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Transcript
[00:00:08] Matthew DeVane, DO, FACC: Hi, I'm Doctor Matt Devane.
[00:00:10] Carolyn Lacey, MD, FACC: And I'm Doctor Carolyn Lacey. We are cardiologists at John Muir Health and this is our podcast, Living Heart Smart.
[00:00:16] Matthew DeVane, DO, FACC: Our physician partners and colleagues are going to help guide you through many different and important cardiovascular topics to help keep your heart happy and healthy.
[00:00:24] Carolyn Lacey, MD, FACC: Thank you for listening and we hope you enjoy our show.
[00:00:31] Matthew DeVane, DO, FACC: Hi, everybody. Welcome back to another episode of Living Heart Smart. We're going to be digging back into our series about atrial fibrillation. We're going to do probably 7 or 8 different episodes. We have a number of our John Muir physician physicians taking part in this series, which we're excited about. So Carolyn and I are here today with one another, one of our partners, Doctor Andy Dublin. We really appreciate you being here. Thank you.
[00:00:55] Andrew Dublin, MD: Yeah, thanks for having me. I'm excited to be here. Good.
[00:00:57] Matthew DeVane, DO, FACC: Well, today we're going to be talking about a procedure that Doctor Dublin specializes in called the left atrial appendage occlusion device, which we're going to talk about more. But I want to give a little background about Doctor Dublin. First Doctor Dublin went to undergrad at Brown University and Ivy League guide. Nice did his medicine training at Wayne State University in Detroit, did his internship and residency at University of California, San Diego, then went on and did cardiology fellowship at Cedars-Sinai in Los Angeles. And then he went on to do his cardiology interventional training at Lenox Hill Hospital in New York. So a lot of training, and we're glad to have them here with us today. Today we're going to be talking about an atrial fibrillation procedure that does help patients the right patients in some patients, not for everybody potentially get off blood thinners if they have atrial fibrillation. So first thing though is we're going to give a little open floor here to doctor Dublin. Tell us a little about yourself. How did you end up here. And Walnut Creek area and John Muir Hospital.
[00:01:59] Andrew Dublin, MD: Sure. Thanks. I grew up in Seattle, Washington, born and raised. And then, as Matt said, I went across the country for some education to the Midwest and then ended up in Southern California. And while I was doing my cardiology fellowship, one of the fellows a year ahead of me was Doctor Perkins Hsu, and he came up here while I was still a fellow down there and getting ready to start my interventional year. And he said, hey, we have an opening for an Interventionalist. Why don't you come up and interview? And I did, and I figured it was still West Coast. It was a nice place to raise a family. My wife wasn't ever going to go to Seattle, so that was kind of off the table. And that's how we ended up here.
[00:02:39] Matthew DeVane, DO, FACC: I did not know you guys knew each other back then. That's great.
[00:02:41] Carolyn Lacey, MD, FACC: Doctor Hsu, just so everybody knows, he's one of our partners. We'll have him on for a different episode. You just signed him up, Andy. Did you know that? Excellent.
[00:02:48] Andrew Dublin, MD: He's also part of the watchman procedure, so he thought he should be part of it.
[00:02:53] Matthew DeVane, DO, FACC: Good. Well, thank you for that information.
[00:02:55] Carolyn Lacey, MD, FACC: So, Andy, something I learned about you while we were getting ready for this episode is that you took a year off from medical school. Not many people do that. Tell us. Tell us about what you did. It was pretty cool.
[00:03:07] Andrew Dublin, MD: So. Yeah, no, I did. I, uh, I had always wanted to learn how to speak a second language. And, you know, in high school, I took Japanese because I grew up in Seattle, and it was sort of the hard language to take in high school, but I was able to get straight A's and yet not be able to speak to a Japanese person at any level. And then in college, I took Hebrew because I'd gone to Israel as a foreign exchange student in high school, and I wanted to get better at Hebrew. But again, after a year getting straight A's still couldn't speak to anybody. And I said, I really need to do an immersion if I'm going to ever learn something. And I said, well, what language do I really want to learn? And Spanish seemed to be both fun and applicable. So I said, well, if I'm going to do it, this is really the only opportunity I have left is between second and third year of medical school because it really second year you finish your your book studies and then third year you start your clinicals. But at least at Wayne State, there wasn't a lot of, you know, problem taking a break in between.
[00:04:06] Andrew Dublin, MD: And so I spoke to my administration at Wayne State and I said, I really want to go to Mexico for a year, not under any program where I'm, you know, getting credit for anything, but I just want to go move there and learn Spanish and then come back and not lose my spot. That was obviously important to me. That's important. And so they were agreeable. So I said, okay, great, I'm going to press pause. And I went down to Mexico. I did do some medical work, but it was more on the volunteer end of things as opposed to getting course credit for it. And after about a month, I was enough that I could probably have a conversation. I felt more confident in Spanish than I did after four years of high school. Japanese. Right. And then after, you know, three months, I felt pretty comfortable. And by the time the year was over, I really felt very good. I mean, my accent is terrible. You can all hear when I speak Spanish with my patients, but but I feel very comfortable having conversations in Spanish, whether they're medical conversations or non. Uh, so that was that was kind of fun. That's great.
[00:05:07] Matthew DeVane, DO, FACC: Yeah. Not many people are able or willing to do that. It's very cool. Well we're going to try to do today's podcast in English if that's okay.
