key: cord-0814901-pm1f29kr
authors: E-Xin Tan, Bryan; Depta, Jeremiah P.; Baibhav, Bipul; Bhatt, Deepak L.
title: Necessity of 45-day transesophageal echocardiography after the WATCHMAN procedure amid the COVID-19 pandemic
date: 2020-05-26
journal: JACC Cardiovasc Imaging
DOI: 10.1016/j.jcmg.2020.05.015
sha: 10105da63da5b83bc055b2ad50bdee5f32e5f2db
doc_id: 814901
cord_uid: pm1f29kr

nan

In atrial fibrillation patients undergoing left atrial appendage closure (LAAC), TEE is typically performed at 45 days to assess peri-device flow <5mm and an absence of devicerelated thrombus (DRT) before oral anticoagulation (OAC) is discontinued. We sought to investigate whether a 45-day TEE is absolutely necessary for patients who underwent LAAC amid the COVID-19 pandemic. 2 We retrospectively studied 200 patients who underwent successful WATCHMAN procedure in a tertiary hospital (June 2016 -June 2019). Upon discharge, patients were maintained on OAC and aspirin. We aimed to assess TEE measured peri-device flow at the time of implantation and at 45 days. Institutional Review Board approval was obtained. The mean age was 75.9 ± 8.3 years, and 42.9% of patients were women. The mean CHA 2 DS 2 -VASc and HAS-BLED scores were 4.8 ± 1.6 and 2.9 ± 0.9, respectively. Patients were discharged more frequently on direct oral anticoagulant (DOACs) (77.5%) as opposed to ( Figure 1 ). Among 11 patients with peri-device flow 1 -5mm at the time of the procedure, 9 underwent TEE at 45 days; where 4/9 patients (44.4%) had an absence of peri-device flow, 5/9 (55.6%) had flow 1 -5mm, and 0/9 (0%) had peri-device flow > 5mm. No patients had DRT on 45-day TEE.

In the PROTECT-AF trial, peri-device flow > 3mm was observed in 13% and 12% of patients on 45-day and 1-year TEE, respectively. However, the more recent EWOLUTION study showed that significant peri-device flow >5mm occurred only in 1% of patients on 1-

year TEE. In our study, one patient (0.5%) developed significant peri-device flow on 45-day TEE, and none had DRT.

For WATCHMAN programs that deviate from standard warfarin regimen post-LAAC, DRT is more common with single/dual antiplatelet therapy than OAC (warfarin and DOACs). 3 The rates of DRT were similar in patients receiving DOAC (0.9%) compared with warfarin (0.5%) in a retrospective multicenter study. 4 Thus, a 45-day assessment may be more relevant in patients receiving single/dual antiplatelet therapy post-LAAC. Additionally, it calls into question the current practice of assessing DRT while on OAC at 45 days. It may be more reasonable to assess for DRT after discontinuation of OAC. This specific question requires further investigation.

In this retrospective analysis, we showed that the incidence of significant peri-device flow and DRT at 45 days is very low. Thus, a 45-day TEE post-WATCHMAN implantation may not be necessary for all patients, and OAC may be safely discontinued at 45 days without a TEE. Currently, the NCDR LAAO Registry requires documentation of device closure and absence of DRT at 45 days post-LAAC. Computed tomography (CT) is a reasonable alternative to TEE for device surveillance. 5 In our opinion (not supported by the present study), the rationale for foregoing a 45-day TEE should also extend to the baseline TEE before LAAC; Use of CT may be considered. Amid the COVID-19 pandemic, deferring 45-day TEE post-WATCHMAN implantation has the potential to minimize use of PPEs and reduce preventable risks of viral transmission. Prospective trials are warranted to see whether this practice should be reconsidered even after the pandemic subsides. 2 

ASE Statement on Protection of Patients and Echocardiography Service Providers During the

COVID-19: An Unintended Force for Medical Revolution?

Propensity-matched comparison of oral anticoagulation versus antiplatelet therapy after left atrial appendage closure with WATCHMAN

Use of non-warfarin oral anticoagulants instead of warfarin during left atrial appendage closure with the Watchman device. Heart Rhythm

Comparison of cardiac computed tomography angiography and transoesophageal echocardiography for device surveillance after left atrial appendage closure