1. Case Selection and Patient Throughput Techniques
Marsha Jones, BSN, RN, CCRP

2. Disclosure Statement of Financial Interest
Within the past 12 months, I or my spouse/partner have had a financial interest/arrangement or affiliation with the organization(s) listed below.
Affiliation/Financial Relationship
Company
Grant/Research Support
Consulting Fees/Honoraria
Major Stock Shareholder/Equity
Royalty Income
Ownership/Founder
Intellectual Property Rights
Other Financial Benefit
Company Names

3. Agenda
Screening and Pre-Procedure Evaluation
Tools for Case Selection

4. Referral to Treatment Timeline
48-72 hours Patient/MD contacted Obtain done studies locally
7 days
Consult with TTE if needed
Additional workup (Baseline brain imaging, neuro assessments)
Pre-auth initiated
10 days
Presented w/treatment plan in place
Scheduled for pre-procedure visit
Within days
Patient is treated/TEE done on table

5. Referrals and Scheduling
Live scheduler/ coordinator receives all referral calls
All outside records screened for:
LAAO suitability
Diagnosis of atrial fibrillation
Notes of prior OHS, obtain operative reports
Does patient meet CHADS/CHADS-VASc requirements for procedure
Will tests need to be ordered at time of consult or have they been done by referring physician?

6. Initial Assessment History and Physical exam with emphasis on:
Type of Atrial Fibrillation
Onset of diagnosis
Presentation at onset
CHADS/CHADS-VASc score
Patient’s functional abilities (Barthel index, Rankin scale assessments)
Is the patient on anticoagulant therapy currently?
Review: TTE, Labs (Labile INR, anemia, blood transfusion history, liver function, zio study, pacemaker interrogation readings
Note dates of prior ablation, cardioversion

7. *Per 100 patient-years without antithrombotic therapy
CHADS2　Score
Item
Points
Congestive heart failure 1
Hypertension
Age ≥75 years
Diabetes mellitus
Stroke/TIA 2
CHADS2 6 5 4 3 2 1
Stroke rate (95% CI)*
18.2 (10.5–27.4)
12.5 (8.2–17.5)
8.5 (6.3–11.1)
5.9 (4.6–7.3)
4.0 (3.1–5.1)
2.8 (2.0–3.8)
1.9 (1.2–3.0)
Add points together
Reference; Gage et al. JAMA 2001;285:2864–2870
*Per 100 patient-years without antithrombotic therapy
Gage et al, JAMA 2001 7

8. CHA2DS2-VASc: A further refinement of CHADS2
Risk factor
Points
Congestive heart failure/LV dysfunction* +1
Hypertension
Age ≥75 years +2
Diabetes mellitus
Previous stroke/TIA/thromboembolism
Vascular disease (MI, aortic plaque, peripheral artery disease)#
Age 65–74 years
Sex category (female)
Maximum score 9
References: Camm et al. Eur Heart J 2010;31:2369–2429, Lip et al. Chest 2010;137:263–272
*Left ventricular ejection fraction ≤40%; #Including prior revascularization, amputation due to peripheral artery disease or angiographic evidence of peripheral artery disease
Camm et al, Eur Heart J 2010; Lip et al, Chest 2010

9. Many Stroke Risk Factors Are Also Risk Factors for Bleeding
Risk factor for stroke*
Risk factor for anticoagulant-related bleeding*
Advanced age14 
History of hypertension1,3,4
History of MI or ischemic heart disease1,3
Cerebrovascular disease1–4
Anemia3,4
Previous history of bleeding3,4
Kidney or liver dysfunction4
Concomitant use of antiplatelets3,4
References: Lip et al. Chest 2010;137:263–272, Hylek et al. Ann Intern Med 1994;120:897–902, Hughes et al. QJM 2007;100:599−607, Pisters et al. Chest 2010;138:1093–1100
*Not exhaustive
The relationship between stroke risk and bleeding risk complicates
the evaluation of benefit–risk
1. Lip et al, Chest 2010; 2. Hylek et al, Ann Intern Med 1994; 3. Hughes et al, QJM 2007; 4. Pisters et al, Chest 2010 9

