Considering the Watchman - but I have questions

]Hello all - I haven't been on here for awhile, like I was before I had my Natale ablation in 2014. I am doing well, thanks to Dr. Natale. No Afib ever since that ablation. I had a LAA ablation, and am still on Eliquis, due to some numbers being less than ideal on my TEE, and because it was a LAA ablation. I am concerned as I get older, that one day I may need surgery, or fall and hurt myself, and being on a blood thinner could be concerning - or worse. I also have something called diastolyic disfunction, so am short of breath on exertion, but I have learned to live with it and exercise to try to keep it in check.

My question is whether getting the Watchman is the best device to be able to get off of Eliquis, and if so, does it need to be done by someone who is a top doctor, like Dr. Natale? My cardiologist says they have been doing them for awhile very successfully here on Long Island, but I hestitate as I've trusted any heart procedures to be done by Dr. Natale. I am not in a hurry...this can wait until after this virus gets under control. Traveling to Austin, Texas right now is not in the cards. Not sure if he'll be up in NYC area anytime soon...Shannon? Or is this a simple procedure that any good EP can do?

Finally, do you have to stay on aspirin after getting the Watchman or can you get totally off all blood thinners?

Thanks for your replies ~ Barb H

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tobherd
]and am still on Eliquis, due to some numbers being less than ideal on my TEE,

Good Question Barb!

Your numbers were less than ideal. Does that mean your LAA is somewhat helping the clot issue since it isn’t silent?

My LAA is non functional. Silent. Zero activity. Dr Natale saw this during my last ablation in 4-21. Prior ablation in 9-20 he isolated the LAA. Does that mean eliquis may possibly not work as well for those without LAA activity?

What numbers (cutoff numbers) would Barb or anyone who had their LAA isolated need to require a watchman to completely protect themselves?

Congratulations on a successful ablation!

Wow, I have not been on here for years. I came on because I had a watchman put in in 2018 and am on aspirin daily but wondered if anyone had thoughts about that. I’m sure my doctor would tell me to take it for the rest of my life, but I think he has to. I remember before I had the procedure someone saying I could probably go off it in 6 months.

I can’t believe I didn’t even have to do a search. Barb, I believe we exchanged private messages years ago and you are the first post asking about the same thing!

I wanted it so I could go off blood thinners. It’s the best, easiest thing I ever did.

I will await responses regarding lifetime aspirin (which, actually is nothing compared to blood thinners).

I've got some thoughts and info on this but I don't have the time to post a useful response right now. I'll get back to this subject tomorrow.

In response to your comments above....Susan d. Whatever numbers they noted, Dr. Natale told my Cardiologist to keep me on Eliquis. However, that would change if I were to get the Watchman, of course. I don't love the idea of still having to take an aspirin, as that has some risks too.

Louise - did Dr. Natale do your Watchman or a local EP? I'm a little nervous to let anyone touch my heart other than him.... is there anything that needs to be watched or updated after getting the Watchman?

And yes Carey, I'd love to hear your thoughts on this too.

thank you ~ Barb

Barb, I had mine done by Dr Doshi at the Pacific Heart Institute in Santa Monica.

Barb, I had mine done by Dr. Natale July 8, 2021. I share your feelings as far as not letting anyone but Natale touch my heart. Carey will give the details and any corrections, but it is my understanding that the LAA has some functioning for pumping blood. Once isolated that pumping action decreases. At certain number it is not pumping hard enough to keep clots from forming in it. This measurement is identified by having a TEE(transesophageal echocardiogram). This number is the indicator Natale uses to determine if you are a candidate for a watchman. The procedure is a walk in the park, but I am a HUGE fan of Natale. After the procedure eliquis is reduced by half and a low dose aspirin is added once a day. A followup appointment (& TEE) is done in about 6 weeks and at that time Natale decides whether you drop the eliquis or baby aspirin. I return next month for the followup so my experience is pretty fresh.
Hope this helps.
Genie

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tobherd
My question is whether getting the Watchman is the best device to be able to get off of Eliquis, and if so, does it need to be done by someone who is a top doctor, like Dr. Natale? My cardiologist says they have been doing them for awhile very successfully here on Long Island, but I hestitate as I've trusted any heart procedures to be done by Dr. Natale. I am not in a hurry...this can wait until after this virus gets under control. Traveling to Austin, Texas right now is not in the cards. Not sure if he'll be up in NYC area anytime soon...Shannon? Or is this a simple procedure that any good EP can do?

Finally, do you have to stay on aspirin after getting the Watchman or can you get totally off all blood thinners?

