Well, it is finally over. I am officially a Watchman implant recipient as of April 27, 2023, and I couldn’t be happier!
For some background as to why I needed the Watchman implant in the first place, read this blog post. In a nutshell, my EP had to ablate my left atrial appendage (LAA) during my last ablation. Once you ablate the LAA, you have to be on a blood thinner for life or have the Watchman implant put in.
You can read this blog post in its entirety, or feel free to jump to any section of this post by clicking any of the table of contents below.
Jump Ahead To:
The Day Before the Watchman Implant Procedure (April 26th)
I was assured by my good friend and owner of afibbers.org, Shannon, that this procedure would be a “walk in the park” compared to any ablation I’ve had so far. That, coupled with my first ablation experiences in 2015 and my second ablation experience in January of this year, I had total confidence this procedure would indeed be easier.
As a result, I shortened my trip to Austin, TX for this procedure. Unlike my previous ablations in Austin where I spent almost an entire week to have plenty of time to recover, this time around I spent only three nights in Austin. I arrived in Texas around noon on Wednesday the 26th, I had my procedure on the 27th, recovered on the 28th, and then flew out of Texas shortly before noon on Saturday the 29th.
Within 30 minutes of landing in Texas around noon on Wednesday, I got a call from the EP’s office to give me instructions for the following day. I was to report to the hospital at 7:30 am. I couldn’t eat or drink anything after 11:00 pm, and the morning of the procedure before heading to the hospital I was to take my usual 5 mg dose of Eliquis and .3 mg of colchicine.
Side Note: They put me on a twice daily dose of .3 mg of colchicine one week prior to the procedure. This is an anti-inflammatory medicine they typically use to treat and prevent gout attacks. My EP uses it off-label to reduce heart inflammation from the procedure.
I knew they would be shaving me down in the prep room prior to my procedure as they had done before for my previous ablations. I figured I would save them the time and spare me the awkward moment of having another man shave me down, so I shaved myself the night before the procedure. I shaved my entire upper torso – front and back – and my entire groin area. I also shaved my face, neck, and arms (for the IV). I also cut my hair a week prior. The only hair on my body that was spared the clippers or the shaver were my legs!
After shaving myself, I took a long hot shower and went to bed to watch TV before getting a little shut eye. I probably slept four solid hours the night before the procedure, which for me is great considering I didn’t sleep more than a couple of hours the night before my previous ablations.
Getting Prepped the Morning of the Watchman Procedure (April 27th)
We arrived at the hospital at 7:15 am, a little earlier than 7:30 am when I was instructed to be there. I had some brief paperwork to fill out and within about fifteen minutes I was sent up to the EP floor to wait for my check in.
After only waiting for about twenty minutes, I was called back into the prep room. It was about 7:45 am. My wife and daughter stepped out of the room as I had to strip naked and get into my lovely hospital gown.
When my wife and daughter came back in, I told them there was really no need for them to stick around as it likely would be a few hours before my procedure would begin. I told them I’d text them as soon as I was wheeled into the lab room for the procedure so they could plan accordingly.
I was in the prep room from about 7:45 am until 10:30 am when I was wheeled into the EP lab. There were a few different nurses and technicians that visited to prep me for the procedure.
I was a bit annoyed that the nurse that put my IV line in insisted on putting it in on my hand and not one of my arms. I’ve had numerous IV’s over the years given my various hospital visits due to my battles with atrial fibrillation, and I’ve never had an IV in my hand. It was so odd.
It didn’t hurt or anything, but I’m a creature of habit and I was a little nervous that it might be sorer being in my hand vs in my arm. Plus, I shaved both my arms in anticipation of needing the IV to prevent the discomfort of having the bandages taken off when I left the hospital.
Before she started the IV, I said to her, “Are you sure the hand is the best choice, here? Wouldn’t one of my arms be better?” That’s my pleasant way of saying, “Please put it in one of my arms instead!” She just smiled and said she’s always done them in the hand. In her opinion it was better because that way when I bent my arms the IV wouldn’t get in the way.
