Watchman Alternatives: Other Options for Left Atrial Appendage Closure

A 78-year-old woman has atrial fibrillation, a CHA2DS2-VASc score of 5, and three significant gastrointestinal bleeds in the last two years. Anticoagulation has become impossible. Her cardiologist talks about left atrial appendage closure as a way to reduce stroke risk without the bleeding consequences of long-term anticoagulation. The first device that comes up in the conversation is the Watchman. But she's asking whether there are alternatives, and the answer is yes. Several options exist now beyond the original Watchman device, and each has its own profile.

I'm Dr. Damian Rasch, a cardiologist in Encinitas. Left atrial appendage (LAA) closure is a procedure that seals off the left atrial appendage, the small pouch attached to the left atrium where most AFib-related blood clots form. With the appendage sealed, the major source of stroke-causing clots is removed, and many patients can stop long-term anticoagulation. The Watchman, made by Boston Scientific, was the first FDA-approved device for this purpose and remains the most commonly used in the United States. But the field has expanded. The Watchman FLX, the Amplatzer Amulet, surgical LAA closure, and AtriClip are all options now, each with their own characteristics. This article walks through what each device or technique does, when one might be preferred over another, and how to think about the decision.

Why LAA Closure Is Done

In atrial fibrillation, the chaotic atrial activity reduces blood flow in the left atrial appendage. Stagnant blood there can clot. When the heart rhythm changes (back to sinus rhythm spontaneously, with cardioversion, or with rapid AFib episodes), the clot can dislodge and travel to the brain, causing a stroke. About 90 percent of AFib-related strokes come from clots that originated in the left atrial appendage.

Anticoagulation reduces stroke risk by about 65 percent in AFib patients with elevated stroke risk. But anticoagulation increases bleeding risk, especially in older patients with prior bleeds, falls, kidney disease, or other risk factors. For patients who can't tolerate anticoagulation, LAA closure offers an alternative. The appendage is sealed off mechanically, the source of most clots is removed, and anticoagulation can typically be discontinued after a brief post-procedure period.

LAA closure isn't for everyone with AFib. It's for patients with elevated stroke risk who have a contraindication to long-term anticoagulation or who have failed anticoagulation therapy (recurrent strokes despite adequate anticoagulation, or major bleeding requiring discontinuation). The risk-benefit calculation has to favor the procedure given the procedural risks.

The Original Watchman and Watchman FLX

The original Watchman device received FDA approval in 2015 based on the PROTECT-AF and PREVAIL trials. The device is a parachute-shaped nitinol frame covered in fabric that's deployed in the left atrial appendage via a transseptal catheter approach. Once positioned correctly, the device seals off the appendage, and over months, tissue grows over it to incorporate it into the atrial wall.

The Watchman FLX, approved in 2020, is the second-generation device. It has a fully retrievable frame (the original was retrievable only partially), a more conformable design that fits a wider range of appendage anatomies, and a closed distal end that reduces the risk of device embolization. The FLX is now the predominant Watchman device used. Most centers have transitioned away from the original Watchman entirely.

Both Watchman devices are deployed via percutaneous transseptal access. The procedure is done under general anesthesia or deep sedation with transesophageal echocardiogram (TEE) guidance. Most patients go home the next day or sometimes the same day. Anticoagulation is continued for about 45 days post-procedure (warfarin or DOAC), then transitioned to dual antiplatelet therapy until the 6-month TEE confirms adequate sealing, then transitioned to aspirin alone indefinitely.

The Amplatzer Amulet

The Amplatzer Amulet, approved in the US in 2021 (after long-standing approval in Europe), is a competing percutaneous LAA closure device made by Abbott. It uses a "lobe and disc" design: a distal lobe that anchors in the appendage and a proximal disc that covers the orifice from inside the atrium. The dual-element design provides occlusion at two levels.

The Amulet's design allows complete occlusion of the appendage at the time of implant, which means many patients can be discharged on dual antiplatelet therapy alone (no anticoagulation) immediately after the procedure. This contrasts with the Watchman, which typically requires 45 days of post-procedure anticoagulation. For patients who need to avoid anticoagulation entirely, this is a meaningful advantage.

The AMULET-IDE trial randomized patients to Watchman vs. Amulet. Both showed similar efficacy for stroke prevention. Procedural success rates and complication rates were similar, with some differences in the specific complication profiles. The Amulet has a slightly higher rate of pericardial effusion in some series, while the Watchman has a slightly higher rate of device-related thrombus.

