TEE or CT scan for 2nd checkup after Watchman?

Dr. Natale asks that you return to Austin for the first checkup where one of the TCAI cardiologists does a TEE. Should there be a problematic leak, I’d guess that Dr. Natale would repair it while you are in Austin. But for the 6 month check they are giving the option of a CT scan done by your local cardiologist OR a TEE done according to Dr. Natale’s specifications by a local EP — if they are deemed experienced enough with post Watchman TEEs.

So my question: I live in a mid-sized city where I may or may not be able to find a sufficiently experienced EP to do a TEE that shows what Dr. Natale needs to see—though after a good TEE at 6 - 8 weeks it is pretty certain that the Watchman will still be holding. So what about taking the CT scan option which his NP says will reliably show what he needs to see? Downside = radiation. Upside = reliably performed at a midsize medical center, no sore throat, and no sedation, meaning that you can drive to and from your appointment.

Also, if one has a failed TEE locally, would Medicare pay for a re-do?

I would do the CT. With modern CT machines it's minimal radiation, probably less than an airplane flight to Austin.

I would expect Medicare to pay for the redo as long as Natale's staff documents it properly, which I'm sure they'll do because they do stuff like that day in and day out.

I am glad to hear about the CT option, Daisy! That was not given to me when I had my TEE 7 months ago. Do you know if his protocol is to have a 12 month TEE also? If so, I am assuming Dr. Natale would be fine with having both CTs done locally. I wonder if he has a referral letter for the CT like he does for the TEE, specifically stating what he is looking for. I am making the assumption that he would review the CT results as he does with the TEEs.

After Carey’s response about the minimal radiation, I think this is good news for anyone who has to travel to Austin!

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Pixie
I am glad to hear about the CT option, Daisy! That was not given to me when I had my TEE 7 months ago. Do you know if his protocol is to have a 12 month TEE also? If so, I am assuming Dr. Natale would be fine with having both CTs done locally. I wonder if he has a referral letter for the CT like he does for the TEE, specifically stating what he is looking for. I am making the assumption that he would review the CT results as he does with the TEEs.

After Carey’s response about the minimal radiation, I think this is good news for anyone who has to travel to Austin!

I think that there is also a 12 month Watchman checkup and it would certainly make sense that they would again give the CT option with specific instructions. And yes, I’d assume that the facility that did the CT scan would send Dr. Natale a CD but that is probably something that the patient would need to arrange. I’m sure that he would want to review the actual image rather than someone else’s report. I’ll be asking more questions closer to the time.

My 12 months tee was optional and considering how difficult it was to get the 6 months tee, I skipped the 12 month tee. At that time Tom P also might had skipped it too if I recall. I had an emergency watchman because I had a GI bleed, high Chads score and was on eliquis. Dr Natale did a comprehensive and careful TEE after the watchman because he knew I had to stop eliquis. It was sealed. My 6 month tee I was leaving the country for 3 months and even though dr Natale does no follow up tees at Robles hospital, his trusted colleagues do them for him. Unfortunately it was so hard to get someone available. It was successfully sealed so I had the option to skip the 12 months tee which I did.

I could have had the CT but it’s a hassle being allergic to CT contact. I usually get steroids and Benadryl but I still get a rash. The 6 months tee only lasted 7 minutes from countdown of anesthesia to waking up. It was a fast procedure and was done by a last moment EP. I would have had picked the CT to make it easier if I didn’t have the allergy.

Thanks Daisy and Susan for responding.

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Daisy
And yes, I’d assume that the facility that did the CT scan would send Dr. Natale a CD but that is probably something that the patient would need to arrange.

These days with electronic medical records you probably won't have to do a thing. Once the radiology place does the scan, it will appear on your medical record and be available to almost any doctor you see instantly, including Natale since he's the ordering physician. CDs are rarely mailed around these days.

For example, I went to see a podiatrist recently for a case of heel bursitis. She had my entire case file on the screen of her tablet when she walked in the door of the exam room, and I'd given them nothing more than my name and DOB at that point. She knew my meds, knew I'd had afib ablations, etc.

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Carey


These days with electronic medical records you probably won't have to do a thing. Once the radiology place does the scan, it will appear on your medical record and be available to almost any doctor you see instantly, including Natale since he's the ordering physician. CDs are rarely mailed around these days.

For example, I went to see a podiatrist recently for a case of heel bursitis. She had my entire case file on the screen of her tablet when she walked in the door of the exam room, and I'd given them nothing more than my name and DOB at that point. She knew my meds, knew I'd had afib ablations, etc.

