John Brown of McGaheysville had been taking warfarin, a medication used to thin the blood, for more than 25 years before he began experiencing any serious side effects.
Then last July, he showed up at the Sentara RMH Emergency Department with major bleeding in his intestines. He spent the next five days in the hospital while caregivers got the bleeding under control.
Brown, 82, had been taking warfarin due to a condition called atrial fibrillation (Afib), an abnormal heart rhythm that can lead to the pooling and clotting of blood inside the heart. When such a clot moves outside the heart and travels to the brain, the result can be a stroke. Warfarin helps reduce the risk of blood clot formation and therefore reduces the risk of stroke.
So Brown needed another option to control his Afib, since continuing to take warfarin over a long period of time could have put him at risk for further bleeding.
After conducting tests with Brown in the hospital’s Heart and Vascular Center, Sentara RMH electrophysiologist Alan Johnson, MD, determined Brown was eligible for an electrophysiology procedure to implant a device known as the WATCHMAN™.
“To be considered for the WATCHMAN Implant, Afib patients have to have a good reason—like the intestinal bleeding Mr. Brown experienced—not to be on a blood thinner,” says Dr. Johnson. “For patients who have complications due to these medications, the WATCHMAN offers a safe, effective alternative.”
During the procedure, the WATCHMAN, a small device made of thin wire and mesh, is implanted in the heart to close off the left atrial appendage (LAA), a small, sac-like extension in the wall of the left atrium, one of the four chambers in the heart. The LAA has no known purpose, but stroke-causing clots originating in the heart most often come from the LAA. After the device is implanted, heart tissue will grow over the WATCHMAN, completely closing off the LAA and preventing any blood clots from escaping from that area.
“The WATCHMAN offers a reduction in stroke risk comparable to that of warfarin, while helping the patient avoid the risk of bleeding associated with long-term warfarin use,” explains Dr. Johnson.
Noninvasive Procedure, Quick Recovery
Dr, Johnson, assisted by electrophysiologist Robert VerNooy, MD, performed Brown’s WATCHMAN Implant in December 2019. The procedure is often performed by two physicians. After inserting a thin, hollow tube known as a catheter into a vein in Brown’s leg and guiding it through the venous system to Brown’s heart and the LAA, they used the catheter to implant the WATCHMAN Implant.
“When we insert the device, initially it’s compressed and folded,” Dr. Johnson says. “Then when we back out the catheter, the WATCHMAN unfolds into place.”
In the weeks following the procedure, Brown’s body created layers of heart cells over the WATCHMAN Implant. In the meantime, he continued to take warfarin to prevent blood clotting.
“To be eligible for the WATCHMAN procedure, the patient has to be able to tolerate warfarin for 45 days afterward, while new tissue grows over the device,” adds Dr. Johnson.
In late January, Brown was back in the Heart and Vascular Center undergoing a test to check for leaks around the device.
“According to guidelines and the manufacturer’s recommendations, we always re-evaluate with transesophageal echocardiography (TEE) after the procedure,” Dr. Johnson says. “This allows us to transition the patient off warfarin.”
TEE is a special type of echocardiogram that uses high-frequency sound waves (ultrasound) to make detailed pictures of the heart. Brown’s TEE showed no leaks around the WATCHMAN Implant, so Dr. Johnson gave him the all-clear to discontinue the warfarin.
“Now I’m just taking aspirin and Plavix,” says Brown, a retired building inspector for the city of Harrisonburg.
If it weren’t for the WATCHMAN procedure, Brown would have had two other options, according to Dr. Johnson. One such option is AtriClip surgery, which involves a small surgical procedure to access the LAA through an incision between the ribs. It is typically performed at Sentara RMH in collaboration with one of the cardiothoracic surgeons in appropriately selected patients.
“The WATCHMAN procedure is a lot less invasive—and has a much shorter recovery period—than AtriClip surgery,” Dr. Johnson notes.
Without the WATCHMAN, Brown’s other option would have been to eliminate the use of blood thinners, which would have increased his risk of stroke.
“The WATCHMAN doesn’t necessarily make you feel any better, but it does prevent clots from migrating out of one of the most risky areas in patients with atrial fibrillation,” Dr. Johnson says.
Brown will continue taking Plavix with aspirin for six months after the procedure to keep his blood thin—the normal course of action for nearly all WATCHMAN patients. After that, Dr. Johnson is confident Brown will only need to take aspirin regularly to keep his blood thin.
“He’s on the classic trajectory, headed for aspirin-only therapy,” he adds.
Reflecting on his experience, Brown is pleased with how well his WATCHMAN procedure went.
“Everything involving the WATCHMAN procedure went really well,” says Brown. “I’m feeling very good about it.”
What is Electrophysiology?
While many people are familiar with the heart’s pumping action that circulates blood through the body, perhaps less well known is the intricate electrical system that regulates the heart’s rhythmic beat. When something goes wrong with the heart’s electrical system, a heart-rhythm specialist known as an electrophysiologist—a subspecialist in the field of cardiology—may be called on to fix the problem.
Sentara RMH currently has two electrophysiologists on staff. Robert VerNooy, MD, who founded the electrophysiology (EP) program at Sentara RMH, has been at the hospital since 2010. Alan Johnson, MD, joined the EP team in August 2019. Together, the two specialists offer a full spectrum of EP services, including cardiac ablations (procedures that remove or alter heart tissue to correct an irregular heart rhythm), the implantation of various cardiac devices to regulate a patient’s heart rhythms and the new WATCHMAN Implant procedure.
Dr. VerNooy began performing the WATCHMAN procedure at Sentara RMH in April 2019. Both physicians provide the WATCHMAN Implant procedure and accept referrals.
Understanding Cardiac Arrhythmias
An irregular heart rhythm, or arrhythmia, occurs when the heart’s rhythm is too fast, too slow, or irregular in some other way. There are several common types of arrhythmias:
- Atrial fibrillation (Afib) is one of the most common types, occurring when the atria (upper chambers of the heart) beat irregularly or quiver, instead of beating normally.
- Premature or extra beats are also very common. People with this condition may feel a fluttering or skipping sensation in the chest.
- Bradycardia is an abnormally slow heart rate.
- Tachycardia is a very fast heart rate.
- Ventricular fibrillation (VF) is the most serious type of arrhythmia, potentially leading to cardiac arrest and death. During VF, the ventricles (lower chambers) quiver, preventing the heart from pumping blood adequately.
Both fellowship-trained in electrophysiology, Dr. VerNooy and Dr. Johnson diagnose and treat all these types of heart arrhythmias in the EP lab, which is equipped with advanced cardiac diagnostic equipment.
“We can evaluate lightheadedness, slow or racing heartbeat, and shortness of breath—all possible symptoms of heart arrhythmia,” Dr. VerNooy says. “Heart arrhythmia symptoms that cannot be controlled with medication may be greatly helped by an EP procedure.”