Starting new thread on Isolating LAA topic

We were having a good discussion regarding isolating the LAA, but we were quite a ways off the original topic. I think it was under an original posting my Oceanmike asking for a doctor recommendation.

Anyway, we were discussing how Dr. Natale seems to have established a treatment pattern where he isolates the LAA more often than other EPs. (I think primarily for those with persistent A-fib.) Then he follows up with a Watchman implant.

And, indeed that is what he did for me. And it brings up the discussion of how an isolated LAA may mean never getting off Eliquis, even with the Watchman.

So someone mentioned that he is aware of elite EPs who are more reluctant to isolate the LAA; and can achieve NSR without doing so.

I typed all this background to lead up to this: According to the procedural notes from my ablation, Dr. Natale treated several areas of my heart before isolating the LAA. So aren't these the areas the other EPs would be treating? Natale only isolated my LAA when I remained in A-fib after he ablated the "safer" areas. Once he isolated my LAA, I converted to NSR.

So that would make it appear Natale did no more than he had to. Unless he would have stopped short of isolating the LAA, and left me in A-fib.

I think your analysis is spot on.

I do not believe that he isolates the LAA automatically or casually. He knows better than most what the consequences are.

I brought this over from one of my posts on the other thread here: [www.afibbers.org]

Unlike many elite EPs, Natale believes in empiric (Iwithout demonstrated LAA triggers) LAA isolation. I cannot speak to your case, and whether another EP could have achieved same result without the isolation, but can state that many other EPs weigh the thrombotic risks of LAA isolation differently from Natale.

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 09/02/2026 04:17AM by mjamesone.

NonThumper: Natale only isolated my LAA when I remained in A-fib after he ablated the "safer" areas. Once he isolated my LAA, I converted to NSR.
So that would make it appear Natale did no more than he had to.

Not really. It just shows his approach is different.

The fact that LAA isolation was the step that terminated your AF doesn’t necessarily mean it was necessary for success. The alternative wasn’t going home in AF, as they could have cardioverted you. That’s what they did with me, and I have been AF free since.

See the randomized CAPT-AF trial. It compares stopping after a predefined lesion set and then cardioverting versus additional lesion sets. No significant improvement in the primary arrhythmia-free endpoint with the termination strategy.

Now that doesn't mean isolating your LAA didn't give you a better chance, we really don't know, but what we do know is that it came at the expense of a greater thrombotic risk.

[www.heartrhythmjournal.com]



Edited 1 time(s). Last edit at 09/02/2026 07:34PM by mjamesone.

Quote
mjamesone
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 "

I'm aware of that statement but the important words are with non-paroxysmal AF, especially longstanding persistent AF. Specifically, he does not do empiric LAA isolations with paroxysmal afib.

But here's the thing: I'm aware there are EPs who disagree with him on this, but I'm unaware of any EPs who can match his success rates with LSPAF. He does better with LSPAF than EPs as a whole do with paroxysmal, which is quite an achievement. I find it very difficult to argue with superior results.

Quote
mjamesone
The fact that LAA isolation was the step that terminated your AF doesn’t necessarily mean it was necessary for success. The alternative wasn’t going home in AF, as they could have cardioverted you. That’s what they did with me, and I have been AF free since.

He isolated the LAA because he mapped afib signals originating there. I know this because I've read a couple of dozen afib procedure reports from Natale patients, I've heard him speak at conferences, and I know he does that routinely. He really doesn't ablate much of anything empirically. He's all about mapping and generally does it more extensively than most EPs. He's also about challenging the afib when he thinks the procedure is complete. He often spends an additional 20+ minutes doing that using isoproterenol and pulsed electrical stimulation. If he provokes an arrhythmia, he maps that and ablates it. Sometimes that mapping happens to point to the LAA.

Carey: He really doesn't ablate much of anything empirically.

We both seem to agree that he does for persistent, which involves many of us, including myself and the Mayo poster who had successful ablations without the isolation,

Carey:
But here's the thing: I'm aware there are EPs who disagree with him on this, but I'm unaware of any EPs who can match his success rates with LSPAF. He does better with LSPAF than EPs as a whole do with paroxysmal, which is quite an achievement. I find it very difficult to argue with superior results.

I doubt he even does better than other elite EPs at high volume centers do with PAF. And dispute he does better with LSPAF than other elite EP does with PAF. He may do better than other eltes comparng LSPAF with LSPAF, but again the trade off might be a higher thrombotic risk.

Jim



Edited 2 time(s). Last edit at 09/03/2026 01:44AM by mjamesone.

Quote
mjamesone
I doubt he even does better than other elite EPs at high volume centers do with PAF. And dispute he does better with LSPAF than other elite EP does with PAF. He may do better than other eltes comparng LSPAF with LSPAF, but again the trade off might be a higher thrombotic risk.

