Geocappy [ PM ]
Re: New Study
February 08, 2026 04:19PM Registered: 3 years ago
Posts: 116
Update. Went to my local EP as recommended by my Cardiologist. He said no way would he have me off of my Xarelto. He said at 72 with Diabetes, sleep apnea, CAC score of 520 he said there is no way I should be off blood thinner. He said study my cardiologist is referring to was for low CHAD people. Not me.

He said Afib symptoms are irrelevant as there are other reasons for risk of blood pooling other than afib and symptoms are not the only important factors and he would not do a loop recorder because the results would not change his opinion due to my high CHAD score.

He said the only way for me to be potentially of blood thinner is if a Watchman is done. Then if successful it maybe possible to switch blood thinner protocol. Question: Is this board as adamant about Natale doing the Watchman as they are him doing the ablation. I flew to Texas for my ablation but my local EP is suppose to be very experienced with the Watchman.

I would appreciate some feedback
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Natale was a magician when he implanted my watchman. I have a crazy twisty loopy vein and he said that he spent a while snaking it up without tearing. Then my LAA had a long slanting shoulder . He did multiple TEEs during the procedure to confirm it was sealed.

I went home a few hours later. I was out of bed in the recovery room to use the bathroom and as soon as I voided, I was discharged. It was, for me, easy peasy.

It was worth doing for me. Obviously there are risks in any procedure.

I would be fine with any EP doing a Watchman as long as they had ample experience with them. It's not the fine mix of art and science that ablations are.

I was admitted at Los Robles after an ablation in tachycardia and I had no EP who could be on call since Dr. N was back in Texas. I got assigned by the hospital a random EP to stop by for a consultation. He was trying to convince me to get a watchman (not by him-just in general). I asked him if he had any complications. He admitted, in fact, he tore up a few (I don’t know the number by “few”) patients veins trying to get the watchman in position. He said he stopped doing watchman implants.

That’s a question-“anyone died while you were doing an ablation to any iatrogenic problems occur?” I ask EPs. It’s really potluck if they are the best for you I think because one may gain confidence when they hear one’s EP is the head of the department-that motivates a sense they are experienced, which they are, but not necessarily having gifted hands or necessarily have high success rates. This link describes it: [www.afibbers.org]

Perhaps implants need the same gifted hands because of the shape of the watchman and how everyone has unique cardiac anatomy that could impose challenges, it’s best suited by using a highly skilled EP.

My watchman is a size 24. If you had ever seen a watchman on display at your EP’s office, it has sharp pointy sharp hook ends compared to a catheter used for ablations. Perhaps skill is as necessary, or better yet combined with manual dexterity. That’s why I boost about Natale’s manual dexterity skills in performing the implant.

When the Watchman device is in the catheter that delivers it to the LAA, it's folded up. Those sharp pointy spikes are safely stowed away and can't touch anything. It's not even in the heart yet if he damaged veins, so he never even got it there. If that EP "tore up" veins trying to insert an LAA then he either wasn't trained properly or he just shouldn't be near any type of catheter. It's a little on the large side but is otherwise no different than ablation catheters.

Thousands of EPs with varying skill levels have been implanting Watchmans for years now around the world and the complication rates are extremely low. I think asking an EP if he's ever killed someone with one is a bit over the top. If they in fact have done so through incompetence then I wouldn't expect them to still have privileges at that hospital to do them.

Thanks for the feedback. I was ok with my blood thinner even though it limits the ability to take other supplements I would consider taking but can’t due to how they interact. However, since my cardiologist started discussing the bleeding risks I started thinking about it. I did have a couple of bad nose bleeds but they were the only bleeds and came during a time we were having tile blasted out of our house and there was lots of dust irritants so I affributed the nose bleeds to the dust. Not sure what direction to go in

“I think asking an EP if he's ever killed someone with one is a bit over the top. If they in fact have done so through incompetence then I wouldn't expect them to still have privileges at that hospital to do them.”

I never asked Dr N that question for both ablations and watchman. Others I have. I asked the EP who did my last ablation.

