Dr. David Weisman was standing in an operating room at Jupiter Medical Center, working inside a patient’s heart, when the questions began coming.

The physicians asking them were not in the room. Some were gathered in Boston for the AFib Symposium, an international conference where heart rhythm specialists gather to learn about innovations in the field. Others had signed on from wherever they were in the world, watching the case unfold virtually as it was happening, as if they were standing near Weisman and looking over his shoulder.

The viewers were tuned in to watch a groundbreaking operation. Weisman was performing two complex procedures at the same time: an atrial fibrillation (AFib) ablation to treat an abnormal rhythm and a Watchman implant to reduce the patient’s risk of stroke. He was also doing it without the need for fluoroscopy—the X-ray imaging often used to visualize equipment inside the body—and without contrast dye. Instead, he had an advanced 4D intracardiac echocardiography, high-resolution ultrasound technology that allows him to see the heart and the device in real time.

As it was being performed on a patient, the virtual audience followed it in real-time by watching a 3D image of the patient’s heart that was created using advanced ultrasound technology. They could see the catheters, the anatomy, and the device placement. They asked questions as he took every step. In his ears, Weisman could hear the panelists asking about his approach, and he could answer questions about his imaging, his timing, and the decision-making behind a procedure many of them had not yet seen performed this way.

For the physicians watching from Boston and beyond, the moment made an impression. One of the panelists said he planned to change his own practice based on what Weisman had demonstrated. “It was a very novel thing,” Weisman says. “It’s nice to know we’re all colleagues at the end of the day and we all learn from each other.”

Weisman is the first physician in the region to offer a concomitant AFib procedure combining ablation and Watchman implantation. At Jupiter Medical Center, the combined procedure reflects the continued growth of the Robson Heart & Vascular Institute and AFib Center of Excellence.

A NEW STANDARD

For patients with AFib, the procedure represents an important shift in care. AFib is a common heart rhythm disorder that can cause palpitations, fatigue, shortness of breath, and a racing or irregular heartbeat. It also increases the risk of stroke because blood can pool and form clots in a small pouch of the heart called the left atrial appendage.

Traditionally, a patient who needed both rhythm treatment and stroke-risk reduction could face two separate procedures, along with two recoveries, two sets of appointments, and two rounds of cost and anxiety. By combining AFib ablation and Watchman implantation into one procedure, Weisman can treat two aspects of the disease at once for eligible patients, while also avoiding radiation exposure and contrast dye. “The great benefit is that we’re treating two aspects of the disease in one setting,” Weisman says.

The need for better AFib treatment is growing. The Centers for Disease Control and Prevention estimates that 12.1 million people in the United States will have AFib by 2050. The American Heart Association says AFib is linked with an estimated fivefold increased risk of stroke.

Watchman, first approved by the Food and Drug Administration in 2015, is designed for patients with non-valvular AFib who need an alternative to long-term blood-thinning medication. In 2024, a national study of more than 97,000 patients found that doctors were able to successfully place the Watchman FLX device in 97.5 percent of cases.

Weisman is a cardiac electrophysiologist, a physician who specializes in the heart’s electrical system. At JMC, Weisman is the medical director of cardiac electrophysiology and the AFib Center of Excellence. His work focuses on AFib, defibrillators, pacemakers, and the devices and procedures used to treat the heart’s pacing (the delivery of electrical impulses that force the heart to beat) and rhythm (the pattern of heartbeats). Thanks to the rapid evolution of technology, the way he treats patients is far different today than when he first began. “The things I was doing 10 years ago are nothing like what we can offer patients today,” Weisman says. “We’re doing them faster and safer.”

AFib ablation is designed to target the abnormal electrical signals that cause the heart to beat irregularly. During the procedure, physicians use catheters to reach the heart and ablate, or destroy, small areas of tissue responsible for the arrhythmia. At JMC, Weisman also uses pulsed field ablation, a newer form of ablation that delivers short bursts of energy more selectively to heart tissue.

A Watchman implant addresses a related problem. In many patients with AFib, stroke-causing clots form in the left atrial appendage. The device is designed to close off that appendage and reduce stroke risk. For some patients, once the device has healed into place and their physician determines it is safe, the procedure may allow them to stop taking longterm blood thinners, which can lead to harmful side effects.

Until recently, patients who needed both ablation and Watchman often had them done separately. One procedure treated the rhythm. Combining the procedures is a game changer. For the patient, Weisman says, the advantages are straightforward: being sedated once, recovering once, and going through the financial and logistical burdens once. It also reduces the risks that come with any procedure by avoiding a second surgery. “This has become the new standard for patients who have AFib and need to get off blood thinners and have Watchman done too,” he says.

ADVANCED TREATMENT IN THE COMMUNITY

The approach is still new. The combined procedure has developed in the field over roughly the past year, Weisman says, and physicians are still learning the technical details that make it possible.

The key advancement, he says, is imaging. The technology that allows him to combine the procedures is 4D intracardiac echocardiography, or 4D ICE. The ultrasound catheter sits inside the heart, providing moving, high-resolution 3D images of the cardiac structures in real time while the Watchman implantation unfolds.

That imaging is what allows Weisman to avoid fluoroscopy, which has long been used in cardiac procedures to help physicians see catheters and devices inside the body. It is effective, but it uses X-rays, which expose both the patient and the clinical team to radiation. In Weisman’s February case, 4D ICE allowed him to see the equipment, the heart structures, and the device position without X-raying the patient. The absence of contrast dye is also important. The dye can help outline anatomy during procedures, but it can be risky for patients with chronic kidney disease or contrast sensitivity.

Weisman says that was one of the main messages he wanted other physicians to see during the live case: the technology has arrived. The procedure can be done safely. The two treatments can be combined with the proper imaging tools and experience using them.

He was first asked to perform the live case for the annual International AF Symposium in Boston, which was highlighting AFib technologies at sites around the world. “To be asked to perform these kinds of complex cases for an international audience was a big honor,” Weisman says.

Some of the physicians watching were peers he had trained with or trained under years earlier. After the case, some reached out to congratulate him. “It stands out as very unique and special,” he says.

In late April, he performed the same procedure again for an even larger audience during the Heart Rhythm Society’s annual scientific meeting in Chicago. In medicine, innovation must be repeatable, teachable, and safe enough to fit into patient care.

Weisman cautions that the combined procedure is not for everyone. Patients need to be carefully evaluated to determine whether they are candidates based on their anatomy, symptoms, stroke and bleeding risk, and overall health.

For the right patients, the combined treatment can have a meaningful impact on their lives. A patient with AFib may feel the heart flutter or race. They may feel tired or short of breath. They may worry about stroke. They may also worry about staying on blood thinners, especially if they have experienced bleeding complications or have other medical conditions that make medication management more difficult. For those patients, a single procedure that treats both the rhythm problem and the stroke-risk problem simplifies a complicated journey. “I’m definitely starting to see more patients who we weren’t treating that way, and now we can offer them this as an option,” Weisman says.

Weisman was proud he could help pioneer this combined surgery and demonstrate it to physicians around the world. “We’re doing things at Jupiter Medical Center that previously you could only get done at major academic places,” Weisman says.