Two days post-Natale ablation

He said it went well, only 2-1/2 hrs, but he did have to go in to LAA. Will have to see how that turns out. Could you give me some more reading refferences on this subject please? so I know what to expect. I am, of course, still on Coumadin, still using flecainide PIP because of kidney problems, down to 100mg metoprolol and (hopefully) reducing. Pulse rate has gone from 60 to 80. This is all new territory.

Neroli,

I think the reason you have not received any replies yet is probably because ablating the Left Atrial Appendage (LAA) is a relatively new addition to the lesion set.

By the way, it is not uncommon to have an elevated pulse rate for a period of time following an ablation.

Where did you have your ablation done?

Buster



Edited 1 time(s). Last edit at 06/17/2012 05:33PM by Buster.

Neroli,

I have found more articles on Medline regrading LAA isolation than I thought there would be.

Here's the search I used: (atrial fibrillation catheter ablation) AND "left atrial appendage"[title]

Here's an article co-authored by Dr. Natale that has a link to the full-text PDF:

[www.ncbi.nlm.nih.gov]

Buster



Edited 2 time(s). Last edit at 06/17/2012 05:59PM by Buster.

LAA isolation is becoming a more controversial subject. At the HRS meeting, randomized results were presented by another research group (Callans and Marchlinski) that suggest that LAA isolation doesn't improve ablation success rate. Natale's group remains the lone proponent currently. More long term followup results are needed.

researcher,

Thanks for posting that information regarding the controversy surrounding LAA isolation! It's very interesting. If I understand the following abstract correctly, the researchers found that inadvertent isolation of the LAA can occur during catheter ablations:

Heart Rhythm. 2010;7(2):173-80. Epub 2009 Nov 5.

Inadvertent electrical isolation of the left atrial appendage during catheter
ablation of persistent atrial fibrillation.

Chan CP, Wong WS, Pumprueg S, Veerareddy S, Billakanty S, Ellis C, Chae S,
Buerkel D, Aasbo J, Crawford T, Good E, Jongnarangsin K, Ebinger M, Bogun F,
Pelosi F, Oral H, Morady F, Chugh A.

Division of Cardiovascular Medicine, Cardiovascular Center, University of
Michigan, Ann Arbor, MI, USA.

[www.ncbi.nlm.nih.gov]

Buster

He did not do an isolation of the LAA, but he did have to track down some sources of arrythmia from there and ablate them. As I understand, this can work out okay (they do not burn as deeply or for as long because of the lesser thickness of the tissue) or it can lead to the necessity of the the isolation of the LAA with the lariat procedure at a later date.. I will read the reference you provided (thanks! Buster) and will search for others. Not doing much computer time at the moment.

Neroli,
It sounds as though you are doing well. Dr. Natale did my ablation in 2010 and he isolated the LAA. As a result, I am on lifelong anticoagulation. Following the ablation, other than warfarin, I was not placed on any medication. I did have metoprolol and propafenone to use as a PIP should I need it but I had no sustained afib. I did take the metoprolol once for tachycardia.
I wish you an uneventful recovery and NSR forever.

Be well,
Laura

Hi Neroli,

Best of luck with your ablation. You had the best so its a good place to start. I too am up for my second ablation in eraly August with Dr, Natale to complete what he wasn't able to finish in my first very long ( 2 hours or actual burn time) hybrid ablation for what was at the time persistent AFIB.

I havent have one blip of AFIB since, as Natale said at the time I likely would never have that again. But he did caution that I would very likely require at least one more procedure to deal with an anticipated atypical left atrial flutter as a consequence of the long ablation and many burns needed tot quell the AFIB ... and the fact that toward the end of that procedure a rate dependant infrahisian left bundle branch block I have had fro a long while triggered and then dropping my blood pressure precipitously requiring him to terminate the ablation with a cardioversion while he was still finishing up the challenge testing portion.

Dr N figured I would be back within a year to a year and a half but I made it four years with the full Strategy protocol and all the other supportive steps I have taken. But as Natale said to me a few times, with that open flutter circuit in there it might become increasing difficult to keep it quiet with biochemical adjustments and supplements alone and that indeed has proven true.