It wasn’t a big deal in the end. It wasn’t any sorer or more cumbersome than it would have been in my arm. It was just so odd to have an IV on the top of my hand and not in my arm. There was one big difference, however. When they removed the IV when I was discharged, it bled heavily. More on that later.
My vitals in the prep room were as follows:
- Weight: 207 lbs
- Pulse Ox: 99%
- Heart Rate: 77 bpm
- Blood Pressure: 122/78
My vitals were great, and I was ready to go.
Finally, at around 10:30 am a nurse came in and told me it was time! She gave me one last opportunity to get up and go to the bathroom, which I took advantage of, and then I texted my wife quickly that I was heading in for the procedure. The nurse then wheeled me into the EP lab which was just a few doors down from the prep room.
The Watchman Implant (and Ablation) Procedure Begins
Just as I was entering the doorway to the EP lab, my EP was just about to enter behind me. I shook his hands and jokingly said to him, “Don’t be shy. Let’s burn it up and make sure all this a-fib and atrial flutter is finally put to rest!” He laughed and said he’d be sure to take care of anything he sees.
When I arrived in the EP lab they had me get into the EP lab bed. They put “sticker pads” on my back and chest and then covered me up. They also had a large vacuum-like tube placed under the covers that was blowing warm air into the bed. It was extremely comfortable!
Then before I knew it, it was time to start. One of the nurses told me they were going to start the anesthesia to put me to sleep. She had me take two deep breaths and before I could finish the second breath I was out like a light.
My wife told me afterwards that she got a text from one of the nurses at 11:15 am that the procedure was under way. I doubt they texted her the minute they started the anesthesia, so my guess is they put me under around 10:50 – 11:00 am. I wasn’t in the EP lab that long before they put me to sleep. Things move rapidly the minute you get into the lab.
Immediately After the Procedure
My wife said she received a text from a nurse at 12:45 pm that I was in recovery and that they were going to be moving me to a room soon. If the procedure started around 11:15 am and I was in recovery at 12:45 pm, that meant the procedure was about ninety minutes, which is what the nurse told me to expect when I was in the prep room.
As I was being wheeled into my room, Dr. Natale stopped by to say hi and to let me know that unfortunately he had to fly out later that afternoon so he wouldn’t have a chance to visit me the following morning as he always does. He said the procedure went well and that he’d see me in about 6-8 weeks for the TEE (more on that later). He also told me that the LAA was totally silent, but he had to touch up other areas of the heart (more on that later as well). Then we shook hands and he left.
I remembered looking at the clock on the wall in my room and it was 1:15 pm when my wife and daughter walked in. The nurse that escorted them into the room told me that I had another hour of bed rest before I had to get up to be weighed and to go to the bathroom.
The hospital uses the VASCADE Vascular Closure System for the groin wounds where the catheters are inserted. The system consists of placing collagen plugs in the wounds. This reduces the required bed rest after the procedure from six hours to just two hours. It also eliminates the need for a urinary catheter. To learn more about this and to see pictures of what they look like, see this section of my blog post about my last ablation experience.
My Aches and Pains After the Procedure (There Were None!)
If you read this section of my blog post about my last ablation, I compared my aches and pains from my first ablation to my second ablation. My second ablation was much easier than my first. This latest procedure was even easier than my second ablation. As I was told, and as I was expecting, it was a walk in the park!
I had zero chest discomfort and unlike my second ablation where I had an incredibly dry and sore throat, my throat this time around was just slightly “phlegmy.” It wasn’t dry at all, and it wasn’t sore either. I just had this small amount of phlegm in my throat that I couldn’t quite get rid of but that was it.
And unlike my second ablation where the puncture wound in my neck was incredibly sore, I had zero soreness in my neck after this procedure.
