Warfarin sensitivity is associated with increased hospital mortality in critically Ill patients.

BACKGROUND: Warfarin is a widely used anticoagulant with a narrow therapeutic index and large interpatient variability in the therapeutic dose. Warfarin sensitivity has been reported to be associated with increased incidence of international normalized ratio (INR) > 5. However, whether warfarin sensitivity is a risk factor for adverse outcomes in critically ill patients remains unknown. In the present study, we aimed to evaluate the utility of different machine learning algorithms for the prediction of warfarin sensitivity and to determine the impact of warfarin sensitivity on outcomes in critically ill patients. METHODS: Nine different machine learning algorithms for the prediction of warfarin sensitivity were tested in the International Warfarin Pharmacogenetic Consortium cohort and Easton cohort. Furthermore, a total of 7,647 critically ill patients was analyzed for warfarin sensitivity on in-hospital mortality by multivariable regression. Covariates that potentially confound the association were further adjusted using propensity score matching or inverse probability of treatment weighting. RESULTS: We found that logistic regression (AUC = 0.879, 95% CI: 0.834-0.924) was indistinguishable from support vector machine with a linear kernel, neural network, AdaBoost and light gradient boosting trees, and significantly outperformed all the other machine learning algorithms. Furthermore, we found that warfarin sensitivity predicted by the logistic regression model was significantly associated with worse in-hospital mortality in critically ill patients with an odds ratio (OR) of 1.33 (95% CI, 1.01-1.77). CONCLUSIONS: Our data suggest that the logistic regression model is the best model for the prediction of warfarin sensitivity clinically and that warfarin sensitivity is likely to be a risk factor for adverse outcomes in critically ill patients.

Association of serum 25-Hydroxy Vitamin D level with lipid, lipoprotein, and apolipoprotein level.

Introduction 25-Hydroxy vitamin D (Vit D3) deficiency was found to be associated with vascular dysfunction, arterial stiffening, extent of coronary artery disease and cardiovascular mortality. Previous studies showed positive correlation between serum Vit D3 and HDL-C and negative correlation between Vit D3 and LDL-C. The aim of this study is to investigate more details about the possible association of serum Vit D3 level with lipid, lipoprotein and apolipoprotein level. Methods Totally 101 patients were included in this study and Vit D3, total cholesterol (TC), low-density lipoprotein cholesterol (LDL-C), High-density lipoprotein cholesterol (HDL-C), total triglyceride (TG), non-high-density lipoprotein cholesterol (Non-HDL-C), low-density lipoprotein particle (LDL-P), small dense low-density lipoprotein particle (sLDL-P), small dense low-density lipoprotein cholesterol (sdLDL-C), High-density lipoprotein cholesterol particles (HDL-P), High-density lipoprotein 2-cholesterol (HDL2-C), Apolipoprotein B(ApoB), Apolipoprotein A1 (Apo A1) and Apolipoprotein B/Apolipoprotein A1 ratio (ApoB/A ratio) were tested. Results Our results show that patients with Vit D3 deficiency (Vit D3 < 30 ng/ml) have significantly higher level of LDL-C, TG, Non-HDL-C, LDL-P, sLDL-P, sdLDL-C, ApoB and ApoB/A ratio compare with patients have normal Vit D3 level (Vit D3 > 30 ng/ml). Patients with normal Vit D3 level have significantly higher level of HDL-C and HDL2-C. Correlation study shows that Vit D3 level is negative correlated with TC, LDL-C, TG, Non-HDL-C, LDL-P, sLDL-P, sdLDL-C, ApoB and ApoB/A ratio and positive correlated with HDL2-C level. Conclusion Our results show that Vit D3 deficiency links to an increased risk for dyslipidemia and that may be the reason that patients with vitamin D deficiency tend to have higher risk of coronary artery disease.

Clinical Model for Predicting Warfarin Sensitivity.