The choice between Watchman FLX and Amulet often depends on operator experience and appendage anatomy. Some appendage shapes fit one device better than the other. Most centers offer one or both, and the decision is made based on imaging assessment of the specific appendage.

Surgical LAA Closure (AtriClip and Suture Ligation)

Surgical closure of the left atrial appendage is an option for patients undergoing other cardiac surgery (CABG, valve replacement, surgical AFib ablation) and is sometimes done as a stand-alone procedure. The most common modern technique uses the AtriClip device, a clip that's placed around the base of the appendage from the outside of the heart, completely closing it off. Suture ligation is an older alternative.

The LAAOS III trial, published in 2021, established that surgical LAA closure during cardiac surgery reduces stroke risk in patients with AFib. The trial showed a 33 percent relative risk reduction in stroke or systemic embolism in patients who had concomitant LAA closure during cardiac surgery vs. those who didn't, with similar safety profiles. This established surgical LAA closure as a standard adjunct in AFib patients undergoing cardiac surgery.

For patients not already having cardiac surgery, stand-alone surgical LAA closure is occasionally done, usually via thoracoscopic (minimally invasive) approach. The stand-alone procedure is more commonly used for patients with very high bleeding risk who are also poor candidates for percutaneous closure due to anatomic factors. The procedure is more invasive than percutaneous closure and is reserved for specific situations.

Comparison of Options

Watchman FLX

Strengths: most studied, longest track record, widest insurance coverage, broad operator experience.

Limitations: requires post-procedure anticoagulation for 45 days, requires TEE follow-up imaging.

Amplatzer Amulet

Strengths: complete occlusion at time of implant allowing immediate transition to dual antiplatelet alone, dual-element design suits some anatomies better.

Limitations: newer to US market, fewer years of long-term data, slightly higher pericardial effusion rate in some series.

Surgical Closure (AtriClip)

Strengths: complete external closure, no foreign body inside the heart, ideal during concomitant cardiac surgery.

Limitations: more invasive than percutaneous procedures, not typically a stand-alone procedure, requires general anesthesia.

Stand-Alone Thoracoscopic Closure

Strengths: avoids percutaneous transseptal puncture, may be appropriate for patients with anatomically unsuitable percutaneous options.

Limitations: more invasive, longer recovery, fewer centers offer it, higher procedural risk profile.

Who Is a Candidate

LAA closure is appropriate for patients with non-valvular atrial fibrillation, elevated stroke risk (CHA2DS2-VASc score of 2 or higher in men, 3 or higher in women), and a contraindication to long-term anticoagulation or a meaningful failure of anticoagulation therapy.

Common contraindications to anticoagulation that make LAA closure appropriate include prior major bleeding (especially intracranial hemorrhage, recurrent gastrointestinal bleeding), severe falls with injury, occupations or activities with high trauma risk, kidney disease that complicates DOAC dosing, and pregnancy or near-pregnancy in younger AFib patients.

Patients on triple therapy (anticoagulation plus dual antiplatelet for coronary stenting) have unusually high bleeding risk. LAA closure can allow simplification to dual antiplatelet alone, reducing bleeding without compromising stroke or stent thrombosis prevention.

Several factors limit candidacy. Severe valvular AFib (rheumatic mitral stenosis, mechanical valves) typically requires anticoagulation for valve-related reasons that LAA closure doesn't address. Active intracardiac thrombus is a contraindication until resolved. Some appendage anatomies are unsuitable for percutaneous closure. End-stage cardiomyopathy with very limited life expectancy may not justify the procedural risk.

The Procedure Experience

For percutaneous closure (Watchman FLX or Amulet), the procedure is done under general anesthesia or deep sedation. After IV access, the patient is positioned, and TEE probe is placed for imaging guidance. Through a femoral vein, a transseptal puncture is made to access the left atrium. The chosen device is positioned in the appendage under TEE and fluoroscopic guidance. Once optimal position is confirmed, the device is released. The procedure usually takes 60 to 90 minutes.

Recovery is typically straightforward. Patients are monitored for a few hours, sometimes overnight, and discharged the same day or the next morning. The femoral access site needs care for 24 hours. Light activity is allowed within a few days.

