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

2. Disclosure Statement of Financial Interest
Within the past 12 months, I or my spouse/partner have had a financial interest/arrangement or affiliation with the organization(s) listed below.
Affiliation/Financial Relationship
Company
Grant/Research Support
Consulting Fees/Honoraria
Major Stock Shareholder/Equity
Royalty Income
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Intellectual Property Rights
Other Financial Benefit
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3. LAAO Watchman Post-Procedure Best Practices
Inpatient Services
Post-Procedure Pharmacotherapy & Testing
Post-Procedure Quality of Life
LAAO Example documents & templates

4. 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

5. 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

6. 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

7. 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

8. LAAO Post-Procedure Pharmacotherapy & Follow Up
POD 1
POD 45
PO 6 mo
Pharmaco-therapy
aspirin mg
warfarin
*prophylactic antibiotics prn
aspirin mg
clopidogrel 75 mg
Aspirin 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

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

10. 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

11. 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

12. 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

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

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

15. Questions?
Thanks for your attention.