Dr. Natale’s Watchman Protocols

I read on this forum that because a few people have developed blood clots a year after their watchman implant, Dr. Natale is recommending a CT scan at the 2 year mark. Since I am approaching 2 years post watchman, I reached out twice to his office to see what the protocol is and who it applies to. I am getting no response, so I am asking any Dr. Natale folks on this forum if they have been contacted and are being told anything about this. I am finding this quite frustrating.

I'm curious about this as well, he's putting a watchman in me in a couple of weeks while doing another PFA. I have a preop telemedicine call with him next Wednesday... I'll ask about it.

G48, thanks for the response. I look forward to hearing about what he tells you.

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Pixie
I read on this forum that because a few people have developed blood clots a year after their watchman implant, Dr. Natale is recommending a CT scan at the 2 year mark. Since I am approaching 2 years post watchman, I reached out twice to his office to see what the protocol is and who it applies to. I am getting no response, so I am asking any Dr. Natale folks on this forum if they have been contacted and are being told anything about this. I am finding this quite frustrating.

Yes, I was told that he was doing a final 2 year scan in a consult I had with him about 6 months ago, but I haven’t discussed it with him or Shannon since. I will ask about it on my next consult. If he has seen a few clots, it seems like a good precaution.

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Daisy

Yes, I was told that he was doing a final 2 year scan in a consult I had with him about 6 months ago, but I haven’t discussed it with him or Shannon since. I will ask about it on my next consult. If he has seen a few clots, it seems like a good precaution.[/quote


Daisy,
My 1 year CT was fine. I would not have known he recommended a 2 year CT until I saw your post about that a month or so ago. I know I told you that I asked Dr. Natale about this when I had a telehealth visit and he said it applies to folks who chose to take aspirin rather than stay on the half dose Eliquis. Then I heard that you knew of folks who were on Eliquis and he recommended they get one also. I really just want to know what criteria he is using to decide who should get that. My 2 year post watchman is the end of September. It is unusual for me not to hear back from Shannon. Do you know, Daisy, who else I could reach out to?



Edited 1 time(s). Last edit at 08/02/2024 01:52AM by Pixie.

If memory serves correctly, they've only seen the DRTs (device-related thrombi) with people who stayed on aspirin rather than low-dose Eliquis and those are the only people they're recommending get a 2-year scan.

I had a recent Telemed and asked Shannon about this. I am one who has been on low dose aspirin almost exclusively after the 45 day period, back in ...'18? There was a several month time frame where I did the low dose Eliquis, then he had me switch to low dose aspirin. I've never received a clear to me answer as why. Shannon said the choice to be imaged is completely up to me, but she made it very clear that the percentage of folks with a thrombus are extremely small. I had no leaks after implantation, and while I have debated going to Austin for the imaging (because I love Austin), I'm still mulling it over, and may book a trip when it cools down. Shannon also stated that even a massive thrombus would be asymptomatic, unless that bad boy breaks loose. Beyond me how a massive clot can be in their and you not feel any adverse effects.

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AB Page
I had a recent Telemed and asked Shannon about this. I am one who has been on low dose aspirin almost exclusively after the 45 day period, back in ...'18? There was a several month time frame where I did the low dose Eliquis, then he had me switch to low dose aspirin. I've never received a clear to me answer as why. Shannon said the choice to be imaged is completely up to me, but she made it very clear that the percentage of folks with a thrombus are extremely small. I had no leaks after implantation, and while I have debated going to Austin for the imaging (because I love Austin), I'm still mulling it over, and may book a trip when it cools down. Shannon also stated that even a massive thrombus would be asymptomatic, unless that bad boy breaks loose. Beyond me how a massive clot can be in their and you not feel any adverse effects.

When I asked Shannon about this, she said do it if it would give me peace of mind. My insurance requires a prior authorization for this and “peace of mind” would not get it authorized. That is why I asked her for the criteria being used to determine which patients should get this. I would want this done locally and because it does not meet the watchman criteria here, my local cardiologist would not order it. I cannot get through to this cardiologist that I am a patient of Dr. Natale and follow his criteria, not theirs!! Because of that, Dr. Natale would have to order it. It is unusual not to hear back from Shannon. I do not know what is going on. Without this forum, I never would have known about a 2 year check. I looked on the Boston Scientific Watchman site yesterday and the only reference was the 45 day and 1 year check.

I hope we can get this straightened. Carey, if you read this, am I in my “overthinking” mode?😧

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Pixie
I hope we can get this straightened. Carey, if you read this, am I in my “overthinking” mode?😧

Heh, not really. It's a legitimate concern. Call Shannon back and ask again.

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Carey
If memory serves correctly, they've only seen the DRTs (device-related thrombi) with people who stayed on aspirin rather than low-dose Eliquis and those are the only people they're recommending get a 2-year scan.

