Met w/Dr. Natale today - a few concerns...and questions

So after 10 years of Afib and almost as many years of vacillating back and forth on whether to get an ablation or not, I finally met with Dr. Natale today. As many have said here, he is warm, attentive and clearly highly knowledgeable and skilled. I liked him alot. He did answer a number of my questions, but I realized after leaving that I still have a few more, as well as some concerns...

I first met with a Nurse Practitioner and was surpised to learn that the staff at my cardiologist office didn't fax over any EKG's with Afib - they were all in NSR! She almost acted like she didn't believe that I had Afib (probably more so because I said I was "self referred") I called the Cardiologist office again and finally got someone who dug up some EKG's that did show my Afib and had them fax it over. It was a little uncomfortable for a few minutes as she didn't seem to believe me that I had AFib! Like I spent the last 10 years with a few minor palpitations...I wish.

One of the things that worried me was that the NP said that they are concerned with anyone having episodes for more then 4-5 hours. I've read here many times that we don't need to worry until we are getting close to 48 hours, no? I have had some episodes - not a lot - but at least some, that have lasted 14 hours....and thought I was OK with that. Also, she said that I have a 2.7 percent chance of a stroke with Afib, versus the a non-Afibber having a .9 percent chance. Again, I thought that lone afibbers don't have more of a chance of stroke. ??

Dr. Natale said that women ARE harder to ablate because they have more focal/trigger (?) points...and because I have had some episodes lasting 14 hours, that it's possible that there may be more ablating that needs to be done, but he will be conservative in his approach this time. I took that to mean that I may need a second ablation, but also that if he needs to go in another area (not sure which area...) I may need to be on blood thinners indefinitely...he didn't say he thought that, as I am "kind of on the border' as I've had frequent Afib and some lasting 14 hours....so he wasn't sure until they went and 'took a look" . I've been worrying about coming out of this alive, for Pete's sake, and now Im worried instead about whether I have Afib activity going on in a more difficult area that may require blood thinners for God knows how long..

I am supposed to get off of Flecainide 5 days before the procedure (which is not yet scheduled as the person doing that wasn't there)...I am definitely worried about going OFF of the Flec as I am on 150mg twice/day and I remember reading how hard it was for Jackie to get off of Flec. as she had a "nasty Afib event". Dr. Natale just said to stop it 5 days beforehand, but shouldn't it be tapered off??

The NP said that I would likely have some Afib for up to 3 months after the ablation, and Dr. Natale said he would probably keep me on the blood thinner for a month afterwards and the Flec for a while longer too, especially since I mentioned that we expect to be traveling to Europe at the end of Sept. He felt the Flec would help to keep the heart calm(er?) until I could see him after the trip. As I know I tolerate Flec well, I'm OK with that.

How common is it to have Afib get worse or become flutter, etc. after an ablation? Does Dr. Natale embrace nutritionals, nattokinase, etc?

I know these are a lot of questions...I think I was a bit star struck in Dr. Natale's presence and didn't think to ask them all...

I'm expecting to be scheduled at the end of July at this point, as Dr. Natale is only in the NY office one week/month, and that's when he's there in July.

Thanks for any answers you may have...~ Barb

Barb,

I'm scheduled for a Natale ablation on June 24. I carried a copy of my medical record with abnormal EKGs with me along with the Echo to Dr. Natale. Like other women have found, I was once regarded as a neurotic female when describing awakening in the middle of the night short of breath, rapid irregular heart rate, dizziness, etc. I wish it had been 'bad nerves' but it was Vagal Afib.

Dr. Natale told me that women tended to have more focal points to ablate and that these focal points tended to originate in the pulmonary veins when the afib terminated in two to five hours. However, in females who have episodes while off heart regulating drugs which last 12-18 hrs such as me, there is a greater chance he will have to do additional ablation involving the atrial appendage and/or coronary sinus. In case a more extensive ablation is required I will have to go on Coumadin permanently. Dr. Natale told me he won't know how much of an ablation he has to do until he finishes with the pulmonary veins. If still able to induce afib, he then looks more for the source. His nurse told me that considering this, my chances for a more complex ablation are 50:50. Not exactly what I hoped to hear.