[00:05:15] Andrew Dublin, MD: That would be.
[00:05:16] Matthew DeVane, DO, FACC: Fine. Okay. Good. Well we're going to talk about atrial fibrillation. We do have a couple episodes out on that already but I do I would like to hear I mean we can never talk enough about what it is. So many of our patients have it. If so, if the doctor Dublin if you wouldn't mind just giving us. We're going to do a basic overview here. What is atrial fibrillation. Then we'll get into a little bit about some of the problems it causes like strokes and why people need blood thinners. But let's start out with the basics. Can you just how do you describe atrial fibrillation to your patient.
[00:05:42] Andrew Dublin, MD: Sure. So even though I'm an interventional cardiologist, a huge part of my practice is general cardiology and atrial fibrillation, really, as you guys all know, is bread and butter for a general cardiologist. So I always start off, the very first thing I say to a patient is I've got great news. You are not going to die from your atrial fibrillation. It is not a fatal heart disease. And then the tension in the room tends to lighten up quite a bit because more than anything, patients are worried about am I going to die from this heart condition? At least that's my experience. And so that's literally the first thing I say. You're never going to die from this. If you do, you'll be the first. We'll both be famous in different ways and the first.
[00:06:21] Matthew DeVane, DO, FACC: Doctor to kill a patient.
[00:06:22] Andrew Dublin, MD: Okay. So they usually laugh and feel, you know, feel better about it. And so then I say, but that doesn't mean it's not a serious condition. And the biggest risk of atrial fibrillation is the risk of stroke. And you can die from a stroke. And also obviously everybody knows about how debilitating strokes can be. So it's not a hard thing to introduce. But I say, but first we really need to separate atrial fibrillation into three different buckets because they're all very different. And the first bucket I'm going to save the stroke part for last. And so I always say I always save the stroke part for last. I say it's the most important and it's the one I want to spend the most time on. So I go through and I talk about first rhythm control and the benefits and, you know, pros and cons of getting back into sinus rhythm versus not. I also talk about how atrial fibrillation comes in different flavors. One that it's the most common arrhythmia in the world. Millions of people have it. So you're not alone or special for that reason, even though you might be special for other reasons. And atrial fibrillation comes in paroxysmal or permanent, which means it comes and goes or you're always in it and it comes in symptomatic or asymptomatic. And the rhythm control strategy we choose depends on which type of atrial fibrillation you have, especially the symptomatic versus asymptomatic. So I go into that part of it with. And then the second bucket we talk about is rate control. And I say in general atrial fibrillation is like a Ferrari or a fast car. It wants to go fast. And so most of the time we need to have a strategy aimed at slowing down atrial fibrillation. And so we talk about that for a few minutes. And then we get to stroke prevention. Yeah this is.
[00:07:54] Matthew DeVane, DO, FACC: The big one right.
[00:07:57] Carolyn Lacey, MD, FACC: Matt did you notice when Andy starts talking about atrial fibrillation. We heard this with Andy Ben too. We talked we've talked about this before that it really is about reassuring your patient. And I think that we've now heard this in multiple episodes where it is something serious and we do need to deal with it, but it's not the end of the world.
[00:08:20] Matthew DeVane, DO, FACC: I like how you. Yeah, that was good. Confront the biggest issue right up front. Hey, you're not going to die. We're going to deal with this. And but as you said, there's a rate control part of the treatment. And then there's the anticoagulation part of the treatment which is the blood thinning part to help prevent strokes. So we did talk about this with Doctor Ben some. But I'd like for you, Doctor Dublin, if you wouldn't mind. Just tell us how is it that atrial fibrillation can even lead to a stroke. How what's the connection there?
[00:08:46] Andrew Dublin, MD: Yeah. So, you know, the best theory understanding that I've heard is that essentially when the heart is in atrial fibrillation, it will change the speed of the blood flow inside of the left atrium, which is a filling chamber for the heart. There's another structure inside the left atrium called the left atrial appendage, which we'll obviously talk a lot more about later in the episode. But inside that left atrial appendage, the blood flows even slower. And I can I compare it to like, brackish water in a river. So you have a river with, you know, water that flows really well, but then there might be a side part of the river where the water is moving slowly and more brackish. Slow moving blood sticks together and forms clots. And so when a clot forms in that area, it then can travel up to the brain and cause a stroke. Um, the reason I say the best that we understand it is because if you really believe that's the only way strokes happen in atrial fibrillation, then the theory of, well, if I'm not in atrial fibrillation, I don't have a risk of stroke should be true. But we know for a fact that that's not true. And just having been diagnosed with atrial fibrillation, even if you pursue a quote unquote rhythm control strategy, you're still at risk for stroke. And we still need to mitigate that stroke risk through some strategy. So I'm sure there is other mechanisms of stroke in atrial fibrillation that don't depend on the rhythm that you're currently in. Although we do know the larger the burden, the more likely the stroke is. But it's not a yes no. And a lot of patients, as I'm sure you guys talked about with Andy, feel like if I'm just out of atrial fibrillation, that's my stroke prevention strategy. And I'm very, very clear with patients that that's not a stroke prevention strategy. And we still have to have one.
[00:10:27] Carolyn Lacey, MD, FACC: I think we all get asked that probably. Multiple times a day. And it's it's a really hard concept for people to sort of wrap their heads around. Yeah, we.
