LAA ablation 9 mo status and path forward question

Hi all,
I now have 9 months since Dr. Natale ablated my LAA, and continue to be Afib-free, just occasional PVCs. I started my regular exercises, and able to do it without triggering Afibs. It is a wonderful feeling to be Afib free, and am very grateful to Dr. Natale's expertise in ablating the LAA, since that really did it for me. However, the LAA ablation is a 2 part drama, the first part being the ablation itself, and the second being getting off blood thinners. I was very successful with the first part so far, and hoping to hold for the long term. I am not very successful with the second part, getting off blood thinners (BT), after the LAA ablation. I had 2 TEEs performed so far and neither of them convinced Dr. Natale that I can get off the BT (both times I had a consistent A wave after each E wave, and the velocity was 42 and 38 cm/s respectively). Dr. Natale recommended that I should proceed to have a surgical procedure to clip my appendage and get off BT. He referred me to another doctor working at the Adventist Heart Institute, Dr. Gan H. Dunnington.

I am a bit ambivalent as to how to proceed forward, I need some advice (Shannon?)
1) Do I really need this second procedure, and would there be any way to take a more conclusive TEE (maybe 3D, that would put some more certainty into the results?), and make Dr. Natale more willing to release me from taking the blood thinners
2) I asked Dr. Natale if I could reduce the dose of ELiquis from 5mg to 2.5mg, and he said that there is no research to show that that is a correct dose
3) Since I am at the limit I could take the risk of going off Eliquis altogether and take natural blood thinners (such as natto, etc.)
4) Dr. Natale told me that he recommended surgical procedure to clip my appendage, because that has a better success rate. According to him the Lariat and watchman has a success rate of 85% only, and he cannot do anything about that , it is a manufacturer issue
5) I am reluctant to go with a surgical procedure since I expect that it would put me back again by many months until I will be able to exercise again, etc.
6) For the appendage clip surgical procedure, does anybody have any experience with the appendage clip surgical procedure, risk, results, recovery time, etc.
7) Does anybody have experience with the Adventist Heart Institute, in general, and with Dr. Gan Dunnington in particular


Thanks much,

Peter

Hello Peter,
I dont have any information to add. I may be facing this same situation myself shortly.
There will probably be many more of us in the same situation as time goes by.

I think it is important for all to remember that getting off blood thinners should only occur when we meet the standard for it to happen. That means a positive test that for sure meets the criteria. Getting off blood thinners to only have a stroke is no bargain.
Supplements that are untested and cause increased bleeding risk is not a smart substitute for the tested medication.
I am 50, on Xeralto and am active. I do things like hang gliding off 5000 ft mountains. When I have cut myself I bleed just a bit longer than before Xeralto. There still is life while being on blood thinners.
I have decided if I am faced with having to stay on the blood thinners because of the LLA issue, I will wait a year and then decide if a procedure make sense for me.

Don

Hi Peter, I'm writing about this very topic in the new AFIB report right now and am so engaged in getting that finished over the next 5 to 7 days that I don't have the time right now to spell it all out in the typical detail , though I will do so here too after I get the newsletter sent out next week.

In short though, DrNatale wants everyone to stay on the side of abundant caution and thus that is why he is suggesting you add the atriclip even though you technically are right at the borderline of being okay. If your velocity was even just 45vm/sec he would likely have said you could stop it, but I think he is just a bit nervous about a 40cm/sec and then subsequent 38cm/sec LAA emptying velocity being slightly trending below the curve and thus over time it might go a bit lower still, as mine did on several subsequent TEEs.

Perhaps there are other nuances to your case too that nudged him to recommend that. I think the Artclip done by an experienced cardiac surgeon is hands down the best solution. In a few years they may well have FDA approval for an EP epicardial subxyphoid access procedure they are working on perfecting right now for the Atriclip that EPs can do with a surgeon involved, much like the epicardial part of the LARIAT without having to do any endocardial phase.

But the ATriclip as a stand alone LAA ligation process is Very straight forward and takes an experienced surgeon only 30minutes to do the entire minimally invasions endoscopic or laparoscopic process and rest assured it is VERY safe and is near 100% effective. It will truly reconfirm total and instant complete electrical isolation of your LAA for good as well as structural removal of the LAA via resorption into the left atrium literally as if you never had one! Surgeons around the world have installed 45,000 Atriclips so far with no significant complications and with huge success rates.