Ive had 13 atypical left flutter episodes in hte last 13 months each one requiring a same day ECV at a local ER where ever I happen to have been. That is getting close to some kind of record and not the kind one wants to shoot for! After this last one two weeks ago, any last questions and reservations were set aside.

I have been on majour magnesium and potassium repletion with not only 800mg/dauy of Jigsaw time released Mag-Malate but 4 weekly dose of 2grams of Mag Sulfate IM and one Myers cocktail a week with 4 grams of IV magnesium sulfate each week for the last 8 weeks!


PLus plenty of potassium. Finally this last flutter and cardioversion, my Cardymeter potassium confirmed 4.5 which was the same as the serum K drawn at the ER and my serum Magnesium was on the high side at 2.6 where before it had been around 2.2 and with a low Exatest mag.

Since I now have a reasonable level of both Mag and Potassium and still triggered into flutter, the last criteria I held out for has been settled and its clear Dr. Natale was right in my case and I cant keep getting shocked once a month indefinitely.

Dr N said that all my 'heroic' strategies and efforts to balance my biochemistry will work far better once this very sensitive open flutter circuit is ablated and then hopefully I no longer will have to walk such a tight rope trying to keep that flutter at bay.

I want to be clear though that I am a BIG supporter of the Strategy and know that it has helped a great deal, even if it wasn't enough in my case to avoid another visit to Dr. N's table was was predicted from the beginning. My situation is a bit different than many here and my flutter was always more of a mechanical issue from the past ablation burns than strictly a matter of Mag and K levels and such. So no one should be discouraged simply because I need the second 'tune-up' Dr N always said I would require.

In any event, I'm keeping my fingers crossed that he can avoid having to fully isolate the LAA, but even if he does need to isolate the LAA to kill the flutter, at least there is a 50% chance my LAA blood velocity will still exceed the 4.0m/sec or greater flow rate after TEE testing 6 months after the ablation. If I'm on that lucky side of 50% I wouldn't need to stay on any blood thinner in any event... so it's a toss of the dice here, but one I have little choice at this point but to go for and hope for the best!

At least I know I'm in as good of hands as humanly possible.

P.S. Dr Natale doesn't isolate the LAA unless its necessary and, as apparently was in your case, he often will first do a focal ablation of trigger points within the LAA, if any are found, and only if that then fails to stop the breakthroughs will he then go ahead and isolate the full LAA in a second or third procedure. It all depends on what he finds in there at the time of ablation.

The Lariet device to seal the LAA from the outside seems the better of the two mechanical options ( Watchman being the other) for 'possibly' eliminating the need for a blood thinner should any of us require a full isolation of the LAA AND our velocity report comes back showing too low a velocity and thus require life long anti-coag. But like the Watchman, the Lariet is still having a few kinks worked out as well to insure a full closure in 90+% of the cases with no remaining small pockets left in the LAA in which clots might still form.

Hopefully, they will have the Lariet procedure even better refined by this time next year and fully ready for prime time? The good news is that there appears to be a couple of good options reaching a stage of development in the not too distant time frame that should make it possible for most of us that might require coumadin long term, the choice of going off of it as well. Time will tell.

Best wishes on your outcome as well!

Shannon

Cheers Shannon

Hi Shannon,

One encouraging note is that Dr. N recognizes the value of your "'heroic' strategies and efforts to balance [your] biochemistry."

George

Yep George, Dr. N has always been open minded with me about these efforts and never tried to discourage me from taking them.. Maybe he realized I was pretty well committed to doing every thing I could and was going to go for it come hell or high water in any event. I dont think he flet the Strategy was a substitute for ablation for most people who are at the point of needing an ablation, but he did recognize they might help somewhat in some cases.

I think most docs look mainly at serum levels of Mag and Potassium and thus its easy to see what looks like the limitations of the protocol when what looks like solid even upper normal range serum Mag and K levels are so frequently accompanying AFIB breakthroughs =.. not necessarily realizing teh IC stores are likely very low in many people.

But then there are folks like me that apparently have a complex nature to my FLutter and past AFIB issues that , while the supplemental do indeed help.. they are not able to stem the tied enough to prevent . what in this case is a needed left flutter ablation since my only way out is to get Cardioverted everytime.

