How many Watchman procedures to be considered experienced for a Doc?

While it may be subjective, how many Watchman procedures is generally considered a good number in order to say a doc has experience in this area?

I'd want to see hundreds, at least. The one thing the studies have shown quite clearly with LAA occlusion devices is that operator experience is everything. That's obvious when you look at older studies conducted when the Watchman was new and no one had extensive experience and newer studies now that it's been in use for 5+ years. The complication rates dropped dramatically as experience increased.

The only place you're going to find EPs with that level of experience is at major medical centers that have been implanting the device for several years. I wouldn't go for such a procedure with an EP who's new to the device or a small center that does very few of them.

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Edited 2 time(s). Last edit at 06/27/2020 11:47AM by NotLyingAboutMyAfib.

Hi Nlama,
In addition to the great advice Carey offered above regarding assessing an experienced Watchman operator, another key factor is in knowing roughly how many transeptal punctures (TP) has an EP done (mostly during AFIB ablations for the EP), or the number of transeptal punctures an expert Interventional Cardiologist (IC) my have done during various vascular plug installs in the left atria, or while doing LAA Closure procedures like the Watchman themselves.

A highly experienced ablation EP or a maestro-level IC with vast experience in TP are generally a safe bet at doing a solid and safe Watchman install even after as little as 75 to 100 Watchman installs under their belts, due to these operators much greater experience working inside the left atria, during which they will automatically become very familiar with the more challenging steps of a Watchman install even before they have actually performed their first Watchman install. Especially compared to a relatively modest experienced ablation EP, or similarly, a less experienced IC.

That is not to imply that anyone should volunteer for a Watchman install by even the most experienced EP or IC operator who is very comfortable working inside the LA, but who has done only a very limited number of actual Left Atrial Appendage closure procedures with Watchman, LARIAT or a Wavecrest, (when that latest device is fully approved before long).

The best option, as Carey noted above, is always to choose the most experienced operator you can arrange for yourself overall for any type of endocardial work, especially within the left atria.

However, though the situation has rapidly improved over the past few years with many more EPs and ICs around the world getting up to, and well past, the 100 mark in number of Watchman cases on their resumé, for those readers in countries where they may not have access to highly experienced ablation EPs or elite ICs, I might prefer the operator with an extensive left atrial ablation experience, yet who may have only done, say, 100 LAA closure procedures, compared to a younger EP with say 200 LAA closure installs, but who may have had very little overall TP and left atrial exposure outside of just the Watchman installations alone.

The rest of us, with wider access to a larger number of highly experienced ablation EPs or elite ICs who have done a good number of LAA Closure installs, should have the luxury of following Carey's cogent advice above, and don't compromise anymore than necessary in choosing a truly high volume Watchman operator with a solid track record of excellence in these type of procedures.

Cheers!
Shannon



Edited 1 time(s). Last edit at 06/27/2020 01:11PM by Shannon.

Shannon,

If someone gets a Natale ablation and AFIB ends - will they eventually not need any anti-coags and also not need a Watchman?

What cases are watchmen needed?

Thanks

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NotLyingAboutMyAfib
If someone gets a Natale ablation and AFIB ends - will they eventually not need any anti-coags and also not need a Watchman?
What cases are watchmen needed?

Depends on if the LAA needs isolation to end the AFIB. If LAA is isolated, then there is a 60% probability of needing lifetime anticoagulation or a Watchman or similar device.

Also, unlikely to happen on an index or first ablation. Here is a description by Shannon of a Natale index ablation. [www.afibbers.org]



Edited 1 time(s). Last edit at 06/27/2020 03:09PM by GeorgeN.

To add to what George said, assuming you've had a successful ablation, you're beyond the blanking period, and your LAA has not been isolated, then whether you need anticoagulants or not will depend on your CHADS-Vasc score. So if you're a 0 then yes, you can stop them. If you're a 1, it's a judgement call. If you're a 2, you should probably continue them. And if you're a 3 or above, you definitely need to continue them.

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Shannon
In addition to the great advice Carey offered above regarding assessing an experienced Watchman operator, another key factor is in knowing roughly how many transeptal punctures (TP) has an EP done (mostly during AFIB ablations for the EP), or the number of transeptal punctures an expert Interventional Cardiologist (IC) my have done during various vascular plug installs in the left atria, or while doing LAA Closure procedures like the Watchman themselves.

Another way that an IC gains experience with TPs and working in the left atrium is through transcatheter work on the mitral valve—either repair or replacement. I had a MitraClip installed by a very experienced IC who also does transcatheter mitral valve replacements and Watchman procedures.