I was told to stop Multaq 5 days before the procedure. Flec has already failed. Due to my concern that I will die from a really nasty afib event those last five days, he gave me a script for low dose beta blocker. It has to be low dose because I normally have bradycardia. Natale assured me I will not die from Afib in those last five days. Obviously he has never been possessed by The Beast!

Good luck, Barb, and keep us posted.
Betty

Dr Natale is talking about ablating in the LAA which if he finds any activity within will likely will not get aggressive the first time around. This area in the Left Atrial Appendage is a pouch that acts like a reservoir where clots form during afib.
When he ablates this area the emptying velocity may be reduced thus the lifetime blood thinners. The other area he talks about is the coronary sinus that may need a second ablation sometimes a 3rd depending on the activity there.
He found nothing in my LAA Thank God but had activity in my CS that he ablated and shut down the last of my afib.
Shannon is the expert on the LAA so I'm sure he'll add more.

Hi Barb, I have a lot of anxity about tomorrow too. I know exactlyhow you feel. Dennis

The LAA deal is a tough call. If the doc needs to ablate there, you're told to be on blood thinners permanently. Well, I don't tolerate warfarin well at all, and I won't take the other junk, nor will I abandon my banged-up body lifestyle. So even though my recent ablation (I was persistent) was mostly successful, I still have a hot-spot that acts up now and then - so I live and eat just as I did before the ablation. I think I'd rather have the occasional afib rather than be on blood thinners, even if I have a slightly higher risk of stroke. I never had a stroke during the 10 years or so I had undiagnosed afib (lone afibber).

I wonder what the actual stroke risk is after an LAA ablation...any large studies done just for that area?

I watched my parents turn listless and depressed while on warfarin and other heart meds - life became a real chore - so how was that any better than a a higher stroke RISK?.

Tom

From another thread Stroke and Chicken Wing Shape of LAA

Does anyone know if Dr. Natale or other EPs who perform ablations use the shape of the left atrial appendage (LAA) in their determination whether or not to recommend that their patients take blood-thinners for the rest of their lives when the isolation of the LAA significantly impairs its function?



Edited 1 time(s). Last edit at 06/13/2013 11:45AM by Buster.

Hi Barb - As for the duration of events... keep in mind that no practitioner is going to want to be quoted as saying you are not likely to clot at X number of hours... the legal liability factor looms large. So they are always going to err on the conservative side which is for the patient's benefit and safety.
My recent bout of AF with the Lyme treatment brought about a couple of events that were very long... one went from AF to A-flutter in the ER and I was even released in flutter... after over 24 hours arrhythmia and not on an anticoag... however, I was on high dose Nattokinase. That event lasted almost six days.

I'm not saying you shouldn't be on anticoags or shouldn't go for cardioversion, but my personal experience is that after many, many years of very long event duration, I didn't have a problem with clotting (thanks to Nattokinase, magnesium and fish oil); otherwise, I might hold the record for the number of Electrocardioversions if I had ECV every time I had an event over 5 hours during those 8 years prior. Of course, I always kept close tabs on all of the blood factors that influence the tendency for clot risk... and my blood was not thick or sticky from inflammation or fibrinogen so I felt relatively confident that my clot risk was low.

My comment on getting off flecainide was during that time when I was doing heroics to avoid the ablation completely by a certain date...and I didn't have time to wean off slowly enough. But during those five days off Flec prior to ablation, I had nary a blip of AF...so just think positive, blissful thoughts that your heart will remain calm while you are off the Multaq. I can understand your trepidation as I certainly had it myself.

I wish you well and will be watching for your news.