Any size or morphology of LAA can easily be clipped successfully with the Atriclip too, unlike with the original LARIAT, though the new 'LARIAT Plus' has several nice improvements and is adjustable to accept larger and more varied shaped LAA types being able to fit a much wider array of LAA anatomies and morphologies. That was one big big limitation in the original Lariat in that too many folks could not pass the initial Ct scan morphology screening to fit the fixed sized pre-tied Lariat suture , but now with the larger adjustable suture a lot more patients will get approval, at least anatomically, to get it done.

The Lariat Plus also has anew braided epicardial catheter that gives more flexibility and steering ability during the pericardial access and transit up through the pericardium to more perfectly join and marry its magnet tip with the endocardial magnet tip already positioned inside the LAA via transeptal puncture. This design improvement also helps avoid possible nicking of the right ventricle outflow track when snaking the catheter within the narrow space between the pericardium and right ventricle, which can and has happened in a relatively few LARIAT cases especially when done by operators not experienced with dry stick pericardial access.

Nonetheless, the Atriclip via with two or three less than quarter inch small incisions in a minimally invasive laparoscopic access method, avoids too the next limitation with LARIAT which is the occasion need to abort the procedure once they are alresfy within the pericardium space in those with too many adhesions in the pericardial fluid filling that gap between the outer pericardial sack around the heart and the heart itself.

Anyone with a prior sternotomy (prior surgery with the heart space opening the pericardium) and who may have had certain viral illnesses or pericarditis in the past are more likely to have too sticky of pericardial fluid for the Epicardial LARIAT catheter to advance all the way to the outer tip and slip fully over the LAA before synching it down to lose off the LAA.

One of our readers had this happen and add Natale and as forced to abort her Lariat and eventually successfully installed a Watchman which is an endocardial acess only LAA plug to avoid blood thinners. The Watchman is similar in concept, but a good deal larger, than my Amplatzer ADOII plug used to seal my LARIAT leak in my LAA.

You avoid all that issue with the Atriclip as they cut a small window in the pericardium sack to access the LAA visually and directly and then tie the pericardium closed with one suture typically allowing some drainage while it heals.

You will have some pericardial pain from a while with both the Atriclip and LARIAT, though perhaps a bit more with the Atriclip during the first two weeks to three weeks. The biggest pain with LARIAT is the pericardial drain tube overnight, but you can have ongoing achy kind of focal pain in the upper left chest area with the LARIAT too for a while as well . I had some periodic passing transient pericardial discomfort off and on for a couple months after my LARIAT but it was no big deal.

The only caveat at all to the Atriclip procedure is that you can expect there will be some discomfort that gradually fades totally within a few weeks. By then, you can get back in the swing with exercise really starting at about the week point after the procedure with light stuff like brisk walking and slowly increase from there until you are back at full tilt.

There are NO chances of leaks with an Atriclip either which is very cool! It really solves almost all of the 'gotchas' or possible caveats with the original LARIAT and Watchman and basically they get access to the LAA via left chest ribcage via a few tiny holes, do the job and get out quick. You will stay in the hospital two to three days max for observation and then you are home free with not one than a couple of single stitches, if any at all, to speak off and no real issues during recovery beyond just accepting and it will hurt a bit for a 'this too shall pass' limited time, so it's not that bad for such a high quality reliably ligated and sealed LAA that is a very easy procedure for the surgeon.

Just a bit of chest discomfort for which they give you pain meds for the couple weeks you might need them to a fading degree after about day three or four it gets a bit better each day, and then you are completely free of all OAC drugs immediately ...you don't have to take an OAC or platelet Aggregation drug for 6 weeks minimum as with the Lariat and longer for Watchman .. You stop all OAC drugs immediately just before the procedure and once the clip is in place then it confirms as well permanent isolation of the LAA so there is zero chance the LAA will electrically reconnect when an experienced surgeon installs it.

I very much think the short few weeks with declining discomfort is well worth the great results.. There is more but will share it later after I finish the AFIB Report I'm slaving away in now. said it

The new version LARIAT Plus is also very effectively effective as well and while it has some similar discomfort in the first several weeks it is generally a bit less so than Atriclio but the oversll success rate of around 85% as Dr Natale noted to you Peter is due to the nature of the design. However you can improve that to close to 100% in the case of leaks big enough to plug being the reason for LAA reopening, with an Amplatzer ADOII which is the two step process with another procedure and one more Transeptal puncture that I had to take to seal my LAA up in and good.

Anyway Peter, I have to sleep now so am closing eyes. We can talk this weekend or in next few days if you send me your number again please.
No worries, you will get off the drugs with robust confidence of being free of any and all AFIB related stroke risk! Plus with a well installed Articlip or successful LARIAT you with have extra insurance you'll never have to deal with an LAA reconnection again nor an embolic stroke or TIA from the LAA ever! No drug can promise those two great outcomes.

