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AFib Patients: Reduce Stroke Risk without Blood Thinners
Dr. Brock Cookman explains what atrial fibrillation is, the different treatment options available, and if the left atrial appendage closure device procedure is right for you.
Featured Speaker:
Brock Cookman, DO, MSA
Dr. Cookman was born and raised in north central Iowa. He joined Bryan Heart in February 2019 and brought with him an innovative focus on less-invasive procedures for patients. Dr. Cookman enjoys personalizing care for each patient, tailoring therapies and building lifelong relationships with patients and families. Transcription:
AFib Patients: Reduce Stroke Risk without Blood Thinners
Melanie Cole, MS (Host): For people who have atrial fibrillation or a-fib, blood clots that can cause strokes are a real danger. The Watchman device may be the answer to issues related to a-fib. Here to tell us about that today is my guest Dr. Brock Cookman. He’s an interventional cardiologist with Brian Heart. Dr. Cookman, I'm so glad to have you with us today. This is such a great topic and such an interesting procedure. Before we get into it, explain atrial fibrillation for the listeners and how this increases the risk of stroke.
Brock Cookman, DO, MSA, FACC, FSCAI (Guest): So atrial fibrillation is an abnormal heart rhythm that comes from the top chamber of the heart. Typically I describe it to patients as a nuisance type rhythm. It’s not a life threatening heart rhythm, but it can make the heart rate go very fast. It can make the heartbeat irregularly. The other nuisance is that it does increase the risk of having a stroke. Basically what happens is that the top chamber of the heart is not able to keep up with the chaotic electrical activity, and blood flow is not moved from the top chamber into the bottom chamber as regularly as it is when somebody is in a normal rhythm. Therefore anytime blood has a chance to kind of sit around it can stick together which then can cause a clot, which would move through the heart, could go to the head and cause a stroke. Patients with atrial fibrillation are about five times more likely to have a stroke than a patient in a normal rhythm.
Host: Doctor, as long as we’re taking about anatomy, please briefly explain about the heart’s anatomy and what the left atrial appendage really is and why we might want to close it.
Dr. Cookman: So the left atrial appendage is a structure of embryonic origin, which basically just means that the left atrial appendage was the premature heart as we were developing in mom’s belly basically. As the adult heart forms, this left atrial appendage gets pushed off to the side. It is almost like a little nook off to the side of the heart where blood can go in. Typically if you're in a normal rhythm, blood can get pushed out of there. But when you're in atrial fibrillation, the blood has a chance to just kind of sit in that area of the heart. With atrial fibrillation, we know that about 90% of the strokes that originate from atrial fibrillation do occur in the left atrial appendage. Therefore the thinking is that if we’re able to remove this structure—if we’re able to wall off the left atrial appendage—then we can adequately reduce the patient’s risk for having a stroke.
Host: Excellent explanation. You're a very good educator Dr. Cookman. So first line of defense, if you determine that someone has a-fib, blood thinners. Speak about what you would do first before you would look to the Watchman, which we’ll be discussing.
Dr. Cookman: First line of defense for atrial fibrillation is always going to be blood thinners. So anticoagulants. They're the kind of initial medication was Coumadin or Warfarin. It’s kind of the old tried and true. It’s been around forever. It does have a lot of issues in terms of interactions with food, interactions with other medications. It does require routine blood monitoring to make sure the blood is not too thick or too thin. So it can kind of hamper or kind of dictate somebody’s quality of life when you're changing doses of medications and getting labs checked on a regular basis. I want to say right around 2009 to 2012, the newer agents in regards to anticoagulants—these would Pradaxa, Xarelto, and Eliquis—became available. Those have all been shown to be equally as effective as Coumadin in regards to their anticoagulation benefits. They don’t require routine blood monitoring. Once you take the medication, you are fully anticoagulated.
So the next step is to figure out who is a candidate for left atrial appendage closure device. I tell you left atrial appendage closure device, right now it is synonymous with Watchman implantation because the Watchman device is the only device that’s medically indicated for this utility. Patients that are not candidates are obvious Watchman candidates. That can be a whole slew of different things. If a patient is on Coumadin or Warfarin and their blood is either too thick or too thin, if it is lifestyle hindering in regards to unable to make frequent doctor’s appointments and things like that to get their blood tested, those patients would be candidates for the left atrial appendage closure. If you have a bleeding episode. If you have for some reason have had a GI bleed or you get frequent nose bleeds or you have blood in your urine, all those could be considerations for Watchman implantation.