10. HAS-BLED Score Clinical characteristic Points
Hypertension (SBP >160 mm Hg) 1
Abnormal renal or liver function
1 + 1
Stroke
Bleeding
Labile INRs
Elderly (age >65 years)
Drugs or alcohol
Cumulative score
Range 0−9
Reference: Pisters et al. Chest 2010;138:1093–110
Pisters et al, Chest 2010 10

11. 1-Year Risk of Major Bleeding Increases with HAS-BLED Score
No.
No. of Bleeds
Bleeds Per
100 Patient-Years
798 9
1.13 1
1286 13
1.02 2
744 14
1.88 3
187 7
3.74 4 46
8.70 5 8
12.50 6
0.0 -
Reference: Pisters et al. Chest 2010;138:1093–110
Pisters et al, Chest 2010 11

12. Barthel Index

13. Rankin Scale

14. Obtain Authorization
Give complete clinical picture of patient in consult note
List CHA2DS2-VASc score
List patient specific risk factors for bleeding complications
Conduct peer to peer reviews over phone first then appeal only if denied over phone
Keep patient and family informed of status of authorization

15. Provide FDA approval letter
Obtain Authorization
Provide FDA approval letter
Watchman is not an investigation device
Established safety and efficacy
Physician procedure code (33340)
Baseline TEE code (CPT 93312)

16. BSC reimbursement tools and resources
Obtain Authorization
BSC reimbursement tools and resources
Procedural (02L73DK) and diagnosis code
Watchman reimbursement guide
Pre authorization and appeals templates
Physician category III code guide (0281T)

17. The Pre-Op Visit Diagnostic/assessments:
Pre op Labs-important for registry Hemoglobin, Creatinine and Albumin
Patient instructed to hold anticoagulant (warfarin) for 3 days. INR ~ 2.0 or less
NOACs held for 48 hours
NPO for 8 hours
Hold meds on morning of procedure except inhalers which should be used
Assess for infections/injuries that may affect recovery
Review procedure booklets, procedure animation

18. Pre-Op Points to Ponder
Change NOAC to Coumadin 5-7 days prior to procedure
Anticoagulation: to hold or not to hold
Meds to be held on morning of procedure (inhalers, HTN meds, antiplatelets, etc)
NPO for 8-12 hours
Assess for infections/injuries that may affect recovery
TEE in echo suite or on table in lab
Foley intra-procedure: yes, no, maybe so
Central line vs peripheral IV
A-line

19. Procedure Considerations
General anesthesia required with TEE
IV antibiotics prior to start of procedure
Patient is heparinized with goal ACT > 250
Procedure requires contrast, schedule on non dialysis days
Foley catheter, yes or no
Single Perclose for groin hemostasis
Device prep by trained staff

20. Procedure Considerations
Scheduling cases in blocks of 3 or 4 works best
Patient should arrive at least 2 hours prior to start time
Have electronic orders entered in EMR or paper orders done prior to patient arrival to hospital
Make sure sufficient device inventory is present
Staffing to allow for device prep
Trained cardiac anesthesiologist and echocardiologist

21. One Day Hospital Stay
Extubated in cath lab
Central line Dc’d
Telemetry unit
4 hour bed rest
Resume warfarin

22. Post-Procedure: Patient Care
IV hydration 4-6 hours. Hydrate to reduce renal injury but avoid volume overload.
Antibiotic therapy (one dose prior to start of procedure, two doses post procedure given at 6 and 12 hours post).
Chloraseptic spray

23. Summary
Scheduling efficiency leads to growth of program and number of patients treated.
Careful attention to pre and post procedure care is critical to procedural success.

24. Questions?
Thanks for your attention.