LAA flow velocity after LAA isolation (3 years after ablation)

In September 2017 I had an ablation that slowed the Left Atrial Appendage (LAA) blood flow velocity.
I had a TEE to measure the LAA flow 14 months after the ablation procedure.
After meeting with a doctor at Scripps in California who does the Watchan device a few weeks ago, we decided to check the LAA flow again to see if anything changed.
Yesterday I had the TEE repeated. The results, no change.

The reasoning behind having the TEE again was the doctor I met with indicated they usually don't check this more than once. Therefore they don't know if flow velocity changes over time.

The TEE had mixed result. Due to Eliquis side effects, I have been on half dose Eliquis. No clots were found.
The TEE doctor checked some other things such as valves, etc. He said all looked good.

Not sure what I will do now. (Im lucky my CHADSVASC is 0). May take my chances with half dose Eliquis for a while. May try Pradaxa. May try Warfarin. May just stop it all together.
Seriously consider tuning out of the medical community and avoiding all doctors unless there is an emergency.

I hear you Don. My initial TEE after the LAA isolation and the following third procedure was great. Something like 50 if I recall. Then, the second TEE indicated 40.. .but even though still an acceptable number, was advised it would be preferable for me to continue on half dose Eliquis. And, I understand that reasoning given my age of 81 and the arrhythmia history, so it's obviously an important professional obligatory precaution... which I appreciate. However, with no other major health issues, the fatigue issue from Eliquis has made my life less than great. and since it's the only drug I take, it's easy to become disgruntled.

My first afib was at age 59 and I did very well avoiding risk of strokes and heart attacks from adverse clotting for 8 years (and I had a lot of events) prior to my first ablation and then for the 11 years after that by using natural, but well-known adjuncts to help keep blood "thin and slippery." I felt especially comforted by the science behind Nattokinase and Pycnogenol along with other naturals such as Omega 3 fish oil, Vitamin E, Ginkgo biloba, plenty of Magnesium and several others that also support healthy blood viscosity.

You are much younger and so I would encourage you to make very smart, calculated decisions and be consistent.
I totally agree about living a healthy lifestyle and avoiding the medical community when it makes sense to do so.

I wish you well with your endeavor.
Kind regards,
Jackie

Hello Jackie,

Thanks for the reply.
What adds to the frustration is the one size fits all standards. It would seem quite reasonable to have a patient have their blood checked for factors that relate to clot time. As you have posted many times, this is a consideration when evaluating how to best proceed. Good luck trying to find a doctor who will do this and help decide if anticoagulant is needed with a slow LAA or afib.

The standard seems to be CYA. Better a bleed than a stroke.I guess I understand it.

My Grandfather on my mother's side needed vitamin K when having surgery. He was a bleeder. My Mother also tended to bleed more than normal. Since she was 30 she had arrhythmia off and on. She was never on a blood thinner.
In her early 70's she began to have some ventricular arrhythmia. They wanted to put in a defibrillator. She said no way!
She died in her early 80's from Emphysema caused be an infection she had in her 50's that was not treated by her doctor. She pleaded for antibiotics but was told it was a virus and given the spiel about over antibiotic use. After a few months she found another doctor who treated her aggressively with multiply antibiotics and she go better.
She never smoked or drank and lived an almost too clean life.

So what if along with the inherited arrhythmia I inherited slow clotting. Before the medications, my clotting seemed slow. Not that I can draw a definitive conclusion from that observation. But it would seem like it should be considered and explored before giving me life long blood thinners. Perhaps I am expecting too much.

Sorry, just venting. My quality of life because of all this is in the toilet. Just passed my pilot physical last week. The thing is every time I go up, I think what if I have a stroke while flying the plane. No fun any more.

Quote
gmperf
It would seem quite reasonable to have a patient have their blood checked for factors that relate to clot time.

Though not ablated and having few episodes, I thought about this myself. For non-afib reasons, my doc, Steve Gundry, prescribed 6g/day of fish oil plus 83 mg aspirin/day.