Post-procedure anticoagulation depends on the device. For Watchman FLX, warfarin or DOAC for 45 days, then dual antiplatelet for the rest of the first 6 months, then aspirin alone after a 6-month TEE confirms sealing. For Amulet, dual antiplatelet immediately for 1 to 6 months, then aspirin alone. Both protocols continue aspirin indefinitely afterward.

Risks and Complications

All LAA closure procedures carry risks. Common minor complications include access site bleeding or hematoma, transient AV block during the procedure, and minor pericardial effusion that resolves spontaneously.

Significant complications include cardiac perforation requiring drainage (about 1 percent), device embolization (rare with modern devices), stroke during the procedure (about 0.5 to 1 percent), and major access site bleeding (under 2 percent). Death is very rare.

Late complications include device-related thrombus (1 to 4 percent of patients, usually treated with brief reinitiation of anticoagulation), peri-device leak (small leaks are common but usually clinically insignificant; large leaks may require additional intervention), and infection (very rare).

Common Patient Questions

Will I be able to stop blood thinners after?

In most cases, yes. After a 45-day anticoagulation period (Watchman FLX) or immediately (Amulet), patients transition to dual antiplatelet therapy. After 6 months and a TEE confirming sealing, most patients transition to aspirin alone indefinitely. The full anticoagulation period after the procedure is the trade-off for permanent removal of the major stroke source.

Is one device better than another?

Both Watchman FLX and Amulet have similar efficacy for stroke prevention. The choice depends on appendage anatomy, the operator's experience with each device, and patient-specific considerations (need to avoid post-procedure anticoagulation, for example, favors Amulet). Both are good devices when used appropriately.

What if my appendage anatomy doesn't fit a percutaneous device?

A small fraction of patients have appendage anatomy that doesn't accommodate any percutaneous device well. For these patients, surgical or thoracoscopic LAA closure is an option. The decision is made after detailed imaging review with the structural heart team.

How long does the device last?

Permanently. Once tissue covers the device (typically by 6 months), it's incorporated into the atrial wall and stays in place for life. There's no battery, no maintenance, and no need to remove or replace it.

What if I get into a clinical situation where I need anticoagulation again?

You can take anticoagulation if needed for a different indication (DVT, PE, mechanical valve, etc.). The LAA closure doesn't preclude anticoagulation; it just makes long-term anticoagulation for AFib stroke prevention unnecessary. Many patients with the device end up on antiplatelet therapy alone, which doesn't conflict with adding anticoagulation if a new indication arises.

Does the device cause any heart problems?

Once incorporated into the atrial wall (typically 3 to 6 months after implant), the device doesn't typically cause functional issues. The left atrial appendage's normal contribution to atrial contraction is small, and its loss doesn't significantly affect cardiac function. Some studies have suggested small effects on hormonal regulation (atrial natriuretic peptide), but the clinical implications appear minimal.

Will I need follow-up imaging?

Yes. A TEE at 45 days (with Watchman) or earlier (with Amulet) confirms initial position. A repeat TEE at 6 months confirms adequate sealing and absence of device-related thrombus. After that, no routine imaging is needed unless symptoms or clinical changes suggest a problem.

Can I have an MRI with the device in place?

Yes. Both Watchman FLX and Amulet are MRI-compatible. The fields used in clinical MRI don't displace or interfere with the devices.

Why didn't my doctor mention this option years ago?

LAA closure as a percutaneous option only became FDA-approved in 2015 (Watchman) and 2021 (Amulet). The data and infrastructure for routine offering have built up over time. Many cardiologists have been increasingly comfortable referring for LAA closure as evidence and experience have accumulated. If LAA closure wasn't mentioned in your prior visits, it may simply have not been on the differential at that point in your care.

When to Escalate Care

Call 911 immediately for severe chest pain, severe shortness of breath, signs of stroke (sudden weakness, slurred speech, vision changes), or signs of significant bleeding (large bruising, severe headache after head injury, significant GI bleeding) after LAA closure. Procedural complications usually present within hours to days; later complications (device-related thrombus, stroke) can present weeks to months later.

Contact your cardiologist or structural heart team the same day for new chest pain, palpitations with concerning features, or any concerns about post-procedure healing. Same-day evaluation can rule out complications.

Schedule a clinic visit within one to two weeks for routine post-procedure follow-up if you have one already scheduled, or for non-urgent questions about medications and activity restrictions.