But the Atriclip in experienced surgeon hands is the most straightforward, safest and assured way to achieve both electrical and structural obliteration of the LAA with the least chance of Periprocedural hick ups or late LAA reopening leaks.bthey price of a bit longer though temporary period of manageable discomfort seems well worth it to me.

Seems like I banged out another big one on this IPhone before bed after all .

Cheers!
Shannon

PS Dr Natale has referred a number of his CPMC folks to that surgeon in the San Fran area who knows the Atriclip well.. Any good cardiac surgeon can get up to speed with this simple procedure for them after some basic instructions and being by told to make a more proximal placement of the clip prior to engaging the spring loaded clip in place , and not just flipping it half way down the LAA length. After a dozen or so Atriclip procedures any good cardiac surgeon will call this a walk in the part for them for sure.



Edited 4 time(s). Last edit at 02/18/2015 02:12PM by Shannon.

Peter, your question 5 above in the first post , you will
Not be waylaid from exercise many months after an atriclip! They are not cracking your chest. You basically have two small main aceess ports for the laparoscopic tubes on the left side of your rib cage between two sets of ribs, and only even smaller drain spot temporarily for a day or so. The do have to deflate the left lung but that is very committed n step in many cardio thoracic surgery procedures and from the 45,000+ Articlip procedures so far I have t seen any reports of any issues there. Although the majority of Atriclips so far have been installed as a secondary part of an open chest primary surgery like CABG or valve replacement.

But in recent years and with all mini maze procedures they use the ATRICLIP in a minimally invasive method with excellent safety and zero deaths or major complications so far from the procedure. The LARIAT is an option too and form many well selected patients can do a fine job, but there are more unknowns such as the possibility of leaks, tough most leaks seem not to need repair at least 6% to 7% of the total range of 13% to 15% of Lariat cases that wi have some degree of leak, the rest of which remain too small to worry about and seal over with endothelial tissue in any event eithin 6 months to a years time, but any leaks =/+ 3mm diameter with confirmed reconnected blood flow between LA and LAA ought to be plugged.

I'm very grateful that my Lariat and ADOII-sealed LAA is now closed up good from this last 3DTEE at 7 months after the ADOII , but had I to do it all over again with all that Ive learned since, I would likely have gone with the Atriclip. That being said, my actual small stroke from the Lariat leak remains a quite rare event though I have heard of one other man on the east coast that had a significant embolic stroke from such a late reopening leak post Lariat.

I have not seen reported any confirmed LAA sourced emoblic strokes or TIA secondary to Atriclipped LAAs so far and they have dramatically moe codes on the books at around 45,000 total including all Atriclips installed during open heart surgery for other issues, so that is a real plus! The one thing will be the simewhatvadded discomfort that will be a bit more botherdome during the first few weeks after the minimal invasive installed Atriclip than the typical type pain experienced in the same time frame after a LARIAT. Both have some discomfort for sure, but the Atticlip I'm told generally aches a bit more during that temporary time frame ... Though I don't know they would have compared that other than just the complaints the two sets of patients have made. It makes sense that Atriclip would be a little more irritated with the small pericardial window being opened.

But unless one is genuinely disturbed by the very thought of some temporary but manageable pain, that shouldn't be a deal breaker at all in my view. Though each person needs to look at all the facts and decide. Either choice the odds are very high for a mostly uneventful success. I hope I've given you some goid info to chew on though and we can run through it over the phone too just to clarify any other concerns or questions Peter.

I'm so glad to hear how well you are doing! I figured you might need the LAA isolation with how active and symptomatic your arrhythmia had become even after the first ablation by your previous EP. It was emphasized again at the ISLAA conference how the LAA/CS has become as a target for isolation and/or removal to really get the beast eliminated in more advanced cases. You could have gone back for ten more procedures that automatically exclude the LAA as a ablation target and do not recongize it as such, and still not get the job done.

I was happy to see many more EPs becoming aware of and conveying this fact at the conference.


Shannon



Edited 3 time(s). Last edit at 02/18/2015 05:28PM by Shannon.

One more issue Peter, and for all others for who this is an important topic,

Even though you showed a consistent A-wave at mitral inflow, the fact that you were not clearly in positive territory on the LAA empyting velocity but were only, at best, right on the borderline of 40cm/sec in one test and lower at 38cm/sec on the other, makes your result close, but not convincing long term. Had your velocity been in the 43 cm to 50cm range also with the consistent mitral inflow A wave, then for sure you would have gotten a pass and could stop blood thinners and not have to deal with one more step, but when one of the two TEE was at 38cm/sec velocity and the other one was right on but not above the clear marker of 40cm/sec, and not say at least 43cm ... this lowish borderline velocity makes the consistent A-wave not convincing for safety long term and that is why Dr Natale is not comfortable taking you off blood thinners.