The other thing that was different after this procedure verses my last ablation was that I wasn’t nearly as tired and exhausted. While you are allowed (and encouraged) to get up and move around two hours after the procedure, after my second ablation I was so tired that I didn’t get up for almost four hours after my procedure. This time around I was ready to pop out of bed right at the two-hour mark.
Minimal Water Weight Gain after the Procedure
They pump you with a lot of fluids during these procedures. For this specific procedure, my nurse estimated they use around 900 ml of fluid. As a result, water weight gain is to be expected. After my second ablation, I gained almost three pounds of water weight! You can read about that here.
This time around I only gained a little over one pound of water weight. When I was told I had to get out of bed at around 2:30 pm to be weighed, I was at exactly 208.2 lbs. If you recall, when they weighed me in the prep room prior to the procedure I weighed 207 lbs. While I did gain water weight, it was minimal.
My Overnight Hospital Stay
After I was weighed and I went to the bathroom, my wife ordered lunch for me around 2:45 pm. My wife and daughter left shortly after placing my order. There was no reason for them to stick around the hospital since I was doing so well. While I was waiting for my lunch to arrive, I sat in the chair in the room and texted, checked my emails, and browsed the internet.
At 3:30 pm I was given my daily Flomax (to prevent urine retention for us middle-aged guys) and a Carafate tablet for my throat, although it was totally unnecessary as my throat was barely irritated.
My lunch finally arrived at 3:45 pm. I wanted to eat light so I went with a peanut butter and jelly sandwich, strawberries, shortbread cookies, and a chocolate pudding cup.
You’re not going to believe this, but this was the first time in my 50 years of life that I ate an entire PB & J sandwich. I tried one once when I was a kid and hated it, so I never tried one again until now. For some reason it just sounded good so I thought I would give it a shot. I’m glad I did because I loved it! It might very well be my go-to lunch and/or snack moving forward. How could I have denied myself this delicious sandwich all these years…lol!
My lunch was so good and was the perfect amount of food that I ordered the same exact thing for dinner!
The rest of the day and evening were uneventful. I spent the bulk of the time texting, emailing, and browsing the internet. I placed my dinner order at 6:00 pm and it arrived shortly before 7:00 pm.
The nurses and techs came in periodically to check on me and to take my vitals. At 10:20 pm I was given my usual 5 mg dose of Eliquis and my .3 mg of colchicine. The nurse offered a Carafate tablet as well, but I told her it wasn’t necessary as my throat was perfectly fine. She also gave me a 5 mg tablet of zolpidem I had requested earlier in the evening. I didn’t take the zolpidem immediately since the nurse said she’d be back in about an hour to take my vitals one last time for the night.
Then around 11:15 pm the nurse took my vitals. My blood pressure was 122/77 and my pulse ox was 96%. The nurse told me she’d be back in around 4:00 am to take my vitals and to weigh me again.
Finally around 12:15 am I took half of the zolpidem as I figured I would take the other half after the 4:00 am vitals check.
At around 4:15 am they came in and woke me up to take my vitals and to weigh me. I was 208 pounds. I had lost .2 lbs of water weight since my last weigh in, which was a great sign the nurse told me.
The Morning After My Watchman Procedure (April 28th)
The nurse came in at around 5:30 am to wake me up and to give me my potassium and Lasix. They wanted me to get rid of as much water weight before I left the hospital so they give me the Lasix early in the day.
Lasix is a diuretic (makes you urinate frequently), but when you urinate you also lose potassium, which is an important electrolyte to maintain a steady heart rate. To make sure your potassium levels don’t get too depleted, they have you take these monster potassium pills when you take the Lasix.
After about 30 minutes waiting for the Lasix to kick, I urinated three times within an hour.
I ordered breakfast around 6:30 am and it arrived around 7:30 am. Here’s a picture of my breakfast:
At around 8:30 am I was given a full dose of Eliquis (5 mg) and .3 mg of colchicine as well as my Flomax.
