Atrial Fibrillation Forum

Re: What % of EPs are capable of isolating LAA?

Taytantuc — Tue, 07 Apr 2026 02:58:35 +0000

We discussed it in advance. Dr Natale said he felt confident that the LAA would need to be isolated. The mapping technology shows if there are signals coming from that area.

Re: What % of EPs are capable of isolating LAA?

mjamesone — Mon, 06 Apr 2026 23:14:45 +0000

I too had my 5th ablation 18 days ago, this time with Natale. He hit a few spots in RA , PV were still silent from previous ablations. He ablated the posterior wall and I converted to NSR. He then isolated the LAA to be certain.

Congrats on the ablation and hope recovery is going well. Curious, since this was your fifth, was LAA isolation something you were aware of and discussed in advance with Natale, or was it decided during the procedure?

Jim

Re: What % of EPs are capable of isolating LAA?

Taytantuc — Mon, 06 Apr 2026 21:04:06 +0000

Re: When the Time Comes to Stop Oral Anticoagulation: Options and Obstacles

GeorgeN — Mon, 06 Apr 2026 15:46:09 +0000

Quote
windyshores
I am trained in hospice work and just want to say that the idea that hospice is only for last weeks or even last days, is unfortunate. My mother lived to almost 96, and was on hospice off and on for three years. She remained on Warfarin until the end. Hospice patients can remain on medications not related to their hospice diagnosis. People are missing out on free services such as a daily aide, visiting nurse, hospice MD, social worker, chaplain and volunteer by waiting too long for hospice but feelings about the "h word" re often behind that resistance. "Hospice" means comfort, not necessarily imminent death. Sometimes hospice services improve health and the patient is discharged, at least for awhile.

Yes, I had a grandmother who was on hospice from 99 to 103, while her daughter, my mother, was on it for an hour or two. I have an adult son, who was on it for 5 years and has been off now for 2 (and has a brain cancer diagnosis where the neurosurgeon said the life expectancy is 12-18 months at diagnosis and 2% survive to 5 years - he's been diagnosed for nearly 9). The US Veterans Administration will pay for treating care on hospice, unlike some other agencies. My mother's doc used to tell me about the "hospice effect," where patients felt a lot better when they were taken off their treating meds.

Re: When the Time Comes to Stop Oral Anticoagulation: Options and Obstacles

gloaming — Mon, 06 Apr 2026 15:39:16 +0000

That's a very good and useful point, Windy. Hospice isn't necessarily 'Stick a fork in me, I'm done.' The concept means a serious attempt to discourage further deterioration and suffering to the extent possible in that facility, so whatever that entails is what is offered to most patients.

Harvard Health says six months or less, but you dear mum is surely representative of another subset.

[www.health.harvard.edu]

Re: When the Time Comes to Stop Oral Anticoagulation: Options and Obstacles

windyshores — Mon, 06 Apr 2026 11:37:08 +0000

I am trained in hospice work and just want to say that the idea that hospice is only for last weeks or even last days, is unfortunate. My mother lived to almost 96, and was on hospice off and on for three years. She remained on Warfarin until the end. Hospice patients can remain on medications not related to their hospice diagnosis. People are missing out on free services such as a daily aide, visiting nurse, hospice MD, social worker, chaplain and volunteer by waiting too long for hospice but feelings about the "h word" re often behind that resistance. "Hospice" means comfort, not necessarily imminent death. Sometimes hospice services improve health and the patient is discharged, at least for awhile.

Re: When the Time Comes to Stop Oral Anticoagulation: Options and Obstacles

JakeL — Mon, 06 Apr 2026 05:23:08 +0000

If there ever is a real published study that anticoagulants become marginally effective after age 87 for warfarin or age 92 for Eliquis, then it might be a real benefit to already have a Watchman in place (assuming it is still effective) to make up for the anticoagulant loss.

I have parents that lived into their 90's.

Re: What % of EPs are capable of isolating LAA?

Carey — Sun, 05 Apr 2026 22:41:14 +0000

Quote
nonthumper
Now, is it possible he should have left me in Afib and see if the condition lessened as my heart healed post prcedure? (Is this what is referred to as the "blanking period"?) I don't know.

No, it would not have lessened. If an ablation doesn't stop the afib, then there won't be any healing post procedure. You'll just remain in afib and the modeling will continue.

Re: What % of EPs are capable of isolating LAA?

