Afib Has Returned

After a very successful ablation with Dr. Natale in 2017, afib has returned. It was diagnosed via a holter monitor over 2 weeks.

In 2024 we moved from Texas to Northern Virginia. I am more than willing to travel to Austin for treatment, however if there are great options within driving distance, I would consider those.

The name I came up with is Dr. Hugh Calkins at Johns Hopkins in Baltimore.

Does anyone have any insights or suggestions?

Thanks, Mike

I'm not familiar with him but his credentials and experience look good. He focuses on afib ablations, and that's who you want. You want the guy or gal who lives and breathes ablations and has done thousands of them, which he probably has. You also want a large institution that does many procedures per year, and I'm sure that describes Johns Hopkins.

What you might consider doing is booking a telemedicine consult with Natale to get his opinion. If this guy is as big in the ablation world as it appears, I'm sure Natale will be familiar with him and he won't hesitate to endorse him if deserved. If he won't, well, then that's a very important data point.

Hopkins and Calkins are excellent. I came across his name when I was trying to get into the PFA trial and I believe he was running it. Hopkins is a top-rated and high volume center, exactly what you want.

Jim

I believe Hopkins is a teaching school. I live in Baltimore and been to Hopkins many times, non cardiac related, and there were always students in the room. I myself would want Calkins and not a student doing it.

MikeN: I myself would want Calkins and not a student doing it.

I hear you, but that is not always possible. But there have been studies that show results are just as good at these teaching hospitals versus private. It's important to understand that you will not get an intern or resident doing anything difficult. It would tend to be a seasoned Fellow, who has probably done hundreds and Caulkins would probably be scrubbed in and present during the whole time. In a way, having two or three mind and sets of hands is not necessarily a bad thing.

That said, it's reasonable to ask the surgeon at a teaching hospital, who will be doing what part of the procedure. And if you're uncomfortable with the answer, express that to the surgeon and try and work something out. So speak to Caulkins and see what he says.

My Cryo was done at a major teaching hospital and to this day, not sure who actually did exactly what, although the surgical notes do state that my EP was present the entire procedure and performed all critical elements. The bottom line is that these teaching hospitals have the highest success rates, so if you pick a top teaching hospital, with a top EP, then I would not overthink.

One thing I did learn in one of the conversations with a forthright EP, was to try and avoid having your ablation during July or early August. That's because the Fellows often rotate July 1st. But he did say by September, they usually know which side of the catheter goes in

In spite of that I had non-cardiac surgery at a major teaching hospital a few week ago. It was something I did not want to put off, new Fellows or not. It went well.

Jim



Edited 1 time(s). Last edit at 08/18/2026 03:32PM by mjamesone.

Many -- probably most -- teaching hospitals won't allow patients to restrict Fellows from participating in the procedure. But keep in mind that a Fellow isn't a med student or even a resident. They're a practicing cardiologist and likely already board certified.

FWIW my 1st ablation performed at a teaching hospital, Indiana University/Methodist (by a then, maybe still? no clue) respected EP, Dr. John Miller. He was following bad science - I think he literally bought into (FIRM/Rotor mapping). I was under general 11hrs47 mins. I had serious post-procedure complications, and he managed to introduce tachycardia, and afib was back in less than 6 weeks as I recall. Horrible, horrible experience. 3 months later Dr. Natale fixed me, durable to this day. So the lesson is, YMMV. Cycling through tachy, afib and NSR brought on many near syncope episodes due to conversion pauses.

I'm happy to report that Dr. Natale has reviewed my test results and agreed to do a Redo ablation with a possible Watchman implant. This was my preferred outcome. Just have to wait on the scheduler to give me a date. They said it could be 2-6 months. Hopefully sooner.

Appreciate the feedback.

Mike

Glad things worked out. In case you're not aware, newer studies such as OCEAN and ALONE-AF are changing the way many EP's handle anticoagulation. The Readers Digest version is that where anticoagulation was once for life, now many of us are being let off of them after a sucessful ablation.

If this is something appealing, I'd then reconsider the Watchman and also discuss with Dr. Natale, under what cirumstances to do, or not to do, an LAA isolation, which is something he practices more than most EPs. Once isolated, anticoagulation and the Watchman becomes less of an option and more of a necessity.

Jim



Edited 1 time(s). Last edit at 08/22/2026 06:52PM by mjamesone.

Quote
mjamesone
Once isolated, anticoagulation and the Watchman becomes less of an option and more of a necessity.

