Watchman Leak: Low Dose Eliquis or Baby Aspirin?

Dr. Natale put my Watchman in back in August 2022. Fast-forward three years and I’m still dealing with a potential "tiny leak." For the past year, he’s had me on this unusual plan — Eliquis 2.5 mg once a day. It seems to work fine since I haven’t had any issues.

My local EP, though, thinks this protocol is crazy. He says I should at least be taking 2.5 mg twice a day (if not the full 5 mg twice a day) or just switch to baby aspirin. He doesn’t think I’m fully protected if a leak is still there.

This spring I met with a Watchman specialist who looked at all three of my CTA scans since the implant. He said he’s not convinced there’s even a leak — and if there is, it’s only about 2 mm, well within Boston Scientific’s 5 mm threshold. He said the “leak” might just be scan noise and that I could safely move to baby aspirin, even every other day or a few times a week if I wanted.

Dr. Natale’s team has me scheduled for one last CTA scan to see if it’s sealed. They’ll give me a final plan after that.

Here’s what I’m wondering:

If there’s still a small leak (around 2 mm), would you stay on the odd 2.5 mg once-a-day plan, switch to twice-a-day, or go to baby aspirin?

If it’s completely sealed, would you move to aspirin or just stick with Eliquis?

For context, I had nosebleeds on 2.5 mg twice daily, but none on the once-daily dose, which is why I suspect Dr. Natale moved me to the one a day protocol. I’m fine staying on this “weird” protocol if it’s actually giving me enough protection, but part of me worries I’m not fully covered. And I keep hearing mixed things about long-term aspirin use and stomach issues, so that adds to the confusion.

Would love to hear what other Watchman folks are doing and what your doctors have recommended in similar situations.

Thanks!
Travis

I would go by your 'adjusted' CHA2DS2-VASc score. Do that calculation, being scrupulous about entering veridical data, and then adjust the score by one full point if your Watchman is suspected by leaking.................upward. That score should give you a decent approximation of your whole-body risk of a stroke. If it's under 2.0, go with what Natale says is right for you. If it's above 2.0 take the recommended 5mg BID. That's what I would do.

I've been on 2.5 mg Eliquis (bid) since I got the Watchman in 2018. Before making the aspirin/Eliquis choice, I ran it past my PCP and my local EP. They both agreed that Eliquis is the safer, more effective choice. It's not a weird protocol. Natale and other EPs use it frequently. And even if you do have a leak, 2 mm isn't really of great concern. I would follow Natale's guidance. He does Watchman's day in and day out. He'd done 700 when he did mine, so I would expect he's well into the thousands now 7 years later. How many has your local EP done?

Carey:

One of the partners in my local EP's practice was involved in the creation and initial testing of the Watchman. Their group was one of the first groups to do the trials on Watchman implants so they are very experienced with these implants.

The issue here, however, is about what protocol makes the most sense given my situation. Assuming I still have this 2mm leak, Natale has had me on ONE 2.5mg tablet of Eliquis per day. My local EP said he's never heard of that protocol. They do 2.5mg 2x daily, 5mg 2x daily, or baby aspirin every day. He just thought the 2.5 once daily protocol was odd and not something they see or recommend -for their own Watchman patients - especially if you have a leak (even if it's a very minor leak).He is just concerned that I'm not fully protected given the half life of Eliquis.

I have no problem taking 2.5mg of Eliquis twice a day but when I was on that dose for the first year, I always got 1-2 "major" nose bleeds in the winter. And when I'd cut myself, I would bleed pretty bad. I brought this to Dr. Natale's attention and that's why he said it was o.k. to go to 2.5mg once daily. Since I did that, I haven't had an issue with nose bleeds, bad bleeding when I get cut, etc.

I respect my local EP because his group is very experienced with these implants but I also respect Dr. Natale. My thinking is if it's not broken, don't fix it so I'm leaning towards just sticking with one 2.5mg tablet a day, but there is this thought in the back of my head that I may not be fully protected. Do I deal with the occasional bad nose bleed and cut bleeds and go to 2.5mg twice daily, or do I just stick with what I'm doing and hope I'm protected enough? And if this latest scan shows that my Watchman is sealed, do I stick with one 2.5mg Elquis per day or do I switch to aspirin.

If I didn't have nose bleeds and bad cut bleeds on 2.5mg twice daily, this would be a no brainer, but because I do I don't know what protocol to follow. For what it's worth, Natale's group told me that if it's sealed, they will give me the green light to switch to aspirin. If the leak is still present, they will keep me on my current protocol indefinitely.

Travis

Natale also participated in the first clinical trials so what you have is two top experts disagreeing with each other. That usually means there's not a huge difference between the choices.

I think if I were in your shoes I'd follow Natale's guidance, but I would probably put up with the nosebleeds and go to twice daily if there's a leak. Get a humidifier to use in the winter and that should reduce your nosebleeds.

I had my Watchman when Carey did, and Natale now has me on every other day low-dose aspirin. No leaks.

I too was on 2.5mg after my watchman. However I got my second DVT and now required a full 5mg BID.

I’m mentioning this in case anyone develops a DVT while on half dose Eliquis.

Thanks Carey. I'll see what happens after my next CT scan. I'm crossing my fingers that the leak is sealed. Otherwise, I'll probably have to switch to 2.5mg twice daily of Eliquis.

Good luck and let us know how the CT turns out.