Carey — Sun, 05 Apr 2026 22:38:28 +0000

The trouble with that reasoning is that 1) sometimes the source of the afib/flutter is the LAA. No procedure of any sort would ever have stopped my flutter if the LAA wasn't dealt with. 2) The LAA is very often the reason that the success rates for longstanding persistent afib are so miserably bad. Natale and a handful of others first began isolating the LAA for this very reason, and it's how they achieve 80%+ success rates when the average EP was performing south of 50%. It's never been a first-line ablation strategy for any EP I've ever heard of. It's done only when it needs to be done to solve the patient's problem.

Re: What % of EPs are capable of isolating LAA?

nonthumper — Sun, 05 Apr 2026 22:34:53 +0000

This is a line of discussion I didn't know to ask about before my procedure. In my specific case I had 100% Afib burden in the 8 months leading up to my ablation. The doctor started with PVI, posterior wall, roof line, and more, but I was still in Afib and then flutter and tachycardia. He could not get me into NSR until he isolated the LAA.

Now, is it possible he should have left me in Afib and see if the condition lessened as my heart healed post prcedure? (Is this what is referred to as the "blanking period"?) I don't know.

But that decision was made for me while I was unconscious. My hope now is that the Watchman procedure in 2 months will get me off Eliquis. That is apparently the Natale strategy.

Re: What % of EPs are capable of isolating LAA?

mjamesone — Sun, 05 Apr 2026 21:26:29 +0000

I think the percentage would be very high, but the question is....are they willing/eager to do it. Many EPs get 'good enough' results to stay afloat just doing a simple PVI since that operation accounts for about 85-90% of all paroxysmal patients.

I agree. For most EPs, and I include mine, at a top 10 cardiac hospital, LAA isolation isn't a first-line ablation strategy, because of the higher resulting thromboembolic risk..This is even more important right now, as newer studies suggest that life-long anticoagulation may not be necessary after a successful ablation. So if you isolate the LAA, then you will lose the choice to go off anticoagulants, even if those studies ultimately support stopping after a successful PVI. Stats are very good for a simple PVI in most cases, making it the appropriate first choice for most. That's what I had over 2 years ago, and still holding.

Jim

Re: What % of EPs are capable of isolating LAA?

Carey — Sun, 05 Apr 2026 21:10:39 +0000

Quote
nonthumper
I would have preferred to take my 1% risk of stroke over the 1% risk from anesthesia and the ablation (if that's what the risk is).

The trouble with that logic is the risk from the procedure is a one-time thing while the risk of stroke is every single day for the rest of your life. So ask yourself this: If my risk of stroke is 1% per year, what's the risk of suffering at least one stroke over the next 10 years? It's not 10%, but it's close. It's 9.6%. How about the next 20 years? It's 18.2%, nearly a 1-in-5 chance.

Re: What % of EPs are capable of isolating LAA?

nonthumper — Sun, 05 Apr 2026 18:31:51 +0000

Hopefully when I get the Watchman it will get me off Eliquis. My pre-procedure stroke risk from Afib was only about 1% per year, if I understood correctly. At that rate, I don't think I would have gone on Eliquis.

I would have preferred to take my 1% risk of stroke over the 1% risk from anesthesia and the ablation (if that's what the risk is).

HOWEVER, it is also my understanding that my Afib would have only gotten worse over time, causing further deterioration of my heart tissue. So we go with ablation and Watchman and hope that does well. Beyond that, I had a level of fatigue from being in Afib that I hope I will be done with now.

The clinical notes indicated I already had "moderate atrial scarring". On my next virtual appointment with Dr. Natale, I have to ask him the significance of that.

Re: What % of EPs are capable of isolating LAA?

GeorgeN — Sun, 05 Apr 2026 15:38:09 +0000

Quote
nonthumper
I asked one regional EP how many ablations he did in a month, and when he did not give a clear answer, I crossed him of the prospective list.

Tweleve or so years ago, I learned my best friend from childhood was in peresistent afib. He lives in Houston & I insisted he go to Natale. He was like, "why? I live in Houston, we have great doctors here." I was very persistent as he is such a good friend. He was referred by his cardio to "the best EP in Houston." He asked the staff how many afib ablations he'd done. They said, "A lot! He's done over 1,000!" At the time, as I recall, Natale had done something north of 12,000. So my friend went to Austin. When he got there, he learned the sibling of a close friend was on the Natale team. He also got a sense of why I was so insistent. He ended up having two ablations with Dr. N, the 2nd isolating the LAA. He's been in NSR since. It did take him a couple of years to get a TEE report that allowed him to get off anticoagulants (meaning it took that long for his body to heal such that the report was good enough to meet the required specs -- the lifetime anticoagulation or the placement of an occlusion device is a material risk for those getting an LAA isolation). As we live states apart, in person visits are relatively infrequent, but when they happen my friend and his wife never fail to thank me for insisting on Natale even now, years later. I tell them they played a big part, by following through on my advice, as many do not.