[00:10:36] Matthew DeVane, DO, FACC: Did talk about that with Andy, Ben, and we kind of all agreed that most of the people that we see with atrial fibrillation are going to be committed to taking a blood thinner for the rest of their life, whether they're in rhythm at that moment or not. The stroke risk is still there.
[00:10:52] Andrew Dublin, MD: So that's the other thing people ask is this forever? And I often will tell them, well, only as long as you want to prevent a stroke. I mean, it's not making you feel better. So any time you want to stop lowering your risk of stroke, you can stop taking your blood thinner.
[00:11:04] Matthew DeVane, DO, FACC: And yeah.
[00:11:05] Andrew Dublin, MD: No, you want to empower empower the patient, right?
[00:11:08] Matthew DeVane, DO, FACC: I like that. And so that sort of brings us a little bit about our main topic today, because prior to a few years ago, I think maybe 2015, five, six years ago, we didn't really have any other options. Blood thinning. If you had atrial fibrillation and we wanted to prevent a stroke, which we do, you had to be taking a blood thinner pretty much for the rest of your life. And there was no alternative to that. And that was okay because the blood thinners do work. Thank goodness they did work right. And they've changed over time from Coumadin, which had its own set of issues, to the newer blood thinners, which have really been a game changer for the patients that we see. And probably most of our listeners are taking one of the newer blood thinners that have atrial fibrillation. But up until again recently, we didn't have any other options. But now we do. So that's what our main topic is. Today, we're going to be talking about a procedure called the watchman device. And I know that may not technically be the right way to refer to this procedure. So if you can just tell us a little bit more about what the device is, what the procedure is called and what it is we're talking about. Yeah.
[00:12:11] Andrew Dublin, MD: So watchman has kind of become like the Kleenex versus tissue paper or Q-Tip versus long stick with something soft on the end. So it's really how most of us think about left atrial appendage occlusion. But the reality is down the line in a number of years we'll have more options. And there's another option, even now that, you know, we don't use for various reasons. So right now we we talk about watchman. But really the concept is left atrial appendage closure.
[00:12:38] Matthew DeVane, DO, FACC: And left atrial. Let's go back a little bit. And you mentioned left atrial appendage as where the potential clot forms this brackish water that you mentioned. So let's talk a little bit more about the left atrial appendage and what it is this procedure this device does and why we think it is useful. Yeah.
[00:12:54] Andrew Dublin, MD: So yeah, it's an interesting structure in the sense that it's clearly part of embryological development. You know, every single heart has one. And they come in all different shapes and sizes. Some are really small, some are really big, some have multiple lobes or little areas, you know, different coves, as you would say, little.
[00:13:15] Matthew DeVane, DO, FACC: Thing, as far as I know. Is there a reason we know that this little structure even exists.
[00:13:20] Andrew Dublin, MD: Outside of embryological development? No it doesn't. Yeah, it doesn't help the heart function. And patients often will ask that. And one of the ways we know it doesn't really make a difference is surgeons have cut out left atrial appendages for quite some time as a stroke mitigation strategy. And there's no clinical consequence from that. From that. Yeah. Okay.
[00:13:40] Matthew DeVane, DO, FACC: So we're targeting in on the left atrial appendage as a spot for stroke formation. And now we're talking about a procedure called the watchman device or left atrial appendage occlusion device that potentially can get our patients off blood thinners. That's kind of where we are. Right. So I wanted to hear about the procedure itself and what it entails. But I think the first thing we should do is identify those patients that should be thinking about a watchman device. So this is an atrial fibrillation patient that one of us in the group has seen that is on a blood thinner, has been started on a blood thinner for stroke prevention. And who and why should we be thinking about. Referring for this type of procedure.
[00:14:21] Andrew Dublin, MD: Yeah. So first of all, you have to have been diagnosed with atrial fibrillation at some point or atrial flutter. But atrial fibrillation or atrial flutter it is not stroke prevention strategy outside of the world of atrial fibrillation atrial flutter. So the world is first defined by being diagnosed with that. You don't have to be in it as we said, but you have to have at least been in it at some point in your life. So that's the first part. The second part is you have to have been recommended to consider blood thinners as a stroke prevention strategy. There is a large group of patients who have atrial fibrillation, but their risk factors for stroke are so low that we don't even recommend blood thinners for them. And I don't know if you talked about this in a different episode, lone AFib essentially. So we would not recommend a watchman patient, a watchman in a patient who wouldn't even be recommended blood thinners for another indication, you know, for stroke prevention. So we have what's called a Chadsvasc score, which you probably also talked about. But essentially it's a way of identifying risk factors that increase your risk of stroke. And the higher your chadsvasc score, the higher your risk of stroke. The other thing I always tell patients, even a patient who has a lot of risk factors, like, let's say an average Chadsvasc score of 4 or 5, that would be considered a higher score.
[00:15:38] Andrew Dublin, MD: The risk of stroke is 6%, 7% per year. It's not 50% per year, right. So oftentimes people overestimate the risk of stroke for themselves. And so I do want patients to understand that you're not flipping a coin. But if you have a stroke it could be minor insignificant, or it could be life altering or life ending. So, you know, just kind of puts things a little bit in more perspective for them. But I think sometimes patients feel a little bit like I'm either going to take it and not have a stroke, or I'm going to not take it and have a stroke. And the reality is all of these strategies, none of them make you immune to a stroke. So whether you take Eliquis, Xarelto, Coumadin, you can still have a stroke. It can be an ischemic stroke from a carotid plaque. It can be a hemorrhagic stroke from bleeding. So there's many types of strokes and embolic strokes from the left atrial appendage are a major one in atrial fibrillation, but not the only one. So it's important for patients to realize that. And generally they do get that concept. Otherwise we put a watchman in every single human and nobody would ever have a stroke. So you know, once we kind of get that on the table, then it makes it a little bit easier to talk about.
