What % of EPs are capable of isolating LAA?

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.

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.

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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.

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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.

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.

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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.

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

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.

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.

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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.

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.

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

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.

I have been struggling with this very issue, but not because of persistent afib. I had 2 ablations, the last over 4 years ago. Since the end of the blanking period, I have had 3 episodes lasting a total of 14 hours. That means my afib burden is 0.04%. It’s well established that the lower the afib burden, the less likely the incidence of stroke. A couple of years ago I had a bad fall. I fractured a wrist in numerous places and had a double brain bleed. I was eliquis during the fall. Fortunately, the bleeds healed, and my neurologist cleared me to resume Eliquis. I’ve had a few falls (not as serious) since and gone to er for ct scans. No further bleeding.

Not wanting to live like this for the rest of my life, I’ve been considering a watchman device to get off eliquis. The problem was I never accepted that leaks under 5mm were clinically acceptable. It was a random number. In Europe they chose 3mm as their random number. By now, many if not most top eps believe no leak is acceptable. That’s why the watchman ng is currently being tested as well as a foam closure. The goal for each is no leaks.

I believe Natale does an electrical isolation of the laa when he does a watchman, since doing one after a watchman is much more complicated and prone to problems. If the laa has been isolated, it no longer pumps and (1) will let blood accumulate and pool in a leak spot, and become a stroke risk, and (2) no longer produce some chemical that is now recognized as important. All this without even knowing if isolating the laa will be beneficial. I believe in burning only as much tissue as is needed to maintain nsr.

There are currently studying the use of an anticoagulant as a pill in a pocket. I don’t qualify for the study because of prior brain bleed, but that should really be irrelevant as my neurologist, one of the best in the USA, has cleared me for eliquis, which I’ve been taking since the bleed 2 years ago. I may still follow this protocol because I don’t see the logic of being on a dangerous anticoagulant 100% of the time when I’m only in afib 0.04% of the time. After a 1 hour or longer event, you take eliquis for 30 days.

Any thoughts appreciated. Anyone who thinks that an anticoagulant is safe, need not say so. I strongly disagree and my goal is to get off it. Cheers.

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jasams
I believe Natale does an electrical isolation of the laa when he does a watchman, since doing one after a watchman is much more complicated and prone to problems.

This is not correct. Natale isolates the LAA only if the LAA is in fact a source of afib or flutter. The LAA can be isolated with a Watchman in place, but you're right that it does make it a little more complicated. But not impossible by any means. It's also not true that the LAA no longer pumps following isolation. Its pumping action may be reduced to the point where a Watchman or lifelong anticoagulation is necessary, but that's only true for about 60% of patients. About 40% don't need to do anything further.

If the pumping action is reduced to the point that requires lifelong anticoagulation or a laao device, then clinically speaking, it’s not pumping. Also, the fact that Boston scientific is developing and is now testing a new generation of the watchman should lead to the conclusion that the leak problems of the previous generations are not merely theoretical.

There are currently studying the use of an anticoagulant as a pill in a pocke[/i

That would be the REACT-AF trial. I have also adapted a modified version of that protocol in the past as opposed to daily AC, for reasons you mentioned.

My modification was to extend the one-hour, 30-day AC trigger point to 10 hours, based on both prior estimates of clot formation and the fact that trial participants are only required to wear the Apple Watch monitoring device 14-hours a day, which means in theory that an 11-hour AF window while not following the letter of the trial, does follow the spirit. The 10 hour wait gives ample time to convert either naturally or via PIP antiarrythmics, therefore limiting further the exposure to daily ACs.

In addition to the pilot studies that REACT-AF is based on, newer studies are showing that AF frequency may be a more important factor than simply the CHADS risk score. All this makes me rethink the role of irreversible interventions such as Watchman and LAA isolation, when it seems increasingly plausible that many of us may be managed either by PIP AC's in the future, or not even need them at all. Given my very low AF burden, my only hesitancy in embracing these emerging theories is that study data is weighted mostly for CHADS 1-3 and I'm a CHADS 4.

Jim