Thinking about LAA closure??

Hello everyone, I have been reading this forum periodically since 2015 when my husband Jerry was first diagnosed with lone A fib (persistent) . We made the trip to Austin in October of 2015 for ablation by Dr. Natale----what a wonderful experience at St. David's!! He enjoyed a year of NSR and then went into A fib/flutter so Dr. Natale did a touch up ablation in October of 2016. Jerry is an otherwise healthy, fit, active 69 year old and has enjoyed uninterrupted NSR since the touch up ablation last year. He has continued his Xarelto because the TEE in April of 2016 revealed that the LAA is not performing adequately. He has no problems or side effects from Xarelto but since he is an active and an avid outdoor sportsman he would like to explore the possibility of LAA closure in hope of getting off the Xarelto eventually.

I was wondering if anyone on this wonderful forum can clue us in on the current status of LAA closure procedures at St. David's? Would this be a good time to request an appt. with Dr. Natale to discuss this?

Thanks everyone, Deb Smith.

Also interested in a answer to OP. I hate taking a blood thinner everyday. I Bruise so Easy and I will turn 60 soon.
Great Forum to get great insight.

Shannon would be the guy to answer this. I'm sure he'll be along shortly.

Indeed Carey is right Deb and Smackman, I have every intention to reply to your thread topic here and welcome Deb to the Forum! Firstly, my sincere apologies though as this has been one of those weekends that could use a real rewind!

Yesterday when I was busy writing roughly the first half of my reply to your questions Deb, my wife and I had gone out in the afternoon for some errands and returned home only to find our water heater had burst at the bottom of the tank and flooding a good section of our Brazilian cherry wood floors and a large section of carpeting too in the master bedroom.

Alas, it would have to be on a Saturday late afternoon when all of the home and hardware stores anywhere near our town had closed for the weekend ... wouldn't you know it :-)! To make a long story short, its been a bit of a nightmare clean up and at least we have a plumber arriving tomorrow (Monday morning) and will buy a new water heater first thing and hopefully will be back in the saddle by tomorrow afternoon water-wise.

It may not be until Tuesday afternoon, though, when I will have the time to finish a formal written answer here to this thread and your important questions above, as I also have my follow-up appointment with my eye surgeon Tuesday morning during the one day each month he travels with his whole staff from Phoenix the two hour drive north to Sedona where we live so he can see retina patients in this part of Northern Arizona one day each month.

However, if you will be so kind to send me your cell number and time zone, I will try to call you tomorrow when the time allows, or after my appointment on Tuesday, and update you and your husband in real time conversation on the phone, which is the best way to cover it all as fully and succinctly as possible in any event.

And I will finish the response to this thread as soon as I can so that others like Smackman might benefit from the your questions as well.

Many thanks Deb for your patience and I look forward to speaking with you and your husband soon as well. Now back to the soggy clean up grind for another hour or two before calling it quits for the evening,

Cheers!
Shannon



Edited 1 time(s). Last edit at 10/23/2017 02:28AM by Shannon.

No worries Shannon; you have certainly had your hands full!! Take care of your home and we can discuss this anytime--there is no urgency. I will email you with our info. We look forward to talking with you. Thank you very much.

Hi there,
I am 58 years old and I had my second ablation a year ago at St. David's and am also on Eloquis. I would like to have the LAA closure done also. It makes me nervous being on a blood thinner. Will insurance companies begin to cover this procedure for everyone? I just don't want to wait to have a bleeding problem before I can have the closure done. I saw a lot of tv ads for the watchman this summer. Does anyone have a medical alert bracelet that you wear that in case you have a bleed or are in an accident?
Thanks so much,
Pamela

If I were on long term anticoagulation therapy, I’d seriously consider a tattoo to that effect.

Although you’d probably have to lie to the tattoo shop about the anticoagulation! Come to think of it, that presents an interesting quandary.

“Why do you want a tattoo that says Eliquis?”

“Um, no reason...”

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wolfpack
If I were on long term anticoagulation therapy, I’d seriously consider a tattoo to that effect.

Although you’d probably have to lie to the tattoo shop about the anticoagulation! Come to think of it, that presents an interesting quandary.

“Why do you want a tattoo that says Eliquis?”

“Um, no reason...”

I was an EMT in a former life. I would recommend a medical alert necklace or bracelet unless you're willing to put that tattoo on your chest where it can't be missed. Nobody pays attention to tattoos these days because about 99.9% of everyone under 40 has more than one and they're 99.9% boring.

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Carey
I would recommend a medical alert necklace or bracelet

I wear one for my extreme NSAID allergy. As a former EMT, did you look for them? Do most?

I guess I need to update mine.

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AB Page
I wear one for my extreme NSAID allergy. As a former EMT, did you look for them? Do most?

Absolutely. If the patient isn't capable of answering questions reliably then it's a mandatory assessment step. Failing to notice one when it mattered would be the kind of fundamental mistake that gets you fired and maybe sued.

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Carey

I wear one for my extreme NSAID allergy. As a former EMT, did you look for them? Do most?

Absolutely. If the patient isn't capable of answering questions reliably then it's a mandatory assessment step.

Thanks Carey, that's very reassuring. I always wondered if it really mattered that I wore one, and I do 24/7. I'll get mine updated asap with mention that I'm on Eliquis.

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AB Page
Thanks Carey, that's very reassuring. I always wondered if it really mattered that I wore one, and I do 24/7. I'll get mine updated asap with mention that I'm on Eliquis.

Yeah, get that updated because the Eliquis matters a lot more than the NSAIDs. You're not likely to be given NSAIDs in an ambulance or ER, but being on anticoagulants will definitely matter to them in many situations.