Warfarin is a widely used anticoagulant with a narrow therapeutic index and large interpatient variability in the therapeutic dose. Complications from inappropriate warfarin dosing are one of the most common reasons for emergency room visits. Approximately one third of warfarin dose variability results from common genetic variants. Therefore, it is very necessary to recognize warfarin sensitivity in individuals caused by genetic variants. Based on combined polymorphisms in CYP2C9 and VKORC1, we established a clinical classification for warfarin sensitivity. In the International Warfarin Pharmacogenetic Consortium (IWPC) with 5542 patients, we found that 95.1% of the Black in the IWPC cohort were normal warfarin responders, while 74.8% of the Asian were warfarin sensitive (P < 0.001). Moreover, we created a clinical algorithm to predict warfarin sensitivity in individual patients using logistic regression. Compared to a fixed-dose approach, the clinical algorithm provided significantly better performance. In addition, we validated the derived clinical algorithm using the external Easton cohort with 106 chronic warfarin users. The AUC was 0.836 vs. 0.867 for the Easton cohort and the IWPC cohort, respectively. With the use of this algorithm, it is very likely to facilitate patient care regarding warfarin therapy, thereby improving clinical outcomes.

Triglyceride Levels Greater Than 10,000 mg/dL in a 49-Year-Old Female without Evidence of Pancreatitis.

We present a rare case of a 49-year-old female with very severe hypertriglyceridemia (HTG) having a total triglyceride (TG) count of > 10,000 mg/dL in the absence of pancreatitis. Based on literature review, this is one of the highest recorded TG counts in an adult without evidence of pancreatitis. HTG is a common occurrence in clinical practice, but rarely do numbers exceed 2000 mg/dl. It is crucial to evaluate and rapidly lower TG levels to prevent potentially life-threatening complications such as severe pancreatitis. Removal of potential predisposing medications, control of underlying diseases known to cause HTG, and maintenance therapies are essential to prevent reoccurrence.

Association of Methylenetetrahydrofolate Reductase (MTHFR) A1298C Polymorphism with Lower High-Density Lipoprotein Cholesterol Level.

BACKGROUND: Evidences about the relationship between methylenetetrahydrofolate reductase (MTHFR) gene polymorphism and metabolic syndrome are controversial. The present study aimed to investigate if MTHFR gene polymorphisms MTHFR C677T and MTHFR A1298C are related to metabolic syndrome (MS). METHODS: 318 patients were enrolled and single nucleotide polymorphisms for MTHFR C667T and A1298C were genotyped. BMI, fasting blood glucose level (FBG), total cholesterol (TC), low-density lipoprotein (LDL), High-density lipoprotein (HDL) and triglycerides (TG) were measured. RESULTS: In our study population, there were no significant differences for BMI, FBG, TC, LDL, TG or any component disease of MS between MTHFR C667T, MTHFR A1298C wild type and variants. MTHFR A1298C wild type had significant higher HDL level than MTHFR A1298C variants (50.9±1.6 VS. 47.1±1.0, P=0.036). Binary logistic regression analysis also showed that MTHFR A1298C variants were significantly associated with lower HDL level (OR=0.963, 95%CI 0.93-0.99, P=0.027). General linear model showed that there was no statistically significant interaction between MTHFR C667T and A1298C gene polymorphism on HDL level. So the reduction in HDL in MTHFR 1298 variants was not due to its linkage disequilibrium with the C677T polymorphism or an interaction between MTHFR 677 and MTHFR 1298 genotypes. CONCLUSION: Our study suggests that MTHFR C667T gene polymorphism is not related to any components of metabolic syndrome. MTHFR 1298 variants were significantly associated with lower HDL level compared to MTHFR 1298 wild type.

Algorithm-based reduction of inappropriate defibrillator shock: Results of the Inappropriate Shock Reduction wIth PARAD+ Rhythm DiScrimination-Implantable Cardioverter Defibrillator Study.

BACKGROUND: Inappropriate shocks (IS) continue to have a major negative impact on patients implanted with defibrillators. OBJECTIVE: The purpose of this study was to assess IS reduction with the PARAD+ discrimination algorithm in a general population implanted for primary or secondary prevention. METHODS: ISIS-ICD (Inappropriate Shock Reduction wIth PARAD+ Rhythm DiScrimination-Implantable Cardioverter Defibrillator) was a 2-year international, interventional study in patients implanted with a dual implantable cardioverter-defibrillator (ICD) or triple-chamber defibrillator (cardiac resynchronization therapy-defibrillator [CRT-D]) featuring PARAD+. IS (shocks not delivered for ventricular tachycardia or fibrillation) were independently adjudicated. The primary endpoint was percentage of IS-free patients at 24 months. Primary and worst-case analyses of annual incidence rates of patients with ≥1 IS, overall and per defibrillator type, were conducted. RESULTS: In total, 1013 patients (80.7% male; age 67.1 ± 11.4 years; 68%/30%/2% primary/secondary/other indication) were enrolled and followed for a median of 552 days (interquartile range 354; 725). Of 993 analyzed patients programmed with PARAD+, 14 had ≥1 IS, corresponding to a percentage free from IS of 98.1% (95% confidence interval [CI] 96.8%- 98.9%). Annual incidence rates (per 100 person-years) of patients with IS were 1.0 (95% CI 0.59-1.69) and 2.1 (95% CI 1.46-3.02) in the primary and worst-case analyses, respectively. In ICD patients, rates were 1.2 (95% CI 0.68-2.23) and 2.3 (95% CI 1.47-3.53), and in CRT-D patients 0.59 (95% CI 0.19-1.83) and 1.8 (95% CI 0.93-3.44) per 100 person-years. CONCLUSION: The annual rate of defibrillator patients with IS using the enhanced PARAD+ discrimination algorithm alone ranged from 1.0 to 2.1 per 100 person-years in a general population implanted for primary or secondary prevention.

