The Watchman Left Atrial Appendage Closure Device: Technical Considerations and Procedural Approach

Percutaneous left atrial appendage closure (LAAC) with the Watchman FLX device is an approved procedure for stroke prevention in patients with nonvalvular atrial fibrillation (AF) who have an appropriate rationale to seek an alternative to oral anticoagulation. The size and shape of the left atrial appendage (LAA) vary widely among individuals. Imaging guidance for the LAAC procedure is of utmost importance for procedural success, as it helps guide the choice and size of the device. Successful LAAC depends on appropriate interaction and apposition of the Watchman device with the LAA walls, ensuring adequate compression of the device and complete exclusion of all LAA lobes. LAAC is affected by various factors including LAA ostial diameter, LAA depth, morphology, septations, trabeculations, number of lobes, and orientation of the LAA body. Failure in device sizing or inadequate device positioning may result in peri-device leakage or even in device embolization. The Watchman FLX device offers significant improvements compared to its predecessor, Watchman 2.5, and demonstrates improved safety and procedural success with a wider variety of appendage anatomies. The Watchman FLX Pro continues the evolution of the Watchman device through advancements in device coating, marker design, and larger size offering.