My recollection is the odds of needing anticoagulation after an LAA isolatiron are approximately 60%. I have a friend that required several years after an isolation with Natloe to have TEE results that passed and he no longer requires anticoagulation. That being said, I have a number of personal friends who are very greatful that an isolation solved their rhythm problem. Certainly, Natale only uses that tenchnique when required to solve the problem.



Edited 1 time(s). Last edit at 08/24/2026 12:09AM by GeorgeN.

Natale only uses that tenchnique when required to solve the problem.

I have a problem with the word "required". I'm sure he uses LAA isolation when he believes it's necessary to achieve a durable result, but other highly experienced EPs may treat the same patient without the isolation. My point is that his approach is different from many at the top level, not that it's good or bad. As a patient, it's up to us to do the homework and see if an EP's approach aligns with what we want. In my specific case, his Natale's approach didn't, and that is why I looked elsewhere.

I also question the 60% figure you cite if it means that the don't need either AC's or Watchman after the isolation. But even so, that still still a high percentage.

Jim



Edited 2 time(s). Last edit at 08/23/2026 04:45PM by mjamesone.

Jim, how might other EP's treat persistent A-fib without isolating the LAA? I went the Natale route, and I do not regret it, but I now realize I didn't do enough research before hand. I think this would be a good discussion for those patients who have not committed yet.

The way I read the notes that Natale made on my initial procedure, he kind of snuck up on the LAA. He tried ablating several other regions of my heart first, and when that did not convert me to NSR, he went ahead and isolated the LAA.

Now there is some blame on me for not boning up ahead of time. I have to admit I went into the procedure without the knowledge that if my LAA was isolated, then I may be on blood thinners forever. Of course, if I had no ablation, that would have been the case anyway.

I don't think I would have liked it if I had woken up from my procedure and he had stopped short of isolating the LAA, leaving me in A-fib, pending further discussion and another procedure.

how might other EP's treat persistent A-fib without isolating the LAA?

Other EPs may deliberately stop short of isolating the LAA, not because it wouldn't necessarily help, but because of the resulting stroke/anticoagulation issues.It's risk vs benefits. So instead they may ablate other areas that might also be driving the AF, It's about how aggressive you want to be. It's not which is the right approach, it's what is the right approach for you.

Jim

Quote
nonthumper
I don't think I would have liked it if I had woken up from my procedure and he had stopped short of isolating the LAA, leaving me in A-fib, pending further discussion and another procedure.

No, you wouldn't have liked it at all. I spent 7 years dealing with exactly that. Three EPs with impressive credentials, 5 ablations, and none of them even knew how to figure out that my LAA was the source, much less how to isolate it. And then I wised up, went to Natale, and in the shortest ablation I ever had, he stopped it cold by isolating my LAA.

This is why there's an annual conference dedicated solely to LAA isolation issues and education. The conference is ISLAA, and Shannon and I were lucky enough to be able to attend one in Kansas City prior to COVID. It was very interesting and the speakers were all EP elites. It's a valuable skill but still too many EPs haven't been trained in it and some even refuse to learn because their training (years ago) was to stay away from it. Those are the ones you'll hear dissing EPs like Natale, calling him "overly aggressive" and "a cowboy."

Quote
mjamesone

I also question the 60% figure you cite if it means that the don't need either AC's or Watchman after the isolation. But even so, that still still a high percentage.

Jim

Quoting Shannon on the 60%
[www.afibbers.org]

Quote

Other EPs may deliberately stop short of isolating the LAA, not because it wouldn't necessarily help, but because of the resulting stroke/anticoagulation issues.It's risk vs benefits. So instead they may ablate other areas that might also be driving the AF, It's about how aggressive you want to be. It's not which is the right approach, it's what is the right approach for you.

This should be a discussion with the EP prior to the ablation and I'm pretty sure Natale brings this up, if I recall correctly from discussioins with friends who've gone through the process with Dr. N.

Simply as a matter of fact, Dr. Natale did not discuss any possibility of LAA ablation or its consequences with me before my initial procedure. And that is when he isolated mine. As another of matter of fact, my only appointment with him prior to the procedure was a telehealth visit which he was several hours late for, because doctors can have emergencies interfere. And I got the impression he didn't have much time because it seemed to be one of those days that doctors can have.

Telehealth was for my convenience to save me a trip from so far away. In fact, I chose Natale over another doctor at another facility because Natale did offer this virtual appointment.

I am not trying to cast aspersions on Dr. Natale. But he did not bring this up, and I did not know what questions to ask. I have already admitted I did not know enough going in, and that is on me. I am offering up my experience so that others may be better prepared than I was.