Another indication that I like is patients that are at a high risk for bleeding. We have construction workers, farmers, very active individuals that are at increased risk for cutting themselves. If you work out in a family farm that is far away from medical personnel and you happen to cut yourself while you were out in the field, that could put you at high risk for complications. So those patients are also ones that I would consider for Watchman implantation.
Host: Well thank you for that description. So tell us a little bit about that procedure itself. How long does it take and what is recovery like?
Dr. Cookman: So the initial evaluation is that you have to have a transesophageal echocardiogram. Basically I just tell people this is kind of a scope ultrasound. Basically we go down the esophagus. This is under a conscious sedation. So we do make patients comfortable during this procedure. That is a same day procedure. So you just come in, you get that procedure done, and then you go home. That basically will define the anatomy of the left atrial appendage. The left atrial appendage is almost like your fingerprint. Basically everybody’s appendage is going to be a little bit different and the anatomy is going to be a little bit different. So we do need the initial screening evaluation. People that can't have the transesophageal echocardiogram can have a CT scan performed of the heart, which can also tell us what the anatomy of the appendage is.
Once we get the initial screening done then we can actually come up with a plan in regards to what sized device would appropriately fit in that appendage to close it. Once that evaluation is done, patients are scheduled for the procedure. This procedure is done with patients on blood thinners and you would need to continue blood thinners for at least 45 days after the procedure. The procedure you come in the day of the procedure. It is done under general anesthesia. So you are on a breathing machine during the time of the procedure. We also do repeat that scope ultrasound—that transesophageal echocardiogram during the procedure. The procedure duration is about an hour or two. What we do is we go through the vein in the leg. We go up into the heart. We go across the dividing portion between the top chambers of the heart and we’re able to deploy that device into the left atrial appendage. If we see that the fit is appropriate and everything looks great, we’re able to then deploy the device after we’ve checked that it’s going to stay in position. The breathing tube is typically removed before patients even leave the room. They go up to the recovery area. They stay overnight one night in the hospital and then they're typically home the next day.
The long term follow up, we do a repeat transesophageal echocardiogram at 45 days. If at that point in time it shows that the left atrial appendage is completely covered by the device and we don’t have any issues, about 90% or more percent of patients are able to get off their blood thinners at 45 days.
Host: What an interesting procedure. So overall, what would you like patients to take away from this segment? You mentioned that they stay on their blood thinners for up to 45 days, but then they're pretty much done. While you're wrapping this up with your best advice doctor, this is not something that cures their a-fib, correct? So just kind of wrap this up with a nice little summary about the Watchman and the left atrial appendage closure device.
Dr. Cookman: Just in general there is no cure for atrial fibrillation. This is something that as a cardiologist we will be dealing with for the rest of the patient’s life. The biggest concern I have is the increased risk for having a stroke with atrial fibrillation. If patients are tolerating blood thinners and they're doing great then I still think blood thinners are going to be our primary line of defense in regards to reducing your stroke risk. But in those patients that blood thinners put patients at increased risk, I think it is important to evaluate those risks and consider those risks because it’s better to be proactive and take care of things before they become an issue as opposed to reactive after we’ve had a significant issue. The long term medical therapy for atrial fibrillation will be kind of determined by the physician and the patient. Something that they're going to follow up lifelong. After the 45 days, they are on aspirin and clopidogrel as a—I don’t want to say a blood thinner, but they are antiplatelet agents. Then they're just on aspirin indefinitely after that six month period going forward.
Host: Do you have any best advice or final thoughts about atrial fibrillation, and what you’d like patients to know about possibly preventing it or questions that you’d like them to ask.
Dr. Cookman: I think if you have atrial fibrillation, it’s just very important to discuss options in regards to stroke reduction with your provider or with your cardiologist because the days of not having options outside of Warfarin are gone. There are better agents in terms of blood thinners and there are better options in regards to procedural stroke reduction procedures that can be performed. So it’s just important for patients to be informed in regards to their options and regards to stroke reduction with atrial fibrillation.