I've been on this program for some time and I'm very active. As I rock climb, I frequently have minor injuries that bleed (we call it a "rock tithe"). I notice they do bleed for quite a while before clotting. I've wondered how you could measure this and how it would compare to the anti coagulant meds.

Geoge

George - Prior to my going on Eliquis, I used 6 grams of Omega 3's daily and I really miss using that much. Limit now to 2 - 3 g. daily... but do read my links about the risks of long-term use of aspirin... even low dose... in the post in the LAA closure thread. There are many more confirming reports.

Jackie

Jackie;

I take aspirin most days, I cannot take coumadin and that would include the other blood thinners according to my doc. Now, do you think that Eliquis is so much better than aspirin as to what it can do to your body? If you are going to show the risks of aspirin than also show the risks of Eliquis, coumadin etc.

Liz

Hi Jackie,

Thanks! Interesting links. I realize there are bleeding risks, as with any anti-coagulant. Dr. Gundry prescribed and specified enteric coated 83mg aspirin as he says salicylate activates anti inflammatory properties with the fish oil. Definitely not the standard reason. He is very through when he prescribes and has a very good track record keeping people healthy.

It isn't like I don't clot. Last summer I took a swing and lacerated my left hand pretty good. Had a doc and a ski-patroller as climbing partners to help. Then a couple of days later, another doc friend flew in from NZ and looked at it and chastised me for putting iodine on it, told me to just flush with water. Anyway they did clot and ultimately healed, but I can still see the skin looks different on my palm where the impacts were.

George

Hi George... I was sure that you had the best of info with Dr. Gundry but didn't want to leave it to 'chance'... but you may still want to investigate the potential for intestinal damage from your aspirin. While it's coated to resist stomach acid, at some point, I presume it reaches the intestine (uncoated) and may still do tissue damage; plus NSAIDs are known to interfere with the health of the microbiome.

An easy tip for quick clotting from scrapes and cuts is to use Essential oil of Lavender .. undiluted or neat. It burns a bit but stops the bleeding quickly. My experience is only with the Young Living brand that is pure, steam-distilled with no solvents etc... so I don't know if other brands of lavender are equally effective. It helps 'sterilize' a wound as well.

However, since I've been using Eliquis for three years, I've had multiple opportunities to Lavender EO including some nose bleeds. A bottle of YL Lavender would be easy for you to carry in your backpack.

Jackie

Liz - I don't think any of the Rx blood thinners are great. But, they are effective and necessary in specific cases and, of course, none are not without side effects and risks. That's a given. Likewise with aspirin and all NSAIDs. One could spend hours researching the potential side effects of each including aspirin because there are many and much depends on the health status and biochemistry of individual using them as to the reactions.

These cautions are for everyone and it is wise to be aware.... especially as we age and tissues become thinner and other biological changes occur that can impact the severity of the side effects of NSAIDs and Rx blood thinners, alike.

Since I have chemical sensitivities (MCS), I've made it a focus to experiment with many alternative, natural options that offer same or similar thinning effects to drugs and I did very well with these including nattokinase, serrapeptase, pycnogenol, ginkgo, vinpocetine, curcumin, and so on. However, with ablation procedures, you have no choice but to use the anti-coagulants that are prescribed.

Jackie

Hi Jackie,

I asked specifically about the biome issue, and he said not a problem & the biome is certainly one of his things. I'll ask about damage "down the line" on my next consult in August. I know he does this himself.

I don't worry about bleeding & just let it bleed til it stops. Unless it is getting on furniture or carpet (which isn't an issue outside) it isn't a problem. It isn't that it won't clot, just takes a while.

So, as an aside, I've posted about my fasting/refeeding experiment. Yesterday was fasting day 5 of my fourth cycle. I made this post on another forum.