That I've learned is playing a bit of Russian Roulette when too many times you have to depend on new and sometimes unknown ER docs!

Less than two weeks ago during my latest Flutter episode and 13th cardioversion in 13 months, the ER doc in a small Arizona town near Sedona where I am living now made a mistake with the Propofol anesthesia ( noramlly its a great drug for this purpose and is fast acting and very fast recovery with no hang over at all) But this fellow instead of using 120mg as I said always works, he used 100mg and pushed in in the IV far too slowly allowing the fast metabolizing drug to start to wear off before I was even asleep!

I had just started feeling like floating on a cloud and said 'good night' and closed my eyes when no sooner than I heard he said to his nurse who was manning the Zapper machine. "Okay go ahead and push the button". I tired to shout 'Not Yet" when the whole world exploded with 100+ joules in the chest whilke still wide awake!

My first startled comment to the even more startled ER doc, after peeling me off the ceiling, was: "I was still awake!!". He then replied "But your eyes were closed and you were slurring your words"... My next comment was "The slurring my words part was your first clue NOT to push the button yet!!" I felt like saying a few other choice words to him as well, but discretion got the better of me at the moment while still laying on the table.

Normally when knocked out and shocked your body is totally limp and relaxed through the whole motion of the shock and you know nothing at all with little to no residual pain or stiffness. When the full blast hit me so unexpectedly like that as if someone threw a 480 volt line across my chest, my whole body tensed and jerked such that it really sprained my lower back and neck some and I am just now getting my full mobility back.

Moral of the story, if you have to go through ECV too many times then you are rolling the dice a bit even though it is overall a fairly simple procedure. No matter how thoroughly you can, and do, try to coach the ER personnel to make sure they do it all right (like insuring they Sync the machine to your pacer when you have one installed ..etc, etc.) you can't think of everything all the time. How could I have imagined that beforehand I would have to tell the ER doc handling my case that day to make bloody well sure I was well knocked-out before pressing the button!? You'd think that would be one of hte first steps drilled into them at an ECV 101 level class... and to certainly not shock me when I was still 'slurring my words' .!

Such experiences definitely incline one to finally get it taken care off.

Take care Shannon

Hi Shannon - Thanks for taking the time to tell your latest news and relate your four-year saga. I agree that your diligence and The Strategy and your heroics with the Magnesium infusions bought you some time and I'm confidently optimistic that this next procedure will be that last little tweak Dr. Natale needs to complete the original and that you will not need life-long anticoagulants.

We will all be sending Angels to you and Dr. Natale on August 6.

Best to you. We'll be watching for your news.
Jackie

Many thanks Jackie,

I too feel confident, as does Dr. Natale that he can finish it up this next go around. Referencing the article above Buster kindly posted from Natale's group titled: "Left Atrial Appendage: An Under-recognized Trigger Site for AFIB' .. out of a total study sample of approximately 3,800 total ablations in a 2 year time span chosen for this study period and done at St Davids in Austin, Cal Pac MC in San Fran, Catholic Univ in Rome and Ospedale dell' Angelo in Venice Italy, Case Western and Akron General in Ohio and Stanford Univ in Palo Alto ... those who needed a second ablation for breakthrough AFIB or left flutter numbered 987 .. and out of those 987 just 266 (a total of 27%) of those patients showed any LAA firing at baseline during the EP study portion of the second ablation and thus only these 266 were including in this study on the effects of LAA focal ablation and/or LAA isolation.

Thus, if these numbers translate into the general population of those who have some repeat AFIB/Atrial Tachycardia (mostly atypical left flutter) after their first ablation, then there is only a 27% chance that he would have to even address the LAA in the second ablation to begin with.

According to Dr. Natale my odds are a little higher that at least some work in or around the LAA could well be needed sicne that is the last area he was working on in me in the first ablation when that Left bundle branch block triggered and he had to terminate the ablation with a cardioversion ( what turns out to have been the very first ECV out of a total of 16 shocks that I have now had since then). I was totally quiet for almost a full year after the ablation and then had another 15 months of quiet after the second cardioversion and first ECV after the ablation. The frequency kicked in staring in May of last year with 13 since May 4 of 2011.