Right. That’s why there are hospital safeguards. The EP who tore up some veins no longer does watchman implants. Many years ago I met another EP who told me he was on the original trials for cyro ablations at a high tier prestigious hospital. He told me he didn’t do it anymore but he didn’t elaborate why. I was later told by another colleague that he was thrown off the trials because of some mistakes.

Interesting watchman trivia on how is the size determined:

AI:
Doctors measure your heart to determine the correct WATCHMAN device size primarily by using transesophageal echocardiography (TEE), a specialized ultrasound, and increasingly, cardiac computed tomography (CT) scans.
These imaging tests take detailed, 3D pictures of the left atrial appendage (LAA)—the small pouch in the heart where blood clots typically form in patients with AFib.
Here is how they measure your heart to select the proper size:
1. Imaging Modalities
Transesophageal Echocardiogram (TEE): This is the preferred method, where an ultrasound probe is placed down the esophagus to get high-resolution, internal images of the heart.
Cardiac Computed Tomography (CT) Scan: This provides 3D X-ray images, allowing doctors to precisely measure the diameter and shape of the LAA, often before the actual procedure day.
2. What They Measure
Doctors look for specific measurements to determine which of the five available sizes (21mm, 24mm, 27mm, 30mm, 33mm) is needed:
Maximum Ostium Diameter: They measure the width of the opening (ostium) of the LAA in several views (0°, 45°, 90°, and 135°) to find the widest point.
Landing Zone: The area inside the appendage where the device will sit.
Usable Length: They ensure the LAA is long enough to hold the device.
Shape: They categorize the shape (e.g., "WindSock," "ChickenWing," or "Broccoli") to determine the best approach.
3. Sizing Guidelines
Compression Rate: The chosen device must be 8% to 20% larger than the widest diameter of your LAA (i.e., 80-92% compressed) to ensure it stays in place securely.
Example Sizing: A 21-mm device is generally used for a 17–19 mm opening, while a 33 mm device is used for a 29–31 mm opening.
4. Verification (During the Procedure)
Even though measurements are taken beforehand, the team verifies the size during the procedure using:
Fluoroscopy: Live X-ray imaging.
"PASS" Criteria: The team ensures Proper Position, Anchor (stable with a "tug test"), proper Size (compresses 80-92%), and complete Seal of the LAA.
The goal is to select a device that perfectly seals the LAA, preventing leaks, without being so large that it damages the heart tissue.

EPs are split on this, but it seems those at the better institutions are relying less on the CHADS score these days, and more on AF burden.

I'm CHADS 4 and two well-respected EPs, each at a top 10-rated cardiac hospital, advised me to stop anticoagulation because I have been AF free for one year post-ablation. Based on newer studies, perhaps the same one your first doctor saw, they felt any incremental stroke-prevention benefit of anticoagulation would be outweighed by bleeding risk.

Personally, I don't see the value of Watchman as a standalone, and even when paired with ablation, its potential problems have to be carefully weighed against its benefits.

Jim

Good luck with your decision. I needed the emergency watchman that they squeezed me in for because I was having a major GI bleed and I needed to stop Eliquis for the colonoscopy. Being a CHAD 5-6 with a family history of strokes (father about 12, brother over a half a dozen), I didn’t want a stroke risk when I temporarily stopped Eliquis without a watchman.

Since then I’ve had numerous surgeries and stopped Eliquis for up to 5 days. Unfortunately I had my second DVT while on half dose Eliquis after my watchman. I was put back on full strength Eliquis but I do stop Eliquis for surgeries-with concerns for getting DVT again. My hematologist is not a fan when I’m told to stop Eliquis for procedures.

Quote
mjamesone


Personally, I don't see the value of Watchman as a standalone, and even when paired with ablation, its potential problems have to be carefully weighed against its benefits.

Jim

In the fall 2024 expereinced a brief event of high heart rate, had a cardioversion and was placed on anti-coagulants. Then a flutter ablatiion in March with Natale. He said that his standard practice now is a Watchman implant after an ablation. I hated being on anti-coagulants, so had no issue with the Watchman procedure.

Curious as to the problems versus the benifits?????


Steve
Klein, Tx.

Jayhawk: Curious as to the problems versus the benefits?????

Given that the evidence from the OCEAN trial and others suggest that patients who maintain sinus rhythm for 12 months post-ablation have stroke rates similar to those without AF, the case for Watchman weakens.

