Utility of Transesophageal Echocardiogram Surveillance after Watchman
Device Placement
Abstract
Background: In atrial fibrillation patients undergoing left atrial
appendage occlusion with a Watchman device, surveillance imaging with a
transesophageal echocardiogram (TEE) is typically performed at 45 days
and 1 year to evaluate for device-related thrombus (DRT) and peri-device
leak (PDL) before cessation of oral anticoagulation. The incidence of
these complications is relatively low, and the ideal timing and duration
of surveillance is unknown. We sought to evaluate the incidence of DRT
and PDL after Watchman placement at 45 days and 1 year to determine the
necessity of surveillance TEEs. Methods: We retrospectively analyzed 361
patients who received a Watchman device between January 2016 and January
2020. Baseline clinical and echocardiographic data, post-procedure
antithrombotic therapy and surveillance echocardiographic data were
collected from the NCDR LAAO Registry. Nested backward variable
elimination regression was performed to derive independent predictors of
the composite outcome of DRT and PDL. Results: A total of 286 patients
who had post-procedure TEEs were included in the analysis. At 45 days, 9
patients had DRT (3.2%) and 44 patients had PDL (15.0%). At 1 year, 5
patients had DRT (5.6%) and 8 patients had PDL (8.9%). All DRT at 45
days was treated with continued anticoagulation while no change in
protocol occurred with PDL. All DRT at 1 year occurred in new patients
without prior thrombus. A history of prior transient ischemic attack
(TIA) and thromboembolism were significantly associated with DRT or PDL
at 1 year. Conclusions: We identified several patients with
device-related complications at 45 days and 1 year despite appropriate
device sizing and adequate use of antithrombotic therapy. The incidence
of DRT increased from 45 days to 1 year and occurred in patients without
prior thrombus. These findings highlight the importance of surveillance
imaging and suggest the potential need for extended surveillance in
select patients.