How can 4 TEES show my watchman is perfectly sealed and today a new TEE shows it leaking?

Dr N performed a watchman because it was an emergency and I had GI bleeding and needed to be off Eliquis. So he did 2 TEES during the procedure to make sure it was sealed properly. Then at 9 months I had another TEE and it was sealed. I might have had a 6 month as well. The 9 month TEE was because I was leaving the country and had it early.

Today I had a 35 month post watchman TEE because my ablation is tomorrow and a TEE is one of the tests they do. I never had a 2 year post watchman TEE and I asked the EP to take a look for me.

It showed it leaking.

How can that be?

Shouldn’t endothelium natural tissue growth creates a permanent seal over the sealed watchman to prevent it from leaking? I’m going to get a CD just to get a second set of eyes. But I am very surprised.

AI’s answer. I don’t remember this ever being discussed:

AI Overview
A previously sealed WATCHMAN device can show a leak after three years due to several factors, including the variability in human healing responses, potential changes in the left atrial appendage (LAA) anatomy over time, or subtle issues with the device itself that develop over the long term. The initial seal is formed by a combination of the device's physical fit and the body's natural healing process, which involves tissue growth (endothelialization) over the implant surface.
The Role of Endothelial Tissue Growth
While the goal of the procedure is for permanent endothelial coverage to create a durable seal, this process is not always uniform or entirely predictable in humans, and in some cases, it may not be completely permanent.
Incomplete or Delayed Endothelialization: Animal studies suggest endothelialization takes about 45 days, but human data is less clear. In some patients, the tissue growth may be incomplete or delayed, even years after the procedure. This could leave microscopic gaps that are initially not detectable but might change over time.
Tissue Changes: The LAA is a dynamic, muscular structure. Changes in heart function, size, or natural remodeling of the LAA over a three-year period could affect the apposition (fit) of the device against the LAA wall, creating or worsening a leak that was not present before.
Potential Causes for a Late Leak Detection
The appearance of a leak after three TEEs showed a seal could be attributed to one or more of the following:
Imaging Sensitivity: Transesophageal echocardiograms (TEEs) have some limitations in detecting very small leaks, and sensitivity can vary between different scans or operators. It is possible a minimal leak was present all along but went undetected in the first three TEEs, only becoming apparent in a later, more sensitive scan or as it slightly increased in size.
Device Migration or Shift: Though designed to be a permanent implant, micro-migration of the device can occur in rare cases over time, altering its position relative to the LAA wall and creating a new pathway for blood flow (a peridevice leak).
Device Integrity Issues: Proposed, though rare, mechanisms for late leaks can include issues with the device material itself, such as fabric fatigue or a nitinol strut fracture.
Anatomical Variability: The LAA has a highly variable and complex anatomy. Achieving a perfect, permanent seal with a fixed-shape device can be challenging, and long-term anatomical changes might reveal initial fitting imperfections.

I'm skeptical of the new TEE results.

Damn....where's that like button when you want one.

Susan knows how to find good info, but I'm standing right behind Carey and nodding. 'Inter-rater variability', or 'inter-operator variability'. A second opinion is a good idea here. If it checks out, then Susan's post seems to fit.

I don’t understand why they didn’t start me on antibiotics for strep throat. My throat is razor blades. I have to have faith these doctors won’t maim me or kill me and I will survive unscathed.

The EP coordinator who admitted me today insisted I stay on Eliquis. My EP refused so with a leaking watchman, i let them fight it out. My EP won and I’m not protected. I have layers of concerns. I’m back on a nebulizer and oxygen and because I’m allergic to iodine, I’m taking 40mg of prednisone, tomorrow two doses of 80mg. I don’t like steroids.

I weaned off of Tenormin from 100mg to zero in 16 days. My palpitations are not pleasant.

Trust me. As frail as I am, I’m an aggressive advocate. I’m trying to find a second opinion.

If I don’t get a fever they want to ablate. I’ll see tomorrow if I get a fever

Quote
Carey
I'm skeptical of the new TEE results.

I hope you are right. I sent you the report. Perhaps I have pacing induced cardiomyopathy. I was warned it could happen after getting an AV node ablation...but not from 50 to 35 in 6 months. I heard I had years. I have a PM set to 70 so although I have a 50% burden (before I weaned it was less than 10%), I don’t see how this escalated so quickly. I had days of pure NSR..it’s not like I was in constant distress.

Plus how did my watchman suddenly started to leak? Enlarged heart according to the chest xray as well?

Also written on my TEE report is a left ventricular septal bounce. I googled it. It doesn’t seem good. I get an echo every 6 months and this one took a negative drastic turn.



Edited 1 time(s). Last edit at 01/04/2026 07:10PM by susan.d.

The first 3 generations of the watchman are rigid. They are round devices out in an oval opening. The belief was any remodeling of the heart perioperative would have the heart close any leaks. It turned out that the rigid nature of the device resulted in the opposite affect. That’s why a 4th generation device, watchman flx pro ng, is currently in trial. Its frame is more flexible and the hope I’d leaks will seal and new leaks won’t form. There’s also another device made of foam being tested, as well as a foam injection that is meant to fill and conform to the size and shape of the laa. Boston scientific would not be under trial with the ng if the current watchman flx pro wasn’t forming leaks over time in some cases. The operator can do all he can to ensure no leaks at implantation, but leaks can form later. That’s why many eps don’t want to electricly isolate the laa, since then you’re on anticoagulants for life.

'...That’s why many eps don’t want to electricly isolate the laa, since then you’re on anticoagulants for life.'

I don't follow. Isolating the LAA is to prevent the emanation of voltage from it which would cause the atrium to contract, but in this case to fibrillate. I would expect an EP to tell me they would first isolate the LAA and then do whatever else they need to do to seal it, which is then why the taking of a DOAC would be obviated.

Sorry, my answer could be clearer. First, it’s not well understood why the leaks lead to clots. Is blood collecting in the leak space and clotting because the laa is not moving? Or is the clots formed in the laa after it’s covered escaping from the leaks? I don’t think they know, but some eps are. Concerned with the pooling and clotting. Also, I think the laa is like an appendix; it’s not fully understood if it has another purpose. I would avoid ablating it unless absolutely necessary, but I’m not a doctor.