Between 8:30 am and when I was officially discharged shortly after 11:00 am, I was visited by a couple of Dr. Natale’s nurse practitioners. This is normally when Dr. Natale himself would stop by but because he was gone, they visited me in his place. They went over my recovery and Watchman instructions, what the next steps would be, and they answered any questions I had.
I was told that starting that day, I could cut my Eliquis dose in half! That’s how effective the Watchman implant is in preventing LAA-related strokes. They would be contacting me soon to schedule the first TEE, which would be done in 6-8 weeks (see details about this below).
One of the last things to be done before I was discharged was to have my IV line removed. As I mentioned earlier, a nurse oddly put the IV line in on the top of my left hand. When the nurse removed the IV line, I bled pretty bad from the IV puncture wound. This did not happen when the IV was in my arms for my previous ablations! Again I ask, why the IV in the hand vs the arm?
She had to compress the wound for about five minutes and then tightly wrap it with gauze and a band aid wrap. The nurse told me to keep it wrapped for at least twenty minutes. It wasn’t a big deal but the sight of my blood oozing out and soaking the gauze made me uneasy. It was a little unsettling. Thankfully, when I took the bandage off about two hours later it was totally fine.
My wife and daughter picked me up from the hospital and when I got back to the house we rented, I had a light lunch and spent the afternoon just chilling and watching TV. Other than being tired for not sleeping that much in the hospital, I felt totally normal and was perfectly fine. I had zero pain or discomfort.
Details of the Watchman (and Ablation) Procedure
While this procedure was first and foremost a Watchman implant procedure, Dr. Natale checks all areas of the heart for any a-fib/atrial flutter activity and ablates them if needed prior to putting the Watchman in.
I knew he’d have to ablate some sources as I had a few atrial flutter breakthroughs during my recent 3-month blanking period. I assumed, and so did my care team throughout the blanking period, that the sources of activity were coming from the LAA. That was not the case.
Dr. Natale said the LAA was actually silent, as were many of the areas of my heart from my previous ablations. He only detected activity from the left atrium, septum of the left atrium, and the coronary sinus. Only a total of seven minutes were spent ablating those areas (compared to the 61 minutes of ablation time during my last ablation).
Here is a copy of the ablation report. Read my blog post on how to interpret an ablation report to fully understand it.
As for the Watchman implant portion of the procedure, the specific implant that was used was called the WATHCMAN FLXTM Left Atrial Appendage Closure Device. It was 31mm in size. Here is a copy of the Watchman implant procedure report.
Here is a video from Boston Scientific, the makers of the Watchman closure device, that demonstrates what happens during the procedure:
Next Steps – 3 TEE’s (Transesophageal Echocardiograms)
I was told the day I was discharged that I could cut my Eliquis dose in half, going from 5 mg twice daily, to 2.5 mg twice daily. If you Google what to expect after a Watchman implant procedure, you’ll likely read varying prescription protocols that need to be followed immediately after the procedure.
While the protocols vary slightly from one EP to another, they all include aspirin, Plavix, or a reduction in the current blood thinners you’re taking. Whatever the specific protocol you are prescribed from your EP, you’ll be on this protocol for 6-8 weeks, or roughly 45 days.
At the 6-8 week mark, I’ll have the first TEE, or transesophageal echocardiogram. This is when I’ll be put under general anesthesia (typically propofol) while a camera is put down my throat to view the LAA. The actual TEE procedure only takes about fifteen minutes but they said the whole appointment will take roughly three hours.
What they are looking for during the TEE is any leaks coming from the Watchman device or any clots forming on the device. They are essentially looking for full endothelialization of the device, which should be complete at this point.
Endothelialization refers to the process in which endothelial tissue is formed over the device. Think of endothelial tissue as a “skin” that grows over the device and completely covers it and seals it. If the device is fully endothelialized, there shouldn’t be any leaks or clots.
