Patients with AF who are above the age of 65, or have co-morbidities such as diabetes, high blood pressure, vascular disease or heart failure are at an increased risk of stroke. It is understood that these patients are at a higher risk of stagnation of blood within the heart; the stagnant blood can form clots within the heart and these clots can get dislodged, travel to the brain, and block the blood supply to areas of the brain resulting in stroke.
The prescription of anticoagulants, which act by reducing the ‘clottability’ of blood, to such patient has been shown to reduce the risk of strokes by about 60%. The problem with anticoagulants however is that they can significantly increase the risk of potentially life threatening bleeding and therefore the management of patients with Afib who are at a higher risk of bleeding poses a great clinical dilemma. Such patients include:
1) Patients with haematological disorders such as thrombocytopenia.
2) Patients with previous life -threatening (especially intracranial) bleeding
3) Patients who are at very high risk of falls
4) Patients who are very poorly compliant with anticoagulants.
If these patients are not prescribed an anticoagulant, they are exposed to a high risk of strokes and if they are prescribed an anticoagulant then they are exposed to a much greater risk of bleeding. It is for such patients, that the WATCHMAN device offers an elegant and very effective alternative solution.
Left atrial appendage occlusion
We have known for a long time that the most likely site for clot formation in AF is a beak shaped structure adjacent to the left atrium called the left atrial appendage. It would be a reasonable assumption that if the left atrial appendage could in some way be mechanically occluded or closed off then there would be no way for clot within the left atrial appendage to get dislodged and travel to the brain. It was this hypothesis that led to the development of a left atrial appendage occlusion device known as The WATCHMAN device.
WATCHMAN
The WATCHMAN device is a self-expandable nitinol cage which is covered by a layer of PTFE membrane and can be inserted into the left atrial appendage using a keyhole percutaneous technique. It is available in 5 different sizes.
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