any opinions welcome re watchman

I was diagnosed with lone afib 1.5 years ago. Previously fully healthy long distance runner, mild hypertension only. no other health issues. I required cardioversions twice over a 16 month period to restore NSR as I had 2 episodes in 16 months, neither would convert on its own. Opted for ablation as wanted to be as aggressive as possible in treating this (I am very active 55 year old) and prevent any long term sequela. Ablation showed sig atrial scarring (? due to running or hereditary?). Did well post ablation except had left atrial appendage isolation from procedure (various areas needed to ablate along with scarring), appendage now with " mild to mod dysfunction" My left atrial size is " upper limits of normal" on last TEE. My EP has me on xarelto and metoprolol. My EP (Dr. Swarup) has done one of the highest numbers of Watchman implants in the country and had encouraged me to get the procedure done as I did not want to be on lifelong anticoagulation.
I was 10 months post ablation with no episodes, about to schedule the Watchman when 3 d ago I had an onset of aflutter/afib which converted after a dose of oral flecanide. I am now doing well again. I had anticipated getting the Watchman placed prior to this last recurrent episode. The plan is now to get a repeat touchup ablation if I have any further episodes. Not sure if I should wait on a Watchman or what the best timing would be for this... The EP says a Watchman will not complicate a repeat ablation if needed.
My gut tells me wait 6 months or so and if no further episodes then get the Watchman. I was wondering if anyone had any thoughts, similar experiences or opinions on the matter. Much appreciated

Quote
redalfa1961
Previously fully healthy long distance runner, mild hypertension only. no other health issues. I required cardioversions twice over a 16 month period to restore NSR as I had 2 episodes in 16 months, neither would convert on its own. Opted for ablation as wanted to be as aggressive as possible in treating this (I am very active 55 year old) and prevent any long term sequela. Ablation showed sig atrial scarring (? due to running or hereditary?). Did well post ablation except had left atrial appendage isolation from procedure (various areas needed to ablate along with scarring), appendage now with " mild to mod dysfunction" My left atrial size is " upper limits of normal" on last TEE.

My path to afib was chronic fitness 12 years ago at 49. Wondered what very active 55 year old means? I say this because my remission program included significant detraining (also magnesium to bowel tolerance). I am very active, though I do no endurance training and limit endurance activity (for example, I can ski the steeps all day at 12,000' without any breaks, but adding hiking on each lap for extra vertical means a good chance of a vagal episode after I stop.

For me electrolytes are key. Having sufficient magnesium and limiting calcium are the main part of this plan (I've not needed an ablation though my first 4 months included a 2 1/2 month episode, My track record over the last 4 years is 3 episodes totaling 2 1/2 hours), in addition to detraining.

As to the mild hypertension, which in my book is related to some metabolic dysfunction as higher levels of insulin will signal the kidney to retain sodium.. About 10 years ago, a study out of Olmstead MN (where Mayo Clinic is located) was published. It was a 30 year study of paroxysmal afibbers vs the average citizen as a control. The afibbers actually had slightly better mortality (probably because they were fitter to begin with). As time went on they got the same metabolic issues as the controls (perhaps because of the afib). When I detrained, I put on weight. I decided that I was not going to be one of those people, so changed to an unusual ketogenic diet, plus intermittent and longer fasting. Today I have no metabolic dysfunction. My BP is 102/58, my fasting insulin is 2 and my BMI is 23.

Good luck!

George

I am wondering how you will get your insurance to pay for the Watchman? Or are paying for it yourself?
Being 55, you are not on Medicare. Im 53 and my Blue Shield PPO will not approve the Watchman.

I am trying to " build a case" for Watchman to my insurance over a period of time. Have not submitted to insurance yet for pre approval. Does anyone know the cost of a Watchman should one pay for it themselves?
The Magnesium is something I will be starting shortly. thank you for the replies

Don and redalfa1961,

It is not that hard to get most insurance to pay for Watchmen at leading top volume centers when ChadsVASc is >/= 2.0 but of course at this time neither your nor redalfa1961 technically qualify for the Watchman based on the stroke risk score. Great effort is being made to push the recognition of LAA isolation as equal to 2 points on the ChadsVasc score but may be a while yet before this entirely common sense change in the metric is adopted.