Before deciding on Natale, I had an in-person appointment with an EP in my home state who I decided against using. He did not mention anything about the LAA either, and this would have been my last visit with him before the day of the procedure, if I had gone on to make that appointment. From what I have learned on this website, I suspect this doctor would have not gone near my LAA, and I would have wakened still in A-fib.

I am thankful Dr. Natale got me into normal sinus rhythm. I only want others to have as much info as possible. So perhaps the biggest thing I learned was prospective patients should learn about isolation of the LAA and bring it up if the doctor doesn't.

I am still hopeful that I got the best possible care and outcome for my specific condition.

The EPs Shannon was talking about who stop short of isolating the LAA for rational reasons are EPs who understand how to know it needs isolating, how to do so, and what the risks and benefits are. Unfortunately, that doesn't describe the average EP even today, 9 years after mine was isolated. Most EPs don't actually know how to map the LAA or how to isolate it. That was demonstrated quite nicely a few years back by my favorite EP curmudgeon, who in the midst of an article criticizing LAA isolation asked how one went about getting a catheter into the LAA in the first place (answer: you don't).

Over on Mayo Community Connect Forums, one person stated he dismissed Natale because he insisted on performing an LAA isolation without even seeing him. I pointed out to this person that his three previous failed ablations might have been the clue to someone as skilled and experienced as Natale. Nope, he was not having hit.

SMH.

Gloaming: Over on Mayo Community Connect Forums, one person stated he dismissed Natale because he insisted on performing an LAA isolation without even seeing him. I pointed out to this person that his three previous failed ablations might have been the clue to someone as skilled and experienced as Natale. Nope, he was not having hit.


Is this the discussion at Mayo Connect? Apparently the person finally did have an ablation without isolating the LAA and is doing fine. It was his sixth ablation.

"I would also recommned UCSF and Dr. Gerstenfeld. I spoke with Dr. Natalie and he was hell bent on ablating my atrial appendage without seeing me. Saw Dr. G and my appendage was fine. He and his team took the time and used both RFA and PFA with the Aferra system this last May. I am now 3 months out and no fib no flutter and exercising regularly. I was an avid cyclist doing 100 mile rides in about 5 hours. I will add this was my 6th ablation. Dr. G and team spent 5 hours finding the problems. I will add to that Dr. G specializes in abnormal rythms following ablations.'

[connect.mayoclinic.org]

Jim



Edited 1 time(s). Last edit at 08/24/2026 04:22PM by mjamesone.

Cary: The EPs Shannon was talking about who stop short of isolating the LAA for rational reasons are EPs who understand how to know it needs isolating, how to do so, and what the risks and benefits are. Unfortunately, that doesn't describe the average EP even today,

Carey,

It looks like you were referring to my quote and not Shannon's. It was a confusing attribution.

ie I wrote: "Other EPs may deliberately stop short of isolating the LAA, not because it wouldn't necessarily help, but because of the resulting stroke/anticoagulation issues.It's risk vs benefits. So instead they may ablate other areas that might also be driving the AF, It's about how aggressive you want to be. It's not which is the right approach, it's what is the right approach for you."

So maybe we do have some agreement here. To clarify, I was never talking about the average EP, but the elite's. Within this group, it's not about skill, it's about weighing benefits vs risks of isolating the LAA. Natale seems to be more willing than many other elite EPs to isolate the LAA for the same patient. Therefore, again, it's really up to us as patients to decide for ourselves which approach we are comfortable with.

Jim

Yes, that's the one, Jim.

From a Natale authored paper in 2020:

[www.jacc.org]

'We feel that in patients with non-paroxysmal AF, especially longstanding persistent AF, LAA should be isolated (no focal ablation) without evidence of triggers "

So in case any confusion still exists, Natale believes in empiric LAA isolation (Iwithout demonstrated LAA triggers) for many of those with non-paroxyysmal Afib, which is a very large group. This explains why he told the poster over at Mayo that he would isolate the LAA even before seeing him. It was apparently based on his Afib category.

By those standards I very possibly would have had my LAA isolated had I gone to Natale. Yet, both the Mayo poster and myself had successful ablation without the isolation. And by avoiding the thrombotic risk of LAA isolation, one retains the possibility of coming off of anticoagulation entirely per recent trial data. In my case I was allowed off of ACs after 4 months. Had my LAA been isolated, I would not have had this option.

Jim



Edited 1 time(s). Last edit at 08/31/2026 03:58PM by mjamesone.

Tomorrow I leave for Austin, for my procedure on Thursday. I spoke with Dr. Natale yesterday (telemed) and he said he would most likely install the Watchman. Thanks for the great information here on the forum. I'll let you know how it goes.

Mike