Re: What % of EPs are capable of isolating LAA?

Carey — Sun, 05 Apr 2026 03:20:32 +0000

Quote
gloaming
I think the percentage would be very high

Actually, it's quite the opposite. Electrical isolation of the LAA is a relatively new procedure. Although surgeons have been clipping off and sewing the LAA shut for decades, interventional cardiologists have only been ablating it since about 10 years ago. (Pioneered by you know who.) So it's not something most EPs have been trained to do and it does take specific training. The result is that most fellowships new EPs attend don't teach the skills. In fact, there are still a lot of EPs out there who believe it's an unnecessary and overly aggressive procedure. I've heard Natale called a "cowboy" and "overly aggressive," which makes me laugh because just like Nonthumper, my atrial flutter didn't stop until Natale got to the LAA, and then it stopped after just 2-3 burns.

There's even an annual conference devoted to the procedure (ISLAA), which Shannon and I attended prior to the pandemic. That's where EPs go to make the connections they need to get the training. Although the numbers are increasing, there are still just a small percentage of EPs who can provide that training so you have to go to a conference like that to find them.

On an amusing note, my favorite EP curmudgeon, Dr. Mandrola, once asked (in the midst of condemning the practice) how one even puts catheters into the LAA. The answer is you don't, but that didn't stop him from condemning it.

Re: Eliquis & cataract surgery

Qwackertoo — Sat, 04 Apr 2026 23:24:35 +0000

Not necessary to stop. Also they will probably want a clearance from your cardiologist or EP to proceed prior to surgery day based on patient history and probably the anesthesiologist too so they cover all bases. If they have name and number they should handle that quickly and easily.

I went from my usual 20/20 all my life to much worse with blurriness and colors were dark. Next day check up I was back to 20/25 and one week check 20/20!!! I just don’t know why they progressed so fast from one eye exam to the next year exam And boom cataracts/surgery. A Fib and circulation? I’ll probably never know why but was thrilled to get that first eye done 3 days before the Winter Olympics started!!!

Re: Anti-arrythmic meds

gloaming — Sat, 04 Apr 2026 22:56:27 +0000

It will go fine. A long day for you, as the last body wheeled into the cath lab, but at least it won't be six weeks from now. >:D< Please come back and share your experience. We like hearing success stories.

Re: What % of EPs are capable of isolating LAA?

gloaming — Sat, 04 Apr 2026 22:49:37 +0000

I think the percentage would be very high, but the question is....are they willing/eager to do it. Many EPs get 'good enough' results to stay afloat just doing a simple PVI since that operation accounts for about 85-90% of all paroxysmal patients.

I asked my EP if he would do an LAA isolation if he felt it were needed and he shook his head no...saying just what I typed above. First things first is what he intended. Let's try the 90% solution, and if it's a bust, I'll have you back for another round. He did have to see me again seven months later, but for another, this time complete, PVI. He found the small gap he'd missed first time isolating the third pulmonary vein.

How many CAN do it? I would say probably between 70-80%.................but I have no stats to back me up.

Re: Eliquis & cataract surgery

gloaming — Sat, 04 Apr 2026 22:45:23 +0000

I did not have to cease taking Eliquis on schedule. The eye only bleeds from the retina, as far as I know, not from the surrounding orb, cornea, etc. The ophthalmologist only slits the side of the cornea and does the phaco-emulsification to bust up the lens and then literally sucks it out. Then inserts the new IOL, and from there I dunno. You get driven home....and keep taking drops two/three times each day for another three weeks in my case.

What % of EPs are capable of isolating LAA?

nonthumper — Sat, 04 Apr 2026 22:43:32 +0000

I am 16 days out from my first ever ablation, after being in 100% Afib since July. The Kardia says I am still in NSR.

I am still analyzing the whirlwind experience. I read Dr. Natale's post procedure notes. Of course, I arrived in the lab in Afib. He did treated several parts of my heart, but was not able to get me into NSR until he isolated my LAA.

I read in a previous thread on here that many EPs do not have the skill to isolate the LAA. So it appears likely that if I had gone to a lesser practitioner, I would have left the hospital still in Afib. So I am wondering what the probabilities of that were.

I now know a good question to ask when you meet prospective EPs would be: "Do you ever isolate the LAA?".

I asked one regional EP how many ablations he did in a month, and when he did not give a clear answer, I crossed him of the prospective list.

As far as how Dr. Natale operates, his clinical notes reveal: A total of 2 minutes of radiofrequency energy lesions were delivered. A total of 199 pulsed field ablations were delivered. Flouro time was 15.6 minutes. (I saw a video where an EP was talking about how important it was to keep flouroscopy times down.)