Yes, it's the best device. There are other devices that are comparable, and Watchman is only slightly "better," but the Watchman has the longest track record, the most data supporting it, and the most EPs experienced in implanting it, at least in the US (probably Europe too).

Implanting a Watchman is a relatively simple, 20-minute procedure and not even remotely as complex as an ablation, so it doesn't demand the maestros of the field. But, as always, experience does matter. I would be comfortable with almost any EP who had done a few hundred Watchmans at a center that does them routinely. In fact, when mine was implanted in 2018 by Natale, he had only done a few hundred himself. So just ask your cardiologist how many he's done. ("We've been doing them for a while" doesn't give me confidence. That could mean he's done 10 in the last six months.) If the answer is less than hundreds, I would find another doctor who's done far more. In the NYC area that shouldn't be difficult at all. You might want to visit watchman.com and do a search for hospitals in the area that do the procedure. I see at least a dozen in NYC and Long Island. You really shouldn't need to leave the area to get a Watchman by an experienced operator.

As for getting off Eliquis entirely -- yes, that should be the end result after about 6 months. The aspirin is a stickier question. The FDA-approved protocol calls for a daily 325 mg aspirin for life after stopping Eliquis, but many EPs, including Natale, think that's more of a knee-jerk reaction that's not well justified. It's kind of the "but we've got to do something" sort of thinking that doesn't have solid science behind it. You're absolutely right that aspirin isn't a risk free drug. In fact, it's probably higher risk than Eliquis, so I don't blame you for wanting to avoid that too.

So I'll tell you what I did and why. Natale's opinion for me was that I should ignore the FDA recommendation and not take aspirin, but I should continue 1/2-dose Eliquis. The Eliquis isn't because of the Watchman; it's because I'm 65 years old with "mild plaque in the ascending aorta" (just like virtually every other 65-year old in the western world). So his recommendation for continuing 1/2-dose Eliquis was basically a substitute for a daily low-dose aspirin that many doctors would recommend for someone like me. (In other words, Eliquis is safer than aspirin.) I ran his recommendation past my PCP, who is extremely conservative, and my local EP, who was the chief of electrophysiology at Yale University, and both agreed with Natale's recommendation.

Could I have safely stopped the Eliquis completely and not taken aspirin? Yes, I could.

Is my risk of stroke lower than it was before the Watchman even without Eliquis and aspirin? Yes, it is, significantly so.

What do I do now if I need to stop the Eliquis for a medical procedure? Simple, I just stop it without worry. I'm only taking it as someone would take a daily low-dose aspirin, so no big deal to stop it for a week.

Bottom line: If I were you I would find an experienced Watchman operator in the NYC area and get it done.

Carey, I am on the recommended 81 mg aspirin daily, I’m curious who told you 325 mg, and also why you believe aspirin is more dangerous than a blood thinner. Dr. Doshi is a highly regarded EP. I will listen to all opinions; but I’m curious what your credentials are.

My only credentials are what I've learned over the last 20 years since afib and I became acquainted. I don't expect anyone to take my word for anything based on credentials. I've already mentioned the guys with the credentials I largely base my opinions on.

You did catch an error on my part about the FDA protocol. It's not 325 mg, so my bad. The FDA protocol is low-dose aspirin + Eliquis for 45 days, then low-dose aspirin + clopidogrel (another anti-platelet, aspirin-like drug) until 6 months, and then low-dose aspirin for life. So I should have said 81-100 mg instead of 325.

Here is the specific FDA protocol for a Watchman device provided to me by Boston Scientific, manufacturer of the Watchman, as a participant in the Watchman FLX clinical trials:

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If the 45 day TEE shows that the Device has closed the LAA and there is no clot on the Device, you can stop taking anticoagulation. You will remain on aspirin (81-100mg) and clopidogrel (75mg) until 6-months, after which you will be on aspirin alone.

If there is blood flow around the WATCHMAN FLX implant into your LAA or if there is a clot on your Device, you will continue anticoagulation and aspirin until the TEE is repeated at 6 months or until there is little or no blood flow around the Device implant into your LAA or the clot has dissolved. At the 6-month TEE, if there is a Device seal and no clot is present you will stop taking anticoagulation and remain on aspirin alone.

Why do I believe aspirin is more dangerous than a half-dose of a NOAC like Eliquis? Well, first I would point to the GI bleeds aspirin is infamous for causing. Aspirin actually promotes GI bleeds; NOACs do not. On a more general level, aspirin disables your platelets permanently. You regain about 10% of them per day since your last dose of aspirin, but if you're taking aspirin daily, you never fully replace them. If something starts bleeding, there's no way to reverse that other than blood transfusions.