"So your blood sugar is 31 mg/dL (1.7 mmol/L), what are you supposed to do? a) nothing, b ) eat some sugar OR c ) go to the gym and do a super slow to failure workout (Fred Hahn, Doug McGuff, Body by Science), beat your last time under load on the exercises by an average of 84% then do a Tabata set (8 reps of 20 seconds max effort with 10 seconds rest) on the Concept 2 fan rower and set a new PR at 968 m for 4 minutes. I chose c) Of course it was my 5th day of fasting on my 4th fasting/refeeding cycle ( stem cell stimulation experiment, for more detail see <[www.afibbers.org] ) , and my serum ketones were at 6.2 mmol/L (no exogenous). I checked my blood sugar and ketones in the afternoon. My blood sugar was 31 mg/dL (1.7 mmol/L) and serum ketones were 6.2 mmol/L. Blood sugar was somewhat lower than other day 5's but ketones were in range. I decided to go to the gym. Did a super slow to failure workout and increased my time under load by an average of 84% on all the exercises

This forum has researchers, docs & many others very serious about nutrition. You would not believe some of the feedback I got. These people never fast. One guy was saying I was going to die 'cause my blood sugar was so low. Don't these people understand that when you have plenty of ketones, the brain is sated. It was very amusing. I'm trying to educate them...

Thanks again!!

One thing I've noticed so far. I've been a rapid plaque former for at least 10 years & have to have my teeth cleaned every 3-4 months. I have an cleaning appointment on Tuesday and I can't find any plaque in my "usual spots." I'll see if the hygienist agrees with me. If so, I'd attribute it to changing my mouth biome.

George



Edited 1 time(s). Last edit at 06/17/2017 11:19PM by GeorgeN.

George:

When you go on these 5 day fasts, without any protein don't you lose muscle?

Liz



Edited 1 time(s). Last edit at 06/17/2017 11:55PM by Elizabeth.

Quote
Elizabeth
George:

When you go on these 5 day fasts, without any protein don't you lose muscle?

Liz

The data on people who are keto adapted suggest probably not. If you aren't keto adapted, then the body will use gluconeogenisis to create glucose to feed the brain. For someone who readily fuels on fat/ketones, then this need is much reduced (~80% of the brain's energy need can be met by ketones). Also glucose can be create from the glycerol when fat is broken down. Also ketones are protein sparing. When Jimmy Moore (co author of <[smile.amazon.com] and a friend) fasted for 28 of 31 days in January 2016. He had DEXA scans before and after and actually gained muscle mass. I haven't gone quite as high tech, but my scale, which also gives muscle mass would indicate stability for me. Also, when I refeed, along with my strength training, will also build muscle mass.

Also if I can increase my time under load on strength training exercises by 84% as well as setting a new personal record on the rower, plus I was able to climb a more difficult route than I've done previously rock climbing - all would be empirical evidence I'm not getting weaker. Additionally, my normal training routine is using the bodyweight TRX straps and their Military Fitness Program. It was developed to train people for US Navy SEAL selection. I do it well and those exercises would tell me if I'm getting weaker, I'm 62.

George



Edited 1 time(s). Last edit at 06/18/2017 11:01PM by GeorgeN.

Great Watchmen and other LAA information at the 2017 ISLLA symposium.
2017 conference link. http://www.islaasymposium.com/islaa-highlights-2017/

Hey Don,

Was nice talking with you week before last on the LAA Closure issue and I'm glad you found the link to the ISLAA conference I encouragedf you too attend at next years 2018 event in February I believe it is, and that will be in LA this time, right in your neck of the woods. Hope to see you there!

The video links from the 2017 ISLAA, which I also attended and that was held in Austin this year, have some great up-to-date in-depth information you won't find anywhere else and highlights the impressive degree of progress being made each year in our understanding and practical application of LAA-based procedures for those folks who are good candidates for LAA isolation and/or LAA closure.

Cheers!
Shannon

Hello Shannon,

Thanks for taking the time to speak with me. It was very helpful.

I think at this point I'm going to hold off on the Watchman for a while.
I'm still not sure I wouldn't be trading one problem for another.

By the way, Scripps was able to get the approval for the Watchman device from Blue Shield.
It looks like perhaps insurance is starting to pay for these procedures.

Don

Hi Don - thanks for posting this news.

