.
In general, for most people with atrial fibrillation,
the main treatment recommendation is gonna be
stronger blood-thinning medication,
such as Eliquis or Xarelto were
probably the most common ones used these days.
But there's also other options as well.
Other medications, including Pradaxa or Savaysa,
can be options as well.
As well as another medication called warfarin,
which has been a very long time.
It's been around well over 50 years.
It's been around for a long time
and that helps thin blood so that you reduce risk of stroke.
Back a long time ago, late 80s, early 90s,
there were some studies comparing warfarin,
which is a stronger blood thinner,
comparing that to aspirin,
which is a much lighter blood thinner.
And back at those times,
warfarin consistently was rated better,
consistently won on all those clinical trials
to reduce risk of stroke compared to aspirin.
So in general,
stronger blood thinners are needed to reduce
that risk of stroke for most people.
And it's been known for a long time.
And these newer blood thinners were studied
together against warfarin in many,
several clinical trials involving 1,000s of patients.
It showed that it was as effective as warfarin
for reducing risk of stroke.
All these stronger blood thinners reduced risk of stroke,
roughly about 60 to 70% based
on the individual clinical trials.
They certainly are very good,
very beneficial for reducing risk of stroke.
However, you wanna prevent a blood clot
in that area of your heart, right?
But it's a blood thinner that you take as a pill,
it thins your blood everywhere, okay?
So it doesn't just thin your blood
in that one specific area.
It can thin your blood everywhere.
And that can unfortunately increase bleeding risk.
People as they get older and they have more health problems,
they have a higher risk of stroke from atrial fibrillation,
which is why they need blood-thinning medications,
but they also have a higher risk for bleeding as well.
And so that is a little bit of a caveat
with being a stronger blood thinner is
that the bleeding risk becomes higher as well.
And so people can either get simple bleeds like nose bleeds,
or significant bruising on their skin.
But you can also have major bleeding as well.
So just bleeding in your stomach,
bleeding in your stool, bleeding in your urine.
Sometimes people can have a slow bleed
that doesn't really become evident as bleed, but then,
become very symptomatic such as dizziness, lightheadedness,
and you know that your blood counts are extremely low.
And that's usually because of a blood loss
that has happened over a prolonged period of time,
several weeks or several months.
So blood loss can be significant
for people who they're on a stronger blood thinner.
So it can be problematic to be
on these strong blood-thinning medications for some people.
Now, there's some people who take these strong
blood-thinning medications and they do great.
They're on it for many years at a time,
never have a bleeding problem.
They do just fine with the medications.
But many people do have bleeding issues
and may not be able to tolerate those standard
recommended blood-thinning medication.
But bleeding isn't the only problem as well.
Sometimes there are injury problems.
There's many people, especially as they get older,
they have balance issues, they have fall issues.
They're at risk for bleeding if they hurt themselves.
Or even they've had a history of passing out as well.
And so those also can increase your risk
if you're on a very strong blood-thinning medication
if you are prone to falls or have some balance problems.
So these all make it very problematic
to take very strong blood-thinning medication
in this particular patient setting.
So what are the alternatives?
Going back many years ago,
the options were either to take
the strong blood-thinning medication
or don't take the strong blood-thinning medication.
And not taking the strong blood-thinning medication
increases risk of stroke.
So taking a lighter blood thinner like an aspirin
or even taking natural blood-thinning medication
which is not as potent as even as an aspirin,
and certainly not as potent as this traditional
blood-thinning medication
increases risk for having a stroke.
And so that was sort of the problem.
You gotta take that blood thinners
and maybe risk for bleeding
or you don't take the blood thinners
and you have risk for stroke.
But fortunately, there are options,
such as your Watchman procedure these days.
Going back to the anatomy of why atrial fibrillation
causes risk for stroke.
That main area is that appendage area.
And excluding that appendage area
or sealing it off is actually not a new concept.
It's the idea of doing it in a minimally invasive way,
which is a relatively new thing
that the Watchman came out with
when it was first approved by the FDA.
That left atrial appendage has been excluded
for variety of years,
but it was just a more invasive procedure.
The left atrial appendage can be excluded.
It can be sewn down.
It can be sutured.
It can be clipped off from the outside surface of the heart.
That usually involved a bigger procedure
that was traditionally usually done
if people were getting heart surgery for another reason.
Like if you were having a heart surgery,
like a bypass surgery where they open up your chest
and they had to do bypass surgery,
they may sew down that appendage area
or they may kind of use a clip
to sew it down from the outside.
Or if you're having a valve surgery.
So usually it was in the setting
of a more open valve surgery is a way
that it was previously kind of sewed off
or excluded from the rest of the circulation.
These days, there are some people
who still get it done surgically.
There are some more minimally invasive surgical options
called an atrial clip,
where you can still sew it from the outside.
But more commonly, it's done in a more
in a minimally invasive and a vascular way,
which is what the Watchman does.
In a Watchman procedure,
a Watchman is basically a plug
which goes into the left atrial appendage,
which helps seal that area off
and excludes it from the rest of the circulation.