My written 6 month TEE report has been received and are in my records for physician review, but I will not get the final results until the disc is reviewed.



Edited 1 time(s). Last edit at 05/01/2023 10:20PM by Pixie.

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Pixie
My written 6 month TEE report has been received and are in my records for physician review, but I will not get the final results until the disc is reviewed.

Well, electronic medical records (EMR) aren't universally adopted yet, of course, but the acceptance rate in the US is so high that I haven't had a medical visit with anyone in several years where I had to request paper records or discs to be sent. So either the people who did your TEE or the doctor you're having the results sent to aren't on board yet. It happens, but it's becoming rare in the US. Not sure about EU, UK, and elsewhere.

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Carey


Well, electronic medical records (EMR) aren't universally adopted yet, of course, but the acceptance rate in the US is so high that I haven't had a medical visit with anyone in several years where I had to request paper records or discs to be sent. So either the people who did your TEE or the doctor you're having the results sent to aren't on board yet. It happens, but it's becoming rare in the US. Not sure about EU, UK, and elsewhere.

Carey, I agree with you completely. What I find interesting is that I had my TEE at a large medical center that uses the EPIC electronic medical records. That is what St.David’s uses also. However, I was told the disc is needed to confirm the results. I am assuming the disc gives Dr. Natale more information than the written report.



Edited 2 time(s). Last edit at 05/02/2023 12:39AM by Pixie.

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Pixie
Carey, I agree with you completely. What I find interesting is that I had my TEE at a large medical center that uses the EPIC electronic medical records. That is what St.David’s uses also. However, I was told the disc is needed to confirm the results. I am assuming the disc gives Dr. Natale more information than the written report.

Yeah, he's definitely going to want to see the actual imagery because he knows specifically what he's looking for while the radiologist might not. A bit surprising they can't get it electronically, though.

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Carey

My written 6 month TEE report has been received and are in my records for physician review, but I will not get the final results until the disc is reviewed.

Well, electronic medical records (EMR) aren't universally adopted yet, of course, but the acceptance rate in the US is so high that I haven't had a medical visit with anyone in several years where I had to request paper records or discs to be sent. So either the people who did your TEE or the doctor you're having the results sent to aren't on board yet. It happens, but it's becoming rare in the US. Not sure about EU, UK, and elsewhere.

Los Robles Hospital in Thousand Oaks CA where Natale performs his magic three days a month has an online patient portal that shows labs but not imaging nor procedures nor doctor reports such as ablations. One must send in a request for medical records and wait for them to be mailed or come back and pick the records up after a few days. Or wait for your follow up appointment in his office and pick it up there.

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susan.d


Los Robles Hospital in Thousand Oaks CA where Natale performs his magic three days a month has an online patient portal that shows labs but not imaging nor procedures nor doctor reports such as ablations. One must send in a request for medical records and wait for them to be mailed or come back and pick the records up after a few days. Or wait for your follow up appointment in his office and pick it up there.

What I have experienced is that with some medical centers you receive an email stating there are test results available. Like you experienced, Susan, I can see lab results but when viewing anything else it come up as “Component not Found”. One must contact the provider for the results. It can take some time to get the results if the provider has a large case load.

I’m still behind requesting the 4th ablation report done 12-1-22. I got the doctors report but I like the surgical report better because they clock each burn, the length of the burns and how many times one was ecv and the joules used. It’s very comprehensive while the doctors report is also of value because it shows what areas were burned. I like both.

Dr. Natale has been telling me since at least August or November of 2022 that I could get a CT scan if I did not want to come back to Austin for TEE (his preferred method) after getting only the initial TEE in Austin, mainly because of the problems getting the images he wants to see from the TEE providers. On the other hand when I had a Telemed visit with Shannon, his "assistant," she said if the drs were on the Boston Scientific Watchman provider list, then their drs routinely performing their TEEs of the Watchmans also had been given the same instructions as Natale as to what images to get - that is where the "instructions all certified Watchman placers are following" have come from, according to the way it sounded being told to me.

Maybe it takes up more space or time to send a disk, but doctors don't always accept another dr's interpretation of an image, they want to see the images for themselves & make their own interpretation. How long does it take a disk/image to be transmitted vs a report, I don't know. Locally, I have always been requested to get disks immediately after the scans & personally take them to my dr's visits for them to view. I have had several MRI brain scans with & without contrast and they always want the disk too. Same thing in the past when I got CT scans for sinus problems.

I don't know why Pixie's TEE disks have not either gotten there or been read yet.