Host: Thank you so much Dr. Cookman for joining us and sharing your incredible expertise explaining this so very well to us. Thank you to our Brian Foundation partner NRC. That wraps up this episode of Brian Health podcast. Please visit our website at brianheart.org for more information and to get connected with one of our providers. If you found this podcast as educational as I did, if you learned as much as I did today, please share on your social media and share with your friends and family. That way we can all learn from the experts at Brian Health together. Be sure not to miss all the other interesting podcasts in our library. This is Melanie Cole. Thanks so much for listening.
AFib Patients: Reduce Stroke Risk without Blood Thinners
Melanie Cole, MS (Host): For people who have atrial fibrillation or a-fib, blood clots that can cause strokes are a real danger. The Watchman device may be the answer to issues related to a-fib. Here to tell us about that today is my guest Dr. Brock Cookman. He’s an interventional cardiologist with Brian Heart. Dr. Cookman, I'm so glad to have you with us today. This is such a great topic and such an interesting procedure. Before we get into it, explain atrial fibrillation for the listeners and how this increases the risk of stroke.
Brock Cookman, DO, MSA, FACC, FSCAI (Guest): So atrial fibrillation is an abnormal heart rhythm that comes from the top chamber of the heart. Typically I describe it to patients as a nuisance type rhythm. It’s not a life threatening heart rhythm, but it can make the heart rate go very fast. It can make the heartbeat irregularly. The other nuisance is that it does increase the risk of having a stroke. Basically what happens is that the top chamber of the heart is not able to keep up with the chaotic electrical activity, and blood flow is not moved from the top chamber into the bottom chamber as regularly as it is when somebody is in a normal rhythm. Therefore anytime blood has a chance to kind of sit around it can stick together which then can cause a clot, which would move through the heart, could go to the head and cause a stroke. Patients with atrial fibrillation are about five times more likely to have a stroke than a patient in a normal rhythm.
Host: Doctor, as long as we’re taking about anatomy, please briefly explain about the heart’s anatomy and what the left atrial appendage really is and why we might want to close it.
Dr. Cookman: So the left atrial appendage is a structure of embryonic origin, which basically just means that the left atrial appendage was the premature heart as we were developing in mom’s belly basically. As the adult heart forms, this left atrial appendage gets pushed off to the side. It is almost like a little nook off to the side of the heart where blood can go in. Typically if you're in a normal rhythm, blood can get pushed out of there. But when you're in atrial fibrillation, the blood has a chance to just kind of sit in that area of the heart. With atrial fibrillation, we know that about 90% of the strokes that originate from atrial fibrillation do occur in the left atrial appendage. Therefore the thinking is that if we’re able to remove this structure—if we’re able to wall off the left atrial appendage—then we can adequately reduce the patient’s risk for having a stroke.
Host: Excellent explanation. You're a very good educator Dr. Cookman. So first line of defense, if you determine that someone has a-fib, blood thinners. Speak about what you would do first before you would look to the Watchman, which we’ll be discussing.
Dr. Cookman: First line of defense for atrial fibrillation is always going to be blood thinners. So anticoagulants. They're the kind of initial medication was Coumadin or Warfarin. It’s kind of the old tried and true. It’s been around forever. It does have a lot of issues in terms of interactions with food, interactions with other medications. It does require routine blood monitoring to make sure the blood is not too thick or too thin. So it can kind of hamper or kind of dictate somebody’s quality of life when you're changing doses of medications and getting labs checked on a regular basis. I want to say right around 2009 to 2012, the newer agents in regards to anticoagulants—these would Pradaxa, Xarelto, and Eliquis—became available. Those have all been shown to be equally as effective as Coumadin in regards to their anticoagulation benefits. They don’t require routine blood monitoring. Once you take the medication, you are fully anticoagulated.
So the next step is to figure out who is a candidate for left atrial appendage closure device. I tell you left atrial appendage closure device, right now it is synonymous with Watchman implantation because the Watchman device is the only device that’s medically indicated for this utility. Patients that are not candidates are obvious Watchman candidates. That can be a whole slew of different things. If a patient is on Coumadin or Warfarin and their blood is either too thick or too thin, if it is lifestyle hindering in regards to unable to make frequent doctor’s appointments and things like that to get their blood tested, those patients would be candidates for the left atrial appendage closure. If you have a bleeding episode. If you have for some reason have had a GI bleed or you get frequent nose bleeds or you have blood in your urine, all those could be considerations for Watchman implantation.