In the meantime, try connecting with a top volume Watchman installer like St Davids Med Center with Natale's team of Rodney Horton and David Burkhardt .. true experts ... and Vijay Swarup is also very experienced with Watchman as well in my state of Arizona (in Scottsdale/Phoenix). These folks know how to present the case to many insurance agency adjusters to get it passed. Some insurance companies are presently more difficult to get it through than others, but keep trying. Before too long it should get accepted on much wider basis with the explosion of experience across the board. You need to have it installed under and FDA registry protocol and only by a high volume LAA Closure center and operator which you both have access to in St David's Med center for Don and Dr Swarup at Arizona Heart.

And redalfa1961, if you have even one more flutter get the follow up ablation. It is more common to have atypical left flutter after LAA isolation as a reconnection in the first 3 months to within the first year. After a full year to year and a half with after LAA isolation, or after LAA follow up re-isolation, it is highly unlike to ever have the LAA reconnect. If you don't reconnect in next 6 months then perhaps this was truly just a rare 'one off' flutter event rather than signaling a real recurrance. But that is the less likely odds and the only way to know for sure is with time.

Technically, you can work around the previously installed Watchman with a follow up Flutter ablation as Dr. Swarup very rightly said, but since the odds are high that this flutter is likely originating either from the LAA or CS (assuming Dr Swarup also ablated in or around your CS ( Coronary Sinus) or may have also Isolated your CS too in addition to the LAA isolation) if it were me I would want to button down that likely still open flutter circuit either around the LAA or CS and then do the Watchman. Particularly if the flutter was from an LAA Isolation reconnection.

I agree with Dr Swarup that LAA Closure is a very good step for you to do redalfa1961 and I highly recommend you pencil that in and work toward getting it approved as I suspect Dr Swarup can very much help you do vi's-a-vi's insurance in that regard.

My preference, since you have already shown a clear atypical left flutter well past the blanking period of your index ablation, means to me you have a very high odds of needing that touch up ablation to put this flutter to bed for good, and I would want to get that done ASAP and then do the Watchman after the blanking period is well over and all is nice and quiet first.

I would prefer to have the LAA not have to undergo possible inflammatory changes with the Watchman in place from a then subsequent follow up ablation, especially should the recurrence also be around the ostium of the LAA (or mouth of the LAA). There are two short areas around both the top anterior and along the lower posterior length of the LAA Ostium surrounding this LAA mouth surrounding the full length of the ostium that is typically ablated to achieve LAA isolation. And these two short areas along the LAA Ostium are often significantly thicker than the rest of the LAA ostium, so it is not surprising that these two areas are the key spots that when either one or both sites need to be re-zapped with the ablation catheter in such a follow up touch-up ablation in order to achieve long term durable LAA isolation whenever reconnection of an LAA isolation occurs ... and which can happen in roughly 20% to 30% of cases of LAA isolation.

Shannon



Edited 2 time(s). Last edit at 06/03/2017 10:15PM by Shannon.

Thanks so much for the detailed reply. At this point, the plan is one of waiting. With any further episodes, I get a touch up ablation. Watchman would be placed at some point after that. IF I don't have any more episodes over the next 6-12 months or so, I would then proceed to Watchman (without getting any touch up ablation). Sound reasonable??

Just exactly what I would do in your shoes redalia ... that is if I already had not done essentially the same thing!

I too required LAA isolation to end all my long history of arrhythmia and then I had too low of an LAA mechanical function at the 6th month follow up TEE after my LAA Iso, so I opted for the LARIAT LAA Ligation procedure that both confirms that the electrical isolation of LAA remains permanent with no chance of reconnection, plus insuring no new clots can form within the LAA which has been entirely sealed off at the mouth of the LAA.

But once you have confirmed a solid success of your LAA isolation for well over a year to 1.5 years the odds are extremely small of the LAA ever reconnecting again, so you can pretty much take it to the bank on achieving the same benefit overall with the Watchman or Amplatzer Amulet as well a LARIAT or Atriclip ligation procedure.

Shannon

Thank you Shannon. Much appreciated