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Next course of action: Watchman or pacemaker?

Posted by Chuck Connors 
Next course of action: Watchman or pacemaker?
September 09, 2017 12:42AM
I'd be interested in learning if any others have had a similar experience as I have.

I've had 2 ablations and have been afib free for nearly two (2) years. Approximately one year ago my doctor stated that he didn't think I was a candidate for a pacemaker, as the pauses were too short to go down that road. This year he had wanted to discuss closure of left atrial appendage. I was told late last year that the new Watchman procedure was being further studied, and his office wanted to wait to see if this would be a good option for me. I'm now being told that I'm a candidate for a pacemaker. I'd appreciate any insight into differences and functionality of both the Watchman and pacemaker. Thank you.

All the best,

Chuck
Re: Next course of action: Watchman or pacemaker?
September 09, 2017 08:22AM
Hi Chuck,

Well that's a head scratcher as the two devices aren't addressing the same issue really at all. Unless there is more to the story that might somehow explain why your Cardio or Doc of another specialty is even discussing the two devices in the same breath, especially for a patient who has been AFIB free for 2+ years now after what sounds like was a successful ablation process!? Did you require a left atrial appendage isolation Chuck as part of your ablation process??

The Watchman is an endocardial plug like device inserted into the LAA to close the ostium or mouth of the LAA in order to protect against LAA-based clot formation that makes for AFIB/AFlutter embolic events like strokes/TIAs. If your LAA is still fully mechanically functional and you are truly in durable sinus rhythm you have no obvious need for LAA Closure and thus no need for a Watchman at all.

Do you have a high CHADS-VASc stroke risk score?? Even if so, in the absence of any bonefide atrial arrhythmia episodes at all the Watchman still would be not indicated.

It sounds like your doc is considering a pacer for you based on bradycardia with long pauses which apparently are still not low enough HR nor long enough pauses for you to be a good candidate for the pacer install ... except your doc has now changed his or her mind and recommends the pacer now, is that correct? Be aware too that very often a modest degree of bradycardia can and usually does improving after re-establishing permanent NSR such as you seem
to be enjoying after your second ablation.

Thus the pacer won't help if you are in durable 24/7/365 normal sinus rhythm now either. So I'm stumped as to why your Cardio or EP is even discussing the Watchman or pacemaker as an either/or choice for you in the first place?? Can you enlighten us any further Chuck on just why your Doc suggests you might benefit from either device at this point?

Absent a good explanation that escapes me here at 5:30am early on Saturday morning, I would want to seriously grill my doc to make sure he or she can defend this rather odd sounding choice!

Thanks for clarifying the context for your docs apparent choice here.

Shannon
Re: Next course of action: Watchman or pacemaker?
September 09, 2017 04:45PM
Hi Shannon,

Thank you for your reply. It is mystifying, which is why I posted. I'm hopeful that I'll be speaking with my doc in the coming week and will make a point of meeting with him in-person, as only so much can be conveyed over the phone.

After the 2nd ablation in December 2015, and the ZEO patch results six (6) months post ablation, as well as results of an additional ZEO patch two (2) months ago, the doc said that my velocity (medical term?) was at 28, which is why he has kept me on Xarelto. The ZEO patch did reveal the pauses, which explains the dizziness I've been experiencing, although no afib. That still doesn't explain the following advise:
1) July 2016. Advised by my doc that I'm not a candidate for a pacemaker, due to the pauses being too short.
2) Oct. 2016. In-person meeting w/ the doc who advised me to call his office in one (1) year to discuss closure of LAA. He told me that the new Watchman procedure was currently being studied, and he wanted to wait to see if this would be a good option for me.
3) Sept. 2017: The doc's nurse practitioner called me to tell me that I'm a candidate for a pacemaker and was going to refer me back to my local cardiologist to perform that procedure.

I'm unsure what my CHADS-VASc score is, although will inquire this coming week.

I'm sure that all of my questions will be resolved once I meet with my doc. Thanks again for the time you took to reply.

All the best,

Chuck
Re: Next course of action: Watchman or pacemaker?
September 11, 2017 08:19AM
CHADS-VASc: <[en.wikipedia.org]

"as well as results of an additional ZEO patch two (2) months ago, the doc said that my velocity (medical term?) was at 28, which is why he has kept me on Xarelto."

If your LAA emptying velocity is 28, then you are a candidate for Watchman, also why you need to stay on Xarelto. However, the way you measure this, as I understand it, is with a TEE <[www.ncbi.nlm.nih.gov] Not sure how a ZIO patch would measure. It would only measure rate and arrhythmia as an ECG. The ZIO could indicate whether a pacemaker is needed, but I'd ask to be shown the data and question what the duration of the pauses are that suggest a pacemaker is needed.
Re: Next course of action: Watchman or pacemaker?
September 13, 2017 12:36PM
Yes George is right Chuck,

A ZIO-Patch report does not measure or detect in any way one's LAA emptying velocity ... nor any other echocardiographic parameter. LAA emptying velocity is accurately measured via a TEE (trans-esophageal-echocardiogram) done at least 6 months after an LAA Isolation ablation.

If your cardio is suggesting he measured an LAA emptying velocity of 28cm/sec you must have also had a TEE post LAA isolation correct?? It is not a test one would typically forget as they either anesthetize you our out you in deep conscious sedation before sticking the TEE tube down your esophagus.

Shannon
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