Incidental descending thoracic aortic thrombus: the conundrum of medical versus surgical therapy.

Background: A mural thrombus in the descending thoracic aorta frequently leads to distal organ and acute limb ischemia, increasing overall morbidity and mortality. Early diagnosis is imperative as thrombi are usually discovered after end organ damage has taken place. The formation of a mural thrombus in descending aorta has not been fully explained; however, the principle of Virchow's triad for thrombogenesis (hypercoagulability, stasis of blood flow and endothelial injury) remains the likely pathophysiologic mechanism. Case Presentation: We present a case of a descending aortic thrombus incidentally detected on computed tomography scan in a 65-year-old female and successfully treated with anticoagulation, preventing subsequent complications. Conclusions: Suspicion for an aortic thrombus should arise when the origin is not known for acute onset distal limb or organ ischemia.

Ensemble of machine learning algorithms using the stacked generalization approach to estimate the warfarin dose.

Warfarin dosing remains challenging due to narrow therapeutic index and highly individual variability. Incorrect warfarin dosing is associated with devastating adverse events. Remarkable efforts have been made to develop the machine learning based warfarin dosing algorithms incorporating clinical factors and genetic variants such as polymorphisms in CYP2C9 and VKORC1. The most widely validated pharmacogenetic algorithm is the IWPC algorithm based on multivariate linear regression (MLR). However, with only a single algorithm, the prediction performance may reach an upper limit even with optimal parameters. Here, we present novel algorithms using stacked generalization frameworks to estimate the warfarin dose, within which different types of machine learning algorithms function together through a meta-machine learning model to maximize the prediction accuracy. Compared to the IWPC-derived MLR algorithm, Stack 1 and 2 based on stacked generalization frameworks performed significantly better overall. Subgroup analysis revealed that the mean of the percentage of patients whose predicted dose of warfarin within 20% of the actual stable therapeutic dose (mean percentage within 20%) for Stack 1 was improved by 12.7% (from 42.47% to 47.86%) in Asians and by 13.5% (from 22.08% to 25.05%) in the low-dose group compared to that for MLR, respectively. These data suggest that our algorithms would especially benefit patients requiring low warfarin maintenance dose, as subtle changes in warfarin dose could lead to adverse clinical events (thrombosis or bleeding) in patients with low dose. Our study offers novel pharmacogenetic algorithms for clinical trials and practice.

Anomalous Left Main Coronary Artery Arising from the Right Sinus of Valsalva in a Young Man Presenting with Recurrent Syncope and Myocardial Infarction.

A 19-year-old man with the left main coronary artery (LMCA) arising from the right sinus of Valsalva presented with recurrent episodes of syncope and myocardial infarction (MI). Anomalous aortic origin of a coronary artery (AAOCA) is an uncommon but extremely important differential diagnosis that should not be missed in patients presenting with syncope, MI, ventricular arrhythmias, or cardiac arrest. A definitive diagnosis with coronary angiography and prompt surgical intervention is imperative in such symptomatic patients.

Elevated troponin and left bundle branch block in the setting of suspected septicemia and demand ischemia: to treat or not to treat.

Elevated troponin and atypical chest pain in the setting of septicemia and Type II Non ST elevation myocardial infarction is frequently encountered. These cases are not necessarily scheduled for emergent cardiac catheterization. High index of clinical suspicion and continuous in-patient cardiac monitoring with serial trending of cardiac enzymes are important in such cases. Subsequent sudden development of electrocardiogram changes requires prompt investigation with emergent coronary catheterization. These types of cases may be missed especially in females who present with atypical chest pain and in patients with Left bundle branch block.