In any event, he still may not need to isolation the LAA, and even if he does have to isolate it, there is still yet that 50% odds that the LAA blood velocity will be high enough to avoid the long term anti-coag in any event.. So, I'm putting all my angel requests on that side of the ledger and the odds look good from here..

Thanks for the best wishes Jackie!

Cheers! Shannon

P.S. Jackie,
There is no question that the Strategy has helped me a lot! Last summer my flutter episodes were happening like clock work at 23 day intervals.

I had assumed my IC Mag was fine since I had two bowel movements a day with no constipation at all and was taking 800mg of Jigsaw Mag orally and at taht time 2gram of Mag sulfate I.M. injection 5 days a week . But my Exatest came back still low in IC Mag at 32!

Adding to my ongoing Mag protocal when I included 4 grams a week of IV Mag Sulfate too, that seems to have really helped and its the only thing that also raised my serum mag and red cell mag levels as well toi the upper end of each of those 'normal' ranges.

Since adding in the IM and IV Mag sulfate my flutter episodes decreased from every 23 days to every 7 weeks almost like clock work as well. In addition I had learned during this period to more vigilantly test my Potassium with the Cardymeter as well as even after taking a daily 20mEQ of time released Potassium Chloride tablet, my Serum K level would first shoot upo to around 4.7 to 4.9 and then descend again rapidly to around 3.7 some 15 hours later!

I suspect its even possible that rapid rate of K level change might have had some triggering effect?? In any event, ever 7 weeks is still far too many Cardioversions on top of all that I have had so the time is up for experiments and I need to get this taken care of now.

At least I can do so knowing I did everything I could to avoid it so that does indeed make it a lot easier to go thorough with it. And liek Natale said, no doubt these biochemical protocals will certainly work a lot better once that open flutter circuit is closed.

Shannon

Hi Shannon,

Thank you very much for the update. I've been under a significant amount of ongoing emotional stress this spring. As a consequence, afib has reared its ugly head more frequently than has been normal for the last 7 1/2 years of my supplement strategy. Fortunately my PIP flec routine still works consistently & quickly, so my total afib time is still very minimal.

As stress will certainly dump mag, your posts point out that I should be ever vigilant with my "cram" policy of mag intake.

I will be sending you good thoughts on Aug 6!

Cheers,

George

Hi George - sorry about your stress.... have you tried the theanine and Bach Flower Rescue Remedy? Theanine used regularly during the day helps many people with unremitting stress and allows for 'coping' without making you sleepy... and some tell me that it helps at the onset of AF as well. Certainly, the Cram Mg Dosing becomes even more critical as we all know. I increased my Ubiquinol dosing and that also seemed to help significantly but that may have just been unique to my needs.
Jackie

Hi Shannon:

Thank you so very much for your responses regarding your experiences with Dr. Natale and LAA ablation. They have been very helpful and illuminating for me, and reinforced to a great extent what I had come to understand about the risks and benefits of LAA focal points. While I stressed to Dr. N that I did not want any work done on the LAA unless absolutely necessary, he pointed out to me afterward that if he had not gone there I would almost certainly be back for more ablation later. I would certainly prefer to only have one procedure because of both my age and not-so-good health.

I remember the story of your blood pressure crash during your procedure, which was a frightful thing to have happen, and that it prevented him from completing the procedure was a real shame. I am so glad the supplements and biochemical adjustments have kept you going this long, but those atypical flutters and cardioversions must be getting really old hat for you by now. And it was horrifying to read about the last one - I am sorry you had to suffer that. It is so reassuring to be in competent hands when someone starts messing with your heart!

It sounds like you have been really diligent with your alkalizing and supplements. I am having to plough some new territory for myself here because of my impaired kidney function which leaves me not really knowing how far to go. Now that the surgery is over I can add in some taurine and L-carnitine; I don't know whether or not to try the potassium gluconate. I take three different sources of potassium and two of magnesium. I think there is still room for me to increase both and I willl have to seek out the Exatest and find out my IC Mg level and get myself a Cardymeter.. It is a shame that I can't do the Strategy, waller water or even LS V8. I will just have to work harder. Where do you get your IM magnesium? I have had to take IM B12 for some time now, and to take magnesium that way might help too.

