Important info for those with LAA isolation and/or those in line for LARIAT, ATRICLIP or WATCHMAN LAA exclusion

This post will be most relevant to a growing number of you, but is good for everyone to at least be aware of and keep in their back pocket.

One issue that became abundantly clear during my 2nd follow up 3D-TEE after my Amplatzer ADOII plugging of my LARIAT leak last summer at Scripps ... as well as was emphasized at the ISLAA conference last weekend in LA ... was the need to only use a very experienced TEE cardiologist when dealing with LAA-related TEE scanning issues, These cardiologist should be familiar and expereinced with measuring LAA emptying flow velocity and doppler A-Wave consistency at the mitral valve inflow function.

The overall scenario is as follows:

More and more EPs are learning to do the LAA isolation/delay procedure and there is a growing wave of recognition as evident by the big advance in understanding, even just since last years ISLAA, of the central importance of addressing the LAA when it is a culprit in arrhythmo-genesis as well as in stroke risk reduction in many more advanced cases of AFI. That was a big message from this years very interesting ISLAA, no longer can you just stick your head in the sand and not bother to learn how to recognize and treat triggering from the LAA/CS, if you want to really progress the field and an EP's success rates. It is clear now that Dr Natale's pioneering efforts in this key area of improving ablation success rates has paid off, yet again. At first he was a lone voice in the forest with a good degree of skepticism over the approach but no longer. A large number of EPs, cardiologist and cardiac surgeons now acknowledge the key role of the LAA in not only stroke risk but as a source of ongoing arrhythmia triggering.

The main caveat to wider adoption so far, of course, has been the issue of life long anticoagulation or LAA exclusion being required for a majority, but not all, who undergo successfull LAA isolation ablation. However, this issue is really a Red Herring and not much of a caveat at all, as the same person whose arrhythmia is being progressed by malignant LAA/CS signals, will absolutely require indefinite OAC as well should they decide to stay in AFIB/Flutter and forgo the LAA isolation... it's a false bargain all around.

Nevertheless, a 6 month post LAA Isolation ablation follow up TEE is required to determine if one can stop OAC (in about 30% of the cases) or a majority who must accept either long term OAC or go for mechanical LAA exclusion via LARIAT Plus ( the new and improved generation LARIAT), ATRICLIP minimally invasive surgical approach with over 45,000 such clips procedures performed world wide as of now by cardiac surgeons, Watchman (just for stroke reduction, but not for added insurance of long term LAA electrical isolation), or surgical amputation.

Scenario One

This first LAA oriented TEE you might require can still be with a 2D-TEE, but if at all possible every attempt should be made to have it done by a TEE cardiologist experienced in LAA Isolation evaluation cases and a TEE that includes 3DTEE capability, even for this initial scan, is worthwhile in helping to better define LAA morphology prior to the procedure.

For those of you who have had their LAA isolation by Dr Natale, Dr Rodney Horton or Dr Doug Gibson in one of Natale's centers, or by DJ Lakkireddy at Kansas Univ Med Center. then by all means return to those centers if you at all can for the follow-up TEE and to meet with your ablation EP for the verdict of where to go from there.

If you simply cannot afford to travel back for this key follow-up TEE and meeting, then please seek out the most experienced TEE expert in your region and make sure he or she has a document from your ablation office defining exactly what they are expected to look for and document .... i.e., an LAA emptying velocity of </= 40cm/sec and the presence of a consistent A-Wave at mitral inflow on doppler imaging are the two key parameters that must be done correctly.

There have been cases where patients who had an LAA isolation ablation and chose not to return to the experienced center for this critical LAA eval TEE, and thus had a local cardio do the TEE instead, got wildly inaccurate readings on what the TEE scan actually showed!

Needless to say, this could potentially be dangerous! Some such locally done TEE scans have been interpreted by the local cardiologist who did the TEE as showing a very adequate LAA flow velocity, and yet when the same TEE CD was reevaluated by more experienced experts in this area at one of these experienced LAA isolation centers, in some cases they discovered the scan actually showed a much too low LAA velocity when viewing the very same TEE scan!!

As such, had your treating EP just accepted the analysis of a local less experienced TEE cardio on face value when they reported a too generously high LAA emptying velocity from their scan, and thus gave the green light to stop OAC, you could unwittingly be at a very high risk of TIA/stroke or some other embolic event!