Postapproval Community Hospital Experience in the United States with Left Atrial Appendage Closure Device (Watchman).

BACKGROUND: To review the procedural safety and postimplantation complications of Watchman device implanted at 2 community hospitals for primary prevention of systemic embolization in patients with nonvalvular atrial fibrillation (NVAF) who were not candidates for long-term oral anticoagulation (OAC). METHODS: This was a retrospective case series of 48 patients carried out in 2 community hospitals in the United States. Patients with NVAF who had a CHADS2 higher than 2 or CHADS2VASc2 (congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, prior stroke or transient ischemic attack [TIA] or thromboembolism, vascular disease, age 65-74 years, and female gender) score of 3 or higher and were not candidates for long-term OAC. These patients were selected for implantation of Watchman device. They were followed up at 45 days, 6 months, 9 months, and 12 months after implantation of Watchman device to assess for complications involving the device and to determine if anticoagulation could be discontinued at the 45 days follow-up. They were monitored for any systemic thromboembolism while off anticoagulation. RESULTS: The success rate of device implantation was 98% (48 of 49). Only a single patient could not get Watchman implantation because of unfavorable left atrial appendage anatomy. Access-related and device implantation-related complications were zero (0%). At 45 days follow-up and end of follow-up duration, the rate of thrombus formation on the Watchman device was 4% (2 of 48). One patient had TIA after warfarin discontinuation. CONCLUSION: With improved procedural technique and well-trained operators, Watchman implantation is feasible in a community hospital also.

Revisiting Atrioventricular Nodal Ablation and Cardiac Pacing of Atrial Fibrillation in a Patient with Dextrocardia.

BACKGROUND Poorly controlled ventricular rate associated with atrial fibrillation (AF) leads to tachycardia-induced left ventricular dysfunction. Atrioventricular (AV) nodal ablation and cardiac pacing is the standard of care in refractory congestive heart failure (CHF) due to AF with moderate to rapid ventricular response that failed conventional medical therapy. If the patient is not a candidate for AF ablation with pulmonary vein isolation and elimination of AF foci, this is an effective approach, but it does have some challenges when done in a patient with dextrocardia and situs inversus. CASE REPORT Our patient was a 77-year-old woman with dextrocardia and situs inversus, with a history of permanent AF due to severe coronary artery disease (CAD), who suffered from recurrent CHF exacerbations from permanent AF with moderate to rapid ventricular response with underlying hypertensive cardiovascular disease. She was a poor candidate for pulmonary vein isolation because of her permanent AF status and high risk of recurrence. She underwent a technically challenging AV nodal ablation with cardiac pacing due to the complex anatomy, with drastic improvement of symptoms within the next 24 h. CONCLUSIONS AV nodal ablation with cardiac pacing is the standard of care in patients with refractory AF with moderate to rapid ventricular response who have failed medical therapy and are not candidates for pulmonary vein isolation.

Successful External Cardioversion via Fluoroscopic Electrode Positioning in Patients with Enlarged Trans-Thoracic Diameter.

BACKGROUND Atrial fibrillation is the most common cardiac arrhythmia. It increases the risk of stroke by at least five-fold and is associated with higher risk for mortality and morbidity. Therefore, prompt diagnosis and treatment is crucial. In addition to anti-coagulation therapy, electrical and pharmacological cardioversion to restore sinus rhythm remains the standard of care. The most common and effective method for electrical cardioversion is achieved with placement of electrodes in the anteroposterior position. CASE REPORT We present three cases of patients with initial unsuccessful cardioversion attempts for persistent atrial fibrillation. These patients had elevated body mass indices and large trans-thoracic diameters. Their initial external cardioversion via the conventional method was not successful for restoration of sinus rhythm. This failure may have been attributed to their body habitus. To ensure that the current would traverse through the atrial tissue, the electrode pads were applied using fluoroscopic guidance for adequate myocardial depolarization. CONCLUSIONS Optimal fluoroscopic placement of the electrode pads during external cardioversion procedure increases the odds of successful restoration of sinus rhythm when compared to the conventional method.

Opposite impact of Methylene tetrahydrofolate reductase C677T and Methylene tetrahydrofolate reductase A1298C gene polymorphisms on systemic inflammation.