All this seems to have been accomplished in a little over an hour.

Re: Eliquis & cataract surgery

Madeline — Sat, 04 Apr 2026 21:43:31 +0000

Thanks, Carey. Mine is a plain cataract surgery, no special lenses. I will ask them too on Monday.

Re: Eliquis & cataract surgery

Carey — Sat, 04 Apr 2026 21:04:28 +0000

You can definitely stop Eliquis for 5-7 days, but I would double check with the surgeon. I've never had cataract surgery and don't know for sure, but my understanding of the procedure is that bleeding isn't really an issue. The only incision is into the cornea, and it doesn't have a blood supply.

Re: Afib post ablation

susan.d — Sat, 04 Apr 2026 20:27:51 +0000

I’m a fan of two 5.5 ounces cans of V-8…plus hydrating with water.

Eliquis & cataract surgery

Madeline — Sat, 04 Apr 2026 16:13:58 +0000

Hi,

A simple question that’s probably already been answered for me, but I wanted to make sure about whether or not to stop Eliquis any period of time before my cataract surgery. I did have the LAA ablation and a Watchman placed and I’m pretty sure Dr. Natale had said in the past that if ever one needed to, they could stop for up to seven days, maybe 5. Since I haven’t heard anything from the cataract people and my procedure is in 10 days, I assume it is not necessary. However, I’d like to get my answers from the experts at A-Fibbers because you all know the specific conditions and answers. I trust the information from most people here.

Thank you.

Re: Why aren't more afibbers trying potassium?

GeorgeN — Sat, 04 Apr 2026 11:31:35 +0000

Quote
bcampbell37211
I use to take a lot more magnesium than I do now, but I had to cut back, you know, bowel intolerance. In most people I believe, our kidneys do their part in keeping the body in homeostasis.

I used to have a magnesium bowel tolerance over 5 g/day. Over time I've learned that this high tolerence/constipation was due to my sensitivity to certain foods. As I've figured out the foods (primarily some kinds of tree nuts) on this list and removed them from my diet, I now take 1.6 g/day. This is still 4x the RDA but a far cry from 5 g.

Re: Afib post ablation

mjamesone — Fri, 03 Apr 2026 21:35:57 +0000

Did you do an EKG or detect irregularity at the pulse? HR alone, especially at the low ate you mention, is a poor metric for AF, especially after an ablation. FWIW there is data that shows an increase in resting HR post ablation is associated with positive outcomes. So, if that's all it is, then good news, not bad. On the other hand, if you have an EKG, email to Natale's office to confirm and as suggested, take it easy and stay hydrated. I generally don't drink electrolyte drinks, but when I was in AF, I found gatorade and similar helpful in terms of hydrating.

Jim

Re: Afib post ablation

Taytantuc — Fri, 03 Apr 2026 21:19:01 +0000

Drank 32 oz of water and lying down. HR down to 66. Hoping I was just dehydrated. Thank you for the positive advice

Re: Anti-arrythmic meds

EricY — Fri, 03 Apr 2026 21:07:49 +0000

Hey everyone. Sorry, I haven't posted in a couple of months but I am scheduled for an ablation next Tuesday and I will admit I am starting to feel anxious about it. Unfortunately I was told I will be the last procedure of the day so most likely will have to stay a night in the hospital. The EP also said I will need to continue Eliquis for about 90 days post op and recommended staying on Flecainide and Metoprolol for the same amount of time. I really hope it will all be worth it and not have more problems after. I know most of you on here have already had at least 1 ablation and soon I will be one of those as well.

Eric

Re: When the Time Comes to Stop Oral Anticoagulation: Options and Obstacles

gloaming — Fri, 03 Apr 2026 21:05:18 +0000

I would say no, not when in hospice, but that's a more personal decision. Hospice means you're definitely not long for this Earth, maybe four weeks tops...typically. So, yeah, in that case, who cares if it's the last agonizing hours of a tumour or your lights go out with a sudden stroke....same diff. Maybe snowed with morphine would be my choice if the former. And no apixaban/rivaroxaban/edoxaban.

Re: Afib post ablation

gloaming — Fri, 03 Apr 2026 21:01:02 +0000

Rest, stay well hydrated, take a bit of potassium and magnesium (not a lot, just enough to cover the bases so-to-speak), and remind yourself that during the blanking period, you WANT to have brief blips like this.....early. You don't want the blanking period to feel great and suddenly, Week 6, you begin to get blips. That is when you should get worried....a bit...because the literature says later if worse. Even so, many have lumpy blanking periods and beyond, and then suddenly it's next Christmas and they realize they haven't had any PACs or AF for weeks.