Therefore, while the much preferred thing is to make the effort to get such TEE's done at the original LAA isolation center where the TEE operators will have lots of experience in deciphering the scans in this special area, if you really must rely on local talent then take the time to find the most experienced TEE operator AND most importantly insure that you personally get a copy of the TEE CD and make sure it is sent and received by your treating EPs staff for full re-evaluation and re-confirmation of results before your in-person meeting or phone meeting with your treating EP to determine if you qualify for stopping OAC therapy.

I have had very good experiences at Scripps, Austin and CPMC over what is as of last week my now 11 total TEE's that I have had so far with two more know for sure required ( the next one in 6 months at one year post ADOII plug and the last one at 2 years post procedure in Aug 2016 ... the last 5 of mine being 3D-TEE capable and all at Scripps)

While all the cardios I have had do my TEEs at these very experienced centers were top flight, I have to give a special shout out to Dr David Rubenson at Scripps who is a renowned TEE expert and leader in the field who other TEE cardios travel to hear whenever he holds a TEE conference. The last two he was the TEE man on my case and both were silky smooth with essentially no post TEE raspiness of even mild irritation in the trough and with very clear images all around.... if you can make it to Scripps La Jolla for your TEE make sure to request Dr Rubenson well in advance to you are sure he is booked for your case ... Dr. Rubenson and expert TEE tech there at Scripps, Eric Reynolds, make a dynamic duo TEE dream team and you couldn't be in any better hands for such a procedure.

Scenario Two

Let's say you are among those of us who, after an LAA isolation or delay, find that we have to deal with the anticoagulation issue long term and then you decide to go for a mechanical exclusion procedure to allow you to have the very likely chance to get off OAC drugs long term.

In that event, all future TEEs both during and after the LAA exclusion procedure should be done with 3D TEE capability for sure (which will include some images in 2D as well as 3D, but do not go for a 2D-only TEE scan) and also by very experienced hands.

We found out with my LARIAT leak. stroke and repair case ... and others after mine ... that 3D TEE is essential for accurately discovering and defining any leaks that may appear with such devices as a LARIAT, or WATCHMAN or Amplatzer AMULET for those in Canada, EU and the rest of the world (the AMULET is not yet approved for US).

So the main thing, once you get to this stage of the game where LAA exclusion is on the table, is just factor in and confirm that all procedural and follow up TEEs looking to evaluate the completeness and success of the procedure use 3D TEE capability in experienced hands.

We will discuss more about the new advances here, and coming done the pike, in the LAA exclusion world in future threads, but I wanted to get this important TEE scan info out for the growing numbers here who may have to make these decisions in the short term.

Cheers!
Shannon



Edited 1 time(s). Last edit at 02/13/2015 06:13PM by Shannon.

Thank you, Shannon, for this very important and detailed report. It's timely for me since I've just passed the 6 month post ablation mark. The holter monitor is being shipped and then the TEE will be scheduled.

Jackie

Thank you Shannon,
I will be at the 6 month mark in a couple weeks. Wearing the monitor now. Will head back to Scripps for the TEE.
Looking forward to the news letter!
Anyone dealing with this please post your experience and I will do the same.
Don



Edited 1 time(s). Last edit at 02/13/2015 10:49PM by gmperf.

Thanks Shannon. I'll be scheduling my 6 month 3D TEE in June at Scripps. I'm just about through the blanking period and so far things are going well.

Nick

Thank You Shannon!
This is important information for me as I prepare to travel to Austin for my February 26th ablation with Dr. Natale. I don't know yet if the good Doctor will need to ablate around my LAA. We will soon see. This week I will be tapering off the sotalol and we will see if the afib re-starts as a result.

HI Shannon - at your earlier suggestions, I am scheduled for a follow up TEE at Montifiore hospital on Feb. 24th. I will be seeing Dr. Di Biase for a consult first, but I don't believe he does the actual TEE...that was my impression.He heads the area up, I believe, but doesn't actually do the procedure. Is it safe to assume that because Dr. Natale endorses Dr. Di Biase, that I can be assured I will be getting an expert to do this? As you know, my first TEE done at St. Luke's hospital did not give a clear reading of the
A-wave....