Also, just saw this report today...

Coverage from the

European Heart Rhythm Association (EHRA) EUROPACE–CARDIOSTIM 2017

Defying Hopes, Dual Antiplatelets May Be Needed With LAA-Closure Devices in AF

Steve Stiles
July 01, 2017

[www.medscape.com]

Gives us more to think about.

Be well,
Jackie

Hello Jackie,

Yes I read that. Thanks for posting.

My impression is the Watchman is just too new with too many unknowns at the moment.
Im sure in a select group it is beneficial.
For others it may be trading one problem for another.

On the other hand it seems the Watchman patients in the studies were on the high risk for health problem side. Perhaps in a young healthy group results would look great.
Im just not sold on the Watchman yet.

At least at this point I can choose to take anticoagulants or stop taking them.
If I have the Watchman installed, then my choices are limited. I know when I took asprin I would bleed like crazy.
Dual anti-platelets may be a deal breaker.

Don

Hi Don,

Please consider setting up a consult with Dr Natale before even considering stopping Eliquis on your own, as someone after having LAA isolation which has shown a too low over all mechanical function to pass with flying colors. You can then discuss your thoughts about Watchman, Atriclip etc and let him tell you directly where we are in the real world progress made in this field as experienced in his own center.

And going to Austin is where it would be wise to consider getting whatever LAA closure system installed, as we discussed, if at some point your comfort zone with this option expands to include either form of LAA closure for yourself with a bit more time to digest all the nuances. And perhaps attend the next ISLAA conference in LA next winter that Im sure you will find highly informative on the issue.

You are right too, a young and otherwise healthy man now free of AFIB but with an impaired LAA mechanical function has a high odds of doing great with either of those procedures ... Watchman or Atriclip ... and with notably less complication issues compared to that reflected in a few earlier studies based on a mix of less experienced operators with older generation methods as well. But there is no rush to jump for LAA Closure for you, so long as you don't just decide to roll the dice and stop OAC unilaterally and without discussing it in person with Dr Natale. That is my only concern Don as a review with Dr Natale when he is next in your neck of the woods with all of this might well help clarify some sticking points for you or at least give more confidence in a decision to stop OAC in your case if he feels that is a reasonably safe option.

One of many things I learned from the past years of researching and reading so many EP and cardiology studies is that we must be careful, too, to keep the details and potential impact of patient selection and characteristics in mind when assessing the big picture of what they are trying to convey. And this is especially true if digesting medical trials and studies is not a common avocation for the reader/patient.

Be well
Shannon



Edited 2 time(s). Last edit at 07/05/2017 10:22AM by Shannon.

Hi Shannon,

That is probably a good idea to talk with Dr. Natale.
I know with a low LAA velocity I need to be on anticoagulation, or have the LAA clipped or plugged. I will stay on anticoagulation until I have the LAA taken care of.

Thanks for all the time and information you have provided. It sure has helped.

I think I am going to wait and see how the Watchman does over the next year or two.
I like the Watchman for the non-evasiveness of it when compared to other devices. But I think I am siding on the AtriaClip or Lariat at this point. Of course the AtriaClip or Lariat would have to be done by the best doctors I could have access to.

Maybe if I get a chance to talk with Dr. Natale I will change my mind about the Watchman. I trust him and trust his judgement. I think he is a good man as well as a fantastic doctor.

Don

That all sounds like a perfectly reasonable plan Don, especially vetting your particular case and working through the best options for you long term with Dr Natale who did such an first class job on your index ablation that required LAA isolation to begin with.

And I agree, Dr Natale absolutely has no incentive to push a procedure on you, or on anyone, that he isn't entirely confident is in your best overall interest and, first and foremost, I've seen that reality and his entirely patient-oriented ethics, validated time and again in numerous very different case scenarios with my good fortune to have worked closely with Dr. Natale increasingly so over the last decade.

You can absolutely trust that his opinion and recommendation springs only from his very best assessment of what is truly best for each patient in his very in-depth elite insight, knowledge and asessment of these very same topics that are so germaine to us AFibbers ... especially advanced Afibbers like so many on this forum.