This is one thing you don't want to guess on or roll the dice on too much Peter. You could stay on blood thinners for another half year and then ask for a repeat TEE to see where it stands then, but its unlikely to improve much after two such TEEs and now, after 9 months of NSR at which point most all reverse structural remodeling that will happen to the LAA will have already occurred, with the rest likely fixed for the long term, I wouldnt count on getting a favorable score, but you could try that too.

If anything, it's probably more likely the velocity level could slide a little bit lower over more time, hence the reason for not being satisfied with a velocity reading right on the cusp of borderline.

NOAC drugs can give a good degree of protection and in your case may work well, but are not without their own risks long term some of which we simply do not know of yet. And even if we assume a 1% to 3% per year stroke risk on NOAC, that adds up over time to a pretty high burden on a relative youngster like yourself! 3% is roundly 30% risk in ten years

Recent studies out of Kansas University Med Centers large AFIB research center run by DJ Lakkireddy, a genuinely superb EP and ablationist, they have done an extensive amount of in-depth evaluation of the LAAs role in the body including the LAALA study looking at Neuro-hormonal effects of LAA ligation with the Lariat or Atriclip.

Some physicians used to speculate that chopping off the LAA might result in loss of ANP atrial natriuretic peptide hormone that controls sodium levels and hence potassium levels in the heart, and thus edema. IN reality there is a brief temporary drop in ANP and BNP ) brain natriuretic peptide in the first few days after ligation after which is bounces back entirely such that by the three month mark both ANP and BNP are back to exactly there pre-Ligation levels! The Right atrial appendage (RAA) is even a bigger source of ANP than is the LAA and other parts of the heart also produce ANP so it is more than capable of compensating for loss of the LAA and does so rapidly after amputation of ligation of LAA.

There is some notable RAAS (Renin, Angiotensin, Aldosterone System) reduction that takes place after ligation that for most people in our age group brings some potential real benefits. After al,l look how many people are put on ACE inhibitors, Angentensin II blockers and Beta Blockers, all of which to some degree try to reduce an overactive RAAS.

The Kansas study shows significant reductions on both Systolic and Dystolic blood pressure even allowing some folks on BP Meds to reduce their dose some, also reductions in Adrenaline, Nor-adrenaline, and Aldosterone were noted on average in Ligation over 74 ligation patients studied, which for most Afib prone people and most older folks in general are general positive changes for sure. Also they noted a marked increase in both Adiponectin and HW Adiponectin hormones and an increase in these key weight control hormones as well as improvement in insulin resistance, which was also noted in those at 3 month post ligation, is a surprising beneficial outcome. On average overweight patients lost a decent amount of weight at the three month mark after a successful Lariat ligation. Exact numbers will be shared once this ongoing study is officially published later this year when it is complete.

In addition, the once speculated loss of added reservoir capacity with loss of the LAA has not been seen or become an issue in practical reality after ligation of the LAA. It could be that the reduction in what is often a slightly or greater expanded overall LA volume in Afibbers by ligation and removal of the LAA provides some compensating benefits the other way, and is thus a help in lowering arrhythmia risk via that reduction in overall LA volume?

We are still learning all the ins and outs of LAA exclusion and more needs to be known for sure, but so far the net sum of what we do know and have learned shows an overwhelming net benefit for those with a real indication for LAA exclusion. And in some areas, it has been surprising and unexpected benefits discovered. The body has some amazing compensation and adaptation facilities to be sure, as is well known, and for most people in our age group, especially afibbers, the LAA is far more of a danger than an asset to our health in any event.

Shannon

Thanks very much Shannon,
I don't know how long it took you to put all the above together but it took me a couple of days to just read and digest everything you so eloquently say. The material you provided is very thorough, based on latest scientific data (when available), and all encompassing. I thank you from the bottom of my NSR heart for all the info you provided. I still have a couple of questions but I am going to see the Atriclip specialist that Dr. Natale recommended (Dr. Gan Dunnington), on Feb. 26 next week and going to ask him those questions from him. Obviously, I don't like surgeries of any kind, and I went along with the ablation for the first time in my life, just because I was at the end of my wits as to what to do. I have to see if I can warm up to this Atriclip minimally invasive surgery idea.