BACKGROUND: Methylenetetrahydrofolate reductase (MTHFR) gene polymorphisms have been found to be related with many diseases. Systemic inflammation is now considered as a major predisposition factor for diseases including diabetes mellitus (DM), coronary arterial disease (CAD), stroke, and cancer. This study aimed to investigate whether systemic inflammation is a possible underlying pathogenesis for MTHFR gene polymorphism-related disease. METHODS: A total of 292 patients were enrolled, and single nucleotide polymorphisms for MTHFR C667T and A1298C were genotyped. Systemic inflammation markers, neutrophil-to-lymphocyte ratio (NLR), and platelet-to-lymphocyte ratio (PLR) were collected. RESULTS: In our study population, MTHFR 677 variants had significant higher NLR level than MTHFR 677 wild type (3.77 ± 0.26 vs 3.06 ± 0.18, P = .028). Logistic regression analysis showed that MTHFR 677 variants were significantly associated with increased NLR level. MTHFR 1298 variants showed the opposite effects which tended to have lower level of NLR (3.21 ± 0.16 vs 3.79 ± 0.34, P = .087) and PLR (137.0 ± 4.8 vs 157.7 ± 9.4, P = .052) than MTHFR 1298 wild type. General linear model showed that there was no statistically significant interaction between MTHFR C667T and A1298C gene polymorphism on NLR or PLR. CONCLUSIONS: This study indicates that MTHFR C677T and MTHFR A1298C gene polymorphisms have opposite effect on systemic inflammation, and systemic inflammation may contribute to the pathogenesis for diseases associated with MTHFR C667T gene polymorphism.

Reducing Radiation Exposure in an Electrophysiology Lab with Introduction of Newer Fluoroscopic Technology.

The use of fluoroscopic devices exposes patients and operators to harmful effects of ionizing radiation in an electrophysiology (EP) lab. We sought to know if the newer fluoroscopic technology (Allura Clarity) installed in a hybrid EP helps to reduce prescribed radiation dose. We performed radiation dose analysis of 90 patients who underwent various procedures in the EP lab at a community teaching hospital after the introduction of newer fluoroscopic technology in June of 2016. Watchman device insertion, radiofrequency ablation procedures, permanent pacemaker (PPM)/implantable cardioverter defibrillator (ICD) placement and battery changes were included in the study to compare radiation exposure during different procedures performed commonly in an EP lab. In all cases of watchman device placement, radiofrequency ablation procedures, PPM/ICD placement and battery changes, there was a statistically significant difference (<0.05) in radiation dose exposure. Significant reduction in radiation exposure during various procedures performed in an EP lab was achieved with aid of newer fluoroscopic technology and better image detection technology.

CYP2C19 genetic variation and individualized clopidogrel prescription in a cardiology clinic.

Background: Clopidogrel (Plavix) is an antiplatelet medication that is routinely used in patients with cardiovascular disease. Cytochrome P2C19 enzymes play a major role in its metabolism, which determines its varied therapeutic level and its effectiveness. Objectives: To customize clopidogrel therapy and evaluate its efficacy by using CYP2C19 genotypic and phenotypic information to improve clinical outcomes in patients. Methods: A total of 465 patients with underlying cardiovascular disease were selected from our out-patient cardiology clinic. DNA sequences of CYP2C19 were analyzed in 465 patients. Results: Of 465 patients, 183 were wild-type homozygous (*1/*1) and 18.8% gain-of function and 19.8% loss-of-function alleles in our patient population The following changes were made: 1) Switching to prasugrel in patients whose genotype noted them to be "Slow metabolizers. This medication adjustment improved clinical outcomes in this patient group. 2) Discontinuing or lowering clopidogrel doses in patients whose genotypes noted them to be "Fast or ultra-fast metabolizes" to decrease bleeding risk. For those who were not on clopidogrel but carried abnormal allele(s), "clopidogrel caution" was documented. These individuals were followed up for 3 years and there has not been any cardiac clinical symptoms, cardiac death or excessive bleeding reported. Conclusions: Given the varied effectiveness of clopidogrel due to its metabolism by CYP2C19 enzyme, and the relatively high frequency of both gain-of-function (18.8%) and loss-of-function (19.8%) alleles in our patient population, we believe that genotyping CYP2C19 is clinically important in order to improve patient outcomes and minimize patient risk.