[00:16:48] Carolyn Lacey, MD, FACC: That's really important.
[00:16:49] Matthew DeVane, DO, FACC: Okay. So the patient has confirmed atrial fibrillation. They've been started on some sort of anticoagulation for their stroke prevention strategy. And so which patients should we be thinking about for this watchman type procedure.
[00:17:04] Andrew Dublin, MD: So right now the most ideal patients for watchman are they met those first two criteria. But then they also have some other reason to seek an alternative to anticoagulation. So the most common reasons both in our area and nationwide are risk of bleeding, which can either be they've had a bleed and that can be spontaneous GI bleed, gastric bleeds, brain bleeds, nosebleeds that are, you know, really recurrent and strong, severe, um, bleeding from the bladder, the urine. So there's there's a million ways you can have bleeding. Some of them are spontaneous. Some of them are because I cut myself and I bleed really badly. So, you know, just bleeding, especially if you needed a transfusion or something like that. So that would be one reason. The other really major, major category here is what we call fall risk. And the more you ask patients hey have you ever fallen. They actually start to tell you that they have and they'll, you know, often try and downplay it. I just tripped and nobody schedules a fall. But the older we get, the more we have balance issues and neuropathies and we don't catch ourselves. I always tell patients, look, I trip as much as anybody, but I can catch myself a lot easier than you can. And so it's not that. I mean, maybe you're tripping because you drag your feet a little bit and maybe I don't. But in general, we all have these potential falls. And the older you get and the less able you are as far as muscle strength and coordination, you are to stop it. And patients can kind of relate to that pretty quickly.
[00:18:35] Matthew DeVane, DO, FACC: And other and other conditions that go along with aging like Parkinson's and dementia, for sure. Higher risk by themselves too, right?
[00:18:40] Andrew Dublin, MD: Absolutely. And so fall risk probably is our number one indication or if not number one like one be. So it's a really common whether it's I've already fallen or I'm so careful and I'm always worried about it. And so that counts as fall as a good enough reason also. So those are the two main categories bleeding and fall risk. And then we get into the I hate blood thinners and refuse to take them whether they're good for me or not I don't care. I'm not going to take them. And so that's a reason to get a watchman device. And then we have the group of lifestyle patients. And so you have I've had a patient. He was older gentleman but he loved to water ski and. He didn't feel comfortable being on a blood thinner while he was waterskiing. So, you know, snow skiers, we have a lot of in this area. We have a couple race car drivers, we have a couple sailboat captains, you know, so different things like that, that, uh.
[00:19:32] Matthew DeVane, DO, FACC: Either lifestyle or occupational risk that a high risk for injury and bleeding issues.
[00:19:36] Andrew Dublin, MD: Correct? Yeah. Farmers. And sometimes it's people who hike in the remote wilderness and they're just really uncomfortable being on a blood thinner in case something happens, you know, in a remote area. So that's a very valid reason. Uh, there's a group of patients who have interactions between their blood thinners and other medications. Most common is probably NSAIDs for arthritis type pain. Um, and so that becomes a group of patients that we talk about. And then there's some other medical interactions. So those are probably the biggest groups. Now the one the two we didn't talk about one are it's too expensive blood thinners. Yeah it's a real thing. And we talk about it at some point Eliquis and Xarelto won't be too expensive we hope. And so I try to let people know, look, don't get this invasive procedure only for the reason of you can't afford Eliquis and Xarelto, but it might be affordable in two months or not. Probably not two months, but down the line in some short period of time and then you're going to regret it. So, you know, it's always just that's a conversation we have. And it might be the reason we do it, but it's not going to be the the leading reason.
[00:20:37] Matthew DeVane, DO, FACC: Cost is one issue, but just compliance in general. I mean, some of these medicines like Eliquis is a medicine you have to take twice a day, correct. Forever. So if that's going to be a struggle for some of my patients, those are some of the ones that I refer for this alternative. Yeah.
[00:20:51] Carolyn Lacey, MD, FACC: So compliance.
[00:20:52] Andrew Dublin, MD: For sure.
[00:20:53] Carolyn Lacey, MD, FACC: You know, and there's always a lot of dosage changes if you're for instance on warfarin and it interacts with every food you eat, every medication you take, all those things. Yeah. And it may be difficult to keep warfarin in the normal range. And then therapeutic range.
[00:21:09] Andrew Dublin, MD: The. Absolutely. And the very last group is I just prefer it. And so the I just prefer it group where that's a conversation. And I really spend a lot of time just talking about pros and cons, because there are pros and cons that we'll talk about in a little bit. But with that group of patients, I just prefer it. The reality is we have that clinical data randomized, double blind, placebo, excellent data against warfarin. We don't have it against Eliquis or Xarelto yet, but there's an ongoing trial called champion AF that's already finished enrolling. And hopefully we'll have data in the next year to two, which if watchman turns out to be equivalent and stroke reduction risk, then I will let patients just make a choice. Hey, we've already proven that it's equal, so you get to choose if it's superior. Of course, that's even better, but the hope is that it'll just at least be equal.