Well, I am on low-dose Eliquis and the two-year scan was recommended for me and I was told that though they had found about three clots at two years, not all of them were in people on aspirin – at least one person was on Eliquis. So as others have said, it would be best to clarify this with Shannon.

Oh, okay, I thought they'd only found them on aspirin patients and only recommended the 2-year for those people.

I'm at year 6, so I guess I missed that boat.

I just got off the phone with Shannon having a preop phone call regarding my 2nd ablation and watchman implant on 8-21 and I queried her about the watchman blood clot protocol. She advised me that the way Dr Natale handles the follow-ups is as follows: 2 months after the implant, the patient will be physically present at St. David's for a TEE. At 6 months, 1 year, and 2 year marks after the implant (total of 4) a CT scan with contrast can be performed by a local hospital with specific instructions from Austin on how to perform the scan. This is instead of doing the next 3 scans at St. David's if you are not local or willing to travel. I mentioned your situation and she asked for your name but I could not gather it from your profile. I do have her email if you would like to reach out to her.

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G48
I just got off the phone with Shannon having a preop phone call regarding my 2nd ablation and watchman implant on 8-21 and I queried her about the watchman blood clot protocol. She advised me that the way Dr Natale handles the follow-ups is as follows: 2 months after the implant, the patient will be physically present at St. David's for a TEE. At 6 months, 1 year, and 2 year marks after the implant (total of 4) a CT scan with contrast can be performed by a local hospital with specific instructions from Austin on how to perform the scan. This is instead of doing the next 3 scans at St. David's if you are not local or willing to travel. I mentioned your situation and she asked for your name but I could not gather it from your profile. I do have her email if you would like to reach out to her.

G48,
Thank you, I really appreciate this information. I finally received a response from Shannon, but did not want to post it until you responded after your phone call with her.
She was going to review my chart with Dr.Natale to see if there was a need for my 2 year scan. It has been a week and she has not gotten back to me, so I will be emailing her again.

She also told me that they are coming across issues with the insurance companies limiting post Watchman imaging! This is all quite interesting!

Thanks again and good luck with the ablation and implant.



Edited 1 time(s). Last edit at 08/07/2024 09:43PM by Pixie.

Just a FYI, I was religiously taking 5mg BID Eliquis from age 67 to when I had my watchman. Then the Eliquis dose was reduced to 2.5mg BID post watchman. That was about 2 years ago.

A few months ago I felt a big lump in my right armpit-side I sleep in. An ultrasound showed a 2.5mg DVT clot.

So having a clot while on half dose is possible. I had to take BID heparin shots for 6 weeks and now I am instructed to take full dose Eliquis for life because half dose didn’t dissolve the clot.

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susan.d
So having a clot while on half dose is possible. I had to take BID heparin shots for 6 weeks and now I am instructed to take full dose Eliquis for life because half dose didn’t dissolve the clot.

I don't believe Eliquis, or warfarin or other NOAC blood thinners, will dissolve clots. They can reduce the risk of having them. Body functions can dissolve clots.

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susan.d
So having a clot while on half dose is possible. I had to take BID heparin shots for 6 weeks and now I am instructed to take full dose Eliquis for life because half dose didn’t dissolve the clot.

I don't believe Eliquis, warfarin, other NOAC blood thinners or even heparin, will dissolve existing clots. They can reduce the risk of having them. Body functions can dissolve clots.

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GeorgeN

So having a clot while on half dose is possible. I had to take BID heparin shots for 6 weeks and now I am instructed to take full dose Eliquis for life because half dose didn’t dissolve the clot.

I don't believe Eliquis, or warfarin or other NOAC blood thinners, will dissolve clots. They can reduce the risk of having them. Body functions can dissolve clots.

BID shots of heparin did dissolve my clot.

Reducing the risks to eliminate clots are two different things.
I felt a false security thinking I was protected while on 2.5mg eliquis.

George is correct. Heparin, the NOACs and warfarin do not dissolve clots. They can only prevent them from becoming larger and prevent new ones from forming. The only drugs that will dissolve clots are the so-called clot busters like tPA. However, tPA is expensive as hell and can't be given outside of a hospital.

According to Mayo Clinic:

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Heparin will not dissolve blood clots that have already formed, but it may prevent the clots from becoming larger and causing more serious problems.

Susan just curious re your dosage, was it based on age/weight etc? Asking because I meet the age/weight criteria and on 2.5mgs bid
anneh

The question that needs to be answered is -- Which option below reduces the risk of stroke the most:

1. Full dose of Eliquis per day
2. Watchman procedure and 1/2 dose of Eliquis per day
3. Watchman procedure and full dose of Eliquis per day
4. Watchman procedure alone

There is a NIH study underway that will determine if the Watchman is a reasonable alternative to NOACs (Eliqus). It is scheduled to be completed in December 2027. I hope it answers all my option questions above, but most likely only option #1 vs option #4 .

