Elderly patients benefit equally from Watchman
Yet, Watchman devices are generally regarded as a success story, and this has led investigators to evaluate safety in patients not well represented or explicitly excluded from clinical trials, such as the elderly and those with end-stage renal disease (ESRD). New data derived from experience in both of these groups were presented at the conference, which was sponsored by MedStar Heart & Vascular Institute.
To tease out the relative safety of Watchman in octogenarians, Samian Sulaiman, MD, a cardiology fellow at West Virginia University Heart and Vascular Institute, Morgantown, performed a competing risk analysis to study the relative benefit of Watchman devices after controlling for the greater overall risk of complications in the elderly.
In raw data comparisons of those 80 years of age or older to those younger in published trials, the not-surprising result is that overall rates of death and ischemic events are far higher in the elderly, according to Dr. Sulaiman, but it’s an “unfair comparison,” he said.
“It is easy to mistakenly conclude that left atrial appendage closure is associated with worse outcomes, but older patients have far higher rates of these events independent of other factors,” Dr. Sulaiman noted.
In fact, in his comparison of 472 older patients to 1,404 younger patients, the seal rates at 45 days, 6 months, and 12 months are almost identical. Moreover, after the extensive adjustments performed for competing risk analysis, the rates of death, stroke, and bleeding were also almost identical for those 80 years or older whether or not they received a Watchman.
Although he acknowledged the risk for residual confounding, Dr. Sulaiman concluded that elderly patients derive about the same benefits as younger patients from the Watchman. He concluded age alone should not be a factor in selecting candidates for this device.
ESRD is not Watchman contraindication
A similar point was made about ESRD based on analysis of 237 patients who received either an earlier generation Watchman or the Watchman FLX. Initiated in Spain, the study was amended to collect data from centers elsewhere in Europe, the United States, and Australia.
Successful implantation was achieved in 99.2% of the patients, reported Armando Perez de Prado, MD, PhD, head of interventional cardiology at the University of Leon, Spain.
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Dr. Armando Perez de Prado
After a median follow-up of 480 days, stroke or transient ischemic attacks were observed in 3.1%, leaks > 5 mm were observed in 1.4%, and systemic emboli were observed in 0.9%. Major bleeding (BARC > 2) occurred in 13.3%.
Although the all-cause mortality over the period of follow-up was high (37.4%), most of the deaths (61.2%) were of noncardiovascular origin, according to Dr. Sulaiman. He said mortality and adverse events linked to the Watchman appeared to be roughly comparable to those seen in patients with ESRD.
“The Watchman device for patients on hemodialysis with nonvalvular atrial fibrillation is an effective and safe intervention to prevent embolic events,” he said. However, he also cautioned these the ESRD and the accompanying comorbidities place these patients at high risk of a limited life expectancy.
“Given the high mortality rate of this population, proper selection of candidates is paramount to ensure the optimal clinical benefit,” he cautioned.
Dr. Samir reported no potential conflicts of interest but stated that this study was funded by Boston Scientific. Dr. Cohen reported financial ties with Abbott Vascular, Boston Scientific, Corvia Medical, Edwards Lifesciences, Impulse Dynamics, MyoKardia, Phillips, Svelte, V-Wave, and Zoll. Dr. Sulaiman reported no potential conflicts of interest. Dr. Perez de Prado reported no potential conflicts of interest but stated that this study was funded by Boston Scientific.