The WATCHMAN left atrial appendage closure device for patients with atrial fibrillation: current status and future perspectives

ABSTRACT

Introduction

Atrial fibrillation (AF) is associated with an increased risk of stroke. Stroke prevention with oral anticoagulation (OAC) is recommended in AF patients at increased risk of stroke. The left atrial appendage (LAA) is the main source of thrombus formation in AF patients. The WATCHMAN percutaneous LAA closure (LAAC) device may serve as an alternative to OAC overcoming disadvantages including the risk of (major) bleeding.

Areas covered

This review will focus on LAAC with the Watchman device for stroke prevention in AF patients. Current status, available literature, clinical safety and efficacy will be summarized. Furthermore, the future perspectives of Watchman will be discussed.

Expert opinion

LAAC with Watchman appears a promising, safe, and effective alternative to OAC. Ongoing and future studies to consolidate the position of Watchman should focus on comparative safety and efficacy of different LAAC devices, patient selection, various post-procedural antithrombotic regimens, head-to-head comparisons with NOAC, better understanding of device-related thrombus, and the role of the LAA in the propagation of non-valvular AF. This research may attribute to a paradigm shift in which LAAC no longer serves as a ’last resort’ treatment for AF patients ineligible for OAC but may serve as a second-line or even first-line treatment option for AF patients.

KEYWORDS:

• Atrial fibrillation
• left atrial appendage
• left atrial appendage closure
• Watchman
• stroke prevention

Article highlights

• Percutaneous left atrial appendage closure (LAAC) with the Watchman (Boston Scientific, MA) device has emerged as a valid alternative to OAC for stroke prevention in AF patients.

• The second-generation Watchman FLX has been designed for improved and simplified delivery to conform to a wider range of LAA anatomies, including wide and shallow LAAs.

• Despite the growing body of evidence regarding safety and efficacy of LAAC from observational studies, there is a number of unresolved matters, including the occurrence of device-related thrombus (DRT), the role of LAAC in OAC-ineligible patients, head-to-head comparisons with NOAC, and head-to-head comparisons of different device types.

• LAAC may serve as a valuable adjunctive to other catheter-based procedures within the left side of the heart to reduce anticoagulation and/or AF burden (coronary stenting, aortic valve replacement, mitral valve clipping, catheter ablation) and may be performed in one single procedure.

• A large number of randomized studies is underway. The expected results may consolidate the position of LAAC as first- or second line treatment for stroke prevention in AF patients and broader expansion the technique.

Declaration of interest

M Swaans reports proctoring fees for training/educational services to the Department of Cardiology from Boston Scientific, and personal fees from Abbott, Philips Healthcare and Bioventrix Inc. L Boersma is a consultant for Boston Scientific and proctor for Abbott. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer disclosures

One peer reviewer is a proctor and consultant for Abbott and Boston Scientific. Peer reviewers on this manuscript have no other relevant financial relationships or otherwise to disclose.

Additional information

Funding

This paper was not funded.