So far, so good - no arrhythmias, no flutters. I can't get an appt. with my cardio until July but I am seeing one of her new proteges on Monday (she is retiring soon) so I am hoping to get some info to her and from her through him. I need a new hypertension regime now that I no longer need the Metroprolol - Dr. N wants me off it. I am not on an anti-arrhythmic since flec. is contraindicated for long-term use for me and I don't tolerate the others, so I am to use flec. PIP if I have any arrhythmias.

I am certainly hoping that Dr. Natale had the "right touch" when working in the area of the LAA and that the foci coming from there have been ablated. I was told in about six months he would do a TEE to see what the blood flow situation was in the LAA. Until then I guess I remain on Coumadin and who knows after that?

For you, August 6 is not very far away. I will certainly be thinking of you and have my fingers crossed for you. Thank you for your good wishes, and right back at you!

I am finding that up here at 5,000 ft, and with my COPD and the lung inflammation (for which I cannot take anti-inflammatories) I have to go tomorrow to get some portable O2 to use until the lung inflammation clears. Otherwise I am tethered like a dog to 25 yards of plastic line attached to my oxygen concentrator, lol. I have to detach myself to make it as far as the computer so don't get on often. So sorry not to have responded and thanked you sooner.

Buster:

I am sorry to have missed answering your question. Since I am in Nevada I went to California Pacific Medical Center, and stayed at the Hotel Kabuki, with whom CPMC have an accommodation plan (discount) and offer shuttle services to the various CPMC campuses and the hospital.. My husband is going there to have a hip replacement in a couple of weeks, having found the right surgeon and because the set-up is so convenient. Similar to what Mayo offers (at least in Arizona).

Laura:

Thank you for your good wishes. NSR forever!!

Cheers,
Neroli



Edited 1 time(s). Last edit at 06/21/2012 12:45AM by Neroli.B.

Friends,

I have had a similar experience to Shannon. Lots of work around the LAA during my Sept. 2009 ablation by Dr. N., resulting (it seems) in low velocity in the left atrium, and Dr. N. is having me continue on warfarin. He has recommended the lariat procedure recently but I've elected to wait for a while for them to have more experience with it. As with Shannon, I was told that it was "possible" I could get off warfarin with a successful lariat procedure.

Best to all,

--Lance

Hi George,

Thanks for the supportive wishes and thought on August 6th, I appreciate it! I got the first ablation on Monday morning at 8am pacific time it starts to get it out of the way pronto and not be twiddling my thumbs all day waiting .. that's the worst part! Plus then OI'll be there in San Fran the whole week Dr. N is in San Fran in case any follow up is needed.

And yes power out in the mag in stressful times and I second the Theanine and can add try adding some Ashwaganda and Holy Basil as well as good stress relieving herbs.

I found that the IV mag really dose the trick while I.M. mag helps but isn't always as effective as you might need it to be, and here I am talking just about raising Exatest IC mag levels For the longest time I was taking 2 grams a day 7 days a week of I.M. Mag Sulfate ( and believe me that gets sore after awhile feeling like a real pin cushion with so much fluid pumped in every day even when alternative thighs and hips) Plus 700 to 800mg of Jigsaw time-released Mag Malate orally and my serum Mag never budged from 2.2 and my Exatest IC mag was STILL only 32!!

That's some serious Mag wasting by definition !

Eight weeks of taking 4 grams of IV Mag Sulfate/week along with a 1.5grams of the IM Mag Sulfate 3x/week plus 600mg of the oral Mag finally got my serum mag to a high level of 2.6 plus just feeling more repleted and I will have my latest Exatest results back on Monday so will let you know where it is now, but alas it wasnt enough to prevent another flutter two weeks ago that happened just like clock work 6.5 to 7 weeks after the last one as it has for eight months now regardless of what I do or how much Mag and K I take.

At least I can embrace the second ablation now with the peace that comes from knowing I did everything I reasonable could to avoid it, but as in all things medical, good ideas such as The Strategy repletion is no guarantee for everyone that it will quiet the beast for good.