The number of times Dr Natale has pushed the field to adopt new approaches, new tools and techniques often in the early years of a new insight ... however slowly they get adopted by the EP field at large ... after proposing a pioneering step forward and meeting initial resistance, even at times begruding resistance, from some corners of the EP world resistant to change and being told they needed to learn more progressive methods to better help all classes of Afibbers beyond the cookie-cutter PVI-only approach that never stretched the boundaries of what is possible for more challenging cases.

Only to see the vast majority of the more reticent sort finally realizing in recent years ( and even more recently with such methods as Non-PV trigger detection and ablation plus LAA/CS isolation in appropriate patients), via the weight of accumulated evidence that such insights have matured into key assets of the AFIB ablation field.

Just some of the important contributions= that Dr Natale has been at the forefront of pioneering and promoting include:

The uninterrupted periprocedural anti-coagulation protocol that has resulted in a major reduction in embolic event risk during, and shortly after, transeptal puncture and throughout early blanking period post ablation.

In addition, Dr Natale's leadership in pushing the field to adopt the Lasso mapping catheter now used by nearly every EP ablationist ... and his strong advocacy from the start for including the ICE (intra-cardiac-echocardiography) camera parked in the RA and giving greater clarity with added real-time sonographic visualization of the RA/LA during the full ablation, as well as during the key phase of transeptal puncture, making for an often safer and more efficacious procedure in addition to the visualization aids of Fluoroscopy and 3D Electro-anatomical mapping (3D-EAM)

Dr Natale's early recognition of the importance of the Left Atrial Appendage as a vastly underrecognized source of arthythmia, led directly to my own now 9+ year freedom from even a single beat of AFIB, from a then 16 year history of increasingly progressive PAF that had morphed throughout that 16th year of 2007/2008 into a highly aggressive 24/7 persistent AFIB that was truly relentless. And with my LAA isolation ablation, after my AFIB-ending index ablation, the completion of my combined two step expert ablation process has resulted in so far perfect absence of even a moment of arrhythmia of any kind recorded on my dual chambered pacemaker over these many years now!!

Not to mention, how many others of us here have benefited in the same way from his insights and courage to buck the trend and status quo in order to realize a larger vision.

And all through this time, and my frequent associations with him, I've never once gleaned even one instant of the profit motive or what a killing he could make financially if he had made that the prime motive of his obvious passion for the field. No doubt, Dr Natale always knew his familie's financial security would take care of itself when he kept his eye on achieving the uneqivocal excellence that he surely has in the EP world. But I've literally never seen, nor heard him be 'money-oriented' in the slightest throughout all of our many conversations and time spent together over these years.

So, yes, I fully agree Don with your innate sense from your own interactions with Dr Natale as your EP too, that you really can trust his advice for all of us is what he truly believes is in our best interest. And I can vouch for this as well many times over, as no doubt so many other of his patients on our forum could surely echo as well!

You have no urgent rush at the moment to make a decision regarding the closure plan, and I'm glad to hear you do not plan to just stop the Eliquis cold turkey on your own initiative without first discussing that thoroughly with Dr Natale in person. I'm sure we will talk again too in the meantime as this all moves along. And it's great that you really are doing so well being totally free from your persistent AfIB too now going on year three I believe it is.

You are right too Don that more insurance is paying for Watchman and LAA closure for good candidates now, and that is surely only going to increase as the results from the ongoing major RCTs are published with their most current longer-term findings due to hit the press in the coming 6 months to 1.5 years time frame.

Take care,
Shannon



Edited 1 time(s). Last edit at 07/05/2017 05:25PM by Shannon.

I'm following this thread closely, and so appreciative of Shannon and everyone else's input. As Shannon knows, my LAA was isolated by Dr. Natale, and I'm awaiing my next visit to Austin in 5 months for my TEE to find out where my LA velocity stands. If at that point another decision needs to be made, I'll have these posts, and hopefully more, as a reference. Thank you all.