[00:22:01] Matthew DeVane, DO, FACC: The floodgates.
[00:22:02] Andrew Dublin, MD: Will open. And then then the answer is look, which one do you want? You can have a one time procedure, or you can take this blood thinner and you can choose either one. So so I hope that's where we end up. But you know, as of right now, I just prefer it leads to a long conversation. Um.
[00:22:16] Carolyn Lacey, MD, FACC: How how did you. So you're one of our implanters here at John Muir for the the watchman procedure. How did you. Get involved. How did you decide? Oh, I want to try this. Yeah.
[00:22:28] Andrew Dublin, MD: So when I was at Cedars-Sinai in Los Angeles in 2007 to 2010, we were one of the clinical trial sites for watchman before it was FDA approved. So before it was on the market. So I worked with Doctor Cibulka, who's an unbelievable operator and unbelievable at clinical trials and actually scrubbed into procedures with him and did watchman cases as a fellow before it was FDA approved. So I've always been excited and aware of it. It's just one of those things that I kind of feel like I grew up with because it was coming out when I was coming up, and so, so it's always been on my radar. And then in 2016, it was finally FDA approved. I had been doing procedures in the left atrium that involved transseptal punctures like mitraclip or mitral valve repair. And so I had some experience with that part of the procedure, which is pretty important part of the procedure and not not every interventionalist has experience with it. So I was qualified in that sense and then just excited about it. And so I put my name in the, you know, in the hat and, and was chosen to be one.
[00:23:31] Matthew DeVane, DO, FACC: How long have you been putting them in now.
[00:23:32] Andrew Dublin, MD: So I think 2016 was was our first one. Yeah. I think that's.
[00:23:36] Carolyn Lacey, MD, FACC: When we started doing them here.
[00:23:37] Matthew DeVane, DO, FACC: Okay.
[00:23:38] Matthew DeVane, DO, FACC: Well so for for a cardiologist we're always talking to patients. It's going to be the risk of the blood thinners which is bleeding mostly right. Versus the benefit of the blood thinners which is stroke prevention. So we get to we have that discussion. We just go through the some of the factors that patients should be thinking about as reasons to consider a watchman device. So let's the patient's going to ask me, the listeners want to know what is this thing you guys keep talking about watchman device or whatever it is. Can you just tell us what the heck is this exactly? So if a patient's coming to you and says, I want it, what do you tell them? Yeah.
[00:24:12] Andrew Dublin, MD: So a picture is worth a thousand words. I'm not sure how much a podcast is worth, but probably less than a picture.
[00:24:18] Matthew DeVane, DO, FACC: Unfortunately, you're going to earn your money by describing it in detail without a picture.
[00:24:22] Andrew Dublin, MD: But what I really do in my office is I on my computer. I pull up, I Google watchman device and then click on images, and then I find my favorite one and I click on it, and it just much easier for me to show people in that sense. But as far as describing it, you know, it's often described as like a parachute shape, but it's a nickel titanium alloy. It's a metal closed cell structure. It's got, you know, the the metal backing kind of comes around and closes itself, and then it has a coating over it, and that coating over it promotes tissue growth over the device to further seal the device. So it's metal with a tissue coated with a coating that promotes tissue growth.
[00:25:03] Matthew DeVane, DO, FACC: I think I tell my patients almost it's like a I describe it. Maybe this isn't what you it's almost like a little umbrella. I mean, we're going into the left atrial appendage to try to close the left atrial appendage off, because that's where the clots are forming. What's the patient supposed to expect if they say, give me one of these.
[00:25:15] Andrew Dublin, MD: Yeah. I also describe it like a cork in a wine bottle. That tends to help people kind of understand.
[00:25:20] Carolyn Lacey, MD, FACC: It, especially in Northern California.
[00:25:22] Andrew Dublin, MD: Exactly. Or even like a bank vault door, and you're closing the door and sort of sealing off, you know, forever. So how we get into the left atrial appendage is we first have to get into the left atrium, and that's called a transseptal puncture. So we go up the femoral vein. So we start in the groin up the vein just an IV.
[00:25:40] Matthew DeVane, DO, FACC: All we're doing is.
[00:25:41] Andrew Dublin, MD: Just putting a lot of patients who are referred to me have had an ablation. So they have already had a procedure through their femoral vein or they've had a cardiac catheterization. So they've had a procedure through their femoral artery. And I say the artery is like a fire hose. The vein is like a garden hose. So generally it's safer to have procedures through your vein than it is through your artery. But similar recovery, similar kind of concept that that people can relate to.
[00:26:04] Matthew DeVane, DO, FACC: This is an open heart surgery. Just no. Correct. A minimally invasive procedure done through an IV from the groin.
[00:26:11] Andrew Dublin, MD: I absolutely tell people I don't own a scalpel. I don't suture anything up. We put a little suture on the inside of the vein, but it's it's not cosmetically.
[00:26:20] Carolyn Lacey, MD, FACC: And it's not like an IV that you put in your arm. It's a pretty large IV. It's a big one.