I am one who cannot make it down to Austin again at this time, so hopefully this is along the same lines in terms of accuracy and quality work done.


Thanks ~ Barb

You will be fine Barb, Dr DiBiase knows what to look and ask for from his TEE Cardio there, and he will share it all with Dr Natale as well. Also make sure you request your own CD copy of the TEE at the time of the procedure so you have both it and the TEE report and you can discuss it was well with Dr Natale at the Montefiore conference on March 7th.

No worries,
Shannon

OK - just wanted to be sure, after reading your post

I did register to attend the conference and am looking forward to seeing the NY "ablatee gang"!

Interesting to basically be an example of what expert doctors are discussing..and for those interested, to be able to share what is was/is like "in the trenches".

Thanks again for looking out for all of us, Shannon ~ Barb

Hi Shannon,

Thank you for your detailed report. It brings up a question for me. I got the all clear to discontinue Xeralto after a holter review at 6 months post ablation. However, I did not schedule for a TEE. I feel pretty darn good with no afib. I do have occational palpitations but thats it. Do you think it would be best to schedule a TEE? If so, I would follow your recommendation and schedule at Scripps or in Austin. I honestly would not trust cardios or EP in my region to have the level of skill or experience to ensure my confidence in their readings.

Thanks

Craig

Hi Craig,

Please remind me again, did you have a full LAA isolation or a did Dr Natale just delay your LAA, I think it was a full one if I remember correctly, right? Sorry Its hard to keep track of everyones procedure details when I hear so many variations each week and month. But if you did have a full LAA isolation, I would have expected you to have had a 6 month TEE a long time ago by now? A halter along isn't enough to rule in or out an LAA velocity and mechanical function status after having a fully LAA isolation You would be wise to get a TEE ASAP, assuming you did have either a full LAA isolation in your index ablation, or in a follow up. If you just had a paroxysmal or even just a persistent AFIB ablation and your CHADS-VASc score is 1 or less, and all other risk factors are well managed, then your are likely fine to consider it all a done deal and in the rear view mirror at this stage.

If your CHADS-VASc ( sorry I dislike typing this two '2's in that acronym :-) is 2 or greater and/or you have some other compelling CVD risk factors likes Sleep apnea, Strong hypertension, prior TIA or stroke etc, then even if just had a persistent AFIB ablation, its a good idea to have a 6 month or as soon as practical TEE (this one isn't required to be 3D TEE necessarily, as a good 2D Scan will suffice, but it would not hurt to have a 3D either except perhaps in added insurance deductable cost).

A recent study out of Japan I am reporting on in this latest soon to be published this coming week AFIB Report is all about doing TEE test on patients who had a successful persistent AFIB ablation as a large center in Japan some 6 months after restoring NSR. All these people had a screening TEE before their ablations while still in persistent AFIB and were found to have an average mean LAAFV ( Left atrial appendage flow velocity) of only 29cm/sec +/1 11cm/sec ... which is much too low and is an ever present stroke TIA risk,which is made even more so when the same person has a CHADS-VASc score >/= 2.

The net result of maintaining solid NSR since their persistent AF ablation for at least 6 months was a huge beneficial improvement in Left atrial diameter, mitral flow characteristic LVEF Left ventricular ejection fraction and for the vast majority of these happily ablated patients and increase of this previously low LAAFV into a higher safer range allowing them to stop OAC drugs after their TEEs confirmed they had made enough reverse structural and electrical remodeling progression over the six+ months of NSR to stop the drugs.

However, 22% (or 23 patients out of a total study arm of a total 104 successful persistent AF ablation patients) did have some improvement in LAAFV over their baseline levels of LAA velocity, even though it was not enough improvement to rise about the low point threshold of >/=40cm/sec and thus it was not wise for this group to stop OAC drugs.

The key finding is that all 23 patients who improved in reverse remodeling after 6+ months in NSR, but not enough to warrant going off OAC (or thus needing to consider choosing to go the ATRICLIP/LARIAT/WATCHMAN route) ALL had a pre-ablation CHADS-VASc score of >/=2!

