I’m pleased this has been brought to light. I was briefed on the device but frankly I didn’t want to undergo the procedure. A relative of mine had it and swears there is no leakage. He says that he can't tolerate a blood thinner. I think I will continue with Eliquis although I am not currently in afib since my last (four in all) cardio conversion in July 2023. I am 80.
Thanks. As to Vinay and COVID, it might be useful for you and I to have a substack discussion on some of the issues he is overly strident and mean-spirited about but upon which he makes good points.
I also utilize Up-To-Date but recognize that the subsection authors are subject to the same biases and limitations as the authors of review articles. My approach is to independently verify the recommendations by scanning the primary literature.
With respect to the indications it is heartening that they have only made it a 2B level recommendations and they recognize "thrombogenesis in patients with AF may not be limited to the LA, and the procedure does not always result in complete occlusion of the LAA."
Up-to-date says LAA) might be considered in patients "who have a contraindication to long-term anticoagulation." Which patients have a contraindication is subject to interpretation. Those who are pushing LAAO have a very low bar for a contraindication. I've seen LAAO recommended and performed because "patient is young" or because of a GI bleed with correctible causes, or because the patient likes to ride his/her bike..
The indication for anticoagulation is also somewhat fuzzy. Does a CHADS2 woman with 10 seconds of afib on a Holter monitor from 10 years and no clinical AFIB since have an indication for anticoagulation? Does a 78 year old man, (CHADS3) with one episode of AFIB 5 years ago at a time when he was septic from a UTI have an indication? Those who are gungho on getting their LAAO experience and numbers up might say yes.
Anyway, thanks for the comments. Always appreciated. I 'm curious how often PCPs weigh in on this issue with their patients or whether they leave the recommendations up to their favorite cardiologist or EP doctor?
Thanks Skeptical. It's so important to keep the bright light on the poor quality of the evidence in support of this device, and on poor quality evidence wherever you find it. Thanks to Mandrola, Vinay Prasad, you and others for keeping at it. There is something rotten among the investigators with a financial interest in their device, the journals who want eyeballs and the device manufacturers, for sure; it needs to stop and your efforts help.
I have afib, though the instances are infrequent my cardiologist at Scripps Clinic in La Jolla says that, counterintuitively, the frequency of incidents isn’t correlated to risk of stroke. So I’ve been on Eliquis for a while. Recently had to stop it because bleeding hemorrhoids put me in the hospital with anemia. Got the bleeding stopped and am working assiduously on getting the hemorrhoids resolved. We’ll see if I can go back on the Eliquis again in a couple of months. The Watchman has been mentioned, but when I did the questionnaire at the Boston Scientific website it said I wasn’t a good candidate. Your summary of the problems and lack of solid RCT data is sobering, to say the least. Here’s hoping I can go back on an anticoagulant!
I’m pleased this has been brought to light. I was briefed on the device but frankly I didn’t want to undergo the procedure. A relative of mine had it and swears there is no leakage. He says that he can't tolerate a blood thinner. I think I will continue with Eliquis although I am not currently in afib since my last (four in all) cardio conversion in July 2023. I am 80.
Ryan,
Thanks. As to Vinay and COVID, it might be useful for you and I to have a substack discussion on some of the issues he is overly strident and mean-spirited about but upon which he makes good points.
I also utilize Up-To-Date but recognize that the subsection authors are subject to the same biases and limitations as the authors of review articles. My approach is to independently verify the recommendations by scanning the primary literature.
With respect to the indications it is heartening that they have only made it a 2B level recommendations and they recognize "thrombogenesis in patients with AF may not be limited to the LA, and the procedure does not always result in complete occlusion of the LAA."
Up-to-date says LAA) might be considered in patients "who have a contraindication to long-term anticoagulation." Which patients have a contraindication is subject to interpretation. Those who are pushing LAAO have a very low bar for a contraindication. I've seen LAAO recommended and performed because "patient is young" or because of a GI bleed with correctible causes, or because the patient likes to ride his/her bike..
The indication for anticoagulation is also somewhat fuzzy. Does a CHADS2 woman with 10 seconds of afib on a Holter monitor from 10 years and no clinical AFIB since have an indication for anticoagulation? Does a 78 year old man, (CHADS3) with one episode of AFIB 5 years ago at a time when he was septic from a UTI have an indication? Those who are gungho on getting their LAAO experience and numbers up might say yes.
Anyway, thanks for the comments. Always appreciated. I 'm curious how often PCPs weigh in on this issue with their patients or whether they leave the recommendations up to their favorite cardiologist or EP doctor?
Thanks Skeptical. It's so important to keep the bright light on the poor quality of the evidence in support of this device, and on poor quality evidence wherever you find it. Thanks to Mandrola, Vinay Prasad, you and others for keeping at it. There is something rotten among the investigators with a financial interest in their device, the journals who want eyeballs and the device manufacturers, for sure; it needs to stop and your efforts help.
I have afib, though the instances are infrequent my cardiologist at Scripps Clinic in La Jolla says that, counterintuitively, the frequency of incidents isn’t correlated to risk of stroke. So I’ve been on Eliquis for a while. Recently had to stop it because bleeding hemorrhoids put me in the hospital with anemia. Got the bleeding stopped and am working assiduously on getting the hemorrhoids resolved. We’ll see if I can go back on the Eliquis again in a couple of months. The Watchman has been mentioned, but when I did the questionnaire at the Boston Scientific website it said I wasn’t a good candidate. Your summary of the problems and lack of solid RCT data is sobering, to say the least. Here’s hoping I can go back on an anticoagulant!