On the other hand, Eliquis and similar NOACs decrease your clotting factors with a half-life of about 12 hours. So those will reverse themselves within a day of simply stopping it. And if you're taking a half-dose to begin with, you can cut that 12 hours down to 6 hours. Meanwhile, aspirin won't reverse for a week.

I had to make all these decisions and I came down solidly on the side of half-dose Eliquis rather than nothing or low-dose aspirin. As I said, it was my decision for me. Your situation and your reasoning may be different.

Carey, thank you for your clarification. It was my understanding that platelets start “rebuilding” after 4 days of discontinuing aspirin. I will research this further. If I am having oral surgery (or any surgery), I am told to stop aspirin for a week before — are you saying that if I’ve been taking aspirin for several years and there is a bleeding issue in the dentist’s chair, I would a full transfusion?



Edited 2 time(s). Last edit at 08/10/2021 10:44AM by Louise.

Gene - I would think the whole idea of getting the Watchman is to get off of Eliquis, so not sure why there's a possibiilty of staying on it...?

I'm assuming you went to Austin to get it done, yes? It's a Covid hotspot right now, so i would not fly there at this time.

Barb

Thanks for taking the time to explain this further, Carey. One thing that concerns me is that I am here in NY and Dr. Natale is in Austin, so I would probably go with someone local, with the experience you mentioned. However, will a local doctor who is basically overseeing you go along with what Dr. Natale says? I had met with the EP from my cardiologist's office to talk about getting this done, maybe about 6-8 months ago. He happens to be the son of Dr. Larry Chinitz, who is highly regarded in the field and in NYC. The son, also Dr. Chinitz, talked about staying on aspirin. I feel like Dr. Natale is the most knowledgeable, but sometimes I am bucking the local docs who don't have that same expertise. As Dr. Natale wouldn't be overseeing me in this situation, is it best/safe to go with his recommendations versus whatever the local doctor believes is the best path to take?

I like your idea of taking 1/2 Eliquis. Not sure what you halved, but currently, I'm taking 5mg twice/day of Eliquis. When a can fell down off a shelf and hit me on the head about a week ago, it got me thinking again that I need to get off of Eliquis...or at least reduce it, as you are saying. I am 68 so I would probably be given the same recommendation from Dr. Natale. As you didn't use him for the Watchman, how did you get him involved in the follow up?

Barb

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Louise
Carey, thank you for your clarification. It was my understanding that platelets start “rebuilding” after 4 days of discontinuing aspirin. I will research this further. If I am having oral surgery (or any surgery), I am told to stop aspirin for a week before — are you saying that if I’ve been taking aspirin for several years and there is a bleeding issue in the dentist’s chair, I would a full transfusion?

Yes, they start rebuilding, but it takes a few more days for the "rebuilt" platelets to reach adequate levels.

It's extremely unlikely you would need a transfusion because of a dental procedure. I was talking more about major surgery, injuries, etc. But the underlying point is simply that platelets take days to recover from aspirin while your clotting factors take only hours to recover from NOACs like Eliquis and Xarelto.

So.. aren't elequis and Xeralto completely different in their mechanism for anti clotting? I had to be on both post an aortic stent. When I started having bleeding problems they said I needed to do aspirin for sure for 6 months. Because it makes the platelets slippery. Then I was going to switch but just didn't go back on xeralto until recently (when I started having more afib episodes). I just find it weird reading how people are going off the Elequis/xeralto- in favor of aspirin.... anyone know?

Louise: You don't mention what dental procedure you're considering. For most the concern is not how much blood is being spilled by the procedure but more that the blood flow gets in the way of seeomg during the microscopic procedures dentists frequently do. A few drops of blood can hide areas they're trying to treat.

In my case the Endodontist and my Cardiologist agreed upon a Lovenox bridging procedure which worked fine. Dentists also like to add epinephrine for pain and blood control so that too should be discussed beforehand for patients with Afib.

Here's an article on bridging that is a bit long but explains the procedure well:

[www.uptodate.com]

ggheld, I’m not getting any procedure done. I was using it as an example because Carey had stated that “aspirin disables your platelets permanently.” That didn’t make sense to me because if platelets never rebuild, why stay on aspirin forever….

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Louise
ggheld, I’m not getting any procedure done. I was using it as an example because Carey had stated that “aspirin disables your platelets permanently.” That didn’t make sense to me because if platelets never rebuild, why stay on aspirin forever….

You left out the part about 10% of your platelets being replaced daily, so you're never entirely out of platelets. If you're taking aspirin daily, you have a chronically lowered number of functioning platelets, but you're never entirely out of them.