Thanks again,

Peter

You are welcome Peter,

Please send me your number too and I can share with you some info and options from the recent ISLAA conference that I will get around too sharing here too after I wrap up this AFIB Report Issue that I am feverishly putting the final touch to this weekend working non stop. But when that is done, we can talk perhaps Tuesday by I can't seen to locate your cell you had sent before. There are a few photos I have of Atriclip procedures that I can send, but which with the currently structure of our website makes it not so handy for posting online at this time. Anyway, I think you will find those both informative as a picture is worth a thousand words, and quite reassuring.

I want to make sure you understand all of your options here clearly going in with Dr Dunnington so you can check off any remaining questions completely with him.

Best,
Shannon

Excellent information Peter and Shannon, thanks very much. Very timely also, I'm ten days out from my third ablation with Dr. Natale (CPMC). This one was to finish isolating the LAA. Nice to be back in rhythm, getting stronger everyday. As much as I hate afib in all its variations I'm so glad Dr. Natale is here and it is a privilege to know him and I feel very secure in his hands. He answers all of my questions directly calmly and serenely. He's a perfect antidote to my anxiety about this disorder. CPMC is excellent as well, I feel very fortunate my home is only 1 1/2 hours away by car. I received same advice from Dr. Natale; the Atriclip is the only 100% solution. It is likely after six months I will fail the TEE with regards to the LAA and Dr. Natale says he does not do the procedure but he will recommend someone. The recovery time and discomfort described is a little daunting but well worth it to get off the Xeralto. Or perhaps there will be a better solution available in six months to a year from now. It appears to be a rapidly changing landscape. I went a few months in NSR not looking up every article I could find about AFIB related stuff. Back to the internet, tons of new articles, devices, videos. Nice to see the continued progress in understanding, it gives me great optimism for the future. I'm 66, in very good health aside from the scarring in the atrial chambers. My wife and I love hiking on Mt Diablo and I love lifting weights and Crossfit and kettlebells. I do think I'm missing something in my diet. I read hundreds of pages on nutrition and the heart and inflammation regarding afib. I experimented with various combinations of supplements, the progression continued. Sometimes I felt great for weeks, then bam, back again. When I first researched the ablation procedures it seemed barbaric, not something I would ever let be done to me. But after a while the quality of life with the continued bouts of afib drove me back to the internet and I found the forums, including this one. Many hours of reading over months, one name kept popping up in very positive contexts, Dr. Andrea Natale. I finally narrowed my search to his name, it was like a miracle he turned out to practice one week out of the month 30 miles from my home. I have to say, he lives up to his reputation and then some. I thank the people on this forum for morale support, tons of suggestions, and general feeling of optimism. AFIB is not the end of the world, it may be the beginning of your new knowledge about your body and all its systems and what it requires to run like clockwork. I think I may live longer because of the experience, the new good habits of diet and exercise and reaching out for help when you're at the end of your rope.
Best wishes to all,
Mike Erickson

Great report Mike and so glad to hear from you!

As you know there is a decent size army of us now here who enthusiastically second your experience with Dr Natale. A truly special and rare man, with a warm heart that matches his enormous skill and pioneering spirit in this challenging area of cardiology. Send me your contact phone and we can discuss the ATRICLIP and options in more detail now that Im on the last two days wrapping up this issue of the AFIB Report ... thank heavens! :-)

Its wonderful to see you have threaded the needle now and can appreciate some of the positives that can come from having navigated this awful condition and learned so much about yourself and body in the bargain... and about so many caring and helpful people we can meet along the road wherever it takes us. It makes it all rewarding in its own way.

Cheers!
Shannon

Thank you Shannon. Nice to hear back from you. I will definitely pm my number to you. Yes, I believe people like Dr. Natale are very rare indeed. I think the whole team at CPMC is first rate. I remember Kara, the NP I spoke with alot after my first ablation in 2012, really helped with a couple of issues and especially advising me on what to expect and what was important and not so important. I worried when she left the dept (I found out she's now working at Stanford which is much closer to her home), but Julie is very good as well, I had an appt with her before this procedure and she listened to my concerns and questions carefully and answered them very well. And Salwa is a life saver, I've called in the middle of the night and gotten transferred to Salwa, she calmed me down, told me what to do and it worked. I remember after the first ablation, after a week I couldn't wait to get back to my exercises and did Tabata intervals on my Schwinn Airdyne. I of course went into strange arrythmia and felt like death. I called and got Salwa on the phone. She determined I was actually going to be okay then gave me a gentle scolding which actually made me feel a lot better. I don't know how that works exactly. But she is an angel. I can't think of a single criticism of any person or experience I've had at CPMC.
Cheers back!
Mike