I will be getting a call from my local EPs nurse re setting up the TEE & I will be asking their opinion about the TEE vs the CT scan too. Either way, I assume once we make the decision we have to get instructions from Natale to coordinate what he wants & how to get it to him.

I did write my Austin nurses about our debate & this is what they said:

"Either a TEE or CT is fine…Dr. Natale prefers TEEs, when performed in Austin for the initial check and to avoid the use of contrast dye. If the first TEE looked good and you have no history of issues with kidney function or contrast dye, a CT scan is generally advised for the 6 & 12 month check, when performed with a local provider versus coming to Austin, so the images are more routine/exact and less likely to be dependent on the performing provider like a TEE."

So it still sounds to me like a TEE is 1st choice, as long as they get the images needed. So, I will still talk to my local people about this whole debate before I make my final decision.

Not long ago I got a call from my Clinic here. The Watchman people here are just as specific as those at St. David's. She said the doctor I wanted to do my TEE, who does them for the EPs who place Watchmans at my clinic only did them for the Watchman providers there. So we have to figure out how to do what. She and another doctor at another location do them all day all week, as I understand, so lots of experience. I let my Austin nurses know just now by email & I also scheduled an appointment at my Clinic so that my cardiologist (who was at Cleveland Clinic when Natale was there & totally has approved of me getting everything done by Natale so far), can help me along with my St. David's nurses as to how to schedule all this.

The Watchman ?rep/nurse/facilitator here too said certain people who had esophageal problem or problems were anesthesia, etc., were getting a certain type of CT with delayed images to suffice for what was needed. But first line is still TEE so far. But, I think I get the import from everyone that either is fine, a personal choice. Have to make sure you have a good TEE for Watchman provider if that is the route you choose.

And as usual, I have the hurdle of trying to figure out how to set it all up, to please everyone, to get approval from everyone & have orders sent from here to there. This whole thing is never easy & is very time consuming, but I still would not trade it because I am totally satisfied with all the confidence and trust and gratitude I have for Dr. Natale.

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Carey
These days with electronic medical records you probably won't have to do a thing. Once the radiology place does the scan, it will appear on your medical record and be available to almost any doctor you see instantly, including Natale since he's the ordering physician. CDs are rarely mailed around these days.

That's what I thought after I had my one year TEE done locally. The hardest part of that whole rigmarole was getting a disc of the video mailed to Dr. Natale because the two facilities had different and incompatible video transmission software.

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JayBros
The hardest part of that whole rigmarole was getting a disc of the video mailed to Dr. Natale because the two facilities had different and incompatible video transmission software.

JayBros, I have run into that same difficulty locally in the past. Computer softwares don't match up necessarily & can't show the images on another's computer. I am afraid of that too. Natale's staff have not mentioned that difficulty though. They just speak of the remote facilities we use as sometimes just not getting the images he needs.

What ended up happening with your situation?

One of my local cardiologist's nurses was given a "make it happen" mission after I did some footwork getting names and phone numbers at TCAI and telling him I couldn't see how it was such a complicated task. The nurse who was given the mission told me she talked to one of the radiology dept. geeks who said it would be no problem, but there was about a month of wasted time before Dr. Natale received the disc.

Interestingly enough, when my six-month TEE time was approaching, my cardiologist recommended that I return to Austin for it because he said that even though he would receive an order of from Dr. Natale, he did not want to risk not getting exactly the images The Maestro wanted, and me then having to go back to Austin to have it redone. The cardiologists at St. David's who do TEEs for Dr. N. know exactly what he wants. I have a tricuspid valve flap problem and at six-month TEE, just told the St. David's cardiologist that my plumber wanted as thorough a look at the tricuspid valve along with what he routinely did for Dr. Natale. Both docs got what they needed.

I have been waiting for many weeks for Dr. Natale to review the images from a 6 month post Watchman TEE I had done by a cardiologist he referred me too. His nurse gave me the preliminary results from the written report. My main concern all along has been that the films will not meet his expectations and I would need to return to Austin. If that would be the case, I will have lost so much time knowing how the implant is after 6 months. I am usually so cautious about decisions I make. I hope this was not a bad decision!!

It doesn't take weeks. You need to talk to your NP contact and see what's going on.

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Carey
It doesn't take weeks. You need to talk to your NP contact and see what's going on.

Carey, they have received the CD. I asked 3 times about the results. My TEE was 3/28.

Then I would ask again. Over a month is not reasonable.

Latest thoughts on detecting leaks from the 2023 HRS Conference, including pluses and minuses of TEE and CT scan. [youtu.be]