Duke Electrophysiologists Expand Options for Patients with AFib at Higher Stroke Risk

Patients with atrial fibrillation (AFib) are at increased risk for stroke, but as many as one in four cannot tolerate oral anticoagulation to prevent stroke. To reach more patients with AFib at risk for stroke, the Duke Electrophysiologist (EP) team encourages physicians to consider referring patients who cannot tolerate oral anticoagulation for evaluation of left atrial appendage closure (LAAC). 

Patients with AFib who cannot safely use anticoagulants face a higher stroke risk as a result of blood pooling in the left atrium, says Duke electrophysiologist Camille Frazier-Mills, MD, MHS, who is helping direct Duke EP’s outreach effort to regional cardiologists. 

The Watchman LAAC device (Boston Scientific, Watertown, MA) was approved by the FDA eight years ago for patients with AFib who are at risk for stroke due to AFib but who cannot tolerate anticoagulants because of bleeding risk. Duke electrophysiologist Kevin P. Jackson, MD, offers options for patients with AFib who have conditions that require distinctive solutions other than the Watchman device. Jackson implants both the AtriClip® (AtriCure, Mason, Ohio) and the Amplatzer™ Amulet™ LAA Occluder (Abbott Cardiovascular, Abbott Park, Illinois). 

The outreach is part of the Duke EP team’s individualized approach to stroke prevention that includes several FDA-approved devices and therapies to respond to the higher risk of stroke with AFib. The initiative is being rolled out in conjunction with a national Centers for Medicaid and Medicare Services (CMS) effort to help cardiologists determine which patients are most likely to benefit from implantation. 

“We believe this campaign to educate cardiologists about the value of referrals for patients needing LAAC will offer prevention benefits to more people who are at risk,” Frazier-Mills says. “As part of the outreach effort, we offer information that can standardize and simplify the referral process.” 

Because it was introduced in limited sizes, the initial Watchman device was effective for a smaller number of patients, Frazier-Mills says. Newer Watchman versions offer multiple sizes and are effective for more patients. 

For the past three years, the Duke EP team has averaged approximately 70 implantations of the Watchman device each year. Duke electrophysiologists have been focused on improving outcomes in persons with AFib and have established an international reputation for their program in AFib research and treatment innovation. 

Jonathan P. Piccini Sr., MD, MHSc, director of the Duke Cardiac Electrophysiology Section, and colleagues recently published a high-impact study in the Annals of Internal Medicine in September 2022 focused on identifying patients most likely to benefit from left atrial appendage occlusion with Watchman and similar devices. 

Duke electrophysiologist Daniel J. Friedman, MD, and a cardiac anesthesia team at the Durham VA Medical Center, performed their first two Watchman implantations in August for veterans with AFib who were not good candidates for anticoagulation. Durham is now the only VA hospital in its regional network to offer the procedure.