I don’t recall what my care team said regarding my blood thinner dosage after the first TEE if everything looks good. I will update this blog post as I learn more. I believe if the device is fully endothelialized at this point I’ll be able to reduce my blood thinner dosage even more, but I’m not certain at the time of this writing. I may have to remain on the 2.5 mg twice daily dose of Eliquis until after the 6-month TEE.
Then I’ll have another TEE at the 6-month mark, which will be in late October or around the beginning of November. If things continue to look good at that TEE, then I know for certain I will be given the green light to come off my Eliquis completely! That is the goal with having the Watchman implant – to get off blood thinners completely.
Finally, I’ll have another TEE at the one-year mark. This is more of a general check up to ensure the device continues to be fully endothelialized without any issues.
I will do the first two TEE’s with my EP’s team down in Texas, but for the one-year check up I will likely do that locally here in Minnesota. It will depend on how the first two TEE’s go.
You might be wondering why I wouldn’t just have all the TEE’s done in Minnesota and send my results to my EP in Texas. This option was made available to me, but I was told by my care team that Dr. Natale is very particular with what he wants to see with these TEE’s. If the TEE isn’t done right (according to his standards), I would need to go back in for a repeat TEE. Of course, this would add an unnecessary delay and expense to the whole process.
I’m not thrilled to have to fly down to Texas twice and go through the expense of airline tickets, car rentals, and hotel rooms just for two 15-minute procedures, but it’s worth it to me to have the peace of mind knowing everything is being handled “in house” and will be taken care of correctly and promptly.
The Importance of Finding an Experienced Watchman Implant Operator
While the Watchman implant procedure is far less complicating than an a-fib ablation, it still requires a skilled and experienced operator. While I would demand my EP to have several thousand a-fib ablations under his belt, with most of those ablations being for complex cases of a-fib, I wouldn’t have nearly as high of a bar for a Watchman implant operator.
I don’t know what the magic number of Watchman procedures is to look for when choosing a Watchman operator, but for me personally, I’d want to see at least 500 or more.
Just like with a-fib ablations, the more skilled and experienced the Watchman operator is, the fewer chances of complications you’ll have and the more success you’ll have at getting off those blood thinners!
What I wouldn’t advise is just settling with any Watchman implant operator in your area. Do some digging and ask questions! Make sure the person doing the procedure has done enough of them and has a low complication rate to give you peace of mind. If that person doesn’t exist locally, don’t settle! Be willing to travel to wherever you need to go to find the most skilled and experienced Watchman implant operator you can find.
And in case you’re wondering, complications as a whole for the Watchman implant are extremely low. When they do occur, they mostly occur during the actual procedure when the device is implanted. If all goes well during the procedure itself, you’re in the clear. And when things do go awry during the procedure (again, very rare), in almost all cases it’s due to an unskilled and inexperienced Watchman operator.
I knew I was in good hands with Dr. Natale so I didn’t think twice about getting a Watchman implant, and I was never worried or scared about it either. As it turned out, I was right not to worry, but then again, I put my heart in the hands of an extremely skilled and experienced operator. You need to do the same if you’re considering the Watchman implant!
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Your blog is very I formative. So thank you! I was just diagnosed with Atrial Fibrillation and am in the midst of a ‘fire hose” of information. Your blog is concise detailed and extremely informative. Regarding the Watchman, it is a good way to avoid having to take blood thinners for life, but do I understand that you still need to control the rhythm (ablation and drugs presumably)? I’m guessing the more often you have an episode, the weaker your heart gets. So the Watchman is a companion technology to a procedure (ablation) to maintain normal sinus rhythm, is that correct?
That is correct. The Watchman does NOTHING to treat or manage atrial fibrillation (or any arrhythmia for that matter). At the end of the day, the Watchman is just a super fancy plug! It plugs your left atrial appendage so blood can’t enter it and then pool and clot. That’s all it does. Addressing atrial fibrillation or atrial flutter is a whole other issue. That can be addressed with drugs or an ablation.
Your detail reporting is generous in time and spirit. THANK YOU
Thank you Jan!
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