In effect, Natale is either discounting these studies, or it's a bet that your ablation will fail, and it's an aggressive bet that is irreversible. You end up with a permanent implant requiring additional procedural risk, possible device embolization, as well as post-procedural antiplatelet therapy and ongoing imaging surveillance for leakage, etc. Alternatively, why not just take anticoagulation for 12 months post-ablation, and if the ablation holds, you walk away without any of this?

The Watchman does make sense if the ablation fails and anticoagulation is contraindicated, but short of that, I don't see it and feel less is more here. Obviously, Dr. Natale takes a more aggressive approach, which not everyone in the EP community agrees with.

Jim

Google AI Overview (rivaroxaban is Xarelto)

Evidence from the OCEAN trial (presented in late 2025) and supporting studies (such as ALONE-AF) indicates that for patients who maintain sinus rhythm for at least 12 months after a successful AF ablation, the stroke rate is very low, making the discontinuation of oral anticoagulation (OAC) a reasonable option.

Evidence from the OCEAN Trial

- Study Design: The OCEAN trial randomized 1,284 patients who had a successful catheter ablation at least 1 year prior to receive either rivaroxaban (15 mg daily) or aspirin (70-120 mg daily).

- Results: The 3-year risk of a composite of stroke, systemic embolism, or covert embolic stroke (detected by MRI) was very low in both groups (0.8% with rivaroxaban vs. 1.4% with aspirin), with no significant difference between the two treatments.

- Stroke Rate: The annualized stroke risk was extremely low (0.3% in the rivaroxaban arm and 0.7% in the aspirin arm), which is similar to the annual stroke rate of individuals without atrial fibrillation (roughly <1% per year).

- Conclusion: The findings suggest that in patients with a successful ablation (12 months post-procedure), ongoing anticoagulant therapy may not provide significant added benefit over aspirin in reducing stroke risk, notes lead investigator Atul Verma.

Supporting Evidence

- ALONE-AF Trial: This study also showed that in patients with no recurrence of atrial arrhythmia for at least 12 months, discontinuing anticoagulation resulted in a lower or similar risk of stroke, systemic embolism, or major bleeding compared to continuing it.

- Long-Term Outcomes: Studies have shown that patients with successfully ablated AF have long-term stroke rates and mortality risk similar to patients without AF, significantly lowering the risk compared to patients on medical therapy alone.

Caveats

- The OCEAN trial results are primarily applicable to low-to-moderate risk patients (mean CHA2DS2-VASc score of 2.2).

- These findings do not apply to patients with high stroke risk or those with recent strokes.

- While stroke risk is reduced, it is not completely eliminated.

This is for informational purposes only. For medical advice or diagnosis, consult a professional. AI responses may include mistakes.

Thanks for posting. The case for discontinuing anticoagulation after a successful ablation is becoming increasingly compelling. As to the first "caveat"...

The OCEAN trial results are primarily applicable to low-to-moderate risk patients (mean CHA2DS2-VASc score of 2.2)

CHADS 1-9 was represented in OCEAN, but yes, the mean was 2.2, so one reasonable conclusion is that the results are "primarily applicable to low-to-moderate risk patients". However, another way of looking at it is that the trial answers a fundamental question, which is whether 12 months of being AF free resets the system to that of someone who does not have AF. If the latter, then the score becomes less relevant.

When two top EPs both told me I could stop anticoagulation as a CHADS 4, the first thing I did was bring up the 2.2 mean, yet neither was persuaded. So they both fell into the second way of looking at it, I think both ways are valid, the first being a bit more conservative, but that does not make it a better interpretation.

But overall, the case is compelling for stopping anticoagulation 12 months after a successful AF ablation, and with that, the case for a Watchman at the time of ablation becomes less compelling.

Jim



Edited 1 time(s). Last edit at 02/14/2026 12:14AM by mjamesone.

Quote
mjamesone
CHADS 1-9 was represented in OCEAN, but yes, the mean was 2.2, so one reasonable conclusion is that the results are "primarily applicable to low-to-moderate risk patients". However, another way of looking at it is that the trial answers a fundamental question, which is whether 12 months of being AF free resets the system to that of someone who does not have AF. If the latter, then the score becomes less relevant.