[00:26:24] Andrew Dublin, MD: Yeah, it's a big IV. Yeah, it's a big IV. So we put that in and then we go up the vena cava up into the right atrium. And then we under echo guidance. So the other important thing to remember is this procedure is done under general anesthesia right now. And we do it with a transesophageal echo which is an ultrasound just like the front of the heart, but it's down the esophagus so we can see a lot better. And that part of the procedure is done by one of my colleagues, Doctor Shubin, one of the people who does it and the one who does it a lot with me. And so he'll show me where I want to cross the septum, because we don't just want to cross anywhere, we want to cross in a specific place. So he'll show me on echo where I want to cross in real time. We also use angiography, which is like x ray. And so I'll identify where I want to cross. And then I'll cross with a radiofrequency to get a cross. And then put a wire and put my plastic delivery tube across that. And from there I can get into the left atrial appendage because I'm I'm oriented in the right direction.
[00:27:24] Matthew DeVane, DO, FACC: Okay. And then once you're in the appendage, what happens?
[00:27:27] Andrew Dublin, MD: So once we're in the appendage, we then can take a picture of it with contrast. If we if we want to, just to really appreciate the shape. Again, the three dimensional structure of the appendage is very different than seen in one in a two dimensional view. So we look at it in a lot of different views. It's it's not circular. It's much more irregularly ovaloid in shape. And so we want to get a sense of how big of a device to use, because we have six different sizes. And those six sizes can close probably 98% of appendages. But every once in a while an appendage is too small or too big. And so we identify that usually before they even come to the cath lab. But we could identify it at the time. Um, and so once we've chosen our device size, then we put the delivery sheath into the left atrium, and then we put the device in, it comes compressed inside of a delivery sheath. And then when it gets into the left atrium is when we unsheathe it, which allows it to expand it. Um, but it's still, even after we release it, it's still attached to a delivery cable, which means if I don't like the position, I can recapture it and reposition it. I can even take it out and put a new size in. If I was estimated a little too big or too small, I can up or down size. So until we let it go, which is a deliberate thing, we have full control and we can completely recapture it. We can partially recapture it.
[00:28:50] Matthew DeVane, DO, FACC: How long does this procedure take?
[00:28:53] Andrew Dublin, MD: It takes a lot longer for the anesthesiologist to say hello, the nurses to bring the patient back to the anesthesiologist, to put the patient to sleep, the patient to get prepped and draped. And then we start the procedure. The total time from in room to out of room averages for me, maybe 70 minutes, something like that. But of that time, me being inside of the patient's body is maybe 20 to 25 minutes.
[00:29:20] Matthew DeVane, DO, FACC: Incredible. And what should a patient expect as far as how long are they going to be in the hospital after this procedure?
[00:29:27] Andrew Dublin, MD: Six hours.
[00:29:28] Matthew DeVane, DO, FACC: They're going home the same day.
[00:29:29] Carolyn Lacey, MD, FACC: Oh, they're going home.
[00:29:30] Andrew Dublin, MD: Home the same day.
[00:29:31] Matthew DeVane, DO, FACC: Because this is an outpatient procedure we're talking about.
[00:30:09] Carolyn Lacey, MD, FACC: You have to be happy with it, too. Yeah. Like you have to be very comfortable with how the procedure went in order to say, okay, but.
[00:30:15] Andrew Dublin, MD: 98% of my patients go home the same day.
[00:30:19] Carolyn Lacey, MD, FACC: That's definitely something that's changed since 2016. We always really nice to see that evolution.
[00:30:26] Andrew Dublin, MD: Yeah, we have we always admitted patients until we had enough experience with the device and really until we got the second generation of the device, which is a much safer implant. We haven't talked about risks yet, but the second generation is a very safe implant. And so not just a jammer, but all across the country, people are sending patients home the same day.
[00:30:45] Matthew DeVane, DO, FACC: I'd like to talk about two different things, but for the first, the risk and potential if side effects or complications of this procedure. But first, I want to back up a little bit. We talked about the procedure itself. There are some steps that a patient would expect before they get the procedure. So after they meet you you describe the procedure. Someone says, hey, let's get this done. Andy, can you tell us a little bit about the risk associated with this watchman procedure?
[00:31:11] Andrew Dublin, MD: Yes. The watchman procedure, generally less than 1% risk of anything bad happening. I always, you know, give patients that number. That's the international data. So what kind of risks can happen. You can have bleeding around the heart called a pericardial effusion. That can be an emergency where you have to even do a surgery to drain it. Worst case can lead to mortality to patients dying. But again that's even less than less than 1% infection pain. The most common things patients actually experience is a bit of a sore throat afterwards because of the echo probe down the throat. And then there's always risks of anesthesia. So I tell people less than 1% risk. When it was the first generation device, it was about 2 to 3% risk. And that was why we kept patients overnight, because that 2 to 3% risk of bleeding around the heart, the pericardial effusion, was too high to comfortably send patients home. But since we've gotten this second generation device of flex, we just don't see it at that level. And we've done over 400 watchman flex procedures and haven't had a single pericardial effusion yet. So when you talk about our institutional risk of bleeding or pericardial effusion, it's. Not right now. It's zero. But there always is a risk okay. Right.
[00:32:27] Matthew DeVane, DO, FACC: So those are the short term procedural risks. What about what kind of things are you looking for in follow up a month down the road or longer.