Best to you,
Jackie

Buster Wrote:
-------------------------------------------------------
> From another thread
> [url=http://www.afibbers.org/forum/read.php?9,1342
> 60,134260#msg-134260]Stroke and Chicken Wing Shape
> of LAA[/url]
>
> Does anyone know if Dr. Natale or other EPs who
> perform ablations use the shape of the left atrial
> appendage (LAA) in their determination whether or
> not to recommend that their patients take
> blood-thinners for the rest of their lives when
> the isolation of the LAA significantly impairs its
> function?

Yes we talked about this. I assume maybe its just one of the criteria he's uses but there are other factors such as prior stoke, Chads score etc.... It's only part of the evaluation he uses unless he ropes off the LAA with the Lariat or uses the Watchman occlusion device. That determination is really made on how compromised the velocity of blood is out of the LAA and too low a number would be the absolute determination. Shannon knows the numbers.



Edited 4 time(s). Last edit at 06/13/2013 02:08PM by McHale.

Quote.....

Dr. Natale told me that women tended to have more focal points to ablate and that these focal points tended to originate in the pulmonary veins when the afib terminated in two to five hours. However, in females who have episodes while off heart regulating drugs which last 12-18 hrs such as me, there is a greater chance he will have to do additional ablation involving the atrial appendage and/or coronary sinus. In case a more extensive ablation is required I will have to go on Coumadin permanently. ...unquote

Does this concept apply to male afibbers? I have paroxysmal LAF and have had my ablation in January and speaking with my EP about another one sigh!! I recently experienced two episodes of AF which one had a duration of 43 hours and then self converted. This was the only long episodes I have ever experienced....the others prior to the ablation subsided within 2 and 6 hours.

Hi Barb,

Was nice speaking with you on Sunday and this morning, glad that your meeting went off fine with Dr Dr Natale, he is very easy to like.

Questions, often even more of them, are par for the course after a first meeting. Lets review some of what we discussed on the phone this morning for the others here following this thread.

1. I can imagine the initial questions of Natale's Nurse Practitioner when they had not received any records from your Cardio showing your AFIB and instead only showing NSR, and when you were in NSR during your visit. It's kind of like going to the auto mechanic for that annoying squeak that, just on que, is whisper quiet when you get there :-). Good that your cardio was able to fax over the real AFIB proof

2. As far as the duration of episodes before being 'concerned'. Keep in mind that there are different levels of concern. The general rule of thumb is that you are likely to require a more extensive ablation when your AFIB history is a long one and includes episodes longer than 24 hours, assuming your are still paroxysmal, and certainly when it has progressed to persistent AFIB. But it's also important to realize this is a progressive condition on a sliding scale and, as such, a person with a 10 year history of AFIB that includes 8 to 10 or more episodes of 14 hours or so of duration will be more likely to have some involvement beyond solely the pulmonary veins than someone whose episodes are only 4 hours long or less during only a two year AFIB history. Structural remodeling happens over time.

When the NP said they get concerned with 4 to 5 hour episodes she was likely referring to an increasing concern for stroke in a person not anti-coagulated. Again this is being exceeding cautious as Jackie indicated above, but do understand that the longer you have had AFIB, even if your episodes have not progressed to being very long duration, there can be some gradual structural impairment happening such that at some point the emptying velocity out of your left atrial appendage ... which is the source or almost all AFIB related strokes ... can drop below the golden 40cm/sec benchmark.

Once your LAA emptying velocity drops below 40cm/sec and/or there is an inconsistent A-wave present at the Mitral inflow on doppler imaging as seen with a Transesophageal Echocardiogram (TEE), then you definitely have an increased risk for LAA clot formation and possibility of an embolic stroke, even when in NSR all the time!

I suspect this kind of progression that isn't often recognized is why you hear of people keeling over with a bad embolic stroke even when they have a perfectly therapeutic INR on Coumadin. It doesn't happen a lot, but it does happen and is a good reason for not just settling for accepting a modest level of AFIB over a long period of time with no anti-coagulation efforts either pharmaceutical and/or natural in origin that is periodically confirmed with TEE as keeping your LAA free of clots while maintaining a robust emptying velocity of greater than 40cm/sec.