Welcome Deb,

There has indeed been real progress in the field of LAA Closure over the last 4 to 5 years, not only in improved design but in significantly improved installation methodology and refinement that has greatly lessened some of the very early stage learning curve issues that are not uncommon in any relatively all new procedure in medicine in its gestation period. The field has matured significantly and most definitely is ready for prime-time now with the one key caveat that clearly you and your husband already know ... to be very discriminating in chosing only a highly experienced operator to perform LAA closure, going for an EP who does many of these procedures with a track
record of success as a key part of their regular practice.

At St. David’s, in addition to Dr. Natale, who does these procedures too, such true expert LAA closure operators as Drs. Rodney Horton, Amin Al-Ahmad and David Burkhardt are all highly reliable experts at LAA Closure with tons of experience and your husband would be in great hands with any of these three top-tier Eps, and not to mention Dr. Natale himself, though his very busy ablation schedule might make for a longer wait for him to do the LAA closure procedure.

When you really know how to perform state of the art Watchman/Amulet occlusion or LAA ligation as all three of these EPs that work closely with Dr. Natale most certainly do, these procedures are very straight forward and typically take only around half an hour for the Watchman/Amulet to perform the actual procedure and with very high safety, especially with the significant advancements in methodology over the last number of years as practiced at such high-volume centers as St David’s.

In speaking with Dr. Natale last week, I asked him which LAA closure method he most often recommends now, and he said they have had great success with both ligation and occlusion methods at St David’s, but with the Watchman/Amulet essentially having no problems or significant issues at all in recent years and with high volume experience, he without hesitation strongly recommends the Watchman for the majority of patients now. So yes, I very much recommend you and your husband set up a consult with Dr. Natale about your husband's specific case and get his input.

Keep in mind too, that Dr. Natale is referencing a group of patients in his recommendation of LAA closure who are near ideal candidates to benefit from LAA closure that are all LAA Isolation patients, such as your husband, whose LAA mechanical function is also too low to safely allow stopping long-term OAC therapy, and yet who strongly prefer not to continue on life-long OAC to minimize their risk of LAA-based clot and embolic stroke/TIA risk. For this group of key patients, as so often found in our group especially, LAA closure with Watchman is very much ready for primetime!

Shannon



Edited 1 time(s). Last edit at 10/30/2017 09:26AM by Shannon.

Just be sure your insurance covers LAA closure (with Watchman or anything else).

It seems many don't.

Example:

"The use of percutaneous left-atrial appendage closure devices for the prevention of stroke in
atrial fibrillation does not meet Blue Cross and Blue Shield of Alabama’s criteria for coverage
and is considered investigational."

Aetna:

"Aetna considers cardiac devices for occlusion of the left atrial appendage (e.g., the Amplatzer cardiac plug/the Amulet, the AtriClip device, the Lariat snare device, the PLAATO device, and the Watchman device; not an all-inclusive list) experimental and investigational for prevention of stroke and all other indications because their effectiveness for these indications has not been established."

Blue Cross/Blue Shield California policy

[www.blueshieldca.com]

Hopefully you're lucky and your insurance company covers it. But it sure seems like a lot don't.

Shannon, thank you so much for that very reassuring information. We will contact Dr. Natale's office (or email Shirley) for a consultation appt., make a trip to Austin and follow his recommendation. Again, thank you for taking the time to assist us with this. You and this forum are awesome and a blessing!!

Mac,

Dont go by BCBS guidelines alone, that’s what they are general
guidelines not immovable lines drawn in the sand and the guidelines themselves change too over time. Work with St Davids staff when, and if, after your index ablation you require LAA isolation and then after the 6 month TEE if it is found you do need to stay on OAC or go for LAA closure, then at that point the support staff will help make your case to BCBS for you having a specific need for the Watchman or whatever closure method Dr Natale recommends. Calling Blue Cross yourself inquire, or trying the interpret what they will do in your case based on these basic guidelines is not the way to approach this and is often putting the cart before the horse,

The St Davids staff can make a much more compelling case for you needing LAA Closure when you really DO need it, rather than you or any patient calling up BCBS and saying "hey, it sounds in your guidelines like you folks won't pay for me to have a Watchman if I might be able to use one in the future, what gives?".. that will not get you very far with most insurance companies, but more and more Watchman's are being approved all the time by a growing host of insurance companies, including many paid for by BCBS already, and that will become standard of care for more classes of afibbers going forward too ... especially for those with LAA isolation.

Just work with the folks at St. Davids (since that is where you have chosen to go for your ablation process) whose job it is to help you seek approval for such procedures as and when that comes up on the radar, rather than speculating whether or not you will ever qualify from a position of not knowing the insurance ropes from within the hospital perspective and not knowing all the right CPT codes to reference etc etc. Doing it the right way can avoid getting all worked up over issues that will work themselves out in due time in the vast majority of the cases as it is.

Shannon



Edited 2 time(s). Last edit at 10/30/2017 09:35AM by Shannon.

Quote
Shannon

Just work with the folks at St. Davids (since that is where you have chosen to go for your ablation process) whose job it is to help you seek approval..... Doing it the right way can avoid getting all worked up over issues that will work themselves out in due time in the vast majority of the cases as it is.

Shannon

Very reassuring words, especially since my insurance is through BC/BS also. Thanks for expanding on this Shannon. On the plus side, I'll be in Austin for a few days in about a month or so, and expect I'll be arriving in beautiful NSR!

One more reason you gotta love the wonderful people of St. Davids and TCAI (and this forum). We are truly blessed!!