They've been studied in numerous clinical trials.
There even has long-term follow-up for well over five years
showing that it's as effective as being
on strong blood-thinning medications,
such as Xarelto or Eliquis.
Looking at their clinical trials,
and I'll put some links underneath this video,
looking at their clinical trials,
the bleeding risk goes dramatically down
when you're not on strong blood-thinning medication.
And overall, the risk of stroke is as effective
as if you were on the stronger blood-thinning medication.
Nothing are 100% protection for risk of stroke.
But if you imagine it is equivalent to being on Eliquis
in terms of stroke risk reduction,
but without having all the bleeding risks.
Let's talk about the procedure itself.
The procedure itself, I usually do 'em under anesthesia,
but they're increasing more to do it
in more of a twilight sedation.
There's a couple of ways in which it can be done.
But just with the needle puncture,
I get inside of your main vein in your left femoral vein,
which is the upper part of your leg.
I take a catheter that goes up to your heart, okay?
In the area of your heart,
you have that left upper atrial appendage,
which is right here, in this demo right here.
Take a catheter and cross over
from the right area to the left area,
take a catheter over to this left atrial appendage.
When I'm inside of that left atrial appendage,
I can kind of figure out what size works best for you
because there's actually five different sizes
of this Watchman device.
And we kind of make measurements inside.
We make sure that we find the right one
that is best for you.
So when I'm happy with that,
then, I would actually deploy the Watchman itself.
It comes collapsed inside of a catheter,
but once I have it a position, I open it up and deploy it,
and it kind of looks like this.
It's like a plug inside of that left atrial appendage.
There's a couple of tests that we have to do
to kind of make sure that we're happy with the size,
happy with the position before I release it and let it go.
So in the end, this is how it gets left behind.
All the catheters get removed, and that's it.
Procedure itself typically takes less than an hour to do.
You lay in bed for a few hours afterwards.
These days, the time when I'm making this video,
most of my patients are going home the same day
of the procedure after a few hours of bedrest.
Things that have changed with Watchman over the years
as more and more experiences happened
since the original device was
originally FDA-approved many years ago,
and then, nowadays, at the time
of this video was being made,
immediately after the procedure,
you do not have to take the strong
blood-thinning medication anymore.
Previously, when a Watchman first came out,
they were recommended to be on 45 days still
of strong blood-thinning medication
like warfarin, or Eliquis, or Xarelto.
But then, checking to make sure it's well-sealed off.
And then, you don't need the strong
blood-thinning medication anymore.
But now, after having a lot more data
and having been around for so many more years,
they have gotten new FDA approval
just about a few months ago.
And immediately after the procedure,
you don't need to be on the strong
blood-thinning medication anymore.
You do still need some lighter blood-thinning medications.
They do recommend taking two light blood thinners
such as a baby aspirin,
as well as another one called Plavix or clopidogrel.
And that can be taken for about six months.
After that, only the baby aspirin is all you really need.
And so it has really been a good benefit
for a lot of patients to immediately to be able to take
the stronger blood-thinning medication,
take only lighter blood-thinning medications afterwards.
Overall, I've implanted almost 200 Watchmans.
I think it's been a very good option
for a lot of patients who cannot tolerate
standard recommended blood-thinning medications.
The pros and cons?
It's a procedure,
so there's always some risks for procedures.
But overall, risks for this procedure
have been relatively low in my experience.
Risks, even nationwide risks of bleeding,
when you look at clinical studies,
major problems like bleeding around the heart
or major bleeding around the leg where it's entered
are all less than 1%.
And I really haven't had any major problems
in any of the patients that I've put in a Watchman in.
I've done it on patients who are in their 60s
all the way through in their 90s, okay?
And so, and then, they all had legitimate medical reasons
to not be on blood-thinning medications, so...
So if you're on blood-thinning for atrial fibrillation
and you've been recommended to do a Watchman procedure,
and you know you really have trouble tolerating
strong blood-thinning medication,
such as you've had bleeding problems,
or maybe you're a fall risk,
certainly consider a Watchman procedure.
I think it is an excellent option for a lot
of patients for their atrial fibrillation.
I've done it many times in my patients.
I'll do links underneath the videos so you can learn more.
But take a look at it
and I think it could be an excellent option
for a lot of patients.
There are also alternatives as well.
There's other competitors coming with different products.
Watchman is the most well-known.
It's been planted the most in patients across the world,
but there's other companies creating
similar products as well.
There's another one called an Amplatzer,
which was recently FDA-approved
within the last year, I believe.
And other companies are also working
on their similar products as well.
So this whole concept of excluding the left atrial appendage
is something that's gonna continue to grow and grow.
And I think more and more patients are gonna get it,
especially as more products become available.
And I'm really excited to see where the future goes
because blood-thinning medications are excellent,
they work well, but a lot of people cannot tolerate 'em.
And we needed to have good options for these patients.
I hope you enjoyed this video.
If you'd like to see more,
please check my channel, "Dr. AFib."