The trouble is, we don't know whether that optimistic view is correct or not, and OCEAN provided no insight. Personally, I wouldn't conclude that anything compelling has been demonstrated by 2 trials involving only 2000 patients. Yes, they're definitely encouraging results, but considering the consequences of being wrong, I'm going to need more repeated results and hopefully larger, more tightly controlled studies. Too many confounding factors floating around for my taste, particularly the selection bias toward low CHADS scores.

This is of interest to me. My husband was getting follow-up ablation work done and a watchman at the same time, by Dr. Natale. I know it's gunna be hard for some to believe, but afterward we were told that it didn't fit and it wasn't put it, but it had been attempted. I asked did they not have the right one on hand? I was told they had them there. Very weird. They couldn't check an image or something before hand? I believe at another time later, they may have said that 2 had been tried, but no go. At this time he is totally done with implanted device numbers for that. He will just use blood thinner. Unless something simple is invented that doesn't require general anesthesia.

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Crosswise
This is of interest to me. My husband was getting follow-up ablation work done and a watchman at the same time, by Dr. Natale. I know it's gunna be hard for some to believe, but afterward we were told that it didn't fit and it wasn't put it, but it had been attempted. I asked did they not have the right one on hand? I was told they had them there. Very weird. They couldn't check an image or something before hand? I believe at another time later, they may have said that 2 had been tried, but no go. At this time he is totally done with implanted device numbers for that. He will just use blood thinner. Unless something simple is invented that doesn't require general anesthesia.

I'm sure they did imaging first to measure, but it's the human body and imaging can only measure some things so well. Most likely, the mouth of his LAA has an irregular shape that just doesn't fit a Watchman well and imaging couldn't detect that. Remember, the heart is moving constantly both when they image and when they insert the device. So there's a lot of art and skill involved. The good news is they simply said they can't find a match rather than inserting something that wouldn't have fit properly.

I would imagine a Watchman could be placed using conscious sedation instead of GA.

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Carey

I would imagine a Watchman could be placed using conscious sedation instead of GA.

I don’t believe it’s done in the states, but I was wide awake, except only the first 10 minutes when they cut the vein and snaked up the catheter I had propofol and then I was wide awake for the remaining ablation. Once it was completed, I had propofol again for 7 minutes while they removed the catheters and closed up the groin cut. My discomfort level was surprisingly minimal (heartburn pain during the burns) except for 10 minutes when the groin site started to hurt so I was given a push of morphine and the pain subsided and they continued while I watched the monitor.

I don’t know if a watchman implant would cause more discomfort than a burning ablation. I wonder if a patient in the states can request being awake. I actually now prefer being awake because I was clear headed and alert afterwards. Where I live now it’s common
Not to be put under.

I'm sure a Watchman would be far less painful than an ablation without general anesthesia. With a Watchman there's only the catheter insertion, septal puncture, and extraction that would cause pain. Total time is typically 20-30 minutes while an ablation is typically 2-4 hours.

From various people I've heard from who've done ablations with conscious sedation, I've heard experiences ranging from "pure torture" to "not very comfortable but tolerable."

Thank you susan.d and Carey. Great info.

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Carey

From various people I've heard from who've done ablations with conscious sedation, I've heard experiences ranging from "pure torture" to "not very comfortable but tolerable."

Except for the two brief times I had propofol, I was wide awake, without conscious sedation, watching the monitor and watching my EP doing his thing. For me the pain level averaged a 2. I didn't really feel discomfort except at the groin area when he was fiddling with the catheters. I had no tranquilizers or drugs. I was extremely lucky I felt no pain and I wasn’t frightened. I also watched my IV so I was aware of the two times they gave me propofol. I told them to give me a slow push so I could enjoy the high.

I had postponed the ablation for 13 months because I was freaking out after hearing the tale from another patient in the waiting room of her screaming the entire time and that she described as worst than childbirth. I was expecting pure torture.

My EP did warn me before he jacked up my heart rate to test if it would trigger any PVCs. That wasn’t painful but I didn’t like it.



Edited 1 time(s). Last edit at 02/15/2026 05:38AM by susan.d.