A recent study using TEE to examine the impact of LAA emptying velocity of 540 people made up of both paroxysmal and persistent Afibbers about to undergo a PVI ablation. All 540 of whom were anti-coagulated within a therapeutic range on Warfarin when the TEE was performed just prior to their ablation. Out of these 540 average ablation candidates, they found that 110 of these people had LAA emptying velocities below 40cm/sec!! Of these 110 who were, by definition, now in the overall greater risk category, three had actual thrombus clots in their LAAs on TEE imaging! Notably these three had among the lowest LAA emptying velocity of 31cm/sec, 29cm/sec and 23cm/sec. The first one of these three with the 31cm/sec LAA velocity had an INR of 3.2, while the other two had an INR of 2.2 !!

This is an eye-opening finding. Dr Natale told me when I asked him about this that it is possible those three had not maintained INR within that therapeutic range for four full weeks prior to the TEE and ablation. He has found, anecdotally, that the people he has examined almost never have a clot problem in the LAA when they have maintained a therapuetic INR consistently for four straight weeks. That give some small measure of comfort that if you are very strict with your testing maybe you can mitigate the stroke risk even with a too low LAA emptying velocity. But he acknowledged that this was a general anecdotal finding so far and that if those three people .. or any one of them for that matter .. had maintained a good INR for at least four weeks prior to the TEE as most people approaching an ablation would be aware of doing, then that could indicate a problem. A problem that would be a greater reason for considering a Lariat or Watchman procedure for eliminating the whole LAA stroke risk issue for good and thus freeing you from the concern or possibility of a stroke originating from the LAA.

Nevertheless, Barb, in your case you do not have to concern youself with the LAA issue at this time. When Dr Natale said he doesn't plan on going there 'this time' that doesnt at all mean he is expecting a second ablation will be needed for you. HE is simply saying he will not address the LAA on a first ablation unless in the rare event it is the only source of your AFIB and you are not triggerable from anywhere else.

Typically he will do the PVI antrum isolation and then search for other real time triggers be they along the back of the left atrium wall, in or around the coronary sinus or superior vena cava, or any focal CAFE (complex fractionated electrograms) trigger spots he might discover. He will address only those areas or focal points outside the PVs that are clearly active trigger sources to give you your best chance of a 'one and done' success.

Rest assured that if he does have to venture out some beyond the PVs, it makes little to no difference to you. You wont know any difference and none of those other areas he might have to ablate, other than full LAA isolation, will require life long anti-coagulation. That is only an issue if he has to fully isolate the LAA AND after 6 months when you do a follow up TEE test it is found that your LAA emptying velocity is below 40cm/sec and you lack a consistent A-wave at the mitral inflow. Only then will you be faced with the choice of life long anti-coagulation or going for an LAA ligation or obliteration procedure like the Lariat or Watchman.

Its important to realize too that from 40% to 50% of people undergoing a LAA isolation do still maintain an LAA emptying velocity above 40cm/sec and keep a consistent A-wave as well at the mitral inflow. For those people, they are done with this business for the long haul and require no anti-coagulation issue.

Do NOT even be concerned with the LAA isolation issue on a first ablation with Dr Natale. He will tell you if he felt like you were a strong candidate for needing LAA work on the first ablation ( for example if you have had AFIB for many years and are having strong symptomatic persistent AFIB now) and will work that out with you. Only exceedingly rarely would he even consider addressing hte LAA on a first abaltion and only then if that was the only source of your problem and it was highly symptomatic.

3.Barb, no worries at all with stopping Flec 5 days before the ablation. If you wish to taper you can cut it to half dose 8 days before ablation then stop all the way at 5 days... he wants it completely out of your system for that long so it doesnt possibly interfer with your ablation by masking any hidden triggers. If you go into AFIB those last days its no big deal as its one less job for him to do in triggering you during the ablation. You can ask him for some beta blocker or calcium channel blocker to take a modest low dose of if you should go into AFIB and the speed is uncomfortable. You might also ask for a few Ativan or Xanax to have on hand for those last days in case you do trigger to help you relax with it all and sleep better while you count down your last hours of AFIB .. someone mentioned their fear of dying suddenly .. you are anti-coagulated for sure by then and there is nearly zero chance of dying from AFIB during such a span. Particularly with a little rate control meds on hand just to make it a bit more comfortable, but dont take more than a small dose... no more than 25mg of Toprol for instance. ... try 12.5mg of toprol and if that calms things down enough then just stick with that. Try not to take too much of and cardiac acting drug those last few days before the ablation.

