LAAO with Watchman Device Post-Procedure Best Practices Lindsay Thomas, MS, RN, CCNS

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LAAO Watchman Post-Procedure Best Practices Inpatient Services Post-Procedure Pharmacotherapy & Testing Post-Procedure Quality of Life LAAO Example documents & templates

Inpatient LAAO Services Dedicated service to facilitate management of the LAAO patient population Standardized protocols for post-procedural management Include key members of multidisciplinary heart team: physicians, PAs, NPs, CNSs, RNs, Fellows, quality, IT… Utilize electronic health resources Continued communication with referring physicians RN staff education: in-services/training

Inpatient LAAO Services Significant learning curve that accompanies LAAO procedures Operator and team should be capable of handling potential complications, while receiving units/nurses should be competent to recognize and react to potential complications Hematoma/vascular injury Pericardial effusion/tamponade Device embolization Stroke

LAAO Standardized Procedures Post-Procedure Orders Determine who will place orders (may want to create cheat sheet) Physician, Fellow, PA/NP/CNS Admit to cardiology service overnight Initiate aspirin & warfarin (low dose) Prophylactic antibiotics Cefazolin 1 gm IV : <1 hr pre-procedure and 12hr post-procedure TTE prior to discharge Assess for pericardial effusion, confirm device placement, and absence of intracardiac thrombus

LAAO Patient Discharge Patient Education & Follow Up No lifting >20 lbs x 3 days, avoid strenuous activity x 1 week Make sure patient receives, “Watchman Left Atrial Appendage Closure Device Patient Information Guide” Watchman Device Wallet Card Reinforce warfarin education and INR schedule Provide lab orders if needed If previously on NOAC confirm patient understands NOT to resume Review when to call MD/RN and provide contact information Schedule follow up TEE and clinic visit

LAAO Post-Procedure Pharmacotherapy & Follow Up POD 1 POD 45 PO 6 mo Pharmaco-therapy aspirin 81-100 mg warfarin *prophylactic antibiotics prn aspirin 300-325 mg clopidogrel 75 mg Aspirin 300-325 mg indefinitely *prophylactic antibiotics Diagnostic Testing TTE: assess device placement and absence of thrombus TEE: assess device placement, absence of thrombus, and leak (≤5 mm) prn Follow up Discharge home: INR lab orders, f/u appointments scheduled Clinic Visit

Contraindication to Anticoagulation Is LAAO in the future for patients who are unable to be treated with OAC due to major contraindications or intolerance?

45-day TEE & Visit Confirm absence of intra-cardiac thrombus Assess Watchman device with TEE Confirm absence of intra-cardiac thrombus If thrombus present recommend continuing warfarin until resolution of thrombus Perform color doppler assessment at TEE angles (0°, 45°, 90°, & 135°) to assess for leak If leak > 5mm continuation of warfarin recommended Clinic visit assess for any bleeding events or neurologic changes Utilize Barthel Index or Modified Rankin Scale to measure disability in patients who have suffered CVA

LAAO Quality of Life Sub-analysis of PROTECT AF trial to measure quality of life Short-Form 12 Health Survey obtained at baseline and at 12 months At 12 months, patients who received Watchman device showed improvements in total physical score, physical functioning, and physical role limitations, while warfarin patients experienced decreases Significant improvement in QOL in patients randomized to device compared to control No More warfarin = better QOL “By taking them off the warfarin, these patients feel great, they eat better, exercise more, and could walk better without the fear of falling and having a bleed.” Ziyad M. Hijazi, MD, MPH

LAAO Work Flow & Responsibilities Example of LAAO work flow to outline and define LAAO team responsibilities Individualize to your team and institution Modify as needed as program evolves

LAAO Cheat Sheet Single page summary provided to all fellows/residents who will provide care to LAAO patients

Standardize LAAO Orders Example: POD 45 standardized TEE order: information included in comments section to make sure all important measurements are taken

Questions? Thanks for your attention.