Should I have the Lariat procedure or Watchman device?

I am 62 years of age, in relatively good health except that I am in constant afib. Approximately 2 years ago I suffered a stroke (not a TIA) but fortunately have had no apparent after effects. I was placed on Pradaxa. I was regularly exercising however my heart rate under strenuous exercise could reach about 220 (prior to my stroke my max HR was about 178). About 7-8 weeks ago I suffered a splenic infarction (my doctors were quite surprised since I was on anticoagulation medication). I was switched to Xaralto and a baby aspirin and advised to stop “strenuous exercise” (I first noticed discomfort from the clot while doing sit ups). I had a complete blood work-up which came back normal. My doctors are recommending the Lariat procedure (actually they had wanted to implant the Watchman device but FDA has delayed approval). Could you offer any recommendation or opinion? Thank you.

Submitted by David from New York on 07/02/2014

by William E. Cohn, MD

Hi David. First, let me be clear. I have a vested interest in SentreHeart and the Lariat, as I invented the technology and started the company. That said, I know the device intimately and I think I can offer you advice.

The fact that you have had an embolic event while on anticoagulants suggests strongly that something should be done with respect to your atrial fibrillation and/or your left atrial appendage (LAA). Although there has not yet been a prospective randomized study looking at stroke and embolic prevention after the Lariat procedure, we are very certain that it is a safe and effective way to close the appendage. It is widely believed that most, if not all, emboli that patients with atrial fibrillation suffer (absent co-existent mitral valve disease) come from the LAA. The Lariat procedure has been performed in approximately 3000 cases. The main complication after Lariat is pericarditis and effusion, although 1% of patients have required urgent surgery after the procedure to repair a puncture to the right ventricle sustained during access of the space between the heart and the heart sack. The main difference between the Watchman and the Lariat is that the Watchman is a metal and fabric implant placed inside the heart, blocking the opening to the appendage. The Lariat on the other hand occludes the appendage by tying off the base of the LAA from outside the heart. I would recommend that you have your LAA addressed by one of these techniques. Conversely, some surgeons will staple or clip the appendage through a small 2-3 inch incision between the left ribs. It also may be a good idea to consult an electrophysiologist (if you haven’t already… you probably have) to see if you are a candidate for an ablation of some sort, either catheter-based or surgical, to see if your atrial fibrillation can be converted to sinus (normal) rhythm. Good luck! Billy