4. It is very rare for AFIB to get worse after a 'good' ablation but a top expert. Flutter can happen depending on what areas of the heart had to be ablated and the degree of your progression beforehand. About 50% of the time it self resolves and is thus self limiting. For the other 50% of post ablation flutter cases, it usually requires a touch up to finish it all off for the long haul.

5. Yes he will likely keep you on Flec for a few months and Coumadin the same time or less after the ablation, all just to help the healing process and keep things going smoothly with the blood flow as the inflammation subsides.

You are good to go Barb, no real issues here to be concerned about. All par for the course and the fact that your heart is normal in size and function are only a plus for making this a routine procedure.

Cheers!
Shannon

Good luck Barb & Betty - it's good to hear from women about ablations, since so much comes from the guys POV. I wish you the best of luck with your ablations and look forward to hearing how WELL you will both be doing.
Nancy

Gianfry59,

Even is Dr N had to eventually go in and isolate your LAA, there is roughly a 50% to 40% chance you would not need to take blood thinners for life. Dr N now routinely tells everyone who might need an LAA isolation to expect to need blood thinners for life if he has to isolate the LAA as that is psychologically easier approach to expect it up front and then be told the good news as a bonus six months later if and when your follow up TEE confirms a LAA emptying velocity of greater than 40cm/sec and the presence of a consistent A-wave at the mitral inflow. Then you are free of AFIB/Flutter and free of anti-coagulation issues.

Only if you are in the other half of the coin .. like me with a LAA emptying velocity of only 20cm/sec and an intermittent doppler A-wave, then you will have to deal with either life long anti-coagulation or get a Lariat or Watchman procedure to eliminate all LAA stroke risk once and for all which, when successful, allows you to forget the anti-coagulation drugs for good as well.

Keep in mind that when it comes to isolation of the LAA, if that is where all your remaining troubles are coming from, then to not address the LAA will very likely result in a gradual progression into persistent AFIB, in which case you will require full time anti-coagulation anyway! Once you really digest this key point, the whole argument against addressing the LAA isolation loses most of its rationale.

And TomB, even if you don't have persistent AFIB and just have periodic breakthroughs, over a long enough period of time if it is confirmed you are already having much, or all, of your remaining trigger from the LAA, then it is very likely that your LAA emptying velocity will slow down anyway to well below 40cm/sec over the following years of activity and then you will be stuck with either needing to stay on blood thinners for life anyway or get the LAA taken out of the picture with the Lariat or Watchman.

There really isn't the kind of cut and dried choice as it might seem at first blush. It sucks to have serious AFIB, it has consequences and your best odds of minimizing those consequences in my book is to do whatever it take to minimize your AFIB/Flutter burden AND do everything you can to maximize your dietary, life style and targeted repletion of key biochemicals needed to best support the whole cardiovascular system and optimize blood flow and lower blood viscosity as well.

I just got approved, across the board, for the Lariat procedure with Dr. Natale and Dr. Burkhardt and am going for it on August 5th in Austin. I will discuss all the considerations that went into that decision beyond the summary above in a separate thread in the days ahead when I have some time to write it out. It takes some well-informed consideration to sort out one's options and while there is no free lunch in this business, I do feel this is the better choice for me for the long haul with all things considered.