[00:32:33] Andrew Dublin, MD: Yeah. And then the thing patients are always worried about is can it dislodge and leave where we put it. So how does the watchman stay where we put it by two different mechanisms. One is radial force or pushing up against the wall of the left atrial appendage. So we always choose a device that's bigger than the space we're putting it in by a certain percentage. And we want to have compression range that we look for. So that's one way. And then the second way is it has these fixation hooks that hook into the tissue. And so between those two things that's how it stays in place. We have not had a single one dislodge or embolize it's called. But you know leave where we put it. In travel they can migrate which means that as the device heals in place, it has the potential to open up a little bit of a space between the wall and where the appendage, where the mouth of it would be, so that you can get leaking into the appendage. Theoretically, if that was big enough, not be comfortable stopping anticoagulation. But again, that's a quotable risk based on international data. At John Muir the risk is negligible and nice.
[00:33:38] Matthew DeVane, DO, FACC: So one of the big questions I think people are going to ask is because we're doing this procedure for patients that want to get off or can't take the blood thinners anymore. So it seems like this is a moving target, at least from the a little bit that I watch it. As far as what blood thinning they would need after the procedure.
[00:33:55] Andrew Dublin, MD: Right.
[00:33:56] Andrew Dublin, MD: So there's two questions. One is what do you need before the procedure. The answer is it doesn't matter. You can be on full blood thinners. You can be on no blood thinners. You can be on any combination of aspirin or whatever it is. We're going to measure the left atrial appendage and look for a clot the moment before we put the watchman in. So we will not put a watchman device in if a clot has formed. So you'll have a lower risk of having a clot there if you're on blood thinners going into the procedure. And we'll hold them for like one day, you know, before. But you don't have to be on blood thinners going in. So that's one important thing. Once the device is in, then we have a few different strategies that we use. And if you come in on blood thinners, we will then put you back on your blood thinners. So if you come in on Eliquis, we'll put you back on Eliquis, and then we'll add a baby aspirin to it, 81mg, and we'll do that for six weeks, and then we'll do a follow up echo down your throat. Transesophageal. And then once we confirm that the device looks good, we'll then stop the blood thinners. So whether it's Eliquis, Xarelto, Coumadin, we'll stop that and we'll give you Plavix, and we'll use that for another four and a half months. So six months from time of implant. And then we stop that. And then you're on just aspirin by itself. So I always tell people when I see them in the office this is a stroke prevention strategy where we transition from your blood thinner to a baby aspirin. And so it's not going from blood thinner to nothing. And it's not happening the day of implant in general, although you know, there's exceptions. But in general it's a transition from full blood thinner to baby aspirin.
[00:35:30] Carolyn Lacey, MD, FACC: And it's a six month procedure a.
[00:35:32] Andrew Dublin, MD: Six month transition.
[00:35:33] Carolyn Lacey, MD, FACC: Transition. Yeah. People people definitely think, oh, I'm coming off right right away. But it's not it's a it's a prolonged. Yeah.
[00:35:40] Matthew DeVane, DO, FACC: What are there any options for people who absolutely can't take blood thinners. What do we do with those.
[00:35:46] Andrew Dublin, MD: So if you if you come in and you're not on a blood thinner for a variety of reasons, we can put the device in and then put you right onto aspirin, Plavix right from time of implant and then use the aspirin Plavix for ideally six months. Um, that's sort of where the best data is. But our experience in other institutions is you can do it with less. It's just a little bit higher risk of stroke down the line in that time when you're off of the Plavix. So we've had patients where we could only get three months out because of recurrent, you know, GI bleeds or a couple of our patients. We could only get one month of dual antiplatelet, but we do want some dual antiplatelet at this point. We'll talk at some point about a clinical trial that will be starting in the summer, where one of the arms of the clinical trial will be aspirin by itself. But that's not standard practice right now. And so I wouldn't offer that to a patient today. That may be different in a year.
[00:36:40] Carolyn Lacey, MD, FACC: You talked to us about that. It is a sort of prolonged period until you get to aspirin. Can you explain a little bit more about why it's a step wise procedure to, to get to get from a blood thinner to this procedure to aspirin.
[00:36:55] Andrew Dublin, MD: Yeah. So yeah, one of the the hopes and we always talk about that holy grail is to be able to put the watchman in. And then you're done with all anticoagulation platelets not you don't need anything afterwards. And why aren't we there yet. So the reason we're not there yet is for two reasons. One, when we put the device in the tissue growth over the device hasn't happened yet. So there's still flow going in and out of the appendage, although it's reduced because there's now a structure in there. But over the first couple of weeks that. Tissue growth happens, and with the second and first generation devices, it took about six weeks. Now we're on our third generation device, and the hope is that it'll be much faster. Like trials outside of the human body, it is much faster, but the trials inside the human body are going to start soon. So there's some, you know, travel in and out of the appendage of blood still right afterwards. But then also because you've got this foreign body in the left atrial appendage, blood clots, so can platelets can stick together and form on the device itself. And they're different than the blood clots that form in the appendage. So we don't use anticoagulation to get rid of them. They're more platelet mediated. And so we use antiplatelet medicines like aspirin and Plavix. So they're all quote unquote blood thinners because they increase your risk of bleeding. But Eliquis xarelto warfarin they do it through anticoagulation versus aspirin. Plavix do it through antiplatelet. So there is something called device associated thrombus which is thrombus forming on the device. And so that's why we use the the aspirin and Plavix.