I wasn't comparing him to other elites. I was comparing him to the widely published success rates for EPs across the profession, which run about 75% for PAF and 45-50% for LSPAF. Last time I saw published numbers, his success rates for LSPAF are a little over 90%.

As for thrombotic risk, if he created more thrombotic risk than other EPs, that would show up in his data and it doesn't. Unlike most EPs, he actually publishes his numbers.

Also, if you look at the attendees list at ISLAA, you'll find most of those elites are on it. I suspect you underestimate how many EPs do LAA isolation these days, particularly with LSPAF. And the ones who do are pretty much all elites.

Carey: Last time I saw (Dr. Natale’s) published numbers, his success rates for LSPAF are a little over 90%.

I get 56% and 63.5%. Sources: BELIEF and ADVANTAGE AF trials.

As to LAA isolation increasing thrombotic risk. No one, even Natale. disagrees. That’s why his safety profile includes anticoagulation for life and/or Watchman. It's a trade off. Personally, I wouldn't take it and if it came down needing it, I'd go with a surgical ablation such as the Wolf Procedure with AtriClip. Also better results for LSPAF, but no anticogulation needed after.

Jim

Quote
mjamesone
Jim: I get 56% and 63.5%. Sources: BELIEF and ADVANTAGE AF trials.

Looking at BELIEF from Gemini AI summary:
Higher Success Rate: After 24 months, about 76% of patients who had the LAA isolation procedure stayed free of irregular heart rhythms.
Standard Comparison: Only 56% of patients who received standard ablation without LAA isolation remained free of abnormal heart rhythms.

These data are for all EP's in study, not limited to AN.

George: After 24 months, about 76% of patients who had the LAA isolation procedure stayed free of irregular heart rhythms.

George, that 76% includes repeat ablations. The single procedure success rate in the BELIEF trial was 56%

Natale was listed as an investigator in both trials. I don' know how many of the ablations he himself performed. And even if he did incrementally better because of his elite skill set, I think we are starting to deviate from the main subject. Which is whether a higher success rate is justified by increasing the thrombotic rate from LAA isolation. That's something everyone has to decide for themselves, and I think we've had a good discussion on that.

Jim

I agree this has been a good discussion. My LAA has been isolated, so nothing for me to do but hope for the best. I have tolerated the Eliquis up to now all right. And have had the dosage reduced to 2.5 mg twice daily now that my Watchman is in.

I was told the hope was to get off Eliquis entirely if my atria shrink back down to normal size. I was told the chances of that were on the order of 60%. But the response to Qwackertoo's thread about reverse remodeling was not real encouraging.

So for the benefit of others who have not committed yet, how would one find one of these elite EPs who get good results converting persistent A-fib without isolating the LAA? Dr. Natale's name comes up here repeatedly, but what are the names of the doctors who follow the different school of thought?

Lastly, I have trouble having faith in cardioversions long term. The one I had prior to my ablation did not last a week. Prior to that cardioversion, my Cardiologist put on the happy face that one jolt my revert me to NSR permanently. But when she read the EKG saying I was back in A-fib, her demeanor gave her away that this was what she expected all along.

Plus, I read where others have had dozens of cardioversions. But that does not mean that one may not do the trick after most of the pathways for spurious signals have been ablated.

Other than the risks involved every time one has a procedure, it seems logical that a person would not get the LAA ablated on the first ablation. But a surgeon with a lot of experience is going to feel qualified to use their best judgement while in the operating room. It is a discussion I wish I could have had ahead of time, but I didn't know to ask.

NonThumper; how would one find one of these elite EPs who get good results converting persistent A-fib without isolating the LAA?

I would start by looking for EPs at the top ten-rated cardiac hospitals such as Johns Hopkins, Mayo Clinic, Mount Sinai, and Penn Medicine.

Alternatively, in complicated cases, or where past catheter ablations have failed, consider surgical ablation such as the hybrid convergent or the Wolf procedure, where success rates are at least comparable to LAA isolation, but with the added benefit of clipping the LAA, so patients can often stop taking anticoagulants entirely vs anticoagulation for life and/or Watchman for LAA isolation.

It’s unfortunate that when you spoke to Natale, not only didn’t you know about LAA isolation, but he never brought it up.

But it’s not limited to Natale. Many EPs assume you’re leaving it all up to them, which is an option many seem comfortable with.

But personally, I like to do as much research in advance as possible so I can better ask questions and better analyze how well their approach aligns with what I want.

Treatment philosophies vary from EP to EP. So in the end, the best EP for one person may not be the best for someone else.

Jim



Edited 1 time(s). Last edit at 09/06/2026 06:52PM by mjamesone.