Plus, getting a Lariat procedure in a preliminary study has shown to fully isolate the LAA mechanically, and as further studies confirm that effect that Dr Natale said also that they are seeing with the Lariat, at some point it might become standard of care for certain afibbers to combine an initial PVI isolation ablation along with any other albation needed along with a Lariat procedure to not only handle all the typical aspects of an AFIB/Flutter ablation, but also to insure isolation of the LAA, and thus to do away with the stroke risk and anti-coagulation issue all at one time as well as stop the arrhythmia killing all birds with one shot.

However, that might be some time before they come to that combination procedure.

The bottom line, though, is it is very unlikely to have to isolate your LAA in a first ablation and even if they do eventually isolate it you are not necessarily committed to a life time of anti-coagulant drugs for sure in any event.

Shannon



Edited 1 time(s). Last edit at 06/14/2013 02:03AM by Shannon.

Lots of good info, Shannon. Thanks!

Shannon is a wealth of knowledge about afib. You need a job in Natale's office educating us. Thanks!

Buster Wrote:
-------------------------------------------------------
> From another thread
> [url=http://www.afibbers.org/forum/read.php?9,1342
> 60,134260#msg-134260]Stroke and Chicken Wing Shape
> of LAA[/url]
>
> Does anyone know if Dr. Natale or other EPs who
> perform ablations use the shape of the left atrial
> appendage (LAA) in their determination whether or
> not to recommend that their patients take
> blood-thinners for the rest of their lives when
> the isolation of the LAA significantly impairs its
> function?

Hi Buster,
Yes Dr Natale and his office consider the shape of the LAA when it requires isolation. In particular, they usually ask for a spiral CT Scan of the heart with particular focus on capturing a dimensional view of both your left atrium, left atrial appendage as well as clearly visualize the PVs using contrast dye to capture the blood flow through the PVs where they connect to the LA.

If you are a candidate for Lariat or Watchman they pay close attention to LAA shape and morphology and identify whether you have the more favorable Chicken wing or any of the other three less favorable shapes ... 'Windsock', Cactus or the least absorbable of all ... 'Cauliflower' ... Alas mine appears to be a Cauliflower.... Just one more reason a Lariat is the better option for me over a life time if anti-coag drugs.

However, the overiding main criteria for determining if you need a Lariat or Watchman is your LAA emptying velocity being below 40cm/sec and the absence of a consistent A-Wave at the mitral inflow on doppler imaging with a TEE exam. If you don't pass both those criteria, then you either have a life-time of daily anti-coagulant drug to add to your daily routine, or go for the Lariat or Watchman.

The next step then to get approved for a Lariat procedure, is to have your CT Scan of your heart analyzed by a Cardiologist/EP ( Dr. Horton does that step for Natale's group if that is who you choose to do your Lariat) that has been trained and approved by SentreHeart .. the makers of the Lariat system .. to determine the suitability of your LAA anatomical shape for accepting the Lariat's 40mm diameter pre-tied Lasso-like loop suture.

If your LAA is too big or has too many oddly shaped lobes for them to fit the Lariat snare over the full length of the LAA from the outside, then you wont get approval for a Lariat at this time and will have to go for the Watchman if you want off the AC drugs. They have found a very few (not many) once they go in during the Lariat procedure, that their LAA tissue has adhesion's between the bottom length of the LAA
and the top of the LA itself such that they have had to abort the procedure because they could fit the Lariat snare around the LAA as a result. I've only heard of that happening once, but it could have happened a few more times however it is very rare for that to occur.

After anatomical approval, then Sentreheart must approve it still, though that step is likely going to go away now that it is becoming a much more commonly performed procedure across the US. Then finally you must get your Medical Insurance approval for the procedure ..or show that you can pay for it.

The Chicken Wing, Cactus, Windsock or Cauliflower shape issue is more part of the doctor patient decision to decide if you are a better candidate for just getting by with anti-coagulation drugs if your LAA emptying velocity is below 40cm/sec or if you have one of the other three less favorable shapes then, in my book, that is a strong vote for going for LAA ligation or occlusion with either the Lariat or Watchman and thus get rid of the small but ever present risk of a stroke even with a great INR and while in NSR as would be the case when your LAA velocity is well below 40cm/sec. Over a course of ten to twenty more years of life what seems to be a relatively small 8% to 10% constant risk of developing an LAA clot would add up over time to a rather large chance in any given individuals case who met that criteria.