Palpitations as a presenting feature of multisystem sarcoidosis.

Introduction: Sarcoidosis is described as a systemic condition characterized by non-caseating granulomas in multiple organs. In this report, we present an unusual manifestation of cardiac sarcoidosis and review management strategies. Case presentation: A 29-year-old African-American man presented with weight loss, fatigue, dyspnea, palpitations, night sweats, painless left eye redness and bilateral leg pain over the course of three months. His physical exam revealed left conjunctival congestion and bilateral crackles on auscultation. Computerized tomography of the chest showed severe parenchymal disease with bilateral fibrotic bands. Bronchoscopy and transbronchial biopsy revealed noncaseating granulomas and multinucleated giant cells, confirming sarcoidosis. Non-sustained ventricular tachycardia developed. Cardiac MRI showed myocardial delayed gadolinium enhancement. He responded to methotrexate and steroid therapy. An implantable cardioverter-defibrillator was placed. Discussion: Although cardiac sarcoidosis manifests in only 5% of sarcoidosis, autopsy reports indicate subclinical cardiac involvement in up to 30%. There are no established criteria for diagnosis of cardiac sarcoidosis. Conclusion: Early recognition and diagnosis of cardiac sarcoidosis is challenging but vital due to unpredictability and high risk for malignant cardiac involvement. Newer diagnostic imaging modalities have further aided in earlier identification and prevention of sudden cardiac death.

Development of New Deep Venous Thrombosis While on Apixaban.

The efficacy of novel oral anticoagulants (NOACs) in preventing deep venous thrombosis (DVT) has been established in large multicenter trials. Predictable pharmacokinetics, avoidance of routine laboratory monitoring, and lesser drug interactions have made NOACs safer and more tolerable treatment option in comparison to warfarin. However, cases of treatment failure mainly due to interindividual variation in plasma drug levels can be seen rarely. In this report we describe a case of acute DVT of right lower extremity in a patient who was on apixaban for prevention of venous thromboembolism (VTE) due to underlying nonvalvular atrial fibrillation (NVAF).

A rare case of apical hypertrophic cardiomyopathy (AHCM).

Apical hypertrophic cardiomyopathy is a rare form of hypertrophic cardiomyopathy that involves thickening of the distal portion of the left ventricular wall. Most commonly seen in the Japan, with a prevalence rate of about 15% of all HCM patient, its incidence in the USA is approximately 3% of HCM cases. We report a case of a 46-year-old woman with history of hypertension who presented to emergency department with worsening dyspnea and orthopnea with features of left ventricular hypertrophy (LVH) and diffuse large T-wave inversions in the lateral leads on a 12-lead ECG. Further work up revealed severe concentric LVH, with near obliteration of the LV cavity. Ventriculogram showed severe symmetric hypertrophy of the mid to lower septum, extending to the apex of left ventricle with significant pressure gradient of at least 160 mmHg across the apex to mid septal cavity, with no significant gradient across the left ventricular outflow tract. These findings were consistent with apical hypertrophic cardiomyopathy. She was treated with verapamil and metoprolol and has remained asymptomatic over last 2.5 years of follow-up. Although the clinical presentation of AHCM can be variable and nonspecific; however, hallmark findings on ECG and echo can be extremely important in its diagnosis. Abbreviations: AHCM: Apical hypertrophic cardiomyopathy; ECG: Electrocardiogram; LVH: Left ventricular hypertrophy; LVOT: Left ventricular outflow tract.

Non-Pharmacologic Approach to Prevent Embolization in Patients with Atrial Fibrillation in Whom Anticoagulation is Contraindicated.

Ischemic stroke is the most common complication of atrial fibrillation (AF). Anticoagulation therapy reduces the risk of systemic embolization in almost all patients with AF irrespective of the type of AF (paroxysmal, persistent or permanent). But, all patients are not suitable candidates for systemic anticoagulation mainly due to the risk of bleeding. Left atrial appendage closure (LAAC) devices have been found to be very effective non-pharmacologic alternative therapy for such patients. There are various types of LAAC devices but United States Food and Drug Administration (US-FDA) have approved only Watchman device. Initially, bigger medical centers in the US had started the insertion of Watchman device but with improving procedural techniques and exciting outcomes, even the community-based hospitals have started to embrace this therapy. We have presented the first three cases of Watchman device placement performed in our hospital and discussed about the indications for placement of LAAC devices. We have also reviewed their efficacy individually.