I would assume that option #3 is the best; but insurance will likely not pay for it. But with the new reduced price of Eliquis in 2026; one might be able to afford option #3 on their own. It would be great if option #4 is the best.

CHAMPION-AF Clinical Trial - NIH US National Library of Medicine

Clots originate in places other than the left atrial appendage (LAA), which is where 90% of all afib-related clots form. So the Watchman will never be the most effective preventative all on its own, but it will reduce clot formation by a huge percentage. That's especially true when you consider patient compliance. The truth is patients are downright terrible about compliance with anticoagulants. The drugs don't stop any symptoms they have so it's easy to just sort of forget to take them. Big numbers of patients stop taking them altogether after a few years (I've seen 50%).

But I agree with your overall assessment. Eliquis is priced the same whether it's full or half-dose, so the insurance companies aren't going to care about that. As for #2 vs #3, that's going to come down to bleed risk. A full dose of Eliquis is presumably going to be more effective at preventing clots than a half dose, but it's also going to be more likely to prolong bleeds. So we need to consider both the benefits (clot prevention) and the risks (bleeds). My bet would be that the optimal answer will be #2.

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JakeL
The question that needs to be answered is -- Which option below reduces the risk of stroke the most:

1. Full dose of Eliquis per day
2. Watchman procedure and 1/2 dose of Eliquis per day
3. Watchman procedure and full dose of Eliquis per day
4. Watchman procedure alone

Thanks Carey, you brought up some points that I did not consider. I did not know that patient compliance with Eliquis was such a large concern (even though I doubt that people on this forum have that issue). But for those where compliance is an issue, the Watchman would be a big plus. In addition the Watchman is a big plus when you have to stop anticoagulants for a surgical procedure.

Your other point that Eliquis has a bleed risk is certainly important, but I have not heard much about it here. What I have heard is the the main reason for taking the anticoagulant is to minimize stroke risk (heard on this board is that stroke can be worse than death). So, avoiding stroke should be the primary reason for making a decision about what option to take.

I realize that all of these issues are what your EP must take into consideration when prescribing a mitigation for Afib. The other point is that in 2026 the price of Eliquis goes down, so insurance companies may want to take the cheaper route with the anticoagulant.

Given all of these considerations, I would opt to go with option #3, Watchman and full dose of Eliquis. Should we take a poll?

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JakeL

The question that needs to be answered is -- Which option below reduces the risk of stroke the most:

1. Full dose of Eliquis per day
2. Watchman procedure and 1/2 dose of Eliquis per day
3. Watchman procedure and full dose of Eliquis per day
4. Watchman procedure alone


Given all of these considerations, I would opt to go with option #3, Watchman and full dose of Eliquis. Should we take a poll?

I am still waiting for an answer from Dr. Natale’s office about the 2 year post watchman implant Ct scan. I also asked him about staying on a full dose Eliquis after the watchman implant. I will be calling them this week because my emails are not being answered. Option 3 is what I would opt to go with also.

JakeL, I don’t remember your history. Did you have a watchman, and, if so, did you have a CT scan at the 2 year mark?

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JakeL
Your other point that Eliquis has a bleed risk is certainly important, but I have not heard much about it here. What I have heard is the the main reason for taking the anticoagulant is to minimize stroke risk (heard on this board is that stroke can be worse than death). So, avoiding stroke should be the primary reason for making a decision about what option to take.

That is the main reason, and you probably heard strokes sometimes being worse than death from me because I like to remind people of that. But keep in mind there are two types of strokes: Embolic strokes, which are usually caused by blood clots and are the type we with afib worry about, but there are also hemorrhagic strokes, which are caused by bleeding in the brain. Brain bleeds happen for many reasons and they're usually unpredictable, but when one does occur, being on an anticoagulant is not a good thing. It can change a minor stroke into a major one.

So my point is simply that you can't ignore the bleed risk side of the equation. I have a Watchman and take a half dose Eliquis instead of full dose for exactly this reason.

PS- And for those who think aspirin is safer, pretty much everything I said above applies to aspirin as well. It's not safer, not by any means.

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Carey



That is the main reason, and you probably heard strokes sometimes being worse than death from me because I like to remind people of that. But keep in mind there are two types of strokes: Embolic strokes, which are usually caused by blood clots and are the type we with afib worry about, but there are also hemorrhagic strokes, which are caused by bleeding in the brain. Brain bleeds happen for many reasons and they're usually unpredictable, but when one does occur, being on an anticoagulant is not a good thing. It can change a minor stroke into a major one.

So my point is simply that you can't ignore the bleed risk side of the equation. I have a Watchman and take a half dose Eliquis instead of full dose for exactly this reason.




Carey, thank you for differentiating the 2 types of strokes. For the reason you stated, I am going to stay on the half dose Eliquis.