Shannon



Edited 1 time(s). Last edit at 06/14/2013 12:11PM by Shannon.

Shannon,

Thank you for being so thorough and detailed in your great answers!

George

Shannon
What is the anticoagulant you are on?
Is the Lariat only done in Tx? When are you going yo have it?
You are on the best hand

Elena

You are welcome George, we've been at this a long time haven't we ...

Take care,
Shannon

Hi Elena,

I am on brand name Coumadin .. 12.5mg/day due to Coumadin resistance which is a genetic anomaly in enzyme function required to metabolize Coumadin. Having to take so much often also makes it tougher to stabilize the dose. Thus taking brand named Coumadin instead of generic Warfarin can help, at least a bit, in stabilizing INR: Also taking a consistent low dose of Vitamin K2 (either 45mcg or 90mcg) every day as well as low dose Vitamin K1 at around 50mcg/day can also help stabilize your INR as well if one is variable.

Regarding the Lariat, I will share more on that in a new thread in the coming days, but yes Dr Natale only does Lariats in Austin at this time.

It is a two man procedure and Dr. N does them with his long time colleague there Dr. David Burkhardt. They often trade off which portion of the procedure they do, but most often Dr Natale handles the endocardial phase with transeptal puncture while Dr. Burkhardt handles the epicardial catheter phase of the procedure snaking the epicardial catheter up under the center of the chest just underneath the ribcage starting from mid line near the solar plexus and wrapping the catheter around the top of the lungs toward the anterior oblique side of the heart where he can get best access to the outside of the left atrial appendage after puncturing the pericardial sack with a #17 pericardial access needle.

Its a conceptually simple procedure but can be rather tricky to get good placement of the epicardial catheter at first until the operator has a little more experience, Both Dr Natale and Burkhardt have as much experience as anyone at this point doing the Lariat, even though it is still a rather new procedure with something like 700 to 800 or so done world wide so far. Maybe a bit more by now as it is rapidly expanding with many more medical centers starting to offer and actively advertise the Lariat procedure this year of 2013 across the US and Europe.

Hope that answers your questions Elena?
Shannon

Shannon
Yes you did thank you very much for all the answer
Good luck with your surgery
Elena

Thanks for your good information, Shannon. Keep us posted on how you are doing.
Betty

[onlinelibrary.wiley.com]

Objectives: To evaluate early outcomes of left atrial appendage (LAA) closure via a percutaneous LAA ligation approach with the SentreHeart LARIAT™ snare device.

Background: Atrial fibrillation increases the risk of stroke 4-5 fold, which can have devastating outcomes. Exclusion of the LAA is believed to decrease the risk of embolic stroke.

Methods: Twenty-seven patients with atrial fibrillation, a high risk of stroke, and contraindication or intolerance for anticoagulation therapy underwent percutaneous ligation of the LAA with the LARIAT device. Initial LAA closure was confirmed with TEE and contrast fluoroscopy.

Results: The acute procedural success was 92.6%. One patient sustained a perforation of the LAA and was treated conservatively. The patient underwent LAA closure surgically the next day. In one patient the attempt to advance the LARIAT over the LAA was unsuccessful. Patients were followed for a mean of 4 months. Preserved LAA closure was confirmed with a 45 day follow-up TEE in 22 of 25 patients completing the procedure. Peri-operative complications included three cases of pericarditis and one case of a periprocedural CVA due to thrombus formation on the transseptal sheath. During follow-up, there was one stroke thought to be non-cardioembolic and one pleural effusion. There were no deaths.

Conclusions: These results show that percutaneous LAA exclusion can be achieved successfully with an acceptable rate of periprocedural and short-term complications. Further studies and longer follow-up are needed to determine whether LAA exclusion lowers the long-term risk of thromboembolic events in patients with AF and contraindications to anticoagulation