I do think though, that for most people with more typical paroxysmal AFIB, The Strategy when done properly and early enough in the progress of the disease may well circumvent the need for an ablation to begin with .. at least for a very long time.

But for a long-timer, such as myself, who had gone persistent AFIB three months prior to the 2008 ablation and with the other complications such as the Left bundle branch block that prevented Dr. N from finishing my first one, it seems this second one was always in the cards from the get go no matter what, just as Dr Natale told me I would need it after the first one, I was just fortunate enough to be able to push it with the supplements out to 4 years rather than the 1 to 1.5 years he suspected it would take before I was back for round two.

Good luck on getting your flippies under control again. Watch the Flec, I know it can really help for a good while, but even the PIP Flec can become pro-arrhythmic after a while as I discovered the hard way. It was using PIP Flec that pushed me into persistent AFIB while in Holland.

Cheers! Shannon

Hi Neroli,

Thanks back at you as well for your reply and and good wishes for my August 6th date with Dr. Natale. And yes, you are right it is always reassuring to have a competent doctor when dealing with heart issues, and with Dr. N we have the best you could ask for which makes it even more comforting. Plus, he is such a nice and personable man who is obviously passionate about what he does and totally dedicated to being the best he can be in his field.

I've always enjoyed every one of the twenty or so times I have met with him over the years and am always amazed at the level of details he can remember about my long ablation from 2008 as if it was yesterday! Even when I know for sure he had just came up from the ablation lab and had no time at all to review my file before seeing me, as was the case this last time in March when I saw him in SF when he grabbed my hand in the waiting room as he came it from finishing an ablation and ushered me back to his office for our consult.

So at least I have no worries over who is handling my case...

You asked where I get the I.M. Magnesium Suflate, it is from a compounding pharmacy called McGuff via a script from my functional medicine MD in Mill Valley California .. Dr. Camp.

Keep in mind the IM Mag Sulfate in the thigh can be a bit sore compared to IM B-12 shots which use such a thin needle. You will need a 25 gauge 1.25 inch needle for the Mag Sulfate IM. If you can arrange some IV Mag infusions that would be great to at least get you started off and fully repleted quickly in a few weeks to two months. Then, some combo of the IM Mag, Oral Mag and topical mag should do the trick on keeping you there for maintenance.. maybe even just a good oral time released Mag like Jigsaw would do the trick after getting topped off with the IV Mag infusions. Whereas sometimes with us depleted AFIBBERs and considering the various stresses and other cardiac drugs we often have to take that only further deplete our Mag stores in particular, it can be difficult and take a long time to get really fully repleted to begin with on oral Mag alone.

Just ask for a Myers cocktail and start with 2 grams of IV mag added to the Myers Cocktail ( note: they may have to adjust this in light of your kidney issues since I don't know your kidney condition?) and if you tolerate the 2 grams fine, then perhaps slowly have them increase the dose up to a max of 4 grams once a week .. or two grams twice a week for a month or two as needed and follow up with an Exatest.

Just make sure you are working with a knowledgeable doc when adding in the minerals with your kidney issue.

I hear you about altitude and breathing though with your COPD no doubt your issue is a good deal more challenging. I'm still adjusting to moving to Sedona where my new wife has lived 25 years, after almost 5 months since moving here at 4,750 feet and wonder how it will be right after this upcoming ablation during initial recovery?

Best of luck on your 6 month TEE and in having a quiet heart with no need for good for a repeat ablation ... or at least anytime soon!

I am just ramping up my Coumadin again this past week after 4 years off of it since 5 months after the first ablation ... Not a drug I like to take, obviously, but am getting the in-home INR meter again next week so that should help make the monitoring easier with the traveling I do. I had to take 15mg per day last time just to barely reach 2.0 INR and I wasn't able to achieve that prior to the ablation .. only getting to 1.85 the day before and thus necessitating a TEE that morning of the ablation to confirm all was clear before Dr. N could start his work.

We are starting me off now at 10mg/day and ramping up quickly so hopefully my INR will be good to go by early August.

Take it easy and speedy recovery!
Shannon