There was also a correlation with female gender and not being able to stop the drugs after 6 months of NSR. However, all of the women who were in the still a bit too low LAAFV camp also had CHADS-VASc of >/= 2 .. so the main finding is that CHADS-VASc >/= 2 is the main predictor up front of which persistent AFIB patients ( at least in this study group) should definitely have a 6 month follow up TEE to determine the LAA emptying velocity and the A-Wave consistency at the mitral valve info and when both are positive with the LAA velocity above 40cm/sec AND there is a consistent A-wave then once can typically be safe in stopping all OAC therapies and avoiding any LAA exclusion issues for now.

The study also found an added risk in those whose baseline TEE prior to the persistent AF ablation showed the presence of SEC (spontaneous Echo contrast or 'Smoke') within the LAA, for having a too low LAAFV at the 6 months point or later after NSR had been total reestablished without any breakthroughs. However each of these patients with SEC found present during the pre-ablation screening TEE also had a CHADS-VASc >/= 2 ... In short this CHADS-VASc while certainly not perfect or infallible is proving to be a useful general guideline for a number of real world CVD risks, including those indirectly associated with strokes/TIA.

The bottomline, this is all just more support and further incentive for each of us to improve our overall life style and dietary, exercise and stress reduction choices to better lower out CVD and stroke risk factors such that we can thus better support any ablation procedure we might have. And is further backing for our long time strong urging here to everyone to not procrastinate too long playing cat and mouse with your arrhythmia when it is still breaking through periodically as you almost certainly will only increase the difficulty of being one and done in any future ablation process, but also may forfeit a golden chance to avoid the whole OAC issue long term as well.

What this study underscores is that there is a limit in which reverse remodeling will happen, even after prolonged recovery of NSR after a successful ablation, for persistent and likely long standing active paroxysmal patients as well.

Do your due diligence early in the game in learning to remodel your diet and life style to improve overall and CV health first and foremost, making these positive changes a permanent change for the better in our lives, and not just to stop AFIB. But do not procrastinate too long at all past 6 months to a year max of early stage going it alone with natural risk factor modification strategies, including even AAR drugs, when the breakthroughs are still happening to any appreciable degree at all in spite of dedicated effort to turn that around.

It is clear now that those who find one rationale or another to continue avoiding an 'expert' ablation by an experience EP are really rolling the dice long term and are not always playing the careful and cautious roll they imagine they have been. Its a rude awakening when that becomes crystal clear after the fact the hard way.

Hi again Shannon,

I had paroxysmal afib. I was very fortunate that Dr Natale performed a straight forward PVI ablation as a first course of treatment. I had only been on Xarelto a few days prior to the procedure, Dr Natale found no reason to isolate the LAA during my index ablation. The only possible risk factor incolves that odd incident I experienced a few days following the ablation. I was enroute home and while at the airport in Las Vegas my vision went kalidascope on me for a few minutes. I ended up being admitted overnight. The docs were concerned for possible stroke or TIA. They found no evidence of such nor were my symptoms totally consistant with stroke or TIA. Their diagnosis was most likely I had experienced vision issues due to dehydrating. After doing my own research I think it was more consistant with an ocular migraine. In any event, unlikely TIA but can not be totally ruled out. The best I can tell, what ever happened, it was an isolated event with no lingering effects.

Neither of the cardiologist I have seen locally since my ablation want me to stop Xarelto. However, thats only because they feel once you have been diagnosed with afib you are on blood thinners for life...regardless of ablation results. The most recent doc admitted it spooks him because he has only been sued once and that was because he did not put a non ablated afib patient on blood thinners and he had a masive stroke. He had a CHAD score of zero. Because of that the doctor prevailed. He was following accepted protocol. Also, both those ddoctors have a mountain of respect for Dr Natale and hesitate to second guess his decision to discontinue Xarelto...so basically they have given me their position and have left the decision up to me. Sounds a little CYA to me!

So there you have it. Seems I would be clear...unless that prior event was in fact a TIA. I do not have that diagnosis. If so, a TEE would be justified and in order.? At this point it unclear to me if I would even be medically justified ( insurance) in having a TEE.

On a side note.....I want to thank you on your guidence regarding my persistant tachacardia during the first 6 months post ablation. You....and Dr Natale...promised me my rate would slow and probably return to normal once the healing process progressed.. You were right on! I'm pretty much back to post ablation level of 61 BPM at rest. Thanks for the reassurance!!

Craig