A Final Note From Me

LAA closure has expanded the options for stroke prevention in AFib patients who can't tolerate or have failed anticoagulation. The original Watchman has been joined by improved versions (Watchman FLX) and competing devices (Amulet), and surgical options (AtriClip) are well-established for patients having concomitant cardiac surgery. The decision about which option is best depends on appendage anatomy, the patient's bleeding history, the operator's experience with each device, and the specific clinical context.

If you have AFib with elevated stroke risk and you've had significant bleeding on anticoagulation, LAA closure is worth discussing seriously. The trade-off is real: you accept a procedure with its own risks in exchange for being able to stop long-term anticoagulation that's already harmed you. For the right patient, the math strongly favors the procedure.

If you're being told that LAA closure isn't appropriate for you, the reasons matter. Some patients are excluded for technical reasons (anatomy, active thrombus), some for clinical reasons (limited life expectancy, severe comorbidities), and some because their bleeding risk doesn't actually exceed their stroke risk. The conversation about whether closure is right is best had with a structural heart specialist who has experience with the procedure.

If you've had LAA closure and you're recovering, the most important things are following the post-procedure medication plan, completing the follow-up imaging on schedule, and reporting any concerning symptoms promptly. The vast majority of patients have uncomplicated recoveries and can return to normal activities within a few weeks. The patients who do best long-term are those who continue to address their other cardiac risk factors, including the underlying AFib management with appropriate rate or rhythm control.

References

1. Holmes, David R., Saibal Kar, Matthew J. Price, et al. "Prospective Randomized Evaluation of the Watchman Left Atrial Appendage Closure Device in Patients with Atrial Fibrillation versus Long-Term Warfarin Therapy: The PREVAIL Trial." Journal of the American College of Cardiology 64, no. 1 (2014): 1-12.

2. Lakkireddy, Dhanunjaya, Andre A. Thaler, Christopher R. Ellis, et al. "Amplatzer Amulet Left Atrial Appendage Occluder versus Watchman Device for Stroke Prevention in Atrial Fibrillation: A Randomized Controlled Trial." Circulation 144, no. 19 (2021): 1543-1552.

3. Whitlock, Richard P., Emilie P. Belley-Côté, Domenico Paparella, et al. "Left Atrial Appendage Occlusion during Cardiac Surgery to Prevent Stroke." New England Journal of Medicine 384, no. 22 (2021): 2081-2091.

4. Reddy, Vivek Y., Hamid Sievert, Jonathan Halperin, et al. "Percutaneous Left Atrial Appendage Closure vs Warfarin for Atrial Fibrillation: A Randomized Clinical Trial." JAMA 312, no. 19 (2014): 1988-1998.

5. Kar, Saibal, Brijeshwar S. Maini, Devi G. Nair, et al. "Primary Outcome Evaluation of a Next-Generation Left Atrial Appendage Closure Device: Results from the PINNACLE FLX Trial." Circulation 143, no. 18 (2021): 1754-1762.

6. Tzikas, Apostolos, Sergio Shakir, Sameer Gafoor, et al. "Left Atrial Appendage Occlusion for Stroke Prevention in Atrial Fibrillation: Multicentre Experience with the AMPLATZER Cardiac Plug." EuroIntervention 11, no. 10 (2016): 1170-1179.

7. January, Craig T., L. Samuel Wann, Hugh Calkins, et al. "2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients with Atrial Fibrillation." Journal of the American College of Cardiology 74, no. 1 (2019): 104-132.

8. Hindricks, Gerhard, Tatjana Potpara, Nikolaos Dagres, et al. "2020 ESC Guidelines for the Diagnosis and Management of Atrial Fibrillation." European Heart Journal 42, no. 5 (2021): 373-498.

9. Berti, Sergio, Domenico Pastormerlo, Christophe Pourbaix, et al. "Periprocedural Outcomes after Left Atrial Appendage Occlusion: Outcomes from the Amplatzer Cardiac Plug Multi-Center Registry." Catheterization and Cardiovascular Interventions 86, no. 1 (2015): 134-141.

10. Boersma, Lucas V., Hueseyin Ince, Stephen Kische, et al. "Efficacy and Safety of Left Atrial Appendage Closure with WATCHMAN in Patients with or without Contraindication to Oral Anticoagulation: 1-Year Follow-up Outcome Data of the EWOLUTION Trial." Heart Rhythm 14, no. 9 (2017): 1302-1308.

Published on damianrasch.com. The above information was composed by Dr. Damian Rasch, drawing on individual insight and bolstered by digital research and writing assistance. The information is for educational purposes only and does not constitute medical advice.