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Delayed endothelialization of watchman device identified with cardiac CT

Bhradeev Sivasambu1, Armin Arbab-Zadeh1, Allison Hays1

  • 1Department of Medicine, Johns Hopkins University, Baltimore, Maryland.

Journal of Cardiovascular Electrophysiology
|July 2, 2019
PubMed

Insights

The Watchman device for left atrial appendage closure shows delayed endothelialization, with significant porosity observed 6 weeks post-implantation. Further research is needed to assess prolonged anticoagulation for reducing device-related thrombus and stroke risk.

Area of Science:

  • Cardiology
  • Medical Devices
  • Stroke Prevention

Background:

  • Left atrial appendage (LAA) closure with the Watchman device is a common stroke prevention strategy for nonvalvular atrial fibrillation.
  • While clinical trials show similar combined stroke risks, Watchman may increase ischemic stroke risk compared to anticoagulation, potentially due to device-related thrombus (DRT).
  • Delayed endothelialization of the Watchman device's exposed material is suspected as a cause for DRT.

Purpose of the Study:

  • To evaluate the degree of LAA occlusion and identify leak types using transesophageal echocardiogram (TEE) and computed tomography (CT) at 45 days post-Watchman implantation.
  • To investigate the porosity of the Watchman device and assess the potential for delayed endothelialization.

Main Methods:

  • A prospective registry of patients undergoing Watchman LAA occlusion was analyzed.
  • 46 patients with both TEE and CT at 45-day follow-up were selected.
  • LAA occlusion and leak characteristics were assessed by CT and TEE, differentiating between peri-device and trans-fabric leaks.

Main Results:

  • TEE showed no significant (>5 mm) peri-device leaks, but nonsignificant leaks (<5 mm) in 58.6% and complete occlusion in 41.4%.
  • CT revealed contrast within the LAA in 60% of patients, with 21.8% showing contrast entering through the device fabric (trans-fabric leak).
  • No device-related thrombi (DRT) were identified in this cohort at 45 days.

Conclusions:

  • The Watchman device exhibits significant porosity at 6 weeks, indicating delayed endothelialization.
  • Cardiac CT is valuable for distinguishing between peri-device and trans-fabric leaks.
  • Further studies are warranted to determine if prolonged anticoagulation can mitigate DRT and ischemic stroke risk in patients with trans-fabric leaks.
Abstract

Keywords:
cardiac computed tomographydelayed endothelializationleft atrial appendage occlusionwatchman device

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