Another indication that I like is patients that are at a high risk for bleeding. We have construction workers, farmers, very active individuals that are at increased risk for cutting themselves. If you work out in a family farm that is far away from medical personnel and you happen to cut yourself while you were out in the field, that could put you at high risk for complications. So those patients are also ones that I would consider for Watchman implantation.
Host: Well thank you for that description. So tell us a little bit about that procedure itself. How long does it take and what is recovery like?
Dr. Cookman: So the initial evaluation is that you have to have a transesophageal echocardiogram. Basically I just tell people this is kind of a scope ultrasound. Basically we go down the esophagus. This is under a conscious sedation. So we do make patients comfortable during this procedure. That is a same day procedure. So you just come in, you get that procedure done, and then you go home. That basically will define the anatomy of the left atrial appendage. The left atrial appendage is almost like your fingerprint. Basically everybody’s appendage is going to be a little bit different and the anatomy is going to be a little bit different. So we do need the initial screening evaluation. People that can't have the transesophageal echocardiogram can have a CT scan performed of the heart, which can also tell us what the anatomy of the appendage is.
Once we get the initial screening done then we can actually come up with a plan in regards to what sized device would appropriately fit in that appendage to close it. Once that evaluation is done, patients are scheduled for the procedure. This procedure is done with patients on blood thinners and you would need to continue blood thinners for at least 45 days after the procedure. The procedure you come in the day of the procedure. It is done under general anesthesia. So you are on a breathing machine during the time of the procedure. We also do repeat that scope ultrasound—that transesophageal echocardiogram during the procedure. The procedure duration is about an hour or two. What we do is we go through the vein in the leg. We go up into the heart. We go across the dividing portion between the top chambers of the heart and we’re able to deploy that device into the left atrial appendage. If we see that the fit is appropriate and everything looks great, we’re able to then deploy the device after we’ve checked that it’s going to stay in position. The breathing tube is typically removed before patients even leave the room. They go up to the recovery area. They stay overnight one night in the hospital and then they're typically home the next day.
The long term follow up, we do a repeat transesophageal echocardiogram at 45 days. If at that point in time it shows that the left atrial appendage is completely covered by the device and we don’t have any issues, about 90% or more percent of patients are able to get off their blood thinners at 45 days.
Host: What an interesting procedure. So overall, what would you like patients to take away from this segment? You mentioned that they stay on their blood thinners for up to 45 days, but then they're pretty much done. While you're wrapping this up with your best advice doctor, this is not something that cures their a-fib, correct? So just kind of wrap this up with a nice little summary about the Watchman and the left atrial appendage closure device.
Dr. Cookman: Just in general there is no cure for atrial fibrillation. This is something that as a cardiologist we will be dealing with for the rest of the patient’s life. The biggest concern I have is the increased risk for having a stroke with atrial fibrillation. If patients are tolerating blood thinners and they're doing great then I still think blood thinners are going to be our primary line of defense in regards to reducing your stroke risk. But in those patients that blood thinners put patients at increased risk, I think it is important to evaluate those risks and consider those risks because it’s better to be proactive and take care of things before they become an issue as opposed to reactive after we’ve had a significant issue. The long term medical therapy for atrial fibrillation will be kind of determined by the physician and the patient. Something that they're going to follow up lifelong. After the 45 days, they are on aspirin and clopidogrel as a—I don’t want to say a blood thinner, but they are antiplatelet agents. Then they're just on aspirin indefinitely after that six month period going forward.
Host: Do you have any best advice or final thoughts about atrial fibrillation, and what you’d like patients to know about possibly preventing it or questions that you’d like them to ask.
Dr. Cookman: I think if you have atrial fibrillation, it’s just very important to discuss options in regards to stroke reduction with your provider or with your cardiologist because the days of not having options outside of Warfarin are gone. There are better agents in terms of blood thinners and there are better options in regards to procedural stroke reduction procedures that can be performed. So it’s just important for patients to be informed in regards to their options and regards to stroke reduction with atrial fibrillation.
Host: Thank you so much Dr. Cookman for joining us and sharing your incredible expertise explaining this so very well to us. Thank you to our Brian Foundation partner NRC. That wraps up this episode of Brian Health podcast. Please visit our website at brianheart.org for more information and to get connected with one of our providers. If you found this podcast as educational as I did, if you learned as much as I did today, please share on your social media and share with your friends and family. That way we can all learn from the experts at Brian Health together. Be sure not to miss all the other interesting podcasts in our library. This is Melanie Cole. Thanks so much for listening.