[00:38:29] Carolyn Lacey, MD, FACC: Your body recognizes that that's there's something in my body that's not supposed to be there. I must fix it. And that's how it forms clot to do that. Yeah. Thanks for that. Matt and I, we talk a lot to our patients about referring for this procedure, and we spend a lot of time talking about it ourselves when I'm actually seeing one of my patients and we decide in shared decision making, okay, it's time. Let's have you schedule with Doctor Dublin and have a watchman procedure. What can they expect just in terms of. Workflow because it's a fairly new procedure. Like you said, it was only FDA approved in 2016. So the FDA still has a lot of rules that we must follow before you actually get to the part of your procedure.
[00:39:16] Andrew Dublin, MD: Yeah. So the main rule, as far as what we we have to have and otherwise the institution won't get paid, you could potentially get a big bill. There has to be two physicians that have counseled the patient on the risks and benefits and recommend the procedure. So that's the shared decision making that you were talking about. And being the implanting physician. Most of my patients come to me from somebody else. And so they're the first opinion and I'm the second opinion. And so we've checked that box. If it's my own patient that I'm talking to, I always send them to another physician to give a second opinion. And so that's kind of the the only thing that's required. What we like to do is we do like to do one of those transesophageal echos, so echo down the throat before the day of implant. And that's for a couple of reasons. One, we talked about that we have six different sizes and that fits 98% of people. But that means there's 2% of people that doesn't fit. We'd rather identify them under propofol or conscious sedation, which is lower risk than identifying them under general anesthesia. In addition, you know, we do do a lot of these procedures. So there's a bit of a wait list a little bit. And we don't like to bring someone in and put them through a whole procedure and then not get the device implant that's taken up a spot that could have gone to somebody else.
[00:40:31] Andrew Dublin, MD: Plus, you know, they had to go under general anesthesia. So so we try and avoid that by doing the echo ahead of time. But every once in a while we get a situation where it's not feasible. And so like we had talked about we still can do the procedure. It's just not preference. You can also get a Cat scan instead of the echo, but the echo is more standard practice. And then you come to the hospital for the procedure. They're all done at Concord. That's our outpatient, high risk heart hospital. So we don't do watchmans at Walnut Creek. So we all they all go to Concord. And then six weeks later, we do another one of those transesophageal echos or Cat scans, but usually echoes. And so it's generally three visits to the hospital. All three. You get to go home the same day. The first and the third are the echoes and those the echo itself takes ten minutes or less. Total time in the hospital's an hour or two. Just because you have to arrive and get prepped. You can't drive to either appointment because we do sedate you. So you have to have a ride. Um, and so that's the first and the third, and then the second is the actual implant. But we don't stop your blood thinners for the pre echo. So if you're on Eliquis you'll stay on it for the echo. So you don't have an increased risk of stroke by stopping the blood thinner.
[00:41:42] Carolyn Lacey, MD, FACC: Are there any situations where you say. Other than the device wouldn't fit where you say, we're not going to be able to do this.
[00:41:51] Andrew Dublin, MD: Yeah, there's a couple. We want the patient's life expectancy to be a year on average. So if somebody is completely bed bound and has terminal cancer and then and gets sent for a watchman, I would counsel them not to have it. Other than that. Well, we talked about the ones who just don't have a high enough chadsvasc score. So if and.
[00:42:15] Matthew DeVane, DO, FACC: Low risk patients don't.
[00:42:16] Andrew Dublin, MD: Right. And sometimes the the Referrers will send them to me just because maybe they're not as familiar with the nuances of it. And so I have had times where maybe I was referred somebody who's really low risk. And I said, you know, I don't recommend you have a procedure right now. So those would be the main I think.
[00:42:32] Carolyn Lacey, MD, FACC: You also made a statement at several minutes ago about if you find a clot in the heart, absolutely no matter which procedure you're on. So let's say you're having your first transesophageal echo done. And you do find a clot in the heart in the left atrial appendage. How do you counsel patients then and how do you move forward from there?
[00:42:52] Andrew Dublin, MD: Yeah. So the good thing is it's rare. And so the 500 or so watchmens we've done, we found one clot before the procedure. So it's very rare. But we didn't you know, we said, okay, we need to put you on your blood thinner. We need to put you on blood thinners, and then you have to be on them for a month. And then we can repeat the echo. And at that point it's gone.
[00:43:14] Matthew DeVane, DO, FACC: This amazing.
[00:43:14] Andrew Dublin, MD: But if it stays, then we can't do it.
[00:43:16] Matthew DeVane, DO, FACC: Even since I, you know, the last the way it's changing, I'm hoping the indications continue to move forward so that some of our patients that are hesitant to get procedures, who just really just don't want to take the blood thinner, right, may be a good candidate. So I'm looking forward to the data down the road. But this is amazing talk. I really appreciate you being here and sharing this information with us. We appreciate all the work that you've been doing. I know our patients are very happy to have a choice these days. They didn't have it before, right?
[00:43:43] Carolyn Lacey, MD, FACC: This has been a another game changer in cardiology just in the last ten years.
[00:43:48] Matthew DeVane, DO, FACC: So with that we say thank you very much and appreciate your time. Yeah.
[00:43:52] Andrew Dublin, MD: Thank you for having me I appreciate it.
[00:43:56] Matthew DeVane, DO, FACC: This is Doctor Matt DeVane and on behalf of my co-host, Doctor Carolyn Lacey and our partners at John Muir Health, we hope that you enjoyed this show and we really hope that you keep living heart smart.
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