LAAO with Watchman Device PostProcedure Best Practices Lindsay
LAAO with Watchman Device Post-Procedure Best Practices Lindsay Thomas, MS, RN, CCNS
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LAAO Watchman Post-Procedure Best Practices • • Inpatient Services Post-Procedure Pharmacotherapy & Testing Post-Procedure Quality of Life LAAO Example documents & templates
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
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
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 12 hr post-procedure • TTE prior to discharge • Assess for pericardial effusion, confirm device placement, and absence of intracardiac thrombus
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
LAAO Post-Procedure Pharmacotherapy & Follow Up POD 1 POD 45 aspirin 300 -325 mg clopidogrel 75 mg PO 6 mo Pharmacotherapy aspirin 81 -100 mg warfarin *prophylactic antibiotics prn Diagnostic Testing TTE: assess device TEE: assess device placement and absence of placement, absence of thrombus, and leak (≤ 5 mm) prn Follow up Discharge home: INR lab orders, f/u appointments scheduled Clinic Visit Aspirin 300 -325 mg indefinitely *prophylactic antibiotics
Contraindication to Anticoagulation Is LAAO in the future for patients who are unable to be treated with OAC due to major contraindications or intolerance?
45 -day TEE & Visit 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 > 5 mm 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
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
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
LAAO Cheat Sheet Single page summary provided to all fellows/residents who will provide care to LAAO patients
Standardize LAAO Orders Example: POD 45 standardized TEE order